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Health News 13/4/21

29/3/2021

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  • How football gear made especially for women is changing the game - 
  • Should footballers have the right to play concussed? - 
  • How New Zealand’s healthcare system is failing people with osteoarthritis - 
  • Brisk Walking Is Good for the Aging Brain - 
  • Does injury incidence really change across the menstrual cycle? Highlighting a recent key study - 
  • Running outside is better for you – and means you’ll run further - 
  • How to Hold on to Your Sprint Speed as You Age - 
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March 16th, 2021

25/3/2021

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  • ANOTHER EASY WAY TO MONITOR YOUR STRENGTH GAINS - 
  • Concussion risks aren’t limited to the AFL. We need urgent action to make sure our kids are safe, too - 
  • INTERVAL TRAINING – WHAT THE RESEARCH SAYS - 
  • HOW TO APPROACH YOUR POSTURE LIKE AN ELITE ATHLETE - 
  • Should The NRL Tighten Its Concussion Rules? - 
  • MILKS – A COMPREHENSIVE REVIEW FOR ATHLETES - 
  • Australian back pain trial slashes opioid use - 
  • ‘Enormous problem’: Surge in patients with sore feet and lower limb pain - 
  • What’s the Minimum Dose of Training to Stay Fit? - 
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Health News 15/3/21

24/2/2021

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  • HOW TO UTILISE MEAL KIT DELIVERY SERVICES TO SET YOU UP FOR SUCCESS - 
  • THERE IS MORE TO PAIN THAN TISSUE DAMAGE - 
  • SIMPLE STRENGTH TESTING TO TRACK YOUR PROGRESS - 
  • How Exercise Enhances Aging Brains - 
  • THE MUSCLE MORPHOLOGY OF ELITE SPRINT RUNNING: BUTTOCK SIZE MATTERS! - 
  • DO YOU KNOW IF YOUR CHILD HAS HAD A PREVIOUS CONCUSSION? - 
  • How the World’s Best Athletes Handle Brutal Heat - 
  • Major concussion shake-up for every rugby league club in Australia - 
  • Getting to the Bottom of the Runner’s High - 
  • AFL to use eye technology and 'smart' mouthguards in new concussion studies - 
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Health News 23/2/21

23/2/2021

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  • Snack your way to better health with bite-sized exercise breaks - 
  • AFL considering proposal for landmark multimillion-dollar concussion trust for players - 
  • HOW ATHLETES CAN SUPPORT STRENGTH GAINS WITH NUTRITION - 
  • AFL pushed to establish $2 billion concussion compo scheme - 
  • How classical music could reinvigorate your exercise regime - 
  • How Much Exercise Do You Need for Better Heart Health? - 
  • RECOVERY – WHAT DOES THE RESEARCH SAY? - 
  • Player push for objective concussion assessment to support protocols - 
  • TRAINING CONSIDERATIONS FOR IMPROVING MAXIMAL POWER PRODUCTION - 
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Health News 16/2/21

16/2/2021

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  • Can Exercise Make You More Creative? - 
  • HOW TO BUILD MUSCLE WHILE LOSING FAT AT THE SAME TIME IN TRAINED INDIVIDUALS (BODY RECOMPOSITION)? - 
  • INCORPORATING DIRECTIONAL CHANGE INTO YOUR TRAINING – DECELERATION - 
  • Training one arm can improve strength and decrease muscle loss in the other arm -
  • Running Is a Total Body Affair -  
  • How Your Body Does (and Doesn't) Adapt to Cold - 
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Health News 4/2/21

4/2/2021

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  • COOL DOWNS – WHAT DOES THE SCIENCE SAY? - 
  • There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sport - 
  • Are you sitting comfortably: the myth of good posture - 
  • Not feeling motivated to tackle those sneaky COVID kilos? Try these 4 healthy eating tips instead - 
  • Planning on running a marathon? A sports dietitian on what to eat for long-distance running - 
  • The ACL injury journey – a guide for patients -  
  • Health Consequences of an Elite Sporting Career: Long-Term Detriment or Long-Term Gain? A Meta-Analysis of 165,000 Former Athletes - 
  • RESISTANCE TRAINING: A GOOD IDEA FOR CHILDREN AND ADOLESCENTS? - 
  • FLOWCHART | YOUR TIMELINE FOR EATING DURING COMPETITION - 
  • The Data Behind a Once-a-Week Strength Routine - 
  • TOP THREE TIPS TO MAXIMISE YOUR SLEEP - 
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Health News 4/1/21

4/1/2021

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  • To Lose Weight With Exercise, Aim for 300 Minutes a Week - 
  • Concussion sufferers twice as likely to develop brain diseases, study finds - 
  • STRENGTH TRAINING : AN EXCELLENT WAY TO BOOST YOUR RUNNING PERFORMANCE - 
  • THIS IS HOW YOU SHOULD EAT TO PREVENT AND TREAT TENDON & LIGAMENT INJURIES - 
  • HOW ATHLETES CAN CHANGE THEIR DIET WHEN INJURED AND WHY - 
  • Improving Your Balance to Prevent Falls - 
  • Can 4 Seconds of Exercise Make a Difference? - 
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Is It Time For Retiring Flexibility As A Major Component Of Physical Fitness?

2/1/2021

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MUSCLE STIFFNESS

22/12/2020

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IS IT BAD TO HAVE "STIFF" MUSCLES?

Stiff muscles are a counterintuitive superpower of NBA athletes

File 20190515 60537 1oj3r9h.jpg?ixlib=rb 1.1
What helps an athlete leap tall distances in a single bound? AP Photo/Tom Lynn
Philip Anloague, University of Dayton

For most people, the term “stiffness” has negative connotations. When you wake up in the morning complaining of a “stiff back,” the remedy might include taking a hot shower, doing some yoga, swallowing aspirin, or visiting a physical therapist to loosen up. Stiffness is typically viewed as unpleasant and can limit one’s physical activities.

Surprisingly, though, for elite athletes like professional basketball players, muscle stiffness is not only something that is necessary, you could say it’s their superpower. As a physical therapist and researcher who works with National Basketball Association players, I’m interested in understanding the key factors that help to minimize injury risk and maximize performance in elite athletes – and understanding stiffness is an important part of that.

A pro player’s jump can seem otherworldly. AP Photo/Nick Wass

Spring in your step

Physiologists think of muscles as being like biomechanical springs. Muscles contract to produce forces that help you move and stretch to allow enough range of movement. Stiffness is a way to talk about how springy a muscle is. It is a characteristic of how much it can lengthen in response to an applied force. The spring of a muscle allows it not only to stretch but also to recoil during muscle contraction. This process allows for movements including walking, running and jumping.

The force required to deform or stretch a muscle is correlated to a degree of spring or stiffness and to the extent the muscle is lengthened. Strength is important, but stiffness can help an athlete generate even more power.

Basketball is a vertical sport that includes up to 46 jumping and landing activities for an individual player per game. That’s 2 to 4 times more jumping than in soccer or volleyball. It’s also a multi-directional sport – an average player changes direction or activity every 2 to 3 seconds, requiring constant acceleration and deceleration of movements.

Russell Westbrook demonstrates what a muscle with just the right balance of stiffness and flexibility can achieve. AP Photo/Craig Mitchelldyer

Lower extremity stiffness is important for optimal basketball performance because athletes who appropriately use greater stiffness characteristics can take advantage of the elastic energy it creates. A muscle can only stretch so far because its length is limited by its degree of stiffness. So, like a spring or a rubber band, when the muscle is stretched, that stiffness helps to create elastic energy that can then be used with a muscle contraction to help you run or jump on the court.

This helps someone like Russell Westbrook leap in the air, stop on a dime, then accelerate down court during a fast break. It takes him just 3.36 seconds to run from baseline to baseline.

The sweet spot

However, there is a point of diminishing returns. Too much muscle stiffness can lead to reduced joint motion and a decreased ability to absorb shock at the joints. This can place one at greater risk for stress fractures or even osteoarthritis, the wear and tear of cartilage that can cause joint pain. Evidence suggests that too much stiffness may lead to injury.

And on the other side of the spectrum, a player needs a certain degree of flexibility and joint mobility to support the proper elongation of muscle and tendons that allow for the appropriate range of motion.

So players need to balance these extremes, landing in the sweet spot of optimal lower extremity stiffness: not too much, which can lead to high levels of force and loading rates and a greater risk for bony injuries. And not too little, which is associated with an increased risk for soft tissue injury and muscle strains.

My research team is investigating these relationships in an attempt to help elite athletes minimize risk of injury and maximize performance. The first step is in understanding what “normal” clinical measurements are for elite athletes.

Philip Anloague measures the degree of ankle mobility, called dorsiflexion. Philip Anloague, CC BY-ND

Textbook values have been established for the general population but this information is lacking for NBA players. For example, a typical value of ankle flexibility for the average individual is about 50 to 55 degrees. Our research team has found that the typical NBA player is more stiff and averages 35 degrees.

When comparing elite basketball players to textbook norms it might appear that they are too tight and even dysfunctional. However, to be successful in their sport, this degree of stiffness is actually their superpower. If trainers start stretching Lebron James’ muscles to match the textbook values of the general population, he may start jumping like the general population. That tactic could very well be kryptonite to an NBA athlete.

Training to minimize injury and maximize performance

Physical therapists know that the so-called fast twitch muscle fibers – the ones responsible for jumping and sprinting – have a higher propensity for stiffness. With training the level of stiffness can be increased to improve performance.

A player demonstrates a plyometric jump – a powerful movement that lengthens then quickly shortens a muscle. Philip Anloague, CC BY-ND

Evidence suggests that plyometric and bounding exercises that involve jumps, hops, or bounds, performed in a stretch shortened cycle do have a positive effect in the ability for muscle to have more spring. But overall, your own degree of stiffness versus springiness is a combination of nature and nurture, genetics and training.

Research related to better understanding the continuum between stiffness and compliance can help physical therapists and trainers when working with basketball players. They need to know dosage – how much to stretch or strengthen. Work is underway that contributes to this endeavor. There are also initiatives that aim to understand player load and the cumulative physical demands that elite athletes undergo when generating fast and powerful movements. Researchers also need to understand what the best methods and technologies are for monitoring these loads. My colleagues and I theorize that there is an optimal level of compliance and stiffness that helps keep our basketball heroes super.The Conversation

Philip Anloague, Chair and Associate Professor of Physical Therapy, University of Dayton

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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More Research on Nordic Hamstring Curls

15/12/2020

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"Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes."

(Nicol van Dyk, Fearghal P Behan, Rod Whiteley, British Journal of Sports Medicine.  Published Online First: 26 February 2019. doi: 10.1136/bjsports-2018-100045)

ABSTRACT
Research question Does the Nordic hamstring exercise (NHE) prevent hamstring injuries when included as part of an injury prevention intervention?

Design Systematic review and meta-analysis.

Eligibility criteria for selecting studies We considered the population to be any athletes participating in any sporting activity, the intervention to be the NHE, the comparison to be usual training or other prevention programmes, which did not include the NHE, and the outcome to be the incidence or rate of hamstring injuries.

Analysis The effect of including the NHE in injury prevention programmes compared with controls on hamstring injuries was assessed in 15 studies that reported the incidence across different sports and age groups in both women and men.

Results There is a reduction in the overall injury risk ratio of 0.49 (95% CI 0.32 to 0.74, p=0.0008) in favour of programmes including the NHE. Secondary analyses when pooling the eight randomised control studies demonstrated a small increase in the overall injury risk ratio 0.52 (95% CI 0.32 to 0.85, p=0.0008), still in favour of the NHE. Additionally, when studies with a high risk of bias were removed (n=8), there is an increase of 0.06 in the risk ratio to 0.55 (95% CI 0.34 to 0.89, p=0.006).

CONCLUSIONS: Programmes that include the NHE reduce hamstring injuries by up to 51%. The NHE essentially halves the rate of hamstring injuries across multiple sports in different athletes.


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INJURY PREVENTION PROGRAMS

14/12/2020

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INJURY PREVENTION IS IMPORTANT FOR RESULTS

​Success in sport is dependent on a number of factors (eg, skill, fitness, squad size, tactics, and psychological factors). Athlete durability is also a key component of success.

In team sports, research shows a strong link between player availability and the success of the team, and that injuries and illness are the most common reasons for athlete unavailability in training and matches (REF). Research in team sports demonstrates an inverse relationship between injury burden and success of the team. Lower player availability is associated with failure to achieve key performance indicators. Injuries detrimentally affect the final ranking position in team sports (REF). And, research from professional European football shows lower season injury rates results in more successful seasons (REF).

Injuries and illnesses also affect success in individual sports. In elite track and field athletics, injuries and illness and their influence on training availability during preparation are major determinants of an athlete's chance of performance goal success or failure. Research shows the likelihood of achieving a performance goal increases by 7-times in athletes who complete >80% of planned training weeks. And, training availability accounts for 86% of successful seasons (REF).

So, injuries can determine success of failure in team and individual sports. Therefore, injury prevention strategies should be a focus for success-driven athletes and teams. 

INJURY PREVENTION PROGRAMS

​A number of sporting bodies have developed standardised injury prevention programs that are very effective at reducing injury rates. Sports that include these programs into their training have been shown to have between 50-80 per cent fewer injuries. These injury prevention programs are a series of exercises that are reasonably quick and easy to perform as part of a warm up. They include plyometric (jumping and landing), neuromuscular control (challenging balance, agility, addressing poor movement patterns), and strength exercises.
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FOOTBALL

​For every 1,000 hours of game play, elite football players suffer between 12 – 35 injuries (REF). The most common types of injury sustained during a football game are muscle strains, ligament sprains, and contusions. Ankle, knee, and groin have the highest incidence of injury, and the greatest risk for sustaining an injury is during a football game as opposed to during a training session (REF).

The warm-up program “FIFA11+” is an injury prevention program designed by the Federation Internationale Football Association (FIFA) Medical and Research Centre (F-MARC) in 2006. It was designed to reduce the occurrence of injuries associated with playing football. 

The FIFA11+ consists of three parts and 15 exercises in total:
  • The first part of the program involves running exercises and active stretching.
  • The second part of the FIFA11+ program introduces six sets of exercises designed to work on the athlete’s core strength, leg strength, balance as well as their agility and plyometric ability.
  • The third and final part of the FIFA11+ includes moderate to high speed running with planting/cutting movements.

The FIFA11+ program has been studied extensively over the last ten years to determine its effectiveness on injury prevention and physical performance measures, across a variety of populations. The FIFA11+ program has been shown to significantly reduce the risk of injuries in football (REF). This includes a 77% decrease in ACL injuries  (REF), a 48% reduction in lower limb injuries (REF), and an overall injury reduction of 35% per 1000 hours (REF).

FIFA 11+ and more resources for injury prevention in football are available here: footballnsw.com.au/protection-and-safety/injury-prevention/

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NETBALL

​Netball Australia has developed the "KNEE Program” to help prevent knee and other lower limb injuries in netball.

Knee and ankle injuries are common in netball, making up three quarters of all injuries. Devastating ACL injuries are unfortunately common in netball, making up 25% of the serious injuries.

The KNEE program offers a range of warm-up exercises that help prevent injury. There are a range of age and experience appropriate exercises for junior, through to elite netballers. They are easily understood by players and coaches, with a number of options offering variability and progression.

It would be great for the KNEE program to be widely adopted by Australia's largest participation sport for females.

​KNEE Program resources are available at: https://knee.netball.com.au

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AUSTRALIAN RULES FOOTBALL

​FootyFirst is a five level progressive exercise training program that has been developed specifically to reduce the risk of common leg injuries in community Australian rules football. 

FootyFirst begins with a warm-up, followed by leg strengthening and conditioning exercises, and training to improve balance, landing and side-stepping skills. It requires only standard training equipment and can replace the traditional warm-up. Once players and coaches are familiar with the exercises, the warm-up should take about 5 minutes, and the strength and conditioning exercises and jumping, landing and changing direction activities about 15 minutes. 

Performed correctly and frequently, FootyFirst will improve performance and reduce injury risk. FootyFirst has been shown to decrease knee injuries by 50% and all leg injuries by 22% (REF). It will improve players’ leg strength and control – from their hip to hamstring, groin to thigh, lower leg, knee, ankle and foot.

Resources include the FootyFirst Coaches’ Manual, a series of posters illustrating the exercises at each level, and the FootyFirst Coaches DVD is available at: aflcommunityclub.com.au/index.php?id=906

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Health News 11/12/20

11/12/2020

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  • Rethinking the Cross-Training Paradox - 
  • England's Professional Footballers’ Association to limit heading ball at training - 
  • Physio, chiro, osteo and myo: what’s the difference and which one should I get? - 
  • RED-S Is a Real Problem for Some Runners - 
  • Female footballers may face greater risk of dementia - 
  • Football and dementia: heading must be banned until the age of 18 - 
  • 8 TIPS TO AVOID DEHYDRATION LEADING INTO TRAINING AS AN ATHLETE - 
  • Feeling sore after exercise? Here’s what science suggests helps (and what doesn’t) - 
  • 11 Minutes of Exercise a Day May Help Counter the Effects of Sitting - 
  • 5 NUTRITION TIPS FOR MANAGING THE SILLY SEASON - 
  • THE ANTERIOR CRUCIATE LIGAMENT INJURIES IN FOOTBALL : MECHANISMS, SITUATIONAL PATTERNS & BIOMECHANICS - 
  • HIGH PERFORMANCE THINKING & SELF-COACHING - 
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WORKING FROM HOME

8/12/2020

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THE PROBLEM WITH SCREEN TIME

Around 30% of patients I treat have a complaint that is caused by prolonged sitting, commonly in front of a screen. This is mostly neck and back pain caused by things like; getting stuck at the desk too long, long commutes, long-haul flights, binge watching Netflix on the lounge, or looking at the iPad in bed.

This is a relatively new activity for humans and we're just not used to it. From an evolutionary point of view, we're just not adapted to sitting still all day. We've had 100,000 generations of hunting and gathering, moving around, doing different things all day. We've had 50 generations of agriculture, and only 10 generations of industry, where we're expected to sit and do the same repetitive task for prolonged periods of time. We're just not used to staying still from 9-5. Our bodies have evolved to move and be used. Staying still makes us sore.

NOW, WORSE THAN EVER

COVID-19 has caused a unique moment in time, with unprecedented social and workplace disruption. Never before have so many people been required to work from home. People are working at the dining table or kitchen bench. People are on their laptops on the lounge or in bed. The home set-up isn't ideal.

Also, some of the usual workplace activities that might get you away from the screen, like getting into the boardroom for a meeting, are now happening online too, so there are less reasons to get up and move away from what you're doing.

My workload has decreased with people self-isolating, but every new patient I've had in the last two weeks has been someone with neck pain or back pain caused by working from home.

THE SOLUTION

So remember, if you're getting a sore neck, or a pain next to your shoulder blade, get up and more around more. It's time to take a break.

If you're getting a sore back, or an ache into the top of your buttock, get up and move around more. It's time to take a break.

It should be very simple. Motion is lotion. Rest is rust.

I CAN HELP

If you need help, come in for an assessment and treatment. Physiotherapy is deemed an essential service, and we are still open. Phone 99696925, or book online HERE.

Alternatively, if you're self-isolating, or practising social-distancing due to COVID-19, you can book a video consultation HERE.

​Stay safe and well.
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Misconceptions about Osteoarthritis

2/12/2020

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PT Inquest, my favourite physio podcast, recently discussed this paper:
Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study
The abstract summarises:

In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and Total Knee Replacement surgery is overused. Empirical evidence and qualitative observations suggest that patients’ willingness to accept nonsurgical interventions for knee OA is low.

Participants’ beliefs about knee OA and its treatment were identified. Beliefs were grouped into five belief dimensions:
  • identity beliefs (what knee OA is),
  • causal beliefs (what causes knee OA),
  • consequence beliefs (what the consequences of knee OA are),
  • timeline beliefs (how long knee OA lasts),
  • treatment beliefs (how knee OA can be controlled).

The participants' beliefs are what I would guess, based on what I hear from patients everyday:
  • All participants believed that their knee OA was “bone on bone” (identity beliefs).
  • Most believed it was caused by “wear and tear” (causal beliefs).
  • Most believed that loading the knee could further damage their “vulnerable” joint (consequence beliefs).
  • All believed that their pain would deteriorate over time (timeline beliefs).
  • Many believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage (treatment beliefs).
  • They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs).

The authors conclude: 

Common misconceptions about knee OA appear to influence patients’ acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss.

Once the participants in this study had been “diagnosed” with “bone-on-bone” changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage.

These misconceptions do feel like commonsense and, as such, are widely held by the general public. Some of them may be true at the very end stage of osteoarthritic disease, but they are definitely not true for all patients with osteoarthritis, and as such, the misconceptions are harmful because patients disregard beneficial conservative treatments like weight loss and exercise, and rush towards surgical options.

"BONE ON BONE" is a metaphor that is commonly used, even by physios and knee surgeons.

"Bone on bone" creates a very dramatic image of what's going on in the knee, and undermines the possibility of osteoarthritis being pain free. Using words like "bone on bone" can cause harm because it sounds like it is definitive and painful, when in reality it's only a metaphor.

The reality could be explained more like: "the joint reinforces and repairs the damaged area by laying down new tissue". Or, "the joint wants to make itself even stronger than cartilage, so it lays down stronger building blocks - bone cells".

​Not everyone with osteoarthritis has "bone on bone", and the perception of "bone on bone" as what's happening in the knee can make patients less likely to stick with evidence-based conservative treatment options.

​The concept of "WEAR AND TEAR" makes sense if you imagine the joint as mechanical. A cupboard's metal hinge can be opened and closed a certain number of cycles before it breaks. Metal and plastic fatigues and fails. Mechanical joints "wear out". But our joints aren't made of metal and plastic. Knees are not mechanical joints. They are biologically active joints, that adapt to what we do. 

If we do a million bicep curls, we don't expect our biceps to "wear out" - we expect to end up with bigger, stronger biceps. Similarly, the bones, cartilage, ligaments and muscles in our knees are biologically adaptive, they have regenerative ability, and adapt to what we do. Our joints get stronger with use.

Rather than "wear and tear", the more appropriate phrase should be: "use it or lose it".

DOESN'T RUNNING "WEAR OUT" KNEES?

Another common misconception is that running "wears out" knees.

Doctors and knee surgeons see patients complaining they have sore knees when they run. The X-ray shows some arthritis, so it's very easy to make the assumption that running causes arthritis. But we know that distance runners don't "wear out" their knees. Runners have better knees than non-runners. ​

This 2017 research comparing 2,637 runners to non-runners (matched for age, weight, mileage, injury, and other variables) concludes: There is no increased risk of symptomatic knee OA among runners compared with non-runners. In those without OA, running is not detrimental to the knees. 

This 2008 research concludes: Long-distance running among healthy older individuals was not associated with accelerated radiographic OA, and long-distance running or other routine vigorous activities should not be discouraged among healthy older adults out of concern for progression of knee OA.

This 2004 research concludes: The results of this literature review strongly suggest that regular mild-moderate impact exercise does not increase the risk of OA, and that there is some evidence that it does not increase symptoms in patients with mild-moderate OA. And: Regular running increases joint space width.

So:
  • Running does not cause osteoarthritis.
  • Osteoarthritis is not caused by "wear and tear".
  • Most osteoarthritis should not be considered "bone on bone".
  • Research supports the conservative treatment of osteoarthritis with weight loss and exercise.



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Injections for Tendon Pain

1/12/2020

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​I’ve been frustrated this week by a couple of patients with Achilles problems that I thought should recover well.  They’ve disappeared to go and have an injection, against my recommendation.  It’s made me think about whether or not I should have made the referral myself?  What are our options for injections, and do they work?

​TENDON PAIN

Tendinopathy (tendon pain) is very common.  They are the most common type of overuse injury (ref).  Achilles tendinopathy affects the majority of runners (ref) and is the reason 16% of athletes have to stop sports participation (ref).

There are a range of commonly prescribed treatment options for tendinopathy, but very few are supported by quality, randomised, prospective, placebo-controlled trials.

​SO WHAT DO I DO?

Considering all the available treatment options, above anything else, I always recommend:
  • load management, in combination with
  • a strengthening program.  

​WHAT ABOUT INJECTIONS?

​Having mapped out a management plan, patients will routinely ask my opinion on getting an injection.  They may have had a friend for whom an injection worked well, or the GP has suggested it as an option, or they’ve had one before and it worked.  

There are a range of drugs to inject into or around a tendon, depending on who you are referred to:
  • Corticosteroid (A strong anti-inflammatory)
  • Prolotherapy (An irritant to stimulate new tissue growth, e.g. hypertonic dextrose/glucose)
  • Sclerotherapy (An irritant to decrease vascularisation, e.g. Polidocanol)
  • Traumeel (A homeopathic preparation derived from arnica)
  • Actovegin (derived from calf blood)
  • Autologous blood (injecting your own blood into the tendon to promote healing)
  • Platelet-rich plasma (blood is taken and PRP is extracted and injected to promote healing)
  • High-volume injections (to damage the tissue and encourage new growth)

​CORTICOSTEROIDS

Corticosteroids are an anti-inflammatory medication injected around the tendon to decrease pain that is caused by inflammation (although it is now thought that inflammation does not play a significant role in tendon pain).  Corticosteroid injections have historically been commonly prescribed but more recently their use is controversial.  Repeated corticosteroid injections can weaken the tendon and increase the risk of rupture.  Corticosteroid injections are good at relieving pain in the short term (2-6 weeks) however, there is strong evidence that long-term outcomes (> 6 months) are worse than other conservative treatments or no treatment at all (ref). 
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​PROLOTHERAPY / SCLEROTHERAPY

Prolotherapy injections act as an irritant causing an inflammatory response then scarring of the nerves that transmit pain.  There is no solid support in the medical literature for this procedure for the treatment of tendinopathies.  A randomised controlled trial of polidocanol injections showed the potential to reduce tendon pain in patients with chronic painful mid-portion Achilles tendinopathy (ref).  However, a systematic review found limited results for use of prolotherapy in sports related soft tissue injuries (ref).  

​AUTOLOGOUS BLOOD INJECTIONS

The rationale of autologous blood injection consists of enhancing tendon healing through collagen regeneration and the provision of cellular mediators.  Good experimental models are lacking, and clinical application is anecdotal.  A 2013 randomised controlled trial investigating the efficacy of autologous blood injections as a treatment for mid-portion Achilles tendinopathy concluded they did not reduce pain or improve function any more than a strengthening program. (ref)  

​HIGH-VOLUME INJECTIONS

The suggested mechanism of high-volume injections is the mechanical disruption of local tissues then stimulates a healing response.   One study (ref) has shown that high-volume injection of normal saline solution, corticosteroids or anaesthetics reduces pain and improves short and long-term function in patients with Achilles tendinopathy.  However, more research is required.

​PLATELET RICH PLASMA (PRP)

Platelets are naturally occurring in your blood, where they play an important role in healing damaged tissue, so superficially it’s inherently appealing to just add more of them to the sore spot.  PRP injections are particularly trendy at the moment and it’s easy to find someone who will tell you they work well.  Unfortunately, research concludes there is no benefit to PRP injections.  This study found PRP injections do not improve plantar fasciopathy pain or function.  This study concluded there is insufficient evidence to support the use of PRP for treating musculoskeletal soft tissue injuries.  This systematic review found strong evidence against platelet-rich plasma injections for tennis elbow.  This study found PRP did not improve tendon structure.  This meta-analysis found no greater clinical benefit of PRP over placebo or dry needling for tendinopathy.

​SO…

​Would I have any of these injections, or would I recommend them to my patients, friends, or family?  Well it depends.  In my experience some people get some benefit some of the time.  HOWEVER, these injectables are not consistently effective and their use is mostly not supported by research.  I suggest that patients try the strengthening program and the results will be overall better in the long term.  

​WHY DO THE INJECTIONS WORK FOR SOME PEOPLE?

​I’ve been frustrated with a couple of patients that cancelled their follow-up appointment and, when I phoned and asked what had happened, they’ve had an injection and now feel fine.  My conclusion is the injections don’t work, but if you were sore and now you’re not, your conclusion would be they do work.  So what is it?..

​REGRESSION TO THE MEAN

​Most people seek treatment when they are at their worst.  By definition the only possible change from being as bad as at can be, is an improvement.  Was it the injection working, or was it getting better anyway?

​NATURAL HISTORY

​Some conditions are self limiting and will just get better by themselves.  Did the injection work, or was it about to get better anyway?

​PLACEBO

Injections are a powerful way to administer a placebo effect.  You need to see a specialist to receive it.  You need to pay more money.  There’s some high-tech equipment spinning the blood.  Everything is set up for you to expect improvement and, in a decent percentage of cases, that’s all it takes to get better.  If you believe the injection will help you then it is much more likely to work.  However, the research tells us it doesn’t really matter what substance is injected, it is your belief in whether or not it will help that is the variable more likely to determine the outcome.
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​SUMMARY

I understand that getting an injection seems like a much easier option than doing 12-weeks of strengthening exercises, but in the long run, a strengthening program is the thing that actually works.

​TL;DR

If treating tendon pain was as easy as getting an injection then that’s what everyone would do first.  Unfortunately it’s not as easy as that.


Have you had an injection for your tendon?

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Health News 24/11/20

24/11/2020

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  • 4 EASY GLUTE EXERCISES TO RELIEVE YOUR LOWER BACK - 
  • After a Broken Bone, the Risk of a Second Fracture - 
  • Dazed and confused: Mixed messages on concussion a serious problem - 
  • Exercise nutrition: whether you should eat before or after a workout depends on your fitness goals - 
  • Balanced snacks are important for athletes to fuel their training and provide energy for recovery - 
  • Let it happen or make it happen? There’s more than one way to get in the zone - 
  • Wearing a Mask During Workouts Really Isn’t So Bad - 
  • Seeking the Fastest Shoe in the Post-Vaporfly Era - 
  • Why has it taken 50 years for football to connect heading with brain injuries? - 
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Are You Out Of Alignment?

20/11/2020

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​I treat a lot of people that have:
  • back pain,
  • neck pain,
  • pelvis pain,
  • hip pain.


​Very commonly they’ll tell me something is “out of alignment”. Either that’s what it feels like, or they’ve had treatment from a therapist that has told them that, or they’ve talked to a friend who has said “maybe your ‘X’ is out?” and that makes perfect sense to them.

The concept of something being “out of alignment” is not a paradigm I’ve ever been taught or taught to patients. My understanding of it as an idea is that it comes from an osteopathic and chiropractic model where pain and illness are meant to originate from vertebral “subluxations”. A vertebra is “out of place”. The subluxation model is now being discouraged by chiropractic associations worldwide as not being valid, but it has definitely seeped into public consciousness. A lot of people when they have back pain will try and describe how it feels and come up with the explanation that they’ve “put their back out”. Patients grab hold of a simple idea that seems to makes sense.

When a patient uses this sort of terminology I used to play along with it because I understood what they were saying and I found I upset a lot of patients if I tried to correct them. They had paid good money to see a chiropractor who’s told them their pelvis was out of alignment, they’ve agreed that’s what it felt like so they’ve bought into the idea. When I question the concept directly it can be upsetting. If someone to whom you’ve paid money tells you something, and they’re a nice enough person, and they seem like they care about you and know what they’re talking about, you believe them. To then be the second therapist offering an opinion and say something different can be tricky and I usually word it incorrectly and put the patient right off side.
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Anyway, I used to let it slide because it’s easier for everyone, I can get on with treatment using my own paradigm, and I didn’t think any harm was done.

But I’ve now changed my mind on staying quiet. 

I saw a lady today who’s been seeing an osteopath twice a week for a year - thousands of dollars - for a radiculopathy from her lumbar spine which has now progressed to a foot drop. Every session her “pelvis was out”. She doesn’t know how it keeps happening. Her only solution was to pay this “expert” for a “re-alignment”. It’s a very common story. I got so upset today. This lady was in tears - she felt so helpless.

I think this sort of treatment is criminal. It makes someone a helpless victim by diagnosing them with something that they have absolutely no control of themselves - the pelvis just keeps going out mysteriously. And sell a solution: “I can put it back for you. Come in twice a week”. Nothing you can do to help yourself. 

The language is dangerous and damaging and takes advantage of a patient that trusts you are a professional providing an honest service.

When a therapist talks about something being out of alignment I hope they are using the terminology as a euphemism rather than believing something is actually out of place. Because we know it’s not. 

So the therapist is either:
  • unknowingly perpetuating an idea that is harmful because they are ignorant,
  • or deliberately deceiving patients for financial gain.

So I’m no longer tolerating the language of something being out of place or out of alignment.

​It’s not, and it’s harmful to talk like that.


​I used to think physios were better than that and the language of alignment was just for other professions. I used to be OK with it because it was Chiro’s and Osteo’s, not physios. But more often these days the language of something being “out” is creeping into physiotherapy. Muscle Energy Technique (MET) is a type of treatment physios are using to treat the hips, sacrum, pelvis, and back pain. “Rotations”, “counter-rotations”, “up-slips”, and “down-slips”. The way they teach it seems like they actually believe it’s a physical/mechanical movement rather than a conceptualised euphemistic explanation. I don’t think it’s a path the physio profession should go down. 

I understand how it happens. An “expert” is in town selling a course. You pay money for the course, you’ve bought the product and are invested in it working, you give it a go with patients and get good results. It’s the same cascade that makes the patient buy in.

Next minute it seems like everyone’s pelvis is twisted. It’s an epidemic.
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How can different professions, and even two therapists in the one profession, come up with completely different explanations for what’s going on? I think that speaks to the size of the problem of back pain and there not being a single treatment option that helps everyone. (Well actually there is and that’s exercise - but it’s harder for people to make money from selling exercise.)

This is a bit of a rant and I’m almost nervous to write it down because there are some well respected therapists across a number of professions who are a lot smarter, have better jobs, and earn a lot more money than me, who speak about things being out of alignment.

Not me. Don’t worry. Your back is strong. Your back is stable. Your back is resilient. It’s sore now, but that is largely unrelated to structure and mechanics. There’s definitely nothing broken, out of place, or alignment.


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ITB (RUNNER'S KNEE)

11/11/2020

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ITB = Ilio-Tibial Band. The ITB is a muscle that runs from the ilium to the tibia. The ilium is the boney wing of your pelvis. The tibia is the big leg bone between your knee and ankle. The ITB has a short little contractile muscle belly on the side of your hip, and a long, non-contractile tendon down the side of your thigh, that anchors onto the bone on the outside of the knee. And that’s where it gets sore in runners. ITB soreness is called “runner’s knee”.

Tendons are the weak link when we overtrain or start new exercise programs. The muscle belly has a good blood supply. We draw them as red on anatomy posters, and the tendon we draw as white, representing the fact that it doesn’t have as much blood. When we train, the muscle belly copes well with whatever we throw at it, but the tendon can let us down. All the overtraining injuries we get are sore tendons: Achilles, ITB, Tennis Elbow, sore Rotator Cuffs, etc. Tendons don’t like the combination of load and stretch. Achilles get sore when we run up hill, putting the tendon on a stretch. Tennis elbows get sore when we hit backhands “late”, which combines stretch and load to the tendon.

ITBs don’t like the stretch/load combination in runners who let their knees turn in.

Ultimately, doing too much too quickly is the cause. Because it would never be sore if you never ran. But the biomechanics of your gait are a contributor. It’s more common in women than men, because women have wider pelvises, their thigh bones start wider apart at the top, and angle in more than men’s (called a Q-angle). We test a single leg squat and see where your knee points, in relation to your foot, and that predicts where your knee travels when you run. Ideally we like the knee to move over the foot. In runners who get runner’s knee, we often see your knee travels more to the inside of the foot. We call this femero-tibial internal rotation. People commonly call it "knock knees”. Biomechanical contributors to this can be:
  • Over-pronation in the foot
  • Fatigue in glutes. Your bum muscles help hold you up straight. Under-utilise your glutes and the hips move more laterally, which increases stretch on the ITB.

Letting the knee twist in, or the hips move out laterally, puts the ITB on more of a stretch. The ITB protests by getting sore.

There’s usually a spike in training load that sets it off. One long run, or more runs per week than usual. If you increase gradually, it adapts.

The initial pain is inflammatory, although it doesn’t always look swollen. If you can rest it for a couple of weeks, and treat it with ice and anti-inflammatory tablets, it usually settles down well. If you run on it when it’s already sore, it can turn into a more chronic problem that takes ages to heal.

I get people to not run for 2 weeks, while you do a couple of strength/control exercises:
  1. Single leg squat in the mirror, slow and controlled, not too deep, aiming to control the knee travelling over the little toe. 10 Reps, 3/day.
  2. Crab walk. Theraband around the feet. 1/2 squat and stay low. Step apart and together, side to side, staying low. 20 reps, 3/day. It gets you feeling what using your glutes feels like.

On the second week I get you to increase your walking distance.

Once you can go for a decent walk without the knee being sore, I’ve got a jogging program that builds you up from 1min through to a 5km, over three or 4 weeks. We add in harder strength exercises as you go.​
0 Comments

Health News 10/11/20

10/11/2020

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  • What to do when your child’s just not into sports - 
  • The missing concussion discussion in local level Aussie Rules - 
  • Concussion injuries taking a toll on young athletes, despite advances at elite level - 
  • We studied mental toughness in ultra-marathon runners. Mind over matter is real — but won’t take you all the way - 
  • Head injury protocols must protect concussed players from their own competitive instincts - 
  • Weight Training May Help Ease Anxiety - 
  • We Now Have the Lab Data on Nike’s Breaking2 Runners - 
0 Comments

Health News 3/11/20

3/11/2020

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  • Why Running Won’t Ruin Your Knees - 
  • Lower back pain: Exercise is the cure but there is a catch - 
  • 7 NUTRITION TIPS TO FUEL YOUR EXAM PERFORMANCE LIKE AN ATHLETE - 
  • ILIOTIBIAL BAND SYNDROME IN RUNNERS - 
  • HOW TO IMPROVE YOUR STRENGTH WITHOUT LIFTING HEAVY - 
  • The Role of Group Norms in the Underreporting of Concussions in Youth Sport - 
  • Head injuries and sport: confusion, anger and lots of difficult questions - 
  • How to Run a Race in a Time of Surging Coronavirus - 
  • How to Harness Your Anxiety - 
0 Comments

Health News 22/10/20

22/10/2020

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  • Try High-Intensity Interval Training. You Might Like It. - 
  • Concussion can accelerate ageing of the brain – research from the rugby pitch - 
  • Sport supplement shake-up to follow federal government intervention - 
  • Hidden cause of cardiac arrests uncovered in perfectly healthy hearts - 
  • How Your Muscle Fibers Might Predict Overtraining - 
  • Physiotherapists on the functional exercises everyone should do from home - 
  • THIS MIGHT BE WHY YOU GET SO HUNGRY AT NIGHT - 
0 Comments

Health News 16/10/20

16/10/2020

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  • Australian women's cricket team tracks players' periods in focus on women's health and fertility - 
  • Why do some people struggle to make ‘healthy’ decisions, day after day? - 
  • Research to curb injury in women’s footy - 
  • HOW LEAFY GREENS CAN MAKE A DIFFERENCE FOR ATHLETES - 
  • High intensity interval training might help you live longer than more gentle exercise, but the link is hard to prove - 
  • Why Don't Runners' Knees Fail More Often? - 
  • STRATEGIES TO ELIMINATE FATIGUE | UNDERSTANDING RECOVERY POST-TRAINING - 
  • New insurance policy for AFL players to cover concussion - 
0 Comments

Health News 9/10/20

9/10/2020

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  • Where You Carry Body Fat May Affect How Long You Live - 
  • Getting back into exercise without hurting yourself - 
  • 9 WAYS YOU CAN MAKE A RECIPE HEALTHIER - 
  • IMPROVE YOUR RUNNING PERFORMANCE IN 5 MINUTES OR LESS - 
  • Overtraining: What and Why? - 
  • Why Endurance Athletes Feel Less Pain - 
  • Healthy Active Ageing - 
  • How the Pandemic Is Changing Our Exercise Habits - 
0 Comments

Health News 30/9/20

16/9/2020

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  • Kids find new ways to stay active in lockdown - 
  • 5 COMPONENTS OF AN EFFECTIVE RETURN TO SPORT - 
  • EXPLAINING RED-S AND ITS IMPACT ON ATHLETE HEALTH & PERFORMANCE - 
  • Turmeric May Ease Knee Arthritis - 
  • NUTRITION TIP | SPRING HAS SPRUNG - 
  • How periods and the pill affect athletic performance - 
  • 5 TIPS TO HELP AVOID OVERTRAINING - 
  • NEVER LIFTED WEIGHTS BEFORE? HERE’S WHERE TO START - 
  • Specialist referral rules haven’t changed much since the 70s, but Australia’s health needs sure have - 
  • WHEN TRAINING IS ABOUT TO CHANGE, YOUR DIET SHOULD TOO - 
0 Comments

Health News 15/9/20

15/9/2020

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  • HOW THE BODY RESPONDS TO NOT EATING ENOUGH TO SUPPORT TRAINING - 
  • Coming to a head over concussion in Australian football - 
  • From energy levels to metabolism: understanding your menstrual cycle can be key to achieving exercise goals - 
  • Stop Counting Your Running Mileage - ​
  • Strength training is more important than electrolytes for preventing cramps - 
  • For Successful Aging, Pick Up the Pace or Mix It Up - 
  • Exercise May Make It Easier to Bounce Back From Stress - 
  • SHOULD I BE WORRIED IF MY JOINTS ARE CRACKING? - 
  • Sports science research debunks stretching myth - 
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