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Maintaining the best results requires knowledge and expertise. Our athletes train and so do we, through our professional development program. Meaning that when a practitioner the treats you, they have the most advanced injury care knowledge. Read about what our practitioners are thinking in the injury blogs below.

Running And Hydration

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Be it for event training or just general fitness - hydration is something that is often poorly managed in runners especially when the weather gets warmer.

When I completed my first Melbourne Marathon, the temperatures in October were considered above average with race day reaching 29 degrees.

Endurance -based activity requires optimal nutrition and hydration to ensure your body is able to achieve maximum potential. The last thing you need after doing all that training is for your body to fail on you due to a lack of fuel. Not only can severe dehydration have physical side effects but it can be as disheartening as running out of petrol in your car only kilometres from the petrol station and having to push yourself to the finish.

A marathon or any distance run as an elite or beginner is as much mental as it is physical and doing your research on food intake and hydration is an important aspect of your training.

Here's a little about Hydration from the pros.

  • Keep up your nutrition/hydration during training just like you would on race day to avoid gastrointestinal upsets (Murray., 1998)
  • Don't increase or change your eating habits, just substitute for the appropriate foods.
  • Do your research - your body needs certain levels of energy stores pre, during and post race (Brukner & Khan., 2005)
  • Water is not enough - you need adequate carbohydrates/sugars (Murray, 1998)
  • Match carbohydrate intake to body weight ratio - endurance athletes undertaking greater than 90 minutes of exercise require a daily carbohydrate intake of between 8 and 10g/kg of body weight required to replenish glycogen stores. (Brukner & Khan., 2005)
  • The most accurate way to determine your adequate fluid intake is to take a ‘sweat rate test.’ Weigh yourself before and after a 1hour run luid intake must be matched with weight loss.
  • Only a small decrement in hydration has been shown to impact body functioning and performance running in the heat (Casa, Stearns & Lopez et al., 2010)

Race preparation

72 hours leading up to a race is when you should be starting to hydrate correctly.

  • Increase your fluid intake by sipping on sports drinks, not just water throughout the day.
  • Everyone is different depending on body weight but as a general rule of thumb - you know you are well hydrated if you void large volumes of pale coloured urine at least 6 times a day (Maharam & Lewis et al., 2006).
  • Drink to thirst - thirst is the physiological feedback that protects athletes from over or under drinking (Maharam & Lewis et al., 2006).

Race day

  • Be educated - wear appropriate clothing for weather conditions.
  • Drink approximately 500ml of fluids the morning of the run, but cease drinking 1 hour prior to give your bladder a rest.
  • Every 15-20mins during the race consume fluids at the drinks stations. Try to consume energy gels with water and consume electrolyte drinks separately to avoid gastrointestinal upsets (Kreiter., 2014).
  • External water helps to cool your body temperature down.

Post race hydration

  • You should slowly consume 750ml fluid (carbohydrate drinks such as Powerade) as soon as you cross the finish line and continue to do so for every kilogram lost. Eat protein and carbohydrates within 1 hour of race completion to allow replenishment of glycogen stores and for muscle repair (Kreiter., 2014).
  • A weight loss or weight gain of more than 2% is a warning sign of drinking improperly and justifies a medical consultation (Maharam & Lewis et al., 2006).

My Hot Tip for first time marathoners

  • Walking through the drink stations only takes approximately 10 seconds. With drink stations every 3-5km this will only add around 2 mins to your overall time - for adequate hydration it is worth the walk!

PFJP

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Patellofemoral joint (PFJ) pain is one of the most common knee complaints in runners and the highest presenting knee pathology to physiotherapists. Patients may commonly describe pain at the front of the knee aggravated by stairs and weight bearing or jarring activities that involve knee bending.

PFJ pain is commonly caused by poor kneecap alignment - where the kneecap does not glide freely through the femoral groove. This causes joint irritation and sometimes degeneration behind the kneecap as the kneecap rubs against the femur.

The malalignment or maltracking of the patella as we bend the knee is caused by a number of factors, the most common causes being a muscle imbalance and poor biomechanics.

Below is a breakdown of the contributing risk factors.

Internal

  • Structural abnormalities - femoral ante-version, shallow femoral groove, genu valgus (knock knees), patella alta (high sitting patella), leg length discrepancy.
  • Poor foot and hip biomechanics - flat feet, high arches, increased Q angle.
  • Muscle weakness - gluteals, VMO.
  • Hip and ankle muscle tightness and/or joint stiffness - such as tight ITB and decreased ankle dorsi flexion.
  • Poor balance and coordination.
  • Poor shock absorption when landing.
  • Gender - more likely in females.
  • Previous lower limb injuries.

External

  • High impact sports.
  • Training/playing surfaces.
  • Training load.
  • Equipment.
  • Footwear.

Common sports where PFJ pain is typically seen includes those with excessive running, jumping and squatting such as long distance running, netball, football, tennis, volleyball, basketball and skiing.

Untreated PFJ pain can result in patella tendonitis or other biomechanical related injures of the lower limb. Physiotherapy treatment to enable a patient to return to their chosen sport may involve:

  • Ice and anti-inflammatories
  • Regaining full range of movement
  • Restoring muscle length
  • Normalising quadriceps muscle control
  • Correcting hip and foot biomechanics
  • Retraining sport specific movement patterns by adding power, speed and agility

References:

(Crossley., Collins., Beller., 2008)., (Brukner & Khan., 2005)., (McConnell., 2000)

A Fresh Perspective On Persistent Back Pain

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Persistent back pain is one of the most costly health problems and one of the most poorly understood. The old approach ‘fix the back’, ‘strengthen your core’ or ‘get a new office chair with lumbar support’ gives short term relief but doesn't address the true cause of persistent pain. By treating the symptom and not the underlying cause you're missing the point. In many cases it is possible to resolve persistent back pain instead of simply managing it.

The key to solving the problem is to understand it.

The very first step in your journey out of persistent back pain is to understand that it's not so much a back problem as it is a pain problem. Pain acts like our body's alarm system that alerts us to something potentially dangerous happening. Persistent or recurrent pain is like the alarm being continually triggered in the nervous system. Pain is not all in your head and it's not all in your body either, it's an altered 'state' of the nervous system as a whole.

One of the tricky concepts on this journey of discovery about pain is that whilst all pain is real - ‘your pain is what you say it is’ pain is also a perception that is open to interpretation. Your pain is not the same as my pain or anyone else's. Your pain is your brain's interpretation of what's going on.

Think about a rainbow. It's an example of a visual perception. Is it real? You can see it but it's not a physical thing. It requires sun and rain and when the conditions change it disappears. Pain is a sensory perception, you feel it but it's not a physical thing. A key skill in relieving persistent back pain is to disassociate it from a physical structure. Changing the belief from ‘my disc is worn out’ or ‘it's bone on bone’ to understanding pain is a 'state' of the nervous system. Our ultimate aim with pain relief is to change the conditions in the nervous system so that pain disappears like the rainbow does and the alarm is not continually triggered.

Pain relief is as much about looking after the physical health of the nervous system as it is about changing the way you perceive it. Here are my top 5 tips on how you can nurture your nervous system for pain relief:

  1. Move, stretch and exercise
  2. Nourish nerves with good nutrition
  3. De-stress and learn how to relax
  4. Improve the quality of your sleep
  5. Understand how pain works

Exercising When Sick

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If you have just started a new exercise routine or you are in full swing of training for a marathon - both require good physical and mental health. If you get struck down with a cold or you are returning from a significant illness, its important to listen to your body.

There is a difference between exercising through a runny nose and sore throat and trying to exercise when you are sick in bed with a fever and significant lethargy. Our bodies generally give us a good indication of when they can function normally and when they cannot. When we are healthy our bodies are designed to cope with the stress of a hard training session, making us fitter and stronger. When we are sick, our immune system is lowered and will not cope with the stress of what may be your normal training session.

This is where we all need to pay attention, exercising with more severe symptoms such as a fever, body aches or nausea will increase your body temperature and in turn make you sicker for longer if you try to push through it. If you miss a few sessions it is important to remind yourself that all the flu needs is rest.

If your symptoms are less severe such as a runny nose, you may still be able to exercise but a different form might suit you better such as walking, a bike ride for fresh air or yoga. This will help you feel active and will allow you to maintain some form of fitness but it wont stress your body with the high demands you normally put your body under with a 2 hour training run.

Exercising is a way to boost your immune system, therefore if you exercise regularly you shouldnt be sick very often, but if you are, its a sign to rest.

Pushing your body too hard can result in more significant illnesses such as glandular fever and chronic fatigue which leaves you more than likely unable to participate in your goal of a marathon or whatever you have been training for. If you are training well you should have begun training early enough that if you do need a week or a few sessions to rest it wont be detrimental to your overall performance.

Here are some signs both physical and mental that may lead to a plateau in your performance:

-You are physically exhausted - lacking sleep or poor nutrition.

-You spend hours doing cardio and hate it - your heart rate is not getting high enough to achieve results.

-You are stressed - more so than normal. In this case, exercise can be an added stress.

-Your muscles are over-sore. You are not allowing adequate rest days.

-You are burnt out - there needs to be a balance to ensure you are able to maintain your routine.

-All in all listen to your body - it usually gives us an honest account of how it feels. Look after your body - you only get one!

HIIT FIT

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Not all active people can be described as FIT. It has different meanings for individual athletes in the context of their fitness goals and chosen sport.

Take the thin, low body weight of the FIT marathon runner vs the muscly, strong yet FIT sprinter. Both are classed as FIT in their own sports.

Athletes and recreational gym goers are incorporating the latest craze into their exercise regime. High Intensity Interval Training.

High Intensity Interval Training involves very intense bursts of exercise incorporated with low intensity exercise. Training of this nature allows you to exercise at high intensities for a much longer period of time than a steady state, ultimately helping you burn more fat.

Associated Benefits of Metabolic Interval Training

Improved fitness

Greater strength

Peak performance

Delayed ageing (and in many cases, rewinding the body clock)

Reduced risk of illness

Increased energy

Lean muscle

On the other hand, long distance runners body types adapt to running greater distances over time and inevitably lose weight on the scales, but this is often both fat and muscle.

Losing muscle can result in:

Decreased strength

Poor performance

Early ageing

Reduced immunity

It must be made clear, any exercise that gets people moving is better than sitting on the couch. However, the latest research shows integrating a combination of both aerobic (endurance) and anaerobic exercise (interval training) results in the best outcome for both fitness and health.

I recommend a balanced approach to training for my clients to keep things fresh and interesting to suit your fitness goals.

Laursen and Jenkins, 2002

Summary of HIIT training methods

Training until muscle fatigue to stimulate new muscle growth

Short concise training 45 minutes or less

Training each group of muscles for no more than once a week and allow rest periods for the muscles to grow

Each repetition should demonstrate correct technique and control. For example, not using momentum to complete the exercise.

Complete exercises at a slow pace to ensure the greatest number of muscle fibres are being recruited during a muscular contraction.

Recovery period differs from person to person. If you do not see results, it is possible that you have overtrained the muscle group.

A high quality nutrition regime is as important as a high quality training program.

Herodek et al., 2014

Movement Therapy

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As a physio I prescribe and encourage movement as therapy. I use my hands to mobilise, stretch, massage and move body parts; I use my voice to educate, encourage, plan and prescribe movement strategies; I use my body to demonstrate and visually communicate movement patterns. Movement really is a metaphorical feast for the senses and it’s also highly therapeutic.

Movement therapy………yes I’ve moved on (pardon the pun) from the term exercise. Patients don’t necessarily want to exercise better, they want to MOVE better and FEEL better and PERFORM better. Maybe even HEAL better.

Movement is widely prescribed as a therapy for most disease states of the body - from pain and stiffness in our muscles and joints to diabetes, asthma, heart disease, cancer and autoimmune disease to name a few. So what is it about movement that is so therapeutic across such a wide variety of conditions?

The common link to all disease in the body is chronic, low grade inflammation. It’s the body’s neuro-immune system attempting to restore balance. Our nervous system and immune system working together, releasing inflammatory chemicals like cytokines and hormones like cortisol. Driven by an overactive autonomic nervous system and exacerbated by stress and modern lifestyle choices.

The prescribed antidote to this modern day chronic disease dilemma is movement. Why? Because the physical organ that is our nervous system moves and stretches as WE MOVE. It glides and slides as we bend and flex and extend. Movement obviously keeps the nervous system physically healthy, infusing it with blood and oxygen. But movement is also highly anti-inflammatory, it changes the balance of the chemicals in the neuro-immune system, calming the inflammatory response.

So movement therapy is really immunotherapy. It balances the immune response by balancing the pro and anti-inflammatory chemicals in the nervous system. Ultimately health and well-being.. FEELING well and MOVING well and PERFORMING well…. is all about achieving the right chemical balance in our nervous system by creating a balance between movement and stillness.

And as for the prescription of movement…. well, I’ve moved on from numbers too. 10 reps 3 times a day is arbitrary. It really depends on the chemical balance in your nervous system. If your inflammatory profile is reasonably low then you can move more vigorously, more often. If your inflammatory profile is high then go gently with less repetitions and adopt the ‘little and often’ rule. Skilled therapists are terrific at judging from your history and examination where you sit along the inflammatory spectrum.

Set a goal and start moving. Find the right balance for you. Your immune system will do the rest.

Staying Motivated

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We’ve all been there – whether it be post-Christmas, post winter, post injury or even post baby – finding the motivation again after a period of time off can be hard. Here’s a few things to help you bounce back into your exercise routine.

Don’t be hard on yourself – Get rid of the guilt, stop setting high expectations that are unrealistic to achieve – this only leads to negativity and punishment. If you have been feeling bad for missing out on exercise, turn it into excitement and confidence about starting again and reaching your goals.

Set a goal and write it down – Going into anything without a plan is a sure way to increase your chances of failing. Have it clear in your mind & put in down on paper. Think about both short and long term goals and make it specific – Eg; how many days do you want to run, what distances/duration you want to achieve and ultimately the long term goal might be completing a fun run on a set date. If it’s written down and in a place you regularly sight it, it will make you accountable for your actions and is often the best form of motivation.

Prepare and set yourself up for success – Plan or allow adequate time for what you want to achieve in your running session or workout. Take note of your progress by ticking or crossing or recording what you have achieved beside your list of goals. Prepare yourself by packing your lunch or gym gear the night before to allow yourself a better night sleep to wake up fresh and lastly if you have good self-control you will spend less time resisting desires against exercise and you are more likely to achieve you goals if everything is prepared.

Start out slow – If you’ve had a break from exercise due to injury or just simply not having the time, it is important to start out slow to reduce the likelihood of re-injury or a new injury from overloading your muscles and joints too quickly. It is also important to allow time to warm up and cool down properly with exercise to best avoid muscle soreness the next day.

Don’t procrastinate and never give up – Whilst it’s easy to procrastinate in life, it is bad for our will power, only making us more stressed as a result. Our willpower can be overused and weakened just like our muscles, but it can also be strengthened by making positive choices. So bite the bullet and stop making excuses, you will feel better for it in the long run.

Try something new – Sometimes routine can become mundane and after a period of time doing the same thing causes a loss of motivation. Stop it in its tracks and make your exercise routine a variety. If it’s running – include some steady runs with some interval/speed or hill running. If you are a gym goer – try exercising outdoors, if you struggle flying solo – try a team sport or recruit a friend to exercise with. Don’t make exercise a chore, for you to be successful at achieving your goals you must enjoy what you are doing.

Reward yourself – Starting anything new is hard, it takes willpower to adopt a change in behaviour, so make sure you reward yourself along the way to further drive your motivation to keep going. It might be little rewards along the way such as a new item of clothing or a massage or even a bigger reward like a holiday once the final goal is achieved.

Remember the important thing is to have a positive outlook on starting a fresh, don’t beat yourself up if you miss a session here or there, recognise you are doing well for having started and keep moving forward. Good luck!

I Rolled My Ankle AGAIN!!

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I rolled my ankle, AGAIN!

Ankle sprains are the most common type of ankle injury and can account for up to 20% of all sporting injuries (Fong, Hong, Chan, Yung, & Chan, 2007). Poor management and insufficient rehabilitation can lead to recurrent ankle sprains, impairment of athletic performance (Yeung, Chan, So, & Yuan, 1994) and persistent disability (Petersen et al., 2013).

What happens when you roll your ankle?

An ankle sprain occurs when the foot rolls inwards, causing over stretching or tearing to the ligaments on the outside of the ankle.

Fig 1 Inversion injury of the ankle showing damage to the lateral ankle ligaments. 

(ref: https://gymnasticsinjuries.files.wordpress.com/2012/10/anklesprainimage.jpg)

 

How bad is it?

There are 3 types of sprains which are defined by the extent of damage to the ligaments. 

 

 Grade 1: Stretched ligaments

Ligaments are stretched during a slight ankle roll. Common versions of this occur when running onto a patch of uneven grass or during an over step in tennis. You may immediately experience mild pain and a small limp. After a few minutes of rest, most people are usually able to continue their activity. Some swelling may occur within 24 hours and with appropriate management, you can expect return to preinjury state within 1-2 weeks. 

 

Grade 2: Partial thickness tear of ligament

Ligament tearing occurs when the ankle rolls further than the ligaments can stretch. You may experience moderate pain, a limp and usually cannot continue to play. Swelling and bruising may occur within 24 hrs and weight baring is particularly painful. If you experience these symptoms, you should seek medical advice to determine the extent of damage. Depending on this, recovery can take between 2 - 6 weeks.

Grade 3: Complete rupture of ligament

Complete ligament rupture is a progression of grade two and occurs when the ankle has rolled beyond its normal limits. Initially, individuals are unable to walk on the effected ankle and can complain of it feeling “unstable”. Excess swelling and dark bruising would be expected 24 hours after injury. On a case by case basis, grade 3 sprains may require surgical intervention or up to 12 weeks of rehabilitation. 

So you’ve sprained your ankle, what to do now?

After following the basic “RICE” principles (rest, ice, compress and elevation), you should seek medical advice from a physiotherapist as soon as possible. Physiotherapists are highly trained health professions who specialise in the assessment, diagnosis and management of ankle injuries. 

What to expect when your see the physio?

Your physiotherapist will ask you questions regarding your injury and what symptoms you are experiencing. If pain allows, an assessment will be performed to diagnose your injury and explain the extent of damage. An accurate diagnosis is crucial in ensuring appropriate management and treatment can be provided. (Wolfe, Uhl, Mattacola, & McCluskey, 2001). 

Firstly, pain and swelling management is commenced. This may involve icing, taping, bracing, crutches or a moon boot. Secondly, your physiotherapist will discuss your diagnosis and expected recovery time, as well as appropriate activity modification. Thirdly, pain free range of motion and strength exercises can commence. Fourthly, an individualised rehabilitation program will be developed and implemented. Goals and sport specific tasks will be incorporated once adequate function has been regained. Completion of your rehabilitation program results in positive outcome measures, optimal recovery and reduced risk of chronic ankle instability (Mattacola & Dwyer, 2002). 

But don’t I need an x-ray?

Physiotherapists follow a set of guidelines called the Ottawa Ankle Rules that are used to determine whether a fracture is suspected (Ivins, 2006). These guidelines have an extremely high sensitivity and are used to reduce the number of unnecessary radiographs by 30-40% (Bachmann, Kolb, Koller, Steurer, & ter Riet, 2003) (Dowling et al., 2009). If your physiotherapist suspects a fracture, an x-ray will be organised. 

Can I stop this from happening again?

Extensive research demonstrates that individuals who adhered to a rehabilitation program involving balance and proprioceptive training were significantly less likely to experience a recurrent ankle sprain (Petersen et al., 2013) (Hupperets, Verhagen, & van Mechelen, 2009) (Postle, Pak, & Smith, 2012). While the risk of re-injury can be reduced, unfortunately accidents can still happen. 

 

 

Reference List

Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ, 326(7386), 417. doi:10.1136/bmj.326.7386.417

Dowling, S., Spooner, C. H., Liang, Y., Dryden, D. M., Friesen, C., Klassen, T. P., & Wright, R. B. (2009). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med, 16(4), 277-287. doi:10.1111/j.1553-2712.2008.00333.x

Fong, D. T., Hong, Y., Chan, L. K., Yung, P. S., & Chan, K. M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Med, 37(1), 73-94. 

Hupperets, M. D., Verhagen, E. A., & van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ, 339, b2684. doi:10.1136/bmj.b2684

Ivins, D. (2006). Acute ankle sprain: an update. Am Fam Physician, 74(10), 1714-1720. 

Mattacola, C. G., & Dwyer, M. K. (2002). Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. J Athl Train, 37(4), 413-429. 

Petersen, W., Rembitzki, I. V., Koppenburg, A. G., Ellermann, A., Liebau, C., Bruggemann, G. P., & Best, R. (2013). Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg, 133(8), 1129-1141. doi:10.1007/s00402-013-1742-5

Postle, K., Pak, D., & Smith, T. O. (2012). Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis. Man Ther, 17(4), 285-291. doi:10.1016/j.math.2012.02.016

Wolfe, M. W., Uhl, T. L., Mattacola, C. G., & McCluskey, L. C. (2001). Management of ankle sprains. Am Fam Physician, 63(1), 93-104. 

Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological survey on ankle sprain. Br J Sports Med, 28(2), 112-116. 

 

R.I.C.E Or M.E.T.H?

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R.I.C.E. or M.E.T.H.?

By Lisa McInnes

I’ll never forget when one of my lecturers asked, “Isn’t Meth the new Ice?” After a few chuckles he was met with confused faces and a collective "huh?" I didn’t investigate this any further until my interest was recently triggered by seeing a journal article titled “The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise.” Working with a football club, I was interested and curious as to the practice of icing an injury and the use of ice baths post game for recovery and also as a nurse with occasionally post-operatively applying ice packs to orthopaedic surgical sites (surgeon dependent of course).

The study investigated the current belief of cold water immersion (ice baths) after exercise and its effect on skeletal muscle. It’s believed this reduced inflammation, compared with active recovery such as resistance exercise. Interestingly, the study found there was no human data available to support the theory of cold water immersion after exercise and that it is no more effective than active recovery for minimising the inflammatory and stress responses in muscle after resistance exercise.

So why has it been drummed into us as consumers and practitioners to use ice, even on acute injuries? Most of us are aware of the acronym R.I.C.E. (or R.I.C.E.R.)  which stands for Rest, Ice, Compression, Elevation, (Rehab/Referral). 

Have you heard of M.E.T.H.? This stands for Movement, Elevation, Traction and Heat and brings us back to the old debate....heat or ice? Does this newer acronym not contradict our current practice and beliefs? Of course it does! So what do we do? I believe the most important question to ask at this point is WHY? Why are we applying heat or ice? What are we actually trying to achieve? What is our purpose? Are we using ice as an attempt to numb the injured area or to reduce the swelling as a direct effect from inflammation?

What were we trying to achieve using ice? For years, with first aid and an acute injury we rested the area so as not to worsen or aggravate the injury further, applied ice to reduce inflammation thereby reducing swelling as this was considered counterproductive. Compression for support and to reduce swelling, elevation to reduce swelling, then rehab to strengthen the injured area. But why do we want to reduce inflammation? The body has an astounding capacity for healing and multiple buffer systems to maintain homeostasis, eg pH levels, water retention and of course conducive environments for healing. Will we really effect it?

So why use M.E.T.H? How does this work in the setting of an acute injury? Mobilising an injury or the tissues around it, with traction, will provide support whilst assisting lymphatic drainage as the muscles compress the lymph nodes moving lymphatic fluid back to the subclavian veins thereby reducing swelling. Elevation helps this process and heat will also increase blood flow enhancing the healing environment. 

 There are three phases of healing - inflammation, proliferation and maturation or remodelling (Physiopaedia.com). Without inflammation, the next two phases of healing are affected and impeded, the body cannot skip a stage. If this is so, then why are we trying to prevent it? 

Current practice is slowly changing and is starting to gain momentum. As Elle’s blog ‘Ankle Sprains: Is Rest Really Best?’ explains, the benefits and importance of early implementation of therapeutic exercise in the successful rehabilitation of ankle sprains. Rest is not really best! Ice is following this path…

Gary Reinl, author of Iced: The Illusionary Treatment Option discusses there can be inflammation without healing but there cannot be healing without inflammation.

Have a look at the video below featuring Kelly Starrett and Gary Reinl about the change in culture for the elite sportsperson in America and their move away from the use of ice with improved outcomes for those athletes. 

Very importantly, Gary mentions we need to keep in mind our purpose for using ice. If we want to numb the area to assist with pain relief then by all means use ice, but if our purpose is to reduce inflammation then we need to reassess our practices. 

 

 

 So what should we do from here? There are many blog posts and opinions on moving away from ice and using heat but what we really need are further clinical studies and research evidence so as practitioners we are using best practice to ensure our clients are receiving the best treatment to help them reach their goals and potential. Remember, if you have any questions contact your practitioner for further advice.

 

Further reading:

Reinl, Gary Iced: The illusionary treatment option. 2nd edn

References:

Peake J, Roberts L, Figueiredo V, Egner I, Krog S, Aas S, Suzuki K, Markworth J, Coombes J, Cameron-Smith D, Raastad T, The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise. The Journal of Physiology, 2013 Nov, Vol 595 (3), p695-711

http://www.physio-pedia.com/Soft_Tissue_Healing

Sever's - The Curse Of The Junior Athlete

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It is “Severs Season” across Melbourne! As kids are getting involved in winter sport and as training loads increase, we are starting to see some common injuries hindering participation across many different sports. One particular concern for pre-teen athletes is the onset of heel pain, particularly in high impact running sports such as Hockey, Soccer, Basketball, Netball and Australian Rules.

By far the most common cause of heel pain in the early teens is Severs disease or “calcaneal apophysitis”.  It is most common in children between the ages of 8-14 and it is generally sporting kids that can suffer from the condition.

As kids go through periods of significant growth, it is not uncommon for the growth plate at the back of the heel to be grabbed, pulled and irritated through the Achilles tendon and related posterior leg muscles. This pain can be so severe that walking can become a challenge and no activity can be completed at all. Pain will normally be felt on the side of heel and in the Achilles tendon.

This condition tends not to affect populations past 14 years old, as the growth plate becomes fully ossified within the calcaneus (heel bone) by that time. Factors that predispose a child to developing Severs include a flat or high-arched foot, tight posterior muscles particularly if they are actively engaging in high impact sports.

What should I do if my child has heel pain?

Heel pain is common in children, and most causes of pain are benign and self-limiting however all pain in children should be assessed. So if your child has heel pain you should:

  • Address the pain initially through the use of Ice and Rest
  • Anti-Inflammatory medication used as directed may be of benefit (if tolerated by your child)
  • See a Podiatrist for assessment and treatment options which may include
    • Ensuring appropriate footwear with rearfoot support
    • Stretches or strengthening program
    • In some cases orthotic devices may be recommended. 

Severs is something that does resolve with time, and generally does not require any type of surgical intervention. There are simple strategies that can help manage Severs disease, which usually have great results with pain reduction and increased mobility. Kids who show dedication to the treatment program improve rapidly and can be back participating in activity pain free after slight delay and with minimal repercussions.  

If you think your child may be suffering from Severs, or other complex foot pain, come and see the Podiatry team at CSSM to help them perform at their best.

About the author – Jim Unkles is a podiatrist at Camberwell Sports and Spinal Medicine.  He understands the demands of competitive sport in children through personal experience in representative Hockey and Cricket. He is currently managing several sporting kids experiencing Severs.

 

References

Marchick, M., Young, H. and Ryan, M.F. (2015) Sever’s Disease: An Underdiagnosed Foot Injury in the Pediatric Emergency Department. Open Journal of Emergency Medicine, 3, 38-40. http://dx.doi.org/10.4236/ojem.2015.34007

Running Light

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We’ve just wrapped up our 4th Run Long, Run Strong forum here at CSSM with all participants loving the opportunity to pick the brain of one of Australia’s most iconic long distance runners, Steve Moneghetti. A key focus of the evening was how important load management is to managing your running program, and how to prevent injury.

Steve’s a big believer in setting yourself a goal and working towards it, and we could not agree more. Signing yourself up for a running challenge can be daunting, but extremely rewarding if it’s done in the correct manor. Loading up gradually is extremely important, and it’s the number one mistake runners make when commencing a training program. Trying too much, too quickly can often lead to the body breaking down and the onset of injury becoming a reality. 

From a planning approach, when training load exceeds load capacity is the moment where we are at risk of developing a load induced injury. Our load capacity will increase and improve with our training program, but researching and implementing other training modalities will improve our running performance. 

Through the use of supplementary training you can continue to build not only your cardiovascular fitness but your muscular strength, endurance and power if you utilise the correct formats. Activities such as swimming, deep water running, weights training and Pilates are all great ways of improving your base level of fitness and reducing your chance of load induced injury!

We also spoke on the importance of recovery and allowing time for the body to rejuvenate from training load. From a biological level, allowing time for adaptation to occur is important for good muscular development. Not allowing a rest day in a full training week could allow for an overload on the tissues, and prevent muscles developing to their optimal level.

After another great forum we are already looking towards the next opportunity to help our #teamCSSM runners, so if you have any ideas from who you’d like to hear from in the future, let us know!

 

About the author.

James Unkles is a Podiatrist who has also completed his Bachelor degree in Exercise and Sport Science, and loves running every week! He can provide expert assistance with managing your running program, gait analysis or explain how the lower limb reacts to aerobic or anaerobic training.

References

Konopka, A. R., & Harber, M. P. (2014). Skeletal Muscle Hypertrophy after Aerobic Exercise Training. Exercise and Sport Sciences Reviews42(2), 53–61. http://doi.org/10.1249/JES.0000000000000007

Sitting Vs Standing

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The jury is out on which is better. Standing all day is no better than sitting. This is because, by standing all day, a variety of new risk factors are introduced such as increasing compression through the spine which can lead to low back pain. It may also increase the risk of developing varicose veins and other cardiovascular problems as the body has to work against gravity to return blood flow back to the heart.

What experts do agree on is that the body was designed primarily for movement, so sitting or standing statically for extended periods is counterproductive.  Therefore, a combination of alternating between sitting and standing is most likely to be the healthiest option. So instead of forking out thousands of dollars on a sit-stand desk, try the obvious solution first –stand up and move as often as possible at work.

The term ‘ergonomics’ is derived from the Greek language and translates as ‘how to work according to nature’. Put simply, it is the interaction between a person and their environment.

In Australia, 45% of all employed adults work in a sedentary job where they spend most of their time sitting. Prolonged periods of sitting not only increases the risk of diabetes, heart disease and obesity, but may result in the development of numerous musculoskeletal disorders and discomfort. Ergonomic adjustment to the workplace environment may increase comfort and productivity, and decrease the risk of chronic injury and disease.

Some basic tips to improve desk ergonomics include:

  • Feet flat on the ground
  • Knees and hips at 90 degrees
  • Hips slightly above knee height
  • Hips positioned in the back of the chair
  • Backrest slightly reclined to 10-20 degrees from vertical 
  • Forearms approximately level with the desk, keyboard and mouse within close distance of each other
  • Computer screen is at arms length from the head, with eye line falling within the upper 1/3 of the screen
  • Sit up tall, chest out, shoulders back and remain upright.

 

Image sourced from: http://www.sittingergonomics.com/

 

Is there anything else I can do to assist my workplace health?

Yes there is. Movement is the key to rejuvenating the neurological system by activating fatigued and ineffective muscles, and allowing fluid movement to keep the spine healthy. Workers should be moving every 25-30 minutes. Get a drink of water at the water fountain, take the stairs instead of the lift or speak to a colleague face to face instead of using email!

Simple stretches can also be completed to assist with pain prevention. These are a few examples of stretches that can be completed whilst sitting: 

 

 

Image sourced from: https://equilibriumnaturalhealth.com/2016/12/01/seated-stretches/

For more information, contact one of our Osteopaths here.

About the author:

Lachlan White is a registered Osteopath. He has an interest in treating patients with acute and chronic pain conditions, including headaches, neck and back pain and assisting in the management of chronic and degenerative disease.

 

References

Australia Bureau of Statistics. (2011). 4835.0.55.001 - Physical Activity in Australia: A Snapshot, 2007-08. [online] Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4835.0.55.001main+features32007-08 [Accessed 20 Mar. 2018].

Chu, A., Ng, S., Tan, C., Win, A., Koh, D. and Müller-Riemenschneider, F. (2016). A systematic review and meta-analysis of workplace intervention strategies to reduce sedentary time in white-collar workers. Obesity Reviews, [online] 17(5), pp.467-481. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/obr.12388 [Accessed 20 Mar. 2018].

Low Back Pain And Paracetamol

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Low back pain and paracetamol by Osteopath Lachlan White

It is expected that 70-90% of people will suffer from low back pain at some time in their lives. 

Low back pain can be a significantly debilitating experience and commonly affects a person’s ability to complete simple tasks, such as getting dressed, getting out of bed or walking a short distance. It also has the potential to burden those who care for low back pain sufferers. 

Paracetamol is one of the most commonly prescribed medications for relieving low back pain – but is it really effective?

Significant research has recently been conducted in this area and has revealed some surprising insights.  The British Medical Journal (BMJ) found paracetamol to be ineffective for reducing low back pain intensity and improving quality of life. Evidence also indicates that people consuming paracetamol are four times more likely to have altered liver function due to the body’s metabolism of the drug.

When compared to placebo (a dummy pill), paracetamol has been shown to have the same effects on pain, function, sleep and quality of life – no improvement. 

So as a sufferer of low back pain, where does this leave me?

In some cases, anti-inflammatories or other forms of pain medication are more likely to be effective. There are also many other self-management strategies which may assist in managing low back pain. 

Osteopathy is a form of manual therapy within the Allied Health profession which can help diagnose, treat and manage low back pain. By using a range of safe and clinically effective treatment techniques tailored to the individual, it can relieve pain, improve mobility and strength, and increase performance. Osteopaths are also able to prescribe rehabilitation programs, provide advice regarding common medications, prescribe other self-management strategies and assist with any other problems that you may be experiencing.

To discuss this further contact CSSM on 9889 1078.  

About the author:

Lachlan White is a registered Osteopath. He has an interest in treating patients with acute and chronic pain conditions, including headaches, neck and back pain and assisting in the management of chronic and degenerative disease.

References

Back problems. (2017). Australian Institute of Health and Welfare. Retrieved 20 March 2018, from https://www.aihw.gov.au/reports/arthritis-other-musculoskeletal-conditions/back-problems/what-are-back-problems

Machado, G., Maher, C., Ferreira, P., Pinheiro, M., Lin, C., & Day, R. et al. (2015). Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ350(mar31 2), h1225-h1225. http://dx.doi.org/10.1136/bmj.h1225

Williams, C., Maher, C., Latimer, J., McLachlan, A., Hancock, M., Day, R., & Lin, C. (2014). Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. British Dental Journal217(4), 183-183. http://dx.doi.org/10.1038/sj.bdj.2014.732

Coming Back From Injury - Peter Hutchings

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Getting back from injury can be a long and lonely road. No matter what sport you play or what kind of athlete you are, everyone has setbacks.

I had hip surgery in 2016 after tearing cartilage in my right hip while training for the Cairns Ironman.

It's been tough because I really enjoy the satisfaction that comes from competing in endurance events both from a physical and psychological perspective.

For me, surgery was inevitable. Even though I tried to avoid going under the knife by focusing on glute and core strength work, I was unable to run pain free. As if that wasn’t enough, I also suffered from a frozen shoulder during the same period.

Regular physio and massage has been part of my rehab program. I have worked on changing my running gait to a more mid-foot strike to reduce impact, increase running cadence and extensive core and glute strengthening work.

Rehab has been frustrating. The improvements have been very slow and I have had to manage my expectations carefully and listen to my body. But I believe early intervention has helped minimise the damage and get me active sooner.

I am currently training 6-7 days a week. Generally 2-3 swim sessions, 2 runs and 2-3 rides. This is supplemented by massage focused on my lower back and legs. Dry needling is also a part of the treatment.

The best advice given to me while I've been injured? "Be patient and don’t skip the rehab exercises even if they don’t seem to make a difference."

My goal is to complete a half marathon triathlon again. If you're injured, be patient, listen to your body, be consistent with training, don’t increase the training volume too quickly and utilise massage as a key rehab treatment.”

 

*Peter Hutchings is 54 and is sponsored by CSSM as part of the 2018 Athlete Sponsorship Program

He is currently 16 months post-surgery and one of our very determined athletes.

CSSM is proud to work with people like Peter to help them achieve their goals.

Sonia Dunne: Living With Rheumatoid Arthritis

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Sonia Dunne was diagnosed with Rheumatoid Arthritis while training for the 2014 Ironman Melbourne. Despite her diagnosis, she still competed the 3.8km swim, 180km bike ride and a 42.2km marathon! It’s this determination that saw her accepted into CSSM’S Athlete Sponsorship Program.

Sonia talks about how rheumatoid arthritis has affected her life and training and how she plans to achieve her goals for 2018.

 

Rheumatoid Arthritis is an autoimmune disorder that causes pain and swelling of the joints. For me to cross the Ironman Melbourne finish line in a very respectable 14 hours and 7 minutes was a HUGE accomplishment to say the least, especially given sufferers of RA at my level are rarely able to get out of bed in the morning and end up with severe depression from the pain associated with the disorder. I did actually end up in hospital at the completion of the event for a week and a half due to the fact that I pushed myself above and beyond in order to make the finish line and become an IRONMAN. Unfortunately, I have paid the price for my sheer determination to cross that finishing line and since then I have seen some very trying times.

I am not a quitter and I refuse to give up often to my own detriment. No matter how hard and crappy my RA is, I always manage to keep a positive attitude in all that I do, and I inspire others around me. The overwhelming symptom I have is pain and stiffness, sometimes it lasts 4 hrs and sometimes it last all day but the mornings are generally the worst. I remember once trying to get out of bed and the pain was so great that I collapsed and my body went into shock and I had a fit. That was probably the disease at its worst. Now, with the treatment I am receiving, I still get pain but it is far more manageable.

My knees, lower back, feet and hands are most effected. My knees of late are causing me the greatest about of pain, so much so that I rarely walk without pain anymore. It often takes me 30 seconds or so to stand up from a seated position and move making running pretty much impossible.

I receive treatment monthly in the form of a drug called Tocilizumab that requires admission to day oncology. In the next few weeks, I am also going to be admitted to hospital to have Yttrium Radio Synovectomy Therapy which is a treatment that destroys painful tissue, stops fluid secretion and reduces joint inflammation on the knees.

Strangely, exercise helps! I'm unclear as to whether that is mind related or mobility related but if I don’t exercise I find myself being very short and irritable. Does it help the pain? Probably not, although I like to say it does but the issue then becomes working out what is RA pain and what is general muscle soreness. The challenge you have with someone like me is that exercise is not going for a walk or an easy swim, exercise is  running 21kms or exercising to max capability for 45 min or riding for 4hrs + anyway you get the idea!

Exercise brings so much more benefit for me other than keeping fit, keeping the weight off etc….its an outlet. It’s something I use to clear my head, digest the day and make a plan for what's next. That is invaluable.

I have certainly not done another Ironman - but I will one day. I have done two ultra marathons, two half IM's and two half marathons and one Olympic distance triathlon over the past two years. Of late, I’ve taken up Functional 45 Training with F45 Oakleigh and this I really love. I am learning so much about the importance of balance as opposed to just run, ride, swim and the strive to beat yourself, I just love it. I have found myself participating in sports that are far less weight bearing on my joints, and shorter time span to avoid stress and fatigue on my body. I can't say I am convinced as I have been programmed for so long to do endurance.

I am also on the Triathlon Victoria Board - VP. This helps me remain connected to the sport I love and enables me to give back in a way that I can manage and that suits my skill set. It also helps me develop both personally and in my career. One day I will race again, but in the meantime this is a great compromise. There is so much that can be done and gained from volunteering in sport.

Diet - clean eating with my disease is a must. I feel it in myself and my body when I don’t eat well. Lots of fish for essential oils and lots of green vegetables and minimising sugar. F45 has also been a huge help with this, it has transformed the way I see food. I have also found wine to be a trigger.

Home - we have had to make a few modifications to make life a little more bearable. Pull taps instead of turn taps, walk in shower recesses as opposed to the old step over the bath style and importantly, we have a furry family member - Molly which I found also helped a lot as the focus shifts from you to her.

Lifestyle - bring back the flats and joggers! Unfortunately, I am not going to win awards for the "style master of the year " at work or heading out as I can only wear flat shoes or when the pain is unbearable, joggers but everyone is used to that now and it suits my lifestyle. The other big change I have made is to prioirtise sleep. Fatigue comes as a symptom of the disease but the more sleep you get the easier things are to bare so I try to get at least 8 hrs sleep a night.

I utilise Remedial Massage, Pilates and core and lower back strengthening exercises thanks to Kobe at CSSM. I had really not maintained my body proactively at all until I was lucky enough to be selected as an ambassador and now I do it all the time. More importantly, I understand why I'm doing it and what I am affecting. Looking after your body is so important. I now believe that if you are good to your body it will be good to you.

The best advice I’ve been given is stop and listen to your body. By nature, I just push and push and push I have learnt that there is only so much your body can take and that is why I am where I am today. Hopefully, others can learn from this.

I have a very supportive specialist who is very keen to support me in achieving my goals whilst also managing the impact on my body and the expectations that I have. At this stage, all I am doing is F45, focussing on strengthening my body through pilates and weights.

My goals for 2018:

Compete in the Kokoda Ultra Trial Marathon

Compete in the Noosa Triathlon

To get a 6 pack!