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Most injuries can be managed with strength training and modifying aggravating activities. Some pain or discomfort during exercise is OK and safe. It is a good sign if your pain warms up as you exercise and doesn’t feel worse the next day. KEEP MOVING Resting too much can be more aggravating than staying active. Reduce your training volume enough to settle symptoms and ensure you don’t feel worse the next day. PLAN AHEAD Avoid consecutive days of impact exercise (like running and jumping) if you are sore. / S / - / T / - / T / - / S / MONITOR MORNING STIFFNESS & SYMPTOMS Low and stable symptoms are OK. A spike in stiffness, tightness, or pain, means you’ve probably overdone it the day before. You don’t need complete rest. Continue resistance training, do less impact training. BE PATIENT There’s no quick fix. GENERAL HEALTH We also need to consider general health variables that contribute to recovery:
A recently published article by Haroy et al, in the British Journal of Sports Medicine, described a simple exercise routine that decreased the number of groin injuries in male footballers by 41%. Groin injuries are very common in football. Research shows that weaker groin muscles are associated with an increased risk of groin muscle injury. So strengthening groin muscles can potentially prevent injury. The paper studied the Copenhagen Adduction exercise, which has previously been shown to strongly recruit adductor longus. Haroy et al, offered the Copenhagen at three levels of resistance, based of the players’ pain. Players started with Level 3. If the exercise gave them more than 3/10 pain, they were instructed to do the exercise level below instead: 3 > 2 > 1.
The training protocol is shown in the following table: Being only one, quick exercise, compliance was high. They found performing the Copenhagens decreased the risk of groin injury by 41%.
The full article is HERE. Copenhagens are definitely worth adding to your training. The concept is similar to strengthening hamstrings with the Nordic Hamstring Curl which has been shown to prevent 70%-85% of hamstring strain injuries. When the Achilles tendon begins to feel painful, two common questions people ask is “what should I do to make it feel better?” and “when should I see a healthcare provider for assistance?”. This infographic guides people with Achilles tendon pain on how they can self-manage their pain and symptoms, plus tips on when to seek professional advice for tendon pain.
J Orthop Sports Phys Ther 2024;54(1):95. doi:10.2519/jospt.2023.9001 HEEL PAIN IN CHILDREN
Sever’s is most common in 9 - 12 year olds. It’s sore to squeeze the bone at the base of the Achilles where it attaches onto the heel. It’s not something that can be seen - it never seems to look red or swollen. It’s worse after sprinting, jumping, and hopping. It settles with rest. It is an overuse injury so it’s common in pre-season, or anytime training loads increase too quickly. My kids get it when they do extra sessions in running spikes or footy boots, without the normal heel support of their running shoes. It’s an overuse injury from excessive loads.
OVERUSE INJURY
When we talk about excessive loads it can be “external” load such as:
I think the running pace is the more powerful multiplier in this list. Extra sprint sessions will do it. My kids got sore once when we did a boot-camp session with a novel plyometric exercise - split jumps. There are also “internal” variables that determine our ability to cope with the training load:
My kids definitely are more prone to Sever’s if they’ve had a couple of late nights that week. And, if they’re having a growth spurt, their bodies are busy spending resources on growing rather than recovering from the stress of a training session. NATURAL RECOVERY
Text books say that Sever’s disease is self-limiting because the growth plate eventually fuses by the age of 15 or 16. But I don’t think there’s anyone who would be happy to just let it run its course until then. It is usually sore enough to stop you participating in sport, so it needs treatment.
WHAT DO WE DO?
I used to put kids with heel pain in orthotics, until I read this research which confirms that a simple heel wedge is more effective than orthotics for Sever’s disease. Cheaper and easier, so that's a win.
I get them to do an isometric Achilles strengthening program which also helps with pain control. But ultimately recovery comes down to load management. Load management means reducing the excessive loads. So this could be:
And aid recovery with:
HAVE YOU HAD A CHILD WITH SEVER’S DISEASE?
Benign paroxysmal positional vertigo (BPPV) is one of the most common forms of vertigo, affecting 2% of the population at some point in our lives.
BPPV is caused by a problem with the inner ear, where a small calcium deposit forms and moves with gravity around the different angled canals of the inner ear. BPPV is “positional” as it is triggered by specific head movements, for example, turning your head to the left with rolling over in bed. Symptoms of vertigo are room spinning, disturbed balance, and nausea. BPPV typically resolves within a few weeks, but can be recurring. Your GP can give you anti-nausea medication, and Physiotherapists treat BPPV with a sequence of movements and positions, called the Epley Manoeuvre, that uses gravity to re-position the calcium crystals. A video of the Dix Hallpike test for BPPV is HERE. Information on the Epley Manoeuvre is HERE. A video of the Epley Manoeuvre is HERE. Do you have vertigo? Book a physiotherapy appointment in Mosman to perform the Epley Manoeuvre HERE.
The ACL Cross Bracing Protocol was developed by orthopaedic surgeon, Merv Cross OAM, and his son, Dr Tom Cross, at The Stadium Clinic in Sydney. The novel concept is to heal a ruptured ACL by bracing the injured knee at 90°, a position that most closely approximates the two ends of the torn ACL. The injured ACL heals, negating the need to replace the ACL with reconstructive surgery.
The Cross Bracing Protocol's first patient to achieve a successful healing of their ruptured ACL was a 19 year old netballer in 2014. A case series of the first 80 patients to follow the protocol was published in June, 2023: 90% of the participants (72 of the initial 80) had signs of ACL healing on 3-month MRI. As of October 2023, there are 487 patients and counting. 284 of the first 301 participants (94%) have achieved ACL healing. There are already more than 100 participants > 2 years post-injury. Currently (only) 11% of ACL Cross Bracing Protocol patients have experienced a re-rupture.
The published protocol is here: ACL Cross Bracing Protocol Since publishing, the protocol has evolved to include more strengthening exercises at an earlier stage, as well as 6-week, and 8-week variations. As of October 2023, some key points of the protocol are: DAY OF INJURY:
Features that determine if the ACL Cross Bracing Protocol is appropriate:
If the Cross Bracing Protocol is appropriate... 4-7 DAYS POST INJURY:
Osteoarthritis (OA) is a leading and increasing cause of disability and has a significant impact on health-related quality of life. Osteoarthritis is a structural change to the cartilage and boney surfaces in a synovial joint. Most of the joints in our skeletal system are synovial joints, which is where two opposing bones articulate in a joint capsule filled with synovial fluid. The synovial fluid is a lubricant to help the joint move, as well as a source of nutrition for the cartilage that lines the joint surfaces. The articulating surfaces in synovial joints are lined with articular cartilage, which is a smooth, glossy surface to decrease the friction in the joint (as opposed to fibrous cartilage, which is the rubbery type cartilage that plays a more structural role, found in the meniscus in knees and the rubbery part of your ribs, nose, and ears).
The fleshy parts of muscles and organs is pink because it is full of blood, which brings oxygen and nutrition, and is important for healing damage. Cartilage looks white because it doesn’t have a blood supply, so articular cartilage relies of the synovial fluid for its nutrition. This isn’t as effective as having a blood supply, so when cartilage is damaged it doesn’t heal well. Nanna damages the cartilage in her knees and it never really repairs. Once articular cartilage is damaged, the joint tries to reinforce and repair the damaged area by laying down new tissue. It would be great if cartilage repaired itself with new cartilage cells, but the joint wants to make itself even stronger than the obviously insufficient cartilage, so it lays down a stronger building block - bone cells. So when we say that Nanna has “worn away” her knee to the point where it’s “bone on bone”, it’s not just that she’s warn away the cartilage, but actually there’s also a build up of “extra” bone, as the knee tries to make itself stronger than cartilage. Rather than being a nice smooth, glossy surface, the extra bone is now a bit rough, so we can hear and feel some gravely crunching and creaking in an osteoarthritic joint. Osteoarthritis occurs most frequently in the knees, hips, hands, and spine and is more common the older we get. Osteoarthritis is diagnosed with an X-ray that shows the changes to the bony profile in the joint. When we look at what causes osteoarthritis:
Osteoarthritis isn't painful most of the time. At a certain age, essentially everyone will have arthritic changes in their joints without knowing about it. When we X-ray the joint, it doesn’t look as good as it used to, but it doesn’t hurt. It’s a bit like my grey hair and wrinkles - they don’t look great anymore, and it's a sign that I’m getting older, but I don’t expect them to be painful. If an arthritic joint is painful, it tends to go through phases of being sore and not being sore at all. It can be sore for a day, a week, a month, or a year, but then will be fine again. Whether or not it is sore is not determined by the severity of the changes we see on the X-ray. We can see nasty looking joints that have never been sore, and we see very sore joints that look fine on the X-ray. There isn’t much of a correlation. What determines whether or not the osteoarthritis hurts is the body’s perception of "vulnerability" in that joint - essentially whether or not it feels strong or weak. Pain is an alarm system “software”, employed to defend against damage to the "hardware”. We can have different levels of sensitivity of how easily the alarm is triggered. Very commonly, an arthritic joint starts to hurt more after a period of rest, as the body looses some fitness, muscles loose some strength, an arthritic joint gets less support from the external scaffolding of the muscles, it feels more vulnerable, and communicates that by being painful, as a way of saying “be careful”. So that gives us some treatment options for arthritis: WEIGHT LOSS (Adipose)
EXERCISE
PAIN RELIEF
SURGERY
How do you decide when it’s time to have a joint replacement? I suggest it’s time when you really can’t walk anymore because of the pain, and/or the pain is stopping you sleeping at night. Joint replacements last for about 25 years on average, so don’t rush into doing it too early. The rehab after surgery is 3-12 months before the leg completely feels like it’s yours. The joint replacements are good for relieving pain, but unfortunately we don’t see improvements in patients’ activity levels after surgery. Total hip replacements are easier all around than total knee replacements. Do you have Osteoarthritis?
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