Optimal Loading for Tendon Rehabilitation

As a physiotherapist having many clients with tendon issues, the biggest question I have is why did injury occur in the first place? Was it due to trauma, is it linked to training loads or is it something else causing effects to the tendons. Our job is to help guide you to have the best rehab getting you back into your sport or activities. This blog will discuss the importance of optimal loading for tendon rehabilitation.

Optimal loading is what physios strive to achieve when talking about rehabilitation, although due to the nature of tissue healing and recovery it can be made difficult to follow a ‘recipe’ program. Therefore we need to adapt our exercises and progress you through the rehabilitation process to get you back to the top of your game.

When deciding what rehab pathway is appropriate we must first look at what stage of injury we are in. There are two key stages of tendon injury, reactive and degenerative. A Reactive tendinopathy can be described as an acute tendon injury where appropriate management strategies would be to de-load the tendon to let the inflammatory process settle down, then proceeding with progressing tendon loading. A degenerative tendon is where symptoms have been present for a while. A good progressive loading program to increase tissue capacity and tolerance to load is needed.

The table below describes the nature of these types of injuries:

Reactive Degenerative
Symptom Acute onset of symptoms, slow to settle down Chronic – long history of symptoms
Age 15-25 30-60
Time 2-6 weeks 3-6 months
Physio management Massage, orthotics, Dry needling etc. Progressive load
Treatment Unload and reload Load,- Heavy and slow

The image below can help us understand the architecture of a tendon. As a tendon injury starts to proceed into a degenerative tendon the striation of the collagen go from being very linear and to being disrupted and become more disorganised.  This demonstrates the change that occurs and therefore it is important to have an appropriate exercise program to prevent further injury.

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Here at Bureta Physio we can help guide you through your injury. We will focus on the injury itself but always ask the question to why this occurred in the first place.

Key points:

  • Depending on the type of injury, we need to work together to establish the best management strategies for rehab
  • Acute reactive tendons may need to be unloaded prior to reloading
  • Chronic degenerative tendons can take months to heal fully
  • As a degenerative tendon develops the architecture of the collagen fibres becomes disorganised. Through loading appropriately we can enable the tendon to be able to adapt to required loading and therefore allowing return to sport.

Please call us on 07 576 1860 to discuss your injury and our team will be more than happy to help.

Written by Braedon Catchpole – Physiotherapist

Concussion is a Mild Traumatic Brain Injury.

Concussions – Written by Kimberley Pilbrow (BHSc Physiotherapy)

With the start of another Winter Sports season now upon us, now is a good time for athletes, parents, coaches, officials & supporters to increase their knowledge about concussion.

Concussion is a Mild Traumatic Brain Injury which occurs when someone receives impact to the head or body causing a force to be transmitted to the brain, ie ‘shaking’ inside the skull. In a concussion injury there is no change to the macro-structure of the brain. Ie there is no permanent damage to the brain. However, there are changes at a micro level, meaning it may take some time to re-access the areas of the brain that were affected.

Historically people believed that to sustain a concussion you must be “knocked out” (loss of consciousness), this is not true- 90% of concussion occur without any loss of consciousness AND Loss of consciousness does not relate to their long-term outcomes. Ie someone who is knocked out may return safely to sport in 3-4 weeks, where as someone who is not may take 3months to recover- there is no relationship between “severity” of concussion and length of recovery.

As Concussion is a brain Injury- there is a wide range of symptoms such as:

Visible Signs:
-loss of consciousness
-slow to get up
-unsteady on feet/poor balance
-poor coordination or inappropriate playing behaviour (eg. standing out of position)
-clutching or grabbing at head
-dazed or confused
-vomiting (>once is of greater concern-take to Emergency Department)
-irritability/changes in emotions

Symptoms:
-dizziness
-headache
-nausea
-drowsiness
-“don’t feel right”
-blurred vision
-difficulty concentrating/remembering

If you (or your child) have an incident like this and have one or more of the following symptoms you should:
1) Be removed from sport immediately
2) Monitored by an adult
3) Seek Medical Attention from your GP or Concussion Trained Physiotherapist (Click here for our team)

A full list of symptoms can be found HERE– the Concussion Recognition Tool is a great resource for parents & coaches

Assessment and Treatment of Concussion:
A concussion must be diagnosed by a health professional. Examination from your Physiotherapist will include a group of tests as required including; SCAT5 or SCAT5 Child Assessment (Symptoms, Neurocognitive processing, Balance), Assessment of neck pain and movements, Neurological Exam, and Eye & Head Movements.
Treatment of each concussion is individual- REST IS NOT BEST!!
Your Physiotherapist will work with you on starting appropriate activities EARLY to aide a gradual return to daily activities (highly supported by research), followed by return to work/school and then return to sport. Your treatment plan may include; education about pacing activities, treatment of the neck joints and muscles, relearning eye tracking movements and gradual exercise progressing back to full function including work and sport specific tasks.

Key Points:
-90% of concussions occur without being knocked out
-If you suspect a concussion, remove the athlete from play IMMEDIATELY
-Seek Medical Assessment from someone trained in Concussion
-Rehabilitation is INDIVIDUALISED
-REST IS NOT BEST!
If you have had a concussion, Bureta Physiotherapy will work with you, your family and your doctor to take you through the required steps for full return to function-including sport, school or work.
Early Diagnosis is important for monitoring symptoms and guiding appropriate rehabilitation, contact us TODAY to book an appointment or discuss if our acute concussion service is right for you.

 

 

Abnormalities found on scans in asymptomatic people.

There have been many studies that have explored the abnormalities within our bodies through using different imaging techniques. The key take home message that research has brought to us is we are not all perfect, even if we are walking around pain free performing all our daily activities without issues.
However when injury does occur we may get x-rays, an ultrasound or refer you to a specialist who can get an MRI which can come back with findings such as a disc bulge. As demonstrated in the infographic above, it shows us that at least 37-96% of individuals can have this problem in their lower back, and up to 87% in their neck.
It is also reported that for men aged between 40 and 70 years old, up to 96% of individuals have shoulder abnormalities . Although these individuals can carry out their daily routine symptom free.
There are many findings on imaging from head to toe that are part of the normal ageing process and yet do not affect any part of our social or work life or our physical activity. What we don’t know is that we may have already been living with them for many years in our lives. This goes to show that even if we have an ‘abnormality’ within our body on imaging, it doesn’t necessarily mean that we are ‘injured’ or that our injuries are as bad as they present.

Image: Leedarrenh

Lateral ankle sprains – How should they be managed?

Diagnosis, Treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline – vuurberg et al., 2018.
Lateral ankle sprains, how should they be managed

Lateral (outside) ankle sprains are the most common ankle injury. Approximately 40% of all traumatic ankle injuries occur during sport, and only 50% of individuals seek medical attention.
Due to the poor attention to injury, a large population develop chronic ankle instability. 1-4 years following initial injury, 5-46% of individuals with chronic ankle instability still experience pain, 3-34% has recurrent sprains, and 33-55% report instability.
Risk Factors
Predisposing factors that increase the risk of sustaining a lateral ankle sprain compose of Intrinsic factors (patient-related), and Extrinsic factors (sport, environment).
Intrinsic risk factors
Modifiable risk factors include:
• Reduced strength around the ankle and calf
• Limited ankle mobility and range
• Poor proprioception (“the sense of the relative position of one’s own parts of the body and strength of effort being employed in movement”)
• Low cardiorespiratory endurance
• Increased BMI (Body mass index)
• Preseason deficiencies in postural control/balance e.g single leg stand
Non-modifiable risk factors include:
• Anatomical abnormalities in the ankle, knee alignment, and multiple clinical defects
Extrinsic risk factors
• Sport dependent – Highest incidence of lateral ankle sprains were found in: Basketball, indoor volleyball (landing following jumping), field sports, climbing.
• Playing surface – Natural grass vs artificial turf vs court
• Position played in sport – e.g within soccer, defenders obtain 42.3% of lateral ankle sprains in the sport.
Treatment
Below is some of the latest evidence for the best treatment options, and how we can get you back running around with the kids, or back onto the sports field.

 R.I.C.E (Rest, Ice, Compression, Elevation)
Purpose: to reduce pain and swelling, improve patient function
RICE alone as a treatment is not enough, the best evidence is to apply the RICE principles alongside with exercise therapy.

 Non-steroidal anti-inflammatory drugs (NSAID’S) – E.g Ibuprofen, naproxen, diclofenac
Purpose: to reduce pain and swelling for acute injuries
If you have any concerns in regards to medication please discuss with your doctor.
Adverse effects may include: stomach discomfort, allergic reactions, heart burn, nausea, vomiting, diarrhea and/or constipation and more.

Immobilisation
A minimum of 4 weeks in a low leg cast following an acute lateral ankle sprain results in less optimal outcomes when compared with functional support (brace, tape, tubigrip/bandage) and exercise strategies with duration of 4-6 weeks.
However recent evidence showed a short period (less than 10 days) of immobilisation with plaster cast or rigid support (brace) can be of added value in the treatment of acute lateral ligament injuries as it helps reduce pain and oedema (swelling), and improves functional outcomes

Functional support i.e ankle brace/ tape/ tubigrip
Tubigrip/compression stocking following the acute phase of treatment begins to become unhelpful as it doesn’t provide sufficient support. Therefore using a lace up brace or semi-rigid brace will provide enough ankle support
Ankle braces results in better outcome compared to rigid or K-tape
K-tape is unlikely to provide sufficient mechanical support to unstable ankles

 Exercise
Consist of neuromuscular and proprioceptive exercises
Reduce the risk of recurrent injuries by reducing ankle instability, and associated with quicker time to recovery and enhanced outcomes

 Manual mobilisations
Manual mobilisations provide short term increase in ankle range of movement and can reduce pain in lateral ankle sprains
However manual therapy in combination with exercise therapy results in better outcomes than exercises alone

 Surgical therapy
60-70% of individuals who sustain lateral ankle sprains respond well to non-surgical treatment programmes
Surgery is mainly reserved for patients who have chronic ankle instability and who have not responded to comprehensive exercise-based physio programme.

Other therapies
Other treatment options are can also be used during treatment, although please discussed with your physio if these are beneficial for you.
These including: Acupuncture, Vibration therapy, laser therapy, electrotherapy, shockwave therapy, ultrasound.

Here at Bureta Physio we can properly assess your injury and give you the appropriate recommendations to get you back into what you love doing. Call 07 576 1860 to arrange an appointment time or click here to book online

 

Strain and sprain is not OK!

“The perfect movers, without strain and pain are under 5 year olds”

Stiffness and strain for many is part of life, indeed a modus operandi for many. But imagine if stiffness and strain equates to dysfunction, pain and harm, this forms much of our function and day. I recently attended a Integrated Movement Patterns Course to upskill on the Milicich Method where the emphasis was on non – specific neck and back pain. These methods were derived from analysing the perfect movers of this world; the few uninjured high performing individuals, who work within gravity, pain free. A small percentage are in the adult population and a high percentage are the 5 years old’s and under, the perfect movers of this world; the young who display natural movement synergies. The ability to move their centre of mass with perfect balance is part of our natural physical development, which sets the foundation for future movement.

The Milicich Method aims to facilitate these fundamental movement patterns that are still within our central nervous system and awaken them to treat strain and sprain. Diaphragm function underpins strength and function within these movement synergies undoing habits, utilising language to facilitate existing pathways. These are key to the learning process. Many people have unlearned the pro-gravity system and reprogrammed the anti-gravity system in their brain, working against gravity instead of with gravity.

One aspect of our daily lives that contributes to neck and back strain is lifting and the Milicich Method addresses this concern looking at the way 5 year old’s squat and how power lifters perform. This was instrumental in re-establishing the pro-gravity movement pattern. The natural flat foot squat (FFS) position is a movement that much of the western society has lost. The FFS that every child performs, moves the centre of mass through a vertical range of motion, and this is a very specific sequence of movement incorporating diaphragmatic breathing to engage the power chain, which gains a successful lift without strain within gravity.
If this concept of eliminating strain and sprain, re-establishing fundamental principles of movement and working within gravity is something that you would like to explore then I look forward to facilitating this learning process.

Marcel Gyde
Senior Physiotherapist

Improve your sleep

Strategies to Improve quality and/or quantity of sleep

Inadequate sleep and/or poor- quality sleep affects the non-athletic and athletic population. Consequently, adequate sleep is a critical component for post exercise recovery thus effecting performance. Therefore, below we have listed strategies you can implement to enhance your sleep quality to optimise your health, work/sport performance and recovery.

Nutrition do’s and don’ts
Do’s

Consume tryptophan containing foods such as milk, meat, fish, chicken, eggs, beans, peanuts, cheese and leafy green vegetables in the evening meal to increase melatonin production.

Try including carbohydrate foods at dinner to assist with Serotonin production, e.g. potatoes, rice, pasta… this may not be ideal if overweight or working on losing fat.

Try consuming 30ml tart cherry juice in the evening to increase exogenous melatonin intake (also decreases DOMS -Delayed Onset Muscle soreness). Use in a periodised way, e.g. around high volume training or to get sleep sorted initially if in a rut or during competition.

Consume a balanced, healthy diet, including adequate wholegrains, low fat dairy foods, fruits and vegetables for magnesium and B vitamins.

Try 300-400mg Magnesium supplement prior to bed.
Don’ts

Alcohol intake prior to bedtime (fragments sleep later in the night)

Caffeine and nicotine stimulants intake prior to bedtime (individual tolerances do exist). This includes coffee, tea, energy drinks, cola, chocolate.

To be cautious of
Be conscious of food portions before bed (eating large portions of food can raise core body temperature and make it difficult to fall asleep) and fluid intake prior to bed (to minimise need to go to the bathroom).

Consume fluids with evening meal to increase absorption, then taper off;
i.e. individual fluid prescriptions may be necessary following late- night training/competition to ensure rehydration.

Aim for no more than one visit to the bathroom during the night to minimise sleep fragmentation.

Combating Stress
Use a journal to write down worries/thoughts before bed

Write a ‘to do’ list for the next day to help clear the mind

Body Temperature
Lowering core body temperature in the evening to induce drowsiness and sleep:

Skin-warming (for cool environmental conditions) – achieved through warm baths/shower/spa, hot foot baths, warm blankets or dressing gowns, wearing warm socks and woollen boots/slippers

Skin cooling (for warm environmental conditions) –achieved through cool showers, cold water immersion, appropriate use of air conditioning, light bed covers

Keep a Routine
It is critical to maintain a pre- bed routine to prime the body for sleep. This is crucial for proper sleep hygiene.

Allow 1 hour ‘the de-power hour’ to unwind before bed

Maintain a regular bed and waking time each day (entrains our internal body rhythm -circadian rhythm)

Avoid computer screens, texting, bright lights for 1-2 hours before bed (stimulates the eye). Some people may find a dimmer TV screen from a distance helps them relax.

Creating a sleep friendly environment
Keep the TV out of the bedroom.

Keep the bedroom for sleep activities only, and ensure it is quiet, dark and comfortable.

If you cannot sleep within 15 minutes of going to bed, get up again and try a different strategy. Eliminate the bedroom clock (avoids stress of ‘losing valuable sleep time/clock watching’).
Napping
Napping can be a valuable way of increasing total sleep hours. Experimenting with a 90 minute nap mid-afternoon (one full sleep cycle). Recommended for individuals during heavy training prior to competition or who are having short nights.

If insomnia is a problem, do not nap in the day. Otherwise time naps for 8 hours after rising time (2-3pm) and keep these no longer than 30 minutes.

Naps times between 30-90 minutes or longer than 90 minutes may result in temporary sleep inertia and performance impairments.

Napping 10-12 hours after morning waking time will likely disturb nocturnal sleep. Set an alarm to wake at the right time post nap.

What is Rehabilitation

Have you ever wondered how exercise works? Watch this video!

This video shows mechanotherapy at work. Mechanotherapy is the science behind how exercise works and why your physiotherapist prescribes your particular exercises. When you put a controlled load through the body’s tissues, like a muscle contracting against resistance, this will cause the cells in that muscle to respond. The cells recognise that muscle is working against resistance and a cascade of reactions begin that eventually lead to muscle fibres increasing in size. How your physiotherapist manipulates the exercise will determine what sort of reaction the cells will have. For example, exercises to build muscle are different to exercises that encourage weight loss. A detailed understanding of how this works is required by your physiotherapist to get the outcome you desire. The physiotherapists at Bureta are well trained in rehabilitation and exercise prescription so are able to tailor a treatment plan specifically for each individual!