After discussing and seeing a few people with injuries brought on by high intensity training to get fit in a short period of time, I felt it was worth looking into one of the principles of training – OVERLOAD!
Overload is a good thing when training and a necessity to get fitter/stronger/faster! However, this has to be balanced with a working understanding of how far and how much you can push your body before it will object.
The envelope of function described by Dye (2005), is a useful way of explaining how to gauge this. too little and there is no training effect, too much and you get injured/niggles/aches/pains.
On the graph below, the red line is the upper limit of the envelope and the blue line is the lower limit, the green area is where you should aim your training to have a beneficial effect. Above the red line is where injuries occur, below the blue line is where training doesn’t cause an increase in function.
Therefore, increased load e.g. heavy weights at a low-frequency can cause injuries. This is the case when the load is ramped up well beyond your capabilities. on the opposite side to this low load exercise, done to excess, will also put you into the potentially injured zone.
It is this second category that I feel I see more of day-to-day e.g. deciding that race is worth doing, but you’ve only two weeks to train. Cram all your training into two weeks, BANG, relatively low load but a high frequency and you pick up a strain and end up not running the race, or unable to train afterwards due to an unnecessary injury!
The next aspect to consider is once you have an injury and feel ready to return to injury, where do you start?
Well, with the above graph everything shifts left, therefore what was below the blue line, now becomes the training zone where you want to work. This is how people get re-injured, by jumping back into what they were doing pre-injury and putting themselves into a zone above their capacity to work.
There are multiple ways of achieving appropriate training, working with fitness professionals, physiotherapists, sports therapists. There are also lots of training plans on the internet – especially for running. You need to consider your level of fitness before starting a plane, and if it feels too hard it probably is.
You also need to give yourself a reasonable time scale to improve, jumping into things with no preparation or inadequate time to prepare is a grand way to get injured.
If you are injured, best bet is too seek the advice of a physio, get yourself a realistic training program and reap the rewards!
Hamstrings
Despite their long history of being problematic, described firstly over 100 years ago (Hamilton, 2012). The management basics have remained relatively unchanged for 40 years with novel and untested treatments coming in and out of fashion with little or poor research to back them up or refute them.
What/Where/How Many?
The hamstring muscle group lies on the back of the thigh, consisting of three (and a half) muscles: Semimembranosus, semitendinosis, biceps femoris and part of the adductor magnus.
How does it get injured?
There is a lot of research looking at the risk factors for a hamstring injury, however Askling(2012) describes the two common methods of sustaining a hamstring injury:
Most of you who watch sport – football, rugby, athletics etc – will no doubt have seen the distinctive sight of an athlete stopping and clutching the back of their leg (usually accompanied by a commentator stating: “that looks like his/her hamstrings gone!”)
What Askling (2012) described was the pattern and expectations of these injuries, and we will come back to this in the section on management.
Risk Factors for injury
Above is a model for Hamstring injury including some risk factors and causes for injury. While some of the points may be debatable it does demonstrate the many factors to be considered in the prevention and rehabilitation of hamstring injury (Mendiguchia, 2012).
There are many studies looking at risk factors and Freckleton & Pizzari (2013) undertook to review many of these. What they suggested (in very brief summary!) is that age, previous injury and quadriceps strength were all important risk factors, and while many others (I counted this at 11) may be risk factors the evidence for them is limited. They also present a list of proposed risk factors which show little correlation. However, as an important conclusion they note that there is very little research examining any relationships between risk factors and we may therefore be missing things which may be important in combination….
Freckleton et al (2013) looked at using the amount of single leg hamstring bridges (See pic), that a AFL could complete and demonstrated a correlation with previous injury and the likelihood of future injury when this was reduced. This therefore could be seen as a risk factor and/or a return to play measure.
Prevention or Cure!
My preference is always to attempt to prevent injuries – though I think this is vastly underused outside elite sports. In the prevention of hamstring injuries eccentric exercise has been widely promoted and studied and has been suggested to be useful in prevention of injuries.
Example 1 – Nordic Hams
An suggested program for nordic curls in injury prevention is shown in the following picture:
Example 2 – Single leg deadlift
Example 3 – Slide leg curls
The theory behind this lies in the double peak of eccentric hamstring action during running and the proposed effects of the exercise on the muscle: increased size, strength and flexibility of hamstrings, change in optimum muscle length and a stiffer muscle spring. (Malliaropoulos, 2012).
Thorborg (2012) also back this up describing a number of studies showing reductions in injuries with pre and in season eccentric hamstring training.
Rehabilitation
Even with the best intentions injuries still happen. So what do we do to rehab them and what timescales should we use?
There are a number of factors to consider and acute injury management of protection, ice, relative rest etc are still important. What Reurink et al (2012) state is there is no evidence of any effect from Anti-inflammatory medication or SI joint manipulation. Though positive effects for the use of stretching, agility and trunk stability exercises, intramuscular actovegin injections and slump stretching.
Eccentrics are also important as stated earlier – though need to be introduced carefully and at the right time as they put a large amount of stress through the muscle.
Above we talked about the mechanism of injury and the effect on rehabilitation (Askling, 2012). What was suggested included:
High speed running injuries:
- High initial impairment
- Shorter rehab period than stretching type injuries
- Danger period at 4-6 days as can feel much better very quickly
- slow jogging can commence early
- High speed eccentrics required at late stage
Stretching type injuries:
- tend to be closer to ischial tuberosity and the closer to this the longer rehab tends to be
- likely to be a longer rehab than high speed running injury
- can begin high intensity exercise early if pain is avoided
- passive stretches and heavy loads tend to provoke the injury by increasing pain
Askling et al (2013) looked at two protocols, lengthening v conventional rehab and compared return to play times, along with re-injury rates over 1 year. They found:
- The lengthening protocol(Active knee extensions, modified single leg deadlift, supported leg glides) significantly reduced the time required to return to football
- Stretching type injuries took significantly longer to return to play than sprinting type injuries
- Only one re-injury was noted and was in the conventional rehab group
- The use of the Askling H test once all clinical tests are normal to determine return to play – this may have been a significant factor in the impressive re-injury stats (usually 12-25%)
Finally, Brukner et al (2012) present a seven point plan to return an athlete to sport injury free (professional football player). Their plan encompasses the following seven points:
- Biomechanical assessment and correction
- Neurodynamics
- core stability
- eccentric strengthening
- overload running program
- injection therapies
- stretching/relaxation
This was applied to a player suffering from recurrent injuries and the nature of elite sport may make some aspects of this difficult to fully implement, however the basic principles are good and can be covered in even the most modest of clinic settings.
Summary
So, to sum up, my opinion is:
- if possible sports and clubs with a physio/interested coach should apply the evidence from eccentric training to prevent injuries to the hamstrings
- Their are many risk factors, but not much good evidence for most and no evidence of correlation between them
- prevention is the best route
- Once injured a comprehensive rehab program is most likely to provide the best return to sport (with least chance of reccurence)
- Pushing too hard and fast for a return is likely to cause a re-injury and further prolonged spell away from sport
Remember, if you do get injured physiotherapists are experts in human movement and injury rehabilitation – seeing one will get you back to what you want to do quickly and effectively!!!
This is a test proposed to determine the fitness to return to sport after hamstring injury
http://www.ncbi.nlm.nih.gov/pubmed/20852842
The test is to be conducted once rehabilitation appears complete and all clinical tests are normal including:
- palpation pain
- passive muscle length
- strength testing
This is a ballistic test, in the study protocol the leg is braced to ensure knee extension throughout and the athlete instructed to “perform a straight leg raise as fast as possible to the highest point without taking any risk of injury”.
The range of motion and degree of insecurity felt were recorded. If insecurity reported an additional 1-2 weeks of rehab was commenced then the test repeated.
This study and a more recent study showed a marked reduction in the normal re=injury rates when this test was used to guide return to play.
Improving Ankle Dorsiflexion
Firstly, there are many articles/blogs/opinions on this subject, and I don’t suspect their will be anything ground breaking in the next few paragraphs. What I will aim to do is bring together some of my most used/favourite techniques, stretches and ideas into one location.
As we talked about in a previous post, restriction of ankle dorsiflexion (knee over toe movement) can be a significant problem in how the body moves in a variety of activities and is well worth ensuring equal movement side to side exists.
I will split this into a few sections:
- Stretches
- Myofascial techniques
- Mobilisation techniques
Stretches
If a lack of ankle movement is being caused by tight calf muscles then calf stretches will improve this. I would usually suggested a gentle non-aggressive stretch of 30-40 seconds with 4-5 repetitions and 1 minute rests between stretches.
(A) Gastrocnemius stretch
Keep rear leg straight with the heel on the ground.
Lean forward until stretch felt in calf of back leg.
(B) Soleus Stretch
In stance for calf stretch, bend knee of back leg. Stretch will usually be lower in calf than regular calf stretch.
(C) Wall stretch
Put toes of front leg against wall.
- Lean hips into wall and hold
- push knee into wall and hold
Keep heel on the ground and toes on the wall.
Myofascial Techniques
(A) Foam Roller
With the foam roller or ball spend 1-2 minutes on each muscle working up/down and across. If you find a particularly tender area in the muscle stop and work on this for 10-20 seconds
(B) Spikey/Tennis/squash ball
(C) More aggressive techniques
I’m going to cheat here and link you to another blog – The Calf Smash
There are numerous other methods of increasing ankle movement on this site so have a search, not for acute injuries but generally mobility improvement. Expect it to be sore!
Mobilisation Techniques
(A) Band/Rope mobilisation
Attach a band/rope/belt to something solid, then attach it round your ankle.
The movement is knee over toes, the pull of the band affects joint position and can help increase range of joint motion.
Try different angles of pull on the band and see which help
(B) Dynamic stretches
In the knee to wall position we talked about in the previous post take knee to wall until tightness felt, repeat this 10-20 times with the following movements:
- Knee inside the foot
- knee over the foot
- Knee outside the foot
Links:
http://www.mikereinold.com/2013/03/ankle-mobility-exercises-to-improve-dorsiflexion.html
So, what I thought I would do in the next few posts is discuss ways of assessing and managing your risk of being injured.
How many of you check yourself for joint stiffness or muscle weakness? There are many common injuries that can be prevented by knowing your body and managing niggles before they become more serious problems that stop you training.
Firstly we are going to look at the Knee to Wall or Lunge test.
(O’Shea & Grafton, 2012)
This test is a simple, easy to complete measure of ankle movement and stiffness. There are many reported ways to complete this and a google image search will give you many more ideas, thought the one in the picture which I will describe has been shown to be reliable and easy to complete.
Why is this important?
A lack of ankle dorsiflexion(toe to shin movement) of the ankle has been shown to predict many potential injuries including tendonosis, fractures, knee pain, inneficient walking and running.
It will also limit your ability to complete simple tasks and exercises, such as squatting, walking up and down stairs, walking and running.
So how do I test it?
1. place a small table or movable piece of furniture in front of you
2. Line up your heel and toe perpendicular to the table
3. Lunge forward and push the table as far forward as possible without raising your heel
4. Keep your knee in line with the 2nd toe
5 Measure the distance from big toe to table
Repeat this 3 times on each leg with a 15 second rest between each attempt and record the average of the 3.
What does this tell me?
You are comparing left with right, there should be no more than 1.5cm of difference between each ankle.
If there is a bigger difference, you have an imbalance in ankle mobility and should be trying to even this out by mobilising the stiff ankle.
The relative distance is important as well, most literature seems to suggest about 8-10cm as normal range, if you have less than this you may want to work on increasing your ankle mobility.
I have a stiff ankle – What do I do?
My next post will look at a variety of methods of increasing ankle dorsiflexion, from simple stretches to some more advanced mobilising techniques you can try.
The Medial Collateral Ligament is the ligament supporting the inside of your knee.
In the USA it is injured in 0.24 people per 1000, meaning in a city the size of Glasgow there is potentially 180 MCL injuries per year. Generally this is a sporting injury where a force pushes the knee in the way as shown here:
It can also occur with rotation or a combination of both movements. There are a number of important structures which support the inside of the knee. These are:
- Superficial MCL
- Deep MCL
- Posterior Oblique Ligament
These structures have a complex role, and complement each other in protecting the knee. The Superficial MCL has 2 functions:
- protecting against valgus (inwards movement) stress at the knee
- protecting against external rotation stress at the knee
It therefore acts as the main(primary) stabilising structure on the inside of the knee. This is supported by other structures, and the deep MCL provides secondary protection against valgus stress.
The deep MCL and posterior oblique ligaments provide secondary restraints to external rotation(foot turning out) stress at the knee. The same structures also act to stabilise against internal rotation (foot turning in) stress to the knee.
So that’s whats there, how do we diagnose an injury to this area?
Well, as always the history of the injury is a big clue. Nearly all injuries to the medial knee will have had a valgus stress to the knee, with or without contact. Some from a tackle, some from a fall/landing that went wrong! There will also be those with biomechanical problems whose leg position irritates the medial knee structures.
The physical examination should comprise at least the following tests:
These tests will allow diagnosis of the classification of the injury, and the structures involved. Valgus stress in extension with an isolated MCL injury should have only a small amount of laxity, a large amount may indicate a combined injury with cruciate involvement. The Dial test, although traditionally used to assess the opposite corner of the knee can be positive in medial knee injuries.
Where there is doubt over the diagnosis or extent of injury, stress x-rays can be used to confirm the amount of laxity and MRI can be used to determine the location and extent of the injury, which is reported to be 87% accurate(Yao et al).
Classification is based usually on a 3 stage model of progressive damage:
- Grade 1
Pain along medial knee on testing but no ligament laxity
- Grade 2
Pain on medial knee, with laxity but the ligaments still have an end feel
- Grade 3
Complete ligament tear with no identifiable end feel on testing the ligament
There may be some difficulty in determining the cause/location of an injury in a chronic problem, and given the rotatory aspect to this, as described above, can be confused with a posterolateral corner injury. Therefore, the anteromedial and posterolateral draw tests can be used to differentiate along with careful interpretation of a dial test.
So now we know a bit about the medial knee, and how to tell if it’s injured.
What to do with it?!?
Typically the first choice of treatment in an isolated MCL injury is rehabilitation. Unless there is a combination injury with other knee structures e.g. ACL or PCL or meniscus, where a different thought process is required.
The aims of most rehabilitation programs are:
- Protect the healing ligament
- Restoring muscle function around the knee
- Restoring full range of motion
- Removing swelling from the knee
There are many rehabilitation programs available, but most include the above principles, expected recovery time depends on the desired outcome of the program and the severity of the injury, though an average of 5-7 weeks has been proposed(Wijdicks et al, 2010)
There is some debate regarding the use of brace post injury, and early movement is shown to be beneficial from as soon as tolerable (La Prade, 2012). Side to side movements should be avoided until at least 3-4 weeks in a grade 2/3 injury to allow good healing to take place.
A post on knee rehabilitation will follow in the near future, so keep a look out!
One of my bugbears is grouping symptoms together, to give someone a diagnosis!
Rarely are these groupings done to facilitate optimal treatment, rather to group a series of problems with various causes into an easy to name bundle (again only my opinion!)
Examples include ‘shin splints’, ‘medial tibial stress syndrome (MTSS)’, ‘ Anterior knee pain’, ‘ Shoulder impingement’. I could continue, but won’t!
In this post I intend to examine PFPS or patellofemoral pain syndrome. Another grouping of various knee ailments, which can all benefit from specific diagnoses and treatment.
A quick google search for patellofemoral pain syndrome reveals 413.000 hits – a popular topic! In this can be found videos for treatment, advice on management and a large number of causes, cures and tips.
I’m sure many of these will help, but how many look at why the pain is there, what is the root cause, and what is a long term fix for the problem?
In the JOSPT, a study from 1998 proposes a classification system for patellofemoral pain. He splits these into a number of categories:
- Patellar Compression Syndromes
- Patellar Instability
- Biomechanical Dysfunction
- Direct patella trauma
- Soft tissue lesions
- Overuse syndromes
- Osteochondritis Dissecans
- Neurologic disorders
Now, you’ll be glad to know i’m not going to wade through all these and their pros and cons, what I will do is outline why as a basic and not recent study it may help in treating these patients.
The main treatments I hear pushed towards anterior knee pain are:
(D) tape the patella
There are others including bracing, foot posture, surgical options.
What if these were commonly related to the above classifications:
For example:
Strengthen the quads and patient gets worse
Could they have a patella compression syndrome?
The quads increase patella compression – why strengthen them in this situation, or tape?
Strengthen the hips and there is no change in pain
What if the patient doesn’t have a proximal biomechanical issue?
Instability of the patella isn’t going to improve with hip strength markedly – especially if its anatomical instability.
You probably see where i’m going with this.
Why not then reduce our use of generalistic terms, explain to people what is happening at their knees ( or anywhere else), and treat a specific problem?
Shoulder pain is a major contributor to the workload of a physio and the diagnosis of impingement is a very common one.
Impingement should be (I believe) regarded as an umbrella term, like anterior knee pain or shin splints, as there are many potential causes. Not searching for and respecting these causes, is likely to prolong treatment or result in unnecessary treatments. Not good – who wants prolonged ineffective treatment!
One test which, from my experience is either used or not heard of is the scapula assistance test. A simple easy to do test which looks at scapular movement during active movement of the shoulder.
Scapular assistance test video
It has been reported in various studies, Cools et al 2008 have it in their impingement algorithim, Kibler et al 2003 has been credited with initially promoting the test.
More recently Rabin et al 2006, present the test as having acceptable interrater reliability. Thus the test appears to gain popularity through the 2000 – 2006 period and has validation of its use in practice
Further validation of it’s use come from Gibson et al and a presentation in 2008 where they state: “Patients demonstrating a positive scapula assistance test at their first assessment were 95% likely to respond to the exercise programme” though some limitations are discussed here.
If this is true it is an excellent reason to use the test, and another way to promote exercise to patients to resolve musculoskeletal conditions.
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