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

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.

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.

 

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.

 

 

BSEMS February Blog

Well January certainly was a trying time for Queenslanders. Many of the staff and specialists at BSEMS were themselves directly affected by the Brisbane floods, or have close friends or family who were. The destruction caused by Cyclone Yasi was equally troubling to see, but we know the Far North Queenslanders are made of stern stuff. We hope everyone is finding their feet again after such a troubling start to the year.

Football Season

It is that time of year again (already!) where the football season gets up and running again. Trial games have already begun for the Reds, and Dr Matt Hislop will be busy covering games for the Reds Academy team, and soon after that the Broncos. After seeing the damage caused to Suncorp Stadium, it will be truly awesome to see it up and running again so quickly. Dr Daelyn Vivers will busy herself with club Rugby games, and hopes to step up to being the Reds full time doctor in the not too distant future. Our new Registrar Dr Tom Gan will be involved in game coverage for the new Gold Coast Suns AFL development team.

Welcome to Beth Sheehan

We are pleased to welcome our newest practitioner Beth Sheehan. Beth is an Exercise Physiologist who adds her wealth of experience to the BSEMS clinic. She has recently returned from overseas work and has re-settled back in Brisbane. Beth specializes in exercise programs for individuals who suffer from chronic pain as well as rehabilitation programs for sporting and work related injuries.

 

Our resident Podiatrist, Mr Craig Page has provided the latest timely fact sheet. Craig now undertakes sessions at BSEMS every Friday afternoon. Craig will assess your foot type, gait pattern and foot function, as well as offer advice on appropriate footwear for your particular foot type and chosen sport.  Please contact our staff for more details.

 

 

 

Choosing the Right Football Boots

The start of the football season often means new boots. Finding the right boot is important for both comfort and injury prevention.  The following information will help you decide on the boot that is best for you.

Features to look for:

Upper – In recent times much research has gone into developing the optimal combination of materials for use in the upper. For instance there are uppers which are designed to enable the player to add spin to the ball and there are uppers that incorporate chemical coatings to provide additional grip. The upper needs to be strong enough to support your foot during rapid changes in direction and when kicking.  Combination leather and synthetic uppers are the strongest particularly when reinforced with ample stitching. Kangaroo leather is becoming particularly popular due to its strength and ability to mould well to the foot, whilst remaining very light.

 

Heel counter – The heel counter or heel cup needs to be very rigid to support your rear foot during swerving & stepping. A sturdy deep heel cup can prevent injuries especially in young footballers.

 

Midsole – More and more boots today have midsoles or wedges under the heel and even the forefoot much like a touch football boot (hybrid between joggers and a conventional boot). A boot with a midsole provides cushioning and support which is desirable for injury prevention. These are particularly good for young footballers that suffer from heel pain or ‘severs’(growth plate inflammation) or any player that suffers from lower limb injuries such as shin splints, Achilles tendonopathy and chronic knee pain. The extra bulk in this type of boot is the only downside and serious players often prefer to use them for training only whilst staying with the traditional style boot for game day.

 

Outsole – The outsole must be rigid and match the width of the foot. A narrow outsole will cause the foot to hang over the edge of the sole and place more pressure on the upper, which decreases the stability of the boot. The outsole should only flex at the forefoot in the position that the toes bend, all other movement in the outsole should be minimal.

 

Moulded Vs Screw-in studs – Football and rugby in Queensland is generally played on very hard surfaces, therefore, a moulded boot is far more suitable and a lot safer. It is important to make sure there are no studs positioned directly under the big toe joint and that the studs do not stop the boot flexing where it is suppose to – under the ball of the foot. Many footwear companies are using cleats/blades rather than the traditional circular stud shape. The advantage of a cleat system is the ability to provide greater grip without increasing the weight of the boot. Anyone who has had a knee reconstruction or suffers from instability in the knee joint should be careful not to use an aggressive cleat design as the increased grip may cause the foot to remain stuck in the turf whilst the upper leg rotates, potentially leading to excessive twisting through the knee.

 

Fit – a correctly fitted boot is an important factor in prevention and treatment of foot injuries. There should always be a thumb nail width from the longest toe to the end of the boot. There should also be adequate depth to ensure your foot sits securely in the boot.

 

At Brisbane Sports and Exercise Medicine Specialists, our Podiatrist Craig will assess your foot type, gait pattern and foot function, as well as offer advice on appropriate footwear for your particular foot type and chosen sport.

Happy New Year to all of our BSEMS patients, staff and friends.

 

We hope that 2011 proves successful in maintaining health and fitness. If you are struggling than feel very welcome to come and see one of our specialists- at BSEMS there is someone who can help get you back on track.

 

Welcome to Dr Thomas Gan

In mid January Dr Tom Gan will be commencing sessions at BSEMS. Tom is a senior registrar, meaning he is nearing completion of his Sport and Exercise Medicine specialty training. Tom has worked as a team physician for various elite sporting teams and has also been medical director for world class sporting events such as the Brisbane International Tennis tournament.

He has many professional interests including lower limb stress fractures, tennis injuries, cricket injuries, and trigger-point acupuncture.  He is available to provide consultations for a variety of paediatric and adult sports medicine conditions.

 

Tom will be working Tuesday mornings between 8am-12pm in the BSEMS rooms.

 

This year we are aiming to include a fact sheet from one of our practitioners to each blog. The fact sheets will be catalogued in our “Patient Info” webpage, under appropriately enough “Factsheets”.

For January we have provided an information sheet for patients and referrers regarding the appropriate preparation needed before a compartment pressure test is performed. This can help ensure that the test is performed correctly the first time and to reduce the chance of a false negative investigation.

 

 

Compartment Pressure Testing

Pre-test Preparation

 

Chronic exertional compartment syndrome is a cause for leg pain with exercise. The usual pattern is a gradual increase in pain during continuous exercise to a point when the athlete has to stop. Pain then takes between minutes to hours to go. Patients describe a feeling of hardness or fullness in their legs, and occasionally will notice lumps in the muscles. The condition is diagnosed by performing a compartment pressure test (CPT).

 

During a CPT the patient must be able to reproduce their leg pain as bad as they can get it. This means that in the days to weeks before the test is done, the patient should perform moderate level exercise (and not rest) so that they can reliably reproduce their symptoms on the day of the test. The patient will also guide the Sport and Exercise Medicine (SEM) Physician as to which compartments need testing, and they must pay attention to where they develop their pain (i.e. front of the leg, side, behind the shin bone, or more than one area).

 

The CPT involves injecting a small amount of local anaesthetic into the skin at the sites where the pressures will be tested. The patient will then jog/run/whatever needs to be done to bring on their symptoms, usually for 10-15 minutes. They then return to the room, and the SEM Physician performs the test, which involves inserting pressure manometer needles into the relevant muscles. One special needle has a catheter inside it, and this remains in the leg while the patient does specific exercises, whilst the pressure in the leg is monitored.

 

The test is very safe, but complications can occur- listed below. The test takes one hour. Typically the patient can drive or fly after the test is completed.

 

The SEM Physician always prefers to see the patient before arranging a time for the test, to ensure the test is done correctly right the first time, reducing the risk of getting a false negative result. If the diagnosis is confirmed, then the only real treatment is surgery (a procedure called fasciotomy, performed by an orthopaedic surgeon).

 

Complications

Compartment pressure testing is a relatively safe procedure, but is an invasive intervention, and some complications may result including (but not limited to):

Infection

Bleeding and bruising at the puncture sights

Possible (permanent) damage to underlying blood vessels

Possible (permanent) damage to underlying nerves, resulting in sensory or motor disturbance

Failure of the procedure

Risk of development of acute compartment syndrome requiring and urgent operation

Risk of development of a complex regional pain syndrome

 

 

 

Please feel free to discuss any questions or concerns you may have with the BSEMS staff and specialists.

 

Important Announcement

Sports and Exercise Medicine has recently been accepted as one of Australias new Medical Specialist groups. Whilst this is more of a bureaucratic decision, it has important implications on patients seeing Sports Physicians.

From the 1st November 2010, patients seeing Sports Physicians will require a current letter of referral from either a GP or other Medical Specialist, if they are to be eligible for a Medicare rebate. Patients without a Doctor's referral can of course be seen, but the consultation will not attract a rebate from Medicare.

The BSEMS staff will be able to tell you whether you have a current letter of referral when you book or confirm your appointment. If you require any aid or a letter to your GP explaining the need for referral, we will be happy to forward this to you. We apologize for any inconvenience this abrupt change may cause in the short term.

Sports Psychology

Allira Rogers is our Sports Psychologist consulting at BSEMS every Tuesday afternoon. Allira has been closely watching the Delhi Commonwealth Games, and has seen how the difficult conditions can play on an athletes mind. Please enjoy her contribution below:

One of the key skills that elite athletes have is the ability to create a consistent mindset for every performance.  You would have heard terms like the ‘zone’, ‘bubble’, or ‘ideal performance state’ or what we at Mental Notes Consulting call ‘A game’.  An athlete’s ‘A game’ is when their mind and body are working together to produce optimal performance on a consistent basis. In short, elite athletes know how they want to think, feel and behave to achieve peak performance consistently and they know what makes them compete to their best.  Having this understanding and identifying what you want to be thinking, feelings and behaving for peak performance is what the team of sport psychologists at Mental Notes help those they work with no matter what level, age and sport through the use of various mental skills.

In addition to having a good understanding of what you think, feel and behave when you perform well it is valuable to consider what factors can affect your performance and take you away from your ‘A game’. Athletes constantly face an array of stressors relating to both the competitive and noncompetitive nature of the sporting environment which subsequently place them under intense psychological and physical strains. That is, athletes of all levels and ability are not immune to the impact stressful events within their sport have on their psychological functioning (e.g., increased anxiety, concentration issues, negative self-talk, lack of confidence).

The 2010 Commonwealth Games have been rich in demonstrating the many demands and setbacks elite athletes from across the world have had to face and deal with so as to limit the impact they have on their performance. Some of these demands and events are controllable and some are uncontrollable. The most important thing that elite athletes can do is realise what is in their control and focus their energy and attention on this; their thoughts, feelings and behaviours. That is, their reaction to an event in is their control. For example, swimmers at the games have had to deal with debris in the pool, delays in the starting of events, loud crowd noise as they have taken the blocks to start a race and false starts. For example, the swimmers in the 200m Men’s Relay Final, had to deal with a delay in starting due to debris in the pool.  South African sprinter Roland Schoeman, had to reset his focus after a mishap in the Men’s 50m freestyle event to progress into the final.

However, what elite athletes possess is the ability to deal with these demands and setbacks more effectively to help get them back into their ‘A game’ to help perform the way they want to. How is this? Well, elite athletes have trained all aspects of their sporting performance; physical, technical, tactical and MENTAL. At this level, these athletes know that their competitors have probably done similar types of training for similar amounts of time. That is, the physical difference between them is smaller and what sets them apart is their ability to deal with setbacks, pre-competitive nerves; their MENTAL performance. A good example of this ability to bounce back after a setback will be Sally Pearson in the 100m hurdle at the Games. She was stripped of her gold medal in the 100m women’s sprint final after a contested false start. However, as Sally mentioned "I am in this sport as a competitor and as an athlete just like anyone else. This is our career, this is our job. This is what we train for. To run the race [and] do the victory lap and then be told; 'Oh no you can't have your medal now' is horrible. But I have to deal with it because that's just the way sport is." Through the use of mental skills, athletes can deal with setbacks and demands of their sport so as to recreate and maintain their ‘A game’ on a consistent basis. We can all learn from the elite athletes no matter what age, ability level and sport as we all want to perform at our best consistently.

For more information, contact MNC consultant Allira Rogers by email at allira@mentalnotesconsulting.com.au. Allira works at the Brisbane Sport & Exercise Medicine Specialists at Hawthorne.  Alternatively, visit our website www.mentalnotesconsulting.com.au.

Welcome to the BSEMS September Blog

 

Platelet-rich Plasma and Autologous Blood Injections

The Sports Physicians at BSEMS are pleased to offer Platelet-rich Plasma (PRP) and Autologous Blood Injections (ABI) to our patients. Please refer to our fact sheet for more information. This intervention should be considered an adjunct to a detailed strengthening programme, and is typically used for recalcitrant tendinopathies.

Welcome to Dr Peter Myers

BSEMS would like to welcome Dr Peter Myers, world renowned Orthopaedic Surgeon to the clinic. Dr Myers has long been the preferred knee surgeon for The Brisbane Broncos and Queensland Reds, and is a world leader in meniscal repair, and transplantation. Dr Myers expertise only adds to the wealth of Specialists consulting at BSEMS, and we are happy to have him on board.

Delhi Commonwealth Games

BSEMS would like to wish all the Australian Athletes all the best for the Commonwealth Games competition in New Delhi! After a bit of a rough start, we are sure now the competition has started that India will have its chance to shine as host. A few of the athletes experienced some last minute hiccups before departing andDr Hislop and Dr Vivers were happy to do their part for Queensland based competitors.

Team Coverage

The long NRL and AFL seasons have finally come to an end for 2010, and not without much drama. The Brisbane Broncos are enjoying a well earned break, but the Reds and Academy players will start their preseason over the next few weeks. Dr Hislop was also privileged to help out with some game coverage for the Brisbane Roar football team in September.

Feedback

Please let us know how we are doing. BSEMS strive to offer a world class service to Queenslanders and if you think of ways we can do better please let us know.

Until next time, stay fit, healthy and active.

The BSEMS team.