2012 keeps moving along! It will not be long before the major football codes are back in full swing, with many clubs working their way through trials as we speak. Although a little way off, the Olympics are also coming, and many athletes are nutting out their preparations for hopeful selection to the Olympic team.

For the average punter this may seem overwhelming, but many of the same acute and overuse injuries apply to the weekend warrior as do the elite athletes. BSEMS offers a one stop solution to any concerns you may have.

This month our Podiatrist, Craig Page has written an article on Sever's Disease, which affects many juniour athletes. Enjoy...

 

Sever’s Disease (Heel Pain)

What is Sever’s disease?

Sever’s disease is an inflammatory condition of the growth plate at the base   of the heel (calcaneus). 

When does Sever’s occur?

Sever’s is often present at a time of rapid growth in adolescent athletic children.  At this time the muscles and tendons become tighter as the bones become larger.  Between 8 – 15 years of age is the usual onset of this condition.

What are the symptoms?

The symptoms of Sever’s Disease may vary but usually include: -

• Generalised pain and discomfort around the back of the heel    
• Can be one sided or both sides
• Starts after child starts a new sport season
• May cause child to limp due to pain
• Increases with weight bearing activity
• Heel becomes red and can be swollen
• X-rays are usually inconclusive and simply show the growth plate.

What causes Sever’s Disease?

Inflammation occurs at the insertion of the achilles tendon into the back of the heel due to a number of reasons. One or several of the following may cause the initiation of Sever’s disease: -

• Rapid growth spurt
• Tight calf muscles
• Change in footwear (soccer boots / athletic shoes no heel)
• Excessive rolling in of feet
• Poor warm up routine
• Remember this condition usually settles as the growth plate fuses within 6-12 months.

How can your podiatrist help?

Your podiatrist can help manage this condition by implementing a treatment program.  This may incorporate one or all of the following: -

• RI (Rest and Ice)
• Activity modification so child becomes pain free
• Daily stretching routine
• Heel raise within shoes to decrease pull on heel
• Biomechanical abnormalities corrected (Orthotics)
• Strengthening of associated muscles
• Footwear modification

New Year and New faces.

 

The staff at BSEMS trust everyone had a safe Christmas break, and enjoyable New Year celebrations. As everyone returns to work, and gets back to their normal routine, rest assured that all of the practitioners at BSEMS are ready and raring to help you stay fit and active.

 

We are happy to welcome a few new faces to our staff this year including Joel Simpson, Exercise Physiologist, and Dr Thomas Hilton, who replaces Dr Thomas Gan as our senior Sports Medicine Registrar. Dr Hilton’s profile will be up soon, but please contact our staff if you have any queries. To start the year off we have included the topic of tennis elbow to our fact sheets, a very common problem that probably affects more non-players than not!

 

All the best for a safe 2012, and happy exercising.

 

Tennis Elbow

AKA Extensor Tendinopathy/ Lateral Epicondylosis

 

Aetiology:

The primary pathological process is thought to be degeneration of the extensor carpi radialis brevis tendon, usually within 1-2cm of its attachment. There is an invasion of fibroblasts and vascular granulation tissue rich in nociceptive nerve endings. There is often continued or repetitive use of wrist extension. The grip on the racquet may be too small or poor technique is present. ECRB crosses 2 joints and works eccentrically at both ends during certain manoeuvres, and may be compressed by the radial head.

 

History/Examination:

There are 2 distinct presentations: The most common is insidious onset of pain 24-72 hours after performing an unaccustomed activity involving wrist extension. The other presentation is a sudden onset of lateral elbow pain associated with a single instance of exertion involving the wrist extensors.

 

Examination shows maximal area of tenderness 1-2cm distal to the lateral epicondyle. The pain is typically reproduced with resisted wrist extension (particularly when the wrist is pronated and radially deviated (Mills’ test) and with resisted extension of the middle finger. There may be neural tension on the upper limb tension test and there may be decreased ROM in the neck particularly around the C5/6 apophyseal joint.

 

Predisposing factors should be treated (e.g. bad technique, wrong grip size) and biomechanical deficits corrected (assess the wrist, shoulder, scapula, neck and back).

Common faults in tennis include:

• “leading elbow”
• early wrist flexion with abrupt extension on impact
• exaggerated wrist pronation
• ball impact in the lower portion of the racquet.

 

Racquet size and stiffness have been postulated as causative factors, although neither has been definitively shown.  A stiffer racquet transmits more vibration to the arm.  Higher string tension will transmit more force through to the arm.  Vibration-damping devices placed between the strings have been shown to decrease string vibration but with no benefit to the arm. A larger grip size has been shown to produce lower muscle activity in the forearm extensors.

 

 

Treatment:

Control pain with rest, ice and NSAIDs. Modalities, stretching and massage may be used. Dry needling may help with trigger points.

Counterforce bracing can be used during the rehab.

Corticosteroid injection and iontophoresis may be used (although benefits are controversial), other adjunctive treatment may be considered (PRP, GTN patches, shockwave and/or sclerosant injection) with surgery as a last resort.

 

To improve wrist flexion mobility place the wrist extensors on passive stretch with the elbows extended. As flexibility starts to approach normal, strengthening should commence with isometric contraction and progress to concentric and then eccentric exercises. A progressive resistance programme is incorporated which may include free weights or a Theraband. Use a weighted rod to strengthen the muscles of pronation and supination. This should follow with a graduated return to activity.

Welcomes and Farewells

Well here we are again at the end of another year! The staff at BSEMS want to wish everyone a safe and healthy Christmas and New Years period. 2012 promises to be a big and exciting year, and the staff at BSEMS would like to help anyone struggling to stay fit or active.

BSEMS are proud to announce a new staff member commencing in 2012- Joel Simpson is an Exercise Physiologist and Australain representative in Kayaking. Visit his profile here. 

We are sorry to farewell our Registrar Dr Thomas Gan, who is returning to Sydney in 2012. Tom has taken up a position as the team Doctor for the new Greater Western Sydney AFL team, so we wish him all the best for what will no doubt be a challenging but exciting time. Tom's professionalism and skills will be missed.

We are fortunate to have a new registrar arriving early in the new year- Dr Thomas Hilton- watch this space, as we will introduce him properly soon!

Be sure to check our Announcements site for Christmas operating hours.

Once again, on behalf of everyone at BSEMS, thankyou so much for your support, and we hope to see you in 2012!

Well here we are in Spring, with the days getting longer and the urge to get out and exercise upon us once again. Overuse injuries can often be prevented with careful preparation and a graded increase in an exercise programme, but some injuries are quite unfair, come out of the blue, and keep you out for a long period. ACL ruptures are one of those, and the blog this month covers this (often) devastating injury. The staff at BSEMS (unfortunately) are experts in the diagnosis and coordinated management of this injury, so for this or any other problematic issue stopping you form doing what you want come and see us.

 

Anterior Cruciate Ligament Tears

Prevention: Grounds which have a predominance of Bermuda grass (as opposed to Rye grass) and which have thicker thatch have an increased incidence of ACL rupture. There is no relationship to the hardness of the grounds or moisture content. Theory is that ↑ traction (thicker thatch) results in ↑ rotational force through the knee.

There is a theory that knees can be trained to land, with coordinated hamstring contraction being protective of the ACL- this may be particularly important in females who have a much higher incidence of non-contact ACL rupture.

 

Anatomy:

The ACL is attached anteriorly to front of tibial plateau and ascends postero-laterally to the posterolateral aspect of the intercondylar notch. Acts to prevent forward movement of the tibia in relation to the femur, and control rotational movement. It provides 86% of the restraint to anterior tibial translation.

 

History:

Landing from a jump, pivoting or sudden deceleration. May describe ‘crack’ or ‘pop’ and usually extreme pain. Usually have tense swelling within a few hours of the injury (occasionally no swelling). Can have associated meniscal tears.

 

Mechanism:

Most ACL injuries are non-contact. The mechanism of an acute ACL tear is a result of forces similar to a pivot shift test: rotation and varus stress stretches the ACL until it fails, the posterior lateral femoral condyle ‘slips’ posteriorly off the tibia, resulting in bony oedema of the lateral femoral condyle, damage to the lateral meniscus, and the avulsion # of the attachment of the inferior lateral meniscus (Segond #) which is pathognomonic of an ACL tear. Chronic laxity may result in O’ Donoghues unhappy triad of ACL, MCL and medial meniscal tears.

 

Examination:

Difficult to examine if acutely swollen. Have decreased ROM especially extension. Can have joint line tenderness- may have associated medial meniscus tear or stretching of lateral joint line. Positive Lachmans is useful. Pivot shift diagnostic but need intact MCL and ITB.

 

Associated bony injury includes:

• # of the posterior aspect of the lateral tibial plateau
• Segond #: these are caused by an avulsion # of the middle 1/3 of the lateral capsular attachment (meniscotibial ligament) and deep fibres of the ITB.
• Avulsion of the tibial spines
• Defects in the lateral femoral condyle e.g. bone bruising to complete #

 

Surgical Treatment:

 

Involves reconstruction of the ligament- can use patellar tendon, ITB, and hamstrings tendon grafts. There is little evidence in the long term that one type of graft (patellar vs. hamstring) is better than another.

Re-rupture rate is similar in each approach, around 10%.

Synthetic ligaments have high failure incidence. It is preferable for the injured knee to have little or no swelling, a full ROM and normal gait preoperatively, like to strengthen hamstrings, quads, hip extensors/abductors and calf- prehabilitation.

 

Rehabilitation Post-op:

 

Aim for return to sport in 4-9 months. Have 4-phase rehab period over this time period. One functional test is the “Heiden hop”- patient jumps as far as possible using the uninjured leg, and lands on the injured leg. If have good function land still, if functional disability take another small hop.

 

Problems with ACL rehab:

 

• Patellar problems: May get typical signs PFJ pain on either leg. Can get damage infrapatellar fat pad during operation. Patella baja (inferior displacement of the patella) may result from tight tissues, and may have patellar tendinopathy.
• Low back pain: secondary altered gait.
• Lower limb stiffness: secondary NWB and braces.
• Soft tissue stiffness (arthrofibrosis): dependent on collagen laying down and scarring.
• Soft tissue laxity: may need to slow rehab to allow scar to heal.

 

ACL graft re-injury rate:

 

In a series of 180 patients followed for 10 years after ACL reconstruction, 11% of patients ruptured their graft. Contralateral ACL rupture occurred in 16%, and young males were a particularly high risk group for reinjury (46% sustained either a graft rupture or contralateral injury). There was no difference in rupture rate between hamstring or patellar tendon grafts. The period of highest risk for graft rupture was between 12 and 26 months from surgery (42% of graft ruptures occurred during this time).

 

Hamstring graft regeneration: Tendons tend to regenerate to within 2cm of the origin within 3 months of the operation. This tendon matures over time from proximal to distal to develop normal tendon biomechanics and histology. Initially there is associated muscle belly atrophy.

 

Conservative management of ACL tear:

Usually will still need an arthroscopy to determine articular cartilage damage. Rehab is similar to post-op rehab and may progress slower or more quickly depending on the injury. Braces may be of help. May be unable to do sports specific and change of direction activity.

 

Chronic anterior instability:

This may follow an acute injury from which the knee has not fully recovered. There is usually giving way with pivoting and twisting movements, and may be a persistent or recurrent perfusion. There may also be locking and clunking, with associated meniscal injuries. Lachman’s and pivot shifts may be positive. Generally conservative management is unsuccessful and operative intervention is necessary.

 

Double bundle ACL reconstruction attempt to recreate the both anteromedial and posterolateral bundles of the ACL to improved rotational control.

 

A newer generation of synthetic graft (LARS) is currently available. The idea of ACL tissue ingrowth associated with a new surgical technical philosophy is argued by the proponents of this product. Long term outcomes are not known.

Spring is here again and welcome after a particularly chilly winter. Now is the time when we dust off our running shoes, pull out the decaying swimmers, and take a new lease out on life!

One problem that rears it's head often at this time of year is that of seasonal allergies, rhinitis, and asthma. One problem particularly troubling to exercisers is that of Exercise Induced Asthma and/or Bronchospasm. This months blog follows this topic- remember management can be difficult and medical advice is wlays recommended. Happy exercising!

Exercise Induced Asthma and Bronchospasm

Exercise Induced Bronchospasm (EIB) is defined as a transitory ↑ in airway resistance that occurs following vigorous exercise. EIB represents a pathology different to that of classic asthma. It represents 6-12% of the general population, and 4-80% of the sporting population. The higher athlete prevalence is thought to be due to the high training loads in combined with the training environment of the athletes.

 

Exercise Induced Asthma (EIA) specifically refers to the individual with background asthma also triggered by exercise. It includes around 90% of asthmatics. EIA severity is ↓ by inhaled steroid treatment in a dose-dependent fashion. EIA is one of the first asthma symptoms and is the last to resolve after inhaled steroid treatment.

 

Symptoms of EIB:

Symptoms classically peak within 5-10 minutes after the cessation of moderate to intense exercise. It is suggested that during exercise surges in adrenaline are protective by stimulating bronchodilatation. After cessation of exercise adrenaline levels drop and mast cell mediator release occurs.

Symptoms of EIB are diverse, often not recognised and include:

• chest tightness
• wheeze
• shortness of breath
• dry cough

Others symptoms include prolonged difficulty in eliminating URTI’s, difficulty sleeping due to night symptoms & reduced performance.These symptoms will usually either resolve spontaneously or with the use of bronchodilators. 50% of patients with EIB are rendered refractory for the 2-4 hours after an event. The reason for this is unclear. It may be related to prostaglandins, and NSAID medications may abolish the refractory period. There may be a seasonal element to symptoms, and atopy is very important. There may be ↑ eosinophils in atopic athlete’s sputum. Winter athletes have been found to have ↑ neutrophils in their sputum (possibly because of respiratory tract trauma).

 

Diagnosis can be made via the use of:

• Clinical history (looking for the above symptoms)
• PEFR diary pre and post exercise and the bronchodilator response (although not entirely reliable and effort dependent).
• EVH challenge test (gold standard)
• Exercise challenge test
• Osmotic challenge tests- mannitol, hypertonic saline
• Allergen testing (SST, RAST, IgE) Total IgE serum levels can be used as a simple assessment of a patient’s allergic profile. Skin testing is for common allergens like dust mite, couch/rye/birch grass, and cats/dogs. If skin tests are positive (>3mm wheal) than should perform an IgE level plus a RAST test for that specific allergen.

 

Treatment

Management begins with a thorough assessment of asthma triggers including animal dander, house dust mites, mould, smoke, and pollen, changes in the weather or airborne chemicals.

 

Asthma and EIB should be distinguished from associated disorders that cause respiratory symptoms during exercise including: fixed airway obstruction, laryngeal dysfunction, gastroesophageal reflux, and vocal cord dysfunction (VCD).

Non-pharmacological therapy:

This should be used as adjunctive treatment, and there is no substitution for pharmacological therapy. Masks reduce severity of EIB; can recover 42 % of water at 16°C (more useful in colder countries). Nose breathing to increase resistance is not effective in all patients. It is difficult to do, especially during vigorous exercise (above 35 L / min). Exercise training effects still controversial. Increased fitness levels increase the threshold at which EIB occurs but won’t stop it.

Refractory period: This does not work in every athlete (~50%) and is not recommended as it may induce severe bronchospasm. Warm up before the actual exercise reduces asthma in subsequent exercise.

 

Pharmacological Agents:

Dependent on level of exercise. Medications just before exercise are adequate. Some patients may require treatment with daily asthma therapy. NB: ALWAYS CHECK MEDICATIONS WITH YOUR SPORTS PHYSICIAN AS SOME MEDICATIONS ARE PROHIBITED, AND MAY RESULT IN AN ADVERSE DRUG TEST FINDING.

 

β2-agonists

 These are effective at relieving of asthma symptoms, and have been reported to improve pulmonary function in 90% of individuals with EIB. They bronchodilate, ↑ air flow, ↓vascular permeability and moderately inhibit mediator release. Studies have demonstrated no ergogenic properties of any IOC approved medication when used in therapeutic doses by the permitted route (oral consumption of beta agonists does have an anabolic effect).

 

Cromones

Thought to block chloride ion flux into mast cells and prevent mast cell degranulation. Most effective within 2 hours of treatment and shown to prevent both early and late phase asthmatic reactions. It has no bronchodilating effects and cannot be used for acute episodes. Side effects: throat irritation, cough, transient bronchospasm. Precautions with abrupt withdrawal. Not restricted in sport.

 

Leukotriene antagonists

They can give protection against EIB and do not show tolerance (unlike β2 agonists). As once daily oral tablets, often have better compliance in younger individuals, and they can reduce corticosteroid requirements. They have around a 50% mean effectiveness in inhibiting post-exercise bronchoconstriction (possibly due to other inflammatory mediators being responsible for symptoms). Leukotrienes are released from eosinophils in response to an increase in osmolarity and could feasibly cause transient migration of eosinophils to the airways. While treatment with inhaled steroids decreases eosinophil number, steroids do not prevent the contractile effects of leukotrienes. Thus, EIA may still occur if there are sufficient cells left containing this potent mediator.

 

Inhaled corticosteroids

Improve asthma symptoms by reducing airway inflammation and bronchial hyper-reactivity. They inhibit multiple segments of the asthmatic cascade, suppressing the generation of cytokines, reducing the population of airway eosinophils, and preventing inflammatory mediator release. They do not have an immediate bronchodilator effect, and are not effective when used prophylactically prior to exercise. 4 weeks treatment with corticosteroids 400 micrograms daily reduced EIA severity and increased lung function.

 

The main role of corticosteroids is that of maintenance therapy to help control asthma, but in doing so they act to reduce bronchial responsiveness to exercise, thereby reducing the propensity for EIA. Often used on a regular basis, with sodium cromoglycate or nedocromil sodium given just prior to exercise. Side-effects of oral candidiasis and dysphonia can be reduced by mouth washing following administration. Others are hoarseness, cough, rhinitis eczema, GIT upset, arrhythmia, headache, light-headedness, thirst, taste disturbance.

 

Anticholinergics (not used in EIB)

This blocks vagal tone and reflexes which mediate bronchoconstriction. Used alone it is not a powerful bronchodilator. Its duration is approximately 6 hours and can be used to augment β2 agonists. Side effects include blurred vision, precipitation of glaucoma and a dry mouth. Theophylline has no role in treating EIA.

 

Well after recommending that everyone lift their game and keep exercising through winter, it seems that we should practice what we preach! We missed the July Blog, and tend to blame short days, cold mornings, and repeat doses of the flu as an excuse! To make up this month we have a blog about Patellofemoral Syndrome- a very common cause of knee pain in exercisers that can be frustrating to manage. Rest assured that the experts at BSEMS will help you with diagnosis, investigations, and appropriate rehab. Until Spring- happy exercising!

 

 

Patellofemoral Syndrome (PFS)

 

 

Definition:

This syndrome describes pain in and around the patella (knee cap). It was formerly known as ‘chondromalcia patellae’, but this has fallen out of vogue. It is thought to be secondary to patellar malalignment to the femoral trochlea, resulting in abnormalities within the articular cartilage. It is also thought to be due to a ‘supra physiological mechanical loading and chemical irritation of the nerve endings denoting loss of tissue homeostatsis’- causing an inflammatory cascade and consequent peripatellar synovitis.

 

Mechanics: At full extension the patella sits lateral to the trochlea. During flexion it moves medially and comes to lie within the intercondylar notch at 10-20°, until 130° when it starts to move laterally again. With increasing flexion, more of the patella articular surface comes into contact with the femur, offsetting the increased load associated with flexion.

 

 

Contributing factors:

• Femoral anteversion (congenitally ‘internally rotated femur’)

• Limited hip external rotation: secondary to soft tissue restriction eg tight anterior hip joint capsule, short adductors, tensor fascia lata, iliopsoas or rectus femoris.

• Tightened ITB: results in overactivity of TFL and decreased activity of posterior fibres of gluteus medius.

• Tightened lateral structures: Superficial structures: vastus lateralis and ITB which restrict medial glide. Deep structures: lateral retinaculum which restricts medial tilt.

• Tightened posterior structures: hamstring and gastrocnemius, cause lateral tracking of the patella by increasing the dynamic Q angle.

• Altered foot biomechanics

 

The VMO (inside quadriceps muscle) in PFS pain sufferers may need to fire earlier to overcome abnormal tracking forces.

 

The patella is the centrepiece of all the stabilizing forces that act around the knee. It increases effective extension force by as much as 50%. A patellofemoral joint reactive force (PFJRF) is created by compression of the patella against the femur and this force is transmitted to subchondral bone.

The PFJRF increases with increased knee flexion: 15º = 1 times body weight; 20º = 2 times; 45º = 3 times; and 75º = 6 times.

• Normal walking creates a PFJRF of half body weight

• Ascending stairs 3.3 times body weight

• Squatting 6-7 times body weight.

Limitation of knee extension necessitates increased tension within the quadriceps and increased PFJRF. A large PFJRF distributed over a large area yields a lesser degree of articular stress, if this area is decreased then stresses are increased.

 

 

History:

A medial site to the femoral pain is indicative of PFS. The onset of PFS pain is often insidious but may present after an acute traumatic episode. Patients often have a diffuse ache, which may be exacerbated by prolonged sitting (‘movie-goer’s knee’) or activity. It can occur during running and gradually worsens. There may be recurrent clicking or crepitus.

 

 

Treatment:

 

In an open kinetic chain, the hamstrings are predominant in flexion and quadriceps in extension. These exercises (e.g. straight leg raises and knee extensions while wearing ankle weights) place a greater load on the patellofemoral joint and should be avoided early in rehab. In closed kinetic chain exercises (e.g. leg presses or partial squats) there is co-activation of both hamstrings and quadriceps. These exercises strengthen agonist and antagonist muscles simultaneously, result in decreased PFJRF, and are far more physiologic for lower extremity sporting activities.

 

 

• Reduction of pain and inflammation: RICE, NSAIDs, and electrotherapeutic modalities.

• Taping: Should reduce symptoms by 50% and result in earlier activation of VMO. Acute cases may need taping for 24 hours per day until pain settles, then gradually reduce.

• Muscle training: Training of VMO and gluteus medius. Isolate VMO by palpating when it is contracting (biofeedback better). Start with closed chain exercises (i.e. foot on the ground) and progress to weight bearing and functional exercises.

• Stretching: Stretch tight lateral structures- side lying position with knee flexed. Glide patella medially using the heel of the hand. Also work on quads, hamstrings, calf and ITB.

• Massage: Work on tight areas, particularly ITB.

• Braces: Not as good as tape.

• Orthotics: may correct excessive subtalar pronation.

• Correction of other precipitating factors: eg training, shoes, surfaces.

• Surgery: only if failure conservative management. May need chondroplasty and rarely lateral release.

 

 

 

Welcome to the June Blog.
Winter is here and it is getting colder in the mornings, and harder to excercise. It takes a lot of motivation to stay fit and active at this time, and being injured only compounds things. Whilst it is all to common to focus on the physical and rehab side of injury, it is important to remember that a strong mental approach can be just as important. This month our Sports Psychologist, Allira Rogers writes about the role of sport psychology in injury recovery.

Remember at BSEMS we aim to have the specialist to suit your every sport and exercise requirement. Happy exercising!

The Role of Sport Psychology in Injury Recovery

 

Allira Rogers (Mental Notes Consulting Sport Psychologist)

Injury is a common occurrence in sport participation.  Ask any athlete and they will tell you that one of the leading setbacks they can experience is injury. Being injured can mean a number of different things to an athlete outside of the physical pain they experience. Firstly, injury can bring a halt to preparations (i.e., training) and can mean that what they have devoted a lot of their time too and energy can be taken away quite suddenly (Crossman, 1997). For an athlete sport is a part of their identity and therefore sport is a significant part of them. When this is taken away, albeit for a short period of time, this can have a possible negative effect on the way an athlete views themselves.  Additionally, injury can take away the positive reinforcements sport provides where athletes experience a sense of mastery, autonomy and sense of control (Deutsch, 1985). Injury may also be considered a setback because athletes use sport as a way of dealing with stress.

Understandably then, it can be expected that athletes may experience a number of emotional responses and stress upon being injured. Athletes’ emotional experiences differ greatly as no one individual experiences injury the same way. However some emotions are more commonly reported than others and include anxiety, fear, anger, tension, fatigue, disbelief, lack of motivation, and irritation (Ahern & Lohr, 1997; American College of Sports Medicine, 2001; Klenk, 2006). Of course it is normal for athletes to experience these emotions in response to injury however it is important to note that not all athletes experience an observable emotional disturbance to being injured.  They are athletes who seem to take being injured in their stride and their emotional reactions appear to resolve. On the other hand, other injured athletes appear to struggle emotionally and their reactions become problematic when symptoms do not resolve.  

Although there is no predictable sequence of athlete’s emotional responses to injury, athletes often display three categories of response to their injury. To help come to terms with their injury, athletes often try to obtain and interpret as much injury-relevant information they can (i.e., “How bad is it?”, “How long?”, “What can/can’t I do”, “How do I fix it?”). Secondly, as already discussed, athletes may experience emotional upheaval and reactive behaviour related to their injury. Often athletes will ask questions or have thoughts that are similar to the following: “I can’t believe this has happened now”, “I’ll never be back to 100%”, and “I am no good to the team now”. Athletes with apparent negative affect can often display a range of signs indicating poor adjustment to injury.

• Feelings of anger & confusion

• Obsession with “when can I return to play?”
• Trying to do too much too soon in terms of rehabilitation program (pushing the limits)
• Denial (e.g., “The injury is no big deal”)
• Repeatedly returning to play too soon & experiencing re-injury
• Exaggerated bragging about accomplishments
• Dwelling on minor physical complaints
• Sleep disturbances
• Alterations in diet
• Guilt about letting the team down
• Withdrawal from significant others
• Rapid mood swings
• Statements like “no matter what is done, it will never get better”

The final category suggests that athletes come to terms with their injury and engage in effective coping. If their emotional responses resolves rather than becomes problematic, athletes often think or voice that the injury is starting to come good, and ask their support network if there is anything they can do at home or can help out in training.  However, if an athlete is showing problematic symptoms of negative affect as a consequence of their injury (see list of signs of poor adjustment) it is very important for them to seek assistance from a sport psychologist who can help them manage and deal more effectively with their injury thus helping their injury recovery process. Research has shown that negative emotions experienced by injured athletes can influence athletes’ attitudes toward and subsequent recovery from injury (Ahern & Lohr, 1997; Crossman, 1997). The use of psychological strategies have been found to improve injury recovery, mood during recovery, coping, confidence restoration, pain management, and adherence to treatment protocols (Brewer et al., 2000).

Psychological skills such as goal setting, imagery and relaxation can help athletes deal better with stress, reducing chances of injury and stress of injury should it occur. In addition, even athletes who deal with injury effectively can still benefit from learning these strategies as they can be used to enhance performance on a consistent basis. Other psychological skills used to deal effectively with injury but can also be used to enhance performance after returning from injury include self-talk to help athletes have a positive attitude to rehabilitation and build confidence as well as problem solving to help cope with setbacks and look for opportunities. In addition to skills, it is very important for athletes to be educated about their injury and the recovery process to keep them informed and provide them with clear expectations and to help reduce uncertainty.

If you would like more information or you have any questions you would like answered regarding the role sport psychology can play in helping recover from an injury please contact the Brisbane Sport & Exercise Medicine Specialist clinic on (07) 3899 0659. Alternatively you can contact our resident sport psychologist Allira Rogers directly by emailing her at allira@mentalnotesconsulting.com.au.

References

Ahern, D. K., & Lohr, B.A. (1997). Psychosocial factors in sports injury rehabilitation. Clinics in Sports Medicine, 16, 775 – 768.

American College of Sports Medicine. (2001). Sideline preparedness for the team physician: a consensus statement. Medicine & Science in Sports & Exercise, 33, 846 – 849.

Brewer, B. W., Cornelius, A. E., Ditmar, T. R., Krushel, R. J., petitpas, A. J., Pohlman, M. H., Sklar, A. J., & Van Raalte, J. L. (2000). Psychological factors, rehabilitation adherences, and rehabilitation outcome after anterior cruciate ligament reconstruction. Rehabilitation Psychology, 45, 20 – 37.

Crossman, J. (1997). Psychological rehabilitation from sports injuries. Sports Medicine, 23(5), 333-339.

Deutsch, R. E. (1985). The psychological implications of sports related injuries. The International Journal of Sports Psychology, 16, 232- 237.

 

Well here we are in May already! The weather is getting cooler, and it is getting harder and harder to get up in the morning to exercise. Remember if you need help with injuries, dietary advice, or which pair of shoes to use we have all the help you need right here. 

This month one of our Exercise Physiologists, Beth Sheehan has written the Blog about the importance of maintaining good core stability. Beth consults every second Friday afternoon at BSEMS adn is happy to take new patients any time.

Core stability

Does having a visible ‘6-pack’ mean you have a strong core?  Not necessarily.

 

The abdominal muscles or the core muscles are made up of a number of muscles which include rectus abdominis (6-pack), external and internal obliques (love handles), multifidis, pelvic floor and transversus abdominis.  Most people when working the ‘core’ focus on the visible i.e. the rectus abdominis.  Consequently they perform exercises that increase the musculature but often don’t have an understanding of how to strengthen the deeper core in particular transversus abdominis(TA).  Having a strong TA and deeper core is the pinnacle of good core strength and core control. 

 

Having good core control has an affect on day to day activities that require good posture (eg computer typing, cleaning & driving) as well as other functional daily activities such as climbing stairs, getting up and down off a bed and gardening. A strong TA enables daily tasks to be performed with minimal risk of new injuries as well as avoiding recurring injuries.  Activation of the TA should become second nature and should be applied during most functional activities performed on a daily basis.  Having a strong TA also assists with good lifting techniques in the gym when utilizing weights as well as performing abdominal exercises.  It also assists with maintaining good balance and stability particularly as we go through the aging process.

 

When the deeper core is engaged i.e. contracted, the various muscles involved (TA, multifidis, pelvic floor etc) stabilize the spine, pelvis & shoulder girdle and consequently establish a solid basis to build our strength.  We as humans are then able to generate considerable amount of power at our extremities.  If however we are not contracting our core initially and utilizing our larger muscle groups we can sometimes lose this power and consequently recruit our larger muscles. This can often lead to injury and overuse conditions (eg carpal tunnel syndrome, repetitive hamstring tears) and generally cause us physical grief and discomfort.

 

When we are encouraged to activate the TA many health professionals who know how to instruct the activation will often use a variety of cues.  Some of these include ‘turn your tummy on’, ‘zip up and in’, ‘pelvic tilt’, ‘pull your belly button to your spine’.  All of these are correct cues however sometimes the activation is not achieved by the TA but rather the larger abdominal muscles such as the rectus abdominis is activated instead.

 

When learning how to strengthen the core it is important that correct activation of the TA is achieved to ensure that the activation of TA can be transferred from daily activities such as house hold duties to manual labour and then to sport and gym based activities.  Core strength is imperative in our daily lives to not only improve our general posture but also our balance and over all well-being.

 

Pilates is an excellent form of physical activity that encourages correct activation of TA and deep abdominals throughout all exercises.  Exercise physiologists and physiotherapists are also well trained in the activation of TA.  By discussing the importance of TA with these allied health professionals you could change your posture, your current pain discomfort and minimize your risk of injury. 

 

Want a strong 6 pack?  Activate the TA J

Happy birthday to BSEMS!

April marks 12 months since BSEMS opened its doors. Queenslanders have been through some pretty tumultuous times over this period, but have emerged stronger and more determined. Likewise, the BSEMS practice has grown and added to its core group of practitioners over this time. We are proud of our Multi-disciplinary clinic, and continue to aim to provide Brisbane and South East Queensland with a world class Sport and Exercise Medicine clinic. We are always open to suggestions as to how we can serve you better, so please feel free to leave your comments or thoughts.

This month’s blog topic covers throwing and overhead injuries. Whether you are a weekend warrior throwing around a park, or an elite athlete upper limb problems can result from the repeated action of throwing or using a racquet. Understanding the biomechanics of throwing helps you to appreciate the forces transmitted to the upper limb, and what problems can result from excessive use or poor technique.

 

Upper Limb Problems in Overhead Athletes

 

People of all ages are heeding the advice to become more active and participate in sport and recreation. So called ‘over head’ sports activities like throwing and racquet sports for the most part are simple, and require no special training to participate. However tremendous forces are placed though the upper limb during these activities, resulting in a combination of acute, and more commonly over-use injuries, that commonly present to General Practice.  This article explains the biomechanics of common over head activities, which explains the forces placed on the upper limb, and subsequent injury development.

Throwing Biomechanics

 

Throwing is a ‘whole body activity’ that commences with drive from the large leg muscles and hip rotation and progresses through segmental trunk and shoulder girdle rotation. It continues with a ‘whip-like’ transfer of momentum through elbow extension and through the small muscles of the forearm and hand, transferring propulsive force to the ball. Movement of the trunk and contact with the ground allow for maximal transfer of energy to the ball. (Water polo players can throw at only half the velocity of baseball pitchers.) The forces transmitted to the shoulder are lower during serving in tennis as the racquet dissipates much of the impact force, allowing a greater intensity of serving compared with throwing.

Throwing can be divided into 4 phases.

1) Preparation and wind up:

 

The major forces arise in the lower half of the body and develop a forward moving ‘controlled fall’. The weight is shifted back on the ipsilateral leg and the body rotates so that the hip and shoulders are at 90º to the target. During this phase lasting 500-1000 milliseconds, the shoulder muscles are relatively inactive.

Problems in any part of the ‘kinetic chain’ (e.g. injured hamstring) could impact on the eventual position of the upper limb, and precipitate injury.

2) Cocking:

 

The shoulder moves into abduction through horizontal extension and then into maximal external rotation (ER). In this position, the shoulder is ‘loaded’ with the anterior capsule coiled tightly in the apprehension position, storing elastic energy, and the internal rotators (IR’s) are stretched.

Toward the end of cocking the anterior shoulder restraints (inferior glenohumeral ligament and capsule) are under the greatest strain- with repetition these structures can become attenuated leading to subtle instability.

The cocking phase, which also lasts 500-1000 milliseconds, ends with the planting of the lead leg, with the body positioned for energy transfer through the legs, trunk and arms to the ball. Together, the first two phases constitute 80% of throwing duration.

3) Acceleration:

 

This consists of the rapid release of two forces: the stored elastic force of the tightly bound capsular fibrous tissue, and forceful contraction from the internal rotator muscles.

This generates excessive forces at the shoulder articulation, and the cuff muscles are highly active to hold the humeral head into the socket. Muscle fatigue can lead to loss of coordinated rotator cuff motion and decreased support. There are enormous valgus forces placed on the elbow, which tends to lag behind the inwardly rotating shoulder. A large degree of torque present on the elbow joint causes shearing forces to the articular cartilage.

This phase lasts 50 milliseconds, 2% of the overall time. It concludes with ball release at approximately the ear level.

4) Deceleration/follow through:

 

Not all of the momentum is transferred to the ball and very high forces pull forward on the glenohumeral joint following ball release, with a distraction force of 80% of body weight. The forces that must be countered are: humeral IR, glenohumeral distraction and elbow extension. This places large stresses on the posterior shoulder structures and elbow flexors.

Both the intrinsic and extrinsic muscles fire at near their maximum, in an attempt to develop >500N to slow the arm down. The spine and its associated musculature have a significant role as a force attenuator. Toward the end of the throwing motion, the torso begins to rotate forward, thus acquiring some of the kinetic energy of the arm, helping reduce the burden on the shoulder stabilizers which are attempting to stabilize the scapula and hold the humeral head within the glenoid. This phase lasts 350 milliseconds (18% of the total time).

 

Changes in throwing arm with repeated throwing:

 

At the shoulder, long term throwing athletes have an increased range of ER, because of repeated stress to the anterior capsule in the cocking phase, and stretch or breakdown of the inferior glenohumeral ligaments. This may lead to anterior instability of the shoulder and secondary impingement. Throwers often have more lax shoulders than non-throwers.

The normal strength of IR: ER is approximately 3:2, but in throwers this is exaggerated and over time lack of ER strength may increase vulnerability to injury.

At the elbow, repeated valgus stress could lead to a breakdown of the medial stabilizing structures (collateral ligament, joint capsule, and flexor muscles). This leads to an increased carrying-angle at the elbow. Less frequently, there may be anterior capsular strains, posterior impingement, or forearm flexor strains and a subsequent fixed flexion deformity.

Injuries associated with overhead activities

 

Shoulder

 

Typically overhead athletes will complain of pain during the throwing action. Repeated throwing often results in impingement, which can be superior or posterior; apprehension or subtle instability (typically anterior); and over time wear and tear changes to the rotator cuff and/or labral cartilage.

Pain during the wind up and cocking phase may be associated with lax anterior restraints, subtle instability and over time cuff tendinopathy.

Pain during the acceleration phase may be due to an internal rotation deficit, tight posterior cuff and internal impingement. Over time this could be associated with the development of a SLAP (Superior labral anterior-to-posterior) lesion.

A thorough biomechanical assessment, including analysis of throwing action, can determine problems with shoulder mechanics, and allow a targeted rehabilitation process. Often weakness in the ‘stabilizing’ rotator cuff muscles needs to be improved, along with scapulohumeral dysrhythm. A Sports Physician is ideally suited to examine such patients and coordinate rehabilitation. Investigations like ultrasound or MRI are occasionally warranted, and rarely operative intervention will be indicated. 

Elbow

 

The primary forces delivered to the elbow during throwing are a valgus and extension opening force. This produces:

• tensile stress to the medial compartment restraints (Ulnar collateral ligament, flexor-pronator mass, medial epicondyle apophysis, and ulnar nerve)

• shear stress to the posterior compartment (posteromedial tip of the olecranon and trochlea/olecranon fossa)
• compression stress produced laterally (radial head and capitellum).

Continued valgus and extension forces may produce olecranon tip osteophytes, loose bodies in the posterior or radio-capitellar compartment, and a kissing lesion (articular damage on the posteromedial trochlea caused by the olecranon osteophyte.  Subtle laxity may cause excessive soft tissue stretch with flexor-pronator mass tendinopathy, and ulnar neuritis)

Treatment typically involves a period of avoidance of aggravating activities, correction of biomechanics, appropriate strengthening rehabilitation, and a graded return to the provocative activity, monitoring for a return of symptoms.

 

Problems specific to young athletes:

 

Younger athletes are especially vulnerable to over head over-use injuries. Whilst they are exposed to the same forces as adults, growth plates remain open and are susceptible to stress related injuries, and may lead to long term deformity.

Problems in the shoulder include:

 

Traction apophysitis at the attachments of deltoid and pectoralis major

Rotational bone stress or stress fractures in the humerus

Shoulder impingement

Problems at the elbow include:

 

Medial epicondyle apophysitis

Lateral compartment osteochondritis dissecans

Traction apophysitis at the triceps attachment to the olecranon

In the sport of baseball, strict regulations apply specific to age, regarding the types of pitch allowed, as well as the number of pitches and innings permitted. This has been effective in reducing ‘little league’ shoulder and elbow pain. Most other sports rely on common sense in relation to appropriate training load. Unfortunately in this day of elite sport and high training volume at a young age, unrestricted load often results in over-use injury.

 

Elbow pain in Racquet sports:

Elbow pain is common in racquet sports, and may be due to dominant activity of the wrist extensors. The impact between the ball and racquet produces a significant amount of force, and the ‘shock’ transmitted to the arm depends on how hard the swing is; the speed of the incoming ball; where on the racquet face the ball hits; the quality of the racquet; the string tension; and the stroke mechanics. The ‘sweet spot’ is the area on the tennis racquet where the initial shock is at a minimum- if the ball misses the sweet spot there is increased shock transmitted to the hand, wrist and elbow.

Tennis elbow or lateral epicondylosis, is an overuse tendinopathy of the common extensor origin. Golfers elbow is the same pathology at the common flexor origin. Ways to reduce the shock at impact include:

Lower the string tension

Increase the flexibility of the racquet

Increase the size of the racquet head

Increase the weight (lead tape to the head and handle)

Increase the grip size

Grip higher on the handle

A larger grip size prevents the player from gripping the handle too tightly. It is only necessary to squeeze firmly on the grip during the acceleration phase of the stroke. Over time an eccentric strengthening programme has been shown to improve strength and function, and reduce pain. Adjunctive treatments such as corticosteroid injection, autologous blood injection or shock wave lithotripsy may have a role in recalcitrant cases.

An understanding of the biomechanics of over head sports allows the astute physician to determine injury likelihood, accelerate diagnosis, and to commence appropriate treatment and rehabilitation.

 

 

 

March is here and the football season is well and truly upon us. The Reds are off to a good start and the Broncos, Titans, Lions and GC Suns kick off their season soon. Of course best wishes to the Brisbane Roar for their impending Grand Final.

 

With all this excitement it is a good inspiration to dust off your sporting gear and get out amongst it. This month, our renowned Sports Dietitian, Lauren Nugent provides a fact sheet about the benefits of a Nutrition check-up. Lauren consults at BSEMS and is available for appointments on alternating Wednesday afternoons.

 

Have you had your nutrition check-up?

 

March is often the month where athletes, whether recreational, elite or simply a weekly participant; start getting serious about their training.  The pre-season is starting for footy codes, triathlon clubs are ramping up, running clubs are in full swing, rowing teams are in the water again, basketball and netball teams begin their competitive season and winter sports are raring to go. 

 

A full training load is not only a challenge to your physical body but also to your nutritional intake.  Many active people will keep their muscles and joints in top form with massage, physio treatment, a medical check, a podiatry review and a stretch regime, but have you considered your nutritional needs?  Do you need a nutrition check-up?

What is a nutrition check-up?

 

Your Eat Smart Dietitian will begin by questioning you about your sporting, life and medical goals.  Do you want to lose body fat, gain muscle, become fitter or lower your blood pressure?  Your Dietitian will then assess your current dietary intake in relation to your training habits.   You will then be given a list of goals to improve your nutritional intake and a complete nutrition plan to help you reach your potential.

I’m not an athlete, do I need a nutrition check-up?

 

Everyone can improve their diet to achieve better energy levels, improve body composition, improve sporting performance or simply get more out of life! 

I train once per week and play a game once per week, what can a nutrition check-up do for me?

 

Many things! Do you know how to prepare yourself on the day of the game?  Are you fuelling your body adequately on your training day?  Do you have adequate recovery fuel to maximize adaptations to training?  Are you confused on what you should eat and drink at half-time?  Or do you simply need to eat better every day to manage your weight? 

I’m just a general exerciser, could a nutrition check-up help me?

 

Absolutely!  Would you like to advance your fitness, step-up and do a fun run, increase your strength in the gym or simply feel better during and after exercise?  Then let one of the Eat Smart Dietitians assess your individual needs for the exercise you do and see what you can achieve!

Ear Smart Nutrition Consultants has 6 experienced Sports Dieititians who can give you a nutrition check-up to achieve your training, exercise and competition goals.