Sports Injuries

Hip chiropractor and trauma specialist, Dr. Alexander Jimenez looks at among the most frequent causes of hip pain -- femoroacetabular impingement (FAI)...

Over the previous 10 years, with the advent of MRI and hip arthroscopy, the reported prevalence of hip labral and acetabular rim pathology has considerably increased(1). Hip pain is a common cause of reduction of training/game time with as much as 15 percent of all AFL injuries reported as hip pain(1).

What's FAI?

FAI happens when the femur impinges on the acetabulum. This happens due to an anatomical variation in either the femur or acetabulum and is present in up to 20% of the population.

FAI is categorized into three main types (see Figure 1):

1) Cam impingement -- this is the most common type of FAI and is most often found in young males(3). It refers to a "bump" most often on the anterior and also superior part of the femoral neck. In a camera lesion, the normally concave head/neck junction of the femur appears flattened or even convex(two) because the hip flexes, adducts and internally rotates this part of the femur then abuts against the acetabulum. Repetitive abutment applies shear stress into the articular cartilage resulting in delamination and labral tears can eventually occur(2). The cause of the anatomical variations on the femoral neck is unknown but a couple of theories have been suggested. Cam lesions could have a genetic inclination and/or they may occur due to over-activity of the epiphyseal plate (because of increased load) during adolescence(2,3). Most probably it is a combination of both of these factors. Ganz (2003) proposed that camera lesions can predispose the athlete to early osteoarthritis of the hip with up to 40 percent of OA hips revealing signs of a camera lesion(2).

2) Pincer impingement -- this refers to over- coverage of the acetabulum with a normal appearing femur. Acetabular abnormalities that may lead to pincer impingement contain a retroverted acetabulum, protrusion acetabula or osteophytic development. This type of impingement is commonly found in middle-aged guys.

3) Mixed presentation of both camera and pincer impingement -- this describes the situation where both cam and pincer impingement exist. It's important to under- stand that all these are anatomical variants and therefore are not in themselves the pathology but they might predispose the athlete to hip pathology both in the long and short term.

How Is FAI Diagnosed?

Subjective Assessment

FAI is most commonly seen in male athletes. They will frequently report a long history of hip stiffness or groin pain. They may report that their hip pain started with a minor trauma but never solved. They often report that their "hip flexors" happen to be tight particularly after prolonged sitting and that they might never sit back. Labral tears must be suspected when the athlete refers to a click or grating, giving way or locking feeling(1).

Objective Assessment

FAI should be suspected in athletes that have limited hip ROM particularly into internal rotation in 90 degrees of hip flexion. This may be quantified in either supine or sitting. These athletes will probably also have a debilitating FADIR and restricted and debilitating FABER(4). Several evaluations are described as diagnostic for a labral lesion; those comprise: FADIR, FABER, impingement provocation test and Fitzgerald test. In Leibold's systematic review they discovered that the current best evidence that a negative finding for these tests gives the clinician good proof that there is not any labral tear present; however, no evaluation has adequate specificity to confidently predict when a labral tear is present(5).

Imaging

Imaging is needed to validate the clinical investigation of FAI. Osseous abnormalities may be seen on x ray (but may be missed). If a bony impingement is suspected then a CT scan has improved precisionnonetheless, you must be aware of the greater radiation dosage associated with CT scanning and a CT scan doesn't specifically diagnose labral or cartilage lesions.

MRI may be utilized to recognize articular cartilage and labral pathologies; however, for imaging the labrum MR arthrography seems to create exceptional results(4).

Treatment

Conservative Therapy

At this stage there is no obvious evidence on when conservative or operative therapy are required. In circumstances where imaging shows minor signs of FAI and no additional significant pathology of the hip, conservative treatment should be trialled.

1) Education

These athletes should avoid exercises and positions which impinge the hip (cool F angle >90deg) ie deep squats, leg press particularly in incline machine along with large step-ups. Some common positions which needs to be prevented are sitting at low seats where knees are higher than hips, sitting cross- legged and position using a hip hitched to a side. These athletes, even if they sleep in their side, must be encouraged to utilize a pillow between their knees and feet to help keep their fashionable from flexion and adduction.

2) Soft tissue work and manual treatment

Soft tissue work through TFL, ITB and adductors can be very beneficial to reduce tone in these muscles. This may be completed in a variety of various ways such as trigger point massage, work, roller and dry needling. Manual therapy methods to restore normal arthrokinematics of the fashionable are also quite useful in decreasing symptoms.

Normally as the hip flexes, the femur glides slightly posterior and conversely since the hip extends the femur should glide slightly anteriorly in the acetabulum.

Considering these arthrokinematics, manual therapy methods which posteriorly slide the femur are very useful in athletes that have inferior posterior glide of the femur during hip flexion (see Figure 2). Approaches that anterior slide the femur may be useful in athletes who lack hip extension. Lateral glides of the femur have also been demonstrated to be rather helpful to reduce symptoms and increase range in athletes with FAI.

3) Exercise Therapy

What Are The Finest Rehabilitation Exercises To Do?

In most instances of hip pain, exercise therapy is vital to ensure long-term effects of therapy. Particular focus should be given to the hip abductor and hip extensor muscles.

The hip abductor synergy includes of glut medius, exceptional glut max and TFL. Frequently in athletes, TFL is overactive and the gluteal part of the abductor synergy is weak. Recently, Selkowitz and colleagues, using EMG, set out to identify that which exercises especially target the gluteal muscles whilst reducing action of this TFL(7). The results of their study identified the five exercises that showed strong stimulation of gluteus medius and superior glut maximal using the least action of TFL (in healthy volunteers).

1) Clam -- activation of glut med and glut maximum was maximized while the pelvis was at a neutral position (vs a reclined position) and the hip was flexed to 60deg(6) (see Figure 3).

2) Side walking with band around thighs in a squatted position was also demonstrated to have minimal TFL action (see Figure 4).

3) Single-leg bridge (see Figure 5).

4) Quadruped hip extension -- short and long lever (see Figures 6 and 7).

In humans the glut max works in 2 ways -- one, it expands and abducts the hip; and secondly it controls flexion of the trunk in walking and standing. If this muscle is weak then it is important that we as clinicians consider including both actions when creating a rehabilitation exercise regiment. A good example of an exercise that targets the component of this glut max that controls back flexion is Romanian deadlifts (see Figure 8).

The above exercises are very great for isolating gluteal stimulation and as the athlete progresses through their rehabilitation further load and multidirectional movement should be integrated into the program. Some examples of exercises which strengthen both the abductor and extensor muscles of the hip include:

1) Split squat with band (see Figure 9);

2) Split squat with rotation (see Figure 10);

3) Wood chop high to low or low to high (see Figures 11 and 12).

The resistance band and pulleys are employed in each of these drills to ease the hip abductor synergy muscles to work.

Operative Treatment

If conservative therapy fails or if a significant bony lesion or labral tear is identified then surgery might be required. The objective of surgery is to not only repair/treat the labral lesion or chondral pathology but also relieve any rectal abutment. Historically this has been done through an open process but most surgeons now are doing these processes through arthroscopy. Chondral pathology might be seen and delaminated components will be trimmed/shaved and chondroplasty, drilling and micro fracturing may be used to help stimulate fibrocartilage regrowth. Labral tears related to FAI occur most commonly on the anterosuperior rim. Where possible these ought to be repaired instead of resected, as eliminating large parts of the labrum alter hip mechanics, which might lead to further damage. To restore the normal anatomy of the femoral head/neck junction if a cam lesion exists, a femoral osteoplasty/ chielectomy should be performed.

Conclusion

Hip pain is a frequent reason for loss of training time in various different sports. This report has outlined the various types of FAI and possible conservative treatment options. Rehabilitation exercises are a critical part of the rehabilitation program of athletes with hip pain and a number of exercises that specifically target the gluteal muscles have also been described.

References
1) Brukner and Khan (2012) Clinical Sports Medicine. 4th edition
2) Kasserjian A, Cerezal L, Llopis E (2006) Femoroacetabular Impingement. Topics of Magnetic Resonance Imaging Vol 17, No5 , 337-345
3) Ganz R, Parvici J, Beck M, Leunig M, Notzli H, Sienbenrock K (2003) Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and related research No 417, 112-120
4) Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Sobelle K (2009) What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthopaedica 80 (3) 314-318
5) Leibold R, Huijbregts P, Jensen R Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review. The Journal of manual and manipulative therapy vol 16 no 2 e24-e41
6) Wilcox E, Burden A (2013) the influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during clam the exercise. Journal of Orthopaedic and Sports Physical therapy Vol 43, No 5 325-332
7) Selkowitz D, Beneck G, Powers C (2013) Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine wire electrodes Vol 43, No 2 54-66

Running might appear the most natural thing in the world, but for many who try, it certainly does not come naturally, nor even easily. The awkward reality is that many people simply shouldn't be running at all if they would like to avoid ongoing injury. Among the rest of us, running styles differ so much that it is fair to say everybody's individual running style will be exceptional -- after all, we all differ slightly in our body position, our lower limb muscle recruitment and our foot placement when striking the floor. El Paso, TX. Chiropractor, Dr. Alexander Jimenez has a look.

For a lucky few, running does appear to come naturally. But most individuals who aspire to run well and injury-free will require work in their technique and overall postural control.

Chiropractors are just as likely as anybody else to be confused by the large amount of analysis available on the biomechanics of running; it's really hard to make sense of information like the subtalar joint axis or level of lumbar rotation whenever you are attempting to figure out what's gone wrong with the wounded client running on a treadmill in front of you.

I have previously written about the method of 'pose running' as one approach which I believe to be highly effective for training individuals to conduct while avoiding injury. This report focuses especially on the technique fault of poor lumbopelvic management, which I think is essential to injury-free running.

Some People Should Not Run

Not all of us are born athletes, and some folks are intrinsically not designed to run. Others will struggle because of a combination of physiology and lifestyle variables. Although the following list is probably not exhaustive, here are some of the main sorts of people that will be more prone than average to running-related injury, and will certainly struggle to sustain any longevity of running form.

Muscular Control Is the Secret

Nicholas Romanov, the leader of this pose running style, characterizes the differences between good and bad running this way:

'A proper technique has particular perception of lightness, brief support, no pressure on muscles, no feeling of loading On your joints... The opposite -- wrong technique -- goes together with muscle strain, loading on your joints, heaviness...' (www.posetech.com)

Over time that I've been involved with conducting athletes, I have come to consider that static stretching is likely Less important and less successful in warding off harm and recovering from it than sufficient muscular strength, endurance and control at crucial sites.

Like I have previously mentioned, the pose method is 1 method that runners can really work on muscular control and postural dynamics in activity-specific positions. Anyone who adheres to this technique should be ready for a great deal of practice in order to learn proper alignment and muscle recruitment.

Pose places plenty of focus on lumbopelvic and eccentric knee muscle management, particularly the way that knee and Hip muscles operate when the mid-foot strikes the floor.

I realized that the need for great lumbopelvic stability partially as a consequence of my own early experiences in practicing pose running. I Discovered I was getting a great deal of calf muscle soreness at the first phases, and really the pose method could lead to jet muscle sprains.

The method requires the runner to lean or 'fall' forwards and pick up their foot off the ground together with the hamstrings. This certainly develops a lot of speed but can place undue strain on the anterior musculature of the joints and leg of the lower back. The eccentric load around the calf will be enormous and often contributes to physical breakdown of this muscle.

The underlying cause of the calf strain, however, is that the pelvic place the runner has embraced so as to lean Forward to gain momentum. It is very easy to over-do the normal inclination to hinge forward from the hips while jogging, which places the shoulders a very long way before the buttocks, also leads the runner to rely in their erector spinae and hamstring muscles to take the strain of the running stride. It is actually not surprising that all these athletes create symptoms within their hamstrings and low backs.

Set your customer on a stepper machine and you'll probably have the ability to see exactly the same muscular imbalances in action. The patient will stick out their bum and push through their quadriceps, not utilizing much hip joint action at all. These people tend to hang on their erector spinae when leaning forwards with regular activities and might benefit from more low abdominal activation.

This understanding has made me to advocate that any running client who presents with calf muscle tears should be Researched for a loss of pelvic control, particularly in the sagittal plane (uncontrolled anterior-posterior motion). While sports support professionals are utilized to the connection between hamstring injuries and inferior pelvic control, in my experience calf tears tend to ship us looking downwards into the over-pronating foot, rather than upward in the over- extending pelvis.

Conclusion

Like any athletic activity, some people make running seem easy, but some have to work at it. The reward for those who do not find running simple initially is that they'll truly appreciate advances in their technique, as It removes pain, effort and risk of injury.

1. Introduction

Stretching is one of those topics in fitness and exercise that is shrouded in mystery and misunderstanding. Most people know that stretching is good for them but concerning exactly what type of moves to do and when? That's where the confusion starts! El Paso, TX. Scientific sports chiropractor Dr. Alexander Jimenez examines the data in part I of a 2 part series.

While stretching is significant and the consequent growth in flexibility may mean the difference between poor operation or injury and establishing up a personal best, the wrong type of stretching at the wrong time may actually reduce the quantity of force your muscles have the ability to generate. Not a good thing...

Many exercisers find the entire process of extending very dull! To a extent this mindset is simple to understand. Most of the exercises we perform are very lively, ramp up your heart rate, make your muscles burn and bring forth lots of sweat. Stretching does not produce that much-sought endorphin rush that we regular exercisers enjoy so much.

Another difficulty that individuals who extend o en experience is a lack of obvious benefits; despite spending extended periods of time stretching. Unlike running or li ing weights, in which the payoff is normally more evident, the benefits of stretching could be slow to manifest, even though this is sometimes as much due to inferior stretching technique, incorrect flexibility program layout and/or doing the incorrect types of stretch.

On the other hand, some exercisers really spend too much time stretching and develop their versatility above and beyond what's healthy or necessary. Stretching, like all kinds of training, should be particular to the activities you are searching for. Excessive or overly-aggressive stretching may be as damaging as not doing enough.

Stretching is just as with any other facet of exercise -- it should be specific to your individual requirements -- your sport, as an instance, or its required range of motion. Those requirements don't just differ from person to person but from muscle to muscle. While you May Need to perform lengthy developmental stretches to your lower body, you may find that you only need quick stretches to maintain the flexibility on your upper body. Your left leg may need more care than your right. It is only by being aware of what your body needs that you could design a bespoke flexibility program that matches your unique requirements and in this e-book you will learn how to evaluate your own flexibility requirements to optimize your stretching program.

Stretching is not the most exciting of fitness issues but it's among the most essential. Adequate flexibility means your joints are going to be able to function optimally which means less wear and tear on your joints and also a great deal of other benefits you may read about in the next chapter.

Flexibility is one of the physical fitness components that you will overlook the most as you get older. It is only once you lose vital freedom and functional movement capacity which you realize that stretching is essential for long-term wellness and functionality. Like so many things, an ounce of prevention is much far better than a pound of cure so be certain that you make stretching part of your workout routine -- albeit the ideal types of stretching at the right time, obviously!

2. Benefits Of Stretching

Stretching is usually performed to preserve or enhance flexibility. The definition of flexibility is that the selection of motion at a joint or group of joints. Increased flexibility may improve joint mobility, but freedom is actually quite different to flexibility. Joint freedom is more to do with the health of the articular surfaces within a joint and explains the fluidity and ease of movement of constructions like your knees, shoulders and hips. For the purpose of clarity, this e-book will focus on extending and flexibility instead of joint distress.

So why stretch? Why should you invest precious time sitting very still for extended periods of time for those who might feel your training would be more useful if you're beating the sidewalk or hitting the squat rack?

Your muscles are arranged in pairs round joints. In the vast majority of cases, these muscles have opposing actions which affect the identical joint. As an instance, your quadriceps extends your knee while your hamstrings ex your knee. In case your quadriceps become excessively tight, your knee joint can be pulled slightly out of alignment that will increase the stress put on the passive articular membranes and connective tissues inside your knee. Is would raise your chances of suffering short-term discomfort and even long-term injuries.

Why do muscles become tight? Interesting question! Is has a great deal to do with workout specificity. The law of exercise specificity dictates that your body will adapt to the stresses put on it. Is means that in case you perform biceps curls but not straighten your arms at the bottom of the workout, your biceps muscles will react by shortening so that you shed that end selection of motion. Is is called adaptive shortening.

Not many exercises or activities take your muscles throughout their fullest range of motion, which means that many exercises are likely to reduce instead of increase your endurance. Running, cycling, li ing weights etc all are inclined to work out your muscles within a restricted selection of movement and, as a result, your muscles shorten because they conform to these stresses.

So what happens when you choose your muscles beyond the range of motion they've been used to? If you're lucky, a slight muscle tear; however if you are unlucky, a major tear which may require surgery to fix.

To illustrate this point, imagine you are a recreational jogger. When you operate, your stride is short and quick and you run mostly with a at foot-strike. You've trained this way for many years as well as your muscles have adapted to the relatively restricted range of motion.

Then, one day, you're crossing the street and a vehicle approaches you in a dangerously large speed. You lengthen your stride, come up in your toes and endeavor to accelerate from the oncoming car's path. Searing pain dissipates at the back of your thigh and you limp across the road to safety.

What happened? You used your muscles outside of their normal array of movement and pulled a hamstring.

Just like over-stretching a rubber ring can cause it to snap, more than stretching your muscles may lead them to tear.

Would you have injured yourself if your hamstring flexibility was better? E response is "maybe". Why maybe? E thing is, flexible people become injured just like non- adaptive people, and it's very hard to prove that stretching reduces your risk of pulling a muscle (actually some research from sport suggests that too much extending at the wrong time, i.e. prior to sport, may actually increase the risk of muscle strains). Logic suggests that in the event that you increase the operational range of movement of your muscles, then you are much less inclined to overstretch them. Is doesn't, however, assure that you'll remain injury free but if reduce your chances -- but by how far it's impossible to say.

Going back to our pairs of muscles version discussed earlier, muscle length imbalances can also have a negative impact on your posture. Posture is best called the best alignment of joints so that no or little force is set on passive structures such as cartilage or ligaments. Posture is generally connected to the place of your spine and neck but can also be applied to your shoulders, knees and hips.

Poor posture is often caused by two linked factors -- too tight muscles and overly weak muscles. Commonly, if one muscle in a pairing is tight, then its opposite number will be feeble. Is is because of a phenomenon called reciprocal inhibition.

Consider this case: a wannabe bodybuilder performs lots of sets of chest exercises. He does multiple sets of bench press, barbell, dips, press ups and utilizes a pec deck. As a result, his torso gets very powerful but also very tight. His tight chest muscles pull his shoulders forward into what's commonly called a protracted position. As a result of the overactive pecs, the opposing muscles, specifically the middle trapezius, rhomboids and posterior deltoids, become inhibited and weak.

Try as he would, our bodybuilder is unable to overcome the strain in his chest muscles and pull back his shoulders into optimal postural posture because the upper back muscles are inhibited and partly "switched off ". That is reciprocal inhibition.

To correct such a substantial postural imbalance, it might be essential to relax the overactive torso muscles using stretching and possible massage while reawakening and strengthening those inhibited muscles of the upper back.

One last benefit of extending is an increase in operational range of movement that contributes to improved efficacy. Fundamentally, your limbs will be free to move though a wider arc. Is is especially important for sportsmen and sportswomen.

For instance, to be an effective sprinter, then you need to cover the ground as fast as possible. Is requires electricity, a fast leg turnover AND the ability to cover a large distance in each stride. If, because of tight muscles, your stride length is significantly diminished, you won't be able to sprint up to per stride and then will cover the ground less efficiently.

The same holds for a boxer, although the implications are slightly different. Most boxers choose to hit than be struck so a long reach is quite important. A prosperous punch is powerful and fast but, if you're able to stay out of your opponent's reach, you are more inclined to avoid a painful counterpunch. Good flexibility can mean a longer punch and subsequently, permit you to remain out of range of your competitor.

As a final example, envision a climber reaching up to catch a very small handhold while hundreds of feet up a rock face. Fantastic lat, arm and shoulder flexibility may indicate the difference between attaining the hold and continuing upward or missing the hold and having to climb back down.

As you can see, flexibility is a vital part of fitness and can make a big difference between success and failure in both sport and exercise. At the very least, stretching is vital for ensuring that your muscles do not get shorter as a consequence of the actions you are doing. Whether stretching reduces your chances of injury is hard to say but when there is even a slight possibility that a couple of minutes of flexibility training might help save you weeks of rehabilitation and pain, then there is actually no good reason not to stretch.

3. Specifics Of Flexibility... How Flexible Do You Need To Be?

We've established that stretching is a good thing and being flexible is important, but just how flexible if we try to be? Is it crucial to have the ability to contort yourself as a yogi or is a more moderate outcome more desirable?

In regards to flexibility, the bottom line is that you need to be as flexible as you need to be! I know this might sound like any kind of Zen conundrum but that is the truth about extending. Every one of us has different flexibility demands depending on our chosen sports, favored form of training, everyday activity patterns and so forth. What could be sufficient for a single person may be nowhere near flexible enough for another.

What is crucial when training for flexibility is to make sure you prepare your body for the tasks

It is most likely to face. For example, a gymnast or high board diver needs much more versatility than a cyclist. The abilities in gymnastics require a high amount of flexibility in virtually every joint of the body whereas biking uses a much smaller motion and so the flexibility demand is much less. That isn't to state the cyclist doesn't need to stretch -- just that their versatility program will be more aligned to minimizing excessive adaptive shortening and promoting good posture. Conversely, the gymnast will need to come up with a high degree of flexibility for performance reasons. Both athletes will need to elongate but the result goal is extremely different.

Precisely the same is true of sports like sports. For example, high hurdlers need a Massive amount Of hip and hamstring flexibility to get in the right position in the air so they skim over the top of their barriers. But a 10,000-meter-runner employs a much smaller variety of motion than a hurdler and would not bene t from such intense versatility.

In chapter Ve you will find out how to evaluate your own flexibility and see if you come up to the minimum criteria required to make sure your joints are able to work as they need to. Any flexibility in excess of these measures depends on what you're stretching for.

In my personal experience, I've noticed that, in the majority of instances, extreme flexibility is o en demonstrated by People Who have no need for such extended ranges Of motion. Getting adaptable for flexibility's sake is little more than a waste of time and may even be the cause of musculoskeletal problems. Extreme flexibility can lead to joint hyper-mobility that could lead to bony surfaces coming into contact in a manner that they were not supposed to. As an example, very flexible hamstrings could result in hyperextension of the knee joint which may predispose the exerciser to atherosclerosis. E same holds of an overly flexible backbone -- the curse of several gymnasts and dancers.

I suggest you get your endurance levels into a point where you can fulfill the basic standards set out in chapter five and after that, if needed for your chosen game, exceed these by Enough that your flexibility is optimized for maximum performance. Unless there is a extending world championship or you are likely to run o and join the circus for a contortionist, extreme versatility is neither necessary nor desired!

4. Stretching Dos & Don'ts... How To Get The Most From It

Before you knuckle down to some serious stretching, it's crucial that you set a few flexibility rules and guidelines. These bullet points are designed to make your flexibility training as safe and productive as possible so It is going to pay to invest a few Minutes ensuring you understand all the next.

Stretching Dos...

Do ease into your stretches gradually. It takes a couple of seconds for the mechanisms that control your level of stretch to kick in and allow you to stretch safely and deeply. Take 20-30 minutes to facilitate into heavy stretches to minimize your chance of injury.

Do extend often. A once-a-week marathon extending session is not likely to have much of an impact on your endurance. You have to stretch little and o en route to make a noticeable difference.

Do unwind as much as you can. Tensing your face or neck when stretching other parts of your body sends the wrong signals to your stretching mechanisms and will inhibit the degree of stretch you may encounter. Attempt to eliminate all tension from your body when extending and not just the muscle you are working to lengthen.

Do make sure that your muscles are warm before stretching. Cold muscles can easily Be injured by over-enthusiastic stretching. Perform some mild cardio and joint mobility work until you attempt any deep stretches and remember to ease into them gradually. Always increase your body temperature first (jog, cycle for a few minutes or even stretch out a er a spa or shower).

Do consider stretching out of your normal workout time. While stretching after your exercise is convenient and logical, you may be overly tired and your muscles overly excited to relax properly. O en, the best time to stretch is when you are feeling relaxed and calm. A few stretches while seated before the TV at the day can be very relaxing and valuable.

Do chose the proper stretches for the ideal moment. There is a lot of information on this topic in chapter six but as a general guideline; static or static stretches are ideal for your cool down while dynamic stretches are ideal for your hot up.

Do focus on the muscles that need the most attention. If you have an especially tight muscle, try to stretch it three to five times every day to help recover the missing range of motion as quickly as possible.

Stretching Don’ts...

Do not bounce when stretching. Bouncing in a stretched position tells your muscles to tighten up and can be called ballistic stretching. If any type of stretch is going to cause harm it's bouncy ballistic stretches! There is more on ballistic flexibility and the reason to avoid it in chapter six.

Do not neglect hydration. Water is an essential part of your muscle building make-up and being dehydrated can impair flexibility. Ensure you are well hydrated by sipping plenty of water during the day. Aim for at least 2 liters of water per day -- more if you exercise aggressively or live in a hot climate.

Don't hold your breath when extending. Is will create tension elsewhere in the human body and negate some of the benefits of stretching. Breathe slowly and deeply to make certain you keep nice and relaxed. In yoga, practitioners are taught to imagine their breath is being directed to the muscle being stretched -- this can be a helpful image to use if you're finding it difficult to relax.

Do not stretch beyond your comfort point. If your muscles are burning or shaking as you stretch, chances are you have gone too far. Back o and then ease back in the stretch. If you feel your muscles have started to cramp up, cease stretching altogether and try again later.

Do not feel you have to stretch each and every muscle to the same duration. Or even at all! If you have tight muscles subsequently x them together with developmental static stretching but when your muscles are relaxed and the right resting length, some rapid stretches for upkeep or even not stretching them whatsoever is also okay.

5. Flexibility Self-Assessments

You can, of course, only stretch every muscle in your body in a "hell for leather" style and hope you are giving your body what it needs. The difficulty with this approach is the fact that it is more hit and expect than a prescription of proper exercise.

Instead of risk wasting time by performing unnecessary moves, you should assess your present flexibility requirements and design your extending program on these results. Should you come up to or are simply shy of reaching these minimal standards then you probably don't need much more than to ensure you stretch correctly in the end of each exercise. If, however, you're a very long way o those standards, you may wish to consider a couple of committed stretching sessions per day until your flexibility is all up to standard.

Keep in mind, these are minimums that nearly everybody should achieve. If your game demands it, you might have to achieve higher levels of flexibility but that is between you and your coach.

Most of these assessments require a partner who will passively stretch your muscles to Obtain the desired outcome. Make sure they read these instructions carefully to avoid providing you with a false result. Additionally, make sure they're comfortable and capable of handling your limbs safely, as over stretching a muscle, even in a flexibility assessment, could lead to an injury.

Note: this Isn't an exhaustive list of flexibility evaluation exercises but covers the main muscles that most of us have to operate on. If your sport has specific flexibility demands, don't hesitate to add suitable tests in to this battery.

Remember to warm up by spending three to five minutes doing some light cardio and then a few dynamic stretches as discussed in chapter six. Perform each test two or 3 times to make certain you receive the most meaningful outcome and, where appropriate, compare your left limb into your right limb. It isn't sufficient that you get to the mandatory minimum standard for these tests but additionally that both limbs are equally flexible.

Log your results in the chart at the end of the chapter and retest regularly to measure progress.

Note: With the exception of the last two tests, these evaluations are supposed to be PASSIVE. At is to say that you, the subject, do nothing. You have to keep your limbs utterly relaxed and allow your partner to discover the magnitude of your flexibility. Is can be hard but any undue tension will invalidate the outcome of the tests.

Warning! Approach the end-range of each test carefully and don't force limbs into unnatural positions. E tester should feel the tension rise in the muscles being Analyzed and be able to expect the approximate end point for each assessment. Ensure that there's plenty of communication between tester and subject so that the assessments are safe and meaningful. If any bony blocks or crepitus (crunching, Clicking or popping) are felt/heard proceed with caution if at all.

Science based chiropractor, Dr. Alexander Jimenez takes a look at the patho-anatomy of a side strain and outlines clinical tests to assess, treat and determine readiness for return to play for a cricket fast bowler.

Side strains are reported in a number of sports, such as javelin throwers, baseball pitchers, tennis players, golfers and cricketers. This article however will focus on side strains in cricketers. Australian cricket information (according to both national and state gamers) reports that in the 18 cricket seasons up to 2013-2014, side breeds had the second greatest incidence and the third greatest incidence of accidents that led to players lost games(1). More than 90% of the reported unwanted strains (called acute onset lateral back pain and also happen throughout the bowling delivery) at cricketers over the past twenty years have happened in fast bowlers(1).

What Is A Side Strain?

A side strain in cricket happens most commonly when bowling. Fast bowlers will describe that through a single delivery, they believed abrupt onset, sharp lateral trunk pain on the side contralateral to their bowling arm(two). On most occasions the bowler is not able to continue bowling (while this isn't always the case) and also often the player will leave the area. The mechanism of injury is thought to be related to the bowler; their quest to increase ball speed, vigorously pulling the front arm (contralateral side to their bowling arm) down causing a strain (see figure 1).

Age and intensity are also potential risk factors for a negative strain(1). Younger bowlers (under 24years of age) have been demonstrated to be twice as likely to suffer harm as those aged between 25-29 and 3 times more likely than bowlers more than 30 years(1). Side strains also occur more commonly in the first portion of the season and most happen during early season games. This implies that changes in intensity from training to aggressive games may contribute to the likelihood of harm in the first parts of a year. With most recurrences of unwanted strain happening within a year, increases in intensity might also be a risk factor in recurrences(1). Interestingly there seems to be no further increase in risk if a negative strain is reported at a previous season.

Clinical Presentation

The quick bowler will commonly report an acute localized sharp lateral back pain (frequently at the mid axillary line) which occurred during their delivery. They might also clarify pain with breathing, coughing and coughing, and they are sometimes quite uncomfortable moving around particularly rolling over in bed. The pain may radiate slightly into the abdominal area. From this description alone a side strain is highly likely. Some useful clinical evaluations that help to confirm the identification (and track its development) are as follows:

• Palpation -- A player with a side strain will be extremely tender over one or more of the lower four ribs (most commonly at the mid axillary line).
• Lateral flexion assortment of motion (ROM) evaluation ROM (see Figure 2) -- The participant stands side on to a wall with feet pelvis width apart, and the pelvis and the lateral border of one foot up against a wall. The hand closest to wall is placed on their mind. Together with the pelvis remaining connected with the wall, the player is then requested to only laterally flex away (avoiding truck flexion or extension) from the wall so far as they can and the therapist steps how far in the ground their middle finger may reach their leg down. This evaluation in the early stage is often both restricted and painful. The therapist steps both the distance and where the restriction is felt -- such as 'jamming' on ipsilateral side or 'stretch' on contralateral side. These results can then be compared with all the non-injured side and/or previous measures. This evaluation is also used as a monitoring tool during a year to determine 'normal selection and feeling' and may pick early indications of tightness. Post injury, players need to have the ability to return to complete lateral flexion assortment of motion and their normal limitation feeling.

Side Pain Contraction Tests

(Note -- these evaluations are progressive with stage 1 being the easiest and stage 3 the toughest. Once a player is pain-free on a single point, the testing could be improved to the next phase.)

Alternative Contraction Tests

Imaging

Identification of a side strain is generally a clinical diagnosis based on the explanation of positive and injury findings summarized previously. Imaging is however beneficial in deciding the degree of damage and precise structures involved(two). Ultrasound may be used however, MRI is the modality of choice. On MRI, an acute side strain is characterized by high signal on T2 image at the muscular, rib/costal cartilage port, and frequently shows partial or complete rest of the abdominal musculature(two). The internal oblique at its attachment on the 11th rib is the most frequent muscle hurt. But, pathology has also been reported in external oblique, transversus abdominus and abdominal muscular attachments of their 9-12th ribs(1,2). MRI imaging may also show rib or costal cartilage damage, including bone strain, bone avulsion or periosteal stripping(1). With these harms, hematoma may be viewed tracking between the internal and external oblique musculature(1). Figure 10 shows a MRI image of an elite level fast bowler with a tear of the inner muscle as it attaches onto the 11th rib.

Differential Diagnosis

Other possible diagnoses that should be considered when analyzing a bowler with side pain are:

• Costoiliac impingement. This happens as a consequence of a drop in space between the lower ribs and pelvis, and might be due to either a hypertrophied internal/external oblique muscle, rib hypertrophy or a hypersensitive scar from a former side strain.
• Referral from thoracic spine and/or either costotransverse or costovertebral joints.

Table 1 summarizes common clinical findings of each of these pathologies and may be utilized as a guide to help the clinician differentiate.

Treatment

At the first stages, the principal intention is to decrease pain especially if coughing, breathing and sneezing are debilitating. This can be done via the usage of pain-relieving medication in the acute phase. After the player can deep breathe and cough afterward cardiovascular training can commence -- initially with bike or walking and then progressing to running as pain allows.

• Soft tissue work throughout abdominal musculature including obliques, and rectus abdominus.
• Thoracic spine and rib mobilisation.
• Gentle stretching to contralateral side, together with deep-breathing drills to help expand ribs.
• Dry needling.

Strengthening ought to also be started as soon as pain allows. This should commence with isometric exercises, and advancement to impede through-the-range exercises. At length, higher-speed drills and sport-specific drills can help prepare for the intensity of bowling. Some examples of useful exercises for each of those stages are:

A player can start a return to bowling plan when they have:

The duration of time to return to play with this harm varies substantially with reports ranging from one to seventy times(1). Rehabilitation should be directed by a player's symptoms rather than based on scanning results or a predetermined time. In season recurrence rates are high with this injury, and as such, the return to bowling plan requires to a graded return to both intensity and volume.

Table 2 shows an example of graduated return to bowling plan for a player who returned to play at week six. Anecdotally, harms that involve the rib/costal cartilage tend to take longer than those that simply involve muscle. However, further study is needed comparing scan time and results to come back to play until this is confirmed.

Conclusion

Negative breeds are a common and significant injury to cricket fast bowlers as they often require considerable periods of rehabilitation and inability to perform. The clinician should be aware that this harm has a high 'within-season' recurrence rate and a graded return to high-intensity bowling is integral part of the rehab process. Further studies have to determine risk factors and also the relationship between imaging findings and time frames for returning to play.

References
1. J Sci Med Sport. 2017 Mar;20(3):261-266
2. British Sports Med 2004 38 (5): e21

There's so much more to stretching than just extending. Chiropractic sports injury specialist, Dr. Alexander Jimenez compares, contrasts & debunks.

Stretching is now a science. A developing understanding of the physiology of stretching means sports support professionals finally have a enormous variety of methods to use with clients for training, injury prevention and rehabilitation. This report provides an summary of some of the most popular types of extending, their benefits and drawbacks, in order to help therapists and trainers pick the most important forms for their clients. I have used the description of a hamstring muscle stretch in every instance to illustrate the various techniques.

Active Stretching (Static)

Popularized in the 1980s by Bob Anderson(1), an active stretch is one in which the client performs the stretch unaided. There's little if any motion as the controlled stretch position is maintained for approximately 30 seconds, then occasionally repeated. Inherent into the practice of yoga, physiologically this Kind of stretch has been termed 'a form of visoelastic myofascial release'(two). Put simply, muscles and their associated fascia begin to lengthen slowly in response to a gentle and constant load.

In therapeutic terms this physiological response is a real property of fascia and muscle known as 'creep'. The fact that the load applied is continuous and gentle is key to the efficacy of active stretching.

Many people wrongly believe that active static stretching can aid warm-ups and cool-downs, reduce DOMS, reduce injury, and enhance athletic performance. There is not much evidence to support these beliefs (3).

How To Do It

A static active hamstring stretch might be done by lying supine, clasping the hands behind an extended knee and flexing at the hip to produce the stretch. Hold the position stable for approx 30 minutes prior to releasing and optionally repeating.

Advantages

• Client can carry out the stretch themselves in the home or after exercise to maintain joint range.
• Gives the athlete control over their own rehab or flexibility routine.
• Useful if the athlete doesn't have access to a trainer or therapist.
• Can be done nearly anywhere and in any time.
• No equipment is necessary.
• Is comparatively simple.
• Strengthens agonistic muscles (see below).
• Is known to enhance range of movement.
• Is allegedly safe.
• Could possibly be utilised in early-stage rehabilitation.

Disadvantages

• Inexperienced clients may embrace an incorrect position and fail to stretch the intended muscle.
• The athlete may not maintain the stretch place for long enough.
• The technique demands strength in the agonistic muscles, which may be troublesome for inactive customers or those with muscle atrophy (although arguably it is also great for them -- view key benefits below).
•  It is boring.
• Most sporting movements are ballistic in nature, so for many athletes there may be little practical bene t from raising static flexibility.

Key Benefits

• Useful in a clinical setting where flexibility has been limited by weakness at the agonist muscles being used to bring about the stretch (as an Example, a sportsperson needing to Obtain knee extension after knee surgery or a hamstring injury where maintenance of quadriceps strength is as important as hamstring rehabilitation).
•  Coupled with controlled breathing, it might be helpful within a comfort program.

Passive Stretching

While an athlete can do passive stretches unaided, by utilizing a piece of gear, the expression is commonly utilized to indicate that another person is needed to help bring about the stretch. This individual is often another team participant, the trainer or a therapist. No muscles are contracted as a way to bring about the stretch.

How To Do It

A passive hamstring stretch might be done lying in supine, using a towel hooked around the thigh to help to bring the hip to flexion in order to extend the hamstring muscles without deliberate contraction of quadriceps. Instead in supine, a coach uses the straight leg raise position to extend the client's hamstring.

Advantages

• Makes stretching less effortful, since the client relaxes into a position that makes it possible for the trainer to facilitate the stretch.
•  When done as a member of a group action, can make stretching more enjoyable, facilitate concern for fellow staff members and enhance feelings of advancement.
•  Is relatively easy to do.
•  Can be performed almost anywhere.
• No equipment is needed.

Disadvantages

• Unless gear is used, a stretching partner is necessary.
• There's a danger of the athlete being overstretched by an inexperienced partner.
• The athlete must trust their partner.

Key Benefits

• Passive spouse stretching is a great option when flexibility is limited by the elasticity of this muscle/s to be stretched.
• Also useful therapeutically when the agonist is too weak to result in a successful active stretch.

Active (Ballistic) Stretching

The stretched muscles serve as a kind of spring to assist the athlete bounce repeatedly and rhythmically in and out of the stretch place, in effect producing several tiny moves. Muscles are not allowed to stay in the extended position even for a few seconds. Instead, the athlete uses momentum to stretch into and beyond their end of scope position with the intent of raising range of movement (ROM) with subsequent movements.

The degree to which ROM is expected to improve with each stretch is not given in research, nor is there a recommended number or variety of stretches required for every targeted muscle (contrast this with AIS below).

Ballistic stretching can significantly raise tendon elasticity(4), a more useful finnding given that tendon elasticity seems crucial to the discharge of stored energy employed in several sports.

Nick Grantham(5) has previously pointed out the similarities between ballistic stretching and the more recent variant of dynamic stretching where controlled leg and arm movements are used to help take the limb into the constraints of the associated joint variety. He notes that in the latter circumstance, movements are gentle and controlled, whereas in ballistic stretching they are forceful and less controlled.

Plyometrics is another form of ballistic training. It utilizes the elastic recoil of this muscle-tendon unit following a surprising stretch of the muscle to enhance muscle strength and is thus helpful in explosive sports. As an instance, after a leap, the muscle-tendon device of the ankle plantar flexors is stretched as the plantar flexors (gastrocnemius and soleus) are eccentrically contracting to help slow the entire body once the feet hit the ground and the ankle begins to dorsi flex. As Sean Fyfe describes(6): '...this stretch-upon-impact can lead to the muscle building larger elastic force in response to the stretch.'

From a security point of view, ballistic stretching is controversial on the grounds that it does not permit sufficient time for tissue adaptation and carries a relatively high risk of harm if poorly implemented. A sudden stretch may stimulate the stretch re ex, muscles contract, muscle strain increases and cells become more challenging to stretch, beating the object of the activity. However, advocates of plyometric training argue that, properly regulated, it plays an important part in late stage rehabilitation, as plyometric movements (running, jumping and throwing) occur widely in sport (6).

How To Do It

A ballistic hamstring stretch may be done standing, bent in the trunk. With straight legs. Make small bounces up and down, trying to touch your toes (this also affects spinal extensors, not just hamstrings).

Advantages

• Reportedly useful for sports with a ballistic component, such as kick boxing.
• Helps build lively versatility, so can be used to increase training specificity.
• Performed after static stretching, it seems to contribute to greater flexibility.
• Clients may do it in your home or following exercise.
• Gives an athlete management over their own flexibility routine.
• Might be done almost anytime, anyplace.
• Does not need any equipment.
• Is relatively easy.

Disadvantages

• Critics think the ballistic movement is more likely to damage muscles, since there isn't sufficient time for creep to occur in soft tissues.
• Can't be used in early-stage rehab.
• The sudden stretch stimulates the stretch re ex, increasing muscle tone and making it harder to extend the muscle.
• Shouldn't therefore be relied on in order to attain developmental flexibility or permanent lengthening of cells, as fast/high-force extending tends to increase muscular stiffness.
• If tissues are stretched too quickly in 1 movement, they may tear, leading to soreness and limited ROM.
• Because of a scarcity of investigation (ethically it is hard to test potentially damaging kinds of stretching), it is not clear what effect ballistic stretching has on range of motion.

Variation

A version of active/ballistic stretching known as busy isolated stretch (AIS) involves stretching one isolated muscle at a time by repeatedly hammering the opposite muscle for only 2 seconds, up to ten times. For each contract/relax, the resistant stage is surpassed by 1-4°. Alter (3), in his literature review of AIS, found 10 almost equal variants on this kind of extending, each using a different title, and differing only on the matter of this 2-second protocol.

AIS (also referred to as the Mattes Method after its developer, Aaron L Mattes) seems to differ in ballistic stretching in 2 ways: it's formulaic in its protocol, and in ballistic stretching the stretch isn't held but simply 'bounced' out of.

PNF Stretching

Developed in the 1940s as a physical therapy to help rehabilitate victims of migraines, there are many forms of proprioceptive neuromuscular facilitation (PNF), all of which use effective muscle contractions.

Probably the most recognizable is the 'single airplane' PNF technique, where an athlete's muscle is accepted several times to a stage of immunity and the athlete restricts the muscle isometrically (often using a coaching partner or therapist as resistance), even before the muscle is then stretched either actively by the client or passively from the spouse. One of the most exhaustive and well-known books on the topic is by McAtee and Charland (7).

The Way To Do It

To carry out a PNF hamstring stretch, in supine the hamstrings are taken into mild stretch. The athlete then isometrically contracts the hamstrings, while the partner provides resistance. There's no consensus on how long to maintain or how powerfully to contract the stretching muscle. Generally PNF contractions are more powerful than those used in MET (see below). Following an agreed period, eg, 6 to ten seconds, the athlete relaxes the hamstrings and the muscle is actively or passively eased to a lengthened position, where the stretch is replicated.

Advantages

• More pleasurable and less boring than straightforward static stretching.

• Improves range of motion.

• Advocates claim many other benefits including improved strength, improved joint stability, improved co-ordination, improved endurance, improved blood circulation.

Disadvantages

• Normally requires a partner.
• Since there are many variants, athlete and spouse / therapist / trainer have to be clear about which protocol they are using.
• There could be more stress in the muscle being stretched than happens in active stretching, raising the potential danger of this technique.
• Done incorrectly, may cause harm, eg, from over- extending by a zealous partner.
• May not be suitable for hypertensive clients, since there's a possibility of the valsalva phenomenon occurring during isometric contraction (customer holds their breath after deep motivation, increasing systolic pressure).
  Key Benefits
• Good for highly motivated people and to aid team- building, in which staff members are encouraged to stretch each other.
• Specific forms may be useful therapeutically where active movement isn't feasible because of pain or weakness, or ROM severely restricted.

Variation

PNF can also involve spiral diagonal patterns of motion, on the premise that muscles have a tendency to spiral around bones; this form of stretch intends to maximize natural motion patterns.

MET Stretching

Muscle energy technique (MET) originated from the late 1950s/early 1960s as an osteopathic technique, by the work of individuals like TJ Ruddy and Fred Mitchell Snr. The main differences between MET and PNF lie inside their roots, coming as they do from two distinct disciplines. This gives rise to different terminology, which can be widespread anyhow within the subject of extending -- helping to add to the confusion.

In technical terms, the force of contraction exerted by a client utilizing MET is reduced in contrast to PNF. The use of submaximal contractions has been shown to be equally as beneficial since maximal contractions at enhancing hamstring flexibility in areas not able to reach 70° of hip flexion, and might therefore be safer in early-stage rehabilitation of cartilage and muscle injuries(8).

There are many variations and applications of MET(two). At its simplest, the therapist requires a client's muscle into a point of mild tension, in which the customer contracts it isometrically (up to 20 percent of their force), whereas the therapist provides resistance.

The muscle can be lengthened either following regeneration, when the client relaxes (called post-isometric relaxation extending, PIR); or during contraction (an isolytic contraction, where the muscle is having to contract eccentrically). In this second kind of MET, rather than fitting the force of the client's contraction, the therapist accomplishes it, raising ROM in the associated joint, thereby stretching the contracting muscle.

MET is gentle and may be used without the stretching component. The very low-level contractions involved in the procedure may be helpful in early stage rehabilitation, to help grow or maintain muscle strength when tissues are in the initial stages of repair.

How To Do It

To carry out a MET hamstring stretch in supine, the client actively exes the hip to its maximum with knee bends, then extends the knee until they reach a point of mild stretch/restriction (therapists can refer to this as the 'point of glancing' or ' first barrier'). The therapist maintains that this position while the athlete tries to ex the knee by contracting the hamstrings, using up to 20 percent of their force, making an isometric contraction resisted by the therapist for 7-10 minutes. The client relaxes and on exhalation, the therapist gently extends the knee to the new barrier position. This place is held for 10-30 minutes and the procedure repeated.

Advantages

• Stretches soft and muscle tissue.
• Strengthens muscle.
• Relaxes muscle.
• Helps regain correct muscle functioning.
• Enhances local circulation.
• Helps to de-activate trigger points.
• Contrary to PNF, among the goals of MET is combined mobilization.
• Advocates claim there are no contraindications.

Disadvantages

• There are many distinct kinds of the technique and coaching is needed to understand how and when to utilize them.

Key Benefits

MET is used to deal with many patterns of muscle dysfunction. Chaitow (2) explains in detail the use of eight variants on the basic MET technique and when they might be implemented.

Soft Tissue Release Stretching

Utilized by physiotherapists, this entails 'locking' a passively shortened muscle close to, or on its own origin prior to stretching the muscle. By forming a false source, the stretch could be applied specifically to areas of brotic tissue.

Advantages

• Stress and stretch are believed to ease a lengthening of soft tissues and an increase in range of motion (9).
• Certain stretches may be performed either actively or passively.
• Comparatively easy to use.
• Performed knowingly, the only equipment needed is a tennis ball.
• Can readily be incorporated into a massage series, so can be helpful where massage is indicated as part of a rehab or care program.
• Helps de-activate activate points.

Disadvantages

• Therapists will need to learn the method, which can take many forms.
• Cannot be used on all customers (eg, people who bruise easily and have fragile skin).
• May result in soreness, very similar to DOMS.

Key Benefits

• Useful where a client can't take a joint through a full range because of injury, or with hypermobile clients where starting a stretch at the end point may not be desirable.
• Valuable for targeting areas of fibrotic tissue in muscles which might otherwise not be stretched with gross active stretching.

Conclusion

This summary isn't meant to be comprehensive -- there is not any space here, for example, to cover techniques like tractioning, neural mobilization and non-traditional kinds of extending. All kinds of stretching can be utilized within a sports-specific endurance regular; it's all up to this support professional to comprehend the repertoire available to help optimize the benefits to their client.

References
1. Anderson B (1981) Stretching.
2. Chaitow L (2001) Muscle Energy Techniques. Churchill Livingstone.
3. Talter, Michael J (2004) Science of Flexibility. Human Kinetics.
4. Witvrouw E, Mahieu N, Roosen P and McNair P (2007) The role of stretching in tendon injuries, Br J Sports Med 41: 224-226.
5. Grantham, Nick (2008) Dynamic flexibility, Sports Injury Bulletin 77, March.
6. Fyfe S (2007) Why you should put plyometric into rehab, Sports Injury Bulletin 71 July/Aug.
7. McAtee E and J Charland (1999) Facilitated Stretching. Human Kinetics.
8. Feland JB and Marin HN (2004) Effect of submaximal contraction intensity in contract-relax proprioceptive neuromuscular facilitation stretching, Br J Sports Med 38 e18.
9. Sanderson M (2002) Soft Tissue Release.

This case study has one of those treatment results that makes you believe you've made a massive difference to somebody's life. Scientific injury specialist, Dr. Alexander Jimenez investigates the case research.

This patient, Mel, loves mountain running. Much of her week revolves round instruction, getting ready for the long term in the weekend, and finally the large competition. I first analyzed her about six weeks out from a race called the Kokoda Challenge, a 96km team race. She was fighting with just two complaints. The first, and lesser, was repeated ankle sprains on both legs; the second has been chronic iliotibial band (ITB) problems, again on both sides. Though these are clearly two distinct issues, they are not entirely separate, as we will see.

Mel was always running on uneven, rocky ground and would roll her ankles several times during training and competition run. On assessment, she demonstrated laxity on both ankles from the anterior talofibular ligament (ATFL, the most commonly strained ligament of the ankle). There was no joint effusion or pain, just increased plantar flexion and inversion and increased joint movement on the ATFL anterior pull test.

Her proprioception was, to put it mildly, terrible. When balancing on one foot, then she'd eliminate balance immediately upon closing her eyes. She was not able to balance on the ball of her foot on one leg, and could not grip balance on one leg when utilizing any balance device such as a wobble board or Bosu ball.

The immediate goal was to stop her rolling her ankles, to prevent long-term joint damage and, importantly, to lower the risk of a serious acute ankle injury -- a risk that is clearly inherent in the nature of her chosen sport. The answer was straightforward: we needed to retrain Mel's proprioception.

And now to Mel's ITB problems. She'd suffered from lateral knee pain for approximately a year. She had fought through the pain in training; it'd come on after distinct distances, but would usually start when she had been going downhill.

Since she had had this problem for quite a very long time and past remedy hadn't been successful, an MRI was indicated; this revealed irritation of this under-surface of the ITB and some quite mild bony inflammation at the lateral femoral condyle. In consultation with all the sports physician, we determined that a cortisone shot would be appropriate. This would permit Mel to carry on doing some running and create a window for a few rehab work. Mel, however, wasn't keen on the concept of an injection and preferred to attempt rehab alone first.

Upon evaluation, she'd just moderate tensor fascia latae, hip flexor and ITB tightness, which we handled with soft tissue massage, trigger points and extending. But these measures didn't actually target the underlying difficulty. Mel managed to continue doing and running her rehab but with the continuing deficit within her range of motion. Back in 1994 Bullock-Saxton, Janda et al (1) revealed that the substantial difference in patterns of muscular activation around the hip in normal subjects in comparison to people who had previously suffered a serious ankle sprain. They revealed that activation of gluteus maximus was postponed on the previously injured side which changes happened in the neighborhood perception of vibration on both the injured and non-insured sides.

On testing, Mel's gluteus maximus activation was very poor. In more than hip extension, it had been nearly non-existent and she fought with another hip expansion- dominant exercise.

And she was finding single-leg stance exercises hard not only because of her lack of proprioception but also because of poor gluteus medius function, evident in isolated hip abduction in side lying, and single-leg posture exercises.

To sum up, Mel, who had been attempting to compete in endurance mountain races, had:

Her running gait represented this great deal perfectly. She conducted with a lengthy stride length. Her heels strike occurred way out before her hip (rather than beneath it), constantly putting gluteus maximus into a lengthened position. This was making it more challenging for the muscle to contract and extend the hip. So Mel was pulling herself along with her hip flexors and rotating her pelvis with a rather forceful hip extension so that she could propel her body forwards at heel strike.

Due to her long stride length, she crossed her midline by a massive level, ramping up the demand on her already weak gluteus medius. It wasn't surprising that in stance stage her pelvis exhibited considerable lateral tilt.

It's worth mentioning that elite runners also often drift across the midline, since they, also, run with a long stride length. The difference is that their greater stride length comes from their strong propulsion through each stride; heel-strike remains firmly beneath the hip.

Not only does a running gait such as Mel's lead to harm, but it is also very inefficient. Because her posture stage was very lengthy, any elastic energy saved from the initial ground contact was lost, causing her to have to work harder to transfer energy with every stride.

That is the reason elite runners tend not to have a heel-toe working routine: they are moving so efficiently that a heel-toe pattern could cause them to spend too long on the floor and therefore lose too much energy. A key aim of all runners -- out of track to marathon -- ought to be to reduce ground contact time, so as to boost efficiency and hence speed.

Rehab

Mel did not want to quit running, despite pleas, because running was more than just exercise for her. Much like many people, it was her solitude and anxiety relief. We had to prioritize proprioception, to attempt to improve this until she suffered a severe ankle injury.

We began with low-level workouts, for example:

Other high-level exercises contained:

• balancing on a wobble board while catching and throwing a ball

• single-leg knee bends on the Bosu ball.

There are just two major goals with proprioceptive training. Firstly, to improve the role of the proprioceptive system with increasingly more difficult activities and secondly (especially essential in Mel's situation, as she had been running long distances on uneven ground), to increase the endurance of their neuromuscular system.

We started her on non invasive activation drills because of her gluteus maximus and gluteus medius. For the glute maximum, she needed to lie prone and practice squeezing left and right glutes together and then isolating each side.

This progressed to prone hip extension, focusing on isolating glute max contraction while maintaining neutral pelvis and spine. Mel also did single-leg bridge exercises, again concentrating initially on squeezing the glute maximum and then extending the hip, but not arching the lumbar spine. We encouraged her to concentrate on feeling like she had been tripping her gluteus maximus in walking and specifically on staircase.

For gluteus medius activation, we utilized clams (side-lying with hips flexed to 30°, heels together and lifting top knee apart without the pelvis shifting; see Fig 1, below) and side-lying hip abduction with a straight leg.

Once Mel had finished these, she improved to standing drills, starting with squats. First we utilized double-leg squatting to boost gluteus maximus power bilaterally, then single-leg squats to add an emphasis on gluteus medius, so as to stabilize the pelvis and knee.

We later introduced the technically demanding Romanian deadlifts (RDLs). These, I believe, are the ideal method for athletes to reinforce the gluteus maximus. Mel finally progressed to single-leg RDLs, an extremely ambitious exercise, which definitely must be worked up to.

Gluteus medius endurance bilaterally was worked on with "crab walk". This involves looping a flexband round the ankles in standing, assuming a semi-squat and widening the stance, then taking little sideways shuffling steps with one foot, then the other, while keeping up the strain on the ring. This impacts the gluteus medius muscles; it can be progressed by increasing the amount of steps or utilizing a more powerful group.

Not Any Old Exercises...

We tailored all of the strengthening exercises to suit Mel's specific sporting needs. She needed to possess exceptional endurance in all those critical muscles we were targeting if she had been going to keep an efficient gait through an occasion. Her program was so designed to signify this, with lower weights but higher repetitions (beginning at 15), and even more than the standard three sets. All these additional repetitions had the additional advantage of assisting her more quickly hard- wire the beneficial motor patterns.

It also meant she had to work very hard indeed on her rehab. Especially during the late-stage rehab, the sessions were very arduous. But then, she wasn't trying to perform what could be considered normal for a 43-year-old girl. One bonus was that since the subsequent sessions were so tough, she had to take adequate recovery period, which restricted her into a maximum of 3 sessions weekly. Mel became technically very capable and powerful; she proceeds to perform her exercises frequently as maintenance.

Running Form

The running procedure re-education was quite simple. We focused on shortening Mel's stride and getting her to feel as though her heel strike was back beneath her body rather than straying over the midline. Next, she had to feel as though she immediately propelled her entire body over her foot, to make a decline in her ground contact time. We also cued her to feel her gluteus maximus contracting as she extended her hip. As she had good body awareness, this worked well for her. I also invited her to connect up the feeling she had been getting in the gym rehabilitation work together with how her gluteals were functioning in her running.

But she wanted to try anyhow. As anticipated, she did not make it and her knees were an issue. But at least she'd ceased rolling her legs. She also began running again, with all the pain improving and still no rolling of their ankles. Mel had a favourite 18km training loop she liked to do regularly and she began running that pain-free -- that she had not been able to do for 12 weeks. Actually, she came to physio after one weekend hugely excited because she'd conquered her personal best by 10 minutes on her 18km training loop.

But the real test was yet to come: a 50km mountain run. This happened around three months after the Kokoda event. Mel ran powerful and pain-free. She was pumped.

Reference
1. Bullock-Saxton J, Janda V et al. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med 1994; 15: 330-334

For the previous five years I have been treating Troy for the injuries he sustains playing soccer/football. Troy is more prone to injury. And unless he's very diligent with his rehab, the more injuries he endures, the more inclined he is to sustain new ones. This is because of the “flow on effect that happens when a body part is not sufficiently mobile or strong to control the forces involved in the client’s chosen activity. Science based chiropractic injury specialist, Dr. Alexander Jimenez discusses the study.

Troy plays goalkeeper, for which he must move quickly in any way after long periods of relative inactivity. He takes goal kicks, which require him to create large amounts of muscular torque, too frequently after comparatively relaxed intervals.

In one match, Troy hurt his right quadriceps muscle after a goal kick really early on -- but he had, he promised me, warmed up before the beginning. Of interest was what Troy reported had been happening in the days before the game. He has a sedentary occupation, and he'd had some low back pain in the previous week. This was likely postural pain caused by a poor sitting position, but in these cases of prolonged sitting plus pain, I am always curious to look at what might be going on with the muscular system. Then, on the day of the game, Troy had undertaken a two-hour car travel, coming only 30 minutes before the warm up.

Following The Trail

The kicking action deploys muscles which stabilize the back, foot and knee together with the ones that provide the power for the approach and kicking of the ball. Since Mark Alexander has reported, the kicking action follows a certain timing and specificity of muscle recruitment.

One of people who have lower back pain, one quite common muscular imbalance is that the failure to recruit gluteus maximus at the right time (if at all), in its function of stretching the hip and strengthening the pelvis when standing on one leg.

The part of psoas major can be to keep the normal lordosis of the lower spine, especially when people are sitting, but also to stabilize the front of the hip joint to prevent injuries such as labral tears. On the football pitch, it is also very active in the approach to the ball and also the effect phase of the kicking action. It is reasonable to assume that the hip flexors may reflexively shorten if they are weak or not able to work throughout their whole selection. Table 1 shows which muscles may overwork or compensate for the reduction of activation of those stability muscles.

In case the psoas is feeble, the athlete may over-recruit rectus femoris to flex the hip, putting extra load with this muscle. What's more, if the hip flexor doesn't have adequate length, it cannot be properly lengthened in the preparation stage of the kick. This may lead to inadequate coordination of the through swing, resulting in poor performance -- and potentially injury.

This was certainly the mechanism behind Troy's muscle injury, as Table 2 shows.

Troy was unable to stand on one leg for any length of time, especially when he had to swing the opposite leg, as from the kicking action. Correction of this was all a part of his house exercise program.

I originally gave him exercises only to trigger the gluteals while lying supine, then standing and sitting. Then we progressed this into the stance leg at the kicking actions.

The principle which you're only as strong as the weakest link is indeed true here. Troy sustained the rectus femoris strain because of muscular weaknesses away from the injury site. Core muscle control is essential for all sports and it ought to be prioritized in every athlete's health program. It must also be specific to the sport: that is, speed and direction-specific. So that the therapist needs sound understanding of the technical aspects of the client's game and has to relate that back into the joint range and muscular control needed to reduce injury episodes and enhance functionality. In the end, a drop-off in performance is often the first warning sign that something's wrong.

Chiropractic back pain specialist, Dr. Alexander Jimenez looks at new study on muscle activation timing in the postural muscles and the implications for lower back pain in sportsmen and women.

Lower back pain (LBP) is a common illness among athletes (see Box 1). However, since our understanding of the etiology of back pain has improved, so have the prevention and treatment approaches. A good instance of this has been the growing emphasis throughout the last 15 years on functional training to the postural muscles of the back -- an approach to LBP treatment/prevention that's now quite widely recognized among clinicians and coaches. But though some research has emphasized advantages of the mode of training for those who have back pain and for carrying out regular activities, less research has been done on the benefits of core training for elite athletes and how this training ought to be carried out to maximize athletic operation. Really, there are many articles in the literature which promote core training programs and exercises for performance enhancement with no solid scientific rationale of their effectiveness, particularly in the sporting context.

Core Training & Muscle Activation

Many elite athletes undertake core stability and core strength training as part of their training program, despite contradictory findings and conclusions regarding their efficacy. This is principally due to the absence of a gold standard way of measuring core stability and strength if performing everyday tasks and sporting movements. A further confounding factor is that due to the diverse demands on the core musculature during regular tasks (low load, slow movements) and sporting activities (large load, resisted, dynamic movements), study conducted in the rehabilitation sector can't be put on the sporting environment and, subsequently, data regarding core training programs and their effectiveness on athletic performance are lacking.

1 aspect of postural muscle function that has received special attention in recent years is muscle activation patterns. Understanding how a particular sort of movement triggers (or fails to trigger) postural muscles in the trunk is vital to unravelling the part of the postural muscles in trunk stabilization. Much of the initial work in this field has tended to focus mostly on the magnitude and patterns of electromyographic (EMG) activation in postural muscles, and this knowledge has proved invaluable to physiotherapists and sports physiologists looking for a better knowledge of LBP. More recently, there has been a developing interest in the timing of these action, and its connection to LBP.

The ability to rapidly modulate the timing of muscles in response to sudden postural perturbations is deemed paramount for maintaining posture and equilibrium, and thus in boosting good lower back health. The literature indicates that, in comparison with healthy controls, besides demonstrating reduced EMG activity, people with chronic LBP also demonstrate delayed activity reaction to both expected and unanticipated postural perturbations(4,5). Moreover, acute experimentally-induced LBP in healthy people has been proven to change trunk muscle activity during trunk flexion--extension, in addition to attaining and quick arm-movement tasks. Simply speaking, sufferers with acute or chronic LBP seem to be at increased risk of further injury in response to unexpected external perturbations(6,7).

Timing & Pain

One criticism of these kinds of studies was that they employed protocols aimed at approximating 'real-life' perturbations but, in reality, these protocols were not sufficiently realistic to enable meaningful conclusions to be drawn. Nonetheless, these criticisms were answered by a 2011 study by Danish scientists, which examined automatic postural reactions in the presence of experimentally induced LBP to quickly, functionally applicable, complete body perturbations(8). These perturbations were created by a computer-controlled platform which enabled movement in 3- dimensions to generate tilting or sliding perturbations closely mimicking 'tripping over an obstacle' or 'slipping on a wet surface'.

In the study, the researchers analyzed the activation of the erector spinae and external oblique muscles in response to unanticipated, bi-directional postural perturbations prior to and after the induction of acute LBP in healthy individuals. Each experimental session consisted of a baseline, control, and also an acute LBP condition. For the management and acute LBP condition, isotonic or hypertonic saline, respectively, was inserted to the ideal erector spinae muscle. In each condition, participants stumbled on a moveable platform during which 32 randomized postural perturbations were conducted. These consisted of eight repetitions of four perturbation types achieved within a period of 4-5 minutes -- 8cm anterior slides, 8cm posterior slides, 10 anterior tilts, and 10 posterior tilts. Throughout those perturbations, bilateral EMG was recorded by the erector spinae and external oblique muscles as well as the subjective pain experienced by these subjects.

The results demonstrated that compared to the 'no back pain' condition (control), back pain delayed the beginning time of both erector spinae and external obliques to the forward and backward slipping perturbations (although only the onset time of the erector spinae systematically varied with all the differing perturbation types and directions). It was also evident that in the back pain illness, the EMG amplitude was reduced bilaterally for all perturbations (see fig 1a 1d).

The findings of the aforementioned Danish study appear to be encouraged by people from a US study on modified electromyographic activation patterns in response to perturbations of standing balance, also published in 2011(9). In this study, researchers evaluated the intermuscular patterns of EMG activations from 24 individuals with and 21 people with no history of chronic and recurrent LBP in reaction to twelve directions of support surface translations. Specifically, the aim was to characterize more thoroughly the shift in muscle activation patterns of people with LBP in response to a perturbation of standing balance, and to gain insight into the influence of early versus late-phase postural responses (differentiated by quotes of voluntary response times).

The authors concluded that a history of LBP is related to higher baseline muscle activation and also that EMG responses are modulated by the activated state, rather than exhibiting acute burst activity from a quiescent state (perhaps to circumvent trunk displacements) as is true in areas without LBP.

Late Onset Muscle Activation In Athletes

The research above looked at start activation instances in (differently) healthy but sedentary individuals. But what are the consequences for athletes? Unfortunately, the literature in this regard is very thin on the ground. However, a brand new study published in 2013 has looked in the reflex reaction of shallow trunk musculature in athletes with chronic low back pain(10) to check whether similar patterns of delayed muscle activation onset exist within the athletic body. In particular, the investigators sought to compare long latency reflex response (happening between approximately within 40ms to 100ms) in athletes with chronic LBP against asymptomatic athletes.

To do this, 24 athletes with chronic LBP were compared with 25 hepatitis athletes. At the position rankings, perturbations were introduced equally expectedly and unexpectedly while the surface EMG of the rectus abdominis and erector spinae muscles were listed. The latency of the onset of muscle activation and the root mean square (RMS) amplitudes within the response length were compared between the two groups.

In comparison with the asymptomatic athletes, the latency of onset has been postponed from the LBP athletes when the athlete underwent unexpected perturbations. However, during the anticipated perturbations, no modification was observed. The investigators went on to conclude that 'chronic LBP athletes exhibit a delay in onset latency to unexpected perturbations and decreased long latency response amplitudes to perturbation tasks compared to asymptomatic athletes. These modifications can induce athletes to recurrent low back pain and further injury.'

Questions

If muscle activation time is a significant element in LBP, an obvious question to ask at this stage is if a core training program (which often creates the staple of many a lower back injury rehabilitation program) can help normalize muscle activation patterns. There is a paucity of research in this area but a study published in 2012 is revealing(11). In this study, researchers sought to investigate feed- forward activation or timing of abdominal muscle activation in response to rapid spinal flexion following an eight-week plan of core stability exercises, sling exercises, or overall exercises.

Of specific interest was the effect on muscle activation onset (listed bilaterally from m-mode ultrasound imaging) at the deep abdominal muscles in response to quick shoulder flexion in the chronic nonspecific LBP patients.

In the conclusion of the eight-week instruction period, there were only insignificant or very modest improvements in the LBP subjects. The baseline-adjusted 'between group' differences showed a 15 millisecond advancement with sling training relative to core stability training, and a 19 millisecond advancement relative to general exercise training. To put it differently, eight months of core stability training produced hardly any advancement in the start of abdominal muscle contractions.

Conclusion & Conclusion

Despite our growth in understanding along with the widespread take-up of core training work, low back pain is still a significant issue among athletes. Recent study on muscle activation patterns suggests that the late onset of stimulation in postural muscles is likely to be a contributing factor in the etiology of chronic low back pain and rehabilitation/ prevention programs relying only on core activation could be insufficient to help normalize postural muscle activity.

References
1. Spine (Phila Pa 1976). 2004 Feb 15;29(4): 449-54
2. Neurosurg Focus. 2006 Oct 15;21(4):E7
3. Br J Sports Med. 2003 Jun;37(3):263-6
4. Brain Res 2001; 141:261–266
5. Spine 2000; (Phila Pa 1976) 25:947–954
6. Exp Brain Res 2003; 151:262–271
7. Spine 2007; (Phila Pa 1976) 32:E801–E808
8. Exp Brain Res 2011; 210:259–267
9. J Neurophysiol. 2011 Nov;106(5):2506-14
10. J Back Musculoskelet Rehabil. 2013 Apr 29. [Epub ahead of print]
11. Spine (Phila Pa 1976). 2012 Jun 1;37(13): 1101-8

Science based therapist, Dr. Alexander Jimenez looks at the several types of SLAP lesions, a few frequent clinical indicators, orthopedic evaluations and explores the very best rehab methods... 

Overhead athletes (like baseball pitchers, tennis, swimming, water polo and throwing athletes). All put enormous strain on their shoulders when participating in their chosen sport. An elite baseball pitcher's arm was listed at over 7000deg/second which puts it arguably as the fastest human body movement in game. This all happens at a joint that's been likened to a golf ball sitting on a tee -- ie it is structurally unstable. Considering all of this, is it any wonder that shoulder pain is a common occurrence in the overhead athlete? Throwers with shoulder pain will often complain of a "dead arm" which restricts them from throwing at pre-injury velocity/or control. SLAP (Superior Labrum Anterior-Posterior) lesions are common causes of this "dead arm" and will be the focus of this article.

What Is A SLAP Tear?

What Is The Mechanism Of Injury?

The exact mechanism still remains controversial with three major theories present. The deceleration theory initially proposed that in a throwing athlete a SLAP lesion happened during the deceleration phase of projecting as a result of eccentric contraction of the biceps tendon(7). They suggested that this overloaded the biceps anchor that detached it from its intra- articular attachment. A direct blow to the shoulder has also been believed to be a cause for a SLAP lesion -- for instance, an athlete landing in an outstretched arm might compress/pinch the labrum between the glenoid and the humerus(1). More lately, Burkhart described the acceleration or "peel back mechanism" which occurs when the arm is at the cocked position of abduction and external rotation. They explained that during arthroscopy in shoulder abduction and external turning the thoracic fascia presumes a more vertical and posterior angle which generates a twist at the bottom of their biceps and a torsional force on the anterior superior labrum(1).

Kuhn experimentally compared the deceleration and acceleration theories in cadavers models(1). They applied a brute force to the biceps tendon from the follow through place and were able to generate a superior labral avulsion in 20% of his specimens with a massive push. To simulate the peel back mechanism they placed the arm at an abducted and externally rotated position. In 90% of the shoulders analyzed, they could create a type 2 SLAP lesion with 20 percent less force than at the deceleration version. From this it can be proposed that the peel back mechanism is more likely to cause a SLAP lesion than the deceleration model and that the bicep tendon is not pulled but peeled from the bone.

What Is The Clinical Presentation?

Subjective

Objective

Standing Posture

Ordinarily, overhead athletes with SLAP tears will have poor scapula position at rest on their dominant side: Figure 2 shows inferior scapula position in a right-arm thrower. Burkhart explained this asymmetrical scapula position as with a SICK (Scapular malposition, Inferior border prominence, Coracoid pain and dysKinesis of scapula motion) scapula(3). It is also important to note thoracic posture, as increased kyphosis and lack of trunk rotation can also increase load on the shoulder when throwing.

Shoulder ROM

Active ROM of the shoulder must then be assessed to ascertain any motion restriction or pain. Glenohumeral rotation range ought to be assessed in all overhead athletes. A thrower's shoulder needs to have enough laxity to allow for excessive external rotation (demand of good throwing) with adequate dynamic stability to avoid subluxation. Glenohumeral rotation array is conventionally done in supine with the arm in 90-degree abduction. Commonly these athletes will get an increase in external rotation range (possibly due to repetitive stretching of their anterior capsule at the cocking phase and/ or humeral retroversion when they threw a lot if they were young) and a drop in internal rotation range. This absence of internal rotation range is frequently due to contracture of the posteroinferior capsule contracture and is popularly known as GIRD (Glenohumeral Internal Rotation Deficit). Sleeper stretches (see Figure 3) have been demonstrated to not only reduce GIRD but also to reduce shoulder injuries by around 40% in major league baseball players(1).

Treatment

A Case Study

Shoulder injuries in the throwing athlete would be initially managed with conservative therapy with therapy focused on improving GIRD and/ or scapula control. In most cases the whole kinetic chain should be assessed and proper exercises should be implemented based upon the requirements of their game.

Figure 2 reveals a cricketer who bowls and throws with his right arm. When I first saw him, he complained of pain and "fatigue" in his shoulder when he bowled and threw from the boundary. He also had pain through range on abduction, which resolved if his scapula position was fixed (posterior tilted). He had no reduction of glenohumeral range on his right side. In this case (because of the success of posteriorly tilting his scapula on his pain through the evaluation) treatment focused on lengthening techniques of the muscles that anteriorly tilt his scapula, ie pec minor, and strengthening for his lower and middle trapezius that help to posteriorly tilt his scapula. This player was given a range of exercises in prone to improve his scapula position (see Figures 10 - 11).

His pain improved over a four- week period and he is now able to throw in the boundary without any signs.

Conservative treatment isn't always effective especially if a type 2 SLAP lesion is current. In such cases operative therapy is required and the athlete can take 9-12 months to return to sport and they'll report that it requires up to two years to go back to their pre-injury level.

Conclusion

In summary, SLAP lesions are typical in the overhead athlete and a structured evaluation particularly looking at scapula control, glenohumeral rotation range in addition to orthopaedic tests can help to identify when a SLAP lesion is current and will also help direct therapy. Frequently in elite-level athletes, particularly when a type 2 lesion is present, surgery is needed(4).

References
1. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 1: Pathoanatomy and Biomechanics. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No4, 404-420
2. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 2: Evaluation and treatment of SLAP lesions in throwers. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No5, 531-539
3. Burkhart S, Morgan C, Kibler B (2003) The disabled throwing shoulder: Spectrum of pathology, Part 3: The SICK scapula, scapula dyskinesis, the kinetic chain and rehabilitation. Arthroscopy: the Journal of arthroscopic and related surgery, Vol 19, No6, 641-661
4. Brukner P and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill
5. Krupp R et al (2009) Long head of bicep tendon pain: differential diagnosis and treatment. Journal of orthopaedic and sports physical therapy Vol 39, no 2 55-70
6. McFarland E, Tanaka M, Papp D (2008) Examination of the shoulder in the overhead and throwing athlete, Clinical Sports Medicine 27, 553-578
7. Myers T et al (2005) The resisted supination external rotation test; A new test for diagnosis for SLAP lesions, the American Journal of Sports Medicine, Vol 33, No9 1315-1320
8. Ryu J, Pedowitz R (2010) Rehabilitation of bicep tendon disorders in athletes. Clinical Sports medicine 29 229-246

El Paso, TX. science based chiropractor, Dr. Alexander Jimenez looks at this uncommon problem – and how it can be treated.

The true incidence of obturator externus accidents is unknown, as frequently they may be misdiagnosed as hip joint pathology and/ or groin pathology as the website of symptoms as well as also the presenting objective signals may mimic other pathologies such as hip joint labrum pathology, anterior femoral triangle issues and perhaps even gluteal pathology.

Injury for this muscle gifts as a deep obscure groin/hip pain and functionally the muscle may still hide direct involvement as a pain generator since it is primarily a equilibrium muscle rather than a force-producing hip muscle.

This case study presents an unusual case of hip-related pain in a professional baseball player which also shown itself as an injury to the contralateral adductor longus.

The Player

As he was wrestled to the floor, his right hip was compelled at a rapid and loaded flexion/internal turning position. His first sensation was pain deep inside the anterior hip/groin area.

When he presented to the medical team with the accident, he complained of a profound catching sensation inside the hip joint location. It had been difficult to fully bend the hip and to also twist on the stationary limb (because he did whilst kicking a ball). His prior background consisted of a right-sided inguinal hernia repair five seasons before as well as a few gentle on again/off back osteitis pubis-type signs that would normally flare from the first period as his goal-kicking amounts have been increased. He was obviously a left- footed goal kicker.

On examination, he observed that the pain to become worse on passive flexion/internal rotation of the hip (hip walkway test). He was noticeably tight and irritated from the shallow TFL muscle, and also posteriorly across the greater trochanter around the insertion for the gluteals and deep hip rotators. He was also particularly high tone in the right iliopsoas muscle.

He was initially diagnosed clinically because of hip joint sprain due to the mechanism of harm being a pressured flexion/internal rotation type position that would always put pressure on the anterior hip joint capsule/labrum.

He was treated initially with deep iliopoas muscle sparks and hip joint mobilizations using a seat belt to gap the hip joint. He reacted reasonably well with the therapy and immediately felt more comfortable on a hip joint quadrant test. He was rested from coaching for 2 days and ran on the next day and played a match on the fourth day. But during the match, though his right hip did not create any pain, he'd notice pain on his left adductor source that was more pronounced during kicking.

Three days post-game he detected this ongoing left adductor origin pain and it was made worse by kicking again through training. An MRI was performed to Look at the left adductor origin and also the report noted:

The surprise finding on the MRI of a grade 2 obturator strain prompted the medical team to more formally assess the participant for ongoing hip joint disorder. The particular features to notice from this medical examination were:

Subjective

Objective

Pathomechanics

It had been suspected that this player had endured a secondary injury to the left adductor longus (a muscle used a lot in goal-kicking) due to the inherent failure in bolstering the proper hip throughout the plant phase of the kick due to the inhibition of the right obturator externus, a muscle considered to be an important hip stabilizer and turning control muscle at the hip. With insufficient hip stabilization in kicking, the left hip was required to create more power to compensate for the unstable right hip to gain the length from the kick. Then the left adductor longus failed along with a strain injury led.

Management

The management of the matter initially centered on the two key features being the left-sided adductor strain and the right- sided obturator externus strain.

In the week following the accident, the player was sent to get a series of Actovegin shots to the left adductor longus. This was done according to protocol that was three injections every 48 hours -- Monday/ Wednesday/Friday. In this five-day period the adductor longus was handled with deep tissue flush massage and gentle isometric adduction exercises at supine (chunk squeezes) in the three positions of examining -- 0/45/90 levels of knee flexion -- also as wall squat adductor squeezes in the same positions. The obturator externus was medicated with heavy tissue releases (obtained through the anterior groin region) and direct theraband strengthening of hip external rotation in sitting and in prone. Actovegin shots to the obturator externus are regarded as difficult because of problems with accessing this muscle through the superficial hip musculature.

The adductor exercises progressed into through array adduction with theraband resistance (equally with the left leg being the motion leg as well as the stability leg).

By 12 days post-injury it had been detected that the obturator externus strength had not improved and the player still had deep- seated right back pain pain. It was rationalised that perhaps the direct treatment to this muscle and also the direct open kinetic chain strengthening was possibly making the muscle texture worse. The choice was made to stop any direct hands-on therapy to the muscle and also to prevent any direct open kinetic chain strengthening. Instead the player lasted with bilateral theraband exercises of both hips into flexion and then abduction and expansion in addition to adduction. The avoidance of lead obturator externus soft tissue treatment and exercise appeared to improve the hip function immediately.

The participant started running 20 times post-injury and quickly progressed through running stages over a five-day period of conducting on alternate days. At this point the player's adductor squeeze scores had improved to steps according to pre- season baselines. However, daily the player ran direct adductor strength operate using a Pilates reformer as a slider drill to immediately load into adduction in addition to hammering theraband adduction exercises in standing and in supine lying.

By 27 days post-injury the player managed to begin kicking, change in direction and rugby training. He played at 30 times post-injury with no ill effects.

Discussion

It arises immediately around the medial side of the obturator foramen, as well as the inferior ramus of the ischium; it also arises in the lateral two-thirds of this outer surface of the obturator membrane, and also in the tendinous arch which completes the canal to the passage of the obturator nerves and vessels.

The action of the muscle is to externally rotate the hip and also helps in hip adduction. It's postulated to also work as a hip balance muscle in one legged stance along with the obturator internus, quadrutus femoris, piriformis and the gemelli muscles. In a practical activity such as kicking, the muscle acts to stabilize or hold the ball of the femur into the socket (acetabulum).

The incidence of harm to the obturator externus muscle is unknown because there are only a handful of case reports from the medical literature that highlight injuries for this muscle. Additionally, among the vexing issues is the difficulty in creating the correct clinical diagnosis based on the history and physical evaluation. MRI imaging is needed to correctly picture injuries to this muscle.

From the case study introduced, injury for the muscle was a direct result of forceful flexion/internal rotation mechanism to the hip joint. As the muscle primarily functions as a hip stabilizer during jogging, it is possible that a patient can mask symptoms during functioning as the muscle isn't required to produce any hip skate for locomotion.

Nonetheless, in this event the muscle has a role in stability of the hip during kicking, and for that reason may have produced a poor pelvic/hip complicated during kicking that then led to an accident to the adductor longus on the other hand.

In addition, it seems that direct treatment to the muscle in the form of deep trigger point releases and also direct strengthening may actually delay healing in the muscle in case of injury. This may highlight the value of the muscle as a hip stabilizer instead of a legitimate torque manufacturer in hip rotation.

Swimming is a intricate sport that places huge demands on the body for propelling through the water. The shoulders often suffer as a consequence of this, but, injury chiropractor, Dr. Alexander Jimenez asks, what are the implications of musculoskeletal shoulder asymmetry?

Overview

Swimming is a hugely popular game for both recreational and competitive functions. The nature of exercising against the water immunity provides a special setting compared to the field or court in all other sports. Likewise, most other sports utilize a dominant side, whereas in swimming that the repetitive, continuous motions require either side of your system to be coordinated and equally strong. This can place an accumulation of stress physically. The overhead actions of a swimming stroke may notably strain the shoulder joints and around 73% of swimmers will experience shoulder pain at any stage within their career(1).

Taking this advice on board, surprisingly, swimmers do not usually develop symmetrically with equal muscle power on each side. And in which there is muscle imbalance, they commonly compensate by using different muscles more than ordinary to guarantee the total force generated is the same(2). Swimming also does not provide that point of contact or source to hold on to enjoy most other sports have. Swimmers rely on their inbuilt strength throughout the body along with the entire kinetic chain to generate maximum force propulsion. Expertise and strategy are important facets to contribute to this, however if there's a natural muscle imbalance then this can further affect technique, however much technique instruction you provide.

Asymmetry is defined when there's a muscle imbalance between the left and right sides greater than 10%(two). This means that the muscles on one side are more powerful or more efficient compared to those on the opposite side. A recent study that screened nationwide- level hens found that 85% were asymmetrical(two). Asymmetry usually develops because of the shoulder or whole arm being used wrongly or too often. Excessive repetition with no adequate rest causes the muscles to exhaustion. This decreases muscle activity and induce generation, and eventually causes biomechanical abnormalities as the swimmer attempts to overcome these failing mechanisms(3). A third of those swimmers in the study that were discovered with asymmetry were also identified as having compensatory plans(2). Asymmetry can lead to:

Every one of these can alter technique and thus performance execution. This might be the difference between finishing first and finishing second in competition.

Screening For Shoulder Asymmetry

Screening is the process of assessing a variety of characteristics that are significant with the game. This allows the identification of possible flaws and muscle imbalances. Strengthening applications to rectify such findings may provide optimum strength, functionality and prevention of injury.

Table 1 details the key screening tests for identifying asymmetry in shoulder power for swimming. This scale details if the athlete can move against gravity (tier 3), then resist your force (grade 4), and supply full strength to resist (grade 5).

Shoulder flexion is not listed here as a screening test as it's been found that it doesn't have any effect on shoulder asymmetry(2). This implies that many swimmers all have an equal stroke length. It seems to be the abduction, adduction and rotational components which become imbalanced and make the asymmetry of the shoulders.

Arm dominance and breathing side can also be often considered significant factors in procedure perfection; however studies have not found these to have any consequences on performance(two). For more technically precise ways to assess these functions with dynamometer, see the original research articles(1,2).

Even though these are significant testing purposes, it's just as important to look elsewhere when trying to identify potential weaknesses. The surrounding muscles like the latissimus dorsi should be considered.

Latissimus Dorsi Stiffness

The latissimus dorsi is your largest muscle of the trunk and is responsible for all pushing and pulling type activities. The repetitive character of swimming and thus overuse of the latissimus dorsi usually means that this muscle may be prone to stiffness.

Each of these issues alters the way the shoulder blade operates mechanically. This modified mechanics can then develop injuries as other structures become caught or pinched within the shoulder joint distances. These injuries will influence technique as the shoulder will slowly lose power and strength.

Have the athlete in crook lying with their back flat against the bed. Ask them to lift their arms over their head. If there is latissimus dorsi stiffness they'll struggle to fully stretch the arms overhead, and/or their spine will lift up away from the mattress.

For a more accurate and technical evaluation method refer to this analysis by Illinois University(1).

Power Exercises For Fat Loss

The added resistance that the water provides requires strengthening exercises to be carried out in similar motions to replicate the coils. This may improve the specificity and ensure the correct muscles have been targeted. Key exercises for scapular strengthening that carry over ideally for swimming are shown below.

1. Breaststroke

2. Swimming

3. Low row

4. Front crawl simulation

Summary

References:
1. Phys Ther in Sport. 2013; 14:50-53.
2. Phys Ther in Sport. 2013; http://dx.doi.org/ 10.1016/j.ptsp.2013.02.002
3. Rehab Res and Practice. 2012; ID:853037; 1-9.
4. McKesson Healthcare Solutions. 2004. www.mckesson.co.uk
5. Phys Ther in Sport. 2004; 3:109-124.
6. Musculoskeletal assessment. 2000. 2nd Ed; 150-156.
7. Clinical Sports Med. 2006. 3rd Ed; .246-247.
8. http://www.shoulderdoc.co.uk/article.asp?article=1381
9. http://www.youtube.com/watch?v=AcPZEtWP1x4 (2013).
10. APPI Pilates Matwork Handouts manual.2012. www.ausphysio.com

Injury specialist, Dr. Alexander Jimenez looks at the latest study about concussion in sports, especially regarding early/on-field assessment and diagnosis of this condition.

The proper medical definition of concussion is: a clinical syndrome characterized by immediate and transient change in brain function, including alteration of mental illness and level of consciousness, resulting from mechanical pressure or injury. But, it is more commonly described as an injury to the brain caused by a blow to the head (eg an uppercut in boxing, a clash of heads in soccer or a fisherman moving over the handlebars on the ground etc), which leads to temporary loss of normal brain function, including disturbances in memory, judgment, reflexes, speech, balance and muscle coordination. A less obvious cause is an indirect blow where the force is transmitted up to the head from a different portion of the body -- for example when a stationary rugby player is tackled from behind causing his head to abruptly flick back, with a number of the force of the tackle passing through his brain; the participant may end up concussed without ever taking a direct blow to the head.

While bruises and cuts might be present on your face or head as a consequence of this blow, in most cases a person with a concussion never loses consciousness. Because of this, less experienced coaches and sports physicians may not immediately assume concussion, or if they do they presume that it's unlikely to be a cause for concern. But, though some concussions are less severe than others, there's absolutely no such thing as a 'minor concussion'; while a single concussion should not result in permanent damage, another concussion shortly after the initial one doesn't have to be very powerful for its consequences to be fatal or permanently disabling. Animal and human studies support the concept of this so-called 'post-concussive vulnerability', showing that a second blow before the mind has regained results in worsening metabolic changes within the cell(1). This explains the crucial importance of correctly and immediately identifying when a concussion has occurred because it affords the opportunity of this athlete to be taken out of the field of play, thereby ensuring a second concussion cannot happen.

Initial Diagnosis Of Concussion

As soon as an athlete suffers a blow to the head, the first priority should be that someone qualified is available to assess whether concussion has occurred. In an ideal world, this assessment could always be performed by a physician specifically trained in this area. In many sporting events (eg a small league football game), it is unlikely that such a individual will be there standing on the sidelines. However, as stated by the America Medical Society for Sports Medicine (AMSSM), the competence to execute this assessment also needs to be decided by training and experience and not purely dictated by specialty(1). To put it differently, with the right training and expertise, coaches, trainers and health care professionals are more than capable to perform a concussion examination.

The AMSSM additionally points out that the identification of concussion is ideally created by a healthcare provider who is not only knowledgeable in the recognition and analysis of concussion but also familiar with the person concerned. The reason for this is that while standardized sideline tests are a useful framework for making an appraisal, the validity and reliability of these tests are greatly reduced without some type of individual baseline test result with which to compare, and some other baseline rating will vary based on the individual athlete concerned.

AMSSM New Guidelines

The primary recommendations were assembled by reviewing the evidence over a number of years and are summarized as follows:

• Coaches/physicians/healthcare providers should take note that while balance disturbance is a specific indication of a concussion, it isn't very sensitive. In particular, performing equilibrium testing about the touchline may yield substantially different results than baseline evaluations simply because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injuries that might have also happened during the episode involving the head injury.

• Any athlete suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status. Importantly, there should be NO same day return to play for an athlete diagnosed with a concussion injury. Meanwhile, imaging should be reserved for athletes where intracerebral bleeding is suspected.

• Even though most concussions can be managed appropriately without the use of neuropsychological (NP) testing, those with athletes in their maintenance ought to bear in mind that NP evaluations are an objective measure of brain- behavior relationships and, as such, are somewhat more sensitive for subtle cognitive impairment than a straightforward clinical examination. However, NP testing should be used only as part of a extensive concussion management plan and should not be utilized in isolation. Also, the ideal timing, frequency and type of NP testing have not been completely ascertained.
• Computerized NP testing should be translated by health care professionals educated and comfortable with the type of test and also the individual test limitations. Paper and pencil NP evaluations are both valuable and are able to test different domain names and assess for different conditions, which may masquerade as or reevaluate evaluation of concussion.
• Concussion symptoms must be resolved before returning to perform with (RTP) and RTP after concussion should happen just with medical clearance from an experienced health-care supplier trained in the analysis and management of concussions -- see Box 2. An RTP progression entails a gradual, step-wise increase in bodily demands, sports-specific activities and the danger of contact. If any signs recur using action, the progression ought to be stopped and resumed in the previous symptom-free step. In the brief term, the principal concern with early RTP is diminished reaction time resulting in an increased risk of a repeat concussion or additional injury and prolongation of symptoms. In the long run, there's a growing concern that head impact exposure and recurrent concussions can contribute to long-term neurological complications and a number of studies have indicated an association between previous concussions and chronic cognitive impairment.
• Physicians should be prepared to offer counseling regarding potential long-term consequences of a concussion and continuing concussions. However, there are currently no evidence-based guidelines for disqualifying/retiring an athlete from a game after a concussion. More commonly, greater efforts are needed to educate involved parties, such as athletes, parents, coaches, officials and school administrators and health care providers to boost concussion recognition, prevention and management.

Recent Findings: On-Field & Same Day Assessment

Make no mistake, but the first assessment of concussion in the mature athlete is tough, given that the elusiveness of harm, the sensitivity and specificity of their sideline assessment tools along with the evolving nature of concussive injury. A very current (2013) review newspaper systematically examined the evidence related to on-field concussion assessment and considered questions related to same day return to play, what to do if no doctor is available onsite, as well as the benefit of distant notification of future concussive events(3). It concluded that the on-field test of sport-related concussion is often a challenge, especially given the elusiveness and variability of presentation, the strain to create a quick diagnosis (as an instance, in the middle of an important match in which the concussed athlete was making a significant contribution), the specificity and sensitivity (or rather lack of) of this on-field assessment tools, along with the dependence on symptom presentation.

However, they cautioned that a range of assessments over a brief time period tend to be necessary and, since signs and symptoms may be postponed, erring on the side of caution (ie maintaining an athlete from participation whenever there's a distress for harm) is important. In addition, they concluded that although a standardized evaluation of concussion is beneficial in the evaluation of the athlete with suspected concussion, it should NOT take the place of the clinician's conclusion.

These findings have been very much in agreement with another 2013 review research on instruments currently utilized in the evaluation of sport-related concussion on the day of injury -- consequently 'same day' assessment tools(4). In this review, a total of 41 research on sports concussion were pooled and their findings analyzed. The authors concluded that several well- supported tests are acceptable to be used in the evaluation of acute concussion from the athletic athletic environment and that these evaluations can provide significant data on the symptoms and functional impairments that clinicians can integrate in their diagnostic formula. But they also cautioned that such tests should not solely be used to diagnose concussion.

SCAT3 Assessment Tool

As mentioned above, the first evaluation of an injured athlete with suspected concussion remains predominant in determining subsequent action. There are a number of diagnostic tools available, but undoubtedly among the most admired is when there is no one with medical training available to tend to an injured athlete, it is recommended that the ‘Sport Concussion Recognition Tool’ be used instead (seeBox 3). The SCAT3 assessment tool can be downloaded here: http://bjsm. bmj.com/content/47/5/263.full.pdf. The SCAT3 is a standardized instrument for evaluating injured athletes for concussion, and is intended for use by medical professionals. SCAT3 supersedes the first SCAT and SCAT2 published in 2005 and 2009 respectively. Importantly, baseline testing together with the SCAT3 can be beneficial for translating post-injury test scores at a later date. The SCAT3 evaluation tool can be downloaded here: http://bjsm. bmj.com/content/47/5/263.full.pdf

SCAT3 is a detailed tool that assesses the following areas: background, symptom evaluation, cognitive and physical function, neck trauma, balance and coordination. According to the SCAT guidelines, the first indications through a sideline evaluation are critical and any of the following warrants triggering emergency procedures and barbarous transport to the nearest hospital:

It is important to highlight, but that scoring on the SCAT3 shouldn't be utilized as a stand-alone process to diagnose concussion, quantify recovery or make conclusions regarding an athlete's readiness to come back to competition after concussion. Additionally, since signs and symptoms can evolve over time, it's very important to consider repeat evaluation from the acute evaluation of concussion. Finally, it needs to be stressed that the identification of a concussion is a medical judgment, ideally created by a medical professional. The SCAT3 shouldn't therefore be used solely to make, or exclude, the diagnosis of concussion in the absence of clinical judgement. An athlete could have a concussion even if their SCAT3 score is 'normal'.

References
1. Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941
2. Am J Sports Med. 2012 Apr;40(4):747-55
3. Br J Sports Med. 2013 Apr;47(5):285-8
4. Br J Sports Med. 2013 Apr;47(5):272-84
5. Br J Sports Med 2013 47: 259
6. downloadable from: http://bjsm.bmj.com/content/47/5/267.full.pdf

Science based chiropractor, Dr. Alexander Jimenez looks at frequent mechanical causes of heel pain -- and how they can be seen and treated.

Plantar heel pain is a frequent presentation to sports clinicians and might be result of mechanical, neurologic, traumatic or other systemic illnesses(9). Plantar fasciitis is undoubtedly the most common pathology in this area seen by cliniciansnonetheless, other causes of heel pain has to be considered when assessing a customer with heel pain. Up to two million Americans report heel discomfort each year at a price estimated to be up to $400million(5). Despite this, little is known about the pathophysiology and etiology of plantar heel pain. This article will discuss plantar fasciitis in addition to other frequent mechanical causes of heel pain such as plantar fascia tears/rupture, heel pain of neurological source, calcaneal stress fracture and atrophy of the heel pad. The anatomy of each of those illnesses will be discussed as well as diagnostic criteria and potential treatment choices will be summarized.

Plantar Fasciitis

The plantar fascia will help to encourage the lateral longitudinal arch and acts as a shock absorber(3). Support of the lateral longitudinal arch is reached via both passive tensioning of the plantar fascia (the Windlass mechanism) as well as lively tension of the plantar intrinsic foot muscles (includes flexor hallicus brevis, adductor hallicus and plantar interossei) and the tibialis posterior. As strength testing of those muscles is very difficult, Chang used volume estimations of their intrinsic foot muscles and tibialis posterior muscles to find out whether there was a gap in quantity of those muscles in individuals with knee pain. He found no difference in muscle mass of tibialis posterior and just 5% difference in the forefoot volume of the intrinsic foot muscles as well as the asymptomatic foot(5 pounds). Further studies will need to be done to determine whether that is of clinical importance and whether strengthening of those intrinsic foot muscles decreases load onto the plantar fascia.

Assessment & Diagnosis

Patients presenting with plantar fasciitis most often complain of pain on the first few steps in the morning when getting out of bed or after prolonged rest(2). This has been termed "post- static dyskinesia"(2). Maximal tenderness is over the origin of the plantar fascia on the medial calcaneal tuberosity(2). Jack’s test, which involves passive extension of the first MTP joint, tests the integrity of the plantar fascia and the Windlass mechanism (see Figure 2).

It has been shown that reduced dorsiflexion ROM, improved BMI and bad biomechanics are risk factors for plantar fasciitis(4).

This could include but should not be limited to:

Generally diagnosis is completed via ultrasound although weight-bearing radiographs may be useful to determine the existence or absence of calcaneal spur in addition to the elevation of this calceneal fat pad(10). In the case of plantar fasciitis, ultrasound guided examination of the plantar fascia at its proximal insertion shows:

An infra-calcaneal spur might be present but these also have been observed in asymptomatic individuals also, and elimination of the spur doesn't appear to add to the achievement of plantar heel pain surgery(10).

Treatment

The Heel Pain Committee of the American College of Foot and Ankle surgeons, based on available evidence in 2010, determined three tiers of treatment modalities for plantar fasciitis(10).

They said that Tier 1 treatment options must be trialled first, which include:

If no response was noted after six months with these modalities afterward Tier 2-based treatments should commence whilst continuing Tier 1 remedies. Tier 2 choices included:

• night splints
• further injections
• immobilization
• prescription orthotics.

The combination of using foot orthotics and dorsiflexion night splints was shown to be more effective than use of orthotics alone(12). Following these recommendations, they reported that 85-90 percent of patients will respond to treatment within 8-12weeks and have full resolution at the same year. The Tier 3 treatment option they explained was operation, which should only be considered in those patients who neglect Tier 1 and two treatment pathways.

Traditionally corticosteroid has been the injection of choice with respect to plantar fasciitis; however, some evidence points to short-term relief only. As well as poor long-term effects, other risk factors related to corticosteroid injection (CSI) such as fat pad atrophy, osteomyleitis of the calcaneus and iatrongenic rupture have all been reported(2). Platelet rich plasma (PRP), which is a concentration of platelets derived from the plasma part of autologous blood (like growth factors), has also been trialled as a treatment option for plantar fasciitis. Aksahin compared CSI and PRP and reported comparable results at three months and six months (approx 50% drop in VAS scores) also claimed that contemplating the risk factors related to CSI PRP might be a better alternative option(1). Diaz-Llopis compared botulinum toxin type A (botox) with CSI and revealed that the botox group was slightly better at one month but considerably better than the CSI team at both six and twelve months(7,8). Additional research has to be conducted on which injection modality gets the best results over both the short and long term.

Plantar Fascia Tears/Rupture

Intense strains of the plantar fascia occur quite frequently and normally, should they happen in isolation, react relatively quickly to treatment. They may be associated with plantar fasciitis, particularly if a CSI was trialled. Clients with an acute tear describe a sudden beginning heel pain and may have localized tenderness over the plantar fascia, along with a palpable lump might be present in case a partial or total rupture is present(4). In the case of significant tears that they are going to have pain on weight bearing. Treatment is symptomatic and involves initially a non-weight posture boot and innovative weight bearing with inviting taping and/or orthotics as pain allows.

Heel Pain Of Neural Origin

Up to 15-20 percent of individuals with plantar heel pain is brought on by entrapment of branches of the tibial nerve(2). This nerve can get entrapped in the possible sites:

The second most frequent cause of heel pain of neural origin is entrapment of the medial calcaneal nerve which innervates the heel fat pad and superficial tissues overlying the inferior calcaneum(two). Most branches of the nerve lie superficial to the intrinsic muscles of the foot so it is less likely to be compressed within these muscles, but might be compressed or irritated following heel pad atrophy(2).

Assessment & Diagnosis

Much like plantar fasciitis, their pain is most often worse after intervals of rest but might also occur at rest and at non-weight bearing positions. Although paraesthesia or anesthesia is infrequent, it may be reported around the medial or plantar surfaces of the heel(2).

On physical examination, nerve entrapment should be suspected if the site of maximum tenderness is over the nerve.

Neurodynamic testing may play a part in the identification of nerve involvement of plantar heel pain. Altered straight-leg increase testing that additional dorsiflexion, eversion and toe extension increased strain on the tibial nerve and LPN and when hip flexion was inserted no additional load on the plantar fascia has been noted(2). Differentiation of the plantar fascia as well as the tibial nerve may be carried out with the addition of hip flexion. Figure 3 shows the modified SLR for the tibial nerve and its branches.

Treatment

Despite its various pathophysiology and etiology, current study suggests the treatment of plantar heel pain of neurological source should be similar to that for plantar fasciitis. This absence of specific treatment options for your differing presentations may be among the reasons why plantar heel pain may be so recalcitrant. It could be suggested, like nerve entrapments in different parts of the body, "port" function and nerve gliding or sliding exercises may be useful to cure and prevent ongoing entrapment. Further studies need to be done in order to determine the most effective treatment for all these neural entrapment syndromes of the foot.

Fat Pad Atrophy/Contusion

The calacaneal fat mat comprised of elastic fibrous tissue and carefully packed fat cells that act as a shock absorber on heel strike(4). This problem is often related to plantar fasciitis but can be an isolated thing. Patients with fat pad atrophy may report pain aggravated with walking particularly in hard shoes or on hard surfaces(4). Commonly due to the heel strike pattern, pain is felt more over the lateral aspect of the heel that helps to differentiate it from plantar fasciitis.

Stress fractures of the calcaneum are quite common and mainly occur at the upper posterior margin of the os calcis or adjacent to the medial calcaneal tuberosity(4). Patients with a calcaneal stress fracture will report insidious onset heel pain which unlike other plantar fasciitis worsens with activity(4). On palpation they'll be tender over the lateral or lateral aspect of the calcaneum and pain will be replicated by the squeeze test (see Figure 4). Plain X-ray or MRI could be used to validate the diagnosis.

Remedy of calcaneal stress fractures involves a period of non-weight bearing rest until the pain disappears; walking and then gradual return of activity can occur after using soft heel pads and coaching to improve biomechanics.

Conclusion

This article has outlined several pathologies that needs to be considered when assessing clients with heel pain. Treatment modalities should be aimed at preventing pain and fixing potential predisposing factors.

References
1. Aksahin E et al (2012) The comparison of the effect of corticosteroids and platelet rich plasma (PRP) for the treatment of plantar fasciitis. Archives of Orthopaedic Trauma and Surgery. Vol 132 781-785.
2. Alsahmi A, Souvlis T, Coppieters M (2008) A review of plantar heel pain of neural origin: Differential diagnosis and management. Manual therapy vol 13 103-111.
3. Anderson J, Stanek J (2013) Effect of foot orthoses as treatment for plantar fasciitis or heel pain. Journal of Sport Rehabilitation Vol 22 130-136.
4. BruknerP and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill.
5. Chang R, Kent Bruan J, Hamill J (2012) Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs. Clinical Biomechanics. Vol 27 500-505.
6. Chen C, Lew H Chu N (2012) Ultrasound guided diagnosis and treatment of plantar fasciitis. American Journal of Physical and medical Rehabilitation, Vol 91 (2) 182-184.
7. Diaz-Llopis I et al (2011) Randomised controlled study of the efficacy of the injection of botulinum toxin type A versus
corticosteroids in chronic plantar fasciitis: results at one and six months. Clinical Rehabilitation Vol 26 (7) 594-606.
8. Diaz-Llopis et al (2013) Botulinum toxin type A in chronic plantar fasciitis:clinical effects one year after the injection. Clinicla Rehabilitation Vol 27 (8) 681-685.
9. Dizon J et al (2013) Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: A meta-analysis. American Journal of Physical Medicine and Rehabilitation Vol 92 no7 606-620.
10. Thomas J et al (2010) the diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. The Journal of Foot and Ankle Surgery. Vol 49 S1-S19.
11. Wearing S et al (2010) Plantar enthesopathy: thickening of the enthesis is correlated with energy dissipation of the plantar fat pad during walking. The American Journal of Sports Medicine Vol 38 (12) 2522-2527.
12. Winson L, Wong W, Kung E, Leung A (2012) Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis Vol 49 (10) 1557-1564.

Chiropractor, Dr. Alexander Jimenez examines the ankle sprain treatment options presented in this case.

The treatment plan I outline below has been utilized in professional sports for years but hasn't entered into mainstream injury management protocols. I suspect the reason is simple: it is very uncomfortable! Nonetheless, it works: I have seen athletes on crutches after sustaining diagnosed Grade 2 2+ ankle sprains who could walk without crutches with only a minimal limp following their first session of this treatment, and who had been back training after three to four days (obviously with a great deal of tape support).

Readers will probably be familiar with what occurs after an ankle sprain: internal bleeding, inflammatory processes, pain and swelling. The brain also gets involved, producing muscle inhibition and a decrease in proprioception, which usually compels the injured athlete to limp in an effort to reduce pain.

By numbing the toe and tricking the brain into allowing the ankle to move through a normal range of motion without pain, I believe we can minimize the detrimental effects of ankle sprains.

25-Minute Cryo-Kinetic Ice Bath

By icing the ankle in an ice tub, just following the protocol outlined below, I think you will be able to:

Precaution!

Perform this regime every two to three hours for the first two days following the injury. In professional sports, injured athletes may also set their alarms and ice a few days, late at night and early morning (eg, 12pm and 3am) to minimize swelling and optimize recovery speed. For your averagely active individual who also has a day job, I'd get them to perform this program as soon as possible following the accident and after that, for the initial two to three days, once a day towards the end of the day once they're back from work and have settled down to the evening. I have even had success using this technique on chronic swollen ankles that was sprained four to six weeks previously. After one to two sessions in the bucket, the swelling was minimal and the range of movement improved dramatically.

Caution!

There are a few basic principles which the patient should be informed of:

Part II

6. Types Of Stretching

The reason that flexibility and stretching are confusing issues is partially because there are so many diverse kinds of stretching and exercisers are just at a loss about what type of moves to do and when. With this in mind, this chapter is devoted to setting the record straight so that you understand what kind of stretching is best for your personal circumstances.

Don't feel you've got to perform them all -- that's definitely not what is intended. Rather, read the descriptions and then use the methods that are specific for your training and workout goals. Use the right sort of extending at the ideal time and you're much more likely to find benefits from your flexibility training.

Static Stretches - Active Vs. Passive

Static stretches are the most identifiable form of flexibility training and also what most people today think about when you mention extending. For several decades, static stretching was how we all stretched -- before, during and a er exercise.

Ere are two major types of static stretches -- active and passive. A passive stretch uses an outside object or power to take you in stretch, for example employing a door frame or partner to elongate your pecs. In a busy stretch, you are using your muscles to maneuver you into a stretched position, e.g. clasping your hands behind your back and pushing your elbows to the rear to stretch your torso.

It really doesn't matter too much if you perform passive or active static stretches as the result is the same. It's worth noting, however, that if you are likely to hold a stretch for an extended time period, passive stretches are o en more comfy. Using the above cases, holding a doorway chest stretch for 60 seconds or more will be much simpler and much more comfortable than holding the hands clasped behind the back at a chest stretch for the exact same period.

1. Static Maintenance

In case your flexibility is already great and you simply want to be certain you don't lose it, for example after a work out to o set adaptive shortening, maintenance stretching is right for you. A maintenance stretch is not meant to enhance your flexibility and, as such, is not held for very long.

Maintenance stretches are normally held for between 10 and 15 seconds with no attempt to move deeper than is initially comfortable.

Commonly used as a member of a cool down, static stretches help reduce muscle strain and return your muscles for their pre-exercise length. However, the downside, static stretches have a tendency to cause your heartbeat to drop and reduce muscle contractility which may lead to a reduction in force production possible. In other words, static stretching can make you temporally weaker. For all these reasons, static stretches are normally omitted from setups.

2. Static Developmental

If you would like to enhance your flexibility, developmental static stretching is a good choice. Developmental stretches are held for between 30 to 60 minutes or longer and, as the name suggests, you should attempt to increase the thickness of this stretch as time passes.

If you stretch a muscle, you reach the natural end point of your muscle's elasticity -- known as the point of bind, or POB for short.

Should you stay in the POB for 15 minutes or so, you may feel your muscles relax slightly and you should then have the ability to move into a deeper stretch. Is happens more readily for those who a) unwind and b) do not hold your breath. Continue extending the POB as many days as possible till you get to your true conclusion of scope. Once you are there, continue for a further 15 to 30 minutes to actually maximize your flexibility training.

To recap:

• Move into POB and hold for 10-15 seconds
• As you feel your muscles relax, move a little deeper to new POB
• Keep your body relaxed and breath steadily
• Repeat steps one to three a couple more times before you reach your true flexibility limitation
• Hold this final place for 15 to 30 minutes
• Slowly ease out of this stretch

As you may see, developmental static stretching can be rather time consuming thus is best reserved for muscles that are really tight. Developmental stretching is best used as part of the cool down or, even if you're serious about improving your flexibility, during committed stretching sessions a er a light warm-up.

Just like all types of stretching, don't force either variety of static stretch. If you feel any burning or shaking immediately back off and use a less extreme POB.

An Exception To The Rule

While static stretches are normally reserved for cool downs, tactical use of a select number of static stretches can be used at a warm-up under specific circumstances.

As an example, when you've got tight chest muscles you might find it rather difficult to pull a barbell into your sternum when performing barbell bent over rows. In this instance, stretching the pecs before performing an upper/mid-back exercise could be beneficial.

Another example: if you've got tight hip flexors, then you may discover that, when squatting, you have a propensity to lean too much forwards which could put an inordinate quantity of stress in your lower spine. Statically extending your hip flexors may help eliminate this issue.

Finally, and again using the squat as an example, if you find your heels lift off the ground when squatting, this may suggest tight calf muscles. Stretching your calves before and between sets of squats may stop this potentially dangerous problem.

3. Dynamic

Where static stretches are generally best used in down the cool, dynamic stretches are much better suited to warming up. Dynamic stretches are stretches performed on the move and into the uninitiated do not actually look like stretches at all!

The beauty of dynamic moves is that they prepare your body for the activities you're going to perform without allowing you to get cold or diminishing the contractility of your own muscles. They also offer an excellent chance to rehearse the motions you are about to perform on your upcoming workout.

Dynamic stretches are also quite time efficient and it is possible to have a synergistic impact on most of your major muscles in as few as three exercises although chances are you're going to want to perform more like five or six so that you feel properly warmed up. You'll discover a lot of dynamic stretches in the stretching library in chapter seven.

Dynamic stretching uses a happening called reciprocal inhibition -- the exact same thing mentioned back in chapter two. Fundamentally, when one muscle contracts, its opposite number, called the antagonist, should unwind and this allows you to stretch it. For instance, if you bend your elbow, your knee contract and your triceps, located on the back of your upper arm, then should unwind and receive a gentle stretch as your arm reaches full flexion. Is is the very essence of dynamic stretching.

By performing specific movements like leg swings, overhead reaches and standing waist spins, you stretch none but two muscles -- you, as you move in one way, which muscle's antagonist as possible return. Is two-for-one stretch is what makes dynamic stretching so time-effective.

Unlike stationary stretching, dynamic stretching does little for the resting length of your muscles. It simply takes your muscles into the POB so that they are adequately prepared for your coming workout.

When performing dynamic stretches, it is very important you increase your assortment of movement slowly over a collection of 10 to 20 repetitions. Start o by being really careful and conservative and then increase the range of movement as you believe that you're prepared.

Also, be sure that every stretch is done rhythmically and with controller. Do not ing your limbs around with complete abandon! Each motion should take a couple of moments to finish and at no point should you feel as though you're bouncing out of the end point of the stretch. Decide on a steady tempo and stick to it for the duration of your set.

Make sure you don't do so many repetitions that your dynamic stretches turn into a test of muscle endurance! Is is particularly true of exercises such as lunges and squats -- Both good examples of dynamic moves for the more advanced exerciser. Do as many reps as you need to feel comfortable but no more. Save your energy for your workout!

Precede your dynamic moves using a couple of minutes of cardio to ensure your joints and muscles are warm and nice though, again, only do as much as you want to prepare your body to the coming workout.

4. Ballistic

Ballistic stretching is a lot like dynamic stretching, just faster and more volatile. Is increase in motion velocity includes a heightened probability of harm which is why ballistic stretching isn't suggested for beginners or those who don't actually need it.

In sports such as kickboxing, sprinting, gymnastics and even fencing, motions are performed a) very quickly and b) via a large selection of movement -- that the very definition of ballistic. Is way that participants in such and similar sports may consist of ballistic stretching as part of the training. Not to do so would invite harm when they practice their preferred sport.

For the rest of us, where rapid and large movements aren't the norm, the chance of ballistic stretching far outweighs any possible benefits. Dynamic stretches are fine for the majority of even the most ardent exercisers and provide many of the advantages related to ballistic stretching without the dangers.

If you're a sportsman or women who needs to add ballistic stretching in your training, be sure that you always warm up thoroughly before commencing. Increase the range of movement slowly to prepare your muscles to what's to come, start o with dynamic stretches and then, ultimately, advancement to ballistic moves (and even then advance your speed). Exercise some control at the end range of movement to minimize the risk of injury and make sure the motion is coming out of the ideal part of your body -- i.e. do not round your back when doing high front leads as the strain is being taken o your hamstrings and also being placed in your delicate passive lower back ligaments and discs.

Ballistic stretching bottom line? Only satisfactorily prepared sportsmen and sportswomen should utilize this advanced kind of flexibility training and then with caution.

5. PNF

PNF, short for proprioceptive neuromuscular facilitation, is an effective form of extending that may result in very rapid improvements in flexibility -- almost instantaneous. While the advancements that result from PNF are very rapid and noticeable, they're not permanent so PNF is not a one-shot x for inferior flexibility. But if you need some immediate gratification from your stretching, PNF is for you! PNF functions on the grounds that once a muscle was contracted, it goes to a place- contraction relaxed condition and is much more amenable to being stretched.

Basically, by using PNF, you "trick" your muscles into relaxing more quickly than they would normally so you can progress the point of bind or POB into a greater degree and in significantly less time.

PNF stretches are best done with a knowledgeable training partner since they may be complicated to do independently but, saying that, many can be performed alone if you're ready to think a little outside the box and also utilize external props like webbing straps to achieve the desired results.

Because PNF stretching takes time, it is generally best left for your cool-down and reserved for those muscles that are really tight. PNF is also a great form of stretching to add in standalone flexibility sessions at which time is less of a problem.

It is vital that there's good communication between the 'stretch-er' and 'stretch-ee' because overenthusiastic limb misuse could lead to serious injury. If in doubt or if you feel any discomfort, back o immediately.

6. CRAC

Standing for Contract Relax Antagonist Contract, CRAC is a variation of PNF and for all intents and purposes, synonymous. Using exactly the same contract/relax happening as PNF to encourage a deeper stretch, CRAC adds an extra component to progress the POB farther and potentially faster.

As you know, when one muscle contracts, its opposite number must relax to allow motion. CRAC utilizes this mechanism to allow you to move to a deeper post- contraction stretch. CRAC is also an efficient way to develop isometric power and is a helpful strengthening instrument o en used in post-injury rehabilitation. (Isometric contractions are the most powerful of all muscular contractions and result in no Motion as a single muscle group operates against the other.)

To illustrate how you can do PNF and CRAC moves independently, this stretching Example uses the doorway chest stretch, which is a excellent way to fix a round- shoulder position while, strengthening the muscles of the mid-upper spine (center trapezius and rhomboids)

● Position yourself in an open doorway. Raise your arms and rest your elbows and forearms against the vertical sides. Your elbows should be roughly level with your shoulders.

● Adopt a staggered stance for stability.

● Keeping your elbows and forearms pressed against the door frame, lean your body between your arms until you feel a stretch across your chest.

● Hold this position for 10-15 seconds until you feel your pecs relax.

● Contract your chest muscles by pressing your elbows and forearms forcefully against the door frame. Do not allow your arms to move. Use between 30-50% of your maximal perceived strength and hold the contraction for 10 to 15 seconds.

● Relax your chest and then use your upper back muscles to pull your elbows further back to increase the stretch in your chest. Lean forwards again so that your arms are resting on the door frame.

● Repeat steps four to six a couple more times until you fail to see any noticeable increases in the range of movement.

Like PNF, CRAC is a fairly lengthy process so is best retained to your tighter muscles and utilized in your cool-down or standalone flexibility sessions. It is quite effective for developing your flexibility but, if performed too aggressively or with a spouse who lacks the necessary experience, could lead to injury. While mild distress is acceptable and may even be desired, pain isn't, so make sure you back o if you're feeling anything untoward.

7. Library Of Stretches By Muscle Group

There are literally hundreds of ways to stretch - some very simple and some really convoluted. The primary point to keep in mind when assessing the worth of every stretch is that, to be effective, you must pull off the ends of the muscle away from each other and do this in a way that puts minimal stress on your joints along with the remainder of the body. By applying these standards, the great number of moves which are possible can easily be whittled down to 50 or so stretches.

In this section, you'll find instructions on how best to perform Various great stretches for every one of your major muscle groups. Ere are inactive stretches, dynamic stretches and, where relevant, some which can be performed using PNF and/or CRAC protocol.

Out of your personal flexibility evaluation, you must now know what areas of your body are tight and what regions are normal concerning flexibility. Pick developmental static stretches or PNF/CRAC on the tight muscles and utilize maintenance static stretches to your muscles that are more flexible. Perform these stretches as part of your cool down or through standalone flexibility sessions. Remember, however, to maintain dynamic stretches to your setups.

If, when performing any of these exercises, then you fail to sense much of a stretch a) test that your limbs are aligned correctly, b) try another stretch for the same muscle and then c) don't worry! It might well be that you're adequately flexible in the muscle in question and then you do not feel a lot of stretch.

As mentioned before, all stretches should be preceded by a few minutes of mild cardio to increase core temperature and enhance blood ow though your muscles.

Gastrocnemius

Is is the larger/upper calf muscle and can be among the most powerful by dimension muscles at the body. As they are so powerful, the gastrocnemius can take a fair bit to stretch, however if it Becomes tight can have an adverse effect on knee health. Its basic function is to stretch your ankle.

Prone cobra

●  Lie on your front with your hands under your shoulders

Pectoralis Major

Standing upper trap stretch

●  Stand with your feet hip-width apart and your knees slightly bent

Overly tight forearms can result in hand, wrist and elbow pain. If you hands naturally gravitate to a clenched position when you relax, chances are you have tight forearms. If you spend a lot of time typing, make sure you stretch these muscles o en to avoid developing a repetitive strain injury (RSI) or carpal tunnel syndrome.

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In the first of a two-part article, scientific injury chiropractor, Dr. Alexander Jimenez explains the anatomy and biomechanics of the medial knee ligaments, the consequences of injury, and how these injuries are identified and graded.

The shallow lateral collateral ligament (s-MCL) is among the most commonly injured structures in the knee, in both contact sports and sports that involve sharp cutting and direction changes. It might also be associated with more serious injuries to the medial knee including deep lateral collateral ligaments (d-MCL) and posterior oblique ligament(1-6).

The vast majority of MCL tears are isolated. These injuries occur predominantly in young individuals participating in sports activities, together with the mechanism of harm between valgus knee loading, external rotation, or a combination of these. These are common in sports as skiing, ice hockey, rugby and football, all of which involve motions requiring knee flexion and valgus loading and potential of direct contact to the outside of the knee(7-9).

The treatment of medial-sided knee injuries has moved away from competitive surgical remedies to largely non-operative management. Surgery is generally reserved for chronic MCL lack that has neglected non-operative therapy, or more acute and intricate injuries. The vast majority of athletes who sustain an MCL injury will reach their pre-injury action level with non-operative treatment.

Anatomy

The iconic anatomy reference point for understanding that the lateral knee joint stabilizers comes from Stan James in Iowa State University, who performed a very thorough dissection study about the lateral knee joint at the 1970s(10). The medial knee was divided into dynamic and static stabilizers:

Superficial Medial Collateral Ligament

LaPrade et al 2007 have made the most comprehensive examination to date on the s-MCL(18). They claim the s-MCL is the most significant structure of this medial part of the knee (see figure 1). It's one rectal attachment and 2 tibial attachments(18). The femoral attachment is oval in shape and, on the average, 3.2mm proximal and 4.8millimeter lateral to the medial epicondyle.

Since the s-MCL classes distally, it has two tibial attachments. The proximal tibial attachment is mainly a soft tissue attachment onto and over the conclusion of the anterior arm of the semimembranosus tendon, and lies a mean of 12.2mm distal to the tibial joint line(18). The distal tibial attachment of this s-MCL is broad and is straight to bone with an average of 61.2mm distal to the tibial joint point; it's located just lateral to the posteromedial crest of the tibia(18). The two distinct tibial attachments are reported to lead to two distinct functioning branches of their s-MCL(19).

A more recent study by Liu et al discovered that the s-MCL was triangular in form and the proximal and distal components were composed of parallel fibers. By comparison, the middle area of the s-MCL consists of parallel and oblique fibers, along with the middle portion was 1.7 times wider than the proximal/distal components(20). It's would be interesting to note if the 'oblique' fibers in this study refer to the posterior oblique ligament, which is discussed further below, and numerous authors have made this identical point(13, 14, 21,22).

Deep Medial Collateral Ligament

Deep into the s-MCL is that the d-MCL, which is comprised of this thickened medial aspect of the joint capsule. It is divided into meniscofemoral (MFL) and meniscotibial (MTL) parts (figure 1) and can be firmly attached to the medial meniscus at the joint line(20)

The bigger, but thinner MFL has a slightly curved convex attachment 12.6 mm distal and profound into the femoral attachment of this s-MCL. The MFL is about three times more than the MTL(20). The MTL attaches just distal to the edge of the articular cartilage of the medial tibial plateau, 3.2 mm distal to the lateral joint line,and9.0mmproximaltotheproximal tibial attachment of the s-MCL(18), also is 1.7 times wider than the MFL(20). It has also been reported that that the MFL attaches deep into the s-MCL, and the MTL attaches just distal to the tibial articular surface(25, 27). The d-MCL might play an important part to anchor the peripheral parts of the lateral meniscus in the medial side of the knee(20).

Relevant Biomechanics

The s-MCL is the primary restraint to valgus laxity of the knee and at 25 degrees flexion it provides 78 percent of the valgus controlling force(1,2,28-30). At this angle of flexion, the posterior oblique ligament gets lax and does not provide valgus support. In total extension, the ACL, posteromedial corner and semimembranosus bring about valgus restraint and the s-MCL only provides 57% of the controlling force(1,2). In general, an isolated s-MCL tear contributes to valgus laxity in flexion, whereas additional injury to the secondary valgus restraints (posterior oblique ligament or ACL) contributes to greater laxity in extension.

It has always been assumed that both different tibial portions of the s-MCL had comparable functions. But less than a decade ago it was ascertained via biomechanical studies that there are differences between the two divisions of the distal s-MCL in terms of their answers to applied loads (19). The two divisions of the ligament actually be conjoined but distinct structures. Therefore, any operative repair of this s-MCL must restore the different functions of the divisions by reattaching both tibial attachments, in an effort to reproduce the total function of the s-MCL.

The posterior thoracic fascia acts as a stabilizer of the two inner rotation and valgus movement at between 0 and 30 degrees of knee flexion(1-4,19,31-35). With the tibia internally rotated at 0 degrees flexion, the loads on the anterior oblique ligament are considerably greater than those on either branch of their s-MCL, which can be tauter in external rotation(19). Furthermore, the load reaction involving the anterior oblique ligament and s-MCL is reciprocal since the knee approaches 90 degrees flexion.

Also of interest is the fact that if d-MCL and s-MCL are surgically cut, significant gains in force are advocated by the posterior oblique ligament under valgus loads at 0, 20 and 30 degrees of knee flexion(36). As a result, the posterior oblique ligament in complete knees experiences tensile load using valgus forces, particularly near knee extension(19,36), and it also has a secondary function in supplying valgus stability of the knee(13,14,31,36).

The operation of the d-MCL (both the MTL and MFL) is poorly understood in comparison to the s-MCL. Its specific role is to function as a secondary stabilizer of the knee to valgus load(35,36). Valgus stabilization is offered by the MFL part at all tested flexion angles. The MTL portion stabilizes mostly at 60 degrees of knee flexion. The d-MCL provides restraint against external rotation torque in knees flexed between 30 and 90 degrees(36).

In studies, It's Been found that the maximum load to failure to the three structures were as follows(36):

• s-MCL -- 534 Newtons
• d-MCL -- 194 Newtons
• Posterior oblique ligament -- 425 Newtons

Controversy also exists as to where the weakest part of the complex is and the way this correlates with real injury in athletes. To outline however:

Injury Classification

The time-honored type of grading ligament injuries is derived from the American Medical Association Standard Nomenclature of Athletic Injuries (see figure 2)(41). Inside this naming method:

It's important to perform valgus stress testing in 0 degrees of flexion, which is different from in full extension. In full extension (almost hyperextension), there's recruitment of ACL function that may hide the laxity of the entire medial-sided injury. There is a high prevalence of associated ligamentous injuries with ACL injuries in grade III cases using this classification method.

Clinical Assessment

History

The traditional mechanism of trauma reported is a sudden touch or non-contact valgus force to the knee with swelling and pain along the medial aspect of the knee. They may feel a tearing feeling with acute pain or in acute cases of rupture could hear a pop up. Those with low grade medial knee injuries involving either the s-MCL, posterior oblique ligament or d-MCL may try to continue competing. However, they often described a side-to-side feeling of uncertainty, particularly when doing pruning and cutting maneuvers.

Clinical Evaluation

The key features that may be found clinically are(18):

Stress Testing

With the patient lying supine, the assessor grasps the ankle with one hand and places another hand on the outside of the thigh above the knee. A gentle outward force is put on the ankle. This can be achieved at full extension, 0 degrees flexion and 30 degrees flexion:

Imaging

Plain film X-rays are often unnecessary unless the clinician would like to appraise the degree of gapping of the medial joint line under imaging. In 1 study, a load applied by a clinician into a knee with a simulated isolated tier III s-MCL injury increased medial joint gapping, compared with that in the intact knee, by 1.7 and 3.2mm at 0 and 20 degrees of flexion, respectively(45). A complete lateral knee trauma, with sectioning of this s-MCL and d-MCL and the anterior oblique ligament, increased gapping by 6.5 and 9.8mm at 0 and 20 degrees of flexion respectively, below the clinician-applied load (45).

Magnetic resonance imaging (MRI) is more commonly used to assess the involved structures in patients with injuries to the medial side of the knee (see figure 3). T2-weighted MRI is the gold standard for diagnosing both partial and complete tears of this s-MCL. MRI has an accuracy of 87 percent for the assessment of MCL accidents(46).

Aspects Of Healing

Studies of the variables involved with the healing of this s-MCL in animals have shown that the healing is location dependent and immobilization dependent:

Conclusion

MCL injuries are a common occurrence in sports which require sharp cutting and changing directions, and in contact sports.

The anatomy of the medial side of the knee is pretty intricate and composed of the static stabilizers such as the s-MCL, d-MCL, posterior oblique ligament and the posteromedial capsule. It is encouraged by the energetic stabilizers, the muscles. Injuries to the inside of the knee predominately demand the s-MCL. This is ideally tested with a 30-degree valgus stress test and could be confirmed on MRI. Direction of grade 1-2, and most grade 3 injuries involves brace immobilization and conservative direction. Surgery is reserved for severe and complicated ligament disruptions or even in the case of chronic valgus instability. Part two of the report will discuss in detail the conservative progression following injury to the s-MCL.

References
1. J Bone Joint Surg Am. 1981;63:1257-69
2. J Bone Joint Surg Am. 1988;70:88-97
3. J Bone Joint Surg Am 1976;58(2): 159-72
4. J Bone Joint Surg Am. 1994;76:1328-44
5. Iowa Orthop J. 2006;26:77-90
6. Rheumatology (Oxford). 2006;45:595-9
7. Am J Sports Med. 1995;23: 597-600
8. Am J Sports Med. 1988;16:392-6
9. Am J Sports Med. 2000;28(5 Suppl):S51-7
10. Fortschr Med 1978;96(4):141-6,166
11. Am J Sports Med 2004;32(2):337-45
12. J Bone Joint Surg Am 1979;61(3):398-402
13. J Bone Joint Surg Am Vol 1979;61(1):56–62
14. J Bone Joint Surg Am. 1974;56:665-74
15. Orthop Rev. 1989;18:947-52
16. J Bone Joint Surg Am. 1983;65:323-9
17. Clin Orthop Relat Res. 1990;256:174-7
18. J Bone Joint Surg Am. 2007;89: 2000-10
19. Am J Sports Med. 2009;37:140-8
20. Journal of Orthopaedic Surgery and Research 2010, 5:6
21. J Bone Joint Surg Am 1973;55(5):923-40
22. J Bone Joint Surg Br.1948; 30:683-8
23. J Bone Joint Surg Am. 1943; 25:121-31
24. J Bone Joint Surg Am. 1941;23:44-66
25. J Bone Joint Surg Am. 1968;50: 211-25
26. AmJ Sports Med. 1985;13:390-7
27. Radiographics. 2000;20 Spec No:S83-9
28. J Bone Joint Surg Am. 1944;26:503-21
29. Acta Orthop Scand. 1965;36:179-91
30. Clin Orthop Relat Res. 1995;321:3-9
31. Am J Sports Med. 1994;22:402-9
32. Am J Sports Med. 1977;5:144-53
33. Acta Orthop Scand. 1984;55:30-4
34. Arch Orthop Trauma Surg. 1984;103:165-9
35. Am J Sports Med. 2009;37:1771-6
36. Am J Sports Med. 2006;34:1815-23
37. J Orthop Res 2003;21(6): 1098-106
38. Med Eng Phys 1999;21(5):279-91
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45. Am J Sports Med. 2010;38:330-8
46. Skeletal Radiol. 1994;23:521-4
47. Acta Orthop Scand. 1995;66:455-62
48. Clin Orthop Relat Res. 1983;172: 265-70
49. J Orthop Res. 1983;1:22-9
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51. Clin Orthop Relat Res. 1992;277:277-88

Chiropractic injury expert, Dr. Alexander Jimenez looks at the human anatomy and biomechanics of the tibialis posterior, & outlines suitable examination protocols as well as the treatment and management alternatives for dysfunction.

The tibialis posterior tendon (TPT) is a major player in the best performance of foot biomechanics, especially since it provides stability to the lateral longitudinal arch (MLA)(1). Dysfunction not only poses as pain on the inside of the lower leg and ankle, but can also be a primary cause of horizontal feet in the event of tendon rupture -- or vice versa, with inherently flat feet causing tendon overload(two). Many health professionals are yet to fully appreciate the significance of the tibialis posterior tendon and its significant role in injury incidence, which makes it important to raise recognition of this condition(3).

Dysfunction Incidence

Lots of risk factors are identified in the incidence of tibialis posterior tendonitis dysfunction. Excess weight is a variable, with heavy middle-aged women being diagnosed in 10% of instances(2). Other aspects including pes planus (flat feet), steroid injections around the tendon, hypertension, diabetes and rheumatoid arthritis(3).

Triathletes often present with this injury because of the persistent loading across both disciplines(4). The demands on this tendon from running are apparent; with poor biomechanics, it is easy to see how the tendon can become overloaded and breakdown occurs. In swimming, the requirements are not so obvious.

But, putting the ankle in plantar flexed position (by simply pointing the feet from freestyle swimming) raises the muscle shortening on the calf complex. Additional to this is the repetitive pushing off the wall at pool swimming. Also as poor foot biomechanics, some of the more frequent factors can lead to tendon overload such as raising training volume/load fast, hill reps, erroneous fitting footwear(4).

During a triathlon consequently, the calf muscle shortening in the swim and the high force production during the bike ride are joined when penetrating the run, which means the run begins with the calf muscles having already been loaded greatly, causing additional fatigue. Thus effective training with good recovery protocols is essential for preventing this sort of injury in triathletes.

Anatomy & Biomechanics

The tibialis posterior (also known as the anterior tibial tendon) originates in the posterior surface of the tibia on the external component, with a muscular attachment to the medial surface of the fibula, and the interosseous membrane between the tibia and fibula(2). It paths through the deep posterior compartment of the lower leg, together with the more dominant calf musculature of the gastrocnemius and soleus, and goes behind the lateral malleolus of the ankle. It is at this stage (just behind the medial malleolus) that the blood supply is diminished(2).

At the distal attachment, then the tibialis posterior divides into three sections with the major section attaching to the navicular tuberosity (bony prominence) on the inside of the foot(2). The plantar segment attaches to the second, third and fourth metatarsals, second and third cuneiforms, and the cuboid bone. The third section referred to as the recurrent portion attaches to the sustentaculum tali of the calcaneus (see figures 1 and 2).

On account of the anatomical landmarks of the tibialis posterior, it's the primary ankle inverter, and also functions to maintain dynamic equilibrium of the MLA of their foot in addition to assisting another calf muscles with plantar flexion(5 feet). Due to its attachment sites at the navicular, calcaneal and cuneiform bones, it's evident how the tibialis posterior plays a significant role in bettering the MLA to raise the rigidity of the back and mid foot during stance. Consequently, this offers an opportunity for the gastrocnemius to function with greater efficacy(2).

Pathophysiology

A substantial period of time in an air cast boot or pot might lead to weakness of this tendon and a reduced height of the MLA. A complete rupture of the tendon in the foot attachment does not have to occur to get a flat foot deformity to occur. Therefore, a rehabilitation program must include strengthening exercises of the foot inverters. Whether this strength work is not carried out then the tibialis posterior tendon can become vulnerable and repeated micro trauma can cause the tendinosis to occur.

As the tendon degenerates it is substituted with fibrotic tissue, and this frequently occurs in areas with inadequate blood flow in areas like supporting the lateral malleolus(2). Bubra and colleagues have stated that because of the rear foot valgus affects, a contracture can occur of the achilles tendon resulting in changes into the forces applied at the back foot(2). These modifications in applied forces can lead to pain because of the touch of the fibula and the lateral calcaneum. A further biomechanical factor linked to changes in the back foot is that the contracture of the peroneus brevis, which causes a mechanical force exerted to the opposing tibialis posterior tendon.

Evaluation

It's critical to formulate a thorough examination protocol when you suspect tibialis posterior tendinosis may be a potential. The first thing to check to get is any swelling behind the medial malleolus of the ankle (figure 3), and when combined with changes in foot shape, has been proven to have 100% accuracy for tibialis posterior tendon dysfunction diagnosis(3).

A progression is to ask the patient to raise up on one leg; a patient with tibialis posterior tendinosis won't be able to do this. The single-leg elevator is one of the major functional tests used for this particular condition. If function is ordinary, a person should be able to finish ten repetitions, pain free.

The ability of the muscle-tendon unit can be analyzed by resisting from a dorsiflexed/ everted position into plantarflexion- inversion, which follows the actions the muscle actively eases(3).

An X-ray taken of the two lower limbs is utilized to observe the individual in standing. The radiographs are best taken in the front and also the outside of the ankle to best view for the presence or lack of degenerative changes in the subtalar and talocrural joints. Even though a radiologist may further request an MRI scan or ultrasound scan, researchers at the Royal National Orthopedic Hospital, UK, have contended that clinical evaluations for tibialis posterior thoracic pain are adequate for forming a diagnosis(3).

Treatment & Management

Tendon degeneration can be simplified into four different phases (Table 1), and the proper therapy at each phase will therefore largely be dependent on the stage of injury. Stages three and four are less commonly observed in athletes, however, at the same time, it is important to acknowledge the progression tendon degeneration can take.

But, stage three is closely associated with irreversible subtalar joint degeneration with irreversible tendon changes. Stage four was added to include degenerative changes within the ankle joint in addition to the constructions involved in phase three. It is important to develop the strength of the tendon in a practical capacity once the swelling has eased and a heel raise can be performed. A simple exercise with a tennis ball between the heels (see figure 5) helps to improve rearfoot eversion and activation of the tibialis posterior.

Summary

A variety of conditions exist as risk factors in the occurrence of tibialis posterior tendon disorder, and these should be regarded as part of the examination. It is important to apply emphasis on the successful rehabilitation of ankle injuries either acutely, or after surgery, to make sure that prior injury does not cause tendon dysfunction later on. Successful screening should take place among an athletic squad to make sure that nobody is present with abnormal foot biomechanics that may cause tendon degeneration.

References
1. Blasimann – J Foot and Ankle Res, 2015, 8, 37
2. Bubra – J Family Med Prim Care, 2015, Jan, 4, 1, 26-29
3. Kohls-Gatzoulis – BMJ, 2004, 329, 1328–1333

A lady in her early 30s recently came to see me complaining of a stone in her shoe. At first I proceeded to check that the sign in the window hadn't changed to say cobbler, instead of physiotherapist! I returned, rather relieved to observe that a waiting room filled with individuals with orthopedic ailments, but confounded with this very strange complaint from Karen the runner. I had to hear more. Chiropractic injury specialist, Dr. Alexander Jimenez examines the case.

Karen went on to detail a three-month history of pain between her second and third metatarsals. It started for no apparent reason. She had been running quite a little down the mountains of northern England, but this was nothing unusual for her and she'd never previously had issues. She could not pinpoint any other changes except one -- she was practicing her bridal dance with Paul, her fiancé. They wanted to dance salsa, also Karen admitted to a particular weakness for high-heeled dance shoes. Right, I thought  possibly there was a loading along with a footwear issue here. By this stage, I was beginning to feel less anxious about the possibility of being expected to resole all of her shoes.

Further questioning revealed that Karen's pain had a burning quality that had first started coming on after about an hour of either running or dance but was now appearing within about 10 minutes of her wearing any kind of shoe that wasn't completely flat. She was not sure, but she felt that it had begun to hurt between her third and forth toes as well. These clues were leading me down the route of considering a nerve (nerve) element for her pain, especially when she clarified a „weird tingling somewhere in my feet . It appeared to be worsening both in intensity, distribution and irritability. She was otherwise in excellent health.

Evaluation proved tricky as Karen's foot wasn't debilitating the morning she came in to visit me and nothing I could do could reproduce her symptoms, much to her dismay and my disappointment. She was my very first appointment of the day. So I asked her to go home, pick up her heels and wear them that day and come back to see me after work, when (hopefully) her symptoms might resurface.

As it was, Karen hobbled in at 6pm. She had decided to make sure her foot hurt by wearing the offending Manolo Blahniks all day and going for a run at lunchtime. Suffice to say, this made my job a lot easier and she received a gold star for being such a dedicated patient!

Evaluation this time revealed that her pain was replicated by doing a heel raise -- a manouver which induced her to keep weight through extended metatarso- phalangeal (MTP) joints. As soon as I palpated the plantar part of her foot at the second and third interdigital spaces (between second to third and third to fourth toes), she jumped with her familiar pain, which now extended into her feet. I was able neither to palpate any unusual lumps nor elicit a click (called Mulder's sign) when I squeezed the metatarsal heads. This can sometimes happen if there's nerve swelling and also a proliferation of scar tissue adjacent to the metatarsal heads.

If the pain had still been hard to localize, I would have considered referring Karen to a sports doctor for them to inject a local anesthetic within the interdigital area to see whether this could relieve her pain, albeit for a brief period. As it was, this measure was not necessary as Karen managed to pinpoint exactly the space between her third and fourth metatarsals, only distal to her fourth MTP joint. She was also experiencing pain at the second interdigital space, although this was less intense.

I was fairly comfortable at this stage with the identification of interdigital neuroma, more commonly called Morton's metatarsalgia. I did want some plain-film X-rays to show me what state the MTP joints were in, however. I asked Karen to avoid running, dance only in flat shoes and to plunge her feet in ice water for 10 to 20 minutes a couple of times every day. And I asked her to see her GP with a view to getting a prescription for some anti- inflammatory medications.

I made her some temporary metatarsal load reliefs from podiatry felt and put these in her shoes. These are meant to distribute the weight-bearing load across all her MTP joints, but not only the irritated ones. She was due to see me in three days, ideally with her X-rays and at less pain. This also gave me three days to refresh my memory on your foot's neural anatomy!

Forefoot Anatomy

Causes Of Interdigital Neuritis

Although often referred to as a neuroma, Morton's metatarsalgia is not usually a true neuroma, but more of a chronic irritation of a nerve, characterized by intra-neural swelling and excessive extra-neural scar tissue formation. A true neuroma is actually a tumor, pathophysiologically different from that which we're dealing with in this example. Some ideas have been put forward regarding the origin of the problem. Some have stated it is the end result of poorly-fitting (usually too small) footwear compressing the interdigital space and all of its contents. Some say it's more to do with faulty biomechanics resulting in degeneration at the MTP joints and chronic synovitis. Others think injury is likely to be the main cause, leading to scarring and thickening of a damaged nerve sheath. Actually, the clinician will often find a combination of these issues.

In Karen's case no joint degeneration showed up on X-ray, but there was a degree of laxity in her third MTP joint, leading to the suspicion of a plantar plate accident at some point in her past. Karen was a former dancer, so this was indeed a possibility. The plan of management we had decided upon appeared to have dampened her pain down significantly. She felt that the anti inflammatory medications were especially helpful, giving additional weight to the theory that the pathology was an active and inflammatory one, most likely kept by loading that the joints in expansion (as seen in high heels and just prior to push-off when running).

Management

Karen was especially keen to pursue conservative (non-surgical) options. The inflammation brought on by loading the loose MTP joint was further distending the joint, rendering it even less stable and more prone to inflammatory processes. Clearly the dual methods of loading and inflammation were perpetuating every other, thus we had to interrupt the cycle.

Karen had to accept this, particularly in the short term, she'd have to take steps to decrease load through the third and second metatarsal joints. We also had to reduce the severe inflammation. Karen carried on together with the anti- inflammatory medications under the advice of her GP for another week and continued to ice her feet. She wore shoes with a wider toe box, allowing her transverse arch be under less strain. I left some metatarsal relief bars out of high-density, low-profile foam, placing these under the insoles of three pairs of her shoes. I put them slightly towards the heel of the metatarsal heads, which prevented the MTP joints in hyperextending.

I also did some manual treatment to ensure Karen' back and forefoot joints were suitably mobile and gave her some intrinsic muscle strengthening exercises. We were able to prevent the need for corticosteroid injections and surgery, although these choices were open to us if the conservative route failed.

Surgery could be aimed at excising built-up scar tissues and is often successful, but only if the underlying biomechanical problems are fixed. I saw Karen twice more over the following three weeks, during which time we could re-introduce her to running. This was initially on the flat after which she was slowly exposed to the increasing toe extension that operating on hills demands. She weaned herself off her meds, but would prophylactically take a few as she returned to dancing salsa. She'd need to take wearing marginally lower heels as a result of her symptoms, but said she'd prefer this compromise to having to hobble around for the remainder of her life with a pebble stuck in the sole of her foot!

A 33-year old finance manager with severe knee pain and a knee injury that had already been examined by a surgical specialist. On the case notes, the surgeon had scribbled a differential diagnosis list. In the top was meniscal injury, and in the bottom were the words "lunge lesion." Science chiropractor, Dr. Alexander Jimenez investigates and discovers a little about this unusual injury.

"Lunge lesion" describes an isolated injury to the femoral trochlear groove -- a single surface of the patellofemoral joint. It was first described in 1978(1). Seen infrequently, it may happen in active young patients involved in recreational sports.

My client recalled a social game of badminton where he'd lunged forward quite deeply on to his right foot in an attempt to reach the shuttlecock for a net-shot. He described a deep ache in his knee and lack of ability to push back through his front foot to endure. He could not play on. During the upcoming few days that he developed swelling and pain, and detected "creaking in his knee when he flexed it. His symptoms hadn't resolved after two weeks of rest.

Plain radiographs (x-ray) of the knee were ordinary and an MRI scan failed to identify any pathology. It confirmed that his ACL, PCL and collateral ligaments were all intact, and it showed up nothing indicative of meniscal tear. A small field of bone bruising was observable beneath the trochlea. The non-specific findings of this MRI further dampened my patient's mood.

His symptoms had been slow to improve, so the decision was made to proceed into a diagnostic arthroscopy, which, despite great improvements in MRI technology, remains the "gold standard investigation of intra-articular pathology from the knee. The arthroscopic findings were normal, except for one thing: an isolated split running lengthways across the femoral trochlear groove (see Figure 1, below). The under-surface of the patella was unaffected. The cartilage edges were stable and no loose flaps were identified which required debridement (tidying up). This reassured my client that he did really have an injury that explained his pain, and it provided information for us to invent a rehabilitation program for him.

The reason behind a lunge lesion injury is usually a rapid deceleration of the flexed knee using co-contraction of the quads and hamstrings(2), though other less common mechanisms like a direct blow to the patella are postulated. This injury classically takes place through a lunging motion of this type that happens in squash, tennis and netball(3). And, because functionally, it is the trochlea that acts to stabilize the patella between 30 and 100 degrees of flexion(4), loading of the joint in this way causes substantial shearing and compressive forces at the bottom of the groove. If the load is high enough, then a fissuring of the intercondylar cartilage can occur, resulting in painful crepitus (creaking) and catching when the knee is bent (envision the wedge shaped patellar- articulating surface dividing the cartilage of the groove).

Despite the injury to the trochlea froma a lunge lesion, the patellar surface remains uninjured. Various hypotheses have been proposed to explain why. One is that the articular cartilage of the patella is heavier and much more malleable than the cartilage of the trochlea. Another suggests that the encompassing soft-tissue supports of those highly mobile patella are somehow able to dissipate load better than the trochlea(5).

Treatment

A guessed lunge lesion doesn't always need arthroscopic debridement. Initial therapy should be the standard practice of rest, ice and elevation, progressing to mild passive and on to active knee mobility exercises. Passive mobilizations of the patellofemoral joint can be initiated after the acute phase (typically four to seven days post injury), as pain allows. Progression of practice back to running and cutting maneuvers will be decided by the customer's tolerance of these actions. Persistent or worsening swelling and pain without improvement within a few weeks would imply that further investigation and possible arthroscopic debridement is essential. The significant determinant of effective lunge functionality is volatile strength of the closed kinetic chain of the lower limb, but at the sports science laboratory, body mass, stamina and leg length has all been found to affect performance(6). So the "return to game" phase of rehabilitation must tackle all four factors. Strengthening the prime movers of the knee with functional activities and progressive loading should be the mainstay of therapy. This area of the program should include eccentric loading of the knee.

It's also very important to help the client regain correct motor patterns once the acute phase is over. An extensive evaluation of biomechanics may identify deficits or imbalances that could be adjusted with orthotics and/or construction techniques.

My patient progressed well and returned to his usual level of function. Unfortunately I am no longer connected with him, so it's not possible to create any longer-term evaluation of the natural history in this case. However, I would expect an injury to the load bearing surface of the patello femoral joint to heal slowly, with a higher likelihood of the individual developing patello femoral joint symptoms at some point in the future.

References
1. Cross MJ “The painful kneeÐ. Australian Patient Management: 11-21, August 1978.
2. Cross MJ, Morgan, DG. “The “Lunge” LesionÐ presented at The Third Congress of Knee and Orthopaedic Sports Medicine Section of WPOA, Sydney, 8-11 September 1993.
3. Cross MJ, Morgan-Jones RL “Knee syndromes and arthroscopic knee procedures. www.kneeclinic.com.au/papers/
ArthProcedures.htm (Access date: 9/12/2004).
4. Heegaard J, Leyvraz PF et al “Influence of soft structures on patellar three-dimensional trackingÐ. Clinical Orthopaedics and Related Research. 1994;299:235-243.
5. Morgan-Jones RL, Cross MJ, Morgan, DG “Isolated articular cartilage lesions of the femoral trochleaÐ. www.kneeclinic.com.au/papers/FemoralTrochleaLesions.html (Access date: 2/3/08).
6. Cronin J, McNair PJ, Marshall RN “Lunge performance and its determinantsÐ. Journal of Sports Sciences, 2003, 21, 49–57.

This case study focuses on the Australian over-105kg weight-lifter Damon Kelly, who injured his left shoulder, which he had jarred while performing a mis-timed snatch. Injury scientist, Dr. Alexander Jimenez takes a look at the case.

In the snatch movement, the bar must be lifted above the head to full arm extension at one continuous rapid movement. The weight-lifter should then be held steady until the judges have accepted the lift.

While practicing, Damon had captured the pub just too far behind his head, causing a slight "shift within his gleno-humeral joint along with a sharp pain. He immediately dropped the bar and had been resting almost completely from the grab component of his training.

Damon currently presented with "stiffness" and pain, largely on reaching across his body (horizontal flexion) along together with his hands behind his back (complete operational internal rotation). All stationary muscle tests were negative, and also his shoulder elevation was ordinary, much to my relief.

He reported being able to perform shoulder press with no pain in any way, even in a moderately heavy load for him. He was, however, getting some pain with the grab position under load, and was quite apprehensive about this (it felt "weak in that position).

I have generally found that the Queensland weight-lifters I've looked after over the years are utilized to training with pain and have very low anxiety over injury. They are specialists at load- modification and development, appreciate strongly the value of correct technique, and the majority of them understand training periodization fairly intuitively.

My provisional identification was a rotator cuff "strain , using a minimum likelihood of this weight-lifter really having ripped any tendon fibers. Posterior impingement of the rotator cuff at the glenoid was a distinct possibility -- hypothetically the pain at the posterior rotator cuff may have been solely due to compressive forces and consequent tendon impingement, maybe not overstrain/ overload at end of scope.

There was also a distinct possibility that he had experienced a small anterior subluxation occasion in the snatch position, but given how quickly it was resolving, and that he noted no parasthesia or clunking/ snapping feelings at the joint, I believed that this was unlikely. Feelings of "instability in the snatch position might have had less to do with any disruption to the normal capsuloligamentous restraints into the joint than using inhibition of the rotator cuff (especially the medial rotator, subscapularis), for example that it couldn't hold the "ball as tightly in the socket as usual.

The Way The Injury Occurred

Let's picture what the position and load of the "snatch needs of the rotator cuff:

With the bar quickly being forced to grab position by a strong concentric contraction of the external rotators, and abruptly coming to sit above the mind in 1 rotational movement, the strength and timing of subscapularis suddenly having to generate a huge eccentric internal spinning force has to be impeccable. If the time is repeatedly poor, or if the external rotators have slowly become too tight (a common result of some number of training variables), then subscapularis might not perform its job quite nicely enough and the ball will slightly shear anteriorly from the socket. Within a untrained shoulder, an entire spectrum of damage is possible, the worst being anterior shoulder dislocation.

Treatment

Employing deep-tissue massage and trigger- point releases, stretching and dry needling, we focused on repeatedly attaining two effects during the following four weeks, so as to restore normal rotator cuff function in the snatch position:

This treatment -- subduing overactive external rotators and triggering a dormant subscapularis -- for me clinically forms a common routine in sport injury.

Aiding Activation

On the very first day I saw Damon, I began experimentation by having him hold the bar in the grab position with elastic tube tensioned to pull the bar back over his head behind him (see Figure 1). He found that this instantly gave him a feeling of "security together with his joint under load. The pull of the tubing enhances the stimulation of subscapularis, so it can be used to centralize the job of this gleno-humeral joint by neutralizing the rotational forces of the cuff. In effect it provides a boost to the less powerful or inhibited subscapularis.

Damon continued to utilize the tubing for 3 weeks since he slowly increased his holding time in snatch standing and introduced the snatch movement with progressively increasing heaps. Then he used the tubing only during warm-up, and finally weaned himself off it entirely using a week to spare before his next contest.

Trainers and gym-goers can certainly use the tubing concept themselves at bench press and shoulder press. First implement a standard shoulder press with the bar, then attach a moderate strength of tensioned tubing to pull the bar from beneath, and see how "smooth and "simple the press movement now feels. It's nearly as though the socket has abruptly been lubricated, as the load requirement for your external rotators is reduced, and the subscapularis has been requested to step up and function. It certainly worked for Damon Kelly, with nearly 200kg over his head.

Injury chiropractic specialist, Dr. Alexander Jimenez Looks in the best ways to monitor and reduce injury within this high pressure, high-stakes world...

Introduction

Football, otherwise known as soccer or association football, is the most popular team game played across the world. The four- yearly FIFA World Cup is the 2nd most watched sporting event behind the Olympics. It is thought that the origin of association football or football (and all the offshoot football sports like NFL, Rugby, AFL etc) started from the Greater Public Schools of England sometime in the 15th and 16th century and evolved to organized sports as they were taken globally around the world through the British Empire.

As a consequence of multimillion dollar TV rights deals, the ownership of clubs by wealthy billionaire football fanatics and the unparalleled popularity of soccer, players are exposed to rapidly increasing amounts of professionalism. The ordinary team participant in elite soccer plays 34 games per year, and training intensity levels have increased to match the increased requirement to have fitter and faster players.

In essence, the purpose of soccer would be to kick a ball into a goal to score a point. To do this the ball has to be held within the field of play (which holds 11 players per group) with just the goalkeeper permitted to handle the ball within the area of play.

The game requires endurance, speed, agility, power and leaping ability, along with a robust musculoskeletal system to defy the rate, turning/pivoting and contact components of the sport. Therefore injury levels in football are high and harms are mostly limited to the lower limb. Interestingly, the amount of potential studies into the epidemiology of professional soccer is relatively sparse. On the other hand, the professional bodies governing the English Premier League (EPL) and the Union of European Football Associations (UEFA) perform conduct long- term harm audits in their respective jurisdictions.

This study also monitored match and training data to comprehend exposure in the contemporary professional elite footballer. This long- term study collected data on 2,226 gamers within the seven-year interval.

What they found over the seven decades of data set was that the ordinary player played 34 games annually and engaged in 162 training sessions. The mean overall per year was determined to be 213 hours of instruction and 41 match hours.

It is anticipated that on average each player will endure at least two injuries during the course of the season that will necessitate removal from play or training for a minimum of one day; along with also an elite group of 25 players may expect about 50 accidents per season with half of these minor and resulting in fewer than seven days' absence.

A previous study conducted by Hawkins et al (2001) on 91 English football clubs (spread over four branches) over a two-year period found trauma rates to be less at just 1.3 accidents per player in a season normally. They also discovered that slight (two to three times) to moderate injuries (four to seven times) accounted for 68 percent of injuries and acute injuries (more than 28 months) accounted for 9 percent of accidents. Hawkins et al (2001) concluded that handling, being handled and collisions accounts for 38 percent of complete injuries and the remaining 62 percent of injuries are a consequence of non-contact mechanisms.

This is quite similar to studies in rugby union (Brookes et al 2005) who also have found that slight injuries (fewer than seven times) account for more than half the total injuries (54%).

Injury Attributes

Very similar to cohort research in rugby union (Brookes et al 2005), it's evident that game accidents account for the vast majority of injuries suffered by the elite professional player in comparison with instruction. Ekstrand et al at 2011 concluded that although coaching time much outweighed playing/match time a year (212 versus 41 hours) over half (57%) of injuries were really match-related. This represents a significant weighting towards match associated injuries when exposure time is believed (about a seven-fold growth when exposure time is a variable).

This is encouraged by Hawkins et al (2001) who found that 34 percent of harms were training-related but match injuries accounted for 63%. Interestingly, foul play in games accounted for 21% of those injuries such as ankle sprains, knee sprains and contusions in the Ekstrand study. Not enough for soccer, 87 percent of all injuries were related to the lower limb. The breakdown of those injuries are as follows (Ekstrand et al 2011):

Therefore hamstring injury in the modern professional elite player is the most frequent injury, suggesting that the high- intensity nature of professional European soccer can predispose players to hamstring injuries. This finding is agreement with Wood et al (2004) that found that more than two seasons with four divisions of English football teams involved, they also found hamstring accidents to account for 12 percent of injuries.

Injury Variance

Ekstrand et al (2011) found that it was more common to suffer traumatic match injuries the more the pliers wore on, possibly suggesting that fatigue is connected to these injury injuries. Also, they discovered that at the pre-season (July and August), overuse-type accidents predominated; and also in season, (September to May) trauma accidents seemed to summit. This concurs with the prior work by Hawkins et al (2001) who also found that injury rates were highest in the first portion of the year and dropped off since the year wore on. Furthermore, they discovered that injury rates are somewhat more common in the past 15 minutes of their first half and last 30 minutes of the next half.

It's been postulated that the well-funded European teams have well-resourced medical/rehabilitation personnel allowing for much more personalized rehabilitation of individual players. It is not uncommon for top English clubs to possess four full time physios and four full-time therapists for a group of 25 players.

Interestingly, a player suffering an accident in a year has a three-fold increase in suffering another injury (new injury unrelated to the initial) throughout the subsequent season. This has implications not only for full and appropriate treatment but also for clubs registering players moving from 1 club to another (in Ekstrand 2008).

Hamstring Injuries

Woods et al (2004) provides a comprehensive analysis of hamstring injuries over a two-year period using four divisions of English players.

Prevention Of Injuries In Soccer

It is unrealistic to expect that all contact- established accidents (from tackling, being tackled and crashes) are avoidable. Whenever crashes at high speed are involved, the possibility of injury exists. Therefore, ankle and knee ligament injuries, though not common in soccer, are basically contact- based injuries and the potential for injury is down to pure chance. However, a percentage of those ankle/knee injuries will probably be non-contact-related and due to twisting/ turning in non-contact situations. Ankle and knee proprioceptive programs are generally used as part of 'pre-hab' in group sports and potentially they may reduce injury risk, particularly re-injury hazard.

Injuries such as hamstrings and quadriceps injuries may be deemed as being preventable and laborious because the majority of these are endured in non-contact situations. So active steps that a professional soccer program may implement to Prevent soft-tissue Injuries like hamstrings, quadriceps and hamstrings really are as follows and will be discussed individually:

2. Musculoskeletal monitoring

Daily or next day measures that may be useful in catching players That Are showing subclinical signals include:

3. Fatigue monitoring

Expensive monitoring units have now been developed and promoted as the new kingdom of quantifying biological markers of exhaustion. Systems like the Omegawave system use sophisticated screens on the athlete such as ECGs, muscle and brain detectors to rapidly collect information on an athletes' biological profile like heart- rate variability, cardiac readiness, hormonal readiness and fundamental system readiness.

4. Periodization and planning

The problem most professional soccer teams face is adequately preparing and planning training loads throughout this season. The pressure of numerous tournaments and enjoying twice-weekly games makes it difficult to strategy overload progressions throughout this season. As an instance, a high degree EPL team for example Chelsea will play 38 Premiership matches a year, six matches in the Champions League pool phases and maybe up to three games in the FA Cup. This represents at least 47 games available to be played during the competitive season.

On average, players will play around 34 games at the year with injuries, form and enforced rest which makes it improbable that players will participate in all matches. However, during a trying period of the season such as Champions League finals stages and high-priority EPL matches, players might want to play with 4-5 times in a two-week period, it's these dividers of high-intensity games back to back in which the player is the most susceptible to soft-tissue injuries.

But, top-performing teams such as Chelsea have the human resources to rotate players throughout the season for games; therefore, it makes it less likely to make soft-tissue fatigue in these players.

5. Preventative strength training.

Players in the elite level are not known for their tendency to being gym junkies. The contemporary elite players' perception is that weight training will 'slow you down' and my resources in elite degree EPL soccer inform me that the non-English players tend to harbor this belief that the most. Thus, having multimillion pound players get to the whole preventative health strengthening may be a difficult sell for the rehab and performance personnel. I'm advised, however, that long-term injured players are more likely to agree to a time of strength training as part of the rehabilitation procedure.

However, some simple bodyweight-type exercises may be used from the soft tissue preparation of the player. These just need to be carried out once per week, instead of the conclusion of a session if the player has no match to perform the following day and they can manage to carry some tissue soreness. This small circuit can be performed post-training and will take no more than 15 minutes.

Conclusion

Soccer is a fast, dynamic and possibly injurious sport played all over the world with top level athletes making large sums of money for their capacity to have the ability to kick a ball into a target. Injury rates, although generally not severe, are common in most players within a group.

Research highlights the way the lower limb is the most susceptible area, and in particular delicate tissue thigh injuries -- hamstrings and quadriceps -- would be the most usual.

Although time missing from play is reasonably small, preventative steps in the kind of frequent monitoring and screening in addition to scheduled rest periods coupled with some small quantity preventative exercises appear the best way to manage soft tissue injuries from the soccer player.

References
Ekstrand et al (2011) Injury incidence and injury patterns in professional football: the UEFA injury study. Br J of Sports Medicine. 45; 553-558.
Woods et al (2004).The football association medical research programme: an audit of injuries in professional football – analysis of hamstring injuries. Br J of Sports Med. 38: 36-41.
Hawkinset al (2001) The association football medical research programme: an audit of injuries in professional football. Br J of Sports Med. 35: 43-47.
Ekstrand J (2008) Epidemiology of football injuries. Science and Sports. 23. 73-77.
Brookeset al (2005) Epidemiology of injuries in English professional rugby union: part 1 match injuries. British Journal of Sports Medicine. 39; 757-766.
Brookeset al (2005) Epidemiology of injuries in English professional rugby union: part 2 training injuries. British Journal of Sports Medicine. 39; 767-775.
Verrallet al (2005) Hip joint range of motion reduction in sports related chronic groin injury diagnosed as pubic bone stress injury. J Sci Sport; 8:1 77-84.
Brookset al (2006) Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. American Journal of Sports Medicine. 34(8) 1297-1306.

It was once believed that inflammation caused impairments such as plantar fasciitis, tendonitis and iliotibial band syndrome -- but new research shows that may not be the case. Injury specialist Dr. Alexander Jimenez examines the data.

The body was made to move; however, moving too far or too often in a repetitive way can overexert tissues. New research is now calling into question the concept that inflammation causes these conditions -- and this may affect our understanding and treatment to what had been considered tendonitis and fasciitis.

Connective Tissue

Ligaments, tendons, ligaments and fascia hold the bony skeleton together. Quite simply, the muscles move the manhood; the tendons connect muscles to bones; the fascia encases the musculotendinous unit, and sometimes become a functional part of the unit, as is true for the iliotibial band and the gluteus maximus and tensor fasciae latae muscles; and the ligaments connect bones to bones.

An athlete might have the occasional ligament strain or inherent ligament laxity, but the tissue itself typically either does its job or doesn't. Current thought on the causes and therapy of the chronic injury of those tissues may change the way you exude your endurance athletes.

Fascinating Fascia

Fascia exists as an uninterrupted matrix of collagen that extends throughout the entire body, forming a web of covering and connection between all organs and muscles. Therefore, it is nearly impossible to isolate and name a region of the continuum in any other way than its nearest anatomical structure. It's three- dimensional and contains freedom in all three planes of motion(1).

While one continuous membrane, fascia has distinct inherent characteristics based on its location and function. Fascia that exists among muscles aids to transmit forces in addition to absorb strain.Studiesinlive specimens with ultrasound reveal that fascia is viscoelastic -- using both viscous and elastic characteristics when deformed -- and is therefore able to slip independently of the contraction of the muscle that it surrounds(1).

Fascia is composed of at least nine of the 28 types of known collagen. Collagen gives construction, durability and strength to the tissue. The extracellular matrix of fascia includes the elastic fibers which provide flexibility. Myofibroblasts are also present in fascia, leading, hypothetically, to its contractility, tension, and equilibrium(1). Fascia has a characteristic fiber arrangement parallel to the common force vectors to which it can be exposed.

Tendons are also viscoelastic structures, composed primarily of type-I collagen fibers, using a little amount of type-III and type-X as well(2). The collagen fibers lie in a parallel structure, with a resultant tensile strength capable of transmitting large forces. The fibroblasts within the tendon, known as tenocytes, lie along the collagen fibers and provide the structure for collagen cross- links. Their sensitivity allows them to regulate the protein synthesis within the extra-cellular matrix dependent on the changes from the load encountered by the tendon. It is the unloading and loading of the tendon that activates the chemical and structural changes in the thoracic structure, which may be why specific types of exercise are important in tendon rehabilitation and recovery.

Mechanism Of Injury

Tendon and fascial injuries both result from overloading. Acute injuries are usually considered as resulting after a one-time incident of intense loading. A chronic injury, subsequently, is considered something that occurs after repeated excessive strain. However, some theories assert that acute accidents occur due to chronic underlying micro-stress into the tissue(two). In any case, nearly 50% of sports injuries reported from the USA are the result of overuse(3).

Traditionally, both tendon and fascial injuries were considered inflammatory processes and were consequently named tendonitis and fasciitis. As more is understood concerning the mechanics of both injury and healing, this nomenclature is now called into question. Tendinopathy is the catch-all phrase that covers any abnormal state of the tendon. Tendonitis refers to some true inflammatory reaction due to bleeding within the gut as a result of an intense event. Tendinosis is the condition of tendon degeneration that develops over time in the lack of a true inflammatory response. It's considered a state of overuse, however, though, can coexist with an inflammatory process from the paratenon. Actually, degeneration along various points on this spectrum can be found all within exactly the same tendon.

A barbell with tendinosis differs histologically from tissue that is healthy. The collagen alignment in tendinosis is no more parallel and the distance between the collagen bundles increases. The tenocytes become much more notable. The quantity of type-III collagen additionally increases when compared to type-I, which generally composes 90 percent of the collagen in healthy tendon(3). Despite an increase in fibroblasts, there are no inflammatory cells present in the extra-cellular matrix. There is an infiltration of blood vessels and nerves, which is referred to as neovascularisation. These microscopic findings are indicative of a fix process gone awry, resulting in further tendon degeneration.

It appears that in response to excessive strain or overuse, the tendon attempts to initiate a healing process that fails to regenerate and really further degenerates the tissue. Some theorize that inflammation occurs initially, but that the repetitive nature of the mechanical stress results in interruption of the normal recovery procedure. When inflammation occurs within a healthy tendon the tenocytes turn into myofibroblasts. The myofibroblasts then normally undergo cell death; however, in tendinosis, the repeated stress may interrupt this process, causing a proliferation of myofibroblasts which cause fibrosis of the tissue.

Hypoxia can interrupt the homeostasis of this extra-cellular matrix, which causes an increase in blood vessels and corresponding nerve pathways. The gain in sensory nerve pathways at the neovascularisation process is thought to be the cause of greater pain in tendonosis(3). The pain of this neo- vascularisation may cause an athlete to insufficiently load the tendon to activate the normal tenocyte reaction to strain, thus further inhibiting healing. The lack of repair contributes to microscopic tears which can finally cause tendon rupture.

Treatment

Fasciitis and tendinopathy are often considered difficult conditions to deal with because of the poor outcomes when using conventional inflammation combating strategies. Understanding that an athlete's condition might not really be an inflammatory process is important when choosing the proper healing modalities. The exact same is true with the usage of non-steroidal anti-inflammatory medications (NSAIDs). While maybe mediating the pain, they don't improve the condition. Masking the pain might cause additional harm as the athlete continues to execute the offending action. Treatment with NSAIDs must be undertaken acknowledging the lack of evidence of efficiency, in addition to the risks related to such drugs, most especially gastro-intestinal upset.

Some modalities are found to be useful in the management of tendinosis and fascial injuries. Intense friction massage, using a tool or merely manually, is often used to evoke changes in the tissue through a physical manipulation that triggers a recovery reaction. True randomized controlled studies are lean for its treatment of tendinosis, and lacking altogether about fasciitis. However, case studies show great results with friction massage when utilized as an adjunct to other therapeutic methods(4).

The use of low-level laser therapy (LLLT) is controversial at best. An overview of six distinct systemic literature reviews on the use of LLLT with tendinopathy came to the conclusion that there isn't enough conclusive evidence to advocate its use in the therapy of tendinopathy(3). The same holds true in the case of ultrasound treatment. While thought to trigger recovery through adrenal effects, ultrasound hasn't been found to be beneficial. The accession of drugs through using ultrasound (phonophoresis) or electric impulses (iontophoresis) conveys nearly the very same effects as LLLT and ultrasound alone. Studies conflict as to the effectiveness of all of these modalities.

What's New?

Another new treatment is the use of exogenous nitric oxide (NO). NO is thought to assist in cell signaling and in the modulation of the immune reaction. Animal studies demonstrate that treatment with exogenous NO contributes to higher collagen synthesis and recovery inside joints, and also depleting NO has a negative influence on the strength and size of a healing tendon(3). The Food and Drug Administration believe the use of exogenous nitric acid to deal with tendinopathy or fasciitis, via a glyceryl trinitrate patch, an off-label usage in america. But, studies show that using a 5mg/24-hour glyceryl trinitrate patch, divided into quarters, is effective in controlling pain and assisting in tendon healing. Treatment lasts from eight weeks to six months, and also the quarter-patch is put directly over the thoracic and changed everyday. Side effects are typically the same as treatment with nitroglycerine -- headache and dizziness due to hypotension -- and therapy using concurrent active therapeutic exercise is recommended.

A Shot In The Arm, Leg, Or Ankle...

A well known method of handling inflammation, corticosteroid shots have long been used with limited success in the management of tendinopathies and fasciitis. The reason for the limited success must now be nicely apparent. Theoretically, tendon degeneration may result in inflammation of the paratenon, which leads to the pain of the injury. Injection adjoining to the injury can help with the inflammation there, but the root cause of degeneration is not assisted whatsoever. If shots are undertaken, they need to be achieved with the assistance of fluoroscopic guidance to assure that the delivery of this steroid is adjacent to the tendon, not inside.

Despite a dearth of evidence to support its use, corticosteroids are still a first line treatment for fasciitis, particularly plantar fasciitis. A British Medical Journal Clinical Evidence report even went so far as to say that steroid injections might be injurious to the plantar fascia through the years(6). This lack of evidence prompted researchers in the section of rheumatology in Musgrave Park Hospital in Belfast to compare the use of ultrasound guided corticosteroid injection to that of non-guided injection and placebo injection in the treatment of plantar fasciitis(7). Results revealed considerable improvement utilizing corticosteroid as opposed to placebo at six and twelve months, although no gap between guided and unguided injection was shown. But, glaringly absent in this research is a description of concurrent or previous treatments undertaken by the participants, or restrictions from the same. Additionally, knowing that, oftentimes, plantar fasciitis is self-limiting, together with progress generally in three to six months, more studies are required to encourage the regular use of steroid injections in treating fasciitis.

Platelet-rich plasma (PRP) is just another process of injection therapy that's gaining in popularity. A concentration of platelets is drawn from an individual's own blood and re-injected at the site of injury. The theory is that the lab-activated platelets will activate enhanced collagen production and promote healing. There aren't any dependable, controlled studies now that reveal PRP to be greater compared to other injectables or physical therapy alone, in treating tendinopathy and fasciitis(3,5). Better-regulated research are required before clinical evidence as to the efficacy of the injection-based treatment approach can be revealed.

First-Line Treatment & Last-Ditch Effort

Overwhelming evidence exists to support the use of eccentric exercise in the treatment of tendinopathy(2,3). Loading the injured tendon appropriately appears to be crucial in preventing the degenerative cascade and initiating proper recovery. The specific mechanism through which eccentric exercise can reorganize the tendon structure isn't well understood; however, it's thought to nourish the tenocytes and reunite the extracellular matrix into homeostasis.

Surgery is considered in hard cases as a last resort. What is consistent, however, is that return to sport after surgery can be a four- to - 12-month time frame, and invasive procedures are not without their own set of risks, including unsuccessful outcomes(3).

Frustrated Yet?

Indeed, that is how many coaches, therapists and athletes believe about the nagging injury that, despite everyone's best efforts, just won't go away. The new comprehension of connective tissue structure and function challenges how typical overuse injuries are treated. No longer considered inflammatory in nature, unless very obviously acute, tendon and fascial injuries call for a novel approach to treatment. In order to bring about healing, a change has to be triggered in the harmful physiological cascade that leads to tissue degeneration. Eccentric exercise, ESWT, transdermal NO, and possibly deep friction massage, are all demonstrating the best results thus far in causing tendon healing and halting degeneration. The specific mechanism by which these treatments work isn't well known. Other remedies methods ought to be inspected, and possibly discarded, until study reveals their efficacy.

Truly halting the progression of an overuse connective tissue harm needs the expert eye of a physiotherapist, trainer, and coach to evaluate musculoskeletal status and motion routines, technique, training schedule, and gear. Very often, there's an offending component that's been overlooked. Once corrected, the connective tissue strain will be eliminated and curative intervention will have a chance to get the job done. In overuse injuries, a more comprehensive approach has to be taken to avoid additional tissue degeneration and injury.

References
1. J Can Chiropr Assoc. 2012;56(3):179-91
2. J Bone Joint Surg Am. 2013;95:1620-8
3. Prim Care Clin Office Pract. 2013;40:453-73
4. J Sport Rehabil. 2012 Nov;21(4):343-53
5. J Fam Pract. 2013 Sep;62(9):466-71
6. Clin Evid 2008. 2008:1111
7. Ann Rheum Dis. 2013;72:996-1002

Chiropractic scientist, Dr. Alexander Jimenez has a look at this painful condition which can be the cause of a lot of lost playing time.

Last year, rugby union player Anthony Allen of the Leicester Tigers endured what he believed was a reasonably straightforward blow to the exterior of his shin -- but it ended up being a nightmare which would keep him out for four weeks of rugby.

In October 2013, he thought he'd sprained his ankle in a match, as he did not recall sustaining a direct blow to the surface of the shin. Over the ensuing days, he noticed that the pain was worsening and he was experiencing swelling and pain sensations further down the shin away from the website of the accident, with some minor paraesthesia into the top of the foot.

He alerted the medical staff to his worsening illness and they immediately referred him to an orthopaedic surgeon who watched the leg using an ultrasound (to exclude a deep vein thrombosis), after which an MRI, which confirmed that the participant was suffering from an acute compartment syndrome in the lower leg. They conducted an operation to successfully alleviate the pressure from the leg, and he was told that the rehabilitation following this harm could be 3-4 weeks.

What Is Compartment Syndrome?

When a body part receives a direct blow because of an external object, muscle damage can ensue. The outcome is a hematoma, which is a swelling inside the muscle due to blood accumulation -- a consequence of the direct bleeding of this muscle as little venules and possibly arterioles are damaged and 'leak' blood to the region, which then collects into a mass.

A hematoma can grow within the muscle or external to the true muscle and involving the fascial sheaths that surround the muscle. The majority of those hematomas are benign and, although painful for 7-21 days, they finally resolve and the sufferer regains full purpose.

The origin of the direct blow may be the sufferer contacting another person forcefully, as in being kicked in soccer or martial arts or a direct blow due to a tackle in football. These are commonly known as 'contusions', ' 'corks' or ' 'charley horses'.

This is called the osteofascial compartment. This growth in volume within a enclosed space eventually compresses the blood vessels and nerves that run through the compartment and symptoms have been exacerbated.

Who Can Get Compartment Syndrome?

Most cases of compartment syndrome are a result of high velocity trauma like motor vehicle accident or falling out of a quick- moving bike/horse. These generally involve a bone fracture like the tibia in the upper leg or the radius in the forearm. The amount of blood discharged from the bone will collect in the osteofascial compartment.

But, they may also be caused by lead high-force 'crush'-type injuries which do not break bones but do end up damaging a lot of muscle tissue. This can be because of a direct hefty blow that spreads the pressure across a wide region and does not violate any underlying bone. Severe burns may also lead to compartment syndromes.

Young males are the most likely victims as ordinarily they're involved in sport and pastimes that may expose them to high velocity or high-force trauma that may cause this pathology. Individuals on anti-coagulant blood thinners are also more vulnerable.

Because the fascia of the compartment does not stretch, a little increase in blood volume can result in large increases in pressure. This rapidly compresses the nerves and blood vessels (typically veins) and the normal late signs of compartment syndrome like needles and pins and deficiency of pulses may then result. Arteries are usually spared as the systolic blood pressure in the gut is usually too high to be compressed by the compartment pressure.

Chronic compartment syndromes which are not medical emergencies may occur in athletes because of a slow growth in muscle size because of hypertrophy with an overlying fascia that doesn't stretch. This impacts runners, cyclists and even bodybuilders.

Signs & Symptoms

The pain and neurological disorders (pins and needles) have been early signals; diminished or absent pulses and paralysis are late signs. Pallor may come with a swollen and tense muscle because of the collection of blood at the underlying muscle compartment.

Diagnosis

The most direct measure for compartment syndrome is a compartment pressure test. In such examples, it has been recommended that the compartment decompression may be necessary.

Treatment

This involves an incision into the thoracic fascia, similar to how a sausage on the BBQ may be sliced to discharge juices from a swelling sausage since it is being heated.

It is common place to perform a fasciotomy on all the compartments in the area affected.

As a result of sudden onset of elevated compartment pressure, if the injury isn't dealt with immediately, catastrophic permanent damage to the muscle, nerves and blood vessels can result, leaving permanent scarring in these types of structures and generally rhabdomyolysis may ensue, leaking toxins into the blood stream that might result in kidney damage.

Rehabilitation

Following operation, the time frame for return to straightforward activities like walking is generally quite quick and the individual might be functional with this particular capacity in 4-6 weeks. They might require gentle soft tissue massage to stop excessive scarring and adhesions, and gentle progressive strength training to recover lost muscle functioning.

The athlete needs a longer time frame to return to perform as they will need a more systematic rehabilitation protocol which takes them from walking to running to sprinting and ultimately explosive movements such as jumps and take-off moves.

They'll require longer to regain strength and full stretch in addition to other high-level capacities such as proprioception and balance control.

Most of us will experience it at some point, but how does it influence on athletic performance? Chiropractic injury specialist, Dr. Alexander Jimenez investigates.

Research postulates that 80 percent of the populace will undergo an acute onset of back pain at least once in their lifetimes. This adds a considerable financial burden not just on the medical system (physician consultations, prescribed drugs, physiotherapy) but also the financing of the workforce in lost employee hours and loss in productivity.

The types of lower back pain that an individual may experience include (but are not limited to):

The focus for this paper will be on the previous group -- that the bone injuries. This may be simply postural (slow onset repetitive trauma) or related to sports; for instance, gymnastics.

The two demographic groups that tend to endure the most extension-related low back pain are:

1. People who endure all day, for instance, retailers, army, security guards etc.. Prolonged position will obviously force the pelvis to start to migrate to an anterior tilt management. This may begin to place compressive pressure on the facet joints of the spinal column as they also change towards an expansion position since they accompany the pelvic tilt.

Pathomechanics

It would be unlikely that a bone stress response or even a stress fracture could be brought on by an isolated expansion injury. It would be more likely that a sudden forced extension injury may damage an already pre-existing bone strain reaction.

Similarly, if an individual stands daily and the pelvis migrates into lateral tilt, then the aspects will be placed under low load compression but for extensive intervals.

With ongoing uncontrolled loading, stress is then transferred from the facet joint to the bone below (pars interarticularis). This originally will manifest as a pressure reaction on the bone. This bone strain may advance to a stress fracture throughout the pars if uncorrected. This fracture is also referred to as a "pars flaw", or spondylolysis.

It was initially considered that stress fractures of the pars was a congenital defect that introduced itself at the teenage years. However, it is now agreed that it is probably obtained through years of overuse into extension positions, especially in young sportspeople involved with expansion sports. What's more, one-sided pars defects often occur more commonly in sport which also included a rotational component such as tennis serving or fast bowling in cricket.

The stress fracture can then advance to impact the opposite side, causing a bilateral strain fracture, with anxiety subsequently being transferred to the disk in between both levels.

Spondylolisthesis features bilateral pars defects which could possibly be a result of repetitive stress into the bilateral pars in extension athletics, but more likely it is an independent pathology that manifests in the early growing stages (9-14) as this pathology is often viewed in this age category. If they become symptomatic in later years because of involvement in expansion sports, it is exceedingly likely that the defects were there by a young age but presented asymptomatically. As a result of rapid growth spurts in teenage years and the high-volume training experienced by teenaged athletes, it is possible that these dormant spondylolisthesis then pose as 'acute onset' back pain in teenage years.

In summary, the progression of this bone stress reactions tends to follow the following continuum:

The vast majority of spondylolysis and sponylolisthesis accidents are Type II -- the isthmic variety.

For the purposes of this paper, we will refer to the above stages as the posterior arch bone stress injuries (PABSI).

Epidemiology

It is a lot more widespread at the L5 level (85-90 percent). It's a high asymptomatic prevalence in the general population and is often found unintentionally on x ray imaging. Nonetheless, in athletes, particularly young athletes, it is a common reason for persistent low back pain. From the young athlete, the problem is often referred to as 'active spondylolysis'.

Active spondylolysis is normal in virtually every gamenevertheless, sports such as gymnastics and diving and cricket pose a much greater danger due to the extension and turning character of the sport. The progression from an active spondylolysis into a non-union type spondylolisthesis has been associated with a greater prevalence of spinal disk degeneration.

Early detection through screening and imaging, therefore, will highlight those early at the bone stress phase and if caught early enough and managed, the progression to the larger and more complicated pathologies are avoided as a result of therapeutic capacity of the pars interarticularis in the early stages.

It is more common to find teens and young adults afflicted by PABSI. This will highlight the rapid growth of the spine through growth spurts that is also characterized by a delay in the motor control of the muscle system during this period. Furthermore, it's thought that the neural arch actually gets stronger in the fourth decade hence possibly explaining the low incidence of bone stress reactions in mid ages.

Tennis

The tennis serve generates excessive extension and rotation force. In addition, the forehand shot may also produce elevated levels of spinning/ extension. The more traditional forehand shot demanded a great deal of weight shift through the legs to the torso and arms. However, a more favorite forehand shot is to currently face the ball and also generate the force of this shot utilizing hip rotation and lumbar spine extension. This action does increase ball speed but also puts more extension and compressive loads on the spine potentially resulting in a greater degree of stress on the bone components.

Golf

The most likely skill component involved in golf that may cause a PABSI are the tee shot with a 1 wood when forcing for distance. The follow-through of this shot entails a significant quantity of spine rotation with maybe a level of spine expansion.

Cricket

Fast bowlers in cricket are the most susceptible to PABSI. This will occur on the opposite side to the bowling arm. As the front foot engages on plant stage, the pelvis abruptly stops moving but the spine and chest continue to proceed. With the wind-up of this bowling action (rotation), when coupled with expansion this can place large forces on the anterior arch of the thoracic. More than 50% of fast bowlers will create a pars stress fracture. Young players (up to 25) are most vulnerable. Cricket governments have implemented training and competition guidelines to avoid such injuries by restricting the number of meals in training/games.

Field Events

The more common field events to cause a PABSI would be high leap followed by javelin. Both these sports create enormous ranges of backbone extension and under significant load.

Contact Sports

Sports like NFL, rugby and AFL all require skill components that need backbone expansion under load.

Gymnastics/Dancers

It goes without saying that gymnastics and dancing involves a substantial amount of repetitive spine expansion, particularly backflips and arabesques. It has been suggested that nearly all Olympic degree gymnasts could have suffered from a pars defect. Many organizing bodies now put limits on the number of hours young gymnasts can instruct to prevent the repetitive loading on the spine.

Diving

Spine extension injuries occur mostly off the spring board and on water entrance.

Clinical investigation

These can pose as preventable injuries. Research shows that the incidence was emphasized from the general population that have nil indicators of back pain. But, individuals will typically complain of back ache that is deep and generally unilateral (one side). This may radiate into the buttock area. The most offending movements tend to be described as expansion moves or backward bending movements. This may be a slow progression of pain or might be initiated by one acute episode of back pain in a competitive extension motion.

On clinical examination:

The one-legged hyperextension test (stork test) was suggested to be pathognomonic for busy spondylolysis. A negative evaluation was stated to effectively exclude the diagnosis of a bone stress-type injury, thus creating radiological investigations unnecessary.

But, Masci et al (2006) examined the connection between the one-legged hyperextension test and gold standard bone scintigraphy and MRI. They discovered that the one-legged hyperextension test was neither sensitive nor specific for active spondylolysis. Moreover, its negative predictive value was so poor. Thus, a negative test can't exclude energetic spondylolysis as a possible cause.

Masci et al (2006) go on to indicate that the bad relationship between imaging and the one-legged test may be because of a number of factors. The extension test would be expected to move a significant extension force on to the lower back spine. In addition to putting substantial strain on the pars interarticularis, it might also stress different regions of the spinal column like facet joints as well as posterior lumbar disks, and this may subsequently induce pain in the existence of other pathology such as facet joint arthropathy and spinal disc disease. This will explain the poor specificity of the test. Conversely, the inadequate sensitivity of the test may be related to the subjective reporting of pain by issues performing the maneuvre, which may vary based on individual pain tolerance. Additionally, this evaluation can preferentially load the fifth cervical vertebra, and so bone stress located in the upper lumbar spine may not test positive.

Grade 1 spondylolisthesis are normally asymptomatic; nonetheless, grade 2+ lesions often present with leg pain, either with or without leg pain. On examination, a palpable slip could be evident.

Imaging

Clinical assessment of active spondylolysis and the more severe pars defects and spondylolisthesis can be notoriously non-specific; this is, not all patients suffering PABSI will present with favorable abstract features or positive signs on analyzing. Thus, radiological visualization is important for diagnosis. The imaging methods available in the diagnosis of bone stress injury are:

1. Conventional radiology. This test is not very sensitive but is highly unique. Its limits are partially because of the cognitive orientation of the pars defect. The oblique 45-degree films may show the timeless 'Scotty Dog' appearance. Spondylolisthesis can be looked at simply on a lateral movie x-ray.

2. Planar bone scintigraphy (PBS) and single photon emission computed tomography (SPECT). SPECT enhances sensitivity in addition to specificity of PBS than straightforward radiographic study. Comparative research between PBS and conventional radiology have shown that scintigraphy is more sensitive. Patients with positive SPECT scan must then undergo a reverse gantry CT scan to assess whether the lesion is active or old.

3. Computed tomography (CT). The CT scan is considered to be more sensitive than conventional radiology and with higher specificity than SPECT. Regardless of the type of cross-sectional image utilized, the CT scan provides information on the state of the flaw (intense fracture, unconsolidated flaw with geodes and sclerosis, pars in procedure for consolidation or repair). The "inverse gantry" perspective can evaluate this condition better. Repeat CT scan can be used to track progress and recovery of the pars defect.

4. Magnetic resonance imaging (MRI). This technique shows pronounced changes in the signal in the amount of the pars. This is recognized as "stress response" and can be classified into five different degrees of action. MRI can be helpful for evaluating elements that stabilize isthmic lesions, for example intervertebral disc, common anterior ligament, and related lesions. The MRI isn't as specific or sensitive as SPECT and CT combination.

MRI has many advantages over bone scintigraphy, for instance, noninvasive nature of the imaging along with the absence of ionizing radiation. MRI changes in active spondylolysis include bone marrow edema, visualized as increased signal in the pars interarticularis on edema-sensitive sequences, and fracture, visualized as reduced signal in the pars interarticularis on T1 and T2 weighted sequences.

However, there is greater difficulty in detecting the changes of busy spondylolysis from MRI. Detecting pathology from MRI relies on the interpretation of distinct contrasts of signals compared with normal tissue. Unlike stress fractures in different parts of the body, the little region of the pars interarticularis may make detection of those changes harder.

However, unlike MRI, computed tomography has the capability to differentiate between acute and chronic fractures, and this differentiation might be an important determinant of fracture healing. Accordingly, in areas using pars interarticularis fractures discovered by MRI, it might nonetheless be necessary to execute thin computed tomography slices to determine whether or not a fracture is severe or chronic -- an important factor in fracture resolution.

Science based chiropractor, Dr. Alexander Jimenez demonstrates that foot injury as a consequence of the foot/pedal interface is amazingly common and under-reported...

Cycling injury research can be broadly collated into two groups: trauma-related, which happens as a consequence of a crash or collapse, and non-trauma-related, which entails overuse-type injuries. The epidemiology of collision/impact injuries in cycling has brought a relatively large amount attention from investigators, presumably because of their life- threatening possible. However, the data indicates that despite the acute dangers of accidents and drops, cyclists are more likely to suffer with accidents resulting from the action of biking. A 2006 research on cycling injuries reasoned that the prevalence of non-traumatic harm was as high as 85 percent(1).

Although coaches, chiropractors, physiotherapists and coaches can not do much about the former, overuse-type injuries are amenable to treatment and prevention. A survey of the literature about non-traumatic cycling injuries demonstrates that much of this research thus far has been focussed on injuries of the trunk, neck, arms, hands, buttocks, perineum and knees(two). This is perhaps understandable; cyclists interface with the bike at three distinct points -- the handlebars, the saddle and the pedals. Incorrect handlebar shape/settings, saddle design/height or framework geometry could lead to excessive loading on muscles and joints as well as undesirable motion biomechanics, significantly increasing the probability of harm (see Box 1).

Overlooked Foot

One area which may have been overlooked, however, is your pedal port, especially because it is the foot/pedal interface which typically encounters the greatest forces during cycling. Unlike other overuse biking accidents mentioned above, there's very little peer-reviewed research accessible on foot injuries, with those foot accidents that are reported in the literature being mainly descriptions of foot numbness, metatarsalgia, achilles tendonitis and plantar fasciitis(3-5).

A study by Dettori and Novell (2006) reported about the prevalence and incidence of lower leg/foot cycling injuries collated by a meta-review of non-traumatic bicycling accidents(1). The data were presented as self-reported heights of pain gathered from cyclists engaging in tour rides, ranging from the shortest distance of 545km over a six-day occasion to the longest distance of 7242km within an 80-day event. The incidence of reduced leg/foot harms was reported to be 7 percent, 13 percent and 22% respectively, with an incidence rate of 24 percent.

Nonetheless, this data believed both the lower leg and the foot to be one homogeneous unit rather than separate anatomical regions, which consequently negates its usefulness as meaningful foot pain data for the wider cycling population. Simply speaking, there's very little research concerning the frequency, etiology and/or management of foot discomfort in cycling available to direct the clinician. The little amount of available literature that's available tends to be descriptive non-systematic literature reviews or view. Moreover, where data are reported, participants have yet to be sampled robustly and research have tended to concentrate only on elite cyclists instead of those engaged in club, recreational and fitness cycling (that the huge majority of cyclists).

New Research On Foot Pain Incidence

To do so, an electronic survey was utilized to collect data from cyclists within South Australia, during December 2010. Cyclists were invited to take part and fill out the questionnaire if they were riding a non-stationary, vertical bicycle at least one time per week for no less than one continuous hour, and so were at least 18 decades old. The sample of cyclists analyzed numbered 397, attracted from Bike SA (the main representative body for South Australian riders) in addition to Mega Bike (a massive bicycle store in Adelaide) and personnel and pupils of the School of Health Sciences in the University of South Australia. The cyclists were requested to give details about their level of cycling participation, the pedal port utilized (clip less/toe straps) and the kinds of foot pain endured.

A number of critical findings became evident, the first of which was that over half of the cyclists (53.9 percent) reported experiencing foot pain whilst biking. The cyclists normally described the pain as 'burning' or 'numbness.'

The most usual methods of dealing with this kind of pain comprised stopping for a period of time through the ride, shoe removal, walking round and massaging/ stretching the foot.

This analysis shows exactly how common foot pain may be among recreational cyclists. The fact that 'cleated-in' shoes increased the danger of pain is perhaps no surprise; studies have already shown that these types of shoe have a tendency to localize plantar pressures, which in turn can be detrimental to blood and nerve supply integrity in that area(2,7). Another implication that follows is that cycling shoe design and choice could be just as essential as saddle and saddle options for pain-free cycling.

Evaluation Of The Foot-Pedal Interface

The foot-pedal port is the sole guide website for energy transport from the fisherman into the bike. In a 'cleated-in' pedal port (one having clip less pedals and shoes or toe clips and straps), all of the body's power to make the bicycle move forward is moved to the pedal through a really small contact area (typically around 60mm2), and there is consistent anecdotal evidence that forefoot pain at this stage of energy transfer is common(2,7). The most obvious issue this raises therefore is if the use of particular sorts of biking shoe structure, insole substances or contoured surfaces can decrease the incidence of pressure hot spots by spreading the load more evenly. Indeed, this approach is embodied by specific cycling shoe makers like Specialized, who utilize a combination of particular material types and contoured surfaces to attempt to minimize forefoot distress.

Looking at shoe building first, a current trend has been the movement towards stiffer and stiffer cycling shoe construction and especially the use of carbon fiber. The reasoning is that higher shoe stiffness contributes to less shoe bend and therefore less electricity wastage during the power transfer. To look into this specific query, US scientists conducted a study into cycling shoe stiffness on forefoot pressure(7).

Plantar pressure data have been recorded in two different shoe types to ascertain the effect of cycling shoe stiffness on peak plantar forefoot pressure in cyclists. Two pairs of shoes of the same size and manufacturer, indistinguishable except for outsole material and stiffness, were analyzed. Shoe stiffness measurements were gathered under controlled conditions and in two different configurations using a dynamic hydraulic tensile testing machine. Measurements of plantar pressure were assembled using 'Pedar' capacitive-based detector insoles while issues pedaled in a seated position in a restricted power output of 400 watts (hard!) . The pressure distribution in carbon fibre composite sneakers during cycling was compared to that of cycling shoes made with (cheaper) plastic soles.

Concerning stiffness, the carbon fibre sneakers were surely stiffer -- 42% and 55% more pliable than plastic sneakers when subjected to longitudinal bending and bending bending, respectively. During pedaling, the carbon fibre shoes generated peak plantar pressures 18 percent higher than people of plastic design, and the authors concluded that competitive cyclists afflicted by metatarsalgia or ischemia must be particularly careful when using carbon cycling shoes because the shoes increase peak plantar pressure, which might aggravate these foot ailments.

Jumping To Conclusions

However, more recent research suggests that assessing a shoe's possible to cause foot pain based purely on its structure may lead to incorrect decisions. This originates from an interesting study published annually by German researchers, who contrasted the effects of carbon fiber foot orthoses with standard cycling shoe inserts on plantar pressure distribution through biking(8). In the study, 11 pain-free triathletes were examined on a cycle ergometer at two different cadences (60 and 90 rpm) and at two unique workloads -- both 200 and 300 watts. These were:

Using carbon fibre for the construction of this orthoses was important; due to its inherent stiffness and capacity to be worked into complex shapes, it is possible to make carbon fibre orthoses that don't yield, even under the greatest loads. This consequently means that the foot has been held more securely in its desired position/orientation regardless of loading. Throughout the trials, the investigators recorded the mean peak pressure, both to the entire foot region and for particular foot areas (rear, mid, esophageal foot (medial, central, lateral) and toe area).

As Figure 1 reveals, peak pressures recorded in the total foot area ranged from 70-75kPa at 200 watts power output, and out of 85-110kPa in 300 watts. Regardless of being stiffer, the carbon fibre foot orthoses reduced peak pressures by approximately 4.1 percent compared to the standard insole. Within separate foot regions, back foot peak pressure was decreased by 16.6 percent, mid foot strain by 20.0 percent and forefoot strain by 5.9 percent. It was mentioned, however, that in the toe region, peak pressure with the carbon orthoses was raised by approximately 16%. Regardless of which fit was utilized, when it came into the forefoot it also had been the lateral forefoot that showed the maximum peak pressures when compared to lateral and lateral forefoot (34 percent and 59% greater for the carbon and standard inserts respectively).

The authors concluded that carbon fiber can serve as a suitable material for foot orthoses in biking partly because plantar pressures don't grow as a result of the stiffness of the carbon and also because with person customization, there's the possibility to further peak pressure in some specific foot places. Surely, it looks like in regards to stress reduction, form/ contouring is more important than orthotic stiffness. By the exact same token, simply substituting padded insoles in an overly embarrassing biking shoe is not likely to result in an automatic treatment for foot discomfort.

Conclusions & Recommendations

The US researchers mentioned previously concluded from their study that the plantar pressures recorded during seated biking were within the range listed for ordinary walking, despite cycling being considered an extremely low impact game(7). If a fisherman poses with foot pain, consequently, the problem of plantar pressures in biking shouldn't be dismissed as the potential origin. This is particularly true for competitive cyclists that will potentially 'push' around 40 million pedal cycles throughout their career!

Excessive plantar pressure is not something that happens in isolation, and much more study is needed about the use of other factors in precipitating foot discomfort during cycling. These include bicycle set-up (saddle height, saddle distance, cleat position), type of cycling shoe (type of cleat, material of sole), shoe fit (too tight, too narrow, attached too tightly), foot type of the cyclist (pes planus, pes cavus), presence of any lower limb biomechanical or structural deformities (genu varum, forefoot supinatus, ankle joint equinus), differences in body mass, the typical cycling terrain (hills or flat terrain) the preferred pedaling cadence and use of low/high gearing, as well as the experience and fitness of the cyclist.

For now, however, coaches, physiotherapists, chiropractors and coaches must know that foot discomfort during cycling is surprisingly common and much more likely associated with plantar pressure issues. Box 2 gives some practical recommendations that can be offered to cyclists in their own care.

References
1. Sports Med. 2006;36(1):7-18.
2. J Bodywork Movement Therapies 2005; 9:226-236.
3. Sports Medicine 1994; 17:117-131 .
4. Sports Medicine 1991; 11:52-70.
5. American Podiatric Medical Association 2000; 90:354-376.
6. Journal of Science and Cycling 2012; 1(2): 28-34.
7. Foot and Ankle International 2003; 24:784-788.
8. Sportverletz Sportschaden. 2012 Mar;26(1):12-7.