Injury

On: Tendons and Ligaments

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Tendons tether muscle, ligaments link bone.

But both can be damaged, become weakened, or scarred.

So how can we, both as practitioners and people, prevent this, or at least minimise its impact?

Prevention is always better than a cure, and therefore ensuring the tendons (when reading tendons, assume ligaments as well, although there are differences in all sorts of subtle ways) remain strong is vital.

Note – If you are currently taking medications, especially certain antibiotics, check with the pharmacy regarding soft tissue effects. For example, Fluoroquinolone antibiotics have a rare side effect with regards to soft tissue, so if you are prescribed those, it may be sensible to reduce training load during and after the treatment.

Tendons can be trained, like any other tissue, and research indicates that they respond best to cycles of isometric tension, of approx 10 – 30 seconds, with 30 – 50 seconds rest. Initially, it doesn’t even matter what joint position you are in, as long as the tendon is under tension, and pain free. Over time, you can increase the load and the number of cycles you carry out, to ensure continued development.

There is also some evidence that longditudinal supplementation with collagen (preferably from biologically similar connective tissue) is beneficial, especially when consumed with vitamin C.

Once you have a stable, platform, you can work on repairing any scarring or weaknesses in the tissue by using long duration concentric / isometric / eccentric training movements, through the pain free range of motion. For example, a squat under light load, with all three phases taking 10 seconds, although this time is individual.

Finally, there is also some evidence that early, and safe return to loading after injury can help reduce the time to competition, since the stimulus causes the scar tissue to form beneficially, rather than scattered.

TLDR: tendons can be strengthed, healthy tendons can increase your overall performance, isometric exercises are beneficial to tendon health.

Resilience and capacity

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In the end you have to have something that I give to give the disease as a price of recovery.

Not sure where I heard that but it makes sense.

The more fitness, the more muscle you have to give a serious illness, the more likely you are to come out the other side.

Professor Oliver (geriatrics) noted that he could guess someone’s probability of a safe discharge from the quality of their handshake. Firm, strong, reassuring. Weak, flaccid, concerning. A handshake conveys vitality, determination, strength, even psychological state.

Put the work in now so your future self can live to fight another day.

On: Rehabilitation / Prehabilitation

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The best way to recover from an injury is to not have an injury.

Other than the sort you simply cannot predict, the majority of injuries are caused by poor preparation or the inability to adapt dynamically to the situation.

Rehabilitation goes through three main stages.

  • Pain management
  • Ranging
  • Loading

First, control the pain. This is both passively and actively. Once the pain is a under control, it is a return of function, within that pain free zone. Optimise the range of motion, or activity that is available without causing excessive complaint. Finally, the loading phase, where we return to activity, initially graded and then competition.

This is, of course, a gross simplification of the tasks at hand, offers no insight into the variety of techniques considered, but is offered as a thought guide for the observer.

As stated at the beginning, the best rehab is prevention, through prehab. Prepare better, prevent problems.

Everybody has a weakness, a compromise point, or an area that appears to be less effective, so train those out to become more capable.

Seek professional input if you are prone to niggles, seek professional input for coaching if required and build steadily. Social media is not your coach, a search engine doesn’t replace a doctor.

You are what you do.

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They presented with a long history of shoulder and back pain, with occasional headaches, particularly in the evening. No other significant complaints, simply a tight and painful upper back, and shoulders, with a stiff neck.

After taking a thorough history and checking pertinent red flags, I carried out a suitable examination, looking at how they used their body, how it wanted to respond passively and actively.

And the thing was, other than the presenting complaint, there wasn’t much to be found. An anteriorised head posture and slightly kyphotic thoracic spine, but nothing much more than you might expect for a modern lifestyle. They exercised frequently, were not obese and tried to optimise their working posture when at a desk.

I treated what I found, and we addressed a few issues, but I was unhappy with their progress, as the complaint didn’t feel like it was resolving along the curve I expected.

Then it clicked. Whenever I went through to reception to collect them, they were playing with their phone. Head slumped forwards on the chest, looking down at the tiny screen and typing or scrolling away.

The problem is, modern expectations are that we are constantly connected, with rewards and punishments meted out by both the device and other people if we do not respond to its electronic siren call. I am as guilty as the next person, at instinctively checking and wasting hours.

It was this small, but frequent behaviour that was causing, in this case, the shoulder pain. Looking down was loading the back of their neck, the shoulders were coming in to support the arms holding close and everything matched when I mimicked them.

However, other than taking the phone away from them, there wasn’t a direct intervention I could do, so instead we discussed possible mitigation strategies, to reduce the automatic reaction, shorten the time spent interacting and change the posture, things that have been shown to work.

Following the rules of three, I suggested:

  • Switching on greyscale. This, interestingly, makes the device far less stimulating, but still allows you to work effectively. It also helps increase battery life on some devices.
  • Clean up the home screen and put apps that distract in a folder so you don’t see them first
  • Turn off notifications for social media applications

The point was simply to create a brain pause that allowed for a moment more reflection before the action, rather than create a wholesale change that would more likely fail.

Having created this awareness and put in some simple measures, we were both very happy to see that the treatment was then far more effective and the presenting issues resolved.

After they had left, I reflected in how the simple actions we do can have profound impacts and that, as practitioners of every discipline, we need to continue to look at the whole person, not just the complaint.

Stability and Mobility

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Picture a runner on the track, an image of power ready to be released at every stride. If we were to snapshot them mid activity, we would see that:

  • The foot, as it contacts the ground, needs to provide a stable platform
  • The ankle, resting on the foot, requires dynamic mobility
  • The knee, for optimal power transfer, requires both mobility in the ankle below it and the hip above.
  • The hip, being a joint with a high potential range of motion, should be mobile enough to support the function of the knee below and the pelvis / lumbar spine above.
  • The pelvis and lumbar spine, one of the biggest force transfer areas in the body, needs a high amount of stability.
  • The thorax responds to load and stress by restricting, when a more fluid movement pattern would benefit
  • The scapula, floating over the potentially stiff thorax, becomes unstable as a compensation
  • The shoulder joint itself, due to posture and poor use, will be restricted
  • The lower cervical spine may become unstable as a response to the restriction in the thorax
  • Finally, and balanced on top of the stack, the head and upper cervical spine stiffens.

Looking at the above list (initially drawn from the work of Gray Cook) it is possible to see why, if one area is not functioning as optimally as we might like, the areas around it will adapt their own function to compensate, which can eventually lead to the risk of injury.

As athletes and professional practitioners, we can help reduce this risk by reversing the process with a well considered mobility and strength training plan, allowing us help the areas that don’t move and should, as well as strengthening the unstable zones.

From a practical perspective, it is generally faster and more effective to get a restricted area moving successfully, since it tends to respond more positively, as well as naturally allow the unstable areas to relearn their correct function,

It can therefore be recommended that we focus on:

  • The ankle, using ankle circles, calf stretching and getting any old twists or sprains reset
  • The hip, by stretching the glutes, lengthening the hip flexors and ensuring the joint is well aligned
  • The thorax, needs three dimensions of movement, flexion, sidebending and rotation
  • The shoulder, the most inherently unstable joint in the body, often needs professional assessment to ensure it is not guarding a hidden injury to the joint, and can be helped by improving the function of the internal and external rotation most effectively

By improving the range of motion in these, we can support dynamic development in the rest of the body automatically.

The use of compression wear in recovery from injury

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Many people use compression wear for racing, training and recovery. However, I’ve been thinking about using for recovery from injury.

As of yet, I haven’t been able to design a suitable controlled trial but we have been trialing it in clinic with some athletes and other active clients.

We noted that it seems to help improve recovery time in people with both calf injuries and tendonopathies. It appears that the compression wear (in this case compressport calf guards) helps reduce buildup of oedema when worn overnight and support the muscle during everyday activity during the day.

We are going to continue trialing this and hopefully will have sufficient day to draw a more solid conclusion soon but i thought i’d put it out there for general consideration. We are also going to try the quad guards for hamstring and quad injuries if suitable clients present.

80:20

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There is an idea called the Pareto law. This says that 80% of the work takes 20% of the time. It can be used in almost any situation, from business management to problem solving, personal training to writing a book. I use it to illustrate a patients recovery plan (and will try to cover this in a post soon).
I also think it applies to our area, not just in terms of treatment processes, but in terms of techniques.Far too many people don’t use their training, expertise and experience sufficiently when working with clients. Instead they fall back on what they know works and do the same thing for everybody. (80% of problems can be solved with 20% of our skill). But every body is not the same. Each client is unique and each time we see them they have changed.

From a therapeutic perspective, this means that we need to reassess and reinterpret them each time, not just do the same thing and hope it will work.

When carrying out a fitness program, this also stands. We can draw up a framework for the series of sessions but need to be flexible enough to modify it as necessary. We should and need to concentrate on what they are saying, how they are responding and whether we are achieving their goals. In either mode, we especially need to take into consideration current research and thinking to ensure we are up to date with what the experts are doing. As with every other part of life, we need to remember the loop: observe, think, apply. Only then will we be doing the best for our clients and ourselves.