Managing an acute injury

Knowing how to immediately look after an injury for the first few days can speed up its recovery. In this blog we look at a more up to date protocol on how to help you manage it.

Many of us are well versed on the R.I.C.E acronym (Rest, Ice, Compression, Elevation). Which eventually was upgraded to P.R.I.C.E (P = Protect). Over the last few decades the advice on the management of acute injuries has rarely been contested. However, with growing research there has been a change in the way clinicians deliver advice on acute injuries to patients. With more recent research there is a new acronym called P.O.L.I.C.E. Standing for Protect Optimal Loading Ice Compression Elevation.

What’s changed?

The term REST can be completely misinterpreted. While it’s important to have a balance of rest AND loading. Too much rest can lead to
deconditioning of tissues, stiffness and weakness. By OPTIMALLY LOADING tissue it provides the right levels of stress to encourage tissue healing, while assisting with the drainage of swelling.

What is the right amount of load?

Firstly, you must listen to the pain and not try to push through it. But if in doubt seek advice from a health professional, whether it be a Dr or Physio. Assessing the injury will help clear any serious problems, like fractures or ruptures. After having the serious issues cleared, you can be guided on the appropriate movements or weight bearing exercises to perform.

If in doubt seek advice from a Health professional

Additionally, to help provide the right loading you may require a moon boot, crutches, brace or strapping for support. Before being gradually weaned off.

Ice

I’ve previously questioned the value of applying ice for reducing swelling. There is growing evidence that shows that we need some swelling to aid in the healing process and  by using ice to minimise swelling, we could be slowing down the rate of tissue healing. 

See: hold the ice in RICE

But using the ice instead to reduce pain, by limiting nerve conduction and lowering tissue temperature. This can be effective within 5-10 minutes of application. Doing this every hour will bring pain levels down allowing you to move or load the tissue as tolerated.

Side note: Make sure you regularly check tissue quality while icing to avoid frost bite.

Compression and Elevation

These two are the least controversial in their benefit of recovery from acute injuries. Having compression helps maintain swelling to a manageable level and the area can still move normally. Making sure the compression is tight but not causing pain or numbness. You can use crape bandaging or a tubigrip.

Elevation, particularly for the lower limb helps again at minimising excessive swelling. While elevated it helps to be gently moving the
area, which also assists with tissue healing and swelling.

Anytime you’re dealing with a new injury it’s important follow the most up to date advice to help you recover as quickly and safely as possible. By seeking physio, we can offer you that guidance and support as you progress. At Fundamental Physio Newmarket, you’ll be thoroughly assessed to identify the extent of your injury, then put on the right treatment plan to help you return to normal activity. 


References

Bleakley et al 2012 PRICE needs updating, should we call the POLICE? Br J Sports Med 

Algafly et al. 2007. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med

Malanga et al 2015. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med

Top 5 Posts of 2017

Entering the new year here’s a look back at last years 5 most popular blogs.

Happy New Year – 2018 is already under way. Hope you all had a great break.

Last year was a busy year with the blogs. Here are the top 5 posts from last year in case you missed them.

5. The Office WOD

  • How many of us at work get stuck in the same position and forget to move?
  • This post was offering some general strengthening and postural awareness exercises to follow regularly at work.
  • Try getting into a routine with these types of exercises. It should help prepare you better for training.

4. Trigger Points – what are they?

  • Those knots felt in your traps after a busy day at work are more than likely trigger points.
  • This blog goes into explaining what they are, how they’re caused and how they’re treated.

3. Recovering from DOMS

  • This was a popular topic as we all love a bit of DOMS.
  • Understanding how to manage your recovery and training while in the DOMS phase will make it more tolerable.
  • Also knowing the difference of pain between DOMS and an injury will help avoid making anything worse.

2. Improving front rack position

  • After doing many mobility assessments, the front rack shape is what most people struggled to hold passively without a bar.
  • This was one of a 4 part series of shoulder shapes we should be achieving to help make movement more efficient.
  • It offered a range of mobility exercises to open the shoulder into the front rack.

1. Anterior knee pain in CrossFit

  • One of the most common injuries in sports and top 3 with CrossFit athletes is a knee injury.
  • This blog looked at anterior knee pain and the common causes. It offers some basic suggestions to self managing the injury.

The purpose of these blogs has been to provide a wider understanding of your body and give you more control of it. Wishing you all an injury free 2018 and keep checking for the new blogs.

What’s causing my muscle tightness?

Muscular tightness is one of the disruptions to normal movement and if not managed well can lead to possible injury. Identifying your tightness and using specific strategies will help relieve tension.

One of the main issues patients struggle with is muscular tightness. They get a feeling of pain or tightness and an inability to relax the muscle.

What is tightness?

When looking at patients I need to find out if they have mechanical stiffness or the “feeling” of tightness or a combination of both, as this would direct my treatment plan.

Is the range of movement limited? does it have a soft or hard end feel? Are movements a struggle at end range, feeling heavy? What’s the rest feeling like, is it a constant tightness?

While we can have mechanical tightness of a joint or muscle, there are also the “feelings” of tightness. You might get your hands to the floor with your legs straight and feel the hamstrings tightening. While another person could do the same, get to their knees and not have tightness.

What causes the feeling of tightness?

Tightness is a sensation like many others, including pain. What we understand from pain is that this is not always brought on physically, but also by the perception of threat.

pathway-of-a-pain-message-via-sensory-nerve-in-injured-muscle,2324600

So like pain, tightness is a protective mechanism from the central nervous system to avoid danger. On a number of levels it detects stressor’s that expose the whole body or specific region to threat.

Examples of this…..

  • Prolonged sitting, without movement we often notice tightness in certain areas, possibly through reduced oxygen supply and increased metabolic toxicity.
  • Stressful situations cause rising cortisol levels and increased activity of the Vagus nerve leading to muscular tightness.
  • Repetitive movement over a period of time causes increased tension.
  • Posture muscle tightnessInjury or pre-existing weakness can cause a guarding response from the nervous system.

Using tightness as a warning sign for these potential threats might allows us to acknowledge the situation and quickly act upon it.

What will help my tightness?

Like all movement patterns, we improve with practice. The same goes for muscle tightness. If we regularly bombard it with neural messages to remain tight we develop trigger points and chronic tightness through a process called central sensitisation. Which makes the tissues more sensitive to pain and tightness.

If we can regularly supply our nervous system with input that is non-threatening we can slowly help desensitise the muscle. But this takes time and regular repetition.

Stretching

Most people with tightness, especially after prolonged rest feel the need to stretch out. But depending on our intended goal there are different types of stretches.

  • Static stretches
  • Active stretches
  • Dynamic stretches
  • PNF (Contract-relax)

While these stretches will help, it might only be temporary without regular repetition and reinforcing the nervous system with good movement.

Strengthening

There is a misconception that resistance training causes our muscles to feel tighter. Mainly due to the effect of DOMS. That feeling of soreness you have the day after a hard workout. But some recent studies have shown that strengthening can be equally, if not more beneficial than stretching.

Improvements in flexibility coming from improved ability to handle higher levels of metabolic stress and lower levels of inflammation. By lowering the threat to the nervous system through increased strength, it allows you to work the muscle through a wider range, without getting a stretch reflex.

Massage and other soft tissue work

Another way to help desensitise these tight muscles is to apply pressure. This could be with the use of a foam roller/lacrosse ball or other manual therapy techniques like deep tissue massage, myofascial release, trigger point release, dry needling.

Relaxation techniques and breathing mechanics

Like in the previous blog, an overactive or dominant sympathetic nervous system can cause muscle tightness. Finding ways of breaking poor postures or shallow breathing using a range of methods like kapalbhati, wim-hof, meditation, yoga etc. Using these methods are just part of the process to lowering overall tightness.

Usually, just following one of these methods individually is not going to be as effective as combining them together. Try to deal with the tightness from all angles.

If guidance is required or manual therapy techniques feel free to call 09 5290990.

Strength Training for Endurance

This is a literature review of the benefits of including resistance training into your running or cycling training programme.

Rønnestad 2014

For recreational runners and cyclists, strength training is not always considered important when developing increased pace, endurance and mechanics. But this paper from 3 years supports the involvement of explosive strength training as part of a training program for endurance runners/cyclists. With benefits of improved endurance to muscle fibres when in an anaerobic state, increased tendon stiffness and greater explosive power.

The study went on to find numerous benefits with the addition of strength training. And provided these recommendations.

  1. To improve the chance of increased endurance performance following a strength training program, the resisted exercises should engage similar muscle groups and imitate sport specific movements. This will result in firing up the same neural pathways connected with the motion of running or cycling.
  2. Force output may increase the ground strike in runners or force velocity in cycling if an explosive focus is put on the concentric phase of the muscle. For example pushing fast out of the back squat.
  3. At least 2 sessions per week of strength training to develop maximal strength over a 12 week program. Beginning with lighter loads in the first 3 weeks to learn correct form before increasing load. Working within 8-12 reps and 2-3 sets.

Some beneficial lifts for runners and cyclists would include back squats, dead lifts, hip thrusters and bent over rows.

Abstract

Here we report on the effect of combining endurance training with heavy or explosive strength training on endurance performance in endurance-trained runners and cyclists. Running economy is improved by performing combined endurance training with either heavy or explosive strength training. However, heavy strength training is recommended for improving cycling economy. Equivocal findings exist regarding the effects on power output or velocity at the lactate threshold. Concurrent endurance and heavy strength training can increase running speed and power output at VO2max (Vmax and Wmax , respectively) or time to exhaustion at Vmax and Wmax . Combining endurance training with either explosive or heavy strength training can improve running performance, while there is most compelling evidence of an additive effect on cycling performance when heavy strength training is used. It is suggested that the improved endurance performance may relate to delayed activation of less efficient type II fibers, improved neuromuscular efficiency, conversion of fast-twitch type IIX fibers into more fatigue-resistant type IIA fibers, or improved musculo-tendinous stiffness.

Rønnestad et al (2014). Optimizing strength training for running and cycling endurance performance: A review. Scandinavian journal of medicine & science in sports

21617700_1637509319612971_4403438680384241559_n.jpg

Do your hips get the green Light?

Functionally the hip has certain positions that create stability and power. We should be looking at accessing its full range to ensure the health of the joint.

Healthy joints make difficult movements easier

Just like the shoulder, the hip has an important role in allowing us to function in various positions. It’s also a ball and socket joint, with both joints acting as catalysts for power, stability and accuracy of its connecting limb.

Unlike the shoulder as you may already know, the hip is held within a deeper socket, but still has a multitude of muscles surrounding the joint, including its own rotator cuff. The hip also has a ligamentous capsule with fibres angling in different directions. Using the capsule the joint can wind up into some very strong and stable positions. Accessing these ranges of tension puts the joint into a safe place to absorb load.

Gray339

These high torque shapes held by the hip are our start and finish points of most movements of the lower limb. Most of the time we can function well within the realms of the inner movement. But if we struggle to start from these positions it becomes difficult to transition and finish in a safe end shape. The goal should be to have full physiological capacity.

In the hip, there are 3 shapes we should all be able to achieve.


  1. The first movement is the squat/hinge a combination of flexion and external rotation at the hip. This movement takes all the glory, it’s all of our squat movements, it’s dead lifting, it’s rowing and the list goes on.
  1. Next is the Lunge/run which is full extension of the hip with internal rotation. This could be the bottom of a split Jerk, in running it would be your trailing leg before leaving the ground.
  1. Pistol is the last movement which alludes a lot of people (including myself), requiring full hip flexion but also full ankle dorsiflexion.

While the squat/hinge position is the most common hip shape used. We should also feel competent at the other 2 positions. Over the next few weeks I’ll go through the 3 movements and provide some ideas to achieve full depths.

Understanding shin splints

There is no satisfaction without a struggle first

Those that have experienced shin splints know how frustrating it can be to train. Whether it’s running, skipping or box jumping. Pain can be so intense that we stop doing these movements for a short period or permanently out of fear. With shin pain, there are many different factors that cause it. This is why having it assessed and treated appropriately can help you ease back into these activities with more control over symptoms.

  • Shin splints is a vague term used to describe overuse or repetitive strain of structures in the lower leg.
  • In athletics and military, “shin splints” can affect up to 35% and is more prominent with females. (1)

Take a look at the several muscles in the shaft of the lower leg, and the layers we have in our bone.

It’s very easy to label the condition as “shin splints”. But looking at the different structures involved with shin pain a more accurate diagnosis would help direct treatment and management of the problem. Shin pain can also be produced by other conditions.  Another reason to get assessed.

Shin splints (other conditions)

Bony shin splints

The outer layer of bone called the periosteum has a great blood and nerve supply. This makes it a common area for feeling shin pain. When training under normal stresses with adequate rest the density of bone increases which allows us to tolerate running for longer. If stress forces increase with little rest time in between, inflammation and pain develops. Pain ignored for long enough could result in a stress fracture.

Rest period of stress fracture: Depending on the severity and nature of the fracture it may take 4-12 weeks. Having it assessed and possibly X-rayed will help guide the timeframe.

Rest period for inflammation of the bone: This requires a shorter rest time but should be closely monitored to ensure we identify the cause of extra stress to the bone. Usual rest periods will be 4-6 weeks.

Muscular shin splints

Compartments of lower leg.gif

Muscles of the lower leg are held within compartments wrapped up by fascia. During running for example these compartments build up in pressure. As the pressure rises, oxygen levels lower, toxicity builds and then results in pain. A condition known as Exertional Compartment Syndrome (ECS). If ignored this could lead to chronic exertional compartment syndrome which often requires surgery . 

Rest period for ECS: Similar to the inflammation of bone, it may require between 2-6 weeks of rest. In this time, it is about identifying the issues causing the problem and building up a tolerance to the activity.

Tendon shin splints

Tendons are the pulleys of muscles, they connect to specific bony points to cause a movement. Inflammation of the tendon can be cause by excessively loading the tendon . Three tendons that lead to shin related pain are the Achilles, tibialis posterior and the peronei. Most common being tibialis posterior.

Shin splints tendinopathy

The Tibialis posterior muscle supports the arch and if it fails can result in many changes to the foot and ankle. Catching this fault early will allow you to correct the problem easier.

Rest period for a tendinopathy: This really depends on the length of time you’ve suffered, the severity and foot mechanics. Recovery time can take up to 12 weeks. Giving time to offload the tendon and building up stress’ again.

Managing shin splints

As mentioned above, it’s important to make a clear diagnosis to provide adequate rest and adjust back into your activity. Along with normal hands-on therapy and exercise prescription, physio can help shin pain specifically through adjustments made to the following:

  • Training error – over training, excessive distances, change in running surface.
  • Poor foot mechanics – A foot with a high arch or that rolls in poses a higher risk for stress fractures and tendon pathologies when running.
  • Footwear – Shoes lacking adequate arch support for an unstable foot causes muscles/tendons to work harder.
  • Running form – Analysing running form will help identify weak structures and correct poor patterns.
  • Movement and balance control – Good balance at the ankle, knee, hip and a strong “core” of your trunk muscles play vital roles in evenly distributing the force.
  • Muscle flexibility – Tightness of muscles can put excessive load on the tibia while running.
  • Ankle mobility – Increased ankle range of movement with joint mobilisations and stretches can reduce stresses on the lower leg.
  • Muscle strength and endurance – The strength of a muscle helps maintain a good position while running or jumping. But it also requires stamina to repeatedly hold position.

Returning to running

Returning to normal running with shin splints is always an uphill battle and is never a smooth transition. It’s a learning experience, understanding what your body can withstand and tailoring your rehab appropriately. It can be frustrating, but having patience with the process will get you back into your activity.

The Office WOD

Do your best when no one is looking. If you do that, then you can be successful at anything that you put your mind to.

Following up from last weeks piece about SITTING POSTURE. It’s not about holding the perfect posture. Whats more important is changing position regularly, adding variation. Holding postures long enough results in changes to the strength of a muscle and how quickly it activates.

Neuroplasticity

This refers to the brain constantly changing to its environment, trying to find more efficient neural connections.

Consider your memory at school, studying a particular subject and you ace the exams. Now think 10 years on and you’ve done nothing relating to the subject, you’ll likely struggle with the same exam paper. The neural connections changed, these memories were not regularly reinforced and were forgotten.

Look at the typical sitting posture above that we find most of us in. Multiple changes are happening from head to toe. This also happens on a neural level. The longer we hold this posture the more the change will be ingrained. When doing complex activities that require fast reactions or more strength the adapted structures will make the task more challenging.

The Office WOD

The office workout is focusing on the neglected muscles we forget to stretch or use throughout the working day. Following this routine, 10-15 minutes at Lunch or on a coffee break will help maintain healthy muscle activity and length.

**This does not substitute exercise that gets your heart rate elevated.

The Workout won’t draw too much attention to you in the office. I won’t have you doing planks off the office chair or dead lifting the photocopier.

1. Chin Tucks (1 minute)

2. Neck Extensor stretch (1 minute)

3. Thoracic Spine Stretch (2 minute)

4. Posterior Shoulder Strengthening (1 minute)

5. Forearm  Stretch (1 minute Each)

6. Glute Strengthening (1 minute)

7. Hip Flexor Stretch (1 minute each)

8. Hamstring Stretch (1 minute each)

9. Calf Stretch (1 minute each)

Try these exercises in your workplace to get muscles fired up again and working. Feel free to leave a comment about any of the exercises or any suggestions for changes.

Ligament Sprains & Timeframes

Ligament sprains are one of the most common injuries, as their main role is to support the
joint. If poorly managed there is a risk of further injury.

Patience is not about doing nothing. Patience is about doing everything you can. But being patient about Results

What are ligaments?

Ligaments are fibrous tissues that attach from one bone to another across a joint. The tissue is very strong, varies in thickness and is dense with nerve receptors. Its role is to provide stability, guide movement, maintain joint shape and act as position sensors for the joint.

Previously ligaments were thought of as inactive structures, they are in fact complex structures that influence the localised joint and the entire body once injured (1).

How are ligaments injured?

Ligament sprains are the result of loads exceeding the maximum strength of the ligament with little/no time to recover. This force causes acute tears of the ligament fibres.

These structures can be damaged through several mechanisms, like contact or direct trauma, dynamic loading, repetitive overuse, structural vulnerability and muscle imbalance (2). A sprain of ligaments usually affect the following joints:

How does it affect us?

As with most soft tissue damage there will be the typical acute pain and swelling. Injury to a ligament will compromise joint stability and ability to control movement. It can also reduce our balance, proprioception and muscle reflex time (3). With poor joint position comes restriction in movement and weakness of the surrounding muscles.

What types of ligament sprains are there?

The severity of ligament injury is graded using various clinical classifications. The most common is a three-level system that determines structural involvement.

Grade 1 Grade 1 sprain1

  • Slight stretching and microscopic tearing of the ligament fibres
  • Mild tenderness and swelling around the ankle
  • Heals within 1-2 weeks 

Grade 2

  • Partial tearing of 10-90% of the ligament fibresGrade 2 sprain1.jpg
  • Moderate tenderness and swelling around the ankle
  • Partial structural instability when tested by Physio or doctor
  • Healing takes up to 6 weeks

Grade 3

  • Complete tear of the ligamentGrade 3 sprain1
  • Significant tenderness and swelling around the ankle
  • Complete instability when put under stress
  • Poor weight bearing
  • Conservative treatment can take 12-16 weeks
  • Potential reconstructive surgery is required

*Timeframes are based upon the guidance of a professional. Treating injuries on your own poses a risk of not fully recovering and a greater chance of re-injury.

For an appointment, call on 095290990 

  1. Frank, (2004) Ligament structure, physiology and function. J Musculoskelet Neuronal Interact
  2. Gabriel (2002) Ligament injury and Repair: Current concepts. Hong Kong Physiotherapy J
  3. Hauser (2013) Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics. The Open Rehabilitation Journal

Recovering from an ankle injury

Ankle sprains are a common injury in sport. If not assessed by the physio and guided correctly through the recovery they often struggle to get back to normal levels and are more likely to re-injure the joint.

Ankle sprains

Ankle sprains account for up to 30% of all sports injuries (1). When the ankle joint is put under strain from sudden twisting forces or landing in an uneven position it causes too much stress on the supportive ligaments, resulting in a tear. More commonly seen in sports with lateral movement and jumping, such as basketball or volleyball. But everyday life, misjudging steps or walking on uneven ground.

Symptoms:

  • Severe pain
  • Swelling
  • Bruising
  • Difficulty walking
  • Stiffness
  • Weakness
  • Loss of balance

What structures get damaged?

Fractures

The ankle consists of 3 bones, the Tibia,ankle fractures Fibula and Talus. Depending on the force from the injury we can have fractures of the tibia and fibula. 25% of ankle sprains could have some form of fracture (2), whether it be a complete break, a chip of the bone or the ligament pulling the bone from its attachment. An Xray would help eliminate this diagnosis and help guide your rehab.

Ligaments sprains

The ankle is the pivot point for the foot and the leg, it gives us a range of different movements. We have ligaments aligning in various directions to provide support for the ankle. When movement is taken too far ligaments can be damaged. On the outer part of the ankle we have 3 ligaments, the inner part has a large dense ligament and the tibia and fibula have connecting ligaments.

An ankle sprain can have more than one ligament involved, but the most common ligament to get strained is the Anterior Talo-Fibila Ligament (ATFL), affected by up to 73% of ligament injuries (3). Most commonly brought on from rolling the ankle.

The degree of damage to ligaments is classified by grades 1-3. Grade 1 meaning small tears of the ligament fibers, Grade 2 a partial tear of the ligament between 10-90% and grade 3 being a complete rupture. All grades have different recovery times and need to be guided appropriately for the best outcome.

Management of my ankle sprain

In the first 72 hours you will go through the first stage of healing. During this time you want to move the ankle within your comfort level, don’t push into sharpness. Compress and elevate the joint to manage the swelling. If you wish to use ice (5 minutes minimum) and NSAID’s, use it sparingly only to control the pain. See my blog about ice for more info.

Diagnosing an ankle sprain and rehab

If you have sprained an ankle it’s important that you are assessed by a Dr or Physiotherapist. Taking a detailed history and clinically assessing your ankle will help us come to a clear diagnosis of your injury. Xrays and ultrasound scans may also be required.

Someone that sprains their ankle is 5 times more likely to sprain their ankle again (4)

Once we understand the severity of the injury, treatment can be more specific to achieve the quickest recovery. Physio can assist in number of ways:

  • Education – Understanding the tissue recovery, the mechanics of the ankle, knowing your treatment plan and the stages of your rehab.
  • Gait re-training – You may start off on crutches or a moonboot, but then weaned off and guided to walk normally.
  • Exercise prescription including sport specific training – As you improved you will be provided the appropriate exercises. Including exercises relating you your sport to make a better transition.
  • Balance exercises – Progressing balance is essential to preventing further ankle sprains.
  • Taping – There are a number of strapping techniques for swelling/bruising in the initial stage. Strapping can ease you back safely into sport.
  • Soft tissue massage – This helps stimulate blood flow and encourage healing. Also, helps desensitise the nervous system to encourage better movement.
  • Mobilisations – to assist in better movement of the joint and gives you more confidence to use it.

For an appointment, call on 095290990 

  1. Fong et al, (2007)A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007
  2. Luciano et al, (2012) Epidemiological study of foot and ankle injuries in recreational sports. Acta Ortop Bras
  3. Woods et al, (2003) The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. A Br J Sports Med.
  4. McKay et al, (2001) Ankle injuries in basketball: injury rate and risk factors. Br J of Sports Med.