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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).

References
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.
4.http://book.bionumbers.org/how-quickly-do-different-cells-in-the-body-replace-themselves/
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.
14.http://www.dailymail.co.uk/health/article-1219995/Believe-lungs-weeks-old--taste-buds-just-days-So-old-rest-body.html

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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).
 
References
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.
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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).

References
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

 

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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
Physiotherapist
Director Bodywise Health

Reference:
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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Bulging Disc? Sciatica? Lower Back Pain?Here's how to Achieve Lower Back Pain Relief.

back-pain-mainJust hearing the words bulging disc, herniated disc or sciatica is enough to strike fear into the hearts and minds of all people. And rightly so, as a bulging disc or disc herniation causing sciatica can be an extremely debilitating and painful condition and if not treated correctly, can have a most disabling effect on your life. 
When describing this condition, it is not uncommon to hear people say that they have a "slipped disc" and have put their "back out". Whilst this is an incorrect over-simplification of this condition, it does suggest that something has slipped 'out' and needs to be pushed back "in". What this refers to is the inter-vertebral disc which can be a potent source of low back pain as they bulge, tear and split.

So what is a Bulging Disc or Herniated Disc?
Except in the cases of paraplegia or quadriplegia, it is impossible for a person to 'put their back out' as the vertebral bodies of the spine are held together by an inter- vertebral disc. This disc acts as a cushion and by deforming in all directions allows the spine to bend in all directions. 

In the middle of this disc is a paste/gel like substance called the nucleus pulposus. This substance acts as a fulcrum for movement and as the disc deforms, it evenly distributes the forces throughout the disc. Enveloping this nucleus is a fibrous casing called the annulus fibrosis. 

Research has shown that there are only two degrees of motion at each level between the 1st and 5th lumbar vertebrae and five degrees between the 5th lumbar and 1st sacral vertebrae. (Sahrmann 1997). Movement beyond this has been shown to result in tearing of the disc. Consequently, repeated minor trauma such as with bent, rotated postures may cause circumferential fissures in the annulus. As only the outer layers of the annulus receive a nerve supply, for a disc to become painful, a lesion must involve the outer third of the annulus. These defects then provide a potential pathway for the nucleus to seep into, causing the disc to bulge, split, tear and seep out. 

By a person's 30's, the nucleus pulposus tends to dry out and consequently true herniations tend to occur in people in their 20's (Bogduk and Twomey 1991). However, disc bulging in the older person can occur due to degeneration of the nucleus and failure of the annulus. Again this pathology is usually associated with repeated poor postures and movement patterns and can lead to spinal canal stenosis, an important source of low back pain. 

Incidence
The most common age for disc prolapses to occur is in the 25 to 45 year old age group. It more common in males at a ratio of 3:2 with the most common site for prolapse being between L5/S1 (46.4%) and the L4/5 disc being the most common transitional area (40.4%).


Other influencing factors leading to disc prolapse include;
1. Poor posture and movement patterns, leading to increased joint strain, wear and tear and eventually fatigue. 
2. Poor equipment and work station setup.
3. Congenital ill development - e.g. excessive spinal curvature
4. Trauma 
5. Joint malalignment 

Signs and Symptoms
The size, severity and direction of the disc injury as well as the associated structures affected, will determine the presenting signs and symptoms. Herniated discs may occur suddenly or gradually, as a result of a single major traumatic event or as the result of some minor event. Stories such as "I bent over" or "I reached forward" are not uncommon and are often associated with a dull ache or knife like pain either in the midline or off to one side. 

The lower back pain may initially be intermittent, but is worsened by sitting, bending and coughing/sneezing and often disturbs sleep. Generally, it is confined to the lower back region, but later may radiate into both or more often one leg. 

The distance of radiation is more indicative of the severity of injury rather than the structures involved and whilst irritation of the sciatic nerve cause pain, direct pressure on the sciatica nerve results in numbness, tingling, weakness and loss of reflexes. 

X-ray Features 
Whilst x-rays do not show soft tissue damage, they may indirectly show the effects of a prolapsed disc, by the presence of deformity, joint mal-alignment and flattening of the disc. Myelography, CT or MRI scans may also reveal a disc bulge or herniation.

Differential Diagnosis
Whilst pain associated with facet joint strains tends to be specific and isolated, disc prolapses pain tends to be more vague and diffuse. Bending which tends to aggravate disc prolapses tends to relieve pain associated with a spinal canal stenosis or spondylolythesis. In contrast, arthritic movements tend to be limited in all directions.

Treatment
Treatment of acute disc injuries will vary with the severity and extent of the person's symptoms. A bulging disc with or without sciatic nerve involvement, treatment may include short term bed rest, electrotherapy, traction, graduated mobilization as well as a prescription of extension exercises and sometimes the use of taping or a back brace. These may be used in conjunction with anti-inflammatory medication to provide further relief. 

It is important to avoid any movements or positions which aggravate your pain. McKenzie exercises may also be given along with 'hands on' and dry needling techniques to assist with pain reduction or to restore the mobility and promote an environment of healing.

Tissue healing may be further promoted through the use of electrotherapy, massage, joint and sciatic nerve mobilisation as well as back pain exercises to give sciatica pain relief. Spinal mobilisation and manipulation be combined with precise stretching and trunk stabilisation exercises to normalise spinal mobility and core control. 

As improvement continues, stabilisation is progressed from slow, controlled contractions to faster and more automated activities to more approximate lifestyle conditions. Both strengthening and aerobic conditioning may then be built on top of this stabilisation base to give maximum protection against re-injury as well as to facilitate a higher level of physical performance. 

Finally, lifestyle components such as work / home environments, equipment, as well as habitual movements and postures must also be addressed if optimal function is to be achieved and injury recurrence is to be minimised. 

I hope that this helps.

 
Until next time, Stay Bodywise,
 
Michael Hall
Director
Bodywise Health

 

 
To learn more as to how Bodywise Health can help you overcome back pain or for an appointment, please call Bodywise Health on 1 300 BODYWISE (263 994).
 
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 doctor.   For more information, please call Bodywise Health on 1 300 BODYWISE (263 994).
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Worried About How Your Child Walks or Runs?

Image result for Feet turned Inwards walking

Are you worried about seeing your child's toes point inward as they stand or walk? Whether you should be depends upon the cause of toe in postioning as well as the age of your child.

Pigeon toe or toe in walking is a common and often painless condition for children. Very often, it occurs in one or both feet in children under the age of 2. The condition usually corrects itself with no intervention. This type of pigeon toe often develops in the womb or is due to genetic birth defects, so little can be done to prevent it. Contrary to popular belief, there are no known shoes or orthotics that help prevent pigeon toe and no evidence to suggest that learning to walk in bare feet has any effect on the condition.

The Causes of Pigeon Toe

Pigeon toe may develop in the womb and often corrects itself.

There are three potential causes of pigeon toe:

1. Metatarsus varus or metatarsus adductus

With metatarsus varus or metatarsus adductus, the front of the foot is angled inward giving the foot a curved, half-moon appearance. This type of pigeon toe is common in babies who were breech in utero or whose mothers had less amniotic fluid. Occasionally, there is a family history of the condition.
Normally, the foot is abled to be straightened out by a doctor or healthcare professional once the child is born with no further treatment generally being required. Although its not imperative, a parent can also gently stretch the baby's feet a few times a day to help correct the shape.

2. Internal tibial torsion

Internal tibial torsion refers to the inward twisting of the shin bone or the tibia. This twisting of the shin bone often becomes noticeable as a child first begins to walk. It is generally not painful, but parents of children with internal tibial torsion tend to report that their child falls frequently. Like metatarsus adductus, the condition often resolves without the need for therapy, bracing or casting.

Sometimes however, in more severe cases and / or the shin does not straighten out by the time a child reaches 9 or 10 years of age, internal tibial torsion may require surgery to fix it. The procedure involves cutting through the twisted bone and reattaching it to make the foot straighter.

3. Femoral anteversion

This type of toe in positioning is very common affecting up 10 percent of children. Here, the thigh bone (femur) is excessively rotated inward in the hip joint. It is thought that this may be due to stress to the hips before birth. Normally this type of in-toeing resolves by the age of 8 years. If it continues after this age, an examination by a physiotherapist, doctor or other paedicatric health care professional is recommended to assess what might be the best course of action to correct the toe in positioning. Occasionally the neck of the thigh bone is angled in such a way as to increase the turning inward of the leg. At other times, this type of toe in standing and walking may be purely a habit that can be corrected with making the child aware of the fact that their feet are turned inward.

When to see a physiotherapist or doctor
Generally there is no urgent need to see a physiotherapist or doctor. However, if the toe in position is still apparent by the time your child reaches 8 years, or if it causes your child to fall more often than normal, a physiotherapist or doctor should be consulted.

Diagnosis

Diagnosis for pigeon toe can often be determined by a comprehensive physical examination. Occasionally, X-rays and other imaging may be necessary.
For metatarsus varus or metatarsus adductus, diagnosis is generally made very early, often during the newborn's post-birth examination. A skilled physical examination will identify that the positioning of the foot bones are cause whilst ruling out out other possible causes such as mal-alignment of the hip joints.

Internal tibial torsion generally apprears only as a child begins to walk and so the earliest diagnosis may be slightly before 1 year of age during a physical examination of the infant's legs. If diagnosed, the physiotherapist or doctor will take measurements of the legs.

Femoral anteversion is most often diagnosed when the child is between the ages of 4-6 years. This will normally start with a physical examination and a review of the medical history of the child and family.

Treating pigeon toe

Toe in positioning may be treated with time, normal growth and reassurance. If more therapy intervention is required treatment may include:

  1. Braces for the legs that slowly correct the position of the bones or feet
  2. Molds that correct the shape of the foot
  3. Specialized therapy that involves specific stretches and targeted activities that encourage the correct positioning of the feet during standing and walking. These activities often involve strengthening of the outside muscles of the hip and improving balance so as optimise walking and running.
  4. Finally surgery may be recommended as a last resort to correct the positioning of the bones that cause pigeon toe.

To fix these issues does require a comprehensive, co-ordinated approach. It is essential to assess whether there are any structural limitations or deficits preventing these children from walking correctly. Do they have an arched or flat back? Are their hips stiff? Are they knock kneed or bow legged? Do they have flat or highly arched feet?

Already these children's bodies have begun to adapt to this way of walking. This means that they are likely to have poor core stability, their outside hip muscles are likely to be stretched and weak, whilst their hamstrings and the muscles on the inside and outside of their thighs are likely to be tight and dominant. Their ankle joints are also likely to be stiff, their calf muscles tight and their foot muscles and plantar fascia weak and overstretched.

These children are also likely to have poor balance which requires that they walk with their feet wide apart making ambulation inefficient and tiring.

Correcting these kids walking pattern is easier said than done. Ultimately, it means loosening stiff joints, strengthening weak muscles and stretching tight soft tissues. It often requires balance retraining and learning to walk with feet less wide apart and a correct heel - toe contact. Taping, bracing and orthotics may all be useful in assisting and accelerating the rate of improvement.

Whilst all these interventions and techniques may sound over-whelming, they can be integrated into a concise, targeted program that usually delivers results within four weeks. It is worth it. Incorrect walking can cause a multitude of problems over your child's life culminating in multiple joint replacements.

It can cause children to be less active, less engaged and less connected. It can lead to a decrease in sports achievements. However, most devastatingly it can take away opportunities and limit your child's potential.

If you do have any concerns regarding your child's posture or movement including the way that they walk, please call Bodywise Health on 1 300 BODYWISE (263 994) for a free examination and advice.  It may save them a life time of physical and social problems.

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Is Your X-Ray or Scan Doing You More Harm Than Good

Image result for X Ray, CT AND MRI Scans

X-rays, ultrasound, CT and MRI scans can be very valuable for identifying serious medical conditions such as fractures, spinal cord injuries and other specific lesions. However, once "serious problems" are ruled out by a radiologist, evidence shows that minor findings may not just be of no value in helping to explain the majority of aches and pains, they may be psychologically harmful especially when they tell patients that they have arthritis, degenerative disc disease, disc bulges, tendon tears and more.

Everyday thousands of Australians become confused and distressed by medical imaging that doesn't match the source or cause of their particular pain or problem. These people have been shown to have more doctor's visits, more lasting pain, more disability and a lower sense of welbieng.1, 2, 3

Here are a few important facts regarding medical imaging that you must be aware of to prevent yourself being fooled by your X-Ray or diagnostic scan.

Lumbar Spine - Lower Back
It is well established that most imaging findings, particularly degenerative changes, correlate poorly with clinical presentation.

Studies have shown that lumbar disc degeneration is present in 40% of individuals under the age of 30 and present in over 90% of people between the ages of 50 to 55.8

Another study showed that amongst healthy young adults aged 20 to 22 years with no back pain, 48% had at least one degenerative disc and 25% had a bulging disc.9

Leading physicians at the department of Neurosurgery in California strongly recommend AGAINST the routine use of MRI for low back pain as they have NO LINK between degenerative changes seen on x-rays or MRI's and low back pain.10

Other research findings include:

1. Individual neuro findings on MRI (disc herniation, root compression etc.) don't provide definitive link to LBP (Endean et al. 2011; Shambrook et al. 2011)

2. MRI does not improve clinical outcomes in the absence of red flags (Chou et al. 2009)

3. Early imaging does not positively impact clinical outcomes (Graves et al. 2012)

4. Inappropriate imaging can lead to misdiagnosis, inappropriate management decisions, potentially unnecessary surgery, poor outcomes and greater financial, social, psychological and physical costs (Flynn et al. 2011; Haldeman et al. 2012)

5. Spine MRI in primary care often leads to surgical assessment - yet MRI cannot discriminate surgical vs. non-surgical cases (You et al. 2012).

Translation: Do not panic if your x-rays shows "problems" with your discs; they simply are normal changes that occur from the age of 20 onwards.

Thoracic Spine - Mid / Upper Back
MRI studies of healthy adults with no history of upper or low back pain found that 47% had disc degeneration , 53% had disc bulges and 58% had disc tears in their thoracic spine. Amazingly, 29% of these healthy young people had a disc bulge that was actually deforming and pressing on the spinal cord, yet they had no signs or symptoms. 6,7

Translation: Do not panic if your x-ray or MRI shows "problems" with your discs; they are simply common and NORMAL findings.

Cervical Spine - Neck
An MRI study of healthy adults and seniors found that 98% of all men and women with no neck pain had evidence of "degenerative changes" in their cervical discs.

A 10 year study compared the MRI's of healthy people to those with whiplash injuries. Immediately and 10 years later both groups had similar MRI's with 75% having disc bulges.5

There was also a recent study where they MRI'd the SAME patient in 10 facilities and got COMPLETELY different reports from all of them - not good!

Translation: The majority of all healthy adults get neck degeneration (arthritis and disc bulges meaning they are a NORMAL aging process! Therefore, neck arthritis and mild to moderate disc bulges can only be a reasonable explanation of your neck pain if they match your clinical examination.

Shoulder
MRI studies of adults who have no shoulder pain show that 20% have a partial rotator cuff tear and 15% have a full thickness tear. In addition, in those 60 and older with no shoulder pain or injury, 50% (half) of them had rotator cuff tears on their MRI's that they didn't know about.16

A study of professional baseball pitchers showed that 40% of them had either partial or full thickness tears yet had no pain while playing and remained pain free even 5 years after the study.17

Translation: Do not panic if your ultrasound and/or MRI shows a rotator cuff tear; it is not necessarily associated with your shoulder pain!

Hip
There is only a weak association between joint space narrowing as seen on x-rays and actual symptoms.11

In fact, one study showed that 77% of healthy hockey players who had no pain, had hip and groin abnormalities on their MRI's.12

Translation: Do not panic if your x-ray or MRI shows cartilage tears or narrowing; it is not a sign of permanent pain or disability.

Knee
Studies have shown that when x-rayed, up to 85% of adults with no actual knee pain have x-rays that show knee arthritis. This means that there is little correlation between the degree of arthritis seen on x-rays and actual pain.13

In fact, one study showed that 48% of professional basketballers had meniscal (cartilage) "damage" on their knee MRI's.

Translation: Do not panic if your knee x-ray or MRI shows degeneration, arthritis or mild cartilage tears; it is NORMAL!

Ankle
Although there is an association with plantar fasciitis and heel spurs, it should also be known that 32% of people who have no foot or heel pain have a heel spur visible on x-ray.15

Translation: One third of all people have a heel spur and yet have no pain.

After reviewing this research you might be thinking that x-rays and diagnostic scanning are useless in identifying sources and causes of the majority of injuries and diseases. Not so. Diagnostic imaging techniques are valuable tools in assisting with diagnosis and healthcare management.

However, x-rays and scans are just one set of tools that provide unique insights that must be considered in the wider context of physical assessment and evaluation, as well as the social, psychological, nutritional status of a person. Only when all these factors have been considered, can an optimal healthcare management plan be devised and implemented to achieve the best health outcomes possible for you.

If you have an injury or pain that you would like to get better as quickly and completely as possible, please call Bodywise Health on 1 300 bodywise (263 994) and receive a no obligation, complimentary injury assessment and advice.

In this session, you will discover the source and cause of your problem as well as the number one thing that you can do to help yourself get better.

References for Diagnostic Imaging of Musculoskeletal Injuries

1. Kendrick D, et al. The role of radiography in primary care patients with low back pain of at least six weeks duration: A randomised (unblended) controlled trial. Health Technol Assess.2001: 5(30);1-69.

2. Ash LM, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR. Am. Neuroradiol. June 2008. 29 (6):1098-103.

3. Modic MT, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiolog. 2005 Nov; 237 (2) 597-604.

4. Okada E, et al. Disc degeneration on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers. Eur. Spine J. 2011 Apr;20(4):585-91.

5. Matsumoto M, et al. Prospective 10 year follow-up study comparing patients with whiplash associated disorders with asymptomatic subjects using magnetic resonance imaging. Spine. (Phila Pa 1976) 2010. Aug 15;35(18):1684-90.

6. Matsumoto M, et al. Age related changes of thoracic and cervical intervertebral disc. Spine. (Phila Pa 1976) 2010. Jun 15;35(14):1359-64.

7. Wood KB, et al. Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg. Am 1995 Nov;77(11): 1631-8.

8. Cheung KM, et al. Prevalence and pattern of magnetic resonance imaging changes in a population study of one thousand forty three individuals. Spine. (Phila Pa 1976) 2009. April 10;34 (9):1934-40.

9. Takatolou J, et al. Prevalence of degenerative imaging among young adults. Spine. (Phila Pa 1976) 2009. Jul 15;34(16):1716-21.

10. Chou D, et al. Degenerative magnetic imaging changes in patients with chronic low back pain: A systematic review. Spine. (Phila Pa 1976) 2011. Oct 1;36 (21 Suppl):S43-53.

11. Chu Miow Lin D, et al. Validity and responsiveness of radiographic joint space width metric measurement in hip osteoarthritis: A systematic review. Osteoarthritis Cartilage. 2011 May;19(5):543-9.

12. Silvis L, et al. High prevalence of magnetic imaging findings in asymptomatic collegiate and professional hockey players. Am J. Sports Med. 2011 Apr;39(4): 715-21.

13. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskel. Disord. 2008 Sep 2;9:16.

14. Kaplan LD, et al. Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy. 2005 May;21(5):557-61.

15. Johal KS, Milner SA. Plantar fasciitis and the calcaneal spur. Fact or Fiction? Foot Ankle Surg Am. 2012 Mar; 18(1):39-41.

16. Sher JL et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

17. Connor PM, et al. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5 year follow up study. Am J. Sports Med. 2003 Sep-Oct;31(5):724-7.

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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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