​I’d guess that most people feel guilty about not stretching enough.

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?…
​

No.  There is a lot of evidence that stretching does not reduce the risk of injury.  This systematic review and meta-analysis of randomised controlled trials found stretching does not prevent injuries, whether done before or after training.  This randomised controlled trial, and this systematic review concluded stretching before exercising only reduces the risk of injury by less than 1%.  

​Therefore, in practical terms the average athlete would need to stretch for 23 years to prevent one injury.  Definitely not worth it.
​

No.  A systematic review concluded that stretching before or after exercising does not confer protection from muscle soreness (ref).  Stretching was found to reduce muscle soreness by a trivially small amount - less than 2%.

​No.  Stretching for the amount of time that most people would hold their stretches, does not make any actual difference to flexibility.  The mechanisms of stretching have been extensively studied.  There is moderate evidence from a systematic review that stretching can increase flexibility (ref). However, to achieve an actual improvement in muscle compliance we know the total duration of stretching needs to be at least five minutes per muscle group (ref).  Therefore to stretch hamstrings, quads, and calves, both left and right, as part of a warm up before sport, it should take at least 30 minutes - which is practically impossible as part of a warm up.  We know the one or two, thirty second stretches the majority of athletes would perform during their warm up are just not enough to actually improve their flexibility (ref).
​

What people find most surprising about static stretching is it impairs subsequent performance (ref).

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: 

• strength
• maximal  voluntary contraction
• isometric force
• isokinetic torque
• one repetition maximum lifts
• power
• vertical jump
• sprint times
• running economy
• agility
• balance

A comprehensive review (ref) from 2011 concludes:

​Obviously, I’ve been talking about sustained, static stretching.  It has been shown that there is no stretch-induced strength loss with dynamic stretching (ref).  However, the efficacy of dynamic stretching for increasing flexibility is yet to be determined (ref).
​

I do get people to stretch if there’s a specific pathology that needs treating.  And you do need to stretch if you need flexibility to achieve certain positions in your sporting performance (hurdlers / gymnasts / divers, etc).
​

If you’re happy with your stretching routine, keep doing it.  If you think it feels good to stretch after exercise then there’s no harm.  But I definitely wouldn’t recommend stretching at the expense of other techniques that are proven to aid recovery.

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. 
/ Sunday / - / Tuesday / - / Thursday / - / Saturday /

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:

• Nutrition
• Hydration
• Stress
• Sleep

​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

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:

• Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol (Filbay et al, 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.

• There is a very useful website to help promote the novel concept at healacl.com
• There is a Facebook group of participants at "CBP Bracing Pioneers" Community 
• A Patient's Story: The Cross Bracing Protocol

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:

• First-aid instructions are here 
• Range of Motion brace set to 30°-90°
• NWB on crutches
• Arrange for an "emergency" X-ray and MRI, specifically requesting a full sequence / double oblique sequence
  with slices no greater than 3mm. PRP Radiology at The Stadium Clinic reserve emergency MRI slots for ACL ruptures.
• If in pain, use paracetamol. Avoid anti-inflammatories (NSAIDS) such as Nurofen.
• Arrange appointment with Dr Tom Cross to assess the MRI to decide if the Cross Bracing Protocol is appropriate. 

Features that determine if the ACL Cross Bracing Protocol is appropriate:

• 4-7 days post injury
• Gap distance between torn ACL tissue < 4-6mm (depending on patient height)
• No ACL tissue displaced outside the intercondylar notch
• Intact femoral origin of ACL

If the Cross Bracing Protocol is appropriate...

4-7 DAYS POST INJURY:

• Brace fitting. (Dr Cross recommends a Bauerfiend SecuTec Genu Brace with additional 90° extension blocks that must be specifically requested.) I can supply and fit these braces.
• Anti-coagulant medication to mitigate risk of DVT for the first 60 days

WEEKS 1-4:

• Brace fixed at 90°, 24-hours/day
• NWB on crutches or scooter
• Weekly Physio for exercise progressions from Week 1 -12

WEEK 5:

• Brace 60°-90° NWB
• Can commence swimming in brace

WEEK 6:

• Brace 45°-90° NWB

WEEK 7:

• Brace 30°-140° WBAT
• Can commence stationary bike

WEEK 8:

• Brace 20°-140° FWB

WEEK 9:

• Brace 10°-140° FWB

WEEK 10-12:

• Brace 0°-140° FWB

WEEK 12:

• Out of brace (still bracing for crowds / risky situations)
• MRI to assess ACL healing

WEEK 16:

• Open chain seated leg extensions

WEEK 17:

• Graded running program

WEEK 20:

• Agility

WEEK 26 (6 MONTHS):

• Return to training

WEEK 52 (12 MONTHS):

• RETURN TO PLAY​​

​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:

1. The biggest contributor is a previous traumatic injury that has physically damaged the cartilage. This can be a landing/twisting injury or sprain, where the trauma of knocking one bone against the other, takes a “divot” or tear in the cartilage, or bruises the cartilage and underlying bone. 
2. The second biggest cause of osteoarthritis is genetic - the way our joints age, based on our family history. Nanna had a hip replacement and so will I.
3. The third biggest contributor to osteoarthritis is BMI. Every 5 kg of weight gain, confers a 36% increase in the risk of OA. Interestingly, it isn’t the extra pressure through the joints of being heavy that causes a problem - fat people have a higher rate of hand osteoarthritis too (which are non weight-bearing joints). The problem with BMI is the systemic inflammatory effect of cytokines produced by fat tissue. Being fat causes inflammation that irritates joints, so fat people get osteoarthritis (and have heart attacks from the scarring/hardening of coronary arteries, also as a reaction to systemic inflammation caused by adipose tissue).

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)

• We know that a 5kg reduction in weight over a 10-year period decreased the likelihood of symptomatic knee OA by 50%. 
• Losing 5% of body weight has been shown to provide some pain relief, and 10% provides significant reductions in pain.

EXERCISE

• Stay as active as possible. Rest doesn’t help. Improve muscle mass and strength so the joint is more supported and feels less vulnerable.
• Both aerobic walking and quadriceps' strengthening exercises have been shown to reduce pain and disability in subjects with knee OA.

PAIN RELIEF

• Paracetamol.
• Hot packs.
• Taping.
• Sleeves.

SURGERY

• There’s a lot of research showing that “tidy up” operations, or arthroscopic surgery for osteoarthritis is no better than an exercise program. It’s the exercise you do after the surgery that provides more benefit than the surgery itself. 
• For people that never get on top of their arthritis with weight loss and exercise, the pain can get so severe that they end up needing a total joint replacement, where the bones are cut out and replaced with an artificial, metal and plastic joint. 

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?