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How to Know When to Return to Sport

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It's one of the more challenging judgement calls to make. When to return to sport or pre-injury activities. Unfortunately, like so many things in healthcare, it is not an exact science.

There are so many things that need to be considered; so many variables. Some of these include:
1. The structure or tissues injured;
2. The severity of your injury;
3. The type of activities that you might be returning to;
4. Your work, living and or playing environment;
5. Your physiological, physical, psychological and social circumstances.

It is estimated that 12-34% of hamstring injuries 1 and 3-49% of anterior cruciate ligament injuries 2 re-occur as a result of incomplete rehabilitation and premature return to sport and their pre-injury activities.

People often severely underestimate the time needed to be able to return to their pre-injury level of performance. Lack of knowledge, lack of experience and lack of perseverance, all play a role.

For example, when a group of runners and dancers were asked to estimate how long it would take for them to return to their activities, the runners replied four weeks and the dancers replied one week. The actual average return was 16 weeks for the runners and 50 weeks for the dancers 3.

For physiotherapists it is a challenge as well. Even if injured tissues should theoretically be healed, trying to determine when they are able to withstand the unpredictable stresses of life and sporting activities is difficult if not impossible.

The Science behind Recovery

The starting point for staging when you can return to pre-injury activities and sport is having an accurate knowledge of the theoretical time-frame that it takes for various tissues to heal. For example, your blood cells turnover every 120 days, your bone building cells every 3 months and your skin cells every 2-4 weeks 4.

The healing time will vary for different tissues and structures but is primarily determined by the blood supply to the area; your age; genes; your general health and nutritional status (e.g. abundance of protein, Vitamin C) and even medication (e.g. Anti-inflammatory medication such as Ibuprofen is known to delay healing).

Soft Tissue Healing as a Guide to Your Treatment
Following trauma and injury, your body will always go through the same phases of healing, the length of each varies depending on the type of tissue damaged, the severity of the injury and the intervening treatment. Healing can be divided into four broad phases which overlap considerably. These phases include:
1. The Bleeding Phase
2. The Inflammatory Phase
3. The Proliferation Phase
4. The Remodelling Phase

The Bleeding Phase
This phase occurs immediately following injury and can last anywhere from 6 to 24 hours depending on the type of tissue injured. In the bleeding phase substances are released which enable the adhesion of various cells. The complication of this phase is excessive bleeding and swelling. This excessive "clot" along with the damaged tissue needs to be removed, thus delaying the laying down of new tissue.

Excessive swelling also delays healing as excessive fluid pressure effectively prevents oxygen from being delivered to the injured cells, leading to increased cellular death and even more debris which has to be removed.

Consequently, it is critical that IMMEDIATELY following trauma or injury, treatment is begun to prevent excessive bleeding and swelling. Treatment such as compression, immobilization, lymphodema massage (massage that removes swelling) and unloading damaged tissue (e.g. crutches), if implemented in the first 24 hours by a competent physiotherapist, CAN SAVE YOU WEEKS IF NOT MONTHS OF TREATMENT.

The Inflammatory Phase
Likewise, the Inflammatory Phase is critical for healing. Inflammation has the classic characteristics of heat, redness, swelling, and pain (which is often constant, throbbing and can wake you at night).

Inflammation escalates rapidly a couple of hours following injury, increases to a maximal reaction at 1-3 days before gradually resolving over the next couple of weeks. Essentially during the Inflammatory Phase, the role of the body's immune system is to act like a demolition company, clearing the 'construction site' of debris and damaged tissue.

The complication of this phase, is that the inflammatory process gets out of control leading to an acidic environment, excessive protein breakdown and further cellular death. Consequently, treatment should include all the same modalities as in the Bleeding Phase with more emphasis on cold packs (15 minutes at least 6 times a day with emphasis on hourly cold packs at the end of the day), compression as well as optimal loading reduce swelling and decrease the activity of the inflammatory cells.

The Proliferation Phase
The Proliferation Phase involves the formation of repair material, which in the case of musculoskeletal injuries is mostly scar (collagen) material. At about day 5, the collagen is weak and easily broken with any chemical and physical stress. From day 6 to day 14, this scar tissue gradually becomes more durable to the point that the fibres have knitted and the defect has been bridged.

Consequently, treatment must be geared towards increasing and optimizing the activity of the cells laying down the repair. Warmth and electromagnetic stimulation (which increases cellular activity) along with hands on techniques and easy pain-free movements that optimizes tissue tension to enhance the repair.

The proliferation phase peaks at about 2-3 weeks, (less time for more vascular tissues) before winding down over the next 4-6 months.

The Remodeling Phase
The Remodeling Phase results in a quality, organized, functional scar that can behave like the parent tissue that it replacing. New evidence indicates that the Remodeling Phase begins as early as the first week. Initially, collagen fibres are laid down randomly. However, with the expert application of specific tension, these fibres become aligned along the lines of force.

Collagen molecules also have an electric charge and stress on collagen fibres produces a piezo-electric effect which may also help to re-orientate fibres.

Whilst it is unclear however how much tension is necessary or optimal, it seems that working to the point of discomfort but not into pain, may be a good guide as to what might be the most optimal tension for ideal adaptation.

From this point, gradual, controlled, progressive, specific loading has been found to accelerate early return to sport4. For optimal rehabilitation, this specific loading must be integrated into graduated functional strengthening, beginning with low level, safe, static and progressing to more physically demanding, dynamic, reflexive sport or functional specific activities.

These dynamic, reflexive, functional or sport specific activities can then become the tests which help to determine if you are ready to return to sport or your pre-injury activities.

Special Tests for Return to Pre-Injury Activity

For Shoulder Injuries - Throw and Catch
The throw and catch test consists of the throwing of varying weighted balls at different speeds and angles and durations until the action replicates as best as possible the intensity of the sport.

For all leg injuries - Balance standing on injured leg to progressing to hopping and then to running
These tests involve being able to maintain alignment of your hip bone, middle of your knee cap and 2nd toe with progressively more demanding, dynamic activities.

This alignment is consistent with ideal biomechanical forces being placed on our body tissues and structures and requires adequate core and leg muscle strength and control as well as sufficient hip, knee and ankle mobility.

All of these activities can be progressed in various ways for example by increasing the instability of the surface (e.g. duradiscs), increasing the depth of squat; height of the step as well as the distance, angle and speed of hopping and running.

Other special tests include:
1. Single leg hop
2. 6 Metre timed loop
3. Triple hop for distance
4. Cross over hops for distance
5. Running Drills

The Importance of Ongoing Rehab

Even once you have returned to pre-injury activities, you need to continue with an ongoing conditioning exercise program to ensure that your body is able to cope with the daily demands that you place upon it.

This conditioning exercise program must consist of strengthening exercises for the injured area and associated areas as well as balance and core stability activities. This needs to be completed at least twice weekly for at least four weeks following return to full activities.

A Final Word

There is no doubt that most people have large misconceptions about when they think that they are better and able to return to their full pre-injury activities. Understanding the process and timeline for healing is a starting point for staging the healing of tissues. This however must be supplemented by specific, injury related, objective testing and compared with the non-injured side and valid data.

Finally, it is important that you stay positive and remain engaged and connected with others and that you celebrate the milestones on your journey back to full health.

If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you weeks if not months of pain, frustration and isolation.

If you are injured or in pain and want to get back to doing the things that you love to do, please call Bodywise Health on 1 300 BODYWISE (263 994) for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.

We look forward to helping you get your life back.

Until next time, Stay Bodywise,

Michael Hall
Physiotherapist, Director
Bodywise Health

Please note:
* Rebates are available through your private insurance extras cover;

* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).

1. Arthrosc.2011 Dec27(12);1697-1705.
2. Sports Med. 2004;34(10);681-695.
3. Br J Sports Med.2006 June;40:40-44.
5. The Phys Sport Med.2000 Mar;28(3);1-8.
6. Clinical Sports Medicine.2006,Revised Third Edition;Australia;McGraw-Hill.
7. Knee Surg Sports Traumatol Arthrosc.2010 Dec 18(12);1798-1803.
8. Phys Ther.2007 Mar;87(3):337-349.
9. Knee Surg Sports Traumatol Arthrosc 2006 14:778-788.
10. Psych App to Sports Inj Reh.Aspen Press 1997.
11. NZ J Physiother.2003 31;60-66.
12. J Sport Reh. 2012 (21);18-25.
13. J Athletic Train.2003 48(4);512-521.


Injured? Here's how to Know When You Need to Rest, When You Need to Move and When You Need to Seek Treatment

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OK, you have just been injured, what are you going to do, rest, stay active or seek treatment? It can be somewhat confusing to know what to do. There is so much misinformation and so many mixed messages. Natural instinct might be to rest as that is what you do when you are "sick". But you are not sick, you are injured. The purpose of this article is to draw on both the latest evidence and clinical experience to give you some guidelines on what is best practice management following an injury.
The Traditional Model of Treatment
The acronym R.I.C.E. (Rest, Ice, Compression and Elevation) was for a long time the benchmark for acute clinical care following injury. This was expanded to PRICER to include Protection and Referral to better address the essential need not to re-aggravate your injury as well as to encourage you to seek professional assistance so that you can minimise any possible complications and optimise your recovery.
But now the term 'rest' is being widely criticised as it can be interpreted to mean 'being inactive' and doesn't reflect the possibility of needing to load or move injured tissues and structures to facilitate the healing process.1,2 
Consequences of the Term 'Rest'
Bed rest, initially thought to be the safest approach in the treatment of acute musculo-skeletal injury (especially for acute low back pain4), has been found to cause further complications and disablement3 physically and psychologically. 
Not only may 'rest' result in increased swelling, poor circulation, slow, delayed and inferior tissue repair, but it may also lead social isolation, catastraphization and a sense of hopelessness.
A New Acronym and Treatment Approach
Recently, the British Journal of Sports Medicine published a new acronym, POLICE, (where Rest is replaced by Optimal Loading) as a treatment guideline. The POLICEacronym, still recognises the importance of Protection through the use of crutches, braces or taping for at least the first 3-6 days to prevent further bleeding, inflammation, damage and pain.
Likewise, Ice, Compression and Elevation are still considered essential in the initial stages of treatment.
How much loading that is optimal depends upon a number of factors including the degree of damage, the stage of healing, the irritability of the tissue (how much stimulus, causing how much pain for how long it lasts) as well as the expertise of a health professional. 
More severe, acute and sensitive injuries may require immobilisation for a time, to protect against re-injury and to allow for repair. However, the research is increasingly advocating early movement to reduce swelling, enhance circulation, maintain joint movement stimulate the formation of collagen fibre networks and facilitate their alignment along lines of force.
Scientists from the University of Tampere, Finland, stated that following a muscle tear, the limb should be immobilised initially for a scar to form before activity is commenced within the limits of pain7. Extended periods of restricting movement however, lead to the random laying down of fibres predisposing the tissue to again being injured and damaged when stress is re-applied3
Optimal Physical Stimulation - The Key to Accelerated Recovery and Optimal Repair 
Physical loading is not just critical for the stimulation, regulation and turnover of healthy, adaptable and strong tissues and structures. Physical loading also can accelerate healing. This is what researchers from the University of Queensland discovered when they applied controlled loading during fracture healing.
Another study at the University of Ulster, Ireland, found that exercises started in the first week following grade 1 and 2 ankle sprains "significantly accelerated tissue healing9.
For joint injuries and post-surgical cartilage repairs, early easy movement with low level optimal loading had been shown to reduce complications, accelerate healing and improve tissue repair5,10
For Achilles tendinopathy, researchers from the University of Emea, Sweden, found that specific loading of the Achilles tendon lead to decreased pain as well as improved Achilles tendon strength and function, 3.8 years after the training finished12.
Finally in another study, early quadriceps activation and progression in strength training was shown to reduce pain following knee injury13,14.
Consequently, if you want to accelerate healing, if you want to optimise repair and if you want to achieve the best most complete recovery possible, early, precise movement and loading under the expert supervision of a skilled health professional is critical. 
Why it is Better to Be Seen Sooner than Later
The sooner you see a qualified health professional skilled in the art of rehabilitation following your injury, the sooner you can begin optimising each stage of healing. Ultimately, this means faster healing, a better repair and a more complete recovery.
A skilled physiotherapist is able to ascertain the source and cause of your injury as well as grade its severity, irritability and the stage of healing. These are critical factors that uniquely influence the intensity and guide progression of your treatment. 
If you are injured or if you know of someone else who has a physical injury, seek or encourage them to seek treatment as soon as possible. It may just save you and them weeks if not months of pain, lack of function and frustration.
To overcome your injury or pain and reclaim your health, please call Bodywise Health on 1 300 BODYWISE (263 994).for a complimentary*, no obligation assessment and Recovery Action Plan from one of our expert physiotherapists.
We look forward to helping you get your life back.
Until next time, Stay Bodywise,
Michael Hall
Physiotherapist, Director
Bodywise Health
Please note: 
* Rebates are available through your private insurance extras cover;
* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).
1. B J Sports Med.2012,6 (4), 220-221.
2. Br J Sports Med. 2009, 43,247-251.
3. The Iowa Ortho J, 1995,15,29-42.
4. West J Med, 2000, 172 (2).
5. The Science and Practice of Manual Therapy, 2005. Elsevier Churchill Livingston London.
6. Rehabilitation Techniques, 2011, McCraw Hill, Singapore.
7. Aust J Phsyiortherapy, 2007, 53, 247-252.
8. Best Practice Res Clin Rheumatol, 2007, 231 (2), 317-331.
9. BMJ, 2010,340, cl1964.
10. The American Journal of Knee Surgery, 1994, 7 (3), 109-114.
11. Knee Surg Sports Traumatol Arthrosc 1999, 7: 378-81.
12. Br J Sports Med, 2004, 38, 8-11.
13. J Multidiscip Healthc, 2011, 4 383-392.
14. Med Sci Sports & Exerc, 2010, 42 (5) 856-864.

How to Rescue Your Arthritic Knee from a Knee Replacement

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Overcoming arthritic knee pain and achieving knee pain relief is one of the greatest orthopaedic treatment challenges there is. Knee arthritis is the most commonly diagnosed cause of knee pain in people over 50 and achieving knee pain relief from knee arthritis is the main reason why people seek a knee replacement (Losina et al 2012, Nguyen et al 2011).

In 2010, 25,970 total knee replacements were performed in Australia, representing a 67% increase over the past seven years and a direct cost to the health system of $2.24 billion (consisting of $900 million in hospitalisation, $8.5 million on GP visits, $2.2 million on specialist visits and $1.4 million on other practitioners).

Despite this, 15-30% of patients report no or little functional improvement in the 12 months following a knee replacement and those people who have a knee replacement too early, report dissatisfaction with their knee replacements (Paulsen 2011).

Knee osteoarthritis can be confusing and frustrating
Pain from knee osteoarthritis can range from barely perceptible to unbearable. This is especially confusing when the amount off pain reported does not correlate with the severity of change found on X-ray (Cubukou et al 2012, Schiphof et al 2013). Likewise, most people over the age of 50 have structural abnormalities consistent with osteoarthritis on MRI but only one third have pain.

The Source of Knee Osteoarthritis Pain
As the cartilage covering the surface of bones where they meet each other (i.e. joints) doesn't have a nerve supply, it is unlikely that it is a source of pain. Other sources of arthritic knee joint pain that have been suggested are:
1. the underlying bone;
2. the synovial membrane (which lines the inner cavity of the joint);
3. the cartilages (or menisci which act as cushions within the knee joint);
4. the ligaments and joint capsule (which holds the knee together); and
5. the fat pad (which sits just under the bottom part of the knee cap).

There is bad news and good news if an MRI shows that you have a horizontal cleavage meniscal tear in your knee. The bad news is that you have torn the cartilage where it has a nerve supply and this can cause immense pain and discomfort especially while sleeping.

The good news is that where there is a nerve supply, there is a blood supply which means that if the appropriate conservative treatment is given, the tear can heal, albeit slowly (it can take up to 12 months).

If you decide to have an arthroscope (partial meniscectomy), research has shown that recovery takes the same length of time, but your knee will become a lot more arthritic, a lot more quickly compared to if you just stick with physiotherapy (Sihvonen et al 2013, Katz et al 2013).

The Causes of Osteoarthritic Knee Pain that You Can Change
Osteoarthritic knee pain increases as your weight increases and as your quadriceps muscle strength decreases (Nguyen et al 2011, Amin et. all 2009, Segal et al 2010. Therefore, the two most important changes that you can make to achieve arthritic knee pain relief is to reduce your weight and increase the strength of your quadriceps muscle.

Research has shown that it is not only knee pain but the fear of pain that can reduce your quadriceps muscle strength (Hodges et al 2009). Furthermore, middle aged people who have decreased quadriceps strength report increased knee pain and MRI scans show accelerated osteoarthritic changes in the knee (Wang et al 2012).

Incorrect knee joint alignment, poor quadriceps muscle control, faulty movement and excessive loading all lead to excessive or abnormal forces being placed upon the structures and tissues of the knee. This can lead to pain which further inhibits your quadriceps muscle strength thereby perpetuating and accelerating your knee degeneration. (Hayashi et al 2012, McConnell and Read 2014).

How to Achieve Arthritic Knee Pain Relief
For treatment to be successful, it must therefore involve:

  1. Reducing your knee inflammation and pain;
  2. Unloading the painful knee structures and tissues;
  3. Promoting healing
  4. Correcting joint alignment;
  5. Improving muscle control and strength especially that of the quadriceps muscle;
  6. Optimising your everyday postures and movements (e.g. walking) so that the most ideal forces possible are placed on your knee joint.
  7. Reduce your knee pain and inflammation

Inflammation is a breaking down process. It must therefore be limited for healing to take place. If you experience constant, throbbing pain and your knee feels warm apply cold packs (wrapped in a damp thin cloth) to your knee for 15 minutes at least 6 times a day (be sure to check your skin every 5 minutes for adverse reactions). Do this until the warmth, constant pain, night pain and morning stiffness in your knee recede.

Or if your knee pain is worse at the end of the day, apply a cold pack 3 or 4 times on the hour before you go to bed. This will help you sleep better and awake in the morning with less knee stiffness.

Unload your painful knee structures and tissues
You can unload your painful knee structures and tissues by:

  1. Reducing your weight. Research has indicated that this is the number one thing that you can do to achieve relief from arthritic knee pain;
  2. Avoiding painful positions, movements and activities (e.g. prolonged standing and walking);
  3. Using orthotics, wearing supportive shoes with good shock absorption, walking on softer surfaces (avoiding concrete, tiles or hardwood floors) and sitting down frequently (e.g. every 20 minutes);
  4. Taping and bracing your knee for added external support;
  5. Walking with elbow crutches for up to 2 weeks to enable reduce inflammation to recede and facilitate healing and repair.

Promote healing
To accelerate healing and optimise your knee's repair, employ "hands on" freeing up techniques, Bodyflow therapy (which improves circulation), Lipus Ultrasound (which stimulates the laying down of tissue), heat therapy (which increases activity) and easy pain-free movement, all of which have been proven to assist with healing.

Correct Joint Alignment
Your knee cap and knee joint alignment can be corrected by using "hands on" techniques to free up stiff joints and loosen tight soft tissues, applying tape or bracing to hold joints in correct alignment and then through targeted exercises that strengthen weak muscles and stretch tight, stiff soft tissues.

Improve the Control and Strength of Your Leg Muscles (Especially your Quadriceps)
Rehabilitation programs which improve the stability and strength of your core, hip and knee and which optimise the way that you move, have been shown to reduce knee pain for up to 12 months following physiotherapy. These programs have also been shown to improve the quadriceps muscle tone as well as the position of the knee cap on MRI scans (McConnell and Read 2014) indicating an increase in quadriceps muscle strength and therefore an improved dynamic stability of the knee.

Optimising your everyday postures and movements (e.g. walking)
Improving your balance and increasing your core, hip and knee muscle strength can ultimately lead to an improvement in everyday activities such as standing, rising from sitting, getting in and out of cars and walking.

And by "normalising" the forces on your knee during your everyday activities, the abnormal or excessive forces that cause the break down and irritation of the knee joint tissues and structures are eliminated.

Ultimately, these rehabilitation programs may help you avoid the need for a knee replacement or at the very least help improve your muscle function, mobility and quality of life thereby delaying your need for a knee replacement. They will also give you the best chance of an optimal outcome if you do have to have a knee replacement.

The evidence is clear. Specific physiotherapy treatment is a proven, safe, effective and lower cost alternative in helping you to attain knee pain relief from arthritis.

So if you do suffer from arthritic knee pain and you want the best, safest, most empowering way of overcoming your knee pain, you should consider a physiotherapy treatment program as your first option.

We might just be able to save our government's bottom line and you a lot of time and heartache.

If you have physical pain and would like a solution to your problem, please call 1 300 BODYWISE (263 994) for your FREE assessment and advice.

Until next time, Stay Bodywise.

Best Wishes,

Michael Hall

Physiotherapist, Director Bodywise Health

Please note: 

* Rebates are available through your private insurance extras cover;

* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).

1. Losina E, Weinstein AM, Reichmann WM, Burbine SA, Solomon DH, Daigle ME, Rome BN, Chen SP, Hunter DJ, Suter LG, Jordan JM, Katz JN. 2012 Lifetime risk and age of diagnosis of symptomatic knee osteoarthritis in the US. Arthritis Care Res
2. Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT. 2011 Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med. Dec 6;155(11):725-32
3. Access Economics, 2007. Painful Realities: The economic impact of Arthritis in Australia in 2007
4. Paulsen MG, Dowsey MM, Castle D, Choong PF 2011 Preoperative psychological distress and functional outcome after knee replacement. ANZ J Surg. Oct;81(10):681-7
5. Cubukcu D, Sarsan A, Alkan H. 2012 Relationships between Pain, Function and Radiographic Findings in Osteoarthritis of the Knee: A Cross-Sectional Study. Arthritis.;2012:984060. doi:10.1155/2012/984060
6. Schiphof D, Kerkhof HJ, Damen J, de Klerk BM, Hofman A, Koes BW, van Meurs JB, Bierma-Zeinstra SM Factors for pain in patients with different grades of knee osteoarthritis. Arthritis Care Res 2013;65(5):695-702.
7. Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, Aliabadi P, McLennan CE, Felson DT. 2012 Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 29;345:e5339.
8. Javaid MK, Lynch JA, Tolstykh I, Guermazi A, Roemer F, Aliabadi P, McCulloch C, Curtis J, Felson D, Lane NE, Torner J, Nevitt M. 2010 Pre-radiographic MRI findings are associated with onset of knee symptoms: the most study. Osteoarthritis Cartilage;18(3):323-8.
9. Felson DT, Parkes MJ, Marjanovic EJ, Callaghan M, Gait A, Cootes T, Lunt M, Oldham J, Hutchinson CE. Bone marrow lesions in knee osteoarthritis change in 6-12 weeks. Osteoarthritis Cartilage. 2012;20(12):1514-8.
10. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL;Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369(26):2515-24
11. Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675-84.
12. Dragoo J L, Johnson C, McConnell J 2012 Comprehensive Treatment of Disorders of the Infrapatellar Fat Pad Sports Med.1;42(1):51-67
13. Clements KM, Ball AD, Jones HB, Brinckmann S, Read SJ, Murray F. Cellular and histopathological changes in the infrapatellar fat pad in the monoiodoacetate model of osteoarthritis pain. Osteoarthritis Cartilage. 2009;17(6):805-12.
14. Amin S, Baker K, Niu J, Clancy M, Goggins J, Guermazi A, Grigoryan M, Hunter DJ, Felson DT: Quadriceps strength and the risk of cartilage loss and symptom progression in knee osteoarthritis. Arthritis Rheum 2009,60:189-198.
15. Segal NA, Glass NA, Torner J, Yang M, Felson DT, Sharma L, Nevitt M, Lewis CE: Quadriceps weakness predicts risk for knee joint space narrowing in women in the MOST cohort. Osteoarthritis Cartilage 2010,18:769-775.
16. Hodges PW, Mellor R, Crossley K, Bennell K. 2009 Pain induced by injection of hypertonic saline into the infrapatellar fat pad and effect on coordination of the quadriceps muscles. Arthritis Rheum. 15;61(1):70-7
17. Wang Y, Wluka AE, Berry PA, Siew T, Teichtahl AJ, Urquhart DM, Lloyd DG, Jones G, Cicuttini FM. Increase in vastus medialis cross-sectional area is associated with reduced pain, cartilage loss, and joint replacement risk in knee osteoarthritis. Arthritis Rheum. 2012;64(12):3917-25.
18. Hayashi D, Englund M, Roemer FW, Niu J, et al Knee malalignment is associated with an increased risk for incident and enlarging bone marrow lesions in the more loaded compartments: the MOST study. Osteoarthritis Cartilage. 2012;20(11):1227-33
19. McConnell J, Read J. 2014 OA-related knee pain: MRI changes following successful physiotherapy – a case series. Rheumatolgy S16: 008. doi:10.4172/2161-1149.S16-008



Tendon Recovery Update - The Latest Research

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There is no doubt that tendon problems can be among the most frustrating injuries for people. Because tendons attach muscles to bone, tendon problems can therefore interfere with movements all over your body from lifting your arm (Rotator Cuff tendinopathy), to holding an object (tennis elbow) to walking (hip tendinopathy), to squatting (knee tendinopathy) and even to pushing off your foot (Achilles tendinopathy).

However, new research from Sydney and Glasgow is uncovering what is really going wrong with tendons and how well designed physiotherapy can deliver better outcomes than surgery.

What is tendinopathy?

Tendinopathy literally refers to tendon pain. It can be extremely debilitating, with at least 40% of all general practitioner consultations involving a tendon problem. Historically, tendon problems haven't been treated very well because the underlying disease process wasn't very well understood.

Who is at risk?

The typical person who tends to suffer from tendon problems is a person in their mid 40's to 50's who is moderately active. Initially, they experience pain following an activity which then becomes more constant often waking them from sleeping at night and worse at the end of the day.

With probing questions, it is often discovered that the pain is related to a repetitive movement. Classic examples of repetitive movement as the cause of tendinopathies include prolonged swimming, playing guitar or painting for shoulder tendinopathies, using the mouse, pruning and knitting for elbow tendinopathies and walking or running for Achilles tendinopathies.

The latest research and the latest discoveries

We've known for 30 years that instead of the tendon being pristine, white, type I collagen which is as strong as steel, the injury has transformed it into the more ragged, greyish, weaker and painful type III collagen. The only problem is that we haven't known why, until recently when it was discovered that the switch for dialing up or down type III collagen becomes dis-regulated.

What the recent research has shown, is that it is mechanical tension or specific strengthening exercises that can re-regulate this switch. The question is how much and how often should exercises be performed for optimal adaptation. Too little and the tendon degenerates (use it or lose it). Too much and the tendon breaks down further.

Professor Jill Cook at Latrobe University has shown that isometric exercises (strengthening exercises where the muscle develops tension but there is no movement of the joint) performed initially have been shown to reduce tendon pain and begin the process of remodeling the tendon.

What you need to do to get better and return to the activities that you want to do.

However to return to the sports and activities that you want to do, requires a whole lot more than just strengthening the tendon in an isolated way. Yes, you need to strengthen the tendon so that it can tolerate forces above and beyond the stresses that it will be placed under. But more than that, you need to strengthen associated muscles, correct sports and functional technique and finally you need to improve the tendon's endurance, so that it can tolerate these forces over and over again.

Failure to complete this extensive rehabilitation will result in just short term pain relief from your pain. It is simply physics. You cannot load a tissue beyond what it has been trained to tolerate and expect it not to break down.

If you suffer from shoulder, elbow, hip, knee or ankle tendon problems and would like some help to get rid of your pain and to return to activities that you love to do, call us here at Bodywise Health on 1 300 BODYWISE (263 994) for a Complimentary, No Obligations Assessment and Recovery Action Plan.

In your Complimentary, No Obligations Assessment session you will learn what the source and cause of your pain is and develop a Recovery Action Plan that will deliver you the best results in the shortest amount of time.

You will also discover:

* How to optimise the phase of healing;
* How to accelerate healing;
* How to get the best, strongest repair;
* How to perfect the performance of every day and sporting activities so that you achieve more efficient, effective results;
* How to have more energy;
* How to prevent the reoccurrence of your injury.
* What improvement to expect and when so that you can monitor your recovery and know that you are on track to achieve your goals in a forecast timeline.

If you have not achieved results in the past and you want to overcome your injury and pain once and for all so that you can get back to doing the things that you love to do, call us here at Bodywise Health on 1 300 BODYWISE (263 994) and take the first step to getting better, moving on from your pain and enjoying life.

We look forward to helping you.

Until Next Time, Stay Bodywise

Michael Hall
Director Bodywise Health

The Health Report, Norman Swan, ABC

Please note:
* Rebates are available through your private insurance extras cover;

* For complex or chronic conditions, you may qualify for the EPC (Enhanced Primary Care Program) allowing you to receive 5 allied health services each calendar year with a referral from your GP. For more information, please call Bodywise Health now on 1 300 BODYWISE (263 994).

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Bodywise Health

364 Hampton St,


Victoria. Australia 3188

03 9533 4257

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