Shoulder Pain overview.

Shoulder Pain Prevention

By Brian Sutton MS, MA, PES, CES, NASM-CPT

Is shoulder pain stopping you from, playing your favorite sport or achieving your personal fitness goals? Chances are, if you are experiencing shoulder discomfort or pain, you’ll have to alter your lifestyle to accommodate this dysfunction. Shoulder pain can occur in a multitude of ways and is prevalent in 21% of the general population with 40% of that population having injuries persisting for at least one year.

Shoulder injuries have many different mechanisms or pathologies ranging from acute trauma to chronic overuse injuries. Acute trauma typically comes from a direct force, such as falling directly on the shoulder, or from an indirect force, such as landing on an outstretched hand. Either of these mechanisms may result in fractures of the humerus, clavicle, scapulae and glenoid fossa, or dislocations and tears of the capsular ligaments or labrum. However, the most commonly seen injuries in athletes or the active population stem from overuse syndromes.

Overuse Injuries

Overuse injuries (aka cumulative trauma disorders) are any type of muscular or joint injury caused by repetitive stress that surpasses the body’s natural repair processes (i.e., tendonitis, stress fractures). Overuse injuries of the shoulder are common among athletes who consistently perform overhead movement patterns (i.e., throwers, swimmers, tennis players) and individuals who repeatedly work with their arms raised (i.e., painters, construction workers). Among the overuse injuries, shoulder impingement is the most prevalent diagnosis accounting for 40-65% of reported shoulder pain.

Common symptoms of shoulder overuse injuries include (11):

▪ Minor pain during activity and at rest

▪ Pain observed at the top or front of the shoulder during overhead activity (i.e., overhead presses) or during chest activities (i.e., incline bench press)

▪ Tenderness on the lateral aspect (outside) of the shoulder

▪ Loss of strength and range of motion (ROM)

▪ Pain during throwing motions

Poor Posture
In addition to overuse injuries, individuals who exhibit poor static posture of the upper body are at risk for shoulder dysfunction. A common postural distortion of the upper body identified by Janda is the Upper Crossed Syndrome (UCS) and is characterized by protracted shoulders and a forward head. UCS generally involves tightness (overactivity) within the anterior chest region (pectoralis major/minor), latissumus dorsi, and cervical extensors (sternocleidomastoid, levator scapulae, scalenes), coupled with lengthening and weakening (underactivity) of the mid-and-upper back muscles (mid/lower trapezius, serratus anterior, rotator cuff) and deep cervical flexors. Individuals who sit for extended periods working on a computer may be at risk for developing upper body dysfunction and poor posture if certain precautions are not made such as taking frequent breaks and working at an ergonomically sound work station.

Exercise Selection
Similar to overuse and poor static posture, improper exercise selection can also contribute to shoulder dysfunction. For example, if a baseball pitcher tries to increase velocity of his pitches by only strengthening the superficial muscles of the shoulder (prime movers) that produce internal rotation (pectoralis major, latissimus dorsi) more than the stabilizers/external rotators of the shoulder (infraspinatus, supraspinatus, teres minor), these stabilizers become reciprocally inhibited (underactive) and fail to stabilize the glenohumeral joint during the throwing motion. Without adequate stability the athlete may develop a subacromial impingement, leading to subacromial bursitis, rotator cuff tendonitis, and possible tears of the external rotators.

Another example of poor exercise selection involves the over reliance on uniplanar, isolated resistance training exercises. Athletes and fitness enthusiasts oftentimes place too much emphasis on uniplanar exercises strictly focusing of concentric force production (e.g., presses and pulls) while neglecting total-body movements that integrate the entire kinetic chain (lower body, core, upper body) in multiple planes of motion (sagittal, frontal, transverse). Everyday activity occurs in all three planes of motion (front-to-back, side-to-side, and rotational) and only training in one plane (predominately the sagittal plane) will not effectively improve the individual’s ability to move in a coordinated fashion in the frontal and transverse planes. This form of program design may lead to muscle imbalance and faulty movement patterns increasing the individual’s risk of injury and/or joint dysfunction.

Using these two examples, fitness professionals should design exercise programs from an integrated (all-inclusive) perspective. An integrated exercise program encompasses both uniplanar and multiplanar movements; single, compound and total-body exercises; and adequately targets on all muscle groups (prime movers and stabilizers).

Shoulder Injury Prevention Strategies
If a client presents pain or dysfunction the fitness professional should never attempt to diagnose the problem but rather refer his or her client to a qualified medical professional. However, utilizing various movement screens, fitness professionals should assess their clients to identify potential muscles imbalances (muscle weakness and muscle tightness) and faulty movement patterns and subsequently implement a corrective exercise strategy to proactively address these concerns. For a list of comprehensive movement screens and corrective strategies for the shoulder complex see NASM’s Corrective Exercise Specialist.

Following a comprehensive fitness assessment (including a battery of movement screens), fitness professionals should implement a corrective exercise program that is individualized for their client:

▪ Step 1: Inhibitory techniques (self-myofascial release) should be used to decrease tension and effects of latent trigger points of the overactive muscles surrounding the shoulder complex.

▪ Step 2: Static stretching should be performed for a minimum of 30 seconds on identified overactive muscles to help facilitate optimal joint ROM and muscle extensibility.

▪ Step 3: Isolated strengthening exercises should be used to facilitate the underactive muscles of the scapulae. Auditory and tactile feedback while performing these exercises can also help develop neuromuscular activation with proper kinetic chain positioning and control.

▪ Step 4: Lastly, exercises are progressed by incorporating activities that integrate the entire kinetic chain (multijoint, compound movements). During these exercises clients should be instructed to maintain scapular retraction, depression, and posterior tilting while limiting winging by keeping the scapula on the costal surface.

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STROUD SPORTS CLINIC Ltd.

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A fantastic article on Ice and its use in sport.

Ice application and its use in sport 

by Peter Thain

Before I discuss the different modalities, it is important to mention the rationale for ice application. Within the sports medicine environment, cryotherapy (just another name for ice application really) is a widely used therapeutic modality for both the treatment of acute soft tissue injures, and during rehabilitation. The immediate application of ice aims to provide a cold induced analgesic effect, thereby reducing the appreciation of pain. The magical skin temperature frequently reported in the literature to produce local analgesia is between 10 and 15°C, and this is readily achievable with most ice modalities.

Pain relief is the main reason you should be applying ice to a musculoskeletal injury, and there are numerous scientific papers that will support this. However, if we were playing family fortunes, and “we asked 100 people to name a reason to apply ice”, you can almost guarantee that ‘reduce swelling’ would earn you a star prize (probably a washing machine or cross trainer!). However, you may be surprised to learn that there is currently no research involving human subjects which supports this. So why not…?

Studies have examined the effect of ice application on metabolism (which is what the ice needs to supress) in animal studies and identified the target tissue temperature to be between 5 and 10°C. At first you may think this is achievable, however, this temperature reduction needs to be reached at depth rather than at the surface. No study to date has achieved this at 2cm below the adipose tissue. So… what does this mean for the future of ice?!

Well firstly make no mistake; ice is a fantastic modality at reducing pain. As far as reducing metabolism, for me the jury is still out. Although having said that, whilst it may not be possible to reduce the tissue at depth to 10°C, you could argue that even if the temperature declines by 1°C then that is of benefit. If you are interested in reading more on this, I would recommend the brilliant article by Dr Chris Bleakley entitled “Is it possible to achieve optimal levels of tissue cooling in cryotherapy?”

So onto the main question: “Which modality?”

The answer to this all depends on the stage of injury. I currently work in semi-professional football so forgive me for these examples, but I think the three different scenarios help to explain the rationale and are applicable to any sport.

Scenario One: Acute setting – Return to play.

The athlete has received a trauma to the ankle/ foot complex but there is no significant structural damage. Here the aim of the ice application is to provide quick pain relief before the athlete returns to activity. The best modality to use is an ice bag containing crushed ice, as it has been shown to reduce temperatures to critical levels required for analgesia within 5 minutes (Jutte, Merrick, Ingersoll & Edwards, 2001; Merrick, Jutte & Smith, 2003). You should consider the use of wet-ice application, where ice is applied through a fabric bag; this porous material provides a barrier to stop potential ice burn, whilst the residual water is in contact with the skin. As cryotherapy modalities absorb heat through conduction and evaporation, wet ice exhibits greater thermal conduction than that of its dry ice counterpart (Belitsky, Odam & Hubley-Kozey, 1987; Merrick et al., 2003).

As I am not just a researcher but a practicing sports therapist, I appreciate the need for the recommendations to be practical. I therefore use a mixture of crushed ice and water mix in a plastic bag and apply pitch-side, as wet ice applications can be messy and impractical. However, during half time, many players will receive crushed ice enveloped in a thin wet cotton cloth to their ankles for fast pain relief following contusions and heavy tackles.

Scenario Two: Acute setting – Remove from play.

The athlete has received a significant trauma to the ankle and there is significant structural damage and must cease activity. Here the ice application aims to provide pain relief, but more importantly, compression needs to be applied. In an effort to reduce the oedema from building up, the compression with shut down the available space for the fluid to accumulate. As a result, wet ice application is no use here as the compression will not be consistent as the water escapes the porous bag. Instead, the dry ice method of crushed ice should be applied in a plastic bag and attached with a compression bandage. The ice is not the most important criteria here, it is the compression.

Apply the ice for 10 minutes on, and then remove for 10 minutes. In the rest period, reapply the compression bandage. After the 10 minutes rest, reapply the ice application. Continue this cycle of 10 on, 10 off, 10 on for as long as possible. Once finished icing and before you return home, place the compression wrap back on the area.

The rationale for 10 minutes on, 10 minutes off, not only allows the skin a rest period from constant cold, but more importantly, the modalities ability to absorb heat is at its maximal for at least 10 minutes, before the modality temperature may begin to rise. Additionally, a thermal gradient is created between the skin and the intramuscular tissues, which allows cold to be reached at depth. When the ice is reapplied for a second 10 minutes, the tissue temperature at depth has not risen to pre-treatment levels and therefore can reach a lower temperature still. So, rather than the traditionally 20 minutes continuous, where the modality may start to warm after 15 minutes, here you still receive a combined total of 20 minutes ice application, but the tissueis maintained at a lower temperature for over 30 minutes.

Scenario Three: Rehabilitation

You may not be aware, but the use of cryotherapy during rehabilitation can potentially promote your recovery by using cryokinetic protocols (cryokinetics simply means cold and motion). In the instance of an ankle sprain, the athlete immerses their foot into an ice and water mix (1-4°C) until their foot becomes numb. The typical sensations you can expect to feel are burning, stinging and aching before a period of analgesia occurs after approximately 10 to 20 minutes of immersion. After this, the athlete begins to perform their rehabilitation exercises, so in the early stages simple non-weight bearing range of motion work. Continue to perform the exercises until the period of analgesia is diminished (typically 5 minutes), before immersing your foot again to achieve another period of analgesia. As you progress through the rehabilitation stages, right up to return to activity, you can still use the cryokinetic protocols. So why are we doing this…?

The ability of cryotherapy to provide an analgesic effect enables exercises to be performed earlier than would normally be possible (Bleakley, McDonough & MacAuley, 2004; Knight, Buckner, Stoneman & Rubley, 2000). The beauty of cryokinetics is that it allows the muscles to contract, and therefore they will actively pump the swelling out of the area via the lymphatic drainage system. So by applying the ice application, you can perform simple range of motion exercises early than normally would be possible, and thus reducing swelling quicker. You may have read the recent work by Bleakley, Glasgow and MacAuley (2012) who recommends calling the POLICE, where optimal loading is required. If you haven’t read this article I would recommend it, as cryokinetics allows for this optimal loading to occur sooner.

Some of you may be concerned that by performing exercises under a period of analgesia you will not be able to appreciate pain, and therefore will not know if you are causing any further damage to the tissue as a result of the exercise being too advanced for your stage of rehabilitation. This is not the case, as the ice application does not remove the pain-sensing mechanisms, but rather removes residual pain such as that caused by pressure from swelling on nerves and damaged tissue. (Hayden, 1964; Knight et al, 2000; Pincivero, Gieck & Saliba, 1993). So, if you do perform an exercise that is too advanced that will cause further damage, you WILL still perceive this pain and should therefore regress the exercise.

Ice immersion should be the chosen modality here rather than wet ice bag application as it provides a longer period of analgesia. We are not concerned with how fast it takes to cause pain relief, but rather how longit lasts. The longer the period of analgesia, the larger the window of opportunity to perform exercises.

Cryokinetics is not only effective with joint injuries but also muscle strains. I have found it to be particularly useful in the treatment of lateral ankle sprains. Pincivero et al. (1993) presented a case study and conclude that cryokinetic protocol hastened the return to activity.

So in summary:

1. Athlete return to play: crushed ice in a damp cotton bag
2. Athlete cease play: crushed ice in a plastic bag with compression wrap applied
3. Rehabilitation: immersion to facilitate exercise

Some other considerations……

What about cold spray?

When I took up my current position, I was given a box of cold spray. I must say, it has come in very useful… I use it as pest control to kill the flies and gnats in my therapy room! I personally see no use for the spray in the field of sports medicine. Often you see therapists run on pitch side and administer the cold spray or vapocoolant. Yes, it may act as a counterirritant, but you have to question the accuracy of application. Often the spray is administered over socks and better still most of it may fly away on a windy day! You are far better applying a crushed ice and water mix.

What about instant cold packs?

Commercially available gel packs have a pre-application temperature of -14°C and therefore remain prevalent in sports clubs, with first aiders believing colder is best. However, a modalities capacity to absorb heat is far greater if required to overcome latent heat of fusion (turn from a solid to a liquid) which is not required in the already liquid gel pack. To put this to the test, when I teach undergraduate students thermal treatments, at the start of the lecture we play pass the parcel. I pass around a bag containing a crushed ice and water mix, and an instant ice pack. No sweets here I’m afraid just the gift of cold hands! This will pass 40 pairs of hands in approximately 10 minutes. When it reaches back to me we repeat it again. During the second round, the crushed ice and water mix is still as cold as it was at the beginning, yet the instant cool pack is room temperature (if not warmer after passing 80 pairs of hands). The evidence also conclusively shows that regardless of application duration, ice based modalities are superior to gel packs at reducing skin temperature (Chesterton et al., 2002; Kanlayanaphotporn & Janwantanakul, 2005; Kennet et al., 2007).

Contraindication to ice application

Athletes with a fear or intolerance to ice including Raynaud’s disease and cryoglobulinemia should not be administered cryotherapy. The risk of frost bite is very rare and can be reduced by application periods of less than 40mins (Knight, 1995). A barrier is advisable, such as crushed ice placed in a plastic or fabric bag. Cryogen gel packs should always be avoided as there are superior modalities to achieve the desired effects. Bleakley and Hopkins (2010) identified no cases of skin burns in their review of over 35 laboratory basedcryotherapy studies.

References

Belitsky, R. B., Odam, S. J. & Hubley-Kozey, C. (1987). Evaluation of the effectiveness of wet ice, dry ice, and cryogen packs in reducing skin temperature. Physical Therapy, 67(7), 1080-1084.

Bleakley, C. M., McDonough, S. M. & MacAuley, D. C. (2004). Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine, 40, 700-705.

Bleakley, C. M. & Hopkins, J. T. (2010). Is it possible to achieve optimal levels of tissue cooling incryotherapy? Physical Therapy Reviews, 15(4), 344-350.

Bleakley, C.M., Glasgow, P. & MacAuley, D. C. (2012). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), 220-221.

Chesterton, L. S., Foster, N. E. & Ross, L. (2002). Skin temperature response to cryotherapy. Archives of Physical Medicine and Rehabilitation, 83(4), 543-549.

Hayden, C. (1964). Cryokinetics in an early treatment program. Journal of American Physical Therapy Association, 44(11), 990-993.

Jutte, L. S., Merrick, M. A., Ingersoll, C. D. & Edwards, J. E. (2001). The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Archives of Physical Medicine and Rehabilitation, 82(6), 845-850.

Kanlayanaphotporn, R. & Janwantanakul, P. (2005). Comparison of skin surface temperature during the application of various cryotherapy modalities. Archives of Physical Medicine and Rehabilitation, 86(7), 1411-1415.

Kennet, J., Hardaker, N., Hobbs, S. & Selfe, J. (2007). Cooling efficiency of 4 common cryotherapeutic agents. Journal of Athletic Training, 42(3), 343-348.

Knight, K. L., Brucker, J. B., Stoneman, P. D. & Rubley, M. D. (2000). Muscle injury management with cryotherapy. Athletic Therapy Today, 5(4), 26-30.

Knight, K. (1995). Cryotherapy in Sports Injury Management. Champaign, IL: Human Kinetics.

Merrick, M. A., Jutte, L. S. & Smith, M. E. (2003). Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. Journal of Athletic Training, 38(1), 28-33.

Pincivero, D., Gieck, J. & Saliba, E. (1993).Rehabilitation of the lateral ankle sprain with cryokinetics and functional progressive exercise. Journal of Sports Rehabilitation, 2, 200-207.

Sports Massage/How it can help you in your training.

Massage in the Fitness arena.

For those who seek a big-picture view of overall health and wellness, it is important to include the regular use of massage therapy as an integral part of true fitness. After all, fitness is not just the strength of one's muscles, a percentage of body fat, cardiovascular power and mental clarity. Fitness also includes the health and wellness of all the body's systems, as well as one's mental and emotional state--and massage therapy has much to contribute in these respects.

Therefore, when it comes to creating overall fitness—fitness that is present both inside and outside the body, from head to toe—one must consider the value of massage therapy for achieving this goal. It may help to think of massage therapy and big-picture fitness as two sides of the same coin, with that coin being overall health and wellness. As you consider this notion, you should begin to see how massage therapy can serve to complement and bolster nearly any aspect of fitness.

For example, consider the common view or stereotype of fitness as a man with a lean and muscular body. This man most likely lifts weights, performs cardio sessions and eats healthy foods on a regular basis. Now, by bringing massage therapy into the equation, this man could also help his muscles and joints stay in the best possible shape, recover from tough workouts in less time and better prevent potential injuries. As you can see with this example, massage therapy and muscle building can go hand in hand to help create optimal fitness.

Another common notion of fitness might be the cardiovascular powerhouse—perhaps a long-distance marathon runner, cyclist or other type of endurance athlete. These people work hard to build their cardiovascular systems in order to achieve faster speeds or longer periods of activity. This type of fitness typically involves repetitive sessions of cardiovascular training.

In this scenario, the benefits of bringing massage therapy into the picture are similar to the previous example, due to the fact that cardiovascular training also has an impact on the body's muscles and joints. Fortunately, regular massage therapy sessions can help reduce the negative side effects that could come about as a result of intense cardiovascular training. For example, the woman who runs many miles nearly every day would be wise to receive massage on a consistent basis, to keep her legs and hips and entire body functioning optimally.

Essentially, one might think of massage therapy as a vital component of the rest and recovery every athlete needs in order to reach his or her maximum potential in the chosen form of fitness, whether it be lifting weights, participating in triathlons or simply maintaining the ability to move with ease and grace in order to prevent potential injury.

The bottom line is massage therapy can contribute to that big picture of fitness by keeping the body's muscles and joints in good shape, speeding the recovery of overworked areas and helping to prevent or rehabilitate any injuries.

Jason Ford NSAM.

How the foot works.

How the foot works:

The foot is a mechanical masterpiece, it has never been re-created by man even with all the computer and technological power that we possess. This wizardry comes from the harmonious link between the 3 “separate” systems Nerve, Muscle, Joint.

The sub talar joint is one of the major reasons that an artificial foot is so hard to produce. With its infinite axis and complex articulations it is the key to the body’s ability of shock transfer. When the foot hits the floor we experience ground reaction force (shock). This force is the very reason that the subtalar joint exists, pronation is our protection against these repetitive shocks or loads.

We Need Shock:

We have developed the ability to pronate not because we want to be rid of shock but to have the ability to control it. Shock is a major player in allowing the pelvis and spine to move properly, this shock could otherwise be explained as a pulse or signal that de rotates the pelvis and spine and evokes tensegrity in our structure (Gracovetsky 1988)

There is no discussion that we need to heel strike when it comes to walking, the interesting debate starts when we bring speed into the equation. With an increase in speed comes an increase in the potential forces that you might encounter. So when we run we put larger forces through the body and this is something the body has to adjust for. Everything in the body is kept in an exact balance, tip that balance and at best compensation is needed, at worst injury or disease can present its self. This pulse from the foot to the pelvis is no different, it has to be just enough to de-rotate the spine and pelvis but not too much so that the knee and hip have to dissipate the excess.

This pulse is also our major economiser, it allows us to switch between our muscular and fascial systems to save energy and maintain a constant work load. This oscillation between muscle and facia is achieved by the pelvis and spine receiving the perfect pulse from the heel strike.
We do have a time when a forefoot strike is perfect. Sprinting is a high power low duration gait that will require us to run on the forefoot. The stretch reflex of the gastocnemius and soleus muscles along with the ridged supinated foot allow a large amount of power to be generated. This form of gait obviously does not produce the pulse needed to de-rotate the spine, requiring extra muscular effort to do so, but this is immaterial as the duration of the activity is only around 10-20 seconds.

So we have the 2 extremes identified. Walking is a heel strike and sprinting is on the forefoot. The big debate is what technique should the middle and long distance runners be using? There a little research out there at the moment that point to a forefoot strike and there are others that point to the heel strike.
The forefoot strike is being named as the most efficient way to run and for some populations this is probably true. If someone is lacking the ability to pronate then they will need to have another form of shock absorption, this is where the forefoot style can be used to reduce ground reaction force by the ankle joint plantar flexors acting eccentrically.

However to suggest that forefoot striking is right for everyone is a challenging concept. Is one technique ever suitable for anyone? When looking at the research published in support of forefoot striking, consider whether the authors or the organisations who pay for the research, have anything to gain from the results. If you go looking for something you are guaranteed to find it.  To reduce bias the study should include 'outside un-bias researchers' performing the full methodology of the study.  If the outcome is the same, then the study is known to have inter-rater and intra-rater reliability and any less is merely commercial hype and too much of this exits in the fitness industry and some of it refers to the forefoot striking research.

Another variable that is not taken into account in any study that we have come across is that of intrinsic biomechanical dysfunction. Dysfunction in the pelvis for example could lead to a functional difference in leg length, this has been shown to be a predictor of injury1. So was it the type of foot strike or the dysfunctional pelvis (or one of the many other intrinsic biomechanical issues that can present) that led to the results gathered in the current research out there?
The best coaches see what the athlete’s body is doing naturally and then refine their technique to suit their natural running style rather than fit everyone into the same box. From a coaching point of view, we need to recognise that the brain has the most amazing ability to make decisions to allow us to move our body and to compensate for any abnormal movement patterns and some biomechanical problems. If we attempt to artificially change its instinctive genius we can easily disrupt the body’s ability to control movement.

The take home message from this is that there is a lot more work needed in the field of research on this subject. There are as many arguments for forefoot striking as against, and while forefoot striking certainly is suitable for some runners who’s intrinsic biomechanics suit that style, there are others who clearly do not.

Knee Injuries

Let’s take a snapshot of each common injury and discuss them individually and then look ways of preventing them.

Cartilage (Meniscus) injury 
Found in your knee fixed to the top of the shin bone (tibia), the cartilage helps to stabilise the knee and help with cushioning when you land. They are commonly damaged in field sports when you are twisting and turning, but runners are prone to this too as they step off a curb or slip doing cross country for example. Typically your knee will buckle and then swell. Sometimes your knee locks and becomes difficult to move and bear weight through it. In these cases Rest, Ice, Compression and Elevation (R.I.C.E) can be helpful. A compressive knee sleeve at this point can be helpful when you are trying to minimise the swelling. Do see a Sports Injury Therapist or Sports Injury Doctor so a decision can be made as to whether conservative measures (R.I.C.E and exercises) will be enough to resolve the problem or whether surgery is indicated. It’s usually worth taking some time to try and get the swelling down and the knee stronger, even if surgery is going to be necessary, as it will heal better after the surgery if the knee is in better shape first.

Anterior Cruciate Ligament (ACL) injury 
This is one of a pair of ligaments in the knee, the other less well known ligament being the Posterior Cruciate Ligament (PCL). They attach from your thigh bone (femur) to your tibia and cross over in the knee and provide stability. They can do this physically by virtue of their attachments, but also by sending your brain useful information about the types of loads going through your knee via strain gauges (proprioceptors) as you move. This enables your brain to reflexly decide how much muscle force is required to control the knee during the task or sport you are performing. When your ACL gets injured these strain gauges switch off and so the knee becomes unstable as your brain doesn’t know how much load is going through the knee and so how much to activate the muscles. When you tear your ACL your knee can become swollen and painful in a similar way to that of a cartilage tear and feel very unstable.

Sometimes surgery isn’t necessary and if it’s not a bad tear, a good rehab programme by a specialist therapist is sufficient to allow a return to sport. You can find that knee bracing is helpful in particular phases of your recovery, so it’s worth discussing this with your therapist. Exercise like the ones in figs 1 and 2 can be very helpful at teaching your muscles to start to engage again. To help this further and to encourage the strain gauges in your knee to fire up again, standing on one leg with your eyes closed is very effective. This type of exercise with your eyes closed means that your eyes cannot help you make balance corrections and you have to rely on your strain gauges if your balance is to improve. Variations on this exercise theme can progressively improve your knee’s ability to provide the right information to your brain at the right time, to improve your balance and stability. Make sure you’re near something you can hold on to for safety reasons in case your balance needs working on!

If it comes down to it though, ACL surgery is now getting so good that it is not as scary a thought as it was 10 years ago.

Plica
A Plica is a fold of the synovial membrane, which is the inner lining of your knee joint. These folds are normal structures which develop while you are in the womb. They are often asymptomatic in most people but sometimes, usually following a minor injury such as a direct blow on the knee, the Plica becomes inflamed and scarred and can click as it slides across the surfaces of the joint. Running can then cause your knee to become painful and inflamed. The pain is usually on the inside of your knee around the knee cap (patella), but it can be on the outside too. Your knee can often click and become stiff and painful when held in the same position for prolonged periods, as with sitting. A knee support called an infra-patella brace can help to take the pressure off the tendon while it is healing and when you start to exercise again. Therapy can help this by massaging the thickened area of scarring, as can exercise, but sometimes surgery is required. This injury can be quite difficult to diagnose so make sure you’re specialist comes recommended. Exercises in fig 1 and 2 will help with a Plica and combine well with the massage to minimise the risk of surgery.

Prevention
There are times though when these injuries do not present in the extreme way described above. Often these structures will become damaged gradually over time due to particular external forces, for example, incorrect shoes or faulty biomechanics (muscle imbalances, leg length discrepancies, tight calves etc). The affects our biomechanics have on our body and the vicious circle of injury and pain it can cause is one of the main reasons knee pain can be recurrent.

A rotated pelvis for example can go unnoticed for many years until the compensations start to cause problems. This abnormal pelvic position often causes one leg to appear longer or shorter and the body must compensate for this. Typically one way it compensates is to overly pronate the foot of the longer leg to try and shorten it, another way is to bend the knee more.

Unfortunately both of these options will increase the load on the knee. If the foot over pronates, it will likely cause the leg to internally rotate excessively and if this is a quick movement, knee problems are exaggerated. This rotation force (torque) will often be absorbed at the knee, which can result in pain. Alternatively if the knee bends too much during mid-stance phase as you run, this can de-stabilise the knee and it will naturally want to rotate inwards. If this is combined with an already over pronating foot, the problem is often exaggerated. Both of these situations are likely to result in knee pain.

It is often suggested that insoles (orthotics) can be helpful to reduce the pressure on the knees. Bear in mind that many causes of knee pain come from the pelvis and the biomechanical problems with your feet are often due to compensations for faulty hip or pelvic biomechanics. It is therefore important that before we start thinking about orthotics, we need to check out the hips and pelvis first. If not orthotics which could potentially be a good thing to help reduce the pressure on the knees, could likely aggravate it.

Managing these biomechanical issues is critical if your knee pain is to be managed and allow you to return to long term training and also to reduce the risk of recurrence. Please make sure you get these biomechanical issues checked by your local therapists as part of your rehab and conditioning programme.

Q

I have noticed over recent weeks my knee has become sore under my knee cap. The band under it is very tender when I touch it and it gets worse either when I train or when I sit and watch TV. I’ve also noticed that the knee can be very stiff in the mornings too. What is it and what should I do?

A

It sounds like to you have damaged your patella tendon, it’s also known as patella tendinitis or Jumpers Knee. It usually occurs gradually if you over-practice jumping and landing type activities, but can also be caused when you up grade your training too quickly especially if it includes hill training or plyometrics.
Ice can help after a run, but longer term you will likely find that massage to the tendon can be very effective. If you find the tender spot and massage it most days for 2-3 mins, although tender at the time, the knee should feel looser and less painful afterwards. Over time this can have a positive effect on the knee. You often find that patella tendon straps help this too as they take the pressure off the tendon and allow it to heal. Many people also find that shock absorbing insoles help by minimizing the impact, especially if you run mainly on hard surfaces.

Last updated: 26-05-2012

The Role of the Transverse Abdominis in Low Back Pain

The Role of the Transverse Abdominis in Low Back Pain

by Jason Ford 

What does Transverse Abdominis do?

The function of the TrA is to stabilize the pelvis and low back prior to movement of the body. It acts within a feedforward bilateral muscle activation rationale from spinal perturbations with everyday activities. Rehabilitation is typically aimed at restoring motor control of this key stabilizing muscle. Literature points to effective means of treating low back pain with trunk stabilization and strengthening of deep abdominal musculature to improve motor control1. 

Diane Lee gives a great description of how to activate the TrA through abdominal drawing-in maneuver (ADIM). However, how long does it take for someone to learn this and do you think they will really do this correctly and efficiently if they are pain?  It has been shown that teaching a patient to perform the ADIM maneuver can be time consuming and difficult.3

How effective is activating the Transversus Abdominis?

It has been shown that the TrA is activated after the deltoid (~50ms) with arm movement task studies with LBP patients.4 A recent study showed that during a volitional recruitment task for the TrA , induced pain was shown to attenuate the activity of the TrA.5  It has also been discovered that pain will alter a muscle’s role as an agonist or antagonist to control movement for protection through the pain adaptation model.6 This has also been demonstrated with many prior studies of reduced TrA muscle thickness with chronic LBP. In turn, the delay of TrA timing and optimal muscle activation is altered, potentially making exercises that activate it ineffective when pain is present.

If we abolish the pain, would motor control and activation of TrA resolve itself? There has not been any conclusive data to show that the spine is controlled less when the activation of TrA is changed and altered timing of the TrA leads to poor core stability. The feed-forward activation of TrA can be interpreted differently from a small study that showed 3 of 8 pain-free individuals did not have the feedforward responses in 70% of trials with bilateral arm tasks.7 Even prophylactically, the isolated muscle pattern in pain-free subjects is controversial.8 This goes to show further that low back pain is complex, multimodal and overall challenging to treat. 

Is a lack of strength or stability really the reason for the low back pain? 

Do we claim to 'stabilize' every patient?  A recent study stated that some patients are not unstable at all and showed that LBP patients actually have increased stability rather than decreased stability.9 Even if we feel a patient is unstable, how do we diagnose it as unstable?  Special tests to clarify this are inconclusive.  P/A force over specific segments of lumbar spine have been found to be useful to identify the segmental impairment.  However, will activating the TrA fix this? PPIVMs for extension & flexion have poor sensitivity values. A common test practiced is the prone instability test also giving poor diagnostic values.10  You might as well flip a coin to determine instability by the values. 

Some thoughts…

As musculoskeletal specialists, we have significant knowledge and a pertinent role in management of low back pain. We need to concentrate on teaching the patients how to control their symptoms independently.  To me, this means giving the patient tools to provide self-pain relief through therapeutic means.  Activating transverse abdominis stating it will give stability when everyday aches and pains arise just doesn’t seem feasible. The use of foam rolls, towel rolls or any other affordable methods can be very effective in not only giving relief, but obtaining joint motion and allowing an exercise program to be more advantageous.  If a treatment doesn't give someone relief or change, he or she will not be adherent to it, consecutively, returning to health care providers and starting the sequence again.

Since low back pain re-occurs in 70% of cases depending on source, we may not be challenging this problem appropriately. I think having the transversus abdominus as an active component in the treatment is somewhat useful but not conclusive.  Pain relieving exercises and education need to be the forefront of each program so muscle activation can be optimal.

The Female Athlete and Osteoporosis

The Female Athlete and Osteoporosis

  Osteoporosis occurs when there is improper bone formation and a decrease in bone mineral density. With this condition, bones become thin, porous, and brittle, which paves the way for stress fractures or broken bones With female athletes, it often comes as part of the Female Athlete Triad, which is a combination of disordered eating, amenorrhea (absence of a menstrual cycle), and osteoporosis. Osteoporosis develops as a result of the lack of estrogen production that accompanies amenorrhea -- a result of disordered eating (1). Competitive sports have has been shown to provide a common link in the development of eating disorders. Also, stress fractures are more common in female athletes with menstrual irregularities and/or low bone mineral density. This risk increases four-fold in amenorrheic females!

For these reasons, it’s especially important that female athletes combat osteoporosis through sound nutrition and exercise that increases bone mineral density. They should ensure that they are taking in adequate amounts of calcium, iron, vitamin D, and potassium which are normally found in fortified milk and other beverages. Further, exercise, although it cannot offset the negative effects of decreased estrogen production, and can’t build bone mineral density as a stand-alone intervention, should be used as a complement to a sound nutrition plan.

Exercises and activities that build bone mineral density are those that are mainly weight bearing, and strength based resistance training for those that participate in non-weight bearing activities such as swimming. For instance, running, hopping, and jumping are all bone density building activities. Bone building exercises include squats, lunges, pushups, seated shoulder presses, and pull-ups. 

For those who work with female athletes, prevention, recognition, and treatment must be a priority. Understanding how osteoporosis occurs, and how to prevent it, or intervene when necessary will prevent related complications for these athletes later in life. Healthy athletes are happy athletes.

National Academy of Sports Medicine.

Jason Ford.

Professional Sports Therapist.