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The Truth About How to Fix Your Tendon Problems

clinical pilates brightonElbow tendonAchilles TendonKnee Tendon

Busting Myths for Tendon Problems

Myth One - Eccentric exercise is the best exercise for rehabilitating tendon.

Whilst eccentric exercise (strengthening exercise where the muscle is lengthening) is the most researched, evidenced based program that is used, world renowned tendon specialist Professor Jill Cook from Latrobe University states that upon reflection, eccentric exercise by itself is deficient because it doesn't address the specific requirements of a person. They may be OK for the middle aged male runner, but they aren't that great for the younger sprinter or for the older person.

More importantly, eccentric exercise doesn't address the strength deficits of the muscle or of the body in general and they don't address the new research findings of the brain's and nervous system's deficiency in activating the muscle. Therefore, eccentric exercises by themselves are quite deficient in being able to restore full function.

What is the best treatment program for tendon problems?
The best treatment for tendon problems is really tailoring a program that best matches each person's individual wants, needs and requirements. For example, a young sprinting athlete with a hip tendon pain will have a different program to an older woman with the same condition.

Likewise a shoulder tendon problem will have a different program to an elbow tendon or an Achilles tendon problem. And even further from this, an Achilles tendon problem where the pain is in the mid portion of the tendon, the same as if the pain is at the insertion (attachment) and you can't treat either the of these the same as if the problem is in the covering of the tendon (peritendon).

This is why people need to be treated so individually. The purpose of treatment is to restore function to the level that a person wants. Anything after this is a bonus.

What are the key principles in tendon treatment?

The key principles include:
1. Promoting muscle strengthening which can only be achieved with strengthening exercises that involve both shortening and lengthening of the muscle. If you have good muscle strength, this will protect your tendons as well as other structures;

2. Having the ability to restore and release energy in the tendon if you are a higher level athlete;

3. Ensuring that the whole body is working efficiently and effectively with good mechanics;

4. Correcting faulty functional movement patterns.

What stages are involved in tendon rehabilitation?
To restore people back to high level function is a four stage process. For a person who doesn't need to meet high level athletic demands, they will not need to go through all four stages.

Stage 1 involves using isometric exercise (strengthening exercise where the muscle is contracting but there is no movement at the joint) to reduce pain and the brain's inhibition to activating muscle;

Stage 2 involves implementing a good strength program for the muscle/tendon unit as well as all other associated parts of your body. For example, the higher up your leg that you go, the more that you need to restore below the problem. If you have an Achilles problem, it is mainly calf that needs to be restored. If you have a knee tendon problem then the quadriceps and calf will also need to be restored. And finally, if you have a hip tendinopathy, it is glutes, quadriceps and calves that need to be restored.

In particular, you need to restore the strength of your anti-gravity muscles and then depending on their activity level, you need to restore the spring. As the tendon act like springs, you need to make them work again especially with the faster the movements and energy storage movement.

Stage 3 involves adding to this is endurance. For example, if someone wants to play football, they not only need to have a great general body strength and control and a great set of springs, they also need to spring repeatedly and therefore their tendons must have great endurance. It is this lack of endurance, or the capacity of the tendons to tolerate prolonged stress, that failure occurs.

Stage 4 involves adding spring strength and endurance. This is why tendons often take so long to get better. They often present extremely debilitated and damaged. There often has been long term pain with the tendons being robbed of their energy, endurance and muscle strength and bulk. And all of this needs to be restored, before the tendon can be made resilient enough to cope with the stresses that a person want to place upon the tendon in the activities that they want to get back to.

People who leave treatment early will often find that their pain will return in a couple of weeks because the tissue is only as good as the load that is placed upon it. And this is the same for tendon, muscle and bone. This means that if tissue hasn't been restored to a capacity that is needed in an activity or sport it will fail again. It's just physics. You cannot continue to load a tendon greater than what is has been trained to do. It isn't rocket science and just self-evident.

Physiotherapy should the first treatment of choice because tendons need exercising and correct loading. Physiotherapy shouldn't come after medication, injections or other intervention.

Myth Two - Tendon problems always involve inflammation

Tendon problems were originally thought to be an inflammation of the tendon (i.e. Tendinitis) in the 1970's until a fantastic study showed that tendon pain was primarily due to degeneration rather than inflammation.

Of course, like any other tissue, there will be some inflammatory markers and there will be some inflammatory cells because it's a tissue that is injured. However, inflammation is not the driving process. It is not the thing which is creating the pain and it is not the thing which is creating the ongoing pathology.

What causes the pathology is due to the over-loading of the tissue either on a prolonged or a short term basis. What causes the pain seems to be the tendon cell releasing pain chemicals.

If a person has an acute injury and ice doesn't help, then don't waste your time putting ice on the injury. Spend your time doing exercise. If ice does help, this is an indication that the injury probably has some peritendon (sheath covering the tendon) involvement. Therefore, ice and anything else which you perceive to be helping can be used along with exercise that has the correct loading. The evidence however, is that rest, ice, compression and elevation won't help you.

Myth Three - Once the tendon is pain free and you have returned to sport you don't need to do your exercises any more.

It is important that you understand that even if your tendon is pain free and you have returned to sport that the pathology in the tendon is still there.

Tendons don't heal even if the pain goes away. Once a tendon, always a tendon. If you do the right things your tendon will stay pain free. If you don't do the right things, your tendon will become painful again.

In addition to this, your brain is still inhibiting the activation of your muscles, because it is worried that you are going to re-injure your tendon again. Consequently, this means that if you return to sport and you stop your strength training, your muscle strength will decrease markedly if you stop your exercises and you will be prone to re-injuring yourself.

To prevent re-injury, it is important that you continue with your strength training exercises at least twice each week for at least a year following full recovery and then you may have a chance to give up the exercises.

For elite athletes they need to continue with their strength exercises 3 times a week for the rest of their careers. This is because these strengthening exercises are acting like an insurance policy. If you can stay strong, you keep your tissue (muscle and tendon) capacity up, you will be less likely to get into trouble again.

Because of your brain protective inhibition on your muscles and tissues, it means that when you have been injured, when you return to sport, you won't run, jump, twist, turn or just move quite the same way that you did before your injury. Therefore, the first season following a major injury is a building season. Following this you will need to do a really good pre-season and the second season back will be a "cracking" season.

It can take this long to be able to use your tendon as a spring and be sure that it is not going to cause your pain.

Myth Four - The tendon will get better quickly

It is critically important that you are educated regarding your tendon pathology.

You need to see how much swelling there is, how much muscle bulk you have lost, how your tendon store energy and how badly you hop.

You need to understand how your tendons react to pathology and how pain is caused and how we need to build capacity.

You need to understand that once a tendon, always a tendon and though you can become pain free and you will be able to return to sport, we want you to be able to play as well as you can.

You might be a bit sore the day after sport, but you will be able to train the day after this.

Understand that unless you are prepared to buy in to a 3 to 6 months rehabilitation process (and sometimes longer), there is no point in starting. You need to understand how long it will take and why, so that you can work with your tendon and your body to achieve the best outcome. Unfortunately there is no quick fix.

If you have tendon problem and you want to get better as quickly as possible, call Bodywise Health on 1 300 Bodywise (263 994) for a no obligation, complimentary assessment and advice.

You have nothing to lose except your pain!

Until next time, stay Bodywise,

Michael Hall
Director
Bodywise Health

Reference
Professor Jill Cook; Busting Tendon Myths Conference; San Diego 2016

 

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Why Hamstring Strains Occur and How to Prevent Them

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Hamstring, Hammies, Hams, or if you're feeling fancy you can use their latin names. Keep in mind there are three muscles that make up the group of muscles called the hamstrings, they are biceps femoris, semimembranosus and semitendinosus.

This group of muscles is a notorious repeat offender for injuries, across numerous sports. AFL, soccer, rugby, cricket and baseball players are all frequently falling victim to the sharp pain in the back of the thigh that can mean anything from missing a few games to ending a career.

There have been a number of superstars with their futures in doubt due to the injury, just to name a few; Michael Clarke (cricket), Chris Judd (AFL), Jamie Lyon (NRL). And more recently Cale Hooker (AFL) was in doubt to play against Geelong in the last preseason game.

What puts someone at risk of a Hamstring Injury?
When all of the studies looking into risk of injury are combined we get a good overall picture of the elements that increase the risk that someone's hamstring will be injured.

As we noted with the ACL injuries (ACL injuries in females), there are a number of factors that contribute to an injury. Some of these we can influence and others are out of our hands.

The two big factors we cannot change that influence your risk of injury are age and previous history of hamstring injury (or previous ACL/knee injury)1.

Though if you haven't had a hamstring injury before, perhaps now is the best time to see a Bodywise Health Physiotherapist for a personalised preventative program.

The good news is there are a number of risk factors that we can improve on. These include muscle strength ratios, strength characteristics of the hamstrings and player endurance1.

Are there different types of Hamstring injuries?
The location of the tear can have a significant impact on the recovery process, especially the time and rehabilitation required to get back on the field.

When considering the location of a muscle tear it is important to appreciate the whole unit. The whole unit includes the bony attachments (both ends), the tendons (a flexible cord on either end of the muscle that transmits the force of the muscle contraction to the bones) and the muscle belly - the power generator. There is also an important transition of muscle to tendon towards either end. These different locations all heal at different rates and sometimes require different rehabilitation strategies.

The extent of the tear arguably will have an impact on the recovery process. Studies looking at imaging results have not consistently shown a clear correlation between the findings on scans like an MRI and the time to return to sport (RTS). Having said that, one can respect that a more substantial sized tear would require longer to repair the damaged tissue, but there are a number of factors that weigh in when considering returning to sport.

If you have been injured, a physiotherapist at Bodywise Health will be able to assess your hamstring and determine what type of injury you have or if further investigations are required.

What can be done to prevent an injury?
This is the most important section. If you have never had a hamstring injury before you want to be proactive in reducing your risk. If you have been unfortunate enough to have sustained an injury previously, you should be working hard to reduce your other risk factors.

There have been many studies looking at reducing the risk of injury. And the great news is there are many things that can be done to reduce your risk.

Your training program should include anaerobic interval training, sports specific training drills and lengthening exercises. Stretching especially while the muscle is fatigued, has also been shown to reduce injury risk. So a proper cool down is important2!

There are also specific exercises that have been shown to reduce the risk of a hamstring injury.

What can be done if I am injured?
Just as was seen in the preventative efforts, lengthening exercises have been shown to have a faster RTS time3. Additionally, agility and trunk strengthening offered slightly quicker RTS and lower re-injury rates, when compared to just strengthening/stretching3.

It was noted that more frequent stretching can still improve the range of movement faster, as well as allowing a faster RTS, suggesting that a home exercise program conducted frequently will be helpful. NSAIDs were not found to be helpful for recovery, PRP injections were also found not to offer benefit in RTS times3.

Sports focused exercises were also found to reduce the number of hamstring injuries sustained by AFL players4.

Unfortunately many of even the elite clubs are failing to adopt the 'evidence based' hamstring injury prevention measures. One study looking at elite soccer clubs in Europe had as many as 83.3% of clubs not following guidelines5.

So if you play a sport that involves running or kicking, get ahead of the competition and see a Bodywise Health Physiotherapist for an assessment and a preventative program. If you've sustained a hamstring injury either recently or a while ago, reduce the risk of re-injury by getting a preventive program.

For a complimentary injury assessment and advice, please call Bodywise Health on 1 300 BODYWISE (263 994).

Until next time stay Bodywise,

Michael Hall
Director Bodywise Health

References
1. T. Pizzari, Risk factors for hamstring injury: An updated systematic review and meta-analysis, Journal of Science and Medicine in Sport, Volume 19, Supplement, December 2015, Page e9, ISSN 1440-2440, http://dx.doi.org/10.1016/j.jsams.2015.12.401
(http://www.sciencedirect.com/science/article/pii/S1440244015006465)

2. Verrall GM, Slavotinek JP, Barnes PG The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players British Journal of Sports Medicine 2005;39:363-368.

3. Pas HI, Reurink G, Tol JL, et al Efficacy of rehabilitation (lengthening) exercises, platelet-rich plasma injections, and other conservative interventions in acute hamstring injuries: an updated systematic review and meta-analysis Br J Sports Med 2015;49:1197-1205.

4. Proske, U., Morgan, D., Brockett, C. and Percival, P. (2004), IDENTIFYING ATHLETES AT RISK OF HAMSTRING STRAINS AND HOW TO PROTECT THEM. Clinical and Experimental Pharmacology and Physiology, 31: 546-550. doi:10.1111/j.1440-1681.2004.04028.x

5. Bahr R, Thorborg K, Ekstrand J Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey Br J Sports Med Published Online First: 20 May 2015. doi: 10.1136/bjsports-2015-094826

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Why female athletes are more prone to knee injuries and what you can do about it

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What a wonderful start to the Women's Australian Rules Football season. It's been fortunate that the injury toll has been keep largely in check. There have been a few exceptions, namely:

  1. Natalie Plane from Carlton with her high-grade ankle sprain
  2. Meg Downie from Melbourne with a hamstring rupture
  3. Stephanie De Bortoli also from Melbourne with an Achilles tendon tear
  4. Brianna Green, a Fremantle player fractured her collarbone


There have been two major knee injuries reported to have occurred during the season so far. Sophie Armitstead with a meniscal tear of the same knee she's previously had an ACL reconstructed and Kim Mickle who ruptured her ACL.

But what is this 'ACL'?
The Anterior Cruciate Ligament is a rope-like structure that supports your knee from the inside. In some ways, it is the last structure that prevents your thigh bone and leg bone separating during not only high force activities but also day to day activities, like walking down stairs. In addition to the structural support offered, it is also considered to give information to the brain about how you are moving from the stretch and pull it undergoes as you move. Ideally, the joint and ligament is protected by strong muscles around the joint that can absorb most the force.

What puts the ACL at risk?
Somethings are out of our control, like the weather. There have been some weather conditions, that lead to a dry field, that have been seen to increase the risk of an ACL injury1.

Regrettably being older or having a previous knee injury also increases the risk of an ACL injury.

A higher grade of football was noted to contribute to an increased risk, but these players were also generally older and had previous injuries.

Gender is also a very interesting element of ACL risk. It has been found that females have an increased risk of ACL ruptures in several sports. These sports include wrestling (4 times the risk, compared to males), basketball (over 3 times the risk, compared to males), soccer (around 2.5 times the risk, compared to males), rugby (nearly 2 times the risk, compared to males) and lacrosse (only slightly higher risk)2. That study was done before the Women's AFL took off, so it did not include females playing AFL as a comparison. It was also interesting to see that AFL had similar ACL injury rates to soccer and basketball.

Fortunately, there are somethings that we can do to help reduce the risk. Increased weight and the associated higher Body Mass Index (BMI) have also been reported as putting the ACL at more risk of a rupture1. So, eating healthy and maintaining a good balance of regular physical activity has yet another advantage!

What should I do?
Most ACL injuries in AFL matches occur without contact. This would suggest that there are elements that could be worked on to reduce the risk of an ACL rupture.

Fortunately, research has backed this up3. Specific movement strategies and muscle groups have been identified as areas that players can work on to effectively reduce their risk of rupturing their ACL3.

If you are an AFL player or play one of the sports mentioned above, it would be worthwhile booking an appointment with a Bodywise Health Physiotherapist to assess your strength and movement patterns.

This allows the physiotherapist to prescribe an individualised exercise program aimed at reducing your risk of an ACL rupture and the expensive surgery and rehabilitation that goes along with it.

For further information on how you can prevent knee injuries or for a FREE assessment, please call 1 300 BODYWISE (263 994).

Until next time, stay happy and be Bodywise,

Michael Hall
Director
Bodywise Health

References

  1. Orchard, John et al. "Intrinsic And Extrinsic Risk Factors For Anterior Cruciate Ligament Injury In Australian Footballers". The American Journal of Sports Medicine 29.2 (2001): 196-200. Web. 3 Mar. 2017.
  2. Prodromos, Chadwick C. et al. "A Meta-Analysis Of The Incidence Of Anterior Cruciate Ligament Tears As A Function Of Gender, Sport, And A Knee Injury-Reduction Regimen". Arthroscopy: The Journal of Arthroscopic & Related Surgery 23.12 (2007): 1320-1325.e6. Web.
  3. Cochrane, Jodie L. et al. "Characteristics Of Anterior Cruciate Ligament Injuries In Australian Football". Journal of Science and Medicine in Sport 10.2 (2007): 96-104. Web.
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Concerned about your child’s backpack?

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With children returning to school in the next couple of weeks, helping them make the right start to the year is critical. It can help them avoid all the negative effects that go hand in hand with pain; loss fitness, decreased confidence and social withdrawal.

And with the incidence of back pain in adolescence approaching that of adults1, the muscle and bone problems associated with backpack use have become an increasing concern with school children2.
A study by Simmons College (Boston) professor Dr. Shelly Goodgold, has found that more than half of children in the study regularly carried more than the recommended 15 % of their body weight in their school pack packs.

The U.S. Consumer Product Safety Commission estimated that more than 3,300 children aged 5-14 years, were treated in emergency rooms for injuries related to backpacks in 1998; these numbers do not include students who went to their family doctor or health professional.

A study by Auburn University researchers (Anniston, Alabama, Pascoe et al.) stated that the most common symptom reported from backpack use is “rucksack palsy”. This condition results when pressure put on the nerve as it passes into the shoulder causes numbness in the hands, muscle wasting and in extreme cases nerve damage (Journal Ergonomics Vol. 40 Pg. 6 1997).

58% of orthopaedic health professionals polled in the USA reported treating children with back pain attributable to carrying backpacks. So if your child is complaining of neck, back, shoulder or arm pain, the cause might be an ill-fitting backpack. And despite the advent of tablets, notebooks and smart phones, it seems that if anything, school bags have become heavier, not lighter. 

Children are especially at risk of injury from backpacks as carrying too much weight in a backpack or an improper fit, can put undue strain in young muscles and bones that have not full developed.backpack2Here’s what can happen. As an overloaded backpack pulls the body backwards, your child may try to re-balance the body by bending forwards at the waist.

How much is too much?
Recent university studies indicate that if a backpack weighs more than 15% of a person’s body weight, it causes adverse effects on the neck as well as upper, middle and lower back which over time will lead to pain and physical problems.  In other words, it is recommended that the weight of the backpack should be no more than 15% of a person’s body weight.For a 50 kilogram child, that’s 7.5 kilograms.

Your child’s still developing muscle and bone systems can handle 15% without much chance of injury or permanent structural change. This weight can be carried without major postural changes occurring.
However an overloaded or incorrectly fitted backpack can cause the wearer to lean forward in an effort to compensate for the additional weight on their back.

Why you should be concerned

  1. There are two main reasons to be concerned about the weight of your child’s backpack.
  2. Holding this abnormal posture for long periods of time, can lead to a weakening of the neck, mid-back, low back and abdominal muscles.

As these muscles are developing, the risk is that they develop abnormally, setting up an abnormal posture for life. The top straps of the backpack which can compress the sensitive nerves and blood vessels as they pass from the neck through the shoulder area and into the arm.

This compression can lead to pain, tingling, numbness and even weakness in the arms and is called “rucksack palsy”.

What you can do
There are 3 things that you can do to ensure that your child is not at risk of injury from an unsafe back pack.
1. Select the correct backpack
2. Load the backpack properly
3. Adjust and wear the backpack correctly

Selecting a Backpack
1. The backpack should be no wider than the torso and not much longer than shoulder to hip.
2. Well-padded straps will distribute the load over a greater area, protecting the sensitive nerves and blood vessels as they pass beneath.
Some bag straps have adjustable air bladders and wait straps for a true custom fit.

Loading a Backpack

The guiding rule is that your child’s backpack should not weigh more than 15% of their body weight. Pack only what is needed for that day and stack the heaviest items closest to the back.

Wearing a Backpack
1. Adjust the straps for a snug fit.
2. Fit the backpack to the upper part of the back as a loose, low bag is more likely to compress the nerves and blood vessels of the neck and arm as well as strain the middle and lower back.
3. Never wear a backpack slung over one shoulder; not only can it compress nerves and blood vessels, but can also cause leaning to one side which may lead to twisting of the spine (scoliosis).

How to detect if there is a problem 
JJposture-webResearch has indicated that the use of computer photography is a valid and effect tool in detecting adverse postural changes that may occur with the wearing of a backpack.3

Bodywise Health has now acquired this technology so that you can identify quickly and easily if you or your child has a postural problem.

Once identified, simple techniques, exercises and strategies can then be implemented to correct joint stiffness, muscle imbalances and faulty postures and movement habits so that physical and health related postural problems can be avoided.

Prevention as the best cure
As with all health problems, the best cure is prevention or at least correction of a problem at the earliest possible instance.Getting a quick posture and / or backpack fitting check is an ideal way to stop problems before they start.

If you are concerned about your child’s posture; if you do worry about the weight of their backpack and you would like to correct the stresses on their body so that they don’t cause physical problems for the rest of their lives, the physiotherapists at Bodywise Health have the technology, knowledge, experience and skill to be able enable your child not only to make a great start to the year, but to enjoy life long better posture, better health and greater happiness.

If you would like further information or an appointment, please call 1 300 Bodywise (263 994).

Wishing you and your family the best of health,

Michael Hall
Director
Bodywise Health

P.S. For the next 2 weeks, Bodywise Health is offering FREE Posture and Backpack checks to you or your children. To get you FREE Posture and Backpack check, just mention this blog at the time of booking your appointment.

References
1. Skagg, D, Early S, D’Ambra P et al. (2006) Journal of Orthopaedics: 26: 3: 358-363.
2. Troussier B et al. (1994): Back pain in school children: A study among 1178 pupils. Scandinavian Journal of Rehabilitation Medicine 26: 143-145
3. Chansirinukor W. et al. (2001): Effects of backpacks on students: Measurement of cervical and shoulder posture. Australian Journal of Physiotherapy 47: 110-116.
4. Siambanes D et al. (2004): Influence of School Back Packs on Adolescent Back Pain. Journal of Pediatric Orthopaedics 24:2:211-217.

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