FOOTBALL RECOVERY STRATEGIES
(Grégory Dupont, Mathieu Nédélec, Alan McCall, Serge Berthoin and Nicola A. Maffiuletti, 2015)
Does Fatigue Cause injury?
Often when I’m talking to my patient about their injury and why it has happened, they guiltily report that they don’t stretch enough.
We’ve all grown up being told how important is it to stretch:
Interestingly, health professionals have changed our tune about the importance of stretching. Research over the last 15 years has suggested static stretching is not as beneficial as was once thought. I’ve been having conversations about the reasons to stretch (or not) for at least the last 15 years, but the current science on stretching just isn’t catching on.
So, what do we know?…
DOES STRETCHING PREVENT INJURIES?
Therefore, in practical terms the average athlete would need to stretch for 23 years to prevent one injury. Definitely not worth it.
DOES STRETCHING HELP MUSCLE SORENESS?
DOES STRETCHING INCREASE RANGE OF MOVEMENT?
DOES STRETCHING HELP PERFORMANCE?
A substantial body of research has shown that sustained static stretching acutely decreases muscle strength and power (ref). Stretching before an endurance event lowers endurance performance and increases the energy cost of running (ref). Cycling efficiency and time to exhaustion are reduced after static stretching (ref).
Pretty much any measure of performance is made worse by stretching. Static stretching impairs:
- maximal voluntary contraction
- isometric force
- isokinetic torque
- one repetition maximum lifts
- vertical jump
- sprint times
- running economy
A comprehensive review (ref) from 2011 concludes:
WHAT ABOUT DYNAMIC STRETCHING?
SO WHY STRETCH?
SO SHOULD WE STOP STRETCHING?
Do you love a good stretch?
Or feel guilty you're not stretching enough?...
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A change has been in the air since a 2002 randomised controlled study allocated 180 patients with osteoarthritis to either an arthroscopic “tidy up”, or sham surgery (where the patient was given an anaesthetic, incisions were made, but no actual “tidying up” was done) and the study concluded there was no meaningful difference in pain or function between the groups at follow up.
Since then, a number of studies have compared arthroscopic debridements and partial meniscectomy for degenerative knee injuries with exercise or doing nothing (Herrlin 2007, Kirkley 2008, Katz 2013, Sihvonen 2013, Yim 2013, Kise 2016) and the results have been unanimous.
A recent systematic review summarises: “these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain, with or without signs of osteoarthritis.”
And another: “A trial of nonoperative management should be the first-line treatment for such patients.”
“Arthroscopy for degenerative meniscal tears is no longer supported.” (ref)
“There is now overwhelming evidence that arthroscopic knee surgery offers little benefit for most patients with knee pain.” (ref)
SO WHY DID THE ARTHROSCOPE WORK FOR ME?
When you come and see me with degenerative knee pain and I tell you, “you need to do six to twelve weeks of strengthening exercises”, it sounds like hard work. Pffft. Understandably we want an easier option.
“Have surgery” sounds like an easier option. Someone else is doing the work for you. After the surgery, you proceed to do six to twelve weeks of strengthening exercises, but this time you’re happier to do the work because we take surgical post-op instructions seriously.
Twelve weeks later both these two groups are a lot better. Bingo-bango, “surgery” fixed me.
Two million knee arthroscopies a year globally, costing billions of dollars.
WHY DO PEOPLE HAVE SURGERY?
- Sore knee
- GP says “you’re silly to have played football”, try some pain killers
- Not much better
- GP says “we better get a scan”
- MRI shows “degenerative changes / meniscal tear” which seems like a structural injury
- Who fixes structural injuries?… Surgeons
- Refer to surgeon
- Surgeon wants to help. What can he do? An arthroscope and a “bit of a tidy up”.
I think we need to be careful at the MRI stage. MRIs are a lot cheaper and easier to get these days so it’s less of a big deal to get one. I was chatting to a mate with a sore knee and his MRI showed some degenerative changes. Rather than being told that it’s normal to see those sorts of things in knees as old as ours, and that it’s not necessarily the thing that’s giving him pain, he was told the knee is “bone on bone”. How can anyone ever expect to recover without surgery with that sort of imagery? Bone on bone seems definitive. Surely the only way to fix “bone on bone” is surgery?
But we know degenerative changes on MRI are poorly associated with symptoms, and degenerative changes are the norm in middle-aged knees (ref).
Let’s try some strengthening. You will be surprised.
SO WHO SHOULD HAVE SURGERY ON THEIR CARTILAGE?
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During this current lockdown, Fit As A Physio is staying open to continue offering quality care to my clients.
The Department of Health has specifically confirmed that physiotherapy is deemed an essential service. The Health Minister has encouraged private practices to remain open, as it will reduce demand on general practice and the hospitals if patients can still see their physiotherapist for their musculoskeletal and acute care management.
I have completed the Department of Health's "COVID-19 Infection Control Training". I have reviewed all clinic hygiene practices, to ensure optimal safety and care for every person who attends the clinic.
There are many things I am doing as a registered health professional to minimise risk of exposure, through rigorous hygiene practices, and patient screening, to keep you safe.
You are welcome to attend your appointment, subject to the following conditions:
- Please do not come to your appointment if you are unwell with any potential COVID symptoms.
- Please do not come to your appointment if you have been advised to quarantine or self-isolate.
- Please sign-in at the front door with the Service NSW QR code.
- Please wear a mask.
- Please use the hand sanitiser at the front desk on entering and leaving.
Thank you for your cooperation with these measures.
For our safety:
- I am leaving space in-between appointments to allow time for cleaning, and to minimise patient interaction in the waiting room.
- I will not be greeting you with hand shakes or other contact hand gestures.
- I am wiping down contact surfaces between appointments with Viraclean Hospital Grade disinfectant.
- I am continuing with my normal hand hygiene measures of thorough hand washing before and after all patient contact.
- I have the COVIDSafe app downloaded and open, and encourage you to do the same.
If you are in self-isolation or would prefer to minimise contact in any way, you may like to consult with me via video. "Telehealth" uses technology that’s readily available on your computer or phone to receive assessment, diagnosis, and rehab prescription. FaceTime, Skype, or PhysiApp are easy options. The standard consultation via telehealth is $39/15mins.
If you would like to talk to me about commencing or continuing your physio through Telehealth, please phone 9969 6925, email firstname.lastname@example.org, or book online here.
Stay safe and well.
Sports & Exercise Physiotherapist
Fit As A Physio | MOSMAN
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Recognising the clinical significance of MRI findings is often a challenge given the substantial discordance that exists between structural pathology and symptoms. Emerging evidence indicates a high prevalence of so-called abnormal findings on MRI in individuals without symptoms. A collation of systematic reviews (and cohort studies when no review available) highlights that typical features of deterioration, such as cartilage lesions, hip and shoulder labral tears and spinal changes (eg, disc degeneration/bulge) exist in many healthy asymptomatic adults (figure 1). Approximately 8 of 10 adults aged ≥40 years have asymptomatic disc degeneration, while almost half of all adults aged ≥40 years have knee cartilage lesions but no pain. Although the prognosis of these asymptomatic findings is not well established, even in cases of further structural deterioration (eg, longitudinal cartilage loss) the association with pain appears minimal.5 These findings are critical for clinicians and patients to understand the relevance of structural pathology and can be used to address recent calls for radiology reports to include age-matched asymptomatic prevalence rates. Such an approach, together with discussion with patients putting MRI findings into context, may help minimise patient anxiety, and beliefs they are damaged and vulnerable, as a result of a diagnostic label. Including such epidemiological information on spinal MRI reports reduced subsequent opioid prescription although had little effect on healthcare utilisation.
The high prevalence of asymptomatic changes on MRI emphasises that such features may not always be the source of pain in symptomatic patients and should not routinely be considered as pathological processes requiring intervention. Instead, in many people they likely represent part of the normal ageing process—like wrinkles on the skin.
Current evidence suggests that it is more common than not to have a cartilage lesion or disc bulge as we age. Perhaps it is time we redefine what a ‘normal’ MRI is and start being ‘CLEAR’ with patients when discussing imaging results—consistent language, including epidemiological information and assessment of relevance.
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- Loading exercises
- A graded increase in running pace
(Other factors include: stretching, massage, rolling, ice, compression, tape, sleep, stress, maintaining cardio, skills, general strength.)
Three exercises to start from day 1, are:
- Active Knee Extension
- Single Leg Romanians / Arabesque
- Hamstring Bridges
ACTIVE KNEE EXTENSION
SINGLE LEG ROMANIANS / ARABESQUE
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LARs Ligament Reconstruction
Low Back Pain