IT’S A BOY!!!

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Simon is very proud to announce the birth of his baby son Archie, who arrived 2 weeks before Christmas, and  2 days before his big sister’s birthday!

How’s that for a busy December??

Speaking of busy, Karen is continuing to work at the clinic through the holiday period, and is covering Simon’s list until he returns to work (for a rest) at the end of January.

Appointments are available at short notice, and Karen is available for mornings and afternoons.

Please call 9775 2962 to arrange your next visit, and remember that we have a new address!

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Tradies National Health Month

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Tradies rely on their musculoskeletal health to do their jobs; and ignoring
aches, pains and body stress could result in disability and debilitation in the
future.

The Australian Physiotherapy Association (APA) and Steel Blue
have created Tradies National Health Month in August to educate and engage
tradespeople on the importance of full body health and safety.

As APA physiotherapists, we can help you manage existing conditions, improve function
and mobility in problem areas, prevent injuries and achieve a healthy lifestyle.

Don’t ignore the pain. Seeking help now can protect your future health,
wellbeing and livelihood.

There is plenty of help available, call
us now to make an appointment today and you can find plenty of resources and
information at www.tradieshealth.com.au

Have you ever “Pulled a Hammy”?

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Unfortunatley I’ve been on the wrong end of this injury far too many times, and it ultimately ended my professional sprinting career! My last Stawell Gift was more like a “stalled gift” as my right hamstring went “Ping” as I came out of the blocks. It can be a recurring nightmare for any athlete, and requires very careful managment.

The following article is a good example of how Sports Physiotherapists would approach the initial assessment, diagnosis, and treatment / management plan for a very common injury – “THE HAMMY”

Although this article seems a bit wordy, much of this information is gathered by a skilled Sports Physio within the first few minutes of speaking to the athlete, and performing some specific movement tests. If you find yourself lost in the ‘double-dutch’, scroll down to find the 4 week program laid out in table format

Although some details in this article might be very similar to your own symptoms or experiences, don’t take this as a ‘recipe’ for self management. Everyone’s injuries are subtly different, and will need careful tailored management, so if you have a “Hammy” give Tanti Avenue Physiotherapy a call.

Remember, you’re one of a kind; so are we!

Happy Hamstrings!
Simon

A Rehabilitation program for a Grade 1 hamstring strain in a hockey player

The situation

A 27 year old male hockey player with a suspected right hamstring muscle strain. The injury occurred today, approximately 6 hours ago. The patient is concerned because he has a major tournament in 4 weeks, which involves playing 4 matches in 10 days. The player indicates that it is his one big tournament for the year and is desperate to play. He has 4 months of no hockey after this tournament.

 

The clinical picture

  • Subjective findings  (what we ask the patient);
    • Developed acute posterior thigh pain whilst sprinting (75% effort) at a training session as part of his fitness training
    • He felt a sudden mild grabbing pain mid-hamstring and came off the field immediately. He was able to jog but had pain and decided to go off the ground, taking no further part in training.
    • He was able to walk off the ground with a minimal limp and now has no pain with daily activities
    • His playing position is on the ‘wing’, which he states requires a high aerobic capacity and his style of play also involves regular, hard sprinting bursts during matches.

 

  • Physical examination (specific tests and movements we perform on our patient)
    • Walking no limp
    • Can jog up to 50% of maximum effort with no pain. Moderate running speed (70% of maximum effort) causes mild pain but can do it. Was not tested at higher running intensity.
    • Restricted straight leg raise;
      • Right = 70°, restricted by mild posterior thigh pain (no increase pain intensity with dorsiflexion  and cervical flexion)
      • Left = 90°, no pain
    • Pain (2/10 Visual Analogue Scale) with single leg hamstring bridge (strength test) on right leg only, but can do it
    • Resisted knee flexion in prone
      • Minimal pain with moderate resistance at 30o knee flexion. Strength R = 130Nm  L = 212Nm (hand held dynamometer)
    • Tender on palpation just lateral to the midline, at the junction between the middle and upper 1/3 of the hamstring muscle group (possibly biceps femoris)
    • Lumbar spine is assessed (summary)
      • Flexion – full range restricted by right ‘hamstring’ pain
      • Extension – full unrestricted

SLUMP – R) No pain. Full range (0º Knee flexion)

L) No pain. Full range (0º Knee flexion)

      • Palpation – hypomobile R mid-low lumbar facets. Overactive right paraspinal erector spinae / quadratus lumborum muscles
      • Real time ultrasound – good activation – transversus abdominus, pelvic floor muscles, quadratus femoris, multifidus
    • Assessment of ‘pelvic stability’ using a single leg squat indicates poor control
    • Unable to hop as he lacks confidence

 

  • Past History
    • Two minor hamstring strains last season (missed 1 week both times). This time seems worse.
    • One episodes ‘acute’ low back pain last 3 months. No games missed.
    • Low back ‘stiff’ last one week before hamstring injury
  • Investigations
    • MRI – 1 hour ago – reported as grade 1 biceps femoris strain

The Diagnosis

Low grade biceps femoris muscle strain injury.

 

 

This player appears highly motivated to recover in time for a major tournament in 4 weeks. It is important to consider firstly whether returning to tournament-intensity function in this time frame is achievable, and secondly, whether recurrence of injury is likely within the tournament period of 10 days. This knowledge will serve to encourage the player to adhere to the rehab plan, and give him confidence in the lead up to the tournament.

 

Clinically, he has sustained a minor lateral muscle strain, perhaps precipitated by an adverse loading on the hamstrings subsequent to lumbo-pelvic stiffness and proprioceptive deficits. He does not appear to have any adverse neuromeningeal contribution, or core weakness contributing to his injury, but he does have a past history of recurrent hamstring injury.

 

Warren, Gabbe, Schneider-Kolsky  & Bennell (2010) found that players able to achieve pain-free walking within 24 hours following hamstring strain were less likely to need longer than 3 weeks to return to competition compared with those who could not.  However, they also found that lateral hamstring strains, and those with a past history are more likely to recur within the first 3 weeks of returning to competition, and recommended that a thorough rehabilitation be carried out in order to reduce the risk of recurrence.

 

Our hockey player should be reassured that as he is already jogging pain free, his prognosis for playing the tournament in 4 weeks is good, but that he must work hard to minimise the chance of breaking down during competition. This 4-week time frame should allow for the four stages of muscle healing described by Huard, Li, & Fu (2002) to occur adequately, namely degeneration, inflammation, repair, and scar tissue formation.

 

This rehab program will focus primarily on the trainable characteristics of strength, endurance and power (Kramer, et al., 2002), which are critical elements of the aerobic, but intermittently explosive requirements for playing in the position of wing. In order to optimise the training effect in a short timeframe, without overloading the muscles, periodised training programs can be used. This refers to “varying the training program at regular time intervals in an attempt to bring about optimal gains in strength, power, motor performance, and/or muscle hypertrophy” (Fleck, 1999, p.82).

 

Although a recent study by Apel, Lacey, & Kell (2011) found greater strength gains from traditional linear periodization compared to a weekly undulating regime, they concluded that this model suited a longer-term training program (>12 weeks). In the current setting of 4 weeks, a non-linear periodization will allow these different neuromuscular characteristics to be exercised in the same rehab phase, and should provide appropriate physiologic stimuli to the key muscle groups  (Fees, Decker, Snyder-Mackler, & Axe, 1998). Only one characteristic is trained on a given day (e.g. strength, power, or endurance). The loading schedule (heavy, moderate or lighter resistance), along with alterations in volume and intensity can then be rotated over the course of the training sequence to address the remaining characteristics. (Kraemer et al., 2002)

 

Our program will consist of a 4-week mesocylce containing 4 microcycles, each of 1-week duration, with the aim of optimising neuromuscular adaptation, whilst limiting atrophy and scar formation at the injured area. Only key exercises to focus on the player’s main problems of decreased hamstring strength and pelvic stability are discussed. Functional stretching of the injured area, as well as lumbar mobility is included in the warm-up prior to each rehab session.

 

In this scenario, we have focussed specifically on the strength and conditioning elements of the rehab program, which are guided by our knowledge of muscle physiology. The player will continue hockey skill training and aerobic conditioning with his coach, with instructions to maintain a sub-pain threshold for all activities, especially during stick drills, where his forward-flexed posture may adversely load the injured area. 

Ideally the player would also have access to additional therapy during the course of rehab, including manual therapy and sports medicine intervention, but we haven’t included that for the purposes of the current article.

 

 

 

Week 1

The week following injury is a transitional stage, allowing for “relearning”. Major aims include i) early minimisation of inflammation and fibrosis during the necrosis / inflammation stage (days 0-2); ii) to avoid disuse atrophy, encourage collagen organisation and promote neuromuscular adaptation by introducing light resistance training following onset of the repair stage (from day 2-3). Exercises will be light intensity, low volume to protect the regenerating muscle fibres from becoming more severely injured if the exercise or activity intensity is higher than the tolerated threshold (Taylor, Dalton Jr., Seaber, & Garrett Jr., 1993)

 

Week 1
DAY TRAINING TECHNIQUE LOADING SCHEDULE RATIONALE
1 Rest R.I.C.E. Resting immediately after trauma can prevent further retraction of the ruptured muscle stumps; Ice and compression is useful to reduce pain, oedema, the size of the hematoma and, subsequently, the size of the connective tissue scar (Jarvinen, Jarvinen, Kaariainen, Kalimo, & Jarvinen, 2005; Orchard et al., 2008)
2 Rest R.I.C.E.
3 Light hockey skills
Pool session		 Controlled movement within pain-free range Maintaining cardio training and sport-specific skill load without stressing injured muscle beyond capacity helps avoid disuse atrophy
4 Isometric heel-holds at varying degree of knee flexion 2×20 reps; 5 second hold; within P1 Jarvinen et al., (2005) recommends early commencement of isometric, isotonic and dynamic activity as soon as pain allows; Khan & Scott (2009) advocate mechanotherapy to load the injured muscle tissue to activate satellite cells, stimulate protein synthesis and improve alignment of regenerating myotubes
Concentric/Eccentric heel drop-catches 2x 20 reps, varying speed limit P1 Introduces eccentric hip-knee deceleration component involved in sprinting (Cameron, Adams & Maher 2003)
Theraband Hip/knee extension pulls in standing 2×20; repeat bilaterally Bilateral training allows for isometric element and introduces pelvic stability component
5 Light hockey skills; Cardio session e.g. Bike
6 Repeat as per DAY 4 Loading adjusted by intensity & speed of contraction Inflammatory stage should be completed by day 5, with the gap between injured parts of the muscle fibres becoming smaller; regenerated myofibrils are present (Hurme, Kalimo, Lehto, & Jarvinen, 1991) permitting small increase in resistance load
7 Recovery Day

 

 

 

 

Week 2

By day 7 there is significant reduction in inflammation with resolution of tissue oedema and haemorrhaging, and the gap between damaged muscle fibres is almost completely closed (Nikolau, McDonald, Glisson, Seaber, & Garrett, 1987; Hurme et al., 1991). Muscle force production should be between 80% and 90% of normal (Crisco, Joki, Heinen, Connell, & Panjabi, 1994; Nikolau et al., 1987). This allows for the introduction of more functional exercises, with more structured training loads. Running drills can be commenced at sub-pain threshold

 

WEEK 2
DAY TRAINING TECHNIQUE LOADING SCHEDULE RATIONALE
1 Warm up, including dynamic hamstring stretch & lumbar mobility
Dead Lift 8-12 reps at 80% RM; 3 sets, 2-3 min rest Recommended Strength training load (Kramer, et al., 2002)
Prone Curl
Arabesque
Interval Running Drill(accelerate / hold / decelerate) 65% Max pace30m/20m/30m (x3)25m/20m/25m (x3)20m/20m/20m (x3)15m/20m/15m (x3)

10m/20m/10m (x3)

 Should be able to maintain good control in pain-free range; High degree of functional specificity as the drill mimics requirements of wing position with changes of speed and also requires aerobic fitness
2 Hockey skills; Cardio
3 Exercises as per Day 1 including warm-up 15-20 reps at moderate velocity, 50% RM; 2 sets; 1-2 min rest Recommended Muscular Endurance training load (Deschenes & Kraemer, 2002)
Running Drill (as per Day 1) 70% max pace  Ensure sufficient rest time between exercise training and running (e.g. am rehab, pm running drill)
4 Hockey skills; Cardio
5 Exercises as per Day 1 including warm-up 3-6 reps at 30-60%RM, with explosive velocity; 3 sets; 2-3 min rest Recommended Power training load (Kramer, et al., 2002)
Running Drill (as per Day 1) 75% max pace
6 Pool recovery Includes leg drills, kick-board and swimming
7 Rest and recover

 

 

 

Week 3

By day 14, scar tissue in the gap is more compact, and by the end of the week the gap between damaged fibers has virtually disappeared. (Hurme et al., 1991) The aim this week is to increase the training load by between 2-10% (larger increase for larger multi-joint exercises) and prepare the muscle for introduction of plyometric drills in the final week.

 

WEEK 3
DAY TRAINING TECHNIQUE LOADING SCHEDULE RATIONALE
1 Warm up, including dynamic hamstring stretch & lumbar mobility
Running Drill (as per week 2) 75% Pace
Dead Lift {Weight increased by 10% from week 2} 8-12 reps; 3 sets, 2-3 min rest Multi-joint exercise should tolerate larger increase in load due to greater force production ability
Prone Curl {Weight increased by 2% from week 2} 8-12 reps; 3 sets, 2-3 min rest Single-joint, isolated muscle group needs care not to progress too quickly resulting in further injury, therefore only small incremental increase
Arabesque {Weight increased by 5% from week 2} 8-12 reps; 3 sets, 2-3 min rest Multi-joint exercise, but in unstable position with large leverage component, therefore only moderate increase
2 Hockey skills; Cardio Include lateral movements / agility drills
3 Exercises as per Day 1 including warm-up 15-20 reps at moderate velocity, 50% RM; 2 sets; 1-2 min rest Strength Endurance – resistance proportionately increased
Running Drill (as per week 2) 80% max pace
4 Hockey skills; Cardio
5 Exercises as per Day 1 including warm-up 3-6 reps at 30-60%RM, with explosive velocity; 3 sets; 2-3 min rest
Running Drill (as per week 2) 85% max pace
Plyometric Double-leg jumps 6 reps, 3 sets; aim for max distance, minimal ground contact time Kraemer et al. (2002) recommend inclusion of plyometrics to aid sprint ability; Double legged drill affords good control for early technique training
6 Pool recovery
7 Rest and recover

 

 

 

 

 

Week 4

Increasing numbers of myofibers extend across, and very little scar tissue remains in the gap (Hurme et al., 1991). Although recovery of full strength after injury can take more than 40 days, muscle force production should be greater than 90% of normal by day 24  (Howell, Chelbourn, & Conaster, 1993; Crisco et al., 1994). In order to return to sport by day 29, high level running and power exercises need to be performed pain-free. Plyometric drills will be included in each running session, and running speed should aim for 95%. Given the pre-existing risk factors, and increased likelihood of recurrence within the first 3 weeks of return to sport, I would recommend maintaining a sub-maximal threshold for speed and power drills until the tournament is completed.

 

WEEK 4

DAY

TRAINING TECHNIQUE

LOADING SCHEDULE

RATIONALE
1 Warm up, including dynamic hamstring stretch & lumbar mobility
Running Drill (as per week 2) 90% Pace; carrying hockey stick
Plyometric single-leg hops 6 reps, 3 sets; aim for max distance and speed
Dead Lift {Weight increased by 10% from week 3} 8-12 reps; 3 sets, 2-3 min rest Progressive loading, provided no increase in pain, and correct technique maintained
Prone Curl {Weight increased by 2% from week 3} 8-12 reps; 3 sets, 2-3 min rest
Arabesque {Weight increased by 5% from week 3} 8-12 reps; 3 sets, 2-3 min rest
2 Hockey skills; Cardio
3 Running Drill (as per week 2) 95% Pace; carrying hockey stick
Plyometric single-leg hops 6 reps, 3 sets; aim for max distance and speed
Dead Lift 3-6 reps at 30-60%RM, with explosive velocity; 3 sets; 2-3 min rest Power focus in preparation for return to sport
Prone Curl
Arabesque
4 Hockey skills; Cardio Simulated match practice; submaximal intensity
5 Running Drill 95% Pace; carrying hockey stick
Exercises as per Day 3 Load as per Day 3 Power focus in preparation for return to sport
6 Fitness test for return-to sport Agility drills; change-of-pace running; Match intensity skill practice Controlled environment allows for careful introduction of higher-risk activity
7 Recovery Assessment following fitness test Manual strength test; Muscle length test; palpatory assessment Clearance to return to play, provided no latent pain or loss of function following fitness test

 

 

 

CONCLUSION

This program, (although not exhaustive in its inclusions) demonstrates a periodised approach to rehabilitation that should facilitate adequate neuromuscular adaptive changes in the injured area to permit return to full function within the short timeframe available. Further assessment of complete lower limb biomechanics and strength should be undertaken in the off-season in order to identify and address any other potential risk factors for further injury recurrence.

 

 

REFERENCES

 

Apel, J. M., Lacey, R. M., & Kell, R. T. (2011). A comparison of traditional and weekly undulating periodized strength training programs with total volume and intensity equated. The Journal of Strength & Conditioning Research , 25 (3), 694-703.

 

Cameron, M. A. (2003). Motor control and strength as predictors of hamstring injury in elite players of Australian football.  Physical Therapy in Sport, 4, 159-166.

 

Crisco, J. J., Joki, P., Heinen, T. G., Connell, D. A., & Panjabi, M. M. (1994). A muscle contusion injury model; Biomechanics, physiology, and histology. The American Journal of Sports Medicine, 22 (5), 702-710.

 

Deschenes, M. R., & Kraemer, W. J. (2002). Performance and physiologic adaptations to resistance training. American Journal of Physical Medicine & Rehabilitation, 81 (11 Suppl), S3-16.

 

Fees, M., Decker, T., Snyder-Mackler, L., & Axe, M. J. (1998). Upper Extremity Weight-Training Modifications for the Injured Athlete. A Clinical Perspective. The American Journal of Sports Medicine, 26 (5), 732-742.

 

Fleck, S. J. (1999). Periodized Strength Training: A Critical Review. Journal of Strength and Conditioning Research, 13 (1), 82-89.

 

Howell, J. N., Chelbourn, G., & Conaster, R. (1993). Muscle stiffness, strength loss, swelling and soreness following exercise-induced injury in humans. The Journal of Physiology, 464 (1), 183-196.

 

Huard, J., Li, Y., & Fu, F. H. (2002). Muscle Injuries and Repair: Current Trends in Research. The Journal of Bone and Joint Surgery , 84 (5), 822-832.

 

Hurme, T., Kalimo, H., Lehto, M., & Jarvinen, M. (1991). Healing of skeletal muscle injury: an ultrastructural and immunohistochemical study. Medicine & Science in Sports & Exercise , 23 (7), 801-810.

 

Jarvinen, T. A., Jarvinen, T. L., Kaariainen, M., Kalimo, H., & Jarvinen, M. (2005). Muscle injuries: Biology and treatment. American Journal of Sports Medicine , 33, 745-764.

 

Khan, K. M., & Scott, A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair . British Journal of Sports Medicine , 43, 247-252.

 

Kramer, W. J., Adams, K., Cafarelli, E., Dudley, G. A., Dooly, C., Feigenbaum, M. S., et al. (2002). American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Medicine & Science in Sports & Exercise , 34 (2), 364-380.

 

Nikolau, P. K., McDonald, B. L., Glisson, R. R., Seaber, A. V., & Garrett, W. E. (1987). Biomechanical and histological evaluation of muscle after controlled strain injury. American Journal of SportsMedicine , 15, 9-14.

 

Orchard, J., Best, T., Mueller-Wohlfahrt, H., Hunter, G., Hamilton, B., Webborn, N., et al. (2008). The early management of muscle strains in the elite athlete: best practice in a world with limited evidence basis. . British Journal or Sports Medicine , 42, 158-159.

 

Taylor, C. D., Dalton Jr., J. D., Seaber, A. V., & Garrett Jr., W. E. (1993). Experimental muscle strain injury. Early functional and structural deficits and the increased risk for reinjury. , ), 190-194. The American Journal of Sports Medicine , 21 (2), 190-194.

 

Warren, P., Gabbe, B. J., Schneider-Kolsky, M., & Bennell, K. L. (2010). Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. British Journal of Sports Medicine , 44, 415-419.

 

 

 

Lumbar Disc…or Jam Donut?

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We assume poor postures for greater amounts of time than we used to, predominantly due to hi-tech gadgets. Sitting a lot in bad positions puts an unnatural load on the lumbar discs, the building blocks of our spine in our lower back. Issues with lumbar discs are debilitating but are surprisingly simple to avoid. If you don’t sit much and your work involves manual labour don’t skip this chapter! Repeated lifting can have the same effect on the lumbar discs as sitting in poor positions.

Anatomy made easy

The spine is made up of a stack of blocks of bone called vertebrae. These vertebrae are categorised into three groups: cervical (neck), thoracic (mid-back) and lumbar (lower back).

Looking at the spine from side, it easy to see it is built with natural mild curves: in at the neck, out over our shoulder blades and back in again at our lower back. From the front or back our spine should be nice and straight.

We have discs sandwiched in between each of the vertebrae in our spine, which are fused to the vertebra above and below. The discs act like a cushion or shock absorber. The presence of these discs combined with the natural curves of our spine work like a spring to absorb the impact and shocks that are imposed on our body from natural movement. The ultimate role of all of this shock absorption is to protect our most precious structure––the brain.

The discs in the spine are made up of concentric rings of fibrous tissue surrounding a pocket of jelly in the centre. Picture a jam donut––a sugary dough casing a heart full of jam in the middle. This is similar to our disc structure (though I’d imagine they don’t taste nearly as good). The discs are springy, and the jam in the middle allows the disc to compress slightly if the spine is loaded.

When our spine is in the upright or straight position, the lumbar spine (lower back) has a natural inward curve. When the lumbar spine is positioned with its natural inward curve, the discs are loaded evenly, and the jam is centred in the middle. Our spine and the discs within it can withstand considerable loads In this upright or neutral position. This includes holding bags full of shopping or carrying a heavy backpack. This neutral position is generally the position we get into when we stand and think tall.

If you have been to an Asian or African country, you may have seen locals gracefully carrying heavy produce and containers on their heads. They are always standing very straight; if they let their head or body bend forwards even slightly, they would either drop their load or create injuries that could threaten their livelihoods. This vision is true testament to the enormous strength of our spines if they are loaded in an upright or neutral position.

What goes wrong

Unfortunately, most of what we do in modern times is not in an upright or neutral spinal position, but rather a position in which we are bent in the middle. We sit at a desk, we sit in a car, we pick up a child’s toys, we lift groceries out of trolleys and we slump on the couch. When we bend, our lumbar spine loses its natural inward curve. The front part of the disc compresses. This causes the jelly in the centre of the disc to move.

Picture this––you raise the enticing jam donut to your mouth. It is full of sweet, warm jam, you take a big bite squashing the front half of the donut and compressing the space available for the jam. Where does the jam go? It squeezes out the back wall of the donut and runs down your hand . . .

This mouth-watering analogy is reminiscent of what happens to our discs when we bend a lot.

In reality, the jelly doesn’t burst out of the back of the disc straight away. Over time, the jelly pushes on the back wall of the disc so much that it creates little fissures or tears on the inside of the back wall of the disc. Then, each time you bend or sit, the jelly keeps pushing back into those fissures making them a bit bigger.

This process can be happening to your discs right now without you even being aware of it. The nerves (and therefore, your pain warning system) only supply sensation to the very outer layer of the disc wall, so internal damage can go undetected until . . .

You bend over to pick up a pen and BANG––sudden pain and spasm in your back. The cumulative disc load has finally caused the outside layer of the disc to become swollen and distended. You register a pain response via the nerves. For some people, the onset of pain is less dramatic (a small niggle that builds), but it can also escalate to a debilitating level.

Disc issues can become recurrent and ongoing. Once you have suffered once, you are ever vulnerable. Some people can correct these issues with rehab, others end up under the surgeon’s knife with a range of outcomes.

The management of these issues after they have occurred is not the focus of this post. We wish to address prevention. This prevention advice can still be relevant to you if you have already suffered a lumbar disc issue; however, this should be in consultation with your health professional.

Tune in next week to get your Back Pain Prevention Tool Kit!