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

Complex movements and a neutral spine

Being aware of what a neutral spine feels like is a good start. But when incorporating it into more difficult movements, it requires patience and consistency.

Let’s start simple before making it complicated

Moving with integrity is essential to getting the best output from your exercise and with that, understanding the principals of neutral spinal position play a primary role. You could be pushing off to sprint or jumping up to block a shot or preparing for an Olympic lift, finding a neutral spine provides your limbs with a stable base to engage.

Maintaining a neutral spine

What is a neutral spine?sPINE

The design spine provides a wide range of movement in different directions, helped by having 25 mobile vertebral segments. This allows you to be highly functional. But not all spinal positions are efficient. It’s a neutral spine that evenly distributes stress through the complex tissue structures of the spine. This reduces the risk of injury when challenged and provides a strong platform for the arms and legs to work from. It also provides the least amount of tension on the nervous system as it branches out from the spinal column.

Looking at the supportive network of the spine, it’s made up of 3 arches. A slight inward cervical arch (neck), an outward thoracic arch (mid back) and inward curve at the Lumbar (lower back). Underneath the lumbar is the sacrum connecting to the pelvis.

Cannons being fired from a battleship have more power, stability and accuracy than once fired from a canoe.

Why do we need a neutral spine?

Physically it’s the most efficient position, but it doesn’t mean we need to be fixed in this shape at all times.

It does however become important when we throw complex movements into the mix. A complex movement is something that requires speed, power and timing from multiple muscle groups across multiple joints. Lacking the coordination of maintaining this posture during difficult movements not only compromises the spine but offers poor performance output.

An easy example of poor spinal position can be the dead lift. Often people race to get a heavier lift while ignoring the potential risks to the tissues of the spine. Finding a neutral position will not only be safe, but will offer better outcomes in developing strength.

Another example I see is the pull up. Coming over the bar there is often excessive chin poke and neck extension to clear the head over the bar. This compromises the neck, shoulders and upper back.

If you’re struggling with maintaining this spinal shape when doing complex movements you might want to remove an element of difficulty, such as weight, speed or scaling the movement. Develop better body awareness before making it more more challenging.

How to find your neutral spine

On the floor – 

  • Lying down on your back with your knees bent and feet flat on the floor.
  • Tilt your pelvis up and down to feel the top and bottom of your sacrum, at the back of the pelvis.
  • Then you want to feel the middle of the sacrum, adjusting your pelvis, it will lie between the top and bottom of the tilt.
  • Then tuck your chin in without fully flattening your neck to the floor.Finding neutral spine

Once you’re confident with the shape, get up into standing and attempt to maintain it through movement. The video below, using a stick will provide feedback to keep you well positioned.

… and then once you’re confident with keeping this shape, slowly start incorporating it into heavier, faster movements. This will put you in a safer position and improve the results of your training.

 

Study: When is bending too much?

This recent study looked at sustained bending and the time it takes before our postural muscles give in and we begin to rely on our passive structures for support.

Alessa 2017

How long is too long, to be in a forward, bent posture? Many of us spend hours doing house chores; weeding, DIY, working on the car etc. Not to mention the time spent leaning over a computer desk or looking down at your phone.

Back pain

Your muscles play an amazing role of suspending us in these positions, but just like with exercise our muscles will reach a point of fatigue. When the postural muscles aren’t able to provide the support we then rely on “passive” structures like ligaments and fascia, which is not their primary role, eventually leading stress and increased risk of injury.

This study looked at 2 angles of the spine leaning forwards and found that within 40 seconds the participants transitioned from the support of postural muscles to the passive structures. While this was found to be a natural transition the prolonged strain on the passive structures has been shown to increase the risk of lower back pain as suggested in another study.

As mentioned in a previous blog, these positions are not “wrong” but it’s better for the overall health of the spine to regularly change position and break from sustained load on an individual structure to provide balance.

Abstract

Static trunk bending is an occupational risk factor for lower back pain (LBP). When assessing relative short duration trunk bending tasks, existing studies mostly assumed unchanged spine biomechanical responses during task performance. The purpose of the current study was to assess the biomechanical changes of lumbar spine during the performance of relatively short duration, sustained trunk bending tasks. Fifteen participants performed 40-s static trunk bending tasks in two different trunk angles (30° or 60°) with two different hand load levels (0 or 6.8 kg). Results of the current study revealed significantly increased lumbar flexion and lumbar passive moment during the 40 s of trunk bending. Significantly reduced lumbar and abdominal muscle activities were also observed in most conditions. These findings suggest that, during the performance of short duration, static trunk bending tasks, a shift of loading from lumbar active tissues to passive tissues occurs naturally. This mechanism is beneficial in reducing the accumulation of lumbar muscle fatigue; however, lumbar passive tissue creep could be introduced due to prolonged or repetitive exposure.

 

Alessaa F. et al (2017) Changes of lumbar posture and tissue loading during static trunk bending. Human Movement Science

Continue reading “Study: When is bending too much?”

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.

Iliotibial Band Syndrome

Whether your running, rowing cycling or lifting. Repeated knee flexion may irritate structures on the outer knee. It is important to get on top of this condition to stop it hindering your training.

Setbacks are the perfect opportunity to grow

Iliotibial band syndrome is most commonly experienced with runners. But also in all sports that require repetitive knee flexion under high load. Early signs and symptoms often go unnoticed (or ignored) until it’s blown up into a fully-fledged injury.

What is the Iliotibial Band?

Iliotibial band

The Iliotibial Band (ITB) is a thick fibrous band of strong connective tissue running down the lateral side of the thigh. Its attachment points at the hip are from the Glutes at the back and Tensor Fascia Latae at the front. The bottom connection feeds into the outer border of the knee and patella. It’s at this attachment point that pain and inflammation develops and would be classed as Iliotibial Band Syndrome (ITBS).

The role of the ITB is to provide the knee with stability and to abduct the hip outwards. When we walk, run or squat it’s working hard to keep the knee in the correct position and force is distributed evenly.

What are the symptoms of ITBS?

Problems arise when the lower limb moves in abnormal directions repeatedly, causing the band to flick over bony structures of the knee, leading to irritation. It may also get tighter than normal through shortening or over activity of the Glutes and Tensor Fascia Latae. This results in the ITB becoming a tighter band pulling more at its attachment and compressing other tissue around it.

ITBS usually is a sharp pain or burning sensation in the lateral knee. Generally, felt during exercise when the knee flexes repeatedly through mid-range. This range of 30-40 degrees is when pressure of the ITB against the bone is at its highest. If this movement is repeated enough, it causes friction and irritates the tissue.

What causes ITBS?

There are a number of factors that can cause a stir up of ITBS. Physically there could be a muscle imbalance, with tightness or weakness around the pelvis, hip or knee, reduced balance, and reduced ground reaction time. Mechanically, often due to the physical limitations that cause incorrect movement patterns, poor weight transferring and distribution of load.

On top of this are issues with training error. How quickly a programme is progressed, especially if it involves load or speed. From running to weight lifting, training loads need to be gradually increased to reduce the risk of injury.

Management of ITBS

Initially you may be restricted from doing the activity that caused your pain while your body recovers. An assessment will help you identify what factors are triggering your ITBS. Treatment will be multifaceted providing advice for tissue loading, gait retraining and specific muscle strengthening and stretches. Additionally, soft tissue manipulation, strapping and dry needling.

With the improved running form, increased strength and flexibility you will gradually be introduced back into the activity. This will make you overall better at your sport and reduce the risk of this problem returning.

Evidence shows that ITBS responds well to conservative management with a success rate as high as 92%.

If you’re struggling with recovering on your own contact me on 09 5290990

Lunge Hip Mobility

The 2nd part of hip mobility focuses on your lunge shape. Having full access to hip extension will improve your running, throwing and kicking abilities.

This is the second part of the hip series. These hip shapes are positions that we should all be striving for to have confidence and feel safe to function if exposed to complex positions. 

Following on from the blog hip opener for the hinge shape is our next hip position we should try to achieve. The lunge shape is full extension and internal rotation of the hip with the knee positioned behind the hip and foot pointing forwards. This shape is most seen in lifters doing split jerks, kicking a football, ball throwing. But most commonly seeing this lack of range with runners, not utilising the full hip extension in the push off at the end of stance phase.

Over the years adaptive changes happen either through injury or more with positions we adhere to. The most common being sitting, which results in anterior structures of the hip becoming limited. Lacking the end range of this movement could mean we’re selling our self short of momentum, power or endurance.

Running-lunge

Using the picture of long distance runner Mo Farah, he demonstrates a great lunge shape at the hip. While maintaining a neutral spine he manages to reach full hip extension and toes are pointed forwards, maintaining the internal rotation of the hip. Lacking hip extension can compromise running form of the upper limb and spine. But as you can see he reaches a good press shape of the opposite shoulder in the arm swing making his running style extremely efficient and balanced.

Below are a series of stretches and mobility exercises to help improve your lunge shape.

Couch stretch

If hip flexors are tight this is one of the best stretches for improving length back. A long sustained hold of this stretch with full diaphragmatic breathing over 2 minutes is extremely effective.

Illiopsoas Trigger Point Release

This muscle sits within the abdominal cavity and if tight it will feel sore with pressure through the abdominal wall towards the muscle. At first the pain can be quite high but relaxing into the pressure overtime the pain subsides and will feel looser once released. Aim for 1-2 minutes hold.

Hip flexor stretch (with band)

Another hip flexor stretch with a joint mobilisation using a band. Position the knee behind the hip. Allow the band to pull the hip forwards, contract the glutes to get the best anterior hip stretch.

Quads and inner thigh release with LaX ball

A lacrosse ball is a great tool for isolating sections of tight muscle. Rolling on the ball like you would a foam roller will be more effective, if tolerated. Then opening up inner thigh/hip adductors using the kettle bell handle. The knee flexion/extension stretches the muscle through range while being tacked down.

Suspended split stretch

This is for the more adventurous. It will help your lunge go deeper while increase stretch through the hamstrings. Throughout this movement, it is important to keep the glutes switched on to avoid hanging of the hip capsules. Spend around a minute each direction.

Continue reading “Lunge Hip Mobility”

Hip Opener for Hinge Shapes

The hip hinge is an important movement in daily activities as well as in sports. Many people are unaware this movement exists and struggle with reaching their potential.

Many lifting injuries result from a lack of movement awareness and weakness of the posterior muscles. The hip hinge is a foundational movement for so many actions like deadlifts, squats, sprinting, jumping. Lacking an effective hip hinge is like racing a formula 1 car on flat tyres.

Developing a good hip hinge will improve the strength of the posterior chain. This includes muscles like the glutes, hamstrings and back extensors. The hinge movement is primarily coming from the hip. The goal is to maintain a neutral spine throughout the movement, the hips start to bend with your butt moving backwards and minimal flexion in the knee. This will increase the tension on the hamstrings and glutes.

The majority of people find this pattern of movement unnatural, as it’s rarely practiced and in most cases, are quad dominant. This quad dominant pattern causes weight to be distributed anteriorly, which is fine with some activities, but most actions we need to be more engaged with our posterior chain.

hip hinge movements.jpg

 

Below are a series of stretches and strengthening exercises to help Improve your hip hinging abilities.

Weighted Hip Hinge

This exercises is a great way to warm up and encourage the hip back movement while fighting the resistance to maintain a neutral spine.

Banded Hip Distractions

These two movements are also great for warming up. Both encourage release of the hamstrings but also the band provides a traction force on the hip socket. This should allow the joint to move free’er and help you access more range in the joint.

Dynamic Hamstring stretch

This is a deeper stretch of the hamstrings. Having more flexibility here will help you hinge better at the hip which will off load the knees.

Jefferson Curl

This movement is a great way of developing movement segmentally and will help build strength when maintaining a stable spine. It’s important to note if you have a spinal injury to avoid this movement until you have gone through the appropriate phases of rehab.

Continue reading “Hip Opener for Hinge Shapes”

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.

Disc Prolapses that Reabsorb

A recent study shown that re-absorption of disc prolapses is higher than previously thought.

Zhong 2017

The Concern and fear that the words “slipped disc” “disc bulge” or “degenerative disc disease” can be worse than the actual symptoms of pain. The image of being broken and not being able to recover. But as previously noted in another blog about MRI scans, a large number of the general public suffer with a disc prolapse without symptoms. They manage to carry out a normal fulfilled life.

This new study of pooled data from the UK and Japan showed a significantly high number of lumbar disc re-absorption. To be precise it was 66.6% (82.94% in the UK I might add!!). All patients received conservative treatment, there was no invasive treatments like surgery or steroid injections.

This goes to show that with patience in your recovery and the right guidance, spinal problems will resolve without being too hasty for surgery.

 

Original Abstract

BACKGROUND: Lumbar disc herniation (LDH), a common disease, is often treated conservatively, frequently resulting in spontaneous resorption of the herniated disc. The incidence of this phenomenon, however, remains unknown.

OBJECTIVE: To analyze the incidence of spontaneous resorption after conservative treatment of LDH using computed tomography and magnetic resonance imaging.

STUDY DESIGN: Meta-analysis and systematic review of cohort studies.

SETTING: The work was performed at The Suzhou Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine.

METHODS: We initiated a search for the period from January 1990 to December 2015 using PubMed, Embase, and the Cochrane Library. Two independent reviewers examined the relevant reports. The references from these reports were also searched for additional trials using the criteria established in the PRISMA statement.

RESULTS: Our results represent the pooled results from 11 cohort studies. The overall incidence of spontaneous resorption after LDH was 66.66% (95% CI 51% – 69%). The incidence in the United Kingdom was 82.94% (95% CI 63.77% – 102.11%). The incidence in Japan was 62.58% (95% CI 55.71% – 69.46%).

LIMITATIONS: Our study was limited because there were few sources from which to extract data, either in abstracts or published studies. There were no randomized, controlled trials that met our criteria.

CONCLUSIONS: The phenomenon of LDH reabsorption is well recognized. Because its overall incidence is now 66.66% according to our results, conservative treatment may become the first choice of treatment for LDH. More large-scale, double-blinded, randomized, controlled trials are necessary to study the phenomenon of spontaneous resorption of LDH.

Chiro.jpg

Reference

Zhong et al, (2017) Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician