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.

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.

Self management for long term pain relief

At Active RX one of our main aims is to give our clients the basic knowledge and understanding of how the body is put together in the hope that one will have the ability to SELF-MANAGE their problems and a visit to the physio becomes a complementary appointment.

At the end of taking a new clients history I will ask – What are the goals of your treatment? Often the first reply will be “to have no pain”  and the second most common answer being self-management strategies.

To achieve long term pain relief self-management strategies are vital and this blog post focuses on a few simple ways that you can start to help manage your own pain and dysfunction.

Strengthening

It’s our belief that strengthening is the key to long term pain relief. Of course there are many other factors that contribute but overall weakness is one that simply cannot and should not be overlooked. When we talk about strength it’s all relative, you don’t have to be the strongest person in the gym but what is required is the strength for you to complete your activities of daily living. For example a labourer who loves to lift weights, surf + run will require different strength to a grandmother who like to go on walks and read BUT both need to be strong in their own right. The key is be aware of where you might be lacking and implement exercises that target such weaknesses. It’s also important to remember that the need for strengthening doesn’t mean you need a gym membership, for many simple resistance exercises can be very effectively done at home.

Mobility

Being flexible and pliable is also extremely important, but the term mobility fits the bill a bit better as to be mobile you need to have strength in your flexibility. It’s all well and good to be flexible but if you can’t control that range of motion of your joints and muscles then you may well find yourself on the physio table. Self management requires awareness of flexibility and the ability to be strong through your entire range of movement.  Too often we see someone who has taken up a vigorous stretching program only to find themselves more injured than before. Why? Because they have not learnt to control their complete range of movement. Mobility requires a balance between strength and flexibility. Too little or too much of one just can easily be a contributing factor to longer term pain.

Recovery

Looking after yourself seems like a no-brainer but it’s actually a part of training many people neglect. Recovering from your workouts, games and even everyday life is another step towards long term pain relief. If you’ve put yourself through a grueling training week, slow down for just a moment– have a dip in the ocean, go get a massage, do some stretching. You can check out our blog on ‘there’s no such thing as over training just under recovering’ for some good ideas. Recovery also applies to every day life situations, if you’re a breastfeeding mother a 10 minute trigger ball session can go a long way to release the upper back and shoulder tension. If you’ve just put in a 60+ hour work week to hit a deadline, go for a long walk & swim on the weekend. Then there is recovery in forms you wouldn’t expect; like nutrition, hydration, adequate sleep, sunshine + Vitamin D.  A body that is physically + mentally worn out will be more sensitive to pain, and this is a conversation we often have with clients because their pain may not necessarily be solely musculoskeletal so for a  long term recovery these other holistic factors need to be addressed.

Training through pregnancy

Falling pregnant is an exciting time for women but it can also be a little bit of an overwhelming and daunting time. Our bodies undergo this amazing transformation and I’ll be honest until I started to experience it myself I couldn’t begin to comprehend how some of my clients were feeling through different stages of their pregnancy.

I think one of the most confusing areas is exercise and training. There is so much information out there about what’s good, what’s bad, what needs to be avoided and unfortunately much of it is conflicting. This blog is aimed at trying to clarify some of the questions around training and exercise while pregnant using a combination of my own experience along with my pre and post natal training.

Can I continue my regular training while I’m pregnant?

The short answer. Yes.

Exercise is very beneficial during pregnancy as it can assist with a whole range of things including preventing excessive weight gain, reducing the risk of Gestational diabetes, reducing the risk and severity of low back pain,  helps maintain physical fitness and may improve symptoms of  depression.

The level of training through pregnancy will depend on a few things.

Firstly what were you doing for exercise before you fell pregnant? If you were regularly engaging in moderate to high intensity training going into pregnancy you can continue with this style of training as long as you are feeling ok.

Someone who was more sedentary prior to pregnancy would be encouraged to commence a lower impact exercise program and slowly progress until they reach the recommended  exercise levels for pregnant women which is 150 minutes of moderate intensity exercise per week (20-30 minutes on most days of the week).

One of the biggest realisations I have had in my own pregnancy is that every day is different. One day energy levels are sky high and I felt great training,  the next day a walk around the block can be a mental and physical struggle. My goal has been to just move in some capacity every single day. I often have to remind myself that I feel better afterwards, and this always runs true.

What exercises should I be avoiding?

This is a tricky one to answer as every women will be different based on their training background.I’m going to break it down into trimesters.

1st Trimester (up to week 13) – assuming you are feeling ok, minimal modifications need to be made. Many women are plagued with fatigue, nausea and morning sickness during the initial stages of pregnancy which can make gym workouts more difficult. I would encourage you to listen to your body, there may be days when. you just don’t feel up to lifting weights, instead go for a walk or a swim.

For cardio workout I encourage women to use their exertion levels as a guide. If 10/10 exertion is maximal activity where you can hardly breathe or speak and 0/10 is at rest then you should aim for about a 6/10 which is a moderate level of intensity. This is a better method than heart rate because naturally your heart rate will be higher during pregnancy.

What about abdominal exercises? Personally I felt uncomfortable performing exercises such as sit ups, crunches and leg lowers from quite early on so I discontinued them. It’s very important to distinguish between this type of abdominal exercise and ‘core’ exercises which are of course very important throughout pregnancy.

I would really encourage you to speak to a trainer or physio who has some experience working with pregnant clients to guide you with this.

As you head into the 2nd Trimester (week 13-27) you will start to notice more physical changes in your body. Yep this is when you will ‘POP’. This is seriously the strangest thing. Literally one day I had that awkward bloated pouch around my midline and then the next day I had this round little pregnant belly.

This is the golden period of pregnancy (for most). A time when you may have a surge in your energy levels and a welcome relief from nausea and morning sickness.

One of the main modifications during this time will be  monitoring (and maybe limiting) exercises that are performed lying flat on your back. (In the past physicians have advised women to  avoid lying on their back because the weight of the baby can put pressure on vena cava which is the main vein which carries blood back to the heart from the lower body). The current guidelines for this vary between different institutions so I think the best approach is to be mindful. If you experience any symptoms such as light headedness, tingling in the legs or general discomfort when on your back then its probably time to modify. You could try performing exercises on a slight incline or just eliminate altogether. At 28 weeks I still feel ok on my back, but every women is different. 

Abdominal exercises such as sit ups, crunches, med ball twists, leg lowers or raises should all be avoided from the second trimester. As previously mentioned ‘core’ based exercises are important and encouraged. If you are unsure I would strongly advice you to seek help from someone that can guide you with what core exercises are suitable at this time. The main concern as you progress into the 2nd trimester is looking for signs of Diastasis Rectus Abdominus which is bulging of the abdominal wall. (Read our blog on Diastasis Recti for more information on this topic)

For cardio based training again I again would encourage a moderate level of exertion (remember 6/10)

What about running? This  is a much debated topic and unfortunately there is no evidence based time when you should stop running.

I absolutely love running and prior to being pregnant I would run 2-3 x week. I chatted to my womens health physio about when I should stop and her advice to me was when it doesn’t feel right anymore and this is what the general recommendation is. This happened at about week 18-20 when I headed out for my usual loop of Centennial park and it just felt different can’t explain exactly what it was but usually running is zone out time and from that day I didn’t enjoy it as much. That was enough for me to consider alternatives.

The concern with higher impact activities such as running and jumping is the extra stress that is placed on our pelvic floor. This hammock of muscles is already working overtime to support the growing weight of the baby so in my opinion there is really nothing to gain my loading it even more. Instead I’ve traded my weekly runs for walking stairs. It get’s my heart rate up, I still get to be outdoors in the fresh air and because summer is coming I get my daily dose of vitamin D.

Trimester 3 (week 28-40): This is a time of rapid growth and also a time when women probably start to become a little more uncomfortable with general day to day movement. With that in mind the training focus from week 28 onwards is really about maintaining a COMFORTABLE level of movement.

Modifications with strength training may need to be made purely as a result if your growing abdomen and what feels comfortable.

I touched on it briefly above but It’s very important to start observing and palpating the abdominal wall for signs of Diastasis rectus abdominus during trimester 3. The abdominals have undergone a huge amount of stretch and the rectus abdominus (your 6 pack muscle) can start to pull apart from the midline of the body. How can you tell? Look and feel. Place your hand on your midline at the level of the belly button and above and you are feeling and looking for bulging. If you do have doming of the abdominals that particular exercise should be ceased or adjusted accordingly. Common exercises that may result in doming can include planks, crunches or front loaded positions.

(Read our blog on Diastasis Recti for more information on this topic)

As an example I regularly used to have cable tricep extension in my program – this is a front loaded exercise. From about 24 weeks I was unable to perform this without getting doming. I have since changed to a single arm version with less weight. This also allows me to use my free hand to monitor my abdominals.

Its also important to be mindful of common everyday positions and movements that can increase the strain on the abdominals such as sitting up out of bed of off the couch – that’s pretty much an identical movement to a sit up. Protect your precious abdominals and begin to roll onto your side to sit up. All these little small stresses can add up over the course of a day!!

Cardio in trimester 3 will really depend on how the woman is feeling. Many will be happy to let go of their higher intensity training towards the end of their pregnancy. Lower impact alternatives include swimming and walking and will probably be the more favourable options during this time.

This has only really scraped the surface when it comes discussing the journey of exercise through pregnancy but think the take home message from me is that if you are unsure of what you can and can’t do don’t turn to the internet for help. Ask someone who knows what they are doing. 

Em is a certified pre and post natal coach and she can help guide you through some of the confusing should and should not’s of exercise through pregnancy. Feel free to get in touch with me via email activerxphysio@gmail.com or comment below if you have any questions!!

Keep an eye out for more pregnancy related posts over the coming weeks!