Knee Ligament Injuries

Winter is usually a time where we tend to see an increase in knee injuries, especially knee ligament injuries. This is largely thanks to the variety of ‘change of direction’ sports that are played during this time of year. Rugby league, union, AFL, netball, soccer and skiing are all sports that are multidirectional and/or have contact involved with huge forces going through the knee joint.

The aim of this blog is to take you through the four major knee ligaments, their roles, how they might get injured and how long you might be on the sideline if you are unlucky enough to find yourself nursing one of these.

ACL (Anterior Cruciate Ligament)

We’ll start with the big one and the one that can quickly end your favourite sports star’s season. The ACL’s role is essential to stop you shin from coming forward and medially (internally) rotating. It’s important as it plays a huge stabilising role in your knee. Often the ACL is actually injuries in a non-contact scenario  such as pivoting,  landing, or changing direction but can also occur (must less likely) in a contact situation. ACL tears will often result in a person needing to undergo surgery which will see them out of non-contact sports for 6-9 months and contact sports for 12 + months. Rehab plays a vital role to strengthen the graft (replacement ligament) and ensure full recovery. More on this in a latter blog.

PCL (Posterior Cruciate Ligament)

The PCL’s role is essentially the reverse of the ACL,working to prevent backwards and lateral (external) rotation of the shin. It is much less frequently injured than the ACL and typically comes from contact where a direct blow occurs on the shin in a bent knee position. They can also occur when the knee is forcefully hyperextended. Generally PCL injuries are treated non-operatively with a comprehensive rehabilitation program, More severe injuries can sometimes be placed in a brace for the first two weeks. Isolated PCL tears, even if completely torn, have good non-surgical outcomes despite some ongoing laxity. They will however sideline an athlete for 6-8 weeks. If a PCL is combined with damage to other structures or if significant instability is present surgical reconstruction might be appropriate.

LCL (Lateral Collateral Ligament)

Probably the least common knee ligament to be injured is your LCL.  The LCL’s role in the knee is stabilise the outside of the knee. Injuries to the LCL are usually due to a direct and forceful lateral stress (contact injury) to the knee. Complete tears will often be associated with other injuries (often PCL rupture) and will result in the need for surgery. Incomplete tears may require a period of bracing if severe enough, however the majority shouldn’t. A specific rehabilitation period will be required nevertheless but it shouldn’t see you out of action more than 6 weeks.

MCL (Medial Collateral Ligament)

MCL injuries are common in the rugby codes. The MCL’s role is to stabilise the inside of the knee. Injuries here occur when there is a medial force to the knee and can occur in both contact and non-contact incidents. More often they are treated non-operatively, however there will be a period of bracing that can last from 6-10 weeks depending on the severity of the tear. For mild injuries bracing may not be required. All people suffering an MCL injury will need a strengthening program and modified training to reduce stress on the healing ligament. Many will return to sport with supportive strapping.

The extent of the damage to a ligament will significantly impact the management and recovery time. Rehabilitation, strengthening and activity modifications are going to be necessary in all forms of these injuries and play a vital role in return to play as well as  reducing the risk of re-occurrence. The best thing you can do is make sure you get a diagnosis and start on the road to recovery as soon as possible. As physio’s we have a variety of tests that we can do to determine the integrity of these ligaments. An MRI may be required in cases where surgical intervention may be necessary but your physio may also suggest a scan to assess other structures within the knee that can also be damaged.

Em & Nick are both experienced in dealing with acute knee ligament injuries. If you have any questions or have an injury you would like assessed feel free to contact us to make an appointment.

Common mistakes in gym based exercises

Working as a Physio inside a gym has been an eye opening experience. Sure when you train at a gym you see the odd person doing an exercise a bit wrong but when you’re here all day you get to see all sorts of ‘modifications’ to common exercises. A lot of the time they are injuries waiting to happen, you might not get the pain straight away but it might be the reason for your nagging shoulder pain, tight back or stiff neck.

Today’s blog isn’t going to highlight the common culprits you would expect to read about like a deadlift or squat but rather mention a few exercises you might not realise you are compensating on.

Incline/Flat Dumbbell or Barbell Bench Press

I’ll start with the one all the guys love to do. The bench press, in its many forms,is a great way to build a big chest. I often see people lift the back of the head off the bench either throughout the movement or as they push up. This chin poke position will compromise your form and may end up being a contributor to  nagging neck pain.  If you find yourself suffering from a constant stiff neck, check in with your positioning next time you bench press.

Leg Press

Many people regard the leg press as a simple controlled leg exercise where form can’t really be sacrificed. Well unfortunately I disagree. The one error I want to focus on is range – are you going too deep for what your body can control? Of course I’m not encouraging people to do half reps (seriously one of my pet hates is when people only care about how many plates they can put on this machine!!!!) but you also don’t want to go too deep if you don’t have the mobility and strength too do so. Going too deep can irritate the front of your hip and/or your lower back. You should work in a range where your glutes and lower back stay in contact with the seat your hips don’t pull forward and up.

Shoulder Press or DB Seated Shoulder Press

In the pursuit of improving and lifting heavier weights often one will compromise form & it’s often seen in shoulder press movements. I regularly see people arching their lower and mid back to improve their chances of getting the weight above their head. In the short term you will probably get away with it, however the repercussions can be a stiff thoracic spine (upper and mid back), pain in the lower back and neck irritations.  Keep the back flat against the bench or think about keeping our rib cage over your pelvis and use appropriate weights that allow you to control this position.

Step Ups

When doing a step up the leg that should be working and taking the most load should be the leg on the step itself. How many of you feel like the leg on the ground pushes you up just as much? This may not  necessarily be a huge deal from an injury risk perspective but it’s a common mistake we see being made.  The second issue is probably more cause for injury and it’s usually the result of a step that is too high or a weight that is too heavy resulting in lack of control of the movement. We tend to see collapse of the knees especially which places undue stress on the hip and knee joints. Ideally we want too keep that knee over the foot or even have the knee drive out to the side as you step up.

Just so we are clear I am by no means suggesting that any of these exercises are inherently bad. Quite the opposite in fact. They are all very effective exercises that I have in my own gym program. At the end of the day it comes down to how the exercise is done. You will only get away with bad form for so long before something in the system becomes overloaded, tight or weak. I believe your goal should always be to  maintain form, in the long term this approach will make you stronger and more durable.

 

Sever’s Disease

Aches and pains are relatively common in growing children, especially these days where it seems to be the norm for kids to play multiple different sports during the one season. Often it can be tricky for parents of younger kids, some aren’t sure if they are being completely over protective while others feel they may not be empathetic enough to their child’s complaints of musculoskeletal pain.

We see kids regularly in our practice and 90% of them are suffering from a form of ‘growing pain’ with one of the most common areas being pain around the heels. This condition is known Severs Disease.

What is Severs Disease and what are the symptoms?

Severs disease is characterised by pain where the Achilles tendon attaches onto the heel bone (calcaneus). In children who are still growing this is a soft area of the bone where the growth plate has not yet closed. During periods of growth the skeleton grows slightly faster than the soft tissues, resulting in a ‘pulling’ of muscles at their attachment sites, in this case the Achilles into the heel bone. This results in pain right at this junction between tendon and bone or in some cases higher up in the tendon.

Quite often the symptoms can occur on both sides and can include;

  • Heel pain during exercise – traditionally this is increased with jumping and high velocity activities
  • Increased pain or ache after exercise
  • Limping or toe walking as they try to take pressure off the heal
  • Localised heel pain on palpation

Factors that contribute to Severs Disease

  • Growth Spurts – sometimes difficult to gauge as a parent that sees their child every day but kids tend to go through some noticeable spurts where they may jump a shoe size or shoot up a few cm in a short period.
  • Physical Activity Level – Sports that involve running & jumping. Kids that play multiple sports may be at a higher risk.
  • Shoes – Poor footwear choice can place extra strain on the Achilles Tendon.
  • Foot Posture – tight muscles, ankle joints, foot and calf strength can all contribute.

TREATMENT

Severs is an activity related and ‘self-limiting’ condition. For this reason parent & patient education play a very important role as the solution for Severs related pain is not to simply stop sport altogether. Relative rest, load management and activity modification will be important to reducing symptoms and improving recovery.

Potential contributing factors should be addressed by your physio such as;

  • Stiff joints: in this case the two ankle joints – subtalar and talocrural should be assessed
  • Tight muscles – especially the gastrocnemius & soleus muscles (aka the calf) may benefit from massage
  • Muscle weakness around the ankle joint.
  • Other biomechanical factors such as pelvic stability & proprioception.

Generally physiotherapy management will incorporate a strengthening and stretching program that will need to be performed on a regular basis.  Your physio may also offer heel raises / inserts which can be placed inside sports shoes – these work to unload the Achilles tendon and can be a useful aid during painful periods.

Analgesic strategies such as cold packs and medication can provide short term symptomatic relief.

Sever’s Disease can be painful and quite debilitating. We think its definitely worth getting on top of early it as early as a proper diagnosis combined with correct treatment strategies can greatly assist with pain levels and performance.

Sciatica. How do we treat it?

As discussed in part 1 there are numerous causes of sciatica, so if you missed part 1 you can read it HERE.

Part 2 of this blog will be discussing some of the treatment options that are available to help relieve sciatica. Remember these are only a guide and we always recommend you see your Physio for a thorough examination to ensure the exercises are appropriate for you.

Trigger Balls

Trigger Balls or foam rolling are both great tools to help provide short term pain relief. Our suggested focus areas would be the lower back, glutes and hamstrings. We always recommend these should include an active component to get the muscles moving. The reasoning behind the effectiveness of a trigger ball is still a bit of a mystery but studies have suggested that it can have a short term analgesic response. Reduction in pain may enable you to complete further exercises that will be effective in creating longer change.

Stretching and Mobility

Light stretching and mobility can also be beneficial in providing short term relief. Stretching should be pain-free and gentle to begin with, again focusing on the lower back, glutes and hamstrings. In certain cases some stretching positions can actually further aggravate sciatica so if you are unsure make sure you check with your physio!  Mobility work should be about controlling movement of joints through pain-free range of motion. Avoiding positions that create pain should be paramount during these exercises.

Neural Gliding

Neural gliding is essentially a stretching exercise that focuses on ‘sliding the nerves’. We use the analogy of the nerve being a piece of string traveling from the base of the skull down the spine out into the leg and down too the foot (this is the route of the sciatic nerve). Along its path it crosses underneath, between and over certain muscles. In order to function efficiently this nerve slides freely along this path. Sometimes with Sciatica the neural pathway gets ‘stuck’ and this sliding mechanism is affected. A neural gliding exercises aims to restore the smooth sliding of the nerve along its path. These exercises are different to static stretches, should be pain free and form an important part of the rehabilitation for neural irritations that are causes by muscles and joints. Due to their ability to aggravate symptoms further we would recommend checking with your physio before you begin.

Strengthening

Re-estabilishing strength shoulder be the long term focus of treatment. It is vital to firstly figure out why the nerve is irritated. Not all lower back pain and sciatica comes from weak core and glutes so focusing only on these two common areas to strengthen may not be  the solution for everyone with Sciatica. Addressing other muscles like the hips flexors, hamstrings, obliques or lats may be what you require.

Movement Patterns

Another treatment that is critical towards long term recovery is correcting movement patterns. Potentially the way you run, squat, deadlift and move in general might be contributing to your sciatica. If you get pain every time after you run, your running style may needs to be checked – and the same goes for other forms of exercise. People with chronic lower back pain or siactica also often pick up poor patterns as a response to long term pain so sometimes movement retraining is required. Most commonly individuals become very stiff in their back and develop fear avoidance patterns where never bend their back which will only contribute to further stiffness. Slow exposure to bending and moving the spine may be a way to get rid of this chronic irritation.

Ultimately to treat sciatica there needs to be a diagnosis and from there a longer term management plan that addresses strengthening what is weak combines with mobilising what is stiff. This will be totally dependent on the individual and one should seek a health care provider’s advice.  There are cases where conservative intervention may fail and more invasive treatments may need to be explored.

If you have any questions about Sciatica, it’s management or any other physio related question feel free to email us activerxphysio@gmail.com or head to our instagram page and send us a message!

Sciatica. What is it?

The word SCIATICA seems to instil fear in patients when it first gets mentioned. Everyone knows a person that has suffered from sciatica at some point in their life, which means that most people have heard the term Sciatica, and whole most people know it has something to do with leg pain very few people actually understand what Sciatica really is.

It’s not uncommon for people to be given the diagnosis of Sciatica, however Sciatica is not a diagnosis but rather a set of symptoms that can include buttock, leg and foot pain that originates from the back.

The goal of this blog is to give you a better understanding what Sciatica is, explain why one might get it and to explore some strategies to prevent it from returning.

What is Sciatica?

As mentioned sciatica is a description of symptoms rather than an actual diagnosis. What that means is – any pain/symptoms that travels from the glute, down the back of the leg to the foot that originate from the back is termed ‘sciatica.’

There are other potential musculoskeletal injuries that can cause a similar pain pattern, clients with these conditions do not have sciatica, even though their symptoms may present like so.

The term sciatica is derived from the sciatica nerve which is the largest single nerve of the body.  It is this nerve that gets ‘irritated’ resulting in this specific set of symptoms. As a result of this irritation one might experience one of more of the following:

  • Sharp pain or a dull ache in the back, glute, back of leg, foot with or without back pain
  • Burning, tingling, pins and needles down the back of the leg
  • Weakness or difficulty moving the leg, foot or toes
  • Pain with sitting (pain may be reduced with the use of a pillow)
  • Pain aggravated by coughing or sneezing

Why do people suffer from Sciatica?

There are numerous reasons why people get sciatica and to cover them all would require countless blogs, but let’s touch on a few in a broad sense.

It’s probably important to mention that sciatica ranges in severity and so too do the conditions that can cause sciatica.  From complete compression of the sciatic nerve which may cause alterations in strength and sensation of the leg to a more localised inflammation which may cause dull radiating pain into the leg. Part of our job is to determine the underlying cause which will ultimately guide the course of treatment.

  • Nerve Root Issues: The nerve root is the exiting portion of nerve that leaves the spinal cord. There are nerve roots for each level of the spine with one exiting each side. Compression and / or irritation of the nerve roots by surrounding structures can result in sciatica.
  • Spinal Stenosis:  This refers to the narrowing of the spinal canal which can place pressure on the sciatic nerve. This is a degenerative condition usually related to osteoarthritic changes of the spine.

    Image highlights a few of the intervertebral disc injuries that can contribute to sciatica
  • Injury of the intervertebral disc: The discs are the shock absorbers in the spine. Injury to these structures can vary from disc degeneration, disc irritation, disc herniation (commonly known as a disc bulge), or a disc rupture all of which have the potential to place pressure on the sciatic nerve.
  • Spondylolisthesis: A condition where one vertebrae slips forward in relation to another. This can often be the result of a stress fracture left untreated in a younger athlete.
  • Neural Irritation: After the nerves exit the spine they have a somewhat complicated pathway as they travel down, under and between all our anatomical structures to supply all the areas of he leg. If the nerve gets irritated or impinged at any point on this pathway you may see sciatic symptoms occurring.

They are just a few very brief descriptions of some issues that can lead to sciatica.

The key to treating sciatica lies in determining the underlying cause. That’s our job. How do we do that? Keep an eye out for next weeks blog which will touch on this.

In the meantime…. any questions? Feel free to email us or contact us via social media.

Proximal Hamstring Tendinopathy

This injury is a serious pain in the butt. Literally.

I actually suffered with for a few months myself and weirdly I have since seen about half a dozen women with the same issue.

Proximal hamstring tendinopathy (sometimes known as hamstring origin tendinopathy) is a painful condition that presents as pain in the lower buttocks which can refer down into the hamstring. Often it will warm up with activity only to return after exercise. It can linger around for several hours, or in more severe cases several days.

In almost all of my clients the onset of pain correlates with a change in volume or intensity of training combined with compression factors such as long periods of sitting and increased hamstring stretching. It’s not unusual for symptoms to appear quite suddenly, but unfortunately don’t tend to resolve quite so quickly.

The rehabilitative phase can take up to 12 weeks however rest assured our tendons are strong, adaptable and in most cases very responsive to a good strengthening program.

Management of hamstring origin tendinopathy can differ slightly between clients but the general principles of rehab are constant.

There may be an initial period of rest required, not from training altogether. I often encourage pain free cross training. Too much rest will actually be detrimental for the tendon when it comes to coping with load again.

I make a concerted effort to allow my runners to keep running, albeit with a modified load. For example reducing the speed, eliminating hills or a shortened stride length are all ways to facilitate overall load reduction on the tendon without stopping running altogether. In the gym one may reduce the weight of their squats & deadlifts or work through a smaller range. Using pain as a guide is important, a 2-3/10 is acceptable, anything more and you are in the no go zone (we call it the red zone)

Avoiding compression is really important. Sitting on softer surfaces instead of hard chairs and steer clear of stretching your hamstrings. Other gym related sources of compression include lunges and heavy deadlifts.

A strengthening program will often start with isometrics – an isometric is a contraction where there muscle is switched on but not moved through range at all. Such exercises have been shown to assist pain modification as well as preparing the tendon for both concentric and eccentric strengthening. The rehabilitative process can take several months so a little patience and perseverance is important.

There are also some hands on techniques that your physio can use which can be helpful. I use both active release and dry needling to target areas of tension both in the hamstring but also around the glutes and lateral hip.

If conservative management doesn’t seem to be working there may be some more invasive options such as PRP injections that your physio or sports doctor may discuss with you. You will most likely need an MRI scan to confirm the diagnosis as hamstring origin tendinopathy prior to this discussion.

Recovery from hamstring tendinopathy can be a slow process, and one that requires careful consideration of each individual case with regards to load management, training and strengthening. We strongly advise you seek guidance from your physio if you’re dealing with a pain in the butt, it may save you weeks worth of rest or self guided rehab that is targeting the wrong issue.

Tips to help you avoid injury

Not all injuries can be avoided, there’s just those freak accidents that no amount of training or foresight can prepare you for. However many injuries occur when the your workload exceeds your capacity.

When we refer to workload we are talking about the demands you have been placing on your body which includes not only your training load but work, gardening, moving house, lack of sleep etc.

To put it simply:

WORKLOAD >> CAPACITY == POTENTIAL INJURY

To avoid these injuries you have one of three choices: increase you capacity, decrease the workload or improve your recovery.

Increase Your Capacity

This means increasing the demands your body can tolerate.

Think of it as a number. If your current capacity is 100, your aim is to improve it to 125 or 150 (or higher if your wish)

How? Through training in all of its forms – strength, flexibility, mobility, aerobic training, sports specific skill work etc. The aim of training  is to push your body as close to your ‘threshold’ as you can. With each session you may try do just a little more, whether its an extra set or few extra reps. This is called progressive overload and it forces your body to start to adapt and change.

Lets consider another example. You are training for your first marathon, and you’re not really a runner. Your first run shouldn’t be 42km, instead you will start small and slowly build up your running tolerance over a matter of weeks; as a result you are increasing your running capacity. This concept can be applied to simple day to day situations. If you don’t normally garden and all of a sudden you spend a weekend shovelling soil there’s a pretty good chance you’ll have a sore back by the end of it because your body is not accustomed to that amount of activity. On the flip side if you garden regularly you have better capacity to tolerate that type of load and your back may not get sore.

Having a greater ‘capacity’ can help to avoid certain types of injuries because the body is better conditioned to deal with greater loads.

Decrease Workload Accumulation

Decreasing workload might seem like the exact opposite of what we just discussed above BUT WAIT… the key word here is ACCUMULATION. Consider 100 as our capacity again. Each different type of workload represents demand on the body and that accumulates over time with the total being our functional capacity.

For example,

    • Workout = 40 + House work and gardening = 20 + Work  = 20

Which leaves us at 70/100. Then your friend rings and asks you if you can help her move house. You politely oblige and that’s another 40 points. Now your capacity is 110/100 and you wake up the next day with a sore, stiff back. It may not  necessarily be the lifting boxes and furniture that caused your back pain but rather an accumulation of that weeks worth of load. What’s the solution? Say no to your friend? Of course not!! It’s more of an awareness thing, firstly to be able to acknowledge that you probably did too much but then also to be able to apply this concept to your training by understanding when you may need back off to protect your body.

Recovery

A very very very important consideration when trying to avoid injury. RECOVERY.

I feel really strongly about this topic (so much so that I have actually written an entire blog on it which you can find HERE).

Let’s stick with our capacity of 100. Remember workload accumulates, and the sum of the total work is the capacity. Strategies that assist with recovery such as sleep, stretching, massages, dry needling, nutrition, hydration, de load weeks etc can all decrease the workload accumulation. They are essentially like a minus in the workload equation because you are paying back to your body. If you find yourself up near your functional capacity threshold, maybe its time to treat yourself to a massage (we have an amazing massage therapist if you need one!!)

These numbers we have used are arbitrary but I think it just helps break it down into simpler terms. Use some of these strategies and you might just notice some of those niggling aches and pains disappear for good!