This month we have an article from our Occupational and Hand Therapist, Lauren Tomasel. Lauren is now working at the BSEMS every Tuesday afternoon. She can help with any acute over use upper limb injury, is very experienced at making thermoplastic and other upper braces, and helps our Upper Limb Orthopaedic Suregons with post-operative rehabilitation. Lauren is this month writing about scaphoid fractures.

Scaphoid Fractures

The scaphoid is one of eight carpal bones that form the wrist and fractures of this bone are the most common of any carpal bone.  A scaphoid fracture, which is a complete or incomplete break in the bone, occurs when the wrist is hyper-extended past 90 degrees when in radially deviated position.  Fractures of the scaphoid are commonly categorised by their location within the bone with waist fractures being most common followed by those to the proximal and then distal pole.

The blood supply to the scaphoid bone influences healing with fractures at the waist sometimes interfering with the blood supply to the bone.  This may lead to a longer healing time and higher potential for avascular necrosis or death of the bone tissue.

Diagnosis

Diagnosis of a scaphoid fracture is made through gaining an understanding the mechanism of injury, clinical examination and radiographic findings.  A patient with a scaphoid fracture may present with pain in the area of the anatomical snuff box (region just above base of the thumb) and on axial compression of the thumb (i.e. application of a load through the thumb, pushing it toward the wrist).  Standard x-rays may confirm the presence of a fracture however some may be unable to be identified on x-ray, requiring further radiological investigations such as an x-ray two to three weeks following the injury, a bone scan, CT scan or MRI. 

The rate at which a scaphoid fracture heals is dependent on a number of factors including:

• Location - proximal pole fractures have a high rate of non-union
• Displacement of the bone at the fracture site - may be suggestive of an additional soft tissue / ligamentous injury
• Obliquity – angulated fractures are unstable and therefore less likely to heal
• Vascular supply

 

Treatment

Conservative management

Stable, non-displaced scaphoid fractures may be treated by casting or immobilisation in a splint / orthosis.  A forearm based thumb spica, as pictured below, is usually required for the first six to 12 weeks following the injury. The period of immobilisation will vary according to the location and is guided by the treating doctor or hand surgeon.

A referral may be made to hand therapy during the early phase of treatment for fabrication of the splint, oedema management and maintenance of range of motion at unaffected joints (i.e. the fingers, elbow and shoulder).  When adequate signs of fracture healing are evident the splint may be removed for hygiene and range of motion exercises to begin with, progressing to strengthening exercises when appropriate.

Surgical management

Surgical repair may be required if the fracture occurs in the proximal pole, is unstable, there is an associated fracture of the distal radius, is more than six to eight weeks old, is displaced greater than 1mm or if fracture angulation is evident. 

Surgical treatment may be completed through the use of percutaneous pins in a closed fashion or via an open reduction and internal fixation (ORIF), generally with a compression screw.  Following surgery a splint can be fitted and is worn until union of the bone occurs.  Mobilisation of the wrist and thumb will generally commence between four to six weeks post surgery.

For further information, regarding this or any other hand therapy intervention, please contact EKCO Hand Therapy on 07 3846 0700.  

 

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.

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.

 

 

 

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.

 

 

 

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.

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.

 

Welcome to the first blog from BSEMS.  We hope to make this a regular occurrence, and a chance to pass on information on what is happening behind the scenes at BSEMS, as well as to provide information on topics provided by our specialists.

Since opening on the 7th April 2010, we have seen hundreds of patients from southeast Queensland with Sports and Exercise medicine issues. The first 5 months have been great, and we look forward to growing and providing a one-stop-shop for Sports Medicine. We have a multidisciplinary team waiting to help wherever we can. Every 1-2 months, we will endeavour to provide a topic of interest on the blog from one of our specialists.

Team coverage

Dr Matt Hislop is joint team physician for the Brisbane Broncos, and looks after the Reds Rugby Academy. The past few months have been a busy time with team cover.

Rugby League:

Dr Hislop was also happy to help with the screening and coverage of the two Queensland teams that played the curtain raisers for State of Origin game 2 held at Suncorp. Of course the real achievement of the night was when Queensland won the series for an historic fifth time.

The last few months have been interesting with the Broncos unfortunately falling short and out of finals contention for the first time in 17 years. Darren Lockyer's rib injury was quite significant, and it is a testament to him that he came close to returning to play. The timing of his injury was incredibly bad for the Broncos, but that is the nature of any sport. The Broncos no doubt are looking forward to some time off, before starting up again for the preseason.

Rugby Union:

The club rugby finals are on at the moment. It has been good to see many past Reds Rugby Academy members progressing to play Super 14 for the Reds- Poutasi Luafutu, Quade Cooper, Scott Higginbotham, Luke Morahan, and Ben Lucas to name a few. Dr Hislop is proud to be part of the team that helps young and upcoming rugby players in the best Academy programme in the country. His Academy role helps with screening, injury prevention, and management of injuries when they do occur.

Soccer:

Dr Hislop was privileged to be invited to help with medical cover for Everton FC when they completed their successful tour of Down Under in July. Thankfully the game was completed injury free, as the team had to board a flight back to the UK later that evening!

Dr Daelyn Vivers

BSEMS have been happy to welcome Dr Daelyn Vivers who has arrived from Perth recently.

She is settling in well and developing a dedicated patient following.

Dr Vivers is the newly appointed QAS Swimming doctor, and also looks after Water Polo.

She was involved in the coverage of National Short Course Championships at the Sleeman Centre, Chandler in July. Many of the well known Queensland swimmers have gone on to do well at the Pan Pacs Championship recently held in the USA, including Jessica Schipper, Sophie Eddington and Emily Seebohm.

Dr Vivers has recently undertaken a thorough review of exercise induced asthma and its management and is happy to manage any musculoskeletal problem.

Feedback

At BSEMS we are proud of our world class new rooms, great website, and our multidisciplinary team of specialists. We want to make life easy for our patients, by offering a one-stop shop for Sports and Exercise Medicine. (We do not have physiotherapy on site, but work closely with many of the excellent sports physiotherapists in our area.) Please peruse our website for more information on what each practitioner does. We welcome and value your feedback, both positive and negative.

Best regards until next blog!

Dr Matt Hislop

Practice Principal