Sports Injuries

Even if you have never stepped foot onto a court before, you may end up with tennis elbow. Occurring along the muscle that allows extension of the wrist, it is a painful condition that can linger for weeks or months.

Previously, tennis elbow primarily showed up in athletes. Due to the increased interest in physical fitness, tennis elbow is being found in everyday exercisers, as well as people who perform work-related repetitive motion.

Tennis elbow presents several symptoms. Pain will occur on the outside of the elbow an inch or so down from the bony part.

There may also be pain when the individual tries to extend the hand and fingers against resistance. Extreme weakness in the wrist is another symptom.

I Have Been Diagnosed With Tennis Elbow. Now What?

Tennis elbow is often difficult to diagnose, which can delay treatment. A correct diagnosis of tennis elbow is the first step towards being able to treat the condition and rehab the afflicted area. From there, a variety of treatments for tennis elbow are available.

Passive remedies like rest, ice, and arm braces are critical components to healing tennis elbow. Take measures to reduce the movements that aggravate the pain, and use ice at regular intervals to help minimize pain and inflammation.

An arm brace supports and stabilizes the area to promote healing. These remedies assist greatly in treating the condition, especially in the beginning.

Active remedies consist of stretching and strengthening exercises, and are vital aspects of improving the condition. Individuals suffering from tennis elbow should begin an exercise regimen as soon as the pain allows.

Follow a doctor's recommendation for the rehabilitative program exercises. The goal is to build strength.

An individual dealing with tennis elbow may utilize a variety of medicinal remedies to manage pain and inflammation. Over-the-counter pain relievers and steroid injections are commonly used to treat the condition. Following doctor's orders when taking medications is strongly recommended.

Untraditional remedies also provide vast improvements in tennis elbow, and these treatments have gained favor in the last few years due to their effectiveness. Regimens of massage therapy and acupuncture work on small areas contributing to the condition, and make significant strides in pain reduction and promote the body's restorative healing process.

Another remedy that offers strong benefits to treating tennis elbow is chiropractic care. A chiropractor assesses the condition, then lays out a plan to promote healing. 

Treatment often includes working to align the bones and treating the surrounding joints so they function at maximum capacity, and can "take up the slack" of the injured area while it heals. Chiropractic care serves the dual purpose of treating the condition directly, and healing the areas around the injury so that the body continues to strengthen and renew.

In a very small number of cases, the only remedy for tennis elbow is surgery. This is considered as the last straw, once all other forms of treatment have been exhausted.

The best way to treat tennis elbow is to avoid it in the first place. Be sure to stretch before exercising, consistently perform strengthening exercises, employ correct techniques and proper equipment during physical activity, and don't overexert your arms (this goes for your entire body, by the way) during physical activity.

If you are diagnosed with tennis elbow, it's essential to understand the variety of treatment options available. The best course is often a blend of more than one remedy. Chiropractic care should be part of your healing process, as it helps decrease pain, reduce healing time, and offers a non-medicinal approach to treating the body as a whole.

The Risks Of College Sports

Question: What is the difference between good pain and bad pain? My coach cautioned me that if I feel bad pain, that I should stop the activity. What does that mean?

Sports injury chiropractor Dr. Alexander Jimenez discusses the difference and the type of action to take.

'No pain, no gain': that famous cliché related to sports and physical fitness training, is frequently discovered but is not necessarily correct. Sometimes, pushing yourself and generating pain in the muscles is advantageous and other times it's damaging.

Physiotherapists and sports medics may be familiar with what are appropriate levels of pain which bring about benefits, and levels that are too stressful that will lead to injury. Fitness trainers and sports trainers may be less confident at making the distinction. This article (based on McFarland et al, 2003, Health and Fitness Journal 7(4), p 11-16) is a guide to trainers and coaches to help them identify one proper levels of training and two whether acute injuries have occurred or chronic injuries are progressing.

What Is Too Much?

During a tough training session an athlete will begin to tire. Fatigue is a sign that the body is stressed. For a training effect to happen, the body requires stress to stimulate the muscles in order to grow back stronger. The body requires only the perfect quantity of stress at a suitable frequency to improve the training benefit. If the athlete is doing a conditioning session (for aerobic or anaerobic endurance), then an exhilarated feeling of fatigue at the end is the right degree of training. An athlete would not be able to maintain the intensity of work or would have to muster mental strength to maintain the intensity, by the end of a tough session.

After a conditioning exercise, it is essential that the athlete refuels and then rehydrates his entire body, and rests. If conditioning sessions occur too often or with insufficient nutrition then the athlete's performance might decline. This is a sign of 'overtraining', that the training program or workouts are past the athlete's current physiology. In the event the athlete continues for a couple of days, assuming good nourishment, he should have the ability to work well again. If the athlete's performance remains depressed even after two weeks of rest, then there may be a medical reason and also a sports doctor should be consulted

Pain That Persists

If an athlete performs strength training (lifting weights), then a specific level of muscle burn through a workout is going to be an appropriate indication that the athlete is training at the right level. This burn will generally cease the minute the exercise stops and begin again throughout another set of the workout. Any soreness or pain at a muscle felt during the performance of a workout that persists while the athlete is resting between sets might be a indication that the athlete has over-stressed the muscle or tendon. For example, if the shoulder joint is sore while lifting a heavy dumbbell and the soreness continues during the rest period while the athlete lifts his arm up and down, the odds are there is some level of injury.

In a strength session the athlete would ordinarily work two to five sets of one particular exercise with maybe 12-25 sets containing an entire workout of four to eight exercises. The athlete will have reduced strength performance following the exercise, maybe for a couple hours. For example, walking up stairs may feel a little tougher than usual.

At the 24-48 hours following a tough work out, an athlete could develop stiffness and soreness in the muscles. This is known as DOMS, or delayed onset muscle soreness. This is extremely common when an athlete starts a new type of training or the level of training is increased quickly. It's also very typical in unconditioned adults following rare bouts of exercise. Eccentric exercise is also associated with elevated levels of DOMS.

Dealing With DOMS

A little DOMS is fine, some athletes even like it after a strength session as it tells them they have trained well, and also a small degree of DOMS is fine for athletes to continue their own training program. When an athlete is accustomed to the exercise or workout then the seriousness of DOMS is generally reduced or disappears entirely. DOMS that triggers serious stiffness, muscle tenderness or swelling to touch is a indication that the training has been too stressful. Full rest is recommended before continuing with training in this situation, otherwise the muscle tissues could be damaged.

The tendons also adapt to stress, in the exact same way that muscles do, getting better able to cope with high or repetitive forces. Too much too soon, can lead to tendinitis, which is associated with pain, stiffness and swelling. A fantastic indicator that the training has caused damage is when the tendinitis causes pain during regular daily activities, in addition to those connected with sport. For example, a knee may feel a little sore at the end of a four-mile run, suggesting patella tendinitis, however if this feeling stops once the run ends then the athlete has likely done little damage. If, however, the athlete wakes up the next morning and the knee feels sore walking up and down stairs then the injury should be taken more seriously.

Stress to the bones could be detected by the feeling of aching along the length of the bone. Any feeling like this should alert the athlete to a potential stress fracture and encourage him to see a sports physician.

Action To Take

Any critical muscle, bone or tendon pain that's described above must be treated. There are four basic techniques of treatment that will help most athletes and should be carried out immediately:

Rest. This means avoiding any activity that stresses the painful area. Athletes can still do upper-body weights and swimming when, they have a leg injury . Aim to rest till pain symptoms have gone. If the pain occurs after rest, it's a sure sign of an injury.

Ice. Useful at any time at controlling inflammation. Be cautioned, however, that if a muscle or joint needs to be constantly iced after each training session then more serious therapy and rest will be required. Ice works, but when it's always needed to reduce pain, then the athlete is most likely pushing him or herself too hard.

Various Movement Exercises. Stiffness is frequently related to pain and increased resistance to movement will stop an injury from healing fully. Non-stressful movements which encourage the entire range-of-motion are helpful for almost any injured muscle or joint. Dynamic stretching exercises without weights work well.

Anti-inflammatory Medications. Over the counter medication is also helpful for reducing soreness.

Staying injury-free can be more of a challenge than training hard and getting fit. Understanding muscle soreness along with the appropriate levels and timescales of this pain will allow athletes and coaches to train at the right levels and rest for the proper time to avoid injury and optimize fitness.

For many athletes following any major endurance event they will return to their houses, to recover, celebrate, reflect and rebuild to their next career step. Some, like the athlete in this case study will need to now focus attention on delayed decisions concerning whether to go under the knife to sort out a chronic injury. El Paso, TX's Injury scientist, Dr. Alexander Jimenez takes a look at the study.

My client has been competing in triathlon for 10 or more years, although his career has included a range of serious injuries which have kept him from races for months on end. In the previous two to three decades, however, he's enjoyed a sustained period of injury-free training and racing, and has climbed to the peak of the world rankings. But the emergence of hip pain has seen him once more return to the physio's table.

The triathlete's accident history highlights a common pattern among sportspeople: 2 tibial stress fractures, a femoral neck stress fracture and a serious ankle sprain -- every one of these on his right side. The significant contributing element to the bone stress injuries is a 1.5cm leg-length gap (his right leg is shorter).

He'd first experienced comparable hip pain in 2004; it kept him from running for three months. At that time, nothing was detected on a bone scan or MRI, or so the pain went paralyzed. An intra-articular cortisone injection (CSI) elicited no improvement. The athlete remembers that he chose to train on his painful hip, never allowing the symptoms to settle. The nearest he ever came into an investigation was a hypothesis that he could have a little, undetected, labral lesion.

The present episode of hip pain began initially at night after a hard three-hour bicycle ride. Earlier this, however, he hadn't cycled for five times. He described his initial symptom as a profound hip tightness (lateral and lateral), together with slight pain in his groin. He was able to continue to train however, was feeling that the hip tightness and pain following both cycling and running (swimming was symptom-free).

A week later his symptoms dramatically worsened when he flew from Australia to Singapore, on his way to a French high- altitude camp. As he got off the airplane, he felt deep hip pain as well as the tightness. As elite athletes tend to do, he coached anyway, running a tricky track session, which made the hip much worse: he was unable to ride or run without pain. He instantly started a course of anti- inflammatories.

I met him in Singapore and evaluated him in the airport, initially ruling out any prospect of a disease or systemic matter. He explained he had been feeling an ache during the night, lying in bed; on waking, the hip would be OK, but got worse the longer he walked.

Luckily, the hip didn't get worse throughout the flight. On arrival at the French high-altitude training centre, we initiated a strategy of two swims and two intensive treatments a day, aiming at reducing muscle tone, restoring his range of hip movement and normal muscle control and stamina. We had been expecting that the problem was not a stress fracture, but just minor hip synovitis that could settle quickly. Following a week of conservative treatment, though, we were just able to keep his hop pain in 2/10, and that he still could not run 20 meters without any pain and limping.

In collaboration with medics, we flew to London to see a sports doctor and get MRI scans. The scans revealed no bone stress reaction, fracture or labral ripping -- which was a big relief; however, it did show signs consistent with FAI (femoro-acetabular impingement). He had hip synovitis with a rectal lesion on his femur.

Hip injuries aren't much reported among triathletes -- in fact they are notably absent from reports on Olympic and Ironman triathlons, which mention knee, back, H/ Achilles, lower leg, ankle and shoulder as the most common accidents (1-3).

In this state, when the hip is in maximum flexion and internal rotation, the labrum and cartilage abut and impinge; damage to the articular cartilage and acetabular labrum results from this pathologic bony contact. The contact generally results in a structural abnormality of the femur ("camera impingement") along with the acetabulum ("pincer impingement") or a combination of both ("mixed impingement"). Over time, via repetitive micro-trauma, the aggravating motion hurts the hip cartilage or labrum (or both) during normal joint motion. This happens along the anterior femoral neck and the anterior--superior acetabular rim. FAI is a possible trigger of early hip joint degeneration (4).

Arthroscopic surgery is the direction of choice for FAI if symptoms do not settle; however as his next Competition was only three and a half a year off, surgery was not an option. Instead, over a five-day interval, the athlete had two cortisone (CSI) and local anesthetic injections into the hip joint (under ultrasound guidance) to settle the indicators.

Our aim was to grow the hip range of motion and extend the capsule to reduce any additional impingement, slowly returning to regular training. Following the competition, the athlete would then should see a hip arthroscopic surgeon to acquire a surgical opinion to the best option for long-term direction.

Injection Relief

After both shots my customer felt sore for five days. The initial CSI settled his pain on hopping to 1/10 and after seven days he managed to operate without symptoms. But minor hip stiffness and aching at the end of the day prevented him from progressing to optimal training, so that he then underwent a second steroid injection. This settled the hop pain into 0/10 and decreased the aching; so after five times he returned to mild cycling and after seven days he started running again, also.

The athlete admitted that, following the first shot, he had done more and gone tougher in training than directed, as he had felt "good. This mistake of "too much too soon -- all too common in elite athletes -- had led to excessive inflammation and aching in the hip nightly after training. After the next injection he returned to normal intensity slower and more gradually.

My client built his training up to regular levels by four months following the final injection (swimming five times per week, cycling four days and running six to seven days). He began with very easy cycling on a wind trainer for 30 minutes, building slowly to 90 minutes before cycling on the street. He cycled two days on and one day away and avoided hills to the first two weeks. He started jogging on the apartment for 15 minutes and slowly built up to 90 minutes after three weeks. He did not run hills or about the track; and as he ran only on every single day, he would diligently concentrate on technique.

From week six to week 11, my client remained on anti inflammatory medication and underwent two treatments a day.

The hands-on treatment continued to:

Eleven weeks after he first felt his hip pain, the triathlete returned to racing; however he failed to finish the first race, partially because of minor hip stiffness but mainly due to "fitness. Fortunately there were not any prolonged symptoms after the race and a week after he successfully returned to competition, coming second in a really strong field. His very minor ongoing symptoms were handled with anti-inflammatory drugs and hands-on treatments.

If this athlete wants to pursue a long- term triathlon career up to the London Olympics, then he will now require surgery. The arthroscopic surgical technique initially assesses the cartilage and labral surfaces, debrides any abnormalities of the hip joint cartilage and hip labrum, removes the non-spherical segments of the femoral head and any prominent sections of the anterior femoral neck and bony growths on the acetabular rim that may continue to contribute to hip joint impingement. The alternative is early joint degeneration and onset of osteoarthritis.

References:
1. Wilk B et al: “The incidence of musculoskeletal injuries in an amateur triathlete racing club”. J Orthop Sports Phys
Ther 1995 Sep;22(3):108-12.
2. Collins K et al: “Overuse injuries in triathletes. A study of the 1986 Seafair Triathlon”. Am J Sports Med 1989 SepOct;17(5):675-80.
3. Korkia PK et al: “An epidemiological investigation of training and injury patterns in British triathletes”. Br J Sports Med 1994 Sep;28(3):191-6.
4. Ganz R. et al (2003): “Femoroacetabular impingement: a cause for osteoarthritis of the hip”. Clin Orthop Relat Res. 417:112–120. For more information see: www.hipfai.com

Injury scientist, Dr. Alexander Jimenez looks at shin guard use in soccer. Just how successful are guards in preventing lower limb injury and which provide the most protection?

Soccer is the most popular team sport in the world, so it is hardly surprising there- fore that there's much interest and effort into managing and reducing the injury risks associated with 'the beautiful game'. The most frequent injuries in football players are muscle strains and tears, ligament damage and contusions caused by impacts(1). Although these types of injuries are highly undesirable, fractures are even more serious; a fracture always contributes to a prolonged lay-off and can sometimes even be career- threatening. The data shows that fracture accidents represent between 2-11% of all soccer injuries among players, and that lower extremity fractures account for 30-33% of all fractures sustained(2). Given the risk, as a result, the use of shin guards in football to prevent lower leg injury (both fracture and soft tissue) is now routine.

The function of shin guards is to protect bones and the soft tissues in the lower extremities from external impact. Shin guards provide shock absorption and facilitate energy dissipation. In 1994, the International Federation of Association Football (FIFA) created FIFA's Medical Assessment and Research Centre (FMARC) to investigate and to stop soccer-associated risks to players' health. FMARC proposed that guard use was a preventive method of reducing injury risk.

However, even though a number of studies have concluded that shin guards can significantly decrease the amount of minor injuries(3), there's still some debate in the literature regarding whether they can prevent more serious injuries such as tibia fractures(4), particularly as tackles causing injuries often create tears or damage to the shin guard. By way of example, 1 study investigated impact forces acting on shin guards protecting simulated tibias (wooden slats) and compared these to non-protected ones(5). It concluded that the shin guards spread the impact forces over a longer time period, thus reducing the peak effect (most damaging) force. When greatest forces were below 3,000 N, the protective effect was observed. At higher forces -- the force that can fracture a tibia -- defense was far less efficient. The authors concluded therefore that shin shield usage was most likely to be useful for protecting against soft tissue injuries.

A later study used dummies to evaluate the effectiveness of shin guards in attenuating the forces which can lead to lower extremity injuries(6). One player being kicked by another was simulated by A pendulum impact apparatus, with impacts delivered to the anterior tibial region of the dummy. The researchers found with the shin guards in place, that the load forces were reduced by between 41 and 77% -- a reduction. Despite their results, however, they were not able to conclude that shin guard use could reduce the risk of tibia fracture.

Shin Guard Design

There's still a rationale for their use, even though the evidence regarding the ability of shin guards to prevent fracture is somewhat limited. All shin guards aren't created equal, which begs the question, 'Just what is a good shin guard design?'

This isn't a simple question firstly, players come in all shapes and sizes, so a design that feels comfortable and provides a good fit might not be suited to another. Then, of course, it is impossible to collect data on injury protection under controlled laboratory conditions because it is unethical to ask a soccer player to sit in a laboratory wearing a shin guard when subjecting his/ her shin to blows in order to see the kind and seriousness of the injuries sustained!

Despite these issues, however, a number of studies utilizing shin models and shin guards have been completed, giving rise to a generalized recommendations. In the simplest terms, use of an appropriate shin guard material, along with the proper geometry are known to be important aspects of shin guard design(7) To achieve this, using rigid materials (vinyl, carbon, Kevlar, etc) are universally used to form the outer shell in modern shin guards, while soft materials are preferred for the lining of the guard. The criteria have been established:

• A well-designed shin guard should provide sufficient protection for the shank, but allow adequate range of motion of the ankle and the knee(8);
• To increase energy absorption, the shin guard shell should be thick and inflexible in the transverse direction, but an increase in shin guard length does not provide better shock absorption(9-10);
• Adding the shin guard to the tibial geometry by adding soft material (eg foam) or air bubbles can reduce the peak impact force(9). Some researchers have even suggested filling such gaps with semi-rigid materials(10).

These standards are reflected in the standards recommendation for shin guard products outlined in Box 1 below.

Carbon: The Way Forward?

The standards criteria were devised to reduce the risk of injury to a participant's lower leg that could be caused by a striker's cleats. But, the consequences that were related and high-energy impacts weren't taken under account, and this has led some researchers to ask whether the recent designs could be improved against fracture, especially to improve security. In a newly-published study, scientists have tried to answer precisely this question by examining three leading branded shin guards as well as two custom designs constructed out of carbon fibre(11).

In this study, two Adidas shin guards (Addidas Predator and Adidas UCL) have been tested alongside one from Nike (Nike Mercurial) as well as two custom-made carbon fibre shin guards (see Table 1 above for a summary of the shin guards' construction). There was with pendulum movement A device designed, which was capable of producing large impact forces. The effect mechanics used in this experimental setup was designed to hit the shin guard by the heel of the foot (an area of about 20cm2) -- see Figure 1. The impact values sent to artificial tibias (prepared by condensed foam and reinforced by carbon fiber and protected with soft garments -- to yield natural anthropometric properties) have been listed for a wide assortment of forces, from low to very high. The forces were recorded under the shin guards, which provided a realistic reflection of the injury risk during soccer tackles that were real from a number of sensors.

A couple of the artificial tibias produced were used to check loading values and the predicted fracture threshold effect force derived from real shin bones in cadaver models. 800N was started at by the impacts and in the tibias, no change was observed till 2850N. After the 2850N range was attained by the impacts, some cracks formed on the front of the artificial tibias. This revealed that the artificial tibias provided an excellent approximation in a real tibia, which in turn meant that data could be derived from fracture about the amount of protection.

Results

Low Impact Force (LIF) -- In the LIF trials, 2.8-9.6 percent of this load was transmitted through the shin guards to the detectors on the artificial tibia. Of the five shin guards analyzed, the highest transmitted force was significantly lower when the two carbon fiber guards were worn (ie these provided more protection) and each of those carbon guards was equally as powerful as the other. Of the three versions the Nike Mercurial shin shield provided better protection than either the Adidas Predator or the Adidas UCL, which performed.

High Impact Force (HIF) -- At the HIF trials 5.2-10.9% of the load was transmitted to the detectors on the artificial tibia. Again, the urge and the force were significantly lower for the carbon shin guards than for the three poly- propylene versions -- typically around load. This time there were no significant differences in the maximum force although the investigators noticed that wearing the Adidas Predator guard led to a longer urge time over which the force acted transmitted through the Nike Mercurial guards, Adidas UCL and the Adidas Predator. Importantly, the nearly 3000N force required to produce fracture was not 262N -- much lower than the highest recorded impact force in any of the tests.

From their findings, the researchers were able to draw a number of conclusions about shin guard design:

• When carbon fibre shin guards were used, impact forces and values diminished in trials. The fact that the carbon models were shown to be exceptional was attributable to the inherently rigid character of carbon fiber (which deforms less) and to their custom-made design, which hugged the shin more efficiently, spreading the load out.
• Shin guards for longer bend more because of their structure, which means forces acting on the tibia tissue.
• Both the ridge of the lining of the Nike Mercurial model and the shell were thicker than those of the Adidas UCL, which resulted during the LIF trials in a performance that is superior.
• The load transmitted onto the front of the tibia was significantly below the load level needed to fracture the tibia. Although the force can exceed those the evidence suggests that all the tested shin guards could provide a degree of protection.

Summary & Conclusions

In summary, then, this study offers evidence that a tibia protected by a shin guard is not likely to sustain a fracture of course, that the shin guard comes between the player's shin and the competitor's boot! Having said this, the forces transmitted via a shin guard are adequate to result in soft tissue injury and in this regard, carbon shin guards seem to offer protection when coupled with an EVA lining. Whatever the lining or shell material, any shin guards should conform to the European standard and be sized to ensure a match that is good that both and the shin hug and feels comfortable in use.

References
1. British Journal of Sports Medicine 1999; 33, 196-203
2. British Journal of Sports Medicine 1996; 30, 171-175
3. American Journal of Sports Medicine 1982 10, 75-78
4. Clinics in Sports Medicine 1998; 17, 769-777
5. Z Orthop Ihre Grenzgeb. 1985 NovDec;123(6):951-6
6. Clin J Sport Med. 1995;5(2):95-9
7. “The biomechanics of soccer surfaces and equipment”. In: Science and Soccer. 1st edition (1996). Ed: Reilly, T. Taylor & Francis Group. 135- 150
8. “The prevention of injuries in youth soccer”. Michigan Governor’s Council on physical fitness, health and sports http://files.leagueathletics.com/Images/Club/6097/The%20Prevention%20of%20injuries.pdf
9. American of Journal Sports Medicine 2000; 28, 227-233
10. Sports Engineering 2003; 6, 207-220
11. Journal of Sports Science and Medicine (2014) 13, 120-127

Chiropractor, Dr. Alexander Jimenez looks at injuries in the Lisfranc joint -- and how they may be treated.

Foot injuries are common in the athlete and they appear in many forms. These include sprains into the joints between the tarsals and metatarsals , chronic soft tissue injuries such as plantar fasciitis and stress fractures of the metatarsals and tarsal bones. Injuries to the midfoot and in particular the Lisfranc joint (or tarsometarsal joint) are a rare but potentially devastating injury to the sportsperson that require particular attention by the sports medicine practitioner.

Athletes were not involved by the type of the injury but involved personnel. Surgeon Jacques Lisfranc Saint Martin first described it who performed midfoot amputations on soldiers through the 'Lisfranc' joint after they'd dropped off their horses.

In present day scenarios, accidents to the joint are often high velocity injuries that cause severe deformity into the midfoot joints due to dislocations. These energy mechanics would be the result of a car/motor bike Collision, severe fall on the foot or a severe injury to the foot usually lasted in an industrial setting. From the athlete, injury severity is usually far less devastating and results from some form of crushing and/or twisting mechanism. But if it occurs it can have devastating consequences for the athlete.

Introduction

Although foot injuries in the athlete are reasonably common (16 percent of sports-related accidents involve the foot -- Garrick and Requa 1988), accidents to the Lisfranc joint are extremely rare. Myers et al (1994) discovered that Lisfranc injuries account for 4 percent of collegiate-level football injuries. However, the forms of the harm can't just be career-ending although season-ending for the athlete.

It is more typical in sports like American Football (using a high percentage of Lisfrancs happening in offensive linemen -- Myers et al 1994) and rugby since these sports involve high levels of touch which may involve force throughout the foot and the harm has also has been seen in horse riding, windsurfing, baseball, rodeo riding, gymnastics and skydiving.

Relevant Anatomy

The support of the midfoot is derived from the dorsum of the foot, the supporting ligaments as well as the extrinsic and intrinsic muscles that span the plantar arch and the skeletal constructions. The Lisfranc complex is a broad term that defines the articulation between the midfoot and forefoot. It comprises the joints between the proximal row of cuneiforms and cuboid with the distal row of metatarsal heads and harm to this 'zone' of articulations may come in many variations.

The architecture's concave structure makes for a structure like a 'Roman arch'. Therefore along with the ligaments that are rigid, the architecture of the midfoot is stable and inherently very strong on the plantar aspect of the foot to avoid collapse of the arch.

The Lisfranc joint is comprised of three main segments (Chiodo and Myerson 2001 and Ouzounian and Sheriff 1989):

1. Medial column. The articulation between the medial cuneiform and the first metatarsal. This allows 3.5mm of dorsal plantar movement.

2. Middle column. Its articulation with the lateral and the middle and medial cuneiform and the recessed second metatarsal cuneiform. It's greater stability as this joint is recessed more proximally than another metatarsals. This creates the 'keystone' . The cuneiform and the metatarsal make up the center column. This has less than 1mm of motion.

3. Lateral column. The articulation between the cuboid and the fifth and fourth metatarsals. This is definitely the most mobile with up to 13mm of motion.

The three columns are separated by three distinct synovial capsules and so constitute three non-communicating synovial systems (Castro et al 2010).

The interosseous ligaments stabilize these bones. However, the base of the metatarsals don't have any interosseous ligament. The second metatarsal is joined into the cuneiform via the cutaneous ligament called the 'Lisfranc' ligament.

The lack of an interosseous ligament between the first and second metatarsals allows them to operate independent of each other which is essential for locomotion and foot function. It makes the surface of the joint complicated reasonably shaky, describing the common mechanism the metatarsals dislocate at a dorsal direction when a load is applied to some plantar flexed foot.

Classic Mechanism Of Injury

Additional tendon insertions support the midfoot. The tendon insertions of the tibialis anterior (to the dorsum of the first metatarsal base and lateral cuneiform), the peroneus longus (attaching into the lateral and lateral aspect of the first metatarsal) and the tibialis posterior (attaching into the navicular so this indirectly controls the position of the arch). At length, the plantar fascia as well as the intrinsic foot muscles may add the plantar arch and further support.

Mechanisms Of Injury

The mechanism of injury to the midfoot can be categorized as low energy or high energy. The high energy variations involve motor vehicle accidents and almost demand some form of fracture and midfoot dislocation and will not be considered.

The energy variations are the harm mechanisms that affect these and the athlete are always ligamentous in character with bone fractures and dislocations. The three common mechanisms for energy Lisfranc injuries are:

1. Hyperplantarflexion of this midfoot if the foot is fixed. Horse riders and windsurfers commonly affect as the foot is fixed by means of a strap. The foot remains bound as the surfer/rider drops backward and the foot is forced by the weight of their body . Here is the mechanism that has been described by Dr Lisfranc years ago when he detected cavalry men fall from the horses.

2. Blow to the heels whilst foot is locked in plantar flexion. This occurs when the foot is shoving off and a weight drops onto the rear of the heel and compels a compression down the heel to the midfoot. This happens in football where a participant is going to push off and then a player falls on this foot whilst the foot is in a plantar flexed position, or it may occur in skydivers who land with the foot caught under these in plantar flexion (Shapiro et al 1994).

3. A injury to the foot since the foot is in a place that is weightbearing and pronated. This is not as common because of the unique anatomy of the midfoot joints whereas the plantar ligaments are a lot stronger than the dorsal ligaments (see anatomy and biomechanics); but a strong compression force throughout the midfoot may stretch and damage the plantar ligaments of the Lisfranc joint.

Due to the strength of because of the forces struck on the foot in injury mechanics, and the plantar ligaments in comparison using the ligaments, dislocations in a direction are considerably more prevalent than dislocations.

Signs & Symptoms

Many injuries to the Lisfranc can be difficult to detect and be subtle as many of the low energy accidents may go undiagnosed. Other distracting injuries like foot fractures or foot injuries might cause the examiner causing the more subtle Lisfranc injury.

Often the athlete will find it tough to describe the original mechanism of injury when the injury additionally involves damage. Since these are deeply debilitating, the athlete might remember the foot was 'twisted' and 'crushed' although maybe not recall the direction or mechanism that the foot has been in.

Upon presentation (that can be days or weeks following the injury), the foot will be debilitating at the midfoot on the dorsal aspect over the Lisfranc joint and generally in the plantar arch as the intrinsic foot muscles will reveal palpable spasm as a protective mechanism.

The key characteristics in evaluation is:

1. In walking, especially push-off.

2. Palpation pain over the aspect over the first joint and then using the tarsals involving the metatarsals and their following articulations.

3. Swelling within the midfoot which may be diffuse and conceal the veins which may be observable on the unaffected side.

4. Eccymosis/bruising in the arch.

Special tests:

1. Pain of the dorsiflexion on the very first tarso-metatarsal joint with forced/ abduction of the forefoot.

2. Anxiety about squeezing the metatarsal heads.

3. Piano key evaluation -- grasping each toe individually and moving them in a direction that is dorsal and plantar.

Imaging

X-rays

Three viewpoints minimum ought to be under- taken, rather in both non-weight- weight bearing and bearing positions. These views include:

1. AP;

2. 30° oblique;

3. Lateral.

The tell tale signs to look out for include:

1. Fracture at neck or the base of the metatarsals.

2. Little avulsion in the base of the second or first metatarsal. A 'fleck' signal is described because of avulsion of the Lisfranc ligament as a small avulsion fracture of the base of the second metatarsal.

3. Orientation of the metatarsals to their corresponding tarsal bones (seen on AP viewpoints for first/second metatarsal and 30° oblique for fourth/fifth).

4. Displacement between the second and first metatarsal heads. Any greater than 2mm is diagnostic for a Lisfranc injury (seen on AP view).

5. The medial cortex of the fourth metatarsal must line up with the medial border of the lateral cuneiform (seen on 30° oblique view).

6. No disturbance of the dorsal cortical lineup of the first metatarsal into the medial cuneiform (viewed on lateral non-weightbearing perspective)

In a recent analysis by Rankine et al (2012) it was discovered that strategy AP radiographs and 45° views missed just over 30 percent of subtle Lisfranc joint separations. The suggestion was that the 30° view was sensitive to extending of the second and initial meta- space and that CT imaging was preferred for assessing joint diastasis.

CT Scan/MRI

CT scans can also be useful in assessing the widening of the joint spaces in addition to detecting any associated fractures. The CT will help the identification of a diastasis and may be utilized in conjunction with the x-ray formulate and to plan surgery.

Although not routinely used, MRI can be used to evaluate any soft tissue injuries in connection to the Lisfrancs such as important tendon disruption (such as the peroneus longus tendon).

Classification

Nearly all classification systems utilized for Lisfranc injuries relate to the severe high energy kind trauma injuries (Myerson et al 1986). For the purposes of this guide, the classification by Nunley and Vertullo (2002) will be utilized as it's more appropriate for the athletic population's Lisfranc injuries. They talked about three aspects that led to the Level of harm

1. Skill to weightbear;

2. Nearby point tenderness over Lisfranc ligament;

3. Radiographic appearance of the joint.

The three phases of Lisfranc injury are as follows:

Stage 1

• Able to weightbear cannot return to play.
• Locally tender over medial aspect of TMT joint.
• Radiologically reveal no greater than 2mm between initial and second MT without a collapse of the arch as quantified by the metatarsal vertical distance.

Stage 2

• Willing to partly weightbear; nonetheless, cannot return to play.
• Very tender on medial element of TMT joint.
• As measured by the cuneiform-fifth metatarsal vertical distance radiologically revealed diastasis involving 2-5mm between first and second MT without a collapse of the arch.

Stage 3

• Inability to weightbear
• Really tender aspect of TMT joint over.
• Diastasis greater than 5mm, collapse of arch.

Chiropractor, Dr. Alexander Jimenez looks at the hamate, the most frequent mechanisms of injury, common clinical features that would make a clinician suspicious of a hook of hamate fracture -- also summarizes some treatment choices.

Introduction

Hook of hamate fractures are described as a often overlooked and rare injury . They are reported to account for only 2% of all carpal fractures and occur most commonly in athletes when the hook of the hamate abuts from a handle of a bat/club whilst swinging (2). Since by imaging the symptoms can be vague and may be overlooked, a delay in diagnosis is common. This delay in diagnosis increases the risk of union of the hook and rupture of the flexor tendons, therefore excision of the hook is advised.

Anatomy

The hamate bone sits on the ulna side of the row of the carpal bones and also articulates with the fourth and fifth metacarpals distally, radially using the capitate and proximally with the lunate and triquetrum(6). It has an osseus prominence which protrudes volarly which will be the hook or hamulus(3) -- (see Figure 1). The hook of hamate is an attachment site for both the transverse carpal and pisohamate ligaments as well the origin for the flexor digiti minimi brevis and the abductor digiti minimi muscles(3).

These attachments give stability but they exert forces that are distracting to it. These distracting forces are considered one of the reasons why hook of hamate fractures have a higher speed of jelqing(6). As well as being an attachment site it also serves as a pulley for the flexor digitorum profundus tendon with gripping within an ulna-deviated place(3).

The hook is located 1.5-3cm along a line from the pisiform into the metacarpal head of the index finger(6) -- (see Figure 2). It may be difficult to palpate because of its policy by thick skin, subcutaneous fibrofatty tissue as well as the palmaris brevis muscle(6).

The hook of hamate is likewise the upper border of the Guyan canal which includes the ulnar nerve and artery. The sensory branch of the ulnar nerve lies close to the tip of the hook whereas the engine division can be in close proximity to margins of this hook and the ulna and lies deeper. The motor division slips involving the flexor digiti minimi brevis and abductor digiti minimi and throughout the opponens digiti minimi giving branches off to all three of those muscles as it paths distally(two).

Mechanism Of Injury

Fractures of the hook of hamate could be described as occurring by either indirect or direct forces. Most commonly by forces when the handle of a bat or bar abuts from the hook in a shot. Baseball players and golfers tend to fracture their non-dominant hand as this is where the hook makes contact with the bat/club -- (see Figure 3). In golfers, fractures tend to happen when the club strikes the ground but in baseball these fractures tend to occur at the end of a forceful assessed swing as opposed to swings which make contact with the ball(two). Occasionally these fractures are seen in racquet sport athletes (tennis and racquetball) to the side once the athlete loses control of the racquet whilst attempting to make a shot(2). Occasionally fractures of the hook have been seen after a fall onto a dorsiflexed wrist(1).

Fractures can also occur from strong contractions of the hypothenar muscles or by injury to the pisiform which worries the pisohamate ligament resulting in an avulsion fracture of the hook(6). In these instances a particular trauma may not be reported but rather the athlete may report a gradual onset of symptoms within a period of months or weeks(1). Due to the gradual onset these happen to be reported to be stress fractures of the hook (1,5). Most commonly, the hook fractures near its base but fractures can happen at any point across the attachment sites(2,6).

Clinical Presentation

Athletes will often describe a vague ulna- sided wrist or hand pain(3). On most events patients can remember the specific moment of harm nonetheless, many studies have clarified hook of hamate fractures in which the athlete doesn't recall a particular incident or drop(1,5). No matter the mechanism, all patients reported point tenderness over the hook(2). Interestingly, tenderness can be often noted on the dorsal aspect of the hamate as well(two). The website of maximal tenderness might be misleading since the thinly-covered dorsolateral aspect of the wrist could be more painful especially if the fracture is in the base of the hook(5). Due to the proximity of the branch of the ulnar nerve into the hook, some patients might also have paraesthesia in the ulnar nerve distribution. Pain on passive or active wrist extension and pain with grasping tasks particularly in ulna deviation can also be reported(5). As described previously, the hook acts as a pulley for the flexor digitorum profundus tendon and as these a small finger flexion may even commonly elicit pain -- (see Figure 4).

Imaging

When a hook of hamate fracture is suspected imaging is required. Regular postero-anterior and lateral views of the wrist normally forget a hook of hamate fracture(3). A carpal tunnel view is described to obtain to get a hook of hamate fracture. But this radiograph can be tough to obtain as it requires forced wrist extension that might be painful in the acute setting(3). CT scan has been shown to have a greater sensitivity (100%) and specificity (94%) compared to traditional radiographs whose sensitivity is 72 percent and specificity 88 percent. CT scan has the advantage of performing bilateral comparison and may identify other congenital variants(2). MRI has been shown to be a good option in this setting.

MRI has the advantage that it shows other soft tissue structures around the area including the neurovascular bundle and triangular fibrocartilage complex also identifying other potential causes of pain, ie ganglia(3).

So differentiation between also a fracture and a non-united ossification facility should be considered, ossification isn't complete until the age of 15. A non-united ossification center will on CT have margins that are corticated whereas a fracture will have edges that are irregular and won't be corticated. A current fracture may have bone oedema on MRI and bone scan will reveal increased uptake on a fracture although not a unfused ossification center(6).

Direction

Management's two main classes are conservative management which involves a period of operation or immobilization which includes either open reduction internal fixation or excision of the hook.

Acute fracture

If a patient presents with a hook of hamate fracture less than four months old and it's minimally displaced (less than 2mm) then a period of immobilization should be trialled(3). Studies report a recovery rate of 17-46% after immobilization in a short arm cast from proximal forearm into the PIP joints of the ring and small fingers for six to eight months(3). The cast must prevent any regeneration of the flexor tendons since these pull the fracture website into the ring and small fingers diminishing the opportunity of union. Some authors assert as a result of the very low recovery rate that excision of the hook should be carried out in most cases as this operation was shown to have good to excellent benefits and a return to previous amount of activities in six to eight weeks(6 weeks).

Intense displaced fractures can be treated by open reduction internal fixation (ORIF) or excision of the hook. Most writers agree that excision is the preferred option in this scenario(two).

Chronic Fracture

Delayed diagnosis is common as I have outlined and as a result non-union or partial marriage is frequently seen. It's thought that poor marriage is not because of inadequate blood supply (such as from the scaphoid) but more due to ongoing forces being transmitted through the fracture site in soft tissue structures(two). Non-united fractures can be broken up into painless and painful. Painful non-united or partially united fractures should be treated with excision of this hook(2). This has a low complication rate (3%) and athletes have been shown to be able to go back to previous level of activity in six to eight months(2,6). Potential complications include fatigue, altered sensitivity and scar tenderness that generally all resolve in a few weeks(two). Reports of median and ulnar nerve injury also have been described(2). In this procedure the whole hook should be excised, as re-fracture has been seen in athletes in which just the tip of the hook was excised(6).

Following resection of the hook to the bottom, wrist and the hand would be immobilized in a splint or cast for 2 to three weeks. From three weeks that the athlete could commence rehabilitation and ought to aim to return to full activity at six to eight weeks(6 weeks).

Controversy surrounds the therapy of marriage or a. Most writers recommend excision of this hook because this prevents Fig rupture which is a typical late complication regarded as attributed to FDP and FDS tendons rubbing the irregular surface of their non united hamate(2). Total rupture has been reported in 15-20% of cases. The tendon into the little finger ruptures first followed by the ring finger tendon. When it does occur then treatment of the tendon and excision of the hook is advocated. Others advocate waiting for tendon signs or signs to present before excision(2).

Conclusion

Hook of hamate fractures might not be as rare as previously thought and they need to be suspected in athletes with obscure ulna- sided hand or wrist pain. So CT or MRI should be utilized to validate the existence of a separation routine radiographs will frequently forget a fracture of the hook. Management may be healed with by A non-displaced intense fracture but the healing rate is low as a result of diversion forces of the tissues that attach onto the hook. Late or early surgical excision of the hook has excellent results with minimal danger. Excision of the hook also reduces the possibility of rupture of the flexor tendons which is not uncommon in non-united fractures. Reports show return to sport six to eight months post- operation. The clinician ought to be suspicious of a hook fracture as stress fractures of the hook also have been reported, when the athlete doesn't report a specific event.

References
1. Ardevol J, Henriquez A (2002) Hook of Hamate Non union: suspicion of stress induced mechanism in a hockey player, Vol 10 pg 61-63
2. Binzer T, Carter P (1996). Hook of Hamate Fracture in Athletes. Operative Techniques in Sports Medicine, Vol 4, No4 pg 242-247
3. Briones M, Aldridge M (2010). Hook of Hamate fractures. Operative techniques in Sports Medicine, Vol 18 134-138
4. David E et al (2003). Symptomatic, partial union of the hook of hamate fracture in athletes. The American Journal of Sports Medicine Vol 31, No1 106-111
5. Guha A, Marynissen H (2002). Stress Fracture of the hook of hamate. British Journal Sports Medicine. Vol 36 pg 224-225
6. Parker et al (1986) Hook of Hamate Fractures in Athletes. The American Journal of Sports Medicine. Vol 4, No 6 pg 517-523

Chiropractor, Dr. Alexander Jimenez assesses some of their most common problems confronted by divers and also how they can be avoided.

Evidence exists that people dove for game as far back as 480 BC(1). From the seventeenth century, their maneuvers were executed by functionality gymnasts from Sweden and Germany at the beach within the water. Diving, as we know it today, began in England and by 1904 men diving. The 1908 Olympic games included men's platform diving. Women's 'plain' diving began in 1912 and 'fancy' diving at the Olympics. Today's Olympic diving events include the individual and dives, and the 10-meter platform individual and dives for both men and women.

Into The Deep

Dives are broken up into the following classes: forward, backward, reverse, inward, twist, and handstand. Once in the atmosphere, divers assume a directly (no flexion), pike (flexion in the hips), tuck (bent knees and hips), or free (a combo of all three) place. Based on their age, divers perform a set variety of optional and required dives.

The dive is comprised of 3 parts: the take-off, flight, and entry. The movement that occurs while the diver is in contact with the board or platform is considered part of the take-off. On the springboard, the take-off for reverse or front dives starts with the approach toward the conclusion of the board. The jump on one foot at the board's end is called the hurdle. When the board is depressed, the press occurs and the air is rushed into by the diver. The take-off for backward and inward dives that are springboard requires swinging the arms while performing the press with the legs without the hurdle, and standing at the conclusion of the board, to initiate movement. If the dive is from a platform, then of the force is generated by the diver for the take-off by pushing off the platform, either with the arms for a handstand dive, or the legs for a standing dive.

The flight portion of the dive begins when the diver leaves the springboard or platform and ends when he contacts the water. The pikes, tucks, and twists are initiated and executed during the flight. The entry phase contains impact with the ensuing movements and the water, called the swim-out, which help execute a entry.

The diver attempts to 'punch a hole' in the water. The impact occurs with arms and hands palms and wrists or with the hands. The elbows locked and are extended and the arms are in line with the ears to protect the head and neck. At impact, the scapulae abduct to guard the shoulder joints and absorb impact forces. The initial impact produces a hole in the water and the diver's goal is to slide his body within this hole in a position, resulting in splashing and minimal forces on the body.

The velocity of the diver at impact ranges between 8.4 m/s to 16.4 m/s depending on the height at take-off(1). Therefore, the resulting forces at impact range from 2.0 m/s2 to 2.4 m/s2(1). Researchers compare the forces experienced at impact to diving from a 1.2-meter platform and landing on a difficult surface(1).

The diver's body is fully submerged within 1.28s -- 1.40s after impact(1). After impact, the diver begins the swim-out. These manoeuvres enable him to 'save' the dive if the entry happens to over- or under-shoot vertical. Swimming in the dive's direction helps and provides a motion align the body to vertical. Doing so results in hyperextension and excessive shoulder flexion.

To study the forces experienced when the dive entry deviates from vertical, researchers in Victoria, Australia, digitised the reverse pike platform dive of an Australian Olympic diver(2). The digitised version was utilized to compute dives of pitch at entry. Simulations of five and 10 degrees of variation from entry angle found that while the forces to the hands remains constant changes occur at other areas of the body.

The hole produced by the hands enables the body to enter the water and thus, stress, when the entry is done nearly vertically. As the dive deviates from vertical, the dive is shallower, the body more horizontal, and impact with the water greater (see Figure 1). The splash that is biggeris the sign.

Researchers found that when a dive deviated from vertical the most significantly increased forces occurred at the wrist and the low back(2). The higher torque means better strain on joints and ligaments as the muscles attempt to stabilize the body under these problems. Researchers concluded that these forces that were larger increase the danger of injury to the back and wrist when the entry deviates from vertical.

Common Upper Extremity Injuries

As previously discussed, the hands and wrists bear the brunt of the forces encountered when diving. Employing the flat-handed entry technique, wrist dorsiflexion is experienced by the diver upon impact. Handstand push-ups to exit the pool further tax the wrists and hands and dives. Use increases the likelihood of subluxation of dorsal ganglion cysts; strains and sprains of the ligaments of the wrist and hand; tendonitis, especially of the flexor carpi ulnaris; and the bones of the wrist and hand. Fractures of the hand and wrist are uncommon but do occur when the hand strikes on the springboard or platform.

Diagnosis of hand and wrist injury is most accurately made using magnetic resonance imaging (MRI), as both the soft tissue and bony structures are visualized. Most hand and wrist injuries respond to conservative treatment of protection, rest, ice, compression, elevation, and rehabilitation (PRICER). Divers return to competition within weeks of injury, with the utilization of taping or bracing to minimize future trauma. Rarely required intervention may be necessary for decreased function or pain.

From the hands and wrists to the shoulder girdle, the elbows permit the transmission of forces during impact. The cranium may strike at entry, or worse, fail to defend the head and neck, if the elbows flex. If impact is hyperextended at by the elbows, the ulnar collateral ligament is vulnerable to strain. Hyperextension contributes to ulnar neuritis and instability. Attention to technique and dry-land strength training protects the elbow and keep the triceps strong.

As with other aquatic sport athletes, shoulder joints are often exhibited by divers. Hypermobility may lead to instability and injury. A survey of the United States National diving team found that 80% of the members had shoulder injuries that required a week or more of rest from training(1). While frank tears in the rotator cuff are rare traction tendonitis and tears of the rotator cuff are common. Treatment of shoulder lesions is typically the same as in any population that is athletic. Scapular stability is being maintained by the key to preventing shoulder injuries. Weakness in rhomboids, the serratus anterior, and trapezius muscles contributes to humeral subluxation and instability. Exercise these muscles in functional positions, with arms extended, in addition to traditional strength training (see Figure 2).

The Back & Spine

Unlike diving, cervical spine injuries are rare in competitive diving. The neck is usually protected by correct technique that is diving . Spinal injuries from diving that is competitive occur in the thoracic and lumbar spine. As the diver executes twists and tucks injuries happen as a result of stresses of the flight maneuvers. Injuries to the anterior section of the lumbar vertebrae when flexed during flight and are due to the stresses experienced at the press in springboard dives. Stress is experienced by the posterior lumbar spine at entry and take off during lumbar extension, reverse and especially for back dives; and when divers attempt to 'save' a dive by hyperextending the back after impact.

The most common orthopaedic spine injuries in divers are lumbar spondylolysis and spondylolisthesis. Spondylolysis is a fracture of the pars interarticularis, the posterior-lateral region of the vertebra that acts as the bridge between the vertebral body and the interlocking facets (see Figure 3). The fracture is usually the result of lumbar extension stressnevertheless, acute traumatic hyperextension can cause a fracture. The L4 vertebra can be involved, although the most common location is in the L5 vertebra. Some athletes have congenitally weaker bone in this region and may be predisposed to fracture.

If the fracture separates and the lumbar vertebra slips forward on the sacrum, then it's called spondylolisthesis. Most cases are diagnosed using a side-view X-ray; however, in athletes with unresolved low back pain, computed tomography scans (CT scans) show a greater sensitivity to detecting pars interarticularis defects than traditional X-ray(3). Spondylolisthesis is graded based on the percentage of slippage of one vertebra on another. In a grade I slip, grade IV, up to 100%; grade II, up to 50%; grade III, up to 75%; and up to 25% of the vertebral body has slipped forward.

Symptoms generally occur with a grade I or grade II slip and so are treated before the severity increases. Symptoms range to nerve impingement pain radiating into hips and legs. Treatment involves rest from the offending movements (anywhere from three to six months for complete healing), occasional bracing to stabilize the fracture, and therapeutic exercises to strengthen the core stabilizing muscles. In severe cases, surgical fusion is necessary.

Diving manoeuvres push at the limits of mobility. Repeated movements may lead to irritation of the facet joints, the joints that connect the vertebrae. Generalised low-back pain that's difficult to diagnose is typically presented with by lumbar facet syndrome. Changes to the facet joint on X-ray are subtle and might be detected using CT scans. By compressing the joint with active extension and rotation reproduce symptoms. Symptoms improve with flexion, which separates the joints. Treat facet pain with anti-inflammatory medications, rest, and physiotherapy. Consider inflammation and decrease pain to calm, if unresponsive to therapy.

Preventing Back Pain

Acknowledging that low back pain occurs in significant numbers in divers, researchers in Japan evaluated 83 elite junior divers (42 men and 41 women) through a questionnaire, interview, and clinical exam, searching for clues as to causes and prevention(4). Of all of the divers, 37.3% reported low back pain. Decreased shoulder flexibility and low back pain correlated in males. Age most strongly correlated with low back pain in females, and secondarily in males. The median age of the low back pain groups was 15.6 years for men and 15.5 years for women. The median age of both male and female non-pain groups was 13.8 years.

The researchers concluded by hyperextending to achieve a vertical alignment at 27, that if shoulder flexibility is diminished, male divers compensate at the low back. Researchers inferred that the age of the pain group correlated to periods of adolescent growth. Based on this study, prevention strategies should concentrate on attention to technique and core strength and strength in men, and shoulder mobility during adolescent growth spurts.

Other Injuries

Diving accidents to the legs, legs, and feet are uncommon, and mostly because of striking on the board or platform.

Divers experience many of the exact same tissue injuries around the knee and ankle which athletes do, because jumping is an significant part the take-off. Treatment for tendonitis or ligament strains around ankle and the knee are just like for different athletes.

The velocity of the water entry and changes in pressure can cause injuries to the ears and eyes of divers. Ruptured membranes occur due to pressure changes underwater or if the water strikes with the side of the head. Contusions and detachments can occur when striking the water with the head. When the board or platform strikes after a faulty take-off rare but dramatic head injuries occur. Pneumothorax and contusion result from going into the water with the thorax, rather than entering vertically into the cone created by the hands.

Conclusion

The Fédération Internationale de Natation, (FINA) statistics reveal that female divers suffer the most injuries of all aquatic sportsmen, with 134.1 incidences out of every 1000 athletes(7). Diving injuries to male divers rank third in frequency of aquatic athletes, just behind water polo, with 118.6 per 1000 athletes(6). Diving injuries are caused by repetitive micro-trauma from instability overuse , faulty technique, or, more rarely, acute trauma. Divers injure back the wrists, and shoulders. Attention at entry to proper technique, together with strength training the lower and upper back and shoulders, show the greatest success at injury prevention.

References:
1. Clin Sports Med. 1999 Apr;18(2):293-303.
2. Harrison, S., Cohen, R., Cleary, P., et al. (2012, December). Forces on the Body During Elite Competitive Platform Diving. Presented at the Ninth International Conference on CFD in the Minerals and Process Industries CSIRO.
Melbourne, Australia.
3. Am J Sports Med. 1997;2:248-53.
4. Br J Sports Med. 2014;48:919-923.
5. Van den Hooogenband, C. R., Miller, J. A Delicate Balance in Aquatic Sports-the Shoulder. Presented at IOC World Conference on Prevention of Injury in Sport.
6. Marks, S. (2012, November). Diving Injuries and Prevention. Presented at the 2nd FINA World Diving Coaches Conference, Mexico City, Mexico.

In part II, Chiropractor, Dr. Alexander Jimenez details what's involved from the post-surgical rehabilitation of a hamstring avulsion.

Post-Surgical Rehabilitation

When planning and delivering the stages of the rehabilitation programs, an awareness of the effect of load exposure, load attenuation and induce generation is critical to provide us with a clear understanding of the landmarks which need to be attained and the pace at which they could pursued. The ideal way to approach the procedure will be to stage the approach to load resilience and performance employing a phased or landmark- based strategy with every stage feeding in the next. In keeping with the strategy, we don't move in line with the passage of time, but the achievement of goals that are functional.

Of hamstring surgery rehabilitation, the four stages are:

1. Stage One: healing and Protection

2. Stage Two: Restoring muscle strength and variety of movement

3. Stage Three: Integrated functional adaptation

4. Stage Four: Sports-specific retraining.

Stage One:

Protection & Healing

Post-surgery the patient will be kept touch weight bearing on crutches with short steps and may be kept in a hip-motion limiting brace to prevent hip flexion to avoid damaging the tendon. It has been suggested that the brace is fixed to then and 0-30 ° for the first 3 weeks 0-60 ° for the next 3 weeks. The brace is then removed and physiotherapy is started (1). However, not all surgeons feel that a hip motion limiting brace is necessary and if not used then the patient is instructed to avoid hip flexion past 45° (2). If the surgeon feels that knee extension should also be limited (in the case of repairs of failed conservative management whereby surgery has been delayed) then the knee might be fixed in a knee brace up to 60-90° to prevent extension and the brace is gradually opened up over the six to twelve weeks.

In this stage intervention is limited to managing muscle tone issues and open chain hip abduction/adduction exercises. It is expected that this stage will take 6-8 weeks.

Stage Two:

Restoring Muscle Strength & Range Of Movement

Once the patient is mobilizing full weight bearing and has progressed off the crutches and surgeon is happy that the patient has soft tissue healing to begin loading, more intensive physiotherapy commences to regain range of movement and to restore muscle strength. This will usually start at 6-8 weeks post-operative.

As the soft tissue structures may still be vulnerable to high load or higher stretch positions, the recommendation is that the patient starts with active stretching in this stage and light load isometric contractions. The contraction type can be progressed to then and concentric eccentric as the hamstring adapts to the loads.

Physiotherapy Interventions

1. Active soft tissue treatment. Direct tissue massage, dry needling, friction therapy all can start to acquire in the hamstring. Soft tissue work will should directed towards other soft tissues such as deep hip rotators, adductor magnus, gluteals and hip flexors like rectus femoris TFL and iliacus.

2. Proprioception training.

3. Core stability.

4. Hip muscle activation work. No weight bearing exercises will also be needed in the hip muscles to guarantee a balance between hip rotators and hip adductors/abductors.

a. Hip extension. With the patient prone, and the knee kept flexed to 90 degrees (eliminates hamstrings), have the patient extend the hip and hold the gluteal contraction. This may be done in sets of holds and repeated until fatigue.

b. Hip abduction. Simple side lying chain hip abduction and clams exercises.

c. Hip adduction. Supine ball that is lying squeezes.

Strength Progressions

Recent research into the efficacy of hamstring repair on muscle strength has shown that even if the patient returns to full athletic function, a strength return of only 78% can be expected while the hamstring strength is objectively using isokinetic testing equipment (3). This is an important consideration to bear in mind as the patients self reported strength gain was felt to be closer to 91-92% improvement (3). Using isokinetic testing may not be as predicting return to 16, overly reliable. The use of isokinetic testing will be excluded from this rehabilitation protocol.

The exercises outlined above form a progression from contraction that was easy through to low load contraction to eventual high eccentric load training. This procedure may take quite a few months to progress through. It's expected that the athlete will have returned to some kind of running re-education sometime during this procedure (usually 14 weeks post- surgical). It could be logistically possible to be working through the strength progressions whilst the athlete parallels this with return to progressions. They'll have the ability to tolerate higher speeds of running as they get stronger.

At this stage the athlete may have started jogging with the emphasis on running mechanics such as Mach drills' utilization such as marching 'A' drills, ' skipping 'A’drills, triple extension exercises. However, the athlete won't have ventured running at this stage.

Neuromobilisation

Due to the unique anatomy of the nerve and the upper hamstring, it is common for fibrosis and the scarring in and around the healing tendon to create adhesions around the nerve. This is termed 'tension'. As the hamstring has to stretch, the athlete might affect and the bands that are fibrotic irritate the sciatic nerve. The perceived symptoms might be referred pain down the sensation and the hamstring they are 'pulling' the hamstring. This may be accompanied by signs such as numbness and paraesthesia.

This may be readily managed clinically by starting some 'nerve-stretching' exercises or 'nerve-flossing' exercises. The most easy way to do that is using a recession position.

The diagram below shows a slump type therapy treatment.

Sitting with cervical, thoracic, and lumbar flexion, the knee is extended and the ankle is dorsiflexed. This is the maximum tension created on the sciatic nerve. The athlete can now be asked to ditch the strain and reload by doing some of the following (in isolation or as mixtures):

1. Cervical extension back to flexion

2. Knee flexion back to extension

3. Ankle plantarflexion back to dorsiflexion.

These movements can be done as slow oscillations (repeated) or they can be held for a period of time (5-10 seconds) to gain a sustained stretch.

It's necessary that these are done to the point of not pain and discomfort.

It is expected that this stage will be completed 12-16 weeks post-surgery.

Stage Three:

Functional Adaptation

The return to running speeds highlights this phase. The patient may have started more easy low force running like jogging and running drills before this stage. Now the emphasis is on returning to high speed running. The athlete should be progressing through the strength stages.

The athlete may perform 2-3 sessions of each stage (on alternate days) before progressing to the next stage. Thus the entire program that is running may take 12-18 sessions spread over a 4-5 week period. The strength work mentioned above should adhere to this running session (within 1-3 hours) and the next day ought to be a no-stress hamstring day. This should be left for recovery for soft tissue work and more easy cross training.

Notes on the table

1. Warm-up drills. These are well-used sprint drills known as 'Mach drills'.

2. 25/20/25. This highlights the acceleration/hold speed/deceleration distance. Notice the acceleration and deceleration distance is shortened as the athlete progresses.

3. 1.2km time trial. This would most likely be a test an whole team has conducted in a pre-season so the rehabilitation coach knows the expected normal for this athlete. This can be done as a time trial or for team sports it is best done as a shuttle test. For example,

A. Run 20m and return.

B. return and Run 40m

C. Run 60m and return

D. Repeat

E. This equals 1.2km.

4. Inner/Outer Length

This area of the program's purpose is to expose the hamstring to contraction types that are inner range, mid selection and outer selection.

o-5m Bum flicks. Running drill with maximum knee flexion.

                               Hit on the bum.

5-10m High knee skips

10-20m Jogging

20-30m A drills -- heels under bum

30-40m Lunges

40-50m Jogging

Repeat and walk return for 4 sets.

5. Agility drills. In this example for a player:

a. A drill. 6-7 random cones set out over a 10 x 10m square. The athlete is instructed to run and touch the cone they are directed to at full speed. The cones are selected at random by the coach. Work and have 90 seconds recovery.

b. B drill. As above the difference being that this time the athlete touches the cone, then jumps onto their front (push-up position) and then bounces up again to go to the next cone.

We suggest the following exit criteria are passed to allow progression to Stage 4 of rehabilitation:

1. Full speed running

2. Able to perform hip flexed Nordics 3 x 6 reps

3. No pain 48 hours post-running/weights

4. Able to change direction comfortably with no pain.

It's expected that this stage will take surgery.

Stage Four:

Sports-Specific Retraining

Now that the athlete has returned to full- speed running, they may be integrated back into sport-specific and team-specific skill training. This phase is going to be characterized by the return to all skill elements done at competition intensity and speed. The athlete should have a part in this process as they are the ones that need to feel confident they can execute the skills. This phase may last 4-6 weeks before they are confident they can return to competition.

Athletes in high speed running sports may take to feel confident to return to play; others in speed sports over distances may take six months post-op.

We suggest the following exit criteria are passed to allow progression to return to competition:

1. Confidence in all skills

2. Perform a Bosch single leg hamstring (bodyweight) 3 x 6 reps.

It's expected the athlete is going to be fit to resume competition post- surgery.

Conclusion

Hamstring avulsion injuries in athletes is a rare but debilitating condition that usually takes a surgical intervention. The return to competition period may take 6-9 months post- surgery and will involve high levels strength work and structured return and return to training programs.

Most athletes who suffer a surgically can expect a hamstring when tested on isokinetic apparatus; nonetheless they might feel confident in returning to competition.

References
1. Domb, B.G., Linder, D., Sharp, K.G., Sadik, A., Gerhardt, M.B. Endoscopic repair of proximal hamstring avulsion.
Arthrosc Tech. 2013. 2(1); p. e35-e39.
2. Folsom, G.J., Larson, C.M. Surgical treatment of acute versus chronic complete proximal hamstring ruptures:
results of a new allograft technique for chronic reconstructions. Am Journal of Sports Med. 2008; 36(1): p.104-9.
3. Chahal, J., Bush-Joseph, C.A., Chow, A., Zelanzy, A., Mather, R.C., Lin, E.C., Gupta, D., Verma, N.N. Clinical and magnetic resonance imaging outcomes after surgical repair of complete proximal hamstring ruptures. The Am Journal of
Sports Med. 2012. 40(10); p. 2325-2330.
4. Bosch, F. Klomp, R. Running. Biomechanics and Exercise Physiology Applied in Practice. 2004.

90% of swimmers will experience shoulder pain at some time in their careers. Chiropractor, Dr. Alexander Jimenez examines injury rehabilitation recommendations and, in particular, the demand for an appropriate return to a swimming program in the pool.

Though swimming is a relatively low-risk sport for injury, shoulder pain is common in swimmers. A variety of studies show that over a lifetime, between 40 percent and 91 percent of swimmers will endure a swimming-related shoulder injury(1-4). However, if you think about that elite swimmers might be racking up in the pool every day over 10km, and that the arms would be the prime generators of forward push, we should be surprised. High volume training may result in muscle fatigue of the rotator cuff, upper back, and pectoral muscles, which in turn might lead to micro trauma as a result of reduction of dynamic stabilization of the humeral head(5,6).

Etiology Of Shoulder Injury In Swimmers

It will help to understand the biomechanics of the stroke cycle, to appreciate the vulnerability of a swimmer's shoulder to injury. Since freestyle is the most commonly used stroke (for example, the stroke of selection in related sports such as triathlon) we'll concentrate on this particular style. The stroke contains four distinct phases, which are shown in figures 1-4.

In freestyle swimming, each one of these phases has the potential to raise the risk of shoulder injury when executed. Some of the common errors are as follows:

Hand entry -- the swimmer's hand enters the water either medial or lateral to the ideal line (with the swimmer's head representing 12 o’clock, a right hand should enter the water at approximately 1 o’clock and a left hand at 11 o’clock). A deviation either way increases stress on the rotator cuff.

Early pull through -- a 'dropped elbow' (where the elbow is lower than the hand while the arm pulls under the body) will fail to fully engage the latissimus dorsi muscles, which can boost the chance of impingement. In addition, it inhibits a symmetrical body roll, which is needed to keep the scapula appropriately anchored on the thorax and to decrease stress on the rotator cuff muscles.

Straight arm recovery -- a fully extended elbow while the arm is out of the water in the recovery phase is another frequent error. In this phase, there is a bent elbow much preferred because it decreases the amount of stress on the rotator cuff.

In more general terms, it's important to appreciate that a balance of muscle forces are critical for maintaining stability, proper motion, and function that is painless and that the shoulder is an joint. Since the bulk of the propulsive force in swimming is generated by adduction and internal rotation of the upper arm involving contraction of pectoralis major and the latissimus dorsi, high training volumes tend to favor increased adduction and internal rotation strength, which may lead to imbalance and reduced glenohumeral stability(7,8). It's also worth noting that female swimmers, on average, have shorter arm strokes than those of their male colleagues and are, from a biomechanical perspective, at a greater risk of suffering an overuse injury, due to the requirement for more arm revolutions per lap(2).

Land-Based Prevention & Rehab Training

Studies indicate that an endurance training and strengthening program for the shoulder and periscapular muscles, with emphasis placed on the serratus anterior, rhomboids, lower trapezius, and subscapularis, may help prevent injuries and speed recovery when injury does occur(9,10). There's also evidence that abdominal and scapular muscle strengthening performed in dry-land training can yield benefits; in particular, the goal of core and abdominal strengthening is to develop greater control of the pelvis by avoiding excessive anterior pelvic tilt and lumbar lordosis(11,12). Table 1 shows some example of some commonly-used dry-land training exercises that fulfill these criteria.

When shoulder injury does occur, clinical evaluation and diagnosis is recommended (see SIB issues 128 and 136 for a fuller discussion), together with complete or relative rest and the judicious use of dry-land rehab exercises. During periods of relative rest, ice may be used and short courses (up to 1 week) of non-steroidal anti-inflammatory medication might be beneficial. Injection of corticosteroid into the bursa is a option and should be limited to swimmers with constant pain. In all circumstances, the resumption of training should be monitored and gradual although it's hard to determine the length of relative rest. A period of absolute rest is recommended, if the pain persists, and the swimmer should be reassessed before resuming training in the water. If pain persists upon the resumption of training, an evaluation by a physician is indicated(13).

Returning To Swim Training

Much has been written about land rehab training following shoulder injury and pain management. On the other hand, the return to pain-free swimming training in the water presents a challenge. All too often, symptoms improve or resolve to replicate after rest and dry-land training only when the swimmer is back in the pool. The specific hurdles that need to be overcome at this stage are ironing any stroke imperfections while building up swimming training volume without overload and gradually.

There are two criteria that have to be achieved before a return swimming program can be begun by a swimmerthe swimmer be in a position to attain active extension and external rotation of the glenohumeral joint and should be nearly pain free in the shoulder complex. Secondly, the strength of the rotator cuff and scapular stabilizing muscles should be scored at 5/5 when tested using traditional manual muscle testing(14,15).

Dry-land training performed is generally very effective at getting the swimmer. As the predisposing factors to injury may be present, it is important for physiotherapists to appreciate that simply handing the swimmer back to the coach without any additional support or advice risks further setbacks. There is a preferred approach collaboration with the coach to ensure the subsequent training is both measured and appropriate.

In a recently published paper on this topic, Spigelman et al suggest a two-phase approach(16):

Phase 1 - Focuses on stroke technique drills to protect against the swimmer from reverting. The distance increases only to allow assessment of the shoulder is coping with the resumption of training and to prevent overuse;

Phase 2 - Once the swimmer has successfully completed phase 1, the focus switches to interval work, which is designed to help build the swimmer's muscular and cardiovascular fitness levels. In this phase distance increases in bigger increments in order to help build endurance -- but only if the swimmer can demonstrate she or he can tolerate practices.

What's important to keep in mind is that a return to swimming program's objective is to return the swimmer focusing on the swimmer's speciality stroke or distance isn't important at this time. When the swimmer can swim reasonable training volumes with technique and without pain should event-specific training be considered.

Communication

It follows from the above that communication is necessary, both between the swimmer and coach, and between the coach and physiotherapist. The coach should communicate with the swimmer the significance of providing constant feedback about how their shoulder is responding to the increasing training load. It needs to be stressed that any signs of pain or discomfort need to be reported so the coach can pause the training if necessary and evaluate the circumstance. A useful instrument in this regard is the 'Swimming Soreness Rules', which can help the swimmer recognize pain, along with the coach/chiropractor adjust the swimming part of shoulder rehab in the swimmer's program(16). These rules are displayed in Box2.

Criteria For Progression

A thorough description of suitable drills and swimming workouts for the swimmer returning to the pool is beyond the scope of this article and will of course depend on the swimmer in question, his/her event, stage of development etc.. On the other hand, the general criteria for progression from phase 1 to phase 2, and from phase 2 to resuming training can be given. A good instance of this in practice is shown in Table 2. It must be emphasized that the swimmer and coach both need to understand that progression should only be very gradual. Any increases in pain, soreness or discomfort have to get recognized by the swimmer and coach as warning signs that are potential to decrease while re-evaluation occurs, or suspend training.

Summary

Overuse injuries to the shoulder are all too typical in competitive swimmers, especially where training volumes are high and stroke technique is less than perfect. Evaluation by the clinician, proper and rest strengthening exercises that are dry-land are an important first phase of any recovery program. The process of rehab shouldn't stop there.

The first couple of weeks in the pool as part of a return to swimming program are important for a full recovery, and this is a time when cooperation between the swimmer's coach and the clinician can be useful. During the return to swimming program, any increase in workload should only be very gradual with an emphasis on correcting any stroke errors as opposed to rushing the swimmer back. A key part of this process is constant feedback from the swimmer and monitoring of that chiropractor and the coach can make any adjustments to the program as needed.

References
1. Clin J Sport Med. 2010;20(5):386-390
2. Am J Sports Med. 1997;25(2):254-260
3. Scand J Med Sci Sports. 2007;17(4):373-377
4. Clin Sports Med. 1999;18(2):349-359
5. Orthop Clin North Am. 2000;31(2):247-61
6. Br J Sports Med. 2010;44(2):105-113
7. Am J Sports Med. 1993;21(1):67-70
8. Clin Sports Med.2001;20(3):423-438
9. Am J Sports Med. 1991;19(6):569-576
10. Rodeo SA. Swimming. In: Krishnan SG, Hawkins RJ, Warren RF, eds. The Shoulder and the Overhead Athlete. Philadelphia, PA: Lippincott, Williams & WIlkins; 2004:350
11. Phys Sportsmed. 2003;31(1):41-46.
12. Kibler WB, Herring SA, Press JM. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers; 1998
13. Sports Health. 2012 May;4(3):246-51
14. J Chiropr. 2004;41(10):32-38.
15. Kendall FP, Kendall FP. Muscles : Testing and function with posture and pain. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2005
16. Int J Sports Phys Ther. 2014; vol 9 (5) 712

Gluteus medius and minimus tendinopathy are painful and debilitating disorders in athletes. Chiropractor, Dr. Alexander Jimenez looks at the identification and rehabilitation options for this kind of injury...

No matter the condition that is overall of an athlete, the fact is that there are instances when their sport's demands exceeds the movement and stability available during the kinetic chain of joints and the muscles utilized to execute that movement. Pattern compensation can occur if any weakness exists in almost any plane of motion and injury might be the outcome.

An illness that can arise from this and similar situations is gluteal tendinopathy (either medius or minimum). The mixture of overuse and inherent weakness of the gluteus medius and minimis can lead to stress, tearing, or degeneration of the muscles or their various tendons, inducing tendinopathy in the athlete.

Hip Anatomy

A schematic view of gluteus medius and minimus can be viewed in Figure 1. The gluteus medius originates in the ilium inferior to the iliac crest and spans to the lateral and superior surfaces of the greater trochanter. Medius has two insertions: the superoposterior facet and the aspect. Of the two, the aspect includes a bigger area of insertion. Medius is a main hip abductor; the hip, while the posterior fibers help in external rotation is internally rotated by its anterior fibres. In weight bearing positions, these muscles keep the pelvis out of falling.

Gluteus minimus is a fan-shaped muscle lying to gluteus medius, and has the anterior and poor lines, as well as a source from the ilium and also the border of the greater sciatic notch. Gluteus minimus (in association with different muscles) chiefly abducts the hip when the hip is in extension and also a most important purpose of this muscle is to help reestablish the head of the femur in the acetabulum when an person is walking.

Indicators Of GlutealTtendinopathy

Tendinopathy is characterised by lateral hip pain in the shared insertion on the greater trochanter of the femur, and is often associated with higher trochanteric bursitis(1). Typically patients will complain of a dull and bronchial lateral hip pain, which can be aggravated abduction and by weight bearing under load.

To help distinguish the underlying muscular pathology (ie whether gluteus medius or minimus tendinopathy lies), medius tendinopathy often poses as tenderness along the anterior aspect of the greater trochanter in the tendinous insertion, whereas pain in the anterior part of the greater trochanter indicates the difficulties are more likely to be credited to gluteus minimus. In addition testing might be useful to help differentiate muscular from bursal pathology.

In some patients, however may present masquerading as other ailments, which then can lead to mismanagement and misdiagnosis of the condition. This is partly due to descriptions of the gluteus minimus are not always true and treatment protocols are not always unique to the pathology. Additionally, referred pain from the gluteus minimus can be acute as well as its source is relatively concealed; pain may be felt at the lateral and posterior element of the lower limb as far as the outer ankle and upward into the buttock, imitating sciatica(two). Palpation of the trigger point that is profound is not easy.

Diagnosis & Testing

When it comes to examining patients with suspected gluteal tendinopathy, a comprehensive and stepwise approach to the evaluation is recommended. This strategy should consist of taking a history from the patient, an inspection of the hip, palpation, followed by evaluations of range of movement, stability, and strength in all planes of motion. Areas and joints around the hip area (eg SI joint, lumbar spine) should also be analyzed. Gait patterns should be observed, noting any discrepancy and compensations due to weakness, in addition to heel strike and avoidance patterns. An MRI scan and/or ultrasound imaging is strongly suggested in case avulsion is suspected.

Unfortunately, there's no definitive test to rule tendinopathy outside or in. But, there are quite a few different tests that can be quite helpful when assessing a patient. These are as follows:

• Trendelenburg test the functional power of gluteus medius. The patient stands unsupported on a single leg. If the pelvis tilts towards the unsupported leg, then this indicates abductor weakness about the stance leg;
• Ober's test -- that the individual lies on the unaffected hip. The symptomatic knee and hip have been held in a flexed position. The hip is abducted and long to centre the iliotibial band over the greater trochanter, and then passively adducted. Pain in This Procedure suggests a tight, contracted or inflamed tensor fasciae latae and iliotibial band;
• Thomas test -- that the patient lies supine And retains the leg at the knee- to-chest place while the leg is kept completely extended on the exam table. If the thigh is elevated off the desk, the test is positive, indicating hip flexor tightness;
• Ely's test -- the patient lies in a prone position, together with the examiner flexing the knee and bringing the heel toward the buttock. If the heel can't touch the buttocks, then the hip of the side rises from the desk, or the patient feels pain or tingling at the back or thighs, the test is positive suggesting rectus femoris tightness.

In a 2008 study investigated the diagnostic reliability for gluteal tendinopathy of two additional tests: the 30-second single leg stance test and also the resisted external derotation test(5). In the single leg stance test, the individual accounts on one leg for 30 minutes with individual's hands held by the examiner to limit trunk influence. The test is deemed favorable if pain is experienced at any given time point. From the outside derotation test (see Figure 2), the patient lies in the supine position with the hip flexed to 90 degrees and brought into end range external rotation (or the point of pain). The individual is then asked to return to neutral. Reproduction of pain is considered a positive test.

The hip is flexed 90°, and the individual is asked to return the leg into the axis of the table against immunity. When the pain is replicated the test result is positive.

The reliability value of these tests is considered high. In the analysis, two groups of patients were compared with both the evaluations -- a target group of 17 patients who were suffering from hip pain anterior, lateral, or posterior to the greater trochanter or involving the thigh, along with a pain-free control group of 19 patients.

In the single-leg, the target group stance reproduced immediate, early, and spontaneous pain in 5 patients, 7, and 5 . The external derotation that was resisted generated pain lying in the supine position. In one of both of these patients, pain has been produced from the position. In the control group, 38 hips were analyzed with only one outcome. Following the tests, MRI imaging was carried, showing tendinopathy and/or bursitis of the gluteus medius and/or minimus tendons.

Statistical analysis showed excellent sensitivity and specificity, with 100 percent and 97.3%, respectively, for its single-leg stance test and 88% and 97.3percent, respectively, for its resisted external derotation test in the supine position. For the latter test, the sensitivity increased to 94\% with results that were positive in the prone position in the case of negative effects in the supine position.

Management & Treatment

As with tendinopathies, the main goal is the reduction of pain and dysfunction before progressing to eccentric training. Although no research on the advantages of eccentric training have been carried out especially on gluteal tendinopathy, there's good evidence in the literature because of this particular rationale, where the therapy of the achilles tendon, patellar tendon, along with lateral epicondylitis are strongly supported(6,7). There are no theoretical reasons why the principles can't be implemented in the treatment of gluteal tendinopathy.

A particularly useful example of training that is gluteal that is bizarre is the 'short fallout'. Here, the patient rolls towards the affected side then externally rotates the unaffected side, then loading the affected side, and then gradually resists the resistance band to the starting position (see Figure 3). Table 1 shows that a three- stage rehab plan based upon the principles outlined above.

Overview

Gluteal tendinopathy is a painful requirement to get an athlete and its diagnosis is not always straightforward. However, a stepwise and comprehensive test in clinic, which includes applicable and tests like the 30-second Single leg stance test and the resisted derotation test will help clinicians arrive at a diagnosis. As with other tendinopathies, that is approached by a rehab focuses on the reduction of pain and dysfunction, followed by a progression to eccentric training that is therapeutic is likely to yield good results.

References
1. Clin J Sport Med. 2011;21(5):447-453
2. Movement, stability and low back pain. New York: Churchill Livingstone; 1997. p.53-71
3. Eur Radiol. 2003; 13: 1339-1347
4. Surg Radiol Anat. 2004; 26: 433-446
5. Arthritis & Rheumatism 2008; 59(2) 241–246
6. Brit J of Sports Med. 2013;47(9):536-544
7. Am J Sports Med. 1998;26(3):360-366
8. Int J Sports Phys Ther. Nov 2014; 9(6): 785–797

Wrist injuries are discussed by Chiropractor, Dr. Alexander Jimenez, with emphasis on the participation of the bone capitate, and how you can modify your training with a wrist injury.

Wrist injuries are underestimated within sport; however, they could account for between 3-9 percent of all athletic injuries (1). Injury can occur from repetitive overuse, or can occur from a single traumatic event, such as falling on an outstretched hand, or impact from a ball or racquet. Regardless of whether it is directly used, the wrist is vulnerable to injury in any sport.

The wrist joint is not supposed to withstand weight bearing or heavy loads like the joint is tight also, though these joints are often thought of in a manner due to the size and distal origin of those limbs. Regardless of this, exercises and many sports involve weight bearing through the wrists or higher impact directed to the joints, ie gymnastics, racquet and hand ball sports, strength training including press-ups, boards, and yoga poses. Sports played hard surfaces can also traumatize the wrist since the body weight of the athlete can land upon the joint, and the difficult surface (astro turf, ice, or racquet court will not absorb the shock as much as a forgiving ground surface). These activities all require wrist extension (the bending of the wrist backwards) and also pain from this is often localized to the dorsal surface (rear of this hand/wrist). Because they are the most commonly encountered this guide will focus on extension accidents.

The wrist is a joint is complex and has a variety of muscles, ligaments and bones inside its space, which should work together for function. Simply diagnosing an injury as a "wrist sprain" is not accurate and additional identification should confirm the exact structure damaged to direct mechanism of treatment.

The "wrist joint" is more anatomically called the radiocarpal joint. This is the connection between the radius (forearm bone) and the proximal row (closest to the forearm, where the wrist crease happens) from the cervical bones. The main job of the radiocarpal joint is to allow motion of the hand upward (extension) and back (flexion). This can be stabilized by the radioulnar ligaments which connect ulna forearm bones and the radius anteriorly and posteriorly.

The bones are then divided into two rows. The proximal row consists from lateral (external nearest the thumb) into medial of scaphoid, lunate, triquetrum, and pisiform. The row is made up of trapezium, trapezoid, capitate, and hamate. Various small ligaments join the carpal bones into each other, permitting fine motions around each other whilst being kept securely in position(3). These connections allow the wrist to have the fine motor control that tasks demand, in addition to the power for heavy gripping tasks.

The wrist joint is capable of roughly 85 degrees of wrist flexion and extension, and this movement happens at the radiocarpal joint and the midcarpal joint (between the proximal and distal rows). It can also move side to side with 15 degrees of radial deviation (towards the thumb) and 45 degrees of ulnar deviation (towards the fifth finger)(2).) These movements again result from the radiocarpal joint but require the accompaniment of the midcarpal joint and intercarpal joints (joints in between the carpal bones). Some movement is required between those bones, but movement becomes problematic.

Common Wrist Problems

Wrist injuries may be continued into the bones, tendon or soft tissues, muscle, or even the cartilage. Within these categories a wealth of injuries may pose. Bones can sustain stress fractures (lean hairline breaks), or entire avulsion or dislocation. Each bone presents if it become sterile and those are often related for their own blood supply to interruption. Due to the inherent tight arrangement of the carpals the flow can quickly become impaired and lead to avascular necrosis (3). Tendons and ligaments may develop tendinitis or tendinopathy. Ligament strains may cause nasal bone instability and extra motion or may occur. At length, the triangular fibrocartilage complex (TFCC), which articulates the distal radius and ulna (forearm bones), as well as the ulna to the carpals and might tear and again pose with uncertainty of the wrist.

Capitate Subluxation

The scaphoid and hamate bones are associated with fractures due to their location on effect nevertheless, the capitate bone is significantly more vulnerable to other athletic trauma, mostly subluxation, due to its substantial size, elongated silhouette using a narrower distal end, along with its central position, which makes it articulate with seven of those other carpal bones. These properties can encourage subluxation to occur with wrist trauma, Pressure to just laxity and instability or the joint around the bone.

Carpal bone instability may be misdiagnosed, or even overlooked, but a capitate subluxation has a presentation that was typical. The individual clunking at the wrist joint on loading bearing exercises and usually does not have any history of trauma but complains of protracted weeks of pain. After exercise there is annoyance or an irregular niggle from the region of the capitate.

Wrist extension would be restricted and painful every time, whereas flexion wouldn't be limited. Flexion can become debilitating over time since the ligaments become pulled on account of the subluxation causing them to stretch that is over. There may be a dip in the end and a bulge at one point where the bone has moved out from its groove that is carpal.

Solutions To Wrist Extension Problems

Rehabilitation of a wrist injury should firstly concentrate on reducing inflammation and pain so that therapy can proceed efficiently. This may involve the use of in ice and severe conditions, immobilization of the wrist to permit no strain and for the recovery process to begin. Range of motion should be increased where possible, and this might involve manual treatment (as described below) if there's a physical block to motion. Progression then should concentrate on strengthening the weakened ligaments and muscles and restoring the wrist to sports specific conditioning, coordination and flexibility (5). A return to game ought to be executed and this may require the use of splints or grips originally to gauge the suitability of wrist recovery for your sport's demands.

1) Manual Therapy

If the capitate has subluxed then it ought to first be reduced (put back in position) by an experienced orthopedic physiotherapist. They will bend the wrist to relax the ligaments and also apply a surprising push whilst applying grip the distance. A palpable clunk will signify the decrease in the capitate and ordinary carpal alignment should then be felt (6). The athlete may feel an immediate relief of symptoms and once is sufficient to restore normal function and recover wrist extension. Based on the laxity of the carpal ligaments, subluxation may re-occur and the procedure should be repeated, as well as following the following steps for prevention.

2) Soft Tissue Stretching

Stretching of some of the upper limb since we discussed intricately linked fascia and the body's connective tissues are muscles would be of benefit. One muscle will have consequences elsewhere. Particular care ought to be taken to the forearm flexors and extensors and these may be elongated holding for 30 minutes and by placing the wrist into extension or flexion.

Global stretching for the upper limb can be performed utilizing the stretches pictured below.

3) The Use Of Hand Bars

Where flooring strength work is vital to training, like press-ups and boards, rather than force the wrist can utilize hand bars. This keeps the wrist in a neutral position and allows you to grasp the handle. This could be recommended for people who have a capitate subluxation also to prevent future injuries and to minimize the strain.

4) Wrist Splints/Supports

For activities occur frequently, the use of a splint or support can decrease. This may be a viable option if the injury is secure and will not receive loading splinting isn't the solution to unstable or severe injuries where certain treatment should be the priority over all instruction (3). The type of support will depend on the harm, your sport, and movement you need to continue looking for advice will be valuable here.

5) Strengthening Exercises

Strengthening the surrounding muscles the wrist is needed to take care of but in addition to further absorb the shock to the wrist in effect and increase its own protection.

Ball Squeezes -- This can be made sports- Specific by using your own sports racquet, ball or similarly. Squeeze the object in your hands for five seconds and then release; replicating for 3 sets of 10. By holding the thing in exactly the positions you'd in game eg holding your tennis racquet at the position as well as in front of you this may be defined.

Wrist Flexion -- Start by holding a little Weight on your hands with your arm down by your side and the palm facing you. Raise the hands upwards into wrist flexion and repeat for three sets of 10.

Wrist extension -- Repeat the above possess the palms although description Body that increasing the back of the hand The wrist is brought by upwards into expansion.

References
1. Am J Sports Med. 2003; 31(6), 1038-1048.
2. Maitland’s Peripheral Manipulation (2014). 5th Ed. Vol II. Churchill Livingstone. Elsevier. pp 327.
3. Sports Health. 2009; 1(6), 469-477.
4. Anatomy Trains (2013). 3rd Ed. Churchill Livingstone. Elsevier.
5. Prim Care Clin Office Pract. 2005; 32, 35-70.
6. Curr Orthop Pract. 2012;23(4), 318-321.

Lower leg pain brought on by chronic exertional compartment syndrome is assessed by Chiropractor Dr. Alexander Jimenez ...

Lower leg pain is a frequent complaint among runners. Pain deep within the calf that starts after 20 to 30 minutes of exercise also resolves with remainder is likely due to chronic exertional compartment syndrome (CECS) of the deep posterior compartment. The pain may be described as a burning, aching, bursting, or tingling along the anterior medial border of the tibia. Numbness or pain may extend to the part of the foot.

The pain always manifests itself soon after starting an activity and continues until the athlete is made to stop the activity to worsen. With chronic deep posterior compartment syndrome (CDPCS), the muscles of the calf may feel bloated or tense upon physical examination, especially immediately after exercise. Pain may be present on passive ankle dorsiflexion or palpation. Pain, numbness across the posterior-medial facet of the calf, and weakness in toe flexion, ankle inversion and plantar flexion, can continue for some time after exercise, but usually resolve with a day's rest, only to re-appear if the athlete returns to instruction. The pain occurs bilaterally in 80-95percent of athletes with CECS, and entails the deep posterior compartment in 32 percent-60percent of all cases of CECS(1).

Anatomy

There are four fascial compartments inside the lower leg: anterior, lateral, shallow posterior, and profound posterior (see Figure 1). A compartment consists of a fascial sheath as well as the contents within -- nerves, muscles, and blood vessels. Also for practical purposes, it is included in the posterior compartment, although some consider that the tibialis posterior to be a compartment unto itself because of its own covering. Chronic exertional compartment syndrome frequently affects the anterior compartment, followed by the deep posterior compartment at frequency(1).

Within the cervical compartment lie muscles, flexor digitorum longus, flexor hallucis longus, and on the tibialis posterior. The anterior tibial nerve, artery, and vein additionally course. The muscles of the posterior compartment help with inversion and plantar flexion of the foot and the anterior tibial nerve (L5-S1) innervates them.

Under Pressure

Compartment syndrome occurs when the pressure of the fluid within the torso becomes so great that it restricts blood circulation. Acute compartment syndrome, brought on by extreme following a traumatic event, is a medical emergency and needs immediate treatment using a fasciotomy. If the action is stopped, chronic exertional compartment syndrome also happens due to the build-up of pressure but differs from the process in the pressure happens with exercise, also resolves.

During strenuous exercise, muscle volume normally increases up to 20 percent(2). The fascia is less compliant or if the muscle is hypertrophied, there is room within the pressure within the compartment raises and the compartment for expansion. It is assumed that, as in acute compartment syndrome, the circulation of blood into the muscles is impeded if the pressure inside the muscle is greater than the fluid pressure within the vessels. Clinicians utilize a needle catheter put into the compartment to measure this strain. The pressure is measured 1 minute after exercise, in the rest, and five minutes.

The only way to correctly diagnose CECS is by measuring the pressure. This can be done with a needle catheter inserted surface of the tibial border. Measurements of over 15 mmHg at rest, 30 mmHg 1 minute after workout, or 20 mmHg at five minutes output signal CECS(two).

Low Flow

Theoretically, the pain together with CECS is due to the ischemia, or cell death, within nerves and the muscles when blood circulation is compromised. Studies trying to confirm this concept fail to demonstrate that the ischemic changes consistent with these levels of pain, except under extreme tissue strain (≥ 160mmHg)(2). Calling the ischemia theory into question, researchers at Victoria, Australia examined 34 patients beneath thallium-201 single-photon emission tomography(3). The perfusion was measured by this imaging inside the muscles of their compartments. Twenty-five of the patients in the analysis had CECS served as controls and confirmed by elevated compartment pressure, while others had pressure but leg pain that is positive. The investigators found no significant difference between the perfusion of people that have CECS and those without, suggesting there is another aetiology for your pain experienced.

Alternative Theory

Fascial tissue is really a connective tissue with minimal elasticity. Some theorize that the fascia is less compliant than in the others, because of repetitive loading into the bone1 on the fascia along with its attachments. To discover which kind of histological changes might happen within the intersection in these individuals, researchers in the University of Melbourne researched the cellular nature of the fascia in people with CDPCS(1). Within this case-controlled research, 10 men and 9 females using CDPCS underwent fasciotomy after conservative measures (not defined inside the analysis) failed to enhance the condition. Tissue samples were obtained in the fascia of the posterior compartment in comparison with control tissue samples taken out of autopsy subjects.

Interestingly, while the tissue samples as supposed, of each one of those issues together with CDPCS they didn't differ in the controls in steps of vascular proliferation inflammatory cells, or fibrocytic activity. The topics differed significantly from controls in the degree of collagen organization. The researchers were surprised to find that the collagen in the fascia of these subjects showed more organization . It had been assumed that their hydration would be organized while the cadaver subjects' practice history wasn't available. Rather, the alignment from the cadaver fascia was irregular.

Researchers the regularity found in the hydration arrangement in areas with CDPCS was due to the remodeling procedure experienced because of constant strain. This study was modest, measured only a few factors, and the controls were not equally matched for activity with the subjects. Noting changes warrants further exploration to determine where it attaches to the bone, rather than ischemia whether the pain from CDPCS happens receptors within the fascia or the periosteum.

Treatment Choices

It's possible, then, that repeated strain and remodeling of the fascia, as hypothesized from the researchers in the University of Melbourne, reduce the pliability of the fascia(1). Stopping the repeated stress and fascial compliance might seem to function as targets for therapy. Analysis may show long- standing patterns of motion that have added stress to the calf over a period of time.

Researching researchers, this assumption in West Point, NY, assessed the running technique of ten armed servicemen with a diagnosis of CECS of the anterior compartment(4). Each of those patients was awaiting fasciotomy for this CECS's therapy. Each underwent a six-week program of conducting re-training to learn a forefoot-strike technique that was operating. The program consisted of running feedback, drills, exercises, and analysis. Following six weeks anterior compartment pressures and reported pain scores decreased significantly, while conducting distances improved in all subjects. Results lasted for one year after intervention in each of ten subjects.

This analysis was restricted in size with whom to compare results, patients with anterior compartment CECS, not CDPCS, and did not consist of matter controls. But, all subjects prevented surgery with a six-week intervention program of 3 sessions per week. This speaks dramatically to the need for analysis of all athletes using CDPCS. The hypothesis is the fascia may cure and function normally if the cause of strain can be eliminated.

The biomechanical investigation should comprise an evaluation of power, range of movement alignment, and gear, such as running surfaces, and shoes, orthotics. Fascial compliance and neural mobility can be assessed and handled with stretches and exercises (see Figures 2,3 and 4). Because sport eliminates the chance for off-season cross-training and a rest from continuous strain training schedules should be assessed.

Easing The Pressure

In the way, acute compartment syndrome save the tissue and to alleviate pressure's build-up is to release the fascia by means of a fasciotomy. The assumption for the operative management of CECS is the same, that releasing the fascia will normalize the compartment's perfusion and relieve the pain. Present research concerns the perfusion concept of pain, and thus the benefit of fasciotomy.

A researcher at the University of California reviewed the literature on the effectiveness of fasciotomy for CDPCS(5). Her review revealed the frequently quoted 80 \% achievement rate of for CECS therapy comprised levels for treatment of the anterior compartment, not the posterior compartment. She suggested that there exists a difference between the success of anterior and posterior compartment fasciotomy, according to individual satisfaction.

Seven studies met criteria from the meta-analysis. The review revealed that there was a substantial gap between the results satisfaction of those with anterior compartment fasciotomy (83%) and people with deep lateral compartment fasciotomy (56%). Closer scrutiny revealed studies at 75% -100 % satisfied with patient satisfaction levels reported return to activity levels of just 50 percent-75! Additionally, the incidence of complication from the procedures in the research reviewed ranged from 4 percent to 90% of instances.

There are contribute to the satisfaction scores. Since perfusion is probably not the cause of pain in CDPCS, a fasciotomy may not cover the problem in any way. Accessing the posterior compartment is difficult, thus releasing the fascia along the compartment is challenging. Dentists might not release the whole compartment in all scenarios. Rehabilitation criteria differ thus adding rehab .

Conclusion

Surveys show that 26%-33% of athletes With exercise induced lower leg pain have CECS in one of the compartments of the lower leg(1). Pain on exertion in the calf of The leg is often brought on by CDPCS. The assumption that the onset of pain After 20-30 minutes of exercise is expected to Greater stress and decreased blood Flow within the compartment is under scrutiny. More likely, fascial strain is that the Reason for pain and the decreased Compliance is what causes the increased Compartment pressure(2). To improve Treatment being used by results, Adhere to a rehab program, With focus on biomechanical analysis And adjusting the factors that may have Instigated the problem at the first position, Biomechanical deficits in conducting Technique, fascial and nerve immobility, decreased muscle, and range of motion weakness.

References
1. Br J Sports Med. 2004;38:709-717
2. Bull Hospital for Joint Diseases. 2005;62(3,4):77-84
3. Eur J Nucl Med. 2001 Jun;28(6):688-95
4. Am J Sports Med. 2012 May;40(5):1060-67
5. Tanza, Sue. ‘The Effectiveness Of Fasciotomy For Deep Posterior Chronic Compartment Syndrome As Measured By Patient Satisfaction: An Evidence-Based Review’. 2011. Presentation.

Chiropractor, Dr. Alexander Jimenez takes a look at a often injured shoulder muscle...

The supraspinatus muscle is one of the four rotator cuff muscles of the shoulder. It originates in the central area of the supraspinatus fossa of the scapula then courses laterally to cross the joint capsule of the shoulder and attaches onto it it then passes under the acromion and the coracoacromial ligament and fans out and inserts to the lateral and superior aspects of the greater tuberosity of the humerus. The fascia supraspinata covers the superficial region of the muscle. Superiorly it contacts the deltoid and trapezius muscles, whereas the deep fascia attaches to the joint capsule.

The supraspinatus has a function in the initiating active shoulder abduction and providing abduction torque (especially in the first 30 levels of shoulder abduction) along with the more powerful deltoid, and it also plays a role in depressing the humeral head and centralizing the humeral head in the glenoid through abduction/flexion moves. It's been proven in biomechanical studies which during busy shoulder abduction, the pressure vector made by the supraspinatus (which acts as a humeral head compressor and depressor) as well as the anterior/middle deltoids (humeral head elevators) creates a force couple whereby the humeral head stays centred in glenoid fossa. In the event of a weakened supraspinatus, greater deltoid activity ensues and this is going to bring about a superior shear of the humeral head with regard to the glenoid(2,3). This may then create the superior rim and a impingement between the humeral head, acromian procedure and arch.

Finally, the supraspinatus may contribute to internal rotation torque manufacturing and external rotation; however, that is varied upon flexion/extension angles of the shoulder and the abduction. For the most part, it contributes little towards pure rotation torque at the glenohumeral joint.

Incidence Of Injury

Injury has a high prevalence From the population. It's very common in the older population which suggests that progressive degeneration is a element in developing a full thickness tear in the tendon. Research has postulated that in individuals under the age of 40 the prevalence is a small 4 percent; however, in those ages 60 and above the incidence rapidly increases to 54 percent(4).

Even in patients with no shoulder pain, The incidence of rotator cuff injury is comparatively high. Tempelhof et al (1999) found that even in asymptomatic people, ultrasound finding demonstrated that at the 50-59 age group 13\% had tears, at the 60-69 age category 20 percent, at the 70-79 age group 31\% and at the older 80+ age group 51 percent of asymptomatic shoulders had tears in the rotator cuff (5).

Yamamoto et al (2010)(6)) supports this Predisposition by indicating arm dominance as well as that and preceding shoulder trauma, era was in creating a rotator cuff tear, another risk factor. What they found was that the incidence of rotator cuff tears increased linearly with age (0 percent in the 20s group, 2.5\% at the 30s group all the way around 50 percent in the 80s group). Interestingly, 17\% of issues with rotator cuff tears complained of no symptoms. In essence, many older individuals may have a true partial/full thickness tear of the supraspinatus and be completely unaware that the injury exists(6).

Research shows that from the Lack of a supraspinatus (due to a complete thickness tear of the supraspinatus tendon), the humeral head will migrate superiorly and abut the acromian, highlighting the value of the supraspinatus in centering the humeral head in the glenoid and preventing a superior migration of the humeral head(7,8,9,10). Repeated exceptional migration of the humeral head will produce an impingement scenario and repeated episodes of impingement will result in breakdown and damage to the subacromial bursa, arthritic changes in and around the glenoid and humeral head and acromioclavicular joint fluctuations in the inferior part of the joint.

From the younger athletic population, true Partial/full thickness tears are rare unless it's associated with a serious shoulder injury such as a dislocation or when the arm is forcefully whilst a scenario which might occur in contact sports such as rugby and NFL, in an abducted position. Injury to the supraspinatus involves phase tendinopathy which might result in an supraspinatus tendon due to mechanical overload. Finally, trigger factors that are active can develop in the supraspinatus that can create searing pain throughout the deltoid and upper arm.

Mechanism Of Injury

Interestingly in the population that is elderly, Injuries to the supraspinatus may come from activities like lifting a heavy bag or holding a puppy on a lead and the puppy runs or stops, leading to a tug onto the arm. From the younger people, direct injury to the supraspinatus may appear due to a trauma episode such as fall onto an outstretched hand, dislocating a shoulder, sustaining a solid adduction force on a flexed/ abducted shoulder or falling off a bicycle and retaining hold of the handles. It might come from exercise like swimming pool, tennis and other sports that are overhead through overload movements such as Olympic-type lifting, repetitive and powerlifting trauma.

The supraspinatus is a tendon that is Exposed to forces within an extended time period, highlighting the prevalence of tears from the people. Neer (1983)(11) has been the first to describe the three phases of rotator cuff disease, particularly the changes found from the supraspinatus. But he didn't elucidate if the trigger was tendon degeneration or mechanical impingement or a combination of the two. Stage I occurs in patients < 25 years using oedema and haemorrhage of the tendon and bursa. Period II involved inflammation and fibrosis of the rotator cuff in patients aged between 25 and 40 years old. Phase III involves tearing of the rotator cuff, either partial or full- depth, and occurs in patients 40 years old(11).

It is possible that some small Supraspinatus tears can heal or become smaller; however, Yamanaka and Matsumoto (1994) revealed that roughly 53\% grow further and 28\% might advance to full thickness tears. It is thought that full thickness tears do not heal due to poor vascularisation within the tendon(12).

Presenting Symptoms & Signs

Subjective
The more serious thickness tears or the patient with a grade supraspinatus injury will complain of antero-lateral shoulder pain that is made worse by any action where the arm is raised up to 90 degrees of abduction or flexion. Sleeping on the shoulder might be painful. Holding weights and lifting like hanging towels on a clothes 14, things might turn out to be rather painful and functionally impossible to perform. As emphasized previously, many incidences of supraspinatus pathology can in reality be curable and painless.

Objective

Palpation

The individual will usually be tender to Palpate in and around beneath the acromian process the head.

Energetic Movements

Abduction moves and full flexion will Most probably be hard and painful to completely execute based on severity of the injury. Whereby the pain will be present from 80-160 levels of abduction, stage 1-type accidents will have an arc of pain throughout abduction. In more serious partial thickness and full thickness tears, complete abduction could be impossible to perform because of an inability of the muscle to commence abduction, or the quality of the movement might be quite poor whereby the individual elevates or 'hitches' the scapula to commence abduction.

The test for supraspinatus/rotator Cuff impingement is the Neer test first Clarified in 1972. In this evaluation the patient is Asked to bend the shoulder Whilst the holds stable the scapular examiner. Typically the pain is felt at Around 120 levels of shoulder flexion(13). Jia et al (2011) looked in the internal Construction of the shoulder an Arthroscope and found that in most cases The rotator cuff (supraspinatus contained) contacted the superior glenoid rim. These findings Patients believed The pain when assessed clinically. Therefore accidents to the supraspinatus May present as pain in the anterior/lateral Once the arm is flexed to 120, shoulder Levels(14).

Resisted Muscle Tests

Patients with grade supraspinatus pathology will test normal with the vast majority of resisted spinning movements and abduction moves. The more serious tendon lesions such as partial/full tears will usually pose as weakness in external rotation and abduction ( with or without pain). Muscle testing to the supraspinatus can be accomplished using an 'empty can' or 'complete can' test.

Researchers have been studying the 'best' position for analyzing and retraining the supraspinatus because Jobe and Moynes (1982) offered the 'empty can' motion as being a successful supraspinatus strengthening workout(15). In this movement, the arm is abducted from the scaption plane (30° lateral to frontal together with the arm internally rotated -- like pouring fluid from a can. The examiner may push downwards on the hands to include extra resistance. This position will ordinarily be felt as being weak and painful in the presence of a supraspinatus lesion.

However, a lot of studies since have shown that the 'empty can' position is not necessarily the ideal position for exercising and testing for supraspinatus with no extra curricular activation. The scientific basis for this debate has stemmed from the many EMG research studies in the past decade which have quantified supraspinatus activity. For example, Blackburn et al (1990) indicates the contrary movement for testing/strengthening supraspinatus -- that the 'full can' movement. That is equal to the 'empty may' the arm has been retained in external rotation as opposed to internal rotation. This elucidates the identical degree of supraspinatus activity, without the superior shear effect of the deltoid(16).

Testing places and exercises that produce higher degrees of activity in regard to supraspinatus activity may be counter-productive in patients with weakness of the rotator cuff, shoulder pain, and stabilization that is ineffective. As a result, the may place may give false positives because the source of pain may be direct impingement of the subacromial structures as a result of superior migration of the head as a result of deltoid contraction.

From an anatomical and biomechanical standpoint, the full can exercise also might be the most beneficial position to both test and exercise and provoke the smallest amount of pain due to the least quantity of humeral head outstanding migration and increased minute arm of the supraspinatus muscle in this place compared with the empty can place.

Rehabilitation Of Supraspinatus Injuries

Partial thickness tears and early stage supraspinatus accidents may do well when managed. Larger partial thickness tears and total thickness tears will need to be properly managed to acquire a favourable outcome. For the paper's purposes, the discussion will focus on the conservatively managed supraspinatus injury.

It appears that the best exercises to the supraspinatus would elicit the best quantity of activity that is supraspinatus while reducing particularly the deltoid, the muscle activity. Boettcher et al (2009)(17) studied this specific phenomenon when they analyzed that the EMG activity (15 subjects) of a number of shoulder muscles including supraspinatus, infraspinatus and deltoids whilst performing these motions: full can moves, empty may move, prone elevation, external rotation in 0 degrees abduction and prone external rotation positions. The exercises were performed together with the scapular in a retracted position. Each of of the exercises were stored isometrically for five minutes, using a one-second build-up phase, a grip along with a discharge phase.

They sought to appear at which ones recruited deltoids at the least but also which exercises greatest supraspinatus that was triggered. What they found was that each of five selected exercises triggered the supraspinatus to a degree, and specifically there was no difference between 'can' and 'empty can' moves. They discovered more prone activated muscles within this order of magnitude: posterior deltoid anterior. The rotation at 0 degrees and the prone external spinning activated infraspinatus the most, however, supraspinatus action still out performed all the deltoids; and more importantly, both of these exercises also recruited far less deltoid than the 'full can' and 'empty may' moves. They contended that the best exercise to get supraspinatus was that the exercises that incorporate external rotation rather than the 'can' and 'can' movements. The researchers assert that exercises need to be selected as it has a superior migratory influence in the head, that restrict deltoidscausing impingement of the supraspinatus against the coracoacromial and acromian space.

Reinold et al (2007)(18) conducted a similar study on comparing the 'empty can', ' 'full may' and 'inclined full can' moves and quantifying EMG activity from the middle deltoid, posterior deltoid and supraspinatus muscles. What they discovered was that even though all three exercises produced comparable amounts of activity that is supraspinatus, the can exercise generated significantly less action of the deltoid muscles and could possibly be considered to be the optimal place to recruit the supraspinatus muscle for testing and rehabilitation. The empty may exercise could be a good exercise and also the full that is more likely can exercise may be a great exercise. These findings have been supported by Lee et al (2014)(19) who revealed using PET/CT imaging the 'full can' position was more effective as an exercise for supraspinatus without predominant deltoid action. Ultimately, Escamilla et al (2009)(20) suggests that scapular protraction and scapular anterior tilt, both of which reduce subacromial space width and increase impingement hazard, are higher when performing scaption moves with inner rotation ('empty can') compared with scaption with external rotation ('total may').

Therefore it appears that the 'safest' exercises to recruit supraspinatus and also minimise the deltoid are the 'full can position' and also the 'external that is prone rotation' exercise. These two exercises may form the basis of applications that are re-strengthening that are supraspinatus. These exercises have been described below. Furthermore, supraspinatus function that is effective will only be evident with a scapula base that is functioning and strong. Immediate exercises to retrain the anterior and strengthen and lower trapezius will be required to allow scapular positioning.

The Exercises

1. Full Can Exercise

Stand holding small dumb-bells (2.5pound women , up to 5kg for guys) or rubber tubing. Begin with the hands by both sides along with the horn turned outwards. Lift the arm to abduction whilst retaining the angle of the arm around 30 degrees to the frontal plane. Initially if the shoulder is painful the scope may be limited to 30 levels; nonetheless, as pain and strength boost they may move the arm to further positions of abduction.Work on three sets of 15-20 repetitions.

2. Prone Spinning exercise

Lie begin with the arm dangling down along with the arm at 90 degrees abduction and face down. Gently retract and depress the scapula. Slowly raise the arm to external rotation whilst attempting to keep up the scapula position. Perform three sets of 15-20repetitions.

3. Scapular Wall Slides

As per the graphic below, begin with the forearms in contact. Slide the arms up the wall slowly externally rotating forearms on the way upward. This will produce scapula spinning and protraction to activate the anterior, a muscle at the control of scapula motion and thus rotator cuff function in overhead sports.

4. Lower Trapezius Setting

The most easy way to perform this and also to teach this as an exercise is to do this drill on a lat pulldown machine. Use only light resistance such as 3-4 plates on the pulldown machine. Seated with the hands gripping the lat pulldown bar, gradually draw on the scapula down and in (retract and depress). Hold for a quick 1-2 seconds and then repeat for two sets of 15 reps.

Conclusion

Research shows that the supraspinatus plays an important part in the shoulder as it centers the humeral head into the movements of the arm/ shoulder. Dysfunction in this muscle may lead to excess of the head which might be a precursor to shoulder instabilities and the more shoulder impingements. Injuries to the supraspinatus are typical as well as also the cause of rotator cuff disorder especially in the older athlete. This article has offered a framework for treatment and evaluation of dysfunction.

References
1. Journal of Ultrasound 2010; 13. 179-187.
2. Biomechanics of the shoulder. In: Rockwood CA, Matsen FA, eds. The Shoulder. Philadelphia, PA: WB Saunders; 1998:233–276.
3. Clin Orthop Relat Res 1978; 135. 165–170
4. J Bone and Joint Surgery (Am) 1985; 77-A. 10-15.
5. J Shoulder and Elbow Surgery 1999; 8(4). 296-299.
6. J Shoulder and Elbow Surgery 2010; 19(1). 116-120.
7. Clin. Imaging 1995; 19. 8–11.
8. Clin. Biomech 2006; 21. 942–949.
9. J. Shoulder Elbow Surg 2003;. 12. 179–184.
10. Clinical Biomechanics 2007; 22. 645–651
11. Clin Orthop 1983. 173; 70-77.
12. Clin Orthop 1994; 708. Pp 68-73.
13. J Bone Joint Surgery (Am) 1977: 54. 41-50
14. Clin Orthop Relat Res 2011; 469: 813–818
15. Am J Sports Med 1982;10:336–339.
16. Athl Train J Natl Athl Train Assoc 1990; 25:40–45.
17. Sci. Sports Exerc 2009. 41(11); 1979-1983.
18. J Athl Train 2007; 42(4): 464–469
19. J Orthop Surg Res 2014; 9(1): 85.
20. Sports Med 2009. 39(8). 663-685.

El Paso, TX. Chiropractor, Dr. Jimenez takes a look at top running shoes that are great for knee pain and Iliotibial (IT) Band Syndrome.

Running Shoes: Knee pain is one of the common problems with most active people. It could get worse for those who love running, especially the athletes. A majority of them suffer from knee pains each year. This pain hinders you from enjoying your daily sports activities and might even become worse with time if not treated correctly. There are causes and cures for such pains that this article is going to look at, but the main focus is on the best shoes for knee pain, also referred to as Iliotibial (IT) Band Syndrome.

This can happen due to various causes like overtraining, running many hills, and wrong running form, among others. These injuries are very frustrating as they can take up to months to go away. This is the reason different companies have designed shoes that will offer you support for any knee problem.

What Goes Wrong

The iliotibial band (ITB) is usually a structure whose job is to provide leg stability whenever you take a step. It works with the hip muscles in a thigh's outward movement and also helps counter the movements within the knee joint. This band starts in the hip and ends just under the knee joint.

Repeated use of the ITB leads to stress, causing knee pain. You will also notice clicking sensations from the joint as ITB snaps across it. This pain is always experienced when the heel comes into contact with the ground; running slowly or downhill tends to make the symptoms worse.

ITBS will usually start as tightness while running but continues to a point where the pain is severe and unbearable. Although ITB continues to tighten when overstressed or injured from training, this is not the main problem. What causes the injury is how the ITB functions and the weakness around it.

The ITB is generally a weak structure and any weakness around it will lead to injury. Most runners have weak core muscles due to the fact that they don't do strength training or have never been in any sports with side-to-side movement.

Signs Of IT Band Syndrome

If you are a runner, you will be able to distinguish ITBS by:

• A swelling
• A cracking feeling when stretching the knee
• A feeling of burning, stinging and aching on the outer side of the knee that might migrate to the thigh. You will notice these discomforts especially, on your second half of the run.
• Bending the knee at 45 degrees causes severe external knee pain

Criteria You Should Follow When Selecting The Best Running Shoes for ITBS

​There are various things that you should always consider when buying running shoes. Since most runners experience knee pain, it is wise to look for shoes that will help alleviate this pain without slowing them down. Below are some of the features to look out for in running shoes:

Stability/ Support

Since it is common to have knee pains due to lack of motion control and lack of stability, it is good to choose shoes that will offer you the support you need while running. If your running shoes don't have any stability, you will end up stressing out your knee, which will result in pain and discomfort while running.

Fit

If you want to do away with pain, you might consider looking for a fit pair of shoes as they will reduce any pain, causing issues in the long run. Pay attention to small specifics like shoes that offer enough heel space, sufficient toe box room, and enough space for wide feet. Your toes should be able to move freely without being constricted.

If your foot cannot move freely and the toes are restricted from spreading, it could lead to painful issues in your feet, legs, and knees.

Motion control footwear is not the whole solution; you need to ensure your feet can still function naturally as they are supposed to.

Comfort

No one wants to wear uncomfortable shoes! Each of these selected best shoes come with upper and underfoot comforts to ensure you get to enjoy your run.

Most of these shoes are made with DNA technology, Gel cushioning, and REVlite midsole for ultimate comfort.

Durability

Your running shoes should run their course without falling apart as this will cause you pain in the long-run. If they promise to offer you support, they should do just that and not start peeling off and tearing when you are on the run.

Breathability

Although this has nothing to do with knees, it is paramount that your running shoes have enough breathing space to avoid accumulating excess moisture, which might bring discomfort and other feet related problems.

There is no magical cure for knee pain and you should always know the root cause. This way, you will be able to come up with the best solution of minimizing or even eliminating the pain entirely. Although there are various causes of knee pain, this article is focusing on ITB syndrome which happens to be one of the causes.

The ​​below 5 shoes have passed the durability test to ensure they give you maximum performance.

Reviews Of The Top 5 Shoes

These shoes have been selected with the runner's welfare in mind. They will help deal with the ITBS, which is a problem for most of them. Since one way of dealing with this condition is getting good running shoes, here is a review of such products.

Asics Gel Kayano 23

This upgraded version is lightweight to help with any knee problems. It offers you comfort through cushioning that help absorb shock as you run as well as other features like grip, fit, and durability. The shoe has an added outer sole to ensure it lasts you as long as possible.

PROS

• ​Gel cushioning will act as a shock absorber for more comfort
• ​Has superb breathability feature
• ​Is ideal for overpronation and knee pain
• ​The outsole's traction will offer the intended support on various surfaces

CONS

• ​It is a bit pricey

New Balance 890v5

It tops the list of 5 best running shoes. Also, it has remained the first choice for most runners with knee pain issues. This pair offers all the above functionalities too, making it your best choice.

PROS

• ​It comes with one of a kind breathability and fit due to its great FantomFit design
• ​Its smooth upper construction will ensure no irritation occurs
• ​The REVlite midsole will give you much needed cushioning

CONS

• ​It has a narrow toe box and might not fit a person with a wide foot

​Puma Faas 600 V3

Puma models have never disappointed, and this one is no exception. Puma Faas 600 is the solution to your knee pain. It is also an affordable option for the short-handed.

PROS

• ​Great breathability
• ​Comes at a reasonable price
• ​It's lacing system and fit offers you a secure and comfortable run
• ​It is designed to fit perfectly

CONS

• ​There have been reported concerns about the outsole's durability

New Balance 1080v7

This is another great choice on the list. It is one of the New Balance Fresh Foam Series. Its midsole offers you the required support coupled with comfort to eliminate knee pains.

PROS

• ​Very durable
• ​Enough breathability for long runs
• ​Good amount of cushioning and support from the Fresh Foam midsole
• ​It fits like a sock giving you a confident use

CONS

• ​The upper design is not seamless
• ​Can be stiff

Saucony Hurricane 16

This is the 16th edition of the Saucony Hurricane, which offers a combination of steadiness and protection. Those with knee pain have agreed with the stability offered by this shoe. It is also cushioned to help you go for long runs without any pain or injury. It is perfect for heavy runners and those who are out of shape due to inactivity.

PROS

• ​Superb stability
• ​Lightweight rubber offers protection and cushioning
• ​Great ground contact
• ​Reflective parts allow you to have a safe run
• ​Comes with Sauc-Fit Technology that enhances its comfortability

CONS

• ​It is a bit narrow
• ​Limited colors to choose from
• ​Might be heavy for fast runners

If you are a long-distance runner, it is good to know that your shoes cushioning will wear out quite easily and you might be tempted to continue using them since they look good on the outside. This is a big mistake. The following will help you prevent any more ITBS recurrences:

• Replace running shoes frequently to avoid wearing those with worn out inner cushioning
• Always give your shoes time to rest so that the cushioning can get restored; it would be wise to have two pairs of running shoes.

Although shoes can offer you relief from ITBS, it is better to look out for other ways of helping you cope with or eliminate the pain entirely. Also, know what triggers the problem and avoid it at all costs.

These shoes have been tried and tested and found to offer support and help in managing the iliotibial band syndrome. Asics takes the lead on these best shoes. It comes with gel cushioning that will offer you the best shock absorption and maximum comfort as seen above. Its sole is also made to help you tackle any terrain and you can be assured that your knees will thank you later. The only drawback is the price, which is on the upper-side. However, always remember that cheap is expensive.

If you are an active person or an athlete suffering from ITBS, go ahead and get yourself a pair of these shoes as per your preference and choice.

in running

Hey there, I'm Zoey, founder and the main editor of The Babble Out. I know nobody's life is smooth as they wish, and it’s the same with mine. I had some terrible news a few years ago and running was the way I got through these issues. This has given me enough motivation to create this blog, so that I can give you a helping hand for as many daily problems as I can. If you are curious why "babble out" is the​ name of the blog, then check the "About" page and find out more about me.

Science chiropractor, Dr. Alexander Jimenez investigates the methods described in treating a tight calf muscle.

Assess The Calf Complex

In the calf complex, the medial sural nerve descends between the two gastrocnemius heads and also at mid-calf level combines with a branch of the peroneal nerve to form the sural nerve(1,2). As we get older, the body's connective tissue gets less pliable. Nerves are naturally surrounded by connective tissues -- sometimes they even run through connective tissues, so with aging the nerves can get trapped, trapped or tethered to surrounding muscle or fascia(3).

This can manifest as a feeling of tightness deep in the calf muscle that never changes, no matter how much the customer stretches the muscles.

Action! Evaluate The Calf

The perfect method to appraise the calf is to palpate the muscle in a relaxed position (see Fig 1. below). Begin with your patient's unaffected calf; palpate (feel) deeply between the gastroc heads supporting the knee and work down the calf into the Achilles tendon. This will give you a sensation of the deep neuro myofascial tissue enclosing the tibial nerve, and what 'normal' feels like in this patient. Beware: it's generally quite uncomfortable to do so because of the sensitive neural structures.

Then feel the affected calf in the exact same way. If there is a difference in the deep center section (eg tightness, pain, lumpiness) and if, when you press, then it replicates their usual 'pain' or 'tightness', it might indicate a nerve tethering problem that needs hands-on intervention.

Assess the nerves of the lower limb by using the slump test (see Fig 2, below) or the straight leg raise test to cross-check your client's neural system and compare sides.

Treat The Neural Calf Complex

Once you've found something asymmetrical, you can treat the problem.

Warning: this therapy could be painful, but in my experience you need to treat very firmly to get results. Warn your patient.

Action! -- Friction The Deep Structures

In the exact same position (see Fig 3, below), ensure finger tips are together and palpating right on the tight, painful area. With firm pressure, friction across the line of the nerve with your finger tips going into the left with both hands and then to the right (firm treatment is essential).

Repeat this along the length of the tibial nerve down the area where the patient has identified a difference in the feel compared to the other side. After you have loosened the neuro-myo-fascial constructions, get your client to walk or jog to see how it feels.

Action! Educate Your Client To Self-Treat

Sitting with knees bent, they should use their thumbs to palpate; ensure they can replicate the sensation you produced with your treatment. This way, your active patient can make chronically tight and painful calves a thing of the past.

Sourced From:

Science based chiropractor, Dr. Alexander Jimenez has a look at the legends and the realities of this very common injury.

Introduction

This paper targets one of the most famous body part injuries -- the Achilles tendon (AT). Injuries to the AT possess a somewhat mythical foundation. It is highly likely that the legendary Greek warrior Achilles ruptured his AT when shot by the bow fired by Paris, King of Troy.

A sudden heel drop at a bud hole whilst conducting, a quick take-off in tennis or a sudden hop are mechanics that usually cause tendon rupture. Due to the exceptional strength of the AT, it's been suggested that rupture of the tendon is almost impossible without prior degeneration from the tendon, and that, coupled with a high mechanical force that's essential to rupture the tendon, may account for the greater incidence in the 30-40-year-old age category.

Only recently has surgery on the AT become the preferred choice of treatment. It was just following the First World War that surgery was attempted on a ruptured tendon; prior to this, distinct kinds of immobilization was utilized to attain a favorable result in a ruptured AT. In contemporary sports medicine, a lot more is known concerning the histological and biomechanical influences in AT rupture and much more is also known on the outcomes of surgical versus non-surgical repairs of this tendon.

This paper will present an in-depth explanation on the human anatomy and biomechanics of the AT, how an AT could be deciphered, what are the presenting symptoms and signs and the way the injury is best handled and rehabilitated.

Anatomy

The AT is the biggest tendon in the human body. It's formed from the conjoined tendons of the gastrocnemius and soleus muscles. The gastrocnemius extends downwards towards the heels and combines together with all the AT about 11-26 cm over the heel bone. The soleus extends further down to combine using the AT about 3-11 cm over the heel bone. Furthermore, the tendon of the vestigial plantaris muscle also blends with the AT on the medial side of the tendon.

Since the tendon runs down to the heel bone it rotates 90° so that the gastrocnemius muscle fibers turn into operate anterolaterally and the soleus fibers turn to run posteromedially. The AT continues to the heel bone and inserts onto the calcaneus. It spreads because it approaches the heel bone so that it's wider at its insertion than at its own mid-portion. A little bursa sits posterior to the AT insertion and it protects it from any rubbing against an external surface (such as a shoe).

The mid-portion of the tendon is the most interesting since it's postulated that it is here that a relative avascular zone exists that may result in a rupture zone. As the thoracic receives a blood supply from the north side through the muscle and also on the south side via the heel bone insertion, the mid-zone between the 2 areas signifies a 'water drop' zone that has poor arterial nutrition. The arterial supply in this mid-zone comes from the fatty tissue that surrounds the tendon. With high mechanical pressure in the shape of tensile and compressive pressure, the tendon fibers can break down and degenerate. Due to this comparative avascular nature of the tendon inside this zone, the thoracic may enter a state of disrepair and become diminished and thus act much like a frayed rope which eventually snaps.

At length, the tendon is coated by a thin paratenon and epitenon and doesn't have a true synovial sheath. These structures include fatty tissue, thin membranes, blood vessels and connective tissues. These anatomical structures are also subject to harm and may be a source of pain in the AT.

Biomechanics Of The Achilles Tendon

It has been suggested that if it had been possible to dissect a healthy AT and bolt it to the ceiling, it would be possible to hang on a one-tonne weight before it would fail and rupture.

Under load it will stretch and presume that a linear orientation. This happens at as little as 2% elongation, is subject to elevated load at 4 percent elongation along with the tendon will neglect macroscopically at 8% elongation.

The cross-sectional area of the tendon is correlated to the magnitude of the calf muscle complex and also height and age of the individual; that's is, the larger the calf and/or the individual, then the larger the tendon. The tendon (such as all tendons) is subject to loading and certainly will change and alter its internal architecture depending on the loads imposed upon it. It'll undergo hypertrophy in exercise-induced wealthy situations.

Histologically, the tendon is constituted of extracellular proteins such as elastin, proteoglycans and other molecules as well as fibroblasts (collagen manufacturers). The turnover time for this type 1 collagen is slow, and it takes about 50-100 weeks to the tendon fibers to flip over. Hence a balance exists between breakdown and synthesis in the veins that are healthy. It speeds up synthesis during growth spurts and following injury and it slows down through immobilization. This histological fact modulates the clinical choice to avoid long periods of immobilization post harm and to promote early movement from the thoracic to stimulate synthesis.

The tendon increases its potency from adolescence until about 30 years of age, after which it steadily declines in strength. It's believed that it is only about 60 percent as strong at age 60. Therefore, gross stomach injury happens in the over-30-year- old group and it's this group that endures the high percentage of tendon ruptures.

Types Of Injuries

There are quite a few possible pathologies that behave on a continuum in the event of an Achilles tendon rupture. The initial pathology is usually an irritation of the peritendon that develops into an injury to the tendon substance. As the tendon becomes more damaged, it will weaken and may then finally rupture.

Demographics

The normal sufferer of an AT rupture is a 35-40-year-old male. Males rupture their ATs in a ratio of 10:1. This might be partly hormonal and mostly behavioral (that is, this age group may generally still be quite active). AT rupture in this age category is much younger than in other tendons such as the supraspinatus from the shoulder which will dominate from the 50+ age category. In the end, AT ruptures can often happen in middle aged men who have had some time away from competitive sport for a 5-10 year period who subsequently return to social sport.

Ball sports like tennis and basketball have a tendency to control the cohort of those suffering an AT rupture since these sports involve abrupt dorsiflexion or plantar flexion force from a dorsiflexed position. Common offending functional moves might be stepping right into a pot hole, sprinting off the baseline in landing or tennis and leaping. This mechanical force is usually coupled with a degenerative element that ends in a weakened tendon because of repetitive micro-trauma and hypovascularity of this tendon. The inherently weaker limb using a sudden implemented force then ruptures. Interestingly, professional athletes only form a small fraction of those suffering rupture, together with recreational athletes comprising the majority of ruptures.

Furthermore, it has also been proven that quinolone antibiotics and long-term corticosteroid use might increase the risk of tendon rupture. Finally it's been found that the COL1A1 TT genotype protects an athlete from an acute soft tissue rupture, AT ruptures included. This could drive future studies in using chemical analysis to predict high risk groups for tendon rupture (Collins et al 2009).

Signs & Symptoms

Subjective

The vast majority of acute ruptures clarify no preceding symptoms of malfunction or pain from the Achilles. Although Achilles pain isn't a predictive indication of future tendon rupture, the proportion of patients who have pre-rupture symptoms does rise with age.

The majority of ruptures are typical with respect to their own symptoms and physical signs and also the mechanism is generally straightforward. The first sensation is really a sharp pain and they may feel/hear a snap- ping sensation. The sufferer will commonly complain that they've taken a hit to the back of the calf as though they have been kicked or hit with a tennis racket. This may replicate a sharp stabbing pain that then subsides to no pain, and it's possible that up to a third of patients have painless ruptures. But, walking can then replicate the pain especially as they try to push off the toes and they will be grossly weak in their push-off.

Objective

Often the clinician will feel a real difference in the tendon with potential instant swelling where the AT should be. They may observe that the calf muscle can pack up into the calf; however, this may be jaded by swelling and edema after a few hours. The website of this palpable defect is usually 2-6 cm above the heel bone.

Functionally they will hobble and find it hard, if not impossible, to push up on the foot. But a percentage of ruptures may be missed since the individual may continue to have the ability to push off using their toe flexors or if the plantaris has been uninjured.

This is achieved by squeezing the calf to mimic a jet contraction that then should transmit pressure to the Achilles and make plantar- flexion in the foot. With no Achilles, force isn't sent and plantar flexion does not occur.

Imaging

It's also useful for viewing the total amount of tendon available that can allow approximation of the tendon ends with an allograft if surgery is the preferred treatment option. Ultrasound will reveal thickening and hypoechoic areas in partial thickness tears. Full thickness tears will show posterior shadowing (because the sound beam is refracted in the thoracic ends) and also reveal retraction with tendon debris. Ultrasound may also show fat herniation.

On the MRI a torn tendon will reveal equilibrium on the T2 picture whereas in degenerated tendons they will show a dark area on T2.

Differential Diagnosis

Although diagnosis of a whole tendon rupture should be relatively simple, a few differential investigations may confuse the examiner.

These include:

1. Flexor hallucis longus tendon rupture;

2. Plantaris rupture;

3. Tibialis posterior rupture;

4. Calcaneus fractures.

Treatment

Conservative cast immobilization

The decision to manage a ruptured AT depends on a number of interacting factors. These include:

Conservative functional management still has great results when compared with surgically-repaired tendons. Thermann and Zwipp (1989) compared 19 operative tendons versus 25 functionally-managed ruptures with a specialized walking boot and also found that results are comparable if the flaw is less than 5mm in length. After 25 weeks, patients in the two groups had complete healing free of re-rupture and the role- ally controlled group resumed sport much sooner than the operated group.

Mattila et al (2013) collected information over a 25-year period in Finland and found that the speed of surgically-treated AT ruptures had declined markedly through the years, suggesting that surgeons are leaning towards non- operative treatment more frequently and enjoying good functional outcomes.

More modern walking boots together with the capacity to control the angles of dorsiflexion have led the progress of competitive operational rehab in conservative AT management. The standard protocol may be to cast immobilize for 2-3 months and then to remove the cast and employ a functional prop (Aircast or CAM walker) with the ankle originally limited to 10-20 degrees of plantar- flexion (or even utilizing heel wedges in an Aircast) and then gradually opened up (or wedges gradually removed) over an additional six- week interval. Therefore, the individual will be liberated to mobilize normally 8-10 weeks post injury. The subsequent strength program will be like this program described further on in the surgical management of AT rupture.

Surgery

The decision to work to surgically repair a ruptured AT depends on the factors mentioned above under conservative management. In the end, if the clinical decision for surgery is indicated, the results are fairly similar to conservatively managed patients. The kind of operation used and the immediate immobilization protocol will fluctuate depending on the surgeon and the anticipated compliance of the patient.

It's common practice now to allow operational mobilization post-surgery through use of a functional walking boot (see Aircast previously). Surgery followed by early mobilization at a functional walking boot has shown better results than just immobilizing the tendon using a cast for 2 weeks. Early mobilization reduces re-rupture rates and also individual compliance is better using a practical walking boot. The post-surgical limb is braced at a situation of plantar flexion originally to offload any stretch to the tendon via the use of heel wedges, and the wedges have been gradually removed over the interval the practical boot is worn. When the boot is eliminated, it is frequently suggested that a single wedge is utilized and slowly removed two months after removal of this boot.

Most surgeons will utilize one of two variants for surgery: either open or percutaneous.

The vast majority of surgeons will urge post-surgical blood thinners (warfarin) and antibiotics.

Rehabilitation

The approved time frame to come back to pre- accident levels ranges from 5-9 months depending on the athlete. Just like most long-term rehab protocols, the rehab stages can be broken down into progressive six-week stages (described below). The particular goals post- surgery are:

Conclusion

AT rupture is a relatively uncommon long- term accident suffered primarily from the 30-40- year- old male. The causative factors include pre-existing limb degeneration combined with high mechanical pressure due to forced dorsiflexion and/or strong plantar flexion from a dorsiflexion posture. Therefore it's more widespread in mid sized runners, tennis players and basketball players.

The AT rupture may be handled either conservatively through utilization of a practical boot such as an Aircast boot or CAM walker, or operatively via a number of surgical options. In either case, the rehabilitation period is protracted and may take as little as five months or as long as nine months based on type of direction and physical characteristics of their athlete and the game involved.

The key feature of return to game post- injury will be gross strength, tendon elongation and how these influence on purpose. The majority of post-injured AT ruptures return to game within six months and the risk of re-rupture is comparatively tiny.

References
1. Thermann H and Zwipp H (1989) Achilles tendon rupture. Orthopade. 18(4); 321-333.
2. Mattila et al (2013) Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study. British J of Sports Medicine. 0; 1-4.
3. Collins et al (2009). The COL1A1 gene and acute soft tissue ruptures British Journal of Sports Medicine. 44; 1063-1064.

The previous rehab masterclass on Lisfrancs injuries highlighted the pathogenesis of injuries, the midfoot joint's relevant factors, and typical injury mechanisms were presented along with diagnostic findings. In this masterclass scientific specialist Dr. Alexander Jimenez discusses the management of Lisfranc injuries...

Management

After the initial injury, it may not be clear exactly what harm the foot has been done to by the athlete. Both athlete and sports medicine staff may confuse. The athlete with subtle stage 1-type injuries will try to 'run off' the pain. As they continue and fail to reevaluate they will stop training/competition.

When an injury into the Lisfranc is suspected, the first MTP joint ought to be assessed to exclude a 'toe' injury and the ankle checked to exclude an ankle injury. They crutches till they could be properly analyzed and remain non-weightbearing ideally with an Aircast boot and need to ice the foot aggressively.

A stage 1 accident that's functionally secure could be handled with a non-weight posture boot or cast for a first two weeks. They can be analyzed for tenderness on palpation over the TMT joint at this time and follow-up x-rays will be required to exclude any latent diastasis of the second and first metatarsal space. If pain-free on palpation and x ray is normal, they could have the weight bearing status assessed using complete weight bearing foot flat and position is raised by a toe. If that is normal they can stay out of the boot using a custom made orthotic and rehabilitation and return to conditioning may begin.

Then the boot is reapplied, if the foot stays painful to palpate or if they neglect raise test and they stay non weight bearing to partial weight bearing for a further four weeks.

For pain along with weight bearing status they're reassessed in the stage. If these are uneventful then the rehabilitation and reconditioning stream is moved to by the athlete. If problematic they need to be assessed for postponed stabilization.

The time period to get a injury that is secure could be a month recovery until return to play.

Operative Treatment Lisfranc Injuries

Stage 2 and stage 3 accidents need to have the midfoot surgically stabilized since they're generally unstable injuries. Interestingly, Hummell et al (2010) recently clarified a successful result in a point 3 football player with non-operative treatment. The objective of surgery is to acquire a fantastic reduction to optimize functional results. Virtually all expert opinions relating to Lisfranc injuries emphasize the importance of gaining as to avoid long- term morbidity from the midfoot.

Myerson et al (1986) identified some things that result in poor outcome for example residual angulation between the metatarsals, diastasis greater than 2mm between the first and second metatarsals. Correcting these defects is essential to avoid long-term complications like chronic functional disability , post-injury arthritis and instability with walking.

To obtain reduction of the TMT joints reduction is usually necessary to remove any tissue for example little bone fragments or ligaments. Reduction is supported with fluoroscopy. Nevertheless, in instances percutaneous fixation can be accomplished if the dislocation can be reduced by the surgeon under fluoroscopy and stabilize the joints together with wires and screws. However, most will require an open reduction to properly visualize and access of the joints that are tarsometarsal.

The choice of hardware for surgery is debatable surgeons the choices are:

1. Cannulated screws;

2. Solid, Non-cannulated screws;

3. K wires;

4. Bridge plates for tarsometatarsal joints.

At a thorough literature review, Stavlas et al (2010) found that injuries to the first few metatarsals (lateral and middle column) react well with screw fixation, whereas harms to the fourth and fifth metatarsals (lateral column) may respond well with K wire fixation.

Post-Operative Rehabilitation

This will often involve a non-weight- bearing cast or boot to get the first 3 weeks with a CAM/Aircast boot used for the subsequent three to five weeks so that the athlete is complete weight. Weight is slowly built around the eight to twelve months post-operative interval so that in a custom-made orthotic the athlete can weight bear by 3 months.

The hardware is often removed at 12-16 weeks post-op in lighter athletes and in heavier athletes (>200 lbs) it's been suggested to take out the hardware in 24 weeks (Nunley and Verullo 2002).

Post-surgery the results are generally favourable. Nunley and Vertullo (2002) discovered that in stable stage 1 harms, great outcome was found with conservative treatment with athletes back to game at 11-18 weeks post-injury. Athletes with stage 2 injuries had good outcomes with ORIF and returned to play 12-20 weeks. Period 3 accidents were not described.

Physiotherapy

The athlete will see that the physiotherapist athletic coach weekly to regain mobility. Interventions will be necessary in addition to direct mobilizations to restore the accessory movements.

The therapist can also start intrinsic foot muscle exercises at approximately 8-10 weeks post-operative using the weight bearing exercises being postponed until week 12 post-operative. These exercises are designed to retrain the arch to be controlled by the foot muscles. Exercises that will satisfy this are towel scrunchies, cup drop, matt equilibrium and lunge exercises (see below).

The movement can be measured by the therapist regularly with knee.

1. Towel scrunchies. These have been used by therapists to strengthen the muscles that support the foot's arch.

A. Place a towel onto a tiled or wooden floor (carpet will not work.

B. set the foot relaxed on the towel with all the foot in line with the knee and hip. The feet should be pointing directly ahead.

C. Initiate the movement by attempting to firstly raise the arch. Think about drawing the ball of the foot to the heel. You will see that the arch is going to lift.

D. Next use all the feet to loosen the towel under the foot.

E. Relax the foot and start again.

F. This exercise doesn't cause any soreness the next day; the muscles should start to fatigue.

G. The development is seated, to standing on one leg and standing on two legs.

2. The cup drop. This can be an interesting and innovative way to integrate inherent arch muscle function and anti- pronator muscle function that is extrinsic using hip muscles that are hip, in particular the gluteus maximus and medius. During weight bearing, the hip is prevented by the gluteus medius muscle from rotating and adducting, and this action works well with the arch muscles preventing excess pronation.

A. Place a few small objects like marbles about one foot in front of your body.

B. Reach forward with the foot and also pick up the masonry with the feet. Of clawing at the masonry this activity will trigger the muscles.

C. Whilst holding the marble in the feet, circle the hip outwards into both sides of the body then behind the body and set the marble at a cup placed at 45 degrees to the cool.

D. It is necessary that the foot stays turned outwards as this retains the gluteus active.

3. The mat balance. This exercise incorporates these together with the arch muscles and adds contraction of the calf muscles both the gastrocnemius and soleus. The drill is done on a gentle matt, to create the exercise challenging. The mat surface generates an unstable situation, and there is mounting evidence that indicates that by incorporating a component of balance control to a rehab exercise may be necessary since the perturbations in movement excite all of the position feedback nerve endings which control proprioception. The nerve endings feedback to the muscle control system and also this potentiates the stimulation of their control muscles.

A.Place a soft mat in addition to a 6mm piece of timber or hard rubber mat. The thicker the mat that the harder the exercise.

B. Stand on the mat but just with the third, fourth and fifth feet connected with the matt. The first and second feet should be hanging unsupported from the mat.

C. This position of the foot makes a scenario whereby the foot wishes to turn in under gravity's effect. The long pronation muscles in the shin and the muscles need to control the interior of the foot to keep it up and of the floor.

D. Attempting to keep equilibrium (and this will be hard when the matt is too soft), marginally boost the heel to participate the calf muscles.

E. Hold this position for 1-2 seconds and then slowly lower down to the beginning position.

F. Perform 3 sets of 10 repetitions.

4. Lunge with towel scrunchie. This workout is a high-level integration workout which combines gluteals and arch muscles whilst performing a exercise such as the lunge. This sort of exercise is done in late phase rehab prior to running as the muscle activation patterns more resemble what should happen in conducting concerning limb assistance -- that is, the arch muscles control pronation, the quads control the knee and patella and the gluteus medius affirms the hip throughout foot strike.

A. Stand on a towel, very similar to Exercise 1 above.

B. Put some theratubing around a post and also wrapped round the upper tibia. The ring has to be guided to pull the tibia inwards, not outwards. This pulling in of the tibia can cause the top leg to follow along with this is imitating hip adduction and internal rotation. The goal of the exercise is to prevent it by maintaining the kneecap aligned with the next toes. The gluteals finally have to work to permit this to occur. Inwards and way would fall from the third toe, if they did not.

C. Gradually lower down into a lunge whilst keeping the monitoring of the kneecap over the next toe and also keeping the towel scrunched up under the foot.

D. Lift up to full knee extension. Rest. Start again.

Strength

The athlete will initially load throughout the foot with the foot impartial. Exercises such as split squat, high- foot leg press and posterior string movements such as deadlifts and stand pulls may start in the weight bearing phase. Exercises requiring more ankle dorsiflexion and so midfoot pronation will be delayed for a couple of weeks until strength and confidence improve (traditional one-leg squats, deadlifts and leg press).

Rehabilitation

The graded progressions for your athlete have been well summarized by Lorenz and Beauchamp (2013). The progression is a staged progression to gradually regain strength and confidence from landing and push-off positions. If the stage is pain free, the progressions could be made, the athlete could do selection and without compensations to the movement.

1. Bilateral heel raises

2. Heel raise, single-leg eccentric lower

3. Single leg-heel raise from standing

4. Bilateral leaning heel raises

5. Bilateral leaning heel raises, single leg eccentric lower

6. Single-leg leaning heel raises

7. Single-leg triple extension heel raises

8. Mini-tramp low Impact exercises

A. Bilateral jumps in position

B. turns in place (two legs).

C. turns in place (two legs).

D. Jog in place

E. Three hops uninvolved, one hop involved

F. Two hops uninvolved, two hops involved

G. One hop uninvolved three hops involved

9. Agility ladder

A. Different frontal transverse plane designs

B. Hopscotch to involved negative (two to one)

10. Single-leg A/P jumps in place

11. Single leg M/L jumps in place

12. Single leg transverse jumps in position

13. Single leg hops in agility ladder

Return To Running

The choice as to when to remove the hardware will influences the choice. As a general rule, when the screws and wires are eliminated, the athlete will be permitted to attend and walk gym sessions to the elimination but running will probably be delayed.

The athlete is encouraged to walk a treadmill using a incline to promote the push. This can start at 12 weeks . The athlete may quickly advance into backward and forward running on grass and it's expected they are doing so by week 14 depending on when the hardware was taken away. As they progress through running they could slowly begin to construct speed they reach sprint speed.

Gentle off-line running drills such as weaving, easy bypassing, stepping and caricoca drills would normally be started in around 16 weeks post-op and progressed into tougher single-leg and hard-cutting plyometrics as pain allowed. It would be expected that by 20 weeks post-op, the foot has sufficient strength, range of movement and confidence to start team- based ability function. Prior to this, the athlete can experience some frequent field hop tests like tests and single-leg triple jump to assess differences in abilities.

Functional Tests

A evaluation that is practical sports-specific is a test or field test that aims to mimic the movements. The use of practical tests aims to recognize imbalances and will boost confidence in both patient and the clinician the injured patient can return to play. It is effectively a way of reducing the hazard. The evaluation ought to be an objective, measurable and quantifiable test that includes a component of:

• Strength
• Agility
• Power
• Balance Neuromuscular status.

The aspects can be incorporated into practical tests such as agility and jumps/ movement evaluations.

The hop tests comprise:

1. Single jump

2. Triple hops

3. Crossover jump

4. 6m timed jump.

Single limb evaluations are necessary as study proves that dual limb and modified double limb tests don't demonstrate any differences between groups since the uninvolved limb can mask deficits of the thoracic (Myer et al 2011). Single-leg hopping evaluations are sensitive enough to discover asymmetry, and specifically the crossover hop test at six months post-op is the most sensitive of these tests at predicting future function of the knee along with the 6m timed test is the most vulnerable and sensitive of under normal function at six months . (Logerstedt et al 2012).

Therefore isolated single-limb performance tests may provide a critical element to field-based operational performance testing to identify deficits in reduced limb performance, including deficits in force attenuation functional power and postural stability. The capability to maintain isolated single limb electricity is significant in sports that require significant control in stepping edge and cutting manoeuvres. This may require and ability to regenerate and divert and then to absorb force on one limb the motion.

Conclusion

Injuries are uncommon in athletes on account of the severe consequences they could have on athletic role, the sports medicine specialist has to be well versed in evaluation and initial management. They can be challenging injuries manage and to diagnose for the clinician.

Stable Lisfranc injuries with no instability can be handled conservatively stage 2 and 3 accidents involving diastasis of their second and first metatarsals requires consideration. This can be done usually using the open reduction and fixation with screws, K cables and/or plates

Rehabilitation after surgery will take no less than 12-16 weeks it's typical for the return to sport to take in contact sport athletes. Successful return to competition time frames extend to the 20-24 week stage post-surgery and rehab will involve reduction of the entire limb kinetic chain but also not only the foot muscles.

References
1. Castro et al (2010) Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers. AJR. 195; W447-455.
2. Chiodo CP and Myerson MS (2001) Developments and advances in the diagnosis and treatment of injuries to the
tarsometatarsal joint. Orthop Clin North America. 32(11); 11-20.
3. Garrick JG and Requa RK (1988) The epidemiology of foot and ankle injuries in sports. Clinical Sports Medicine. 7: 29-36.
4. Hummell et al (2010) Management of a stage 3 Lisfranc ligament injury in a collegiate football player. Athletic Training and Sports Health Care. 10(10); 1-5.
5. Logerstedt et al (2012) Single-legged hop tests as predictors of self reported knee function after ACL reconstruction. The Delaware-Oslo ACL cohort study. American Journal of Sports Med. 40(10); 2348-2356.
6. Lorenz and Beauchamp (2013) Case report. The functional progression and return to sport criteria for a high school football player following surgery for a Lisfranc injury. The International Journal of Sports Physical Therapy. 8(2); 162-171.
7. Myer GD, Schmitt LC, Brent JL, Ford KR, Barber KD, Scherer BJ, Heidt RS, Divine JG and Hewett TE (2011) Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction.
Journal of Sports Physical Therapy. 41(6); 377- 387.
8. Myers et al (1994) Midfoot sprains in collegiate football. American Journal of Sports Medicine. 21; 392-401.
9. Myerson et al (1986) Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot and Ankle. 6(5); 225-242.
10. Nunley JA and Vertullo CJ (2002) Classification, investigation and management of midfoot sprains: Lisfranc injuries in the athlete. American Journal of Sports Medicine. 30(6); 871-878.
11. Ouzounian TJ and Sheriff MJ (1989) In vitro determination of midfoot motion. Foot and Ankle. 10; 140-146.
12. Rankine et al (2012) The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection. AJR. 198; W365-369.
13. Shapiro et al (1994) Rupture of the LisFranc’s ligament in athletes. American Journal of Sports Medicine. 22(5); 687-691.
14. Stavlas et al (2010) The role of reduction and internal fixation of Lisfranc fracturedislocation: a systematic review. International Orthopaedics. 34; 1083-1091.

Menstrual dysfunction among female athletes is uncommon, but is associated with health consequences that are undesirable. Chiropractor Dr. Alexander Jimenez looks at new research, which points to a potential way ahead...

Introduction

In recent decades, there's been much research from game and unsurprisingly so to the topic of disordered eating. Not only does this remain an intractable problem in men and (especially) female athletes, and across a wide range of engagement levels(1-6), but the low nutrient and calorie content that result from a lengthy period of sub-optimum nourishment can contribute to quite a few health problems. However, while recognized eating disorders such as anorexia nervosa, anorexia athletica and bulimia nervosa are sure-fire paths to nutritional and health problems, it's important to understand that for female athletes in least, sub-optimum nourishment and health can easily arise when there's no eating disorder present.

The Female Triad

To understand this, we need to appreciate the interrelatedness of energy accessibility, menstrual function, and bone mineral density (BMD), which according to the American College of Sports Medicine defines the 'female triad'(7). In very simple terms, the female triad describes how energy accessibility (dietary energy intake minus the energy necessary for exercise -- ie the quantity of dietary energy staying for additional body functions after exercise training) may affect negatively on menstrual function and thus bone mineral density (see Figure 1).

Because of its effect on BMD , menstrual irregularity is stressing in particular. Irregular menstruation during adolescence has been associated with decreased BMD(8), and it's known that approximately 50% of peak bone mass is accrued through adolescence, which is a vital time to attain maximal bone mass(9). Irregular menstrual function may manifest as oligomenorrhea (infrequent or very mild menstruation) or amenorrhoea (absolute absence of menses). Changes in bone mineral density meanwhile are detectable using scanning techniques like DXA, and may also present clinically as osteoporosis, osteopenia, or stress fractures. There is also some evidence that menstrual irregularity in athletes is associated with a greater risk of musculoskeletal injury (see Box 1).

Energy Menstrual Dysfunction & Demand

In comparison to the overall female population, studies have found a greater incidence of abnormal menstrual role from the female athletic inhabitants(12-14). But while it's true that there's a greater prevalence of eating disorders among female athletes than the overall female population, we need to see that the high training loads and therefore energy requirements of some female athletes may easily lead to energy availability problems, even when eating patterns are regular.

As stated above, 'energy availability' is defined as the amount of dietary energy available for all functions in your system once energy expenditure from exercise was taken into consideration. In young individuals that are wholesome, energy balance occurs at an energy accessibility of 45kcals a kilo of fatty mass per day. As an instance, assume a 50kg lady with 15% body fat has around 42.5kg of lean body mass. She would want 45kcals x 42.5 -- ie approximately 1900kcals daily to achieve energy balance. By contrast, when energy availability falls to less than about 30kcals per kilo of free fatty mass daily, the reproductive function and bone formation are reduced to revive energy balance, resulting in an impairment of reproductive and skeletal health(15).

This deficit in energy availability of 15kcals a kilo of lean body mass equates to around 640kcals daily. This shortage can happen through simple calorie intake limitation -- were our hypothetical female to go on a 1200kcal daily diet, her body would experience negative changes linked to the female triad and she would start to 'move to the left' about the triad spectrum (see Figure 1). Another route is that she does not increase her calorie count accordingly -- and undertakes a training program that involves expending 640 + kcals daily -- by running nine mph easily achieved.

It's easy to understand some some female athletes in sports like gymnastics, ballet dance, or figure skating, in which aesthetics and leanness are highlighted, are at risk of the female athletic triad.

Not only are they engaging in training, they might also develop poor nutrient behaviors such as food restriction, binging or purging etc in order to attain what they perceive as a perfect body form. Equally however, female endurance athletes undertaking large training volumes (eg triathletes) may often struggle to meet their energy needs despite having really healthy eating behaviours.

Health Implications Of The Female Athletic Triad

The health implications of this female athletic triad stem from the three key qualities of the illness -- an energy (calorie) lack, menstrual dysfunction and reduced bone density.

Energy deficiency -- A moderate and short-term energy deficiency does not normally present problems, particularly if the diet is balanced and nutrient loaded. However, when energy shortages become bigger and occur over prolonged intervals, there are likely to be nutrient shortfalls (along with calories), which can lead to many different problems. These include decreased body mass, depleted glycogen stores, chronic fatigue deficiencies, anaemia, dehydration, erosion of tooth enamel disorders or electrolyte and acid-base imbalances. Psychological issues, such as anxiety, depression or diminished self-esteem, may also occur, particularly after prolonged periods of undernutrition(16).

Menstrual dysfunction -- Menstrual cycle problems result in the reduction of the regular secretion of hypothalamic gonadotrophin-releasing hormone (GnRH), which consequently contributes to a diminished secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH), and thereby preventing ovarian stimulation, also inducing a drop in the levels of estrogens and progesterone. Early research indicated that menstrual dysfunction in female athletes has been due to too low body fat (below 17%). The theory was the sensitivity of the hypothalamus to steroids would be changed and this percentage of body fat the metabolic rate decreases. However, more recent research suggests that menstrual dysfunction isn't caused by stress or a minimal proportion of body fat, but results from the disturbance of their GnRH 'heartbeat' as a result of low energy availability(17) -- in other words having enough higher quality nourishment, low levels of body fat do not necessarily result in menstrual dysfunction.

Regardless of the mechanism, we all know that when menstrual dysfunction occurs, the resulting hormonal alterations can cause a number of complications; these comprise inadequate and damage repair of tissue, inhibition of thyroid and immune function, lost of their cardio- protective effects on lipids and vessel walls and changes in kidney function(18). Additionally, absence of stimulation of oestrogen receptors in blood vessels could result in impaired endothelium-dependent arterial vasodilation(19,20).

Bone health -- since it encourages better bone mineralization, resulting in increased BMD and consequently higher bone power, Exercise is beneficial for bone health. But female athletes with menstrual dysfunction tend to have considerably lower BMDs than those with who don't(21); the factors contributing to menstrual dysfunction may therefore put athletes at risk for compromised bone health and for the development of low BMD (osteopenia) and osteoporosis(22). A major factor for bone health as a result of menstrual disorder is diminished estrogen. Dysfunction causes a drop in estrogen levels, which is undesirable since estrogen helps preserve BMD. Low energy availability may impair bone formation through effects on other hormones like leptin and cortisol. Blend this with a likely shortfall in calcium and vitamin D intake (both of which are necessary for bone formation/maintenance) and it's easy to understand why bone health can suffer.

The risk for athletes suffering from reduced BMD is stress fracture. Even though the prevalence of stress fracture can also be influence by other factors such as age, prior exercise, and alcohol intake, studies reveal that female athletes afflicted the female triad are especially at risk(23) The most frequent site of stress fractures in female athletes would be that the tibia, accounting for 25 percent to 63 percent of cases(24). Alarmingly, the effects of as a consequence of the female triad BMD seem to be somewhat persistent -- to date no study has demonstrated that lost BMD could be recovered when athletes recover their status. Additionally, because peak bone mass is attained by the third decade old, the problem of diminished BMD is especially crucial for adolescent athletes(25).

Overcoming Menstrual Dysfunction In Female Athletes

Whether moderate or acute, disorder is widespread among female athletes. Given the health consequences, it is unsurprising that effort was aimed at reducing the prevalence of the condition. To date, much of the focus has centered about the discovery and treatment for eating disorders, which are common among female inhabitants. Trainers in training that is heavy may struggle to achieve a energy equilibrium despite excellent eating habits. This becomes an impossible undertaking when eating disorders are found.

A number of the early eating disorder prevention programs have typically consisted of educational and psychological interventions; sadly however, research generally suggests that while this type of intervention is capable of increasing awareness about the problem, it's less effective at actually changing eating behaviors(26,27). In more recent decades, eating disorder prevention programs have improved and programs with good empirical support would be the cognitive dissonance-based prevention (DBP) and the Healthy Weight Prevention Intervention (HWPI) applications(28, 29).

Regardless of the positive findings in the DBP and HWPI methods the issue is that neither has been properly tested on athletes -- a population that may be resistant to making changes. Another consideration of course is that a number of athletes who suffer from dysfunction don't have an eating disorder as such -- instead they simply struggle to consume sufficient energy.

A Nutritional Approach

The problem is, of course, that lots of female athletes and/or their coaches are (quite naturally) loath to include rest times to their training programs. However, a 2013 case study on two female athletes makes for additional intriguing reading (31). Two athletes using amenorrhoea were chosen to investigate the effects of increased calorie intake on recovery of menstrual function and bone health. 1 participant (amenorrhoea for three months) was 19 years old and had a body mass index (BMI) of 20.4kg/m2 in baseline. She increased her calorie intake by 276kcals every day (13%), on average, during the intervention, and her entire body mass increased by 4.2kg (8 percent). The second participant (amenorrhoea for 11 months) was 24 years old and had a BMI of 19.7 kg/ m2. She improved her caloric intake by 1,881kcals every day (27%) and improved body mass by 2.8 kg (5 percent). Figure 2 shows how her reproductive hormones changed over the intervention period. Resumption of menses occurred 74 and 23 days to the intervention for those girls using short- duration and amenorrhoea along with the start of regular and ovulation cycles corresponded with changes. The following observation was that while no increases in BMD were detected from the 2 athletes, a marker of bone formation, P1NP, increased by around 50% in both areas.

Further Proof

The case study below suggests that just adding energy could be enough to help reunite amenorrhoeic athletes back into a regular cycle, with no need for extra rest. However, strong evidence can not be provided by a case study upon which to draw conclusions. But a recently published study by US scientists suggests that this method is indeed a legitimate one(32).

The researchers investigated whether a six-month carbohydrate-protein supplement providing 54g of Vitamin and 20g of protein (360kcals) per day can improve energy status and restore menses in eight female athletes experiencing menstrual dysfunction. Before and after the intervention, reproductive and thyroid hormones, bone health (BMD, bone mineral content, bone markers), muscular strength/power and protein metabolism markers, profile of mood state (POMS), and energy intake/energy expenditure in 7-day food & action records were quantified.

The results showed that in relation to muscular strength/power bone health and hormone balance, there were no important changes. What was striking, however, was that each of the athletes resumed their menses, carrying on average 2.6 weeks to first menses (3.5 cycles). Another interesting observation was that athletes who had been longer or amenorrhoeic for 2 months took longer to restart menses than those amenorrhoeic for less than 8 months. As a side note, spinal area BMDs from the over- eight-month group were also significantly lower compared to under-eight-month athletes. There was A additional finding that POMS depression scores rose as a result of the intervention by 8 percent. The importance of these findings is that this study is the first to show that when athletes suffering from menstrual dysfunction consume an additional 360kcals every day for 2 months menses can be restored even though exercise training is continuing. As such, this approach could prove an extremely useful tool for helping female athletes who suffer from exercise-related menstrual dysfunction.

Summary & Conclusions

Menstrual dysfunction (using its associated implications for health) is surprisingly common in female athletes. A root cause is insufficient calorie intake. This may be as a result of an eating disorder, but a lot of athletes who have perfectly healthy eating habits may suffer with abnormal menses simply because of the high volumes of instruction (and so energy expended) they undertake. Disorder intervention/ prevention programs are of undoubted value where an eating disorder exists. However, restoring energy balance remains critical, where nutrient intervention appears to be extremely beneficial -- to all athletes that struggle to meet their energy demands whatever the rationale, which is. Even more studies are still needed, the most recent research suggests that consuming a daily carbohydrate and protein nutritional supplement containing around 360kcals with approximately 2.5 parts of carbohydrate to one portion of protein could be a really effective intervention to normalize the menstrual cycle, together with all the health benefits that brings to the body.

References
1. Clin J Sport Med. 2004 Jan;14(1):25-32
2. American Psychiatric Association: “Diagnostic and Statistical Manual of Mental Disorders” (DSM-IV-TR), 4th Edition, June 2000
3. Int J Sports Med. 2007 Apr;28(4):340-5
4. Nutrition 2009 Jun;25(6):634-9
5. Med Sci Sports Exerc. 2003 May;35(5):711-9
6. Phys Ther Sport. 2011 Aug;12(3):108-16
7. Med Sci Sports Exerc; 2007;39(10):1867-1882
8. Bone. 2007;41(3):371-377
9. Arch Pediatr Adolesc Med. 2006; 160(1 0): 1026-1 032.
10. Clin J Sport Med. 2000; 10(2): 110-116
11. Am J Physiol Endocrinol Metab. 2005;289(3):E373-E381
12. Int J Sport Nutr Exerc Metab. 2002;12(3):281- 293
13. Clin J Sport Med. 2009;19(5):421-428
14. Acta Obstet Gynecol Scand. 2007;86(1):65-72
15. J Sport Sci 2007; 25: S67-S71
16. J Sport Sci 2007; 25: S67-S71
17. Exerc Sport Sci Rev 2003; 31:144-8.26
18. Curr Sports Med Rep 2007; 6: 397-404(
19. PM R 2011; 3: 458-65
20. Clin J Sport Med 2011;21: 119-25
21. Bone 2009; 45: 104-9
22. Perform Enhanc Health 2012; 1: 10-27
23. Orthop Clin North Am 2006; 37: 575-83
24. Am J Sports Med 2006; 34: 108-15
25. Clin J Sport Med 2004; 14: 25-32
26. Psychological Bulletin. 2004; 130:206–227
27. Annual Review of Clinical Psychology. 2007; 3:207–231
28. Prevention Science. 2008; 9:114–128
29. J Consulting Clin Psychology. 2008; 76:329–34
30. Int. J. Sport Nutr. 1999, 9, 70–88
31. J. Int. Soc. Sports Nutr. 2013, 10, 34
32. Nutrients 2014, 6, 3018-30

Frozen shoulder isn't a common disorder in women and sportsmen, however when it does happen & it can be debilitating. Chiropractor, Dr. Alexander Jimenez looks at the most recent thinking on the best treatment options for restoring shoulder functionality.

Frozen shoulder, even more properly known as adhesive capsulitis (AC), has been a frequent source of shoulder pain and loss of movement in the over 40s. In 'primary' cases of AC, there is absolutely no reason for the onset stiffness or pain, whereas AC can happen following illness, trauma, surgery or an injury. AC is believed to affect around 3 percent of the population, with women at higher risk than men. In people below age 40, AC that is primary is likely to be secondary in character -- for instance, also is infrequent, however. However, it could lead to significant disruption particularly given the timescale it requires to resolve, when it does occur.

Causes Of AC

As its terminology implies, adhesive capsulitis describes a state where the joint capsule becomes inflamed and 'sticky' (see Figure 1), making the whole joint rigid and difficult/painful to move. AC's etiology is known. We do understand, however, that because the capsule becomes inflamed, scar tissue forms, which leaves space for the humerus to move through its normal selection of motion and causes pain.

Histological samples of capsular tissue from patients with frozen shoulder have identified a pathological picture comparable to Dupuytren's disease, with an increase in neighborhood collagen production, myofibroblasts, and fibroplasia, suggesting a fibro-proliferative mechanism to the condition(1). On the macro-scale, patients using AC present with synovitis with thickening and contracture of the anterior capsule, particularly the ligament and also the glenohumeral ligament, and inside the rotator interval. This process contributes to a diminished glenohumeral joint volume, and limits movements of the shoulder, especially affecting external rotation in neutral and mid-elevation(two).

Some studies have suggested that poor posture (especially rounded shoulders) can cause shortening of at least one of the ligaments of the shoulder, which might also lead to the condition. Athletes whose training results in and/or that are overdeveloped abbreviated pectoral and anterior musculature may therefore be at increased risk. Also, prolonged immobility (such as after a rotator cuff injury or shoulder fracture) is regarded as a risk factor for AC -- a fantastic reason for athletes to rehab a shoulder injury as quickly as possible.

There appears to be a link between AC risk and some conditions. For example, studies indicate that a greater than normal amount of blood sugar (eg in diabetes) is a risk factor for AC(3). Insulin-dependent diabetics are at the maximum risk, and the problem is particularly severe in such cases. Likewise, high blood lipid levels are also associated with an increased risk of AC(4), while AC is also frequently observed in thyroid disorders, Parkinson's disease, and a variety of cardiac and pulmonary disease. Despite each of these risk factors, however cases of AC remain idiopathic in nature, something which can be very frustrating for clinicians and sufferers .

Typical Characteristics

Concerning characteristics, AC typically displays a progression through three distinct phases: freezing, frozen and thawing (schematically represented in Figure 2). In the initial phase (freezing), patients typically present with noticeable pain that comes on over a span of a couple weeks with action. There isn't a loss of range of movement. During this phase, many individuals respond by utilizing the shoulder which subsequently contributes to stiffness, developing a kind of vicious cycle.

The frozen (adhesive) phase typically lasts for 3-9 months, together with significant stiffness and pain in the extremes of motion. Patients presenting within this stage maintain the arm in adduction and internal rotation. From time to time, atrophy of the shoulder muscles are available and on palpation, there can be diffuse tenderness along the shoulder joint. There is a worldwide restriction of debilitating, movements of the shoulder and, in particular, there's almost complete reduction of external rotation.

The thawing (resolution) stage typically lasts for 9-18 months, and is characterised by steadily diminishing levels of pain and stiffness. The advancements are just slow and it might thawing to happen. Indeed, several studies have clarified AC for a self- limiting condition which typically resolves in 12-36 months(5-7). But some studies have suggested that a substantial percentage of patients may remain symptomatic for up to ten years after the initial phase(8). Regardless, even an early resolution of AC still present a challenge for any sportsman or woman. If their sport does not rely heavily on shoulder joint usage and variety of motion, there are few sports in which shoulder motion is absent, meaning that sport exercise may cause or increase pain and distress.

Diagnosis

AC can be difficult to differentiate from ordinary shoulder ailments and to diagnose in its early stages. Because of this, X-rays of the shoulder can be very useful to exclude constipation of the other or joint pathologies. Besides the clinical features described above (specifically the nearly total loss of external rotation in passive movement), the typical routine of AC beginning is also useful in making a diagnosis. In situations where uncertainty remains, MRI scans demonstrating a thickening in the joint capsule and the ligaments that are affected, in addition to indications of synovitis provide further evidence for AC(9,10).

The widely held opinion among clinicians is that a diagnosis of AC can typically be verified in the practice and doesn't normally require extensive investigation(11). However, recent research published this season suggests caution, especially in early- stage AC(12). Scientists studied the validity of widely used clinical identifiers of early- phase primary/idiopathic adhesive capsulitis. These identifiers were range of motion pain and loss during eight moves. The results demonstrated (rather surprisingly) that none of the clinical identifiers for early-stage AC formerly suggested by expert consensus were verified as well as the researchers concluded: "Clinicians should bear in mind that commonly used clinical identifiers may not be related for this point."

Treatment Options

AC's treatment stays controversial, based on the extent of the pain and stiffness, and the stage of the disorder. Conservative treatment options include the use of non-steroidal anti- inflammatory medication (NSAIDs) and physiotherapy. NSAIDs can help provide some symptomatic relief but there's little evidence they affect the disease development. Physiotherapy by contrast may be more successful. Lots of studies examining the use of physiotherapy in the early and mid-stage of AC have shown an improvement in pain scores, operation and range of motion(13-19). Despite these more recent study is much equivocal, as we will see.

When treatment options are ineffective, surgery or injections remain options. The most common approaches are manipulation under anaesthesia capsular release and capsular distension medications. In a poll of UK caregivers, just 3 percent recommended surgical procedures for the initial painful freezing stage but for its second and third phases, this increased to almost 50 percent of the surveyed(20).

There remains controversy about efficacy. As an example, 1 study on 110 instances of AC found that patients receiving physiotherapy alone had better clinical results than patients undergoing MUA(14). By contrast, however, a study of 77 patients with AC demonstrated that 'supervised neglect' supplied better results at two years in comparison with a intensive physiotherapy regime, suggesting that physiotherapy might not alter disease progression, especially if the regime is too aggressive(21).

Latest Thinking

The character of AC perhaps explains why there's no clear consensus on the optimum treatment protocol for AC. It so happens that 2014 watched the publication of a Cochrane Database systematic review to the efficacy of manual therapy and exercise -- specifically, how it than the glucocorticoid shots(22).

The research groups accumulated statistics from 32 randomized controlled trials (RCTs) and quasi-randomized trials (a total of 1836 patients), which compared with any manual therapy or exercise intervention versus placebo, no intervention, another sort of manual therapy or exercise or any other intervention. Interventions included mobilization, manipulation and exercise, delivered independently or in conjunction. The outcomes of interest were active shoulder abduction, overall pain, shoulder function, global evaluation of treatment success pain relief of 30% or greater, quality of life and also the amount of participants.

The main findings were as follows:

• The outcome differences involving interventions Which Were clinically important were discovered up to seven weeks, after
• A combination of exercise and therapy for six months resulted in improvement at seven months but a similar number of adverse events compared with glucocorticoid injection;
• The mean improvement in pain with shot was 58 points on a 100-point scale, and 32 points with exercise and manual therapy;
• The improvement in function with glucocorticoid injection was 39 points onto a scale, and 14 points with exercise and manual therapy;
• Forty-six per cent of participants reported treatment success with manual therapy and exercise in comparison to 77 percent (40/52) of participants receiving glucocorticoid injection;
• Including a combination of manual therapy, exercise and electrotherapy for four months to injection did not confer benefits over glucocorticoid injection at every time point.
• 1 trial of 119 participants discovered a combination of manual therapy, exercise, electrotherapyandoralnon-steroidalanti- inflammatory drug (NSAID) for 2 weeks didn't confer clinically significant benefits over oral NSAID independently in terms of function and patient-reported treatment achievement at fourteen days.

The authors concluded: "The best available data show that a mix of manual therapy and exercise might not be as effective as glucocorticoid injection in the short term." These findings fit with a previous meta- review carried out in 2012(23). In this analysis, the authors pooled data from 31 clinical efficacy research, which assessed the benefits of steroid injection, sodium hyaluronate, supervised neglect, physical treatment (mainly physiotherapy), acupuncture, and manipulation under anaesthesia, distension and capsular release. The authors concluded that there was limited evidence on the effectiveness of treatments for primary shoulder but in regard to cost-effectiveness, some evidence suggested that steroid shots may be more cost-effective compared to steroid physiotherapy or plus physiotherapy alone.

Stretching Success

One study that wasn't included in the above mentioned review (since it is too recent) is much more promising. This analysis looked at the efficacy of sustained stretching of the inferior capsule in the managing of a frozen shoulder -- specifically the potency of a shoulder counter grip apparatus on range of motion, pain, and function in patients with a frozen shoulder(24). A total of 100 participants were randomly assigned to a control group or an experimental group, with each group. While the experimental group obtained traction and physiotherapy the control group received. The treatment time was 20 minutes a day for five days per week for two weeks.

When countertraction was given along with physiotherapy, the scores for shoulder flexion improved from 94.1° at baseline to 161.9° after intervention (see Figure 3). Abduction selection of movement rose from 90.4° into 154.8° after intervention, while pain decreased from a score of 8.00 to 3.48. Overall, 60 percent of the participants were enhanced to the fourth stage of satisfactory joint function (based on the Oxford Shoulder Score) at the experimental group compared to only 18% in the management group. Whether these improvements were sustained over a longer period of time was not investigated, but the first results are encouraging.

While bars show before/after scores for abduction bars show before and after for shoulder flexion goniometer scores

Ultrasound/PRF Benefits?

Recent studies have demonstrated that pulsed radiofrequency (PRF) lesioning of the suprascapular nerve (SSN) using a fluor- oscopy- or computed tomography-guided technique can relieve shoulder pain.

Until recently, there were no studies into PRF lesioning using practices. However, a newly published 2014 study has compared the effect of physical treatment alone with physical treatment and PRF lesioning of their SSN using guided ultra- noise(25). From the study, 60 patients have been randomized to the following two classes:

• An intervention group comprising patients who received a treatment of weeks of therapy;
• A control group comprising patients who received 12 weeks of therapy alone.

The researchers assessed shoulder pain (visual analogue score -- VAS), disability indicator, and passive array of motion at 1, 4, 8, and 12 weeks after therapy and compared the 2 groups.

The results demonstrated that the intervention group had a notably shorter time to onset of significant pain relief (6.1 vs. 28.1 times) and a much greater decrease of VAS score at week 1 (40% .4.7 percent) than the control group. A comparison of both groups indicated progress in the intervention group at all times in shoulder pain and VAS, passive array of motion and in handicap index scores -- an effect that lasted for at least 12 weeks.

Surgical Options

Finally, in cases what exactly does the current study say about effective choices? A 2014 study has compared the outcomes of three different forms of operation in patients experiencing persistent primary AC(26). These were:

• A combination of arthroscopic capsular release and subacromial decompression (21 topics);
• Subacromial decompression combined with mobilisation under anaesthesia (18 topics);
• Selective capsular release. (15 subjects).

Before and after operation, all the subjects were assessed for glenohumeral selection of movement (abduction, flexion and external rotation) and the subjects were monitored for an average of 37 weeks after surgery.

Each of three surgical treatments enhanced the selection of motion in every direction, with equal improvements in abduction and flexion. All treatments also improved external spinning, but selective arthroscopic capsular release trended towards a greater gain than the other two treatments (though this result was not big enough to be considered statistically significant). The authors reasoned that the surgical techniques improved ranges of motion in the glenohumeral joint but that overall, arthroscopic capsular release (independently or with subacromial decompression) demonstrated the best results postoperatively and should hence be advocated as the first choice treatment in persistent AC.

Summary & Conclusions

AAC is fairly infrequent and uncommon in younger sportsmen and women . Trainers who suffer with type I diabetes are at increased risk, as are athletes near the time of the menopause it may affect anyone at any time.

AC presents challenges for the clinician. Not only does this take a considerable time to resolve even in the best case situation, there remains much uncertainty about treatment approaches that are effective. But even if there is little evidence that it significantly simplifies the length of the problem, any intervention that can help reduce pain is desired, possibly making all the difference between an athlete not being able to tackle any training whatsoever and having the capability to execute some restricted training.

The evidence healing speeds is feeble although conservative approaches such as therapy remain the primary port of call. But some recent evidence suggests that the accession of countertraction or ultrasound-guided PRF lesioning into physiotherapy maybe more effective than physiotherapy.

These more specialized techniques may be harder to justify and are of course time consuming and expensive to do given the evidence from systematic reviews suggesting that shots alone may be an effective treatment. In persistent and severe cases of AC, surgery may be the best option. In this situation, while the data is limited evidence suggests that arthroscopic capsular release is likely to be more effective than manipulation.

References
1. J Bone Joint Surg Br. 1995;77(5 ):677
2. J Bone Joint Surg Am . 1989 ;1(10 ):1511
3. South Med J. 2008 Jun;101(6):591-5
4. Rheumatol Int. 2014 Jan;34(1):67-74
5. Br Med J 2005;331(7530): 1453-6
6. Curr Rev Musculoskelet Med 2008; 1(3): 180-9
7. Br J Gen Pract 2007; 57: 662-7
8. Scand J Rheum 1975; 4(4): 193-6
9. J Bone Joint Surg Br 1995; 77(5): 677
10. J Bone Joint Surg Am 1989 ;71(10): 1511
11. Open Orthopaedics J, 2013, 7, (Suppl 3: M10) 352-355
12. Phys Ther. 2014 Jul;94(7):968-76
13. J Bone Joint Surg Am 2000; 82(10): 1398.
14. Arch Orthop Traum Surg 1995; 114(2) : 87-91.
15. Ann Rheum Dis 1984; 43(3): 353-60.
16. Arthritis Rheum 2003; 48(3): 829-38.
17. Physiotherapy 2002; 88(8): 450-7.
18. Br Med J 1998; 317(7168): 1292-6.
19. Cochrane Database Syst Rev 2003;(2): CD004258
20. Shoulder Elbow 2010; 2(4): 294-300
21. J Shoulder Elbow Surg 2004; 13(5): 499-502
22. Cochrane Database Syst Rev. 2014 Aug 26;8:CD011275
23. Health Technol Assess. 2012;16(11):1-264
24. Clin Orthop Relat Res. 2014 Jul;472(7):2262-8.
25. Anesth Analg. 2014 Sep;119(3):686-92
26. Acta Orthop Belg. 2014 Jun;80(2):172-7.

Chiropractor, Dr. Alexander Jimenez looks at the way this common injury shows itself.

Introduction

Iliotibial band syndrome (ITBS) between the knee is frequently diagnosed in sport injury clinics. ITBS presents having an incidence rate of around 22% in most lower extremity running-related injuries (1) also has been said to be the second most common complaint amongst distance runners (2). ITBS has been given the expression 'runner's knee'.

Trainers like endurance runners who perform flexion and extension combined with loading are subjected to this illness. ITBS presents during the first two or three miles in running with no mechanism of injury, which can make identifying the cause more interesting. With plenty of factors having been considered within the literature, changes are often purported to be a cause of ITBS. But some biomechanical factors have been researched and have been found to have little or no effect in the start of ITBS. Therefore this text's point would be to examine the biomechanical changes which may induce an individual to the beginning of ITBS. The research published reviewed is largely based on a current systematic review that was published in Physical Therapy in Sport in 2014 (3).

Anatomy & Function

The iliotibial band (ITB) encapsulates the tensor fascia latae (TFL) presenting with both deep and superficial fibre attachments at the pelvis (4). In addition to attaching to the TFL, approximately three-quarters of the gluteus maximus tendon also conjoins with the ITB (4). The ITB courses along the lateral aspect of the hip and passes the greater trochanter. The ITB maintains an attachment on the posterior ridge of the femur whilst attaching itself to the fascia. The ITB has a fixed attachment at the lateral femoral condyle where it then divides into three segments with the first being the lateral patella (3). The remaining two segments cross the knee joint to insert at the head of fibula and most distally at the infrapatellar tubercle also known as Gerdy's tubercle on the tibia (3). Figure 1 illustrates the location of the ITB.

The ITB passively functions to resist hip adduction, hip internal rotation and internal rotation of the knee in accordance with its attachments at the pelvis, femur and tibia(3). The gluteus maximus functions, through its attachment, to increase stability through the hip and knee complex by increasing the tension of the ITB(4). It is possible to see, based on its attachments at both the knee and hip, how changes could bring about the onset of ITBS.

Studies have proposed that as the knee flexes and extends the ITB 'slides or flicks' over the lateral femoral condyle of the knee causing an irritation beneath. This notion was debated by Falvey and colleagues (5), who stated that it was highly unlikely that the ITB would flick or slide over the bone during knee flexion due to it not being a loose structure. But the authors did agree that the impact of compression on the richly innervated fat pad was pain's cause but by strain of the ITB where pain presents crossing the lateral femoral condyle. Strain rate and strain magnitude were measured in a prospective study involving female runners (6). The results indicated that frequency of strain of the ITB at the lateral femoral condyle was greater that the strain magnitude. This implies that a runner might have the ability to run for a short period but then incur lateral knee pain because of the strain to the ITB.

MRI scans have ascertained the knee flexion angle of 30° elicited the greatest compression of the ITB at the point of heel strike, whereas others have said that maximal compression occurs between 20-30°(2,6). A knee flexion angle at the point of heel strike has been found to be significantly different with 20.6° in ITBS patients compared to 15.3° in the control(7). Downhill running produces a greater knee flexion angle at the point of heel strike eliciting a larger strain load to the ITB and therefore this is often a main precursor to ITBS (6). Although an elevated knee flexion angle at the point of heel strike has been considered to contribute to ITBS, it is essential to examine the lower extremity from the frontal and transverse planes too and not solely from the sagittal plane (2).

Rearfoot Eversion

It's possible to envisage how rear foot eversion could contribute to ITBS causing internal rotation of the tibia resulting at the distal attachment in greater strain of the ITB. In contrast Ferber and colleagues (2) indicated that there was no significant difference in the peak eversion angle of the female subjects, who were previously diagnosed with ITBS but were now symptom free, compared to controls. In a similar study non-significant differences were found between the currently symptomatic ITBS patients and controls for rear foot eversion (8).

Louw & Deary(3) found that ITBS patients sometimes demonstrated decreased eversion angles, accompanied by decreased internal rotation of the knee, at the point of heel strike. Ferber and colleagues (2) noted an increased inversion moment in the ITBS group which was suggested to control and limit the eversion moment. By comparison, currently symptomatic ITBS patients demonstrated a substantial difference compared to a control group with twice the rear foot motion during running (9).

Knee Internal Rotation

Peak internal rotation angle of the knee was found to be significantly greater in the ITBS patients when compared with controls at the point of heel strike (2). This research was supported by other studies who also found a significant effect for increased internal rotation of the knee following a run of moderate intensity to physical exhaustion(7). With excessive rotation comes compression due to increased strain of the ITB at the attachment.

An explanation of increased internal rotation of the knee was attributed to excessive external rotation of the femur perhaps due to shortening of the piriformis, gemellus inferior and superior and the obutrator externus (8). The authors added that excessive rotation at the hip might result from muscular activity of the rotators that were hip being the medius, minimus and the tensor fascia latae. These studies(2,7) were retrospective in design in that they tested healthy runners with a history of ITB pain, whereas(8) was a prospective study of patients with ITBS at the point of testing.

Hip Adduction Angle & Hip Abductor Strength

The hip adduction angle during the stance phase has been suggested to be greater. Ferber and colleagues(2) found that the peak hip adduction angle was significantly greater in the ITBS cohort and stated that with 95% confidence. Increased angle results in increased stress to the ITB and consequently increased compression at the lateral femoral condyle when combined with increased internal rotation of the tibia.

Figure 2 illustrates, when peak hip adduction and internal rotation combine, how this may result in increased the compression of the ITB at the lateral femoral condyle. Louw and Deary(3), however, stated that it remained inconclusive whether the peak hip adduction angle was a substantial element. Additional research is therefore required to support Ferber and colleagues'(2) initial findings as this study was a retrospective study carried out on healthy female runners with a history of ITBS.

Hip Abductor Strength

It's been proposed that an increased peak hip adduction angle may coincide with hip abductor activity involving the gluteus medius in this group. During the stance phase of gait the gluteus medius functions to keep stability. Research has indicated that during stance the adduction forces can exceed three times an individual's body weight(3). What's more, it was stated that these forces were beyond the metabolic capacity of the gluteus medius to main pelvic stability during the stance phase using just this muscle alone(3).

Louw and Deary (3) were not able to identify a heightened hip abductor moment in the ITBS patients with increased peak hip adductor angles and suggested that it was more of an issue of timing as opposed to the size of the hip abductors. Louw and Deary (3) stated that the research is yet to examine trunk and pelvic movements in ITBS patients and it is plausible to suggest that biomechanical changes from higher up the kinetic chain has the potential to be a contributing element in ITBS etiology.

A research study of 24 (14 female, 10 male) patients with ITBS undertook a six-week rehabilitation programme to increase the strength of the hip abductors(10). Following six weeks of hip abductor strengthening to running 22 patients reported being pain-free and had returned. The female patients reported an average hip abductor torque increase of 34.9% and the male patients found 51.4% increase. However this study used a hand held dynamometer to measure isometric strength and therefore Fedricson (10) findings should be viewed with caution.

A more recent study assessed the hip abductor strength of currently symptomatic patients with healthy controls in a fixed position(11). The results indicated that no substantial differences occurred for static and dynamic hip abductor strength between the groups. Further research should look into the EMG and strength of the hip abductors in the role of managing ITBS. Table 1 shows of significance in the some of the variables of the studies used in this text.

Rehabilitation programs, following periods of immobilization and during, should include gluteal exercises to provide stability to the leg that is involved. If active exercises for the gluteal muscles are provided in a manner that is secure and effective then this can influence the period of transition from non weight. It's prudent based on the research provided to date to develop function although research is lacking in terms of quality and volume as to the biomechanical influences on the etiology of ITBS. This guarantees that once load bearing commences that the leg that is involved has the stability and control that is active to keep the beginning of load of the ITB.

Summary

The recent review published by Louw and Deary(3) indicates that much of the research published within the literature depending on the etiology of ITBS is inconclusive. The level of research is relatively low and is based on retrospective trials. The research does indicate that knee biomechanics and abnormal hip is involved in the occurrence of ITBS. The authors ascertain that muscle strength is involved as is foot biomechanics that are abnormal. It is recommended that future research should measure kinematic movements of the hip and knee during downhill running as this is a complaint of ITBS onset.

References
1.Clini J of Sports Med, May 2006,16, (3), 261-268
2.J of Sports Phys Therap, Feb, 2010, 40, 2, 52-58.
3.Phys Therap in Sport, 2014, 15, 64 e75.
4.Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 - 446
5.Scand J of Med & Sci in Sports, Aug 2010, 20 (4), 580-587.
6.Clini Biomech, 2008, 23, 1018-1025.
7.Gait Posture. 2007 Sep, 26 (3), 407-13
8.Clini Biomech, Nov 2007, 22 (9), 951-956.
9.Med Sci in Sport & Ex, 1995, 27, 951-960.
10.Clini J of Sports Med, 2000, 10:169–175.
11. Int J of Sports Med, Jul, 2008, 29 (7), 579-583.

Chiropractor, Dr. Alexander Jimenez discusses a case study in which a chiropractor reports a problem.

This case study isn't about an athlete. It is all about somebody who works with athletes. Physiotherapists, chiropractors, osteopaths - we all get injured from time to time and we are the worst at getting treatment. We 'suck it up' and attempt to handle the issue ourselves. After all, if we can't fix our own problems, how can we be expected to repair the problems of our clientele? This case study presents an unusual case of neck pain brought on by a seemingly remote problem.

The Patient

A 35-year-old sports physiotherapist working with a professional rugby team had been suffering with right-sided neck pain for a few months caused by some heavy deadlifts and bench pressing a week before the pain started. He did not seek any treatment from a professional for this issue, as he was self-managing with regular self-releases to his cervical spine, his upper traps and some self 'Mulligan mobes' to his cervical spine.

I noticed that he was 'attending' to his neck issue a bit so I asked him what the problem was one day. He disclosed that the neck pain had started following a heavy gym session when he had attempted a personal best on the deadlift. Since that day whenever he attempted a deadlift or bench-pressed heavy the 'nagging' pain would start up a day or two.

The pain was focused extending down to the point of the joint and starting below the occiput. He noticed some tingling into his forearm and into the underside of his arm. This was sporadic and did not bother him too much.

He described the pain as being a vague stiffness in the neck that would cause him to wake up with a 'locked' . He found that although stretching the levator scapulae and self-releases with a trigger ball would give a temporary relief, the pain was a constant low-level ache that would have periods of increased intensity following a gym session that was heavy.

Objective Findings

Upon examination he had a complete range of neck movement but he felt that rotating his head would feel tighter on the right side of his neck. Feeling through his upper trapezius and levator scapulae muscles, it was evident he was holding a lot of muscle tone by means of these muscles in and around those neck muscles. Passive mobilization of his joints on the side, although not painful, did feel hypomobile.

A postural assessment of his scapula position highlighted the scapula was downwardly rotated and also anterior tilted. Based on this I felt that having a feel around his pectoralis minor was warranted and unsurprisingly the pec minor felt hypertonic and tight.

What was also evident was the way he used his right arm and shoulder whilst. Working on elite level players in a hands-on capacity can be a task requiring a lot of muscle contraction through the therapist's arms and shoulders. Becoming right-handed dominant, whenever he used this arm/hand to work on a participant (massage a tight hamstring, release a tight shoulder muscle, mobilise a stiff lumbar spine or cervical spine) he would unconsciously roll his right shoulder into internal rotation and protract the ideal scapula a lot in comparison with the left side. He was 'closing' up the chest space on that right side and generating a habitual shortening of the pec minor muscle.

Probable Cause

With a presentation like this, many causes for the pain may co-exist. The problem may have been focused solely on the tightness and trigger points in the two neck muscles -- the levator scapulae and upper trapezius. He had just cause for this to be a problem as the heavy deadlifts can create a 'traction' effect due to the force of gravity and weight on the elevator muscles that were scapula.

There was A additional possibility an injury to the right-sided facet joints and/or intervertebral disc. Both these structures can cause referral of pain down the neck and into the shoulder and the history of tingling in the arm could be the result of a nerve root compression at the cervical spine level.

The final possibility was that he suffered from a kind of thoracic outlet syndrome whereby the nerves that pass under the clavicle and through the neck muscles and in addition to the first rib may become compressed due to a downward scapula. I felt this was most unlikely as his feature was muscle pain and more cervical and not the standard symptoms found with thoracic outlet.

These three sources for the neck pain did not fit with me. He had already instigated some self-management to these above muscles; however the pain was still ongoing. And I could not help but think that the combination of the deadlifts, the occupational hazards also and he had to endure the natural position of the scapula led to a tight and hypertonic pectoralis created the problems.

I proposed that the pec minor dragged his scapula into a downwardly rotated position and anterior position that was tilted. My suggestion was that this scapulae position was shortening up the levator scapulae (as it is also a downward rotating muscle of the scapulae) and that this downward rotation was lengthening the upper trapezius (an upward rotator) and creating a lot of passive tension through this muscle. Tension by means of these muscles and trigger points could explain the radiation of pain down through the neck on the tip of the acromian process.

As the levator scapulae attaches to the processes of the cervical spine, a tight and hypertonic muscle may pull down and cause these joints. The little disc and fat pad within the facet joint can then become inflamed and create unilateral neck pain. What's more, the upper trapezius attaches to the base of tension and the occiput though this muscle will 'pull' the head down onto the neck and also increase neck compression through the disc and also place pressure on the facet joints.

What's more, the Brachial Plexus (nerve bundle) and some essential arteries and veins run under the pec minor muscle as they course through the chest and migrate down the arm. It was possible that the pec minor, when super- creating and may in reality be pressing on the nerve bundle.

I suggested that heavy deadlifts would exacerbate this problem as the pull of the bar as he deadlifted perpetuate a tight pec minor and possibly would drag the scapular. I also believed that heavy bench pressing would recruit the pec minor to help with the pushing and scapular protraction phase of the bench press.

Therapy

We focused on some deep tissue massage and trigger point releases to the pec minor. This was done in two unique ways. The first way was the approach that is common through the chest wall and pressure directed down onto the pec. The second method was the approach of directly finding the pec minor under the pec major.

After a short 10-minute session he felt that the neck ache wasn't as prevalent as previously. We discussed some common tactics to manage the tightness in his pec minor himself at home such as some points utilizing a brief broomstick. We agreed that I would spend 15-20 minutes working through the minor muscle.

What he had to do was some scapular setting exercises. This consisted of the following steps:

1. Sit in a chair with hands on the lap.

2. Gently tuck the chin in and activate the neck flexor muscles.

3. Gently pull the scapula into retraction position and an upward rotation to activate the trapezius muscle.

4. Hold for 10 seconds. Repeat for 10 repetitions.

The Outcome

He noticed that within 10 days the pain was just a vague awareness in the neck and also the upper trapezius and levator scapulae. He admits that over the course on the upcoming few months the pain had at some point disappeared and he was benching and deadlifting without issues.

Discussion

The pectoralis (pec) minor is a muscle that originates on the anterior rib cage on ribs 3,4,5. It is then directed upwards to insert onto the coracoid process of the scapula. It is a triangular muscle that's under the pectoralis major and as mentioned above connected with the neurovascular bundle that moves across the chest and into the arm.

Its functions are to:

a. Protract the scapula

b. Depress the scapula

C. the scapula tilts

D. the scapula rotates

e. Work as an accessory muscle during inspiration to open the chest to take in a deep breath. This can only happen if the arms and scapula are fixed and can't move, like when you place your hands on your hips or on a railing when you are attempting to catch your breath, behind your head.

It's been implicated in many quadrant pathologies of shoulder, the neck and arm. It's a muscle that commonly gets very tight, particularly due to habitual use on the dominant side of the body (for most of us right side).

This case study presented a special example of neck pain brought on by a tight pec muscle.

Chiropractor, Dr. Alexander Jimenez provides an update into the latest research on the benefits of working with the Swiss ball.

The ball, which is also known as a fitness center or stability ball, has become an integral part of the physiotherapy practice and the traditional gym setting. Some still perceive the Swiss ball to be a gimmick, whilst others rely on it as being essential for handling low back disorders and increasing trunk control.

Low back pain is indicated to be a common criticism in 60-80% of the population and 60-86\% of the group will experience more than 1 episode(1). Studies have suggested that back stability exercise is successful in reducing low back pain compared to general exercise in the brief term(two). The Swiss ball has shown to be effective in improving control of the back stability muscles in healthy and low back pain inhabitants(3). Research exploring changes in low back pain correlating with core muscle action whilst is lean. The purpose of the text is to review the current research pertaining to the usage of this Swiss ball and this tool may influence core stability purpose. The Swiss ball is used by physiotherapists and trainers worldwide to ease the equilibrium muscles of the back to enhance core control. These 'core' muscles, that are active across the lumbopelvic and hip complicated, include shallow and deep muscles (Table 1). The deeper muscles provide stability to the inactive structures (vertebrae, intervertebral discs and ligaments) of the lower back while the shallow muscles alleviate trunk motion. For optimal pain-free movement to happen, both the shallow and deep core muscles must engage in unity together with simultaneous timing and tension (4). Failure of these muscles to activate sequence might result in compromise movement function and back pain.

Core Muscle Recruitment

Researchers at the California State University studied the muscle activity (electromyography, EMG) of the significant trunk muscles through eight Swiss ball exercises (decrease press-up, pike elevator, inverse plank tuck/jack-knife with and without turning, seated march, board roll-out, prone hip extension left and right) and also contrasted to a classic floor-based abdominal pinch(4). The rectus abdominis, internal and external oblique, latissimus dorsi, lumbar paraspinals and rectus femoris were normalized with a maximal voluntary isometric contraction (MVIC) and also measured using surface EMG. Eighteen (nine male and eight female) healthy participants were assessed in each one of the Swiss ball positions.

The results of the study suggested that the plank roll-out (Figure 1) and pike elevator (Figure 2) were significantly more effective in activating the trunk muscles. The board roll-out elicited a mean EMG signal of the upper rectus abdominis of MVIC that is 63%, lower rectus abdominis of 53 percent MVIC, external MVIC and internal oblique of 46% MVIC. The pike lift elicited an average EMG signal of the rectus abdominis of 46 percent MVIC, lower rectus abdominis of external oblique of 84% MVIC, MVIC and oblique of 56% MVIC. The EMG activity of the trunk muscles was recorded at the whilst at the march position and the floor established collapse of 7-8% MVIC respectively. In addition, the activity of the lumbar paraspinal muscles has been relatively low with 10% MVIC action through each of the exercises.

The outcomes of the study suggested that the plank roll-out (Figure 1) and pike exercises (Figure 2) were more successful in activating the inner and external obliques and the lower and upper rectus abdominis. The research, though useful, is restricted as it lacks dimension of these deeper stabilisers such as the multifidi or even the transverse abdominis.

Researchers from Poland published an article measuring rectus abdominis, external oblique and inner diaphragm with transverse abdominis during Swiss ball bridging in prone, supine and side, lying on both unstable and stable surfaces(5). This prospective study quantified the back muscle activity of thirty-three healthy guys, in each of the positions, by surface EMG and the results indicated the back muscles were more active during Korean chunk likely extending (plank). The MVIC of each of those muscles were rectus abdominis 44.7%, external oblique 54.7percent, and inner oblique with transverse abdominis 36.8percent. Supine bridging in comparison on a surface produced MVIC of action. From the preceding two studies a conventional board exercise on the ball with all the knees on or off the ground is suggestive of becoming one of the best in engaging back muscle activity(4, 5).

Single and double leg squatting exercises are recommended for patients with knee pain and other lower limb ailments. The gluteus medius and maximus feature, through its own attachment, to increase stability through the hip and knee more complex(6). Researchers studied the effects of double and single squatting on gluteal maximus and medius activity using both a baseball match against the wall and in position (Figure 3)(7). An observational study quantified the surface EMG of the gluteal muscles in nineteen healthy participants (11 male, 8 female) throughout the squat period. Single leg squatting was completed using the participant standing to the wall.

The results indicated that there was considerably greater maximus and medius muscle activity during single leg compared to dual leg squatting as quantified as % MVC (Table 2). The outcomes found a substantial difference with activation together with the Swiss ball, in comparison glute med, during single leg squat and without a ball, in the max activity. An increase in muscle activity was observed whilst using the Swiss ball although a significant difference wasn't noted in the med.

Multifidus

The lumbar multifidus muscle was recognized as an important stabilizer of the lumbar spine(8). The fibers originate in also the lamina of the vertebrae and the process and descend towards the anus where they fit whilst crossing as many as five segments. The fibers attach in the inferior edge of the process and also the border lamina of the fascia and attach distally in the process and facet joint capsule of the vertebrae at least 2 degrees below. The fibers are active whilst the moment arm isn't possessed by the fascicles that are deeper and so assist in control.

A research study recently published in Physical Therapy in Sport studied the muscle activity of the lumbar multifidus during sitting exercises whilst on either a stable or unstable surface using the Swiss ball (3). A cross-sectional layout, of 40 patients, 20 healthy and 20 with chronic low back pain (CLBP), found that the lumbar multifidus was more active during sitting exercises on the Swiss ball in both healthful and CLBP groups compared to steady surface was. The results, although optimistic, should be viewed with care as muscle activity was measured using ultrasound with no execution of electromyography (EMG). Pain levels weren't recorded in this particular research and so no correlation between low back pain reduction and increased action. But, it does indicate that sitting offers assistance for using the Swiss ball for a chair and is successful in both cohorts.

The Swiss Ball As A Seat

It is not uncommon for a Swiss ball to be used instead of a conventional desk chair in an office or staff meeting to manage pain and improve muscle control. This method has been questioned by some as the caliber of the research in pertaining to this way is constrained. A research paper published in the Journal of Canadian Chiropractic Association provided two case studies on the usage of sitting on a Swiss ball through daily tasks (9).

Overview

The research indicates that the Swiss ball is effective in enhancing control of the core stability muscles in a variety of positions. The quality of the available evidence is limited at additional and present research, using random allocation, should endeavor to quantify to get a correlation between core muscle activity and pain decrease. It is desirable to use reviews and randomized controlled trials at which possible is also important to review case studies to monitor the effects of an intervention. The case studies described, provide evidence of how the Swiss ball might be used in handling CLBP. The Swiss ball is a and readily available to use in the house, gym or work place along with the study available is due to its addition for both healthy and low back pain.

References
1. The American Academy of Physi Med and Rehabili, Feb 2010, 2, 142-146.
2. Plosone, 2012, 7, 12, 1-7.
3. Phys Thera In Sport, 2014 - http://www. sciencedirect.com/science/article/pii/S1466853X1400011X.
4. J of Ortho and Sports Phys Thera, May, 2010, 40, 5, 265-276.
5. Phys Thera in Sport, Aug 2014, 15, 3, 162-168.
6. Surgic and Radiologic Anatomy (Dec) 2004; 26, (6), 433 - 446
7. Phys Thera in Sport, Feb, 2014, 15, 1, 39-46.
8. Spine, 2002, 27, 2, F29-F36.
9. J Can Chiropr Assoc, Mar, 2007, 51, 1: 50-55

Chiropractor Alexander Jimenez investigates the relevant anatomical and biomechanical considerations related to the subscapularis, plus injury within the subscapularis, how to assess subscapularis function & finally rehabilitation ideas for injured as well as dysfunctional subscapularis muscles.

Introduction

Injuries to the muscle are infrequent causes of shoulder pain in the athlete. Immediate injuries to the muscle- tendon unit can affect the athlete like swimmers and tennis players. Malfunction in the subscapularis in the kind of fatigue and inhibition can lead to biomechanical abnormalities in the glenohumeral joint such as poor lateral stabilization of the shoulder joint in the shoulder that is athletic.

Anatomy

The subscapularis originates the anterior scapular (subscapular fossa) and inserts onto the lesser tuberosity of the humerus. It's the largest of the rotator cuff muscles and its cross-sectional area is larger than the other three rotator cuff joint (infraspinatus, teres minor, surpraspinatus). Its main roles on the glenohumeral joint are:

1. Depressor of the humeral head;

2. Anterior stabilizer of the humeral head (glides the humeral head posteriorly relative to the glenoid fossa);

3. Internal rotator of the shoulder (together with the highly effective pectoralis major and latissimus dorsi).

The tendon fibres mix with the anterior capsule of the shoulder and therefore fortify the posterior shoulder capsule. The muscle is regarded as less significant as a shoulder internal rotator (as the pectoralis major and latissimus dorsi are powerful internal rotators) also is significantly more important as a dynamic anterior stabilizer of the glenohumeral joint through its activity in preventing anterior shear/glide of the humeral head.

The subscapularis has an intimate relationship with the long head of the biceps via the shoulder "Twist". This is a complex that functions to stabilize the long head of the biceps tendon in the bicipital groove. The pulley complex consists of the superior glenohumeral ligament, the coracohumeral ligament, along with the ventral attachment of the subscapularis.

Tendon, and is located inside the rotator Interval between the anterior edge of the subscapularis tendon of the superior edge and the tendon. Injuries to the subscapularis tendon may compromise the integrity of their bicep's 'sling' (Nakata et al 2011). To keep the knee tendon in place and stabilized, tension from the superior glenohumeral ligament and the help of the very superior insertion stage of the subscapularis from supporting the fascia is demanded (Aria et al 2010). Disruption of this 'biceps sling' is a frequent pathology in athletes that require forceful and frequent shoulder rotation such as the position in baseball pitching.

Injuries To Subscapularis

Like All of the rotator cuff muscles subscapularis is susceptible to pressure forces which may damage the muscle-tendon and also muscle unit's integrity. Although tears to the subscapularis are not as prevalent as tears from the other rotator cuff (particularly supraspinatus), injuries to the subscapularis might prove to be problematic due to its anatomical proximity to the long head of the biceps tendon.

Ruptures of the subscapularis have been reported in the literature (Gerber and Krushell 1991). The mechanism is a pressured hyper-extension rotation force such as falling onto an outstretched arm, on the shoulder or infrequently it might be a result of a shoulder dislocation. These kinds of injuries will lead to severe shoulder pain using a painful weakness in internal rotation, greater range of motion into external rotation (which is then constrained by pain at end of range) along with also a weak/pathological 'lift-off' test (see below).

Injuries to the subscapularis tendon can also occur in athletes or occupations that take a great deal of forceful shoulder internal rotation (baseball pitching, tennis, swimming). Overuse of those complicated can create a strain response and fibrosis tissue deposition in the gut, may lead to. Trigger points in the muscle can create that weaken and tighten the muscle.

In these instances, pain is felt as a deep anterior shoulder pain, exacerbated by overhead inner spinning movements (swimming and serving), weakness in the 'lift-off' evaluation (see above) and also reduced array of passive external rotation whilst the arm is placed by the side is noted (Thurner et al 2013).

Finally, a neighborhood muscle imbalance shoulder between the subscapularis and the infraspinatus can cause positional faults from the mind of the humerus, whereas the humeral head is not centralized in the glenoid fossa and excessive anterior shear of the humeral head happens that leads to impingement and uncertainty sensations in the shoulder.

Role Of Subscap In Shoulder Stability

Hess et al (2005) found that in a simulated throwing action using shoulder rotation, participants with shoulder pathology had a delayed onset on recruiting of subscapularis compared infraspinatus and supraspinatus. Nevertheless, in regular pain free shoulders that the subscapularis was activated earlier and until the shoulder began to externally rotate, evidence that the subscapularis functions in a mechanism to 'pre-empt' movement and also to contract to provide anterior shoulder stability.

It is suggested therefore that shoulder pain patients lose part of their energetic mechanisms that are stabilizing in the shoulder and as a result the humeral head shear and can glide anteriorly and superiorly from the glenohumeral joint, thus leading to anterior shoulder impingements.

Imbalances in force production involving the subscapularis and the externally infraspinatus could create a local issue from the glenohumeral joint. It's typical for the athletic shoulder to really have a misaligned and tight infraspinatus in connection to the subscapularis. This neighborhood imbalance sets a mechanical issue in the shoulder the infraspinatus pushes forward the humeral head in relation to the glenoid and the inhibited subscapularis can't counteract this lateral shear effect. Consequently the head shears and impinges the anterior pain and shoulder structures may result.

Conclusion

Research shows that the muscle has an significant role in supplying anterior glenohumeral joint stability. It centres the humeral head into the movements of this arm/shoulder. Dysfunction in this muscle may lead to of the humeral head which might be a precursor to shoulder instabilities and the more shoulder impingements.

It's important for the clinician to detect dysfunction inside this muscle through a battery of tests and also direct exercises will be required to rehabilitate function for this muscle.

References
1. Aria et al (2010) Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon. Journal of Shoulder and Elbow Surgery. 19(1):58-64
2. Barth et al (2006) The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 20(10). 1076 -1084.
3. Burkhart SS, Tehrany AM. (2002) Arthroscopic subscapularis tendon repair: Technique and preliminary results.
Arthroscopy ; 17:454-463
4. Gerber C and Krushell RJ (1991) Isolated rupture of the tendon of the subscapularis muscle. The Journal of Bone and Joint Surgery. 73-B(3); pp 389-394.
5. Hess et al (2005). Timing of Rotator Cuff Activation During Shoulder External Rotation in Throwers With and Without Symptoms of Pain. JOSPT. 35(12); pp 812-820.
6. Nakata et al (2011). Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 31(3):791-810
7. Scheibel et al (2005) The Belly-Off Sign: A New Clinical Diagnostic Sign for Subscapularis Lesions. Arthroscopy: The
Journal of Arthroscopic and Related Surgery, 21(10): pp 1229-1235
8. Thurner et al (2013) Subscapularis Syndrome: a case report. International Journal of Sports Physical Therapy. 8(6); pp 871-882.

Studies suggest that between 3 and 9 percent of all sports injuries involve the hand or wrist. Chiropractor, Dr. Alexander Jimenez examines ulnar impaction, among the more common injuries to affect this region, particularly among older athletes...

Ulnar impaction syndrome (UIS -- sometimes called ulnocarpal abutment) is a condition where the ulna of the forearm is too long relative to this radius, resulting in excessive loading on the ulnar side of the wrist. Ulnar impaction syndrome could be secondary to shortening of the radius, although this condition is congenital and present from birth. Regardless of the origin, however, most patients become symptomatic in life, when accumulated and degenerative wear and tear takes its toll on both the ligaments and cartilage, resulting in wrist pain. For athletes whose sports involve loading of their limbs, this can be a problem.

Wrist Stability

To appreciate ulnar impaction may result in ulnar-sided wrist pain, it will help to comprehend the structure and function of the triangular fibrocartilage complex (TFCC) and loading across the ulnocarpal joint (see Figure 1). Wrist stability is improved an arrangement of ligaments and fibrocartilage, via the TFCC arising from your sigmoid notch on ulnar border of the radius and inserting into the base of the ulnar styloid and fovea of the ulnar head.

Studies have shown that there's a direct relationship between raising ulnar length (relative to radius span) and also enhanced force transmission throughout the TFCC. At a neutral wrist, the ulnacarpal joint takes approximately 18 percent of the entire load applied to the wrist (with the radiocarpal joint taking another 82\% approximately). However, a favorable variance of 2mm increases the ulnocarpal load to about 40\%, while a heightened dorsal tilt because of previous injury of this radius may further boost the ulnar load to 65 percent of overall load transferred(1,2). Moreover, thinning of the articular disc (that is common with increased ulnar length) also raises the risk of TFCC wear and perforation (3).

While it connected with congenital or acquired positive ulnar variance, UIS can also happen in ulnar neutral or even negative ulnar variance wrists(4,5). Athletes doing power and/or grasping activities connected with axial loading and rotation are especially at risk of ulnar impaction syndrome because of their 'dynamic ulnar variance' that occurs during tasks requiring maximum traction and pronation(6). More commonly events which set compression and rotation demands on the upper limbs increase the risk of ulnar impaction via traumatic development.

Although symptoms of UIS rarely present in athletes, the risk for all these symptoms in later life could be increased by events during those formative years. One reason for this is that distal radius fractures are the most frequently occurring fracture in children under the age of sixteen. Research shows that when significant radial shortening (5mm or more) happens as a result of these fractures, there's a considerably increased probability of long-term operational impairment (7). Additionally, even in the absence of distal radius fractures, we know that submitting an immature wrist into prolonged compression and insistent micro-trauma has can result in a premature arrest of radial growth plate and following ulnar overgrowth(8,9), and that of course greatly raises the risk of UIS in later decades.

Symptoms Of Ulnar Impaction Syndrome

UIS's development Results in the degeneration and abutment of TFCC or the ulna against the ulnar carpus. Although any athlete could suffer from this racquet, gymnasts, boxers, illness and adhere sport athletes are particularly at risk, together with symptoms of pain particularly occurring during wrist rotation. It is important to comprehend, however, the development of this problem is not always linear; the load-bearing demand put on the TFCC means that there is a heightened susceptibility towards an acute traumatic injury, in addition to the secondary degenerative concerns implicated with ulnar impaction(10).

Common symptoms of ulnar impaction syndrome include the following:

• Pain (especially during spinning), aggravated with activity and (normally) relieved with rest;
• Painful bending or clicking during pronation and supination;
• Occasional edema;
• Reduced wrist Assortment of motion;
• Decreased forearm rotation;
• Tenderness to palpation dorsally, just distal to the ulnar head and just volar into the ulnar styloid process;
• Each of the above tend to be aggravated by forceful grip, forearm pronation, and ulnar deviation.

What tends to differentiate chronic ulnar impaction syndrome by a serious TFCC injury (which may itself be made more likely by ulnar impaction) is the insidious, progressive nature of the pain, which slowly limits range of motion, grip strength, and performance. In 1981, Palmer and Werner introduced (a now widely utilized) classification system to help clinicians determine if it's the TFCC injury is mostly innovative and degenerative or acute in character (or indeed both). This is shown in Box 1.

Diagnosis

When attempting to make a diagnosis of UIS, a thorough wrist examination is necessary, together with a comprehensive patient history (as an example, has the individual suffered a radius fracture previously?) . Regrettably, however, there's no single clinical test that can completely diagnose UIS, not least since most tests conducted in the clinic are inconclusive as to whether TFCC- related pain is acute or degenerative in nature (see Box 1). For this reason, diagnostic imaging (eg MRI) should be conducted to confirm the findings in the clinical examination. Having said that, the clinician can gain valuable supporting evidence from a comprehensive examination that includes the following:

On palpation, is there:

• Tenderness just distal to ulnar head?
• Tenderness just volar to the ulnar styloid process?
• Positive ulnar variance, while stationary or dynamic?

Do range of motion tests show:

• Painful ulnar deviation and forceful pronation?
• Decreased flexion, extension ulnar deviation?

Does a power measurement reveal:

• Reduced grip strength in comparison to the wrist if using dynamometer?

Is an ulnocarpal stress test positive? (see Box 2)

Is The Gripping Rotary Impaction Exam

(GRIT) positive? (see Box 2)

The ulnocarpal stress test described in box 2 was initially introduced by Nakamura and his coworkers(13). In the writers' unique study, 33 of 45 patients (73%) with favorable ulnocarpal stress test results revealed positive ulnar variance of 1mm or more about the wrist. In the 33 patients that had a positive ulnar variance, 19 (58%) were confirmed as suffering from course II TFCC lesions resulting from ulnocarpal impaction. The vast majority of those patients suffered a spontaneous onset of pain, and so were diagnosed with course IIB lesions involving TFCC wear with lunate and/or ulnar chondromalacia (see Box 1). Generally, a history of spontaneous ulnar sided wrist pain combined with testing should prompt the astute clinician to seek additional evaluation utilizing imaging.

Treatment Options

When treating athletes sooner is better; studies reveal that early diagnosis and intervention may significantly lessen the danger of long-term disability and injury progression(14,15). Treatment should be attempted before surgery and can include limiting movements such as pronation, gripping and ulnar deviation for 6-12 weeks or immobilization. After immobilzation/restriction, other conservative treatment choices include, non-steroidal anti- inflammatories (NSAIDs) and corticosteroid injections.

However, while conservative therapies such as anti-inflammatories limiting range of motion or combined with immobilization may be effective for the overall populace, they are frequently insufficient for athletes because they do not deal with the fundamental biomechanical variables that predispose the athlete to UIS. Therefore, when conservative management fails to produce a substantial improvement, evidence indicates that surgery is indicated(16,17).

When surgery is required Athletes opt to postpone surgery before the season's finish, permitting recovery from operation to take place. In terms of surgical possibilities, this is determined by the surgeon following screening that was comprehensive. These options may include:

• Ulnar shortening osteotomy -- that the ulna is abbreviated by 2-3mm of shaft and fixated using a tubular or compression plate. This choice is indicated when there is ulnar wrist pain worsened a positive stress test by turning and ulnar deviation, and positive ulnar variance with or without changes.

Following operation, athletes may expect to experience at least 3-4 months or recovery/ rehabilitation. Depending on the surgical process and individual response, this period will generally include:

• Weeks 1 & 2 -- control pain and swelling with ice/anti-inflammatory medication. Wearing a sugar-tong splint or long-arm cast to protect the surgical site while maintaining as much selection of movement (ROM) from rigid joints.
• Weeks 3 to 6 -- Shield site and continue to maintain ROM in joints. Switch into a detachable splint or wrist cock-up brace. Try to boost wrist & knee ROM. Attend to scar management.
• Weeks 7 & 8 -- Alter to removable splint worn in the nighttime. Progress to ROM present isometric elbow flexion/extension and supination/pronation and exercise for wrist & elbow.
• Weeks 9 onwards -- continue with Stretching and mobilization. Introduce low-load resistance exercises to develop strength.

Athletes should anticipate a return to complete activity around 3-4 months following an arthroscopic wafer procedure, and around six months following an ulnar shortening osteotomy.

Summary

Although ulnar impaction syndrome is often congenital in its etiology, Athletic activity and years can combine to produce progressively more debilitating symptoms . For the clinician diagnosis is desirable but not always straightforward; even if scope of motion tests imply UIS, imaging will be asked to ascertain if intense or degenerative affects treatment options. Unless the UIS Is mild or the athlete is able to significantly modify his/her activity may be that treatment is unsuccessful and surgery is required. The choices will be different based on the person but in many cases- term results are favorable despite the requirement for recovery that is protracted and rehab after surgery.

References
1. Hand Clinics. 2005: 21; 567 – 575
2. Clin Orthop Relat Res. 1984; 187: 26 – 35
3. J Hand Surg. 2013; 38(7): 746 – 750
4. Br J Hand Surg. 1998; 23(6):754 – 757
5. Magn Reso Imaging Clin N Am. 2004; 12: 281 – 299
6. J Hand Surg Am. 1993; 18(4): 713 – 716
7. Prim Care Clin Office Pract. 2013: 40; 431 – 451
8. J Med Sci.2001; 64: 81 – 91. J Ped Orthop. 1989; 9: 23 – 28
9. Hand Clin. 1990; 6: 493 – 505
10. Hand Clinics. 2005: 28; 307 – 321
11. J Can Chiropr Assoc 2014; 58(4)
12. J Hand Ther. 2001; 14(3): 173-179. J Hand Surg. 1997; 22B: 719–723
13. Br J Hand Surg. 1991; 16: 84 – 88
14. Arthroscopic Rel Surg. 2004; 20(4): 392 – 401
15. Hand Clinics. 2005: 28; 307 – 321.2,6,8,31
16. J Hand Ther. 2001; 14(3): 173-179.
17. J Hand Surg. 2008; 33A: 1669-1679

Chiropractor, Dr. Alexander Jimenez reviews the possible approaches to deal with these hamstring issues -- and the evidence offered.

Tendon injuries account for 30-50\% of accidents reported to physiotherapy clinics and also 30\% of all running injuries relating to tendon overuse (1). If handled tendinopathies are complicated to control and might cause a from long-term and sport harm. High heeled tendinopathies (HHT) are less commonly recognized than other tendons of the thoracic and might present as either deep buttock pain and or as anterior thigh pain(2).

The Objective of this review is to provide an insight into the direction for HHT and when to explore injection therapy. High hamstring tendinopathies may also be referred to as proximal hamstring tendinopathy (PHT) or hamstring origin tendinopathy (HOT). The research pertaining to conservative therapy for HHT is restricted(two) and therefore some of the research provided in this review is connected to tendinopathies of additional major joints of the lower limb.

Anatomy Hamstring Muscle

The muscle comprises of three separate muscles; s) semitendinosus, ii) semimembranosus and iii) biceps femoris (long head) all originate at the ischial tuberosity of the pelvis. The head of the biceps femoris, in contrast, originates at the posterior aspect of the femur on a ridge called the linear aspera. The hamstring muscles route down the anterior thigh using the biceps femoris (long and short breaths) attaching cartilage into the head of the fibula whereas the semitendinosus and semimembranosus attach medially to the tibia. The hamstring muscles are innervated by the tibial division of the sciatic nerve and facilitate hip extension and knee flexion (3).

Pathophysiology

The expression tendinosis is used to describe the process of degeneration from tendinopathy, although many still use the age old term of tendinitis. The 'itis' suggests an inflammatory reaction is present but intratendinous degeneration is defined as being hypoxic and calcific from factors like reduced blood flow, aging and microtrauma rather than posing as an inflammatory response(4). A hypothesis explaining the pain undergone at a tendinopathy is from the ingrowth of the vessels and nerves termed as 'neovascularisation' which causes a pain response from the swelling of an irrititable limb(5).

The part of a tendon appears as grey and of dull look as it loses its glistening white look as seen in Box 2(6). The illustration of an injured tendon in Box 2 has been a limb removal combined with repair of the superficial digital flexor tendon in rabbits and wasn't a tendinopathy. The authors,(6)) however, drew comparisons to the therapeutic stages in tendinopathies in humans in exactly the same timelines of 28 and 84 days (four and 12 months). The picture illustrated in section C box 2 reveals the biomechanical properties of the immature collagen fibers and significantly lesser to the normal tendon in sections B and D.

Clinical Assessment

The hamstring tendon is placed under load when the knee is extended and the hip is completely flexed. Running, or running-related sports, induce an individual to tendinopathy due to the extended length the thoracic is stored within this eccentrically loaded position(7). Additional factors exposing somebody to HHT might consist of low hamstring to quadriceps muscle ratio, inadequate warm-up protocols, preceding hamstring injury and reduced hamstring flexibility(2). Other factors could include pelvic dysfunction and diminished activity of the core stability muscles and therefore a wide evaluation should be undertaken with the onset of deep buttock pain (3).

Pain may be included by symptoms of HHT during repetitive eccentric loading, acceleration during jogging and in extreme instances sitting on hard surfaces. The taking the shoe off test, resisted by the uninvolved foot, was proven to have a High sensitivity and specificity of 100% for hamstring-related injuries and ought to be considered to be used with a suspected HHT(8). Normally pain is felt on active and passive stretching of the hamstring muscles at the origin attachment with pain too experienced on palpation of the ischial tuberosity(two). Moreover, there is minimal decrease in power of the hamstring muscles with knee flexion or cool extension in isolation without a neurological deficit is current unless additional lumbosacral spine pathology is included(two). Pain is often detected with the hip completely flexed placing the best load on the muscles like phase of the swing period in gait's terminal when the knee is extended.

Conservative Therapy

An eccentric contraction, which refers to higher tension of a muscle-tendon unit through lengthening, has been widely employed as a treatment tool for tendon pathologies(7). Tendons need seven and half times less oxygen compared to skeletal muscle does and throughout the eccentric phase oxygen consumption rarely rises to more than double its resting value(9). Research compiled through the 1970s indicated that faster concentric contractions demand a greater oxygen supply and consequently an increase in heat generation and cellular metabolism happen(10). Consequently a greater quantity of waste products are transported into the active site possibly causing a chemical reaction of nerve endings and an increase in pain(10). Thus the justification for bizarre exercise in the management of tendinopathies is supplied as opposed to concentric contractions.

Research has suggested that eccentric exercise boosts collagen fibre cross-linkage inside the thoracic that eases remodelling of the injured tissue(7). This was supported by Langaard and colleagues who found that 12 weeks of eccentric loading of the Achilles tendon improved the collagen synthesis rate of type one fibres(5). It's been said that pain and neovascularisation are reduced following a different 12-week bizarre training program for an Achilles tendinopathy(11). A period of 12 months is considered sufficient for tendon regeneration to occur, although positive outcomes might be observed.

A case study was printed in the Journal of Manual and Manipulative Treatment of a 41-year-old feminine Recreational runner who completed five Three-mile runs per week (7). The individual Had a start of buttock pain that is right however had been Able to continue training at a lesser Intensity for 12 months. The patient then developed left buttock pain with worsening Pain on Patient to cease running. The Patient's objective was to make a return that is full to running. Pain ranged from 0-6/10 on VAS scale depending on activities. Pain Was walking In and out of automobiles and sitting on hard Surfaces and when taking off shoes ('taking off a shoe evaluation').

An assessment of the individual in the case analysis (7) suggested straight leg testing with ankle dorsiflexion and slump tests were negative bilaterally and pain-free thoracic spine motions with over- stress in all directions were unfavorable. Pain in buttock with lumbar flexion with her knees fully extended was, nevertheless, noted. No pain on palpation of the lumbosacral spine was detected but the individual has been tender on the ischial tuberosity and the proximal two inches of the hamstring tendon. Pain was not discovered on the hip quadrant test of either hip and no hassle has been noted on sacroiliac joint testing. Hip flexors, abductors and external rotators were all pain-free and recorded as 5/5 on the Oxford scale. Hip extension was slightly painful on both sides with a reduction in strength 4/5. Knee flexion reproduced greater pain amounts on both sides with 4-/5. Pain was replicated on both sides by extending the knee with the hip claimed in 90 degrees of flexion.

The therapy program of the runner presenting with HHT is highlighted in Box 4. It should be noted that a HHT won't present in exactly the same fashion but the case study above will admit different areas to be examining as part of your clinical evaluation. This patient has been treated with a progression of exercises within the span of 16 therapy sessions using hamstring eccentric exercises, gluteal equilibrium exercises, stretching, and ASTYM. ASTYM is a soft tissue procedure proposed to regenerate a response in the delicate tissue to promote healing, but published research is yet to be supplied on people. The soft tissue procedure is performed by carrying out gliding techniques in the management of the muscle fibers. The rehabilitation exercises were selected depending on the physical capacities of the individual throughout the rehab and three sets of 10 repetitions were employed on each of the exercises.

The outcome of the case published by McCormack(7) signaled a steady progression during with no hassle on taking shoes off at visit . After the treatment the patient has been able to walk two and half an hour pain-free and after 12 remedies able to jog one mile pain- free. After 16 treatment sessions that the patient reported 95% postoperative improvement and managed to operate for 2 weeks and a half miles pain-free.

Shockwave Therapy

Shockwave therapy has been cited as being an effective tool for handling HHT. A study investigated the effects of hamstring resistance training (not specifically eccentric loading) using anti inflammatory drugs and shockwave treatment on the tendinopathy of the proximal hamstring in 40 professional athletes (12).) The shockwave implemented was 2500 impulses per session without anaesthesia of a single session per week for four weeks. The four-week study, which used a randomized controlled study design, found at three months post-study which 17 of the 20 athletes that received shockwave had a decrease in pain of 50%, whereas in the treatment group only two patients received a decrease in their pain from 50 percent. Even though the contrast between the shockwave versus therapy group should not be contrasted against bizarre training, it's significant evidence for the use of shockwave in curing HHT.

Steroid Injection Therapy

Research of tendinopathies has suggested that 20% of individuals will stay as symptomatic at three to six months after a conservative direction program was applied(13). Further interventions must be researched at this point and one of the options is in the kind of injection therapy. It needs to be noted that once injection therapy has been carried out it's key that the conservative management program be continued to get optimum results.

A fluoroscopy-guided peritendinous corticosteroid injection was provided for 18 athletes using HHT diagnosed by MRI (two). The followup, on average being 21 months, also suggested by questionnaire that pain had considerably decreased from 7.22 pre-injection into 3.94 article injection. The results also indicated that athletic involvement had significantly increased from 28.76\% to 68.82\% with 38.8percent of individuals being completely asymptomatic in a mean follow up of 24.8 months. There was no proof of a conservative programme and this is the limit of the research. Had a structured management program been supplied it would be beneficial to draw on the results obtained and draw comparisons between the classes.

Researchers from the University of Copenhagen studied the effects of corticosteroid injections, bizarre training and significant slow resistance training on patients with patellar tendinopathy(14). With a randomized controlled single blind study design, 39 male participants were assigned to one of the three intervention groups. Factors measured were work, pain, symptoms, tendon swelling and vascularisation and limb mechanical components prior to the study, in 12 weeks and at six months after the analysis.

The outcomes of the research yielded that each intervention significantly improved in pain, symptoms and function during the initial 12-week period. What's more, pain, symptoms and function continued to improve in the eccentric and heavy slow resistance training groups at the follow-up but had considerably diminished in the corticosteroid injection group. Additionally at the six-month follow-up the heavy slow resistance training team suggested they were the very satisfied with the therapy result which coincided with increased collagen turnover. Even though the corticosteroid injection alone provided favorable first results at 12 weeks the results weren't substantive for its long- term clinical effects.

Overview

A rehabilitation program invented for HHT should depend upon the findings in the first examination and also the load in which the hamstring muscle may withstand. What's more, the sophistication and load of the rehab exercises should be particular to the patient's pain tolerance. If the tendon is not responding to conservative treatment then steroid injection is an avenue to explore based on the individual's age and present symptoms following a period of 12 weeks. To draw greater comparisons involving steroid injection therapy and a conservative management plan, research should endeavor to contrast the effects of both forms of treatment using randomized research design. The current review is unable to provide a firm conclusion at this stage as additional research is required.

References
1. The Int J of Sports Phys Thera. 2011 Mar; 6 (1):27-45.
2. The Ortho J of Sports Med. 2014; 2 (3).
3. J of Chiro Med. 2011; 10: 93–99.
4. Br J Sports Med. 2002; 36: 239–249.
5. Scand J Med Sci Sports. 2007; 17: 61–66.
6. Sports Med, Arthro, Rehabili, Thera & Techno. 2012; 4: 14.
7. J Man Manip Thera. 2012 Aug; 20 (3): 142–146.
8. Clin J Sport Med. 2006 Mar; 16 (2):166-9.
9. Sports Med. 1986; 3: 114-135.
10. J Physiol. 1976; 260: 267-277.
11. Knee Surg Sports Traumatol Arthrosc. 2003 Sep; 11 (5): 327-33.
12. Am J Sports Med. 2011 Jan; 39 (1): 146-53.
13. J Bone Joint Surg Am. 1999 Feb; 81 (2): 259-278.
14. Scand J Med Sci Sports. 2009 Dec;19(6):790-802.