Coaches Corner

New addition to the Sports Injury Scotland website is our Coaches Corner, where we will post information on training and nutrition. If there is a particular topic you would like us to cover please contact us

Management of the Injured Tendon: Difficulties in Diagnosis and Treatment

Abstract

Background: Tendon injury is a painful and often debilitating affliction, which commonly presents to the sports medicine professional. Researchers have often struggled to determine the most appropriate way to manage this condition. Despite the plethora of literature on management strategies, there appears to be little stemming from sound scientific evidence. Objective: The aim of this is to identify studies that demonstrate a greater understanding of the pathophysiology of tendon injury and evaluate the most effective management strategies for this difficult condition. Methods: A systematic review of the literature was conducted. Results: The current review found support for the early use of corticosteroid injections, despite long term detrimental effects. The review also demonstrated exercise therapy designed to stretch and strengthen will be more effective in the long term. Conclusion: Individuals with tendinopathy should perform a regular strengthening and flexibility regime as early as possible. Patients with pain limiting daily activities may benefit from corticosteroids injections, to allow them to perform activities with reduced pain.

Management of the injured Tendon

Is Self Administered Proprioceptive Neuromuscular Facilitation (PNF) Stretching superior to Static Stretching at increasing Range of Motion and Flexibility?

An important component to overall fitness is good flexibility, which is the ability to move and bend joints through a full range of motion (ROM). Adequate flexibility allows minimal stress to be applied to joints, allowing them to function more efficiently. Research has documented many benefits to improved flexibility including a reduced risk of injury, performance improvements and improved coordination and stability. Many methods of stretching exist, however choosing the most appropriate is often challenging. Two common methods of improving ROM is by static stretching (taking the body into a position and holding for a prescribed timeframe) and PNF (Where a muscle is taken to end range and held, with intermittent isometric contractions, also known as hold-relax). PNF has always been thought of as time consuming due to the need of a partner to perform the exercises, however recently it has been suggested that self administered PNF may yield the same improvements as partner assisted PNF. A recent study by Wicke et al (2014) compared self administered PNF to static stretching to evaluate the effects on ROM and flexibility. The study included 19 healthy college aged individuals. Pre measurements of hip ROM (Gonniometer) and hip, back and shoulder flexibility (sit and reach test) were taken and retested post intervention. The participants were split into 2 groups (group 1: static stretching – 2x40sec holds and Group 2: PNF – 2x40sec holds with intermittent contractions) both groups stretched the hamstring muscle and completed 2xweekly for a period of 6 weeks. following the 6 weeks individuals had a 1 week break before switching protocols for another 6 weeks. The study found improvements in overall flexibility in both groups, however only the PNF group had significant improvements in hip ROM. the results of this study suggest that self PNF may be used in place of static stretching due to not requiring a partner. The study results, while interesting the individuals were under direct instruction with regard to protocol, therefore it may be difficult for an inexperienced individual to develop this technique, and as static stretching did improve overall flexibility levels, this method should not be overlooked. The study also utilised hamstring in the PNF group, inclusion of other muscles need to be examined before further conclusions can be made.

Wicke, J., Gainey, K. and Figueroa, M. (2014). A comparison of self administered proprioceptive neuromuscular facilitation to static stretching on range of motion and flexibility. Journal of Strength and Conditioning Research, 28(1), 168-172.

Can the inclusion of a plyometric training program improve performance in middle to long distance runners?

The importance for runners to achieve their personal best, whether this be in a quicker time or longer duration, how they get there has always led to much debate between runners, coaches and health professionals. The inclusion of strength training programs has been met with much resistance in the running community, with many runners fearing it will make them “too bulky” or it will “slow them down” with regard to maximal strength training where mass and strength are the main goal, this may be the case, however there are many ways to incorporate strength training into a schedule to actually enhance performance. A recent study by Ramirez-Campillo et al (2014) evaluated the effects of a 6-week plyometric training program on competitive middle to long distance runners. Participants were split into two groups (Group 1: Plyometric group performed 30mins 2x week of plyometric training alongside their normal training regime, and group 2: a control who continued training as normal). Prior to commencement of the 6 week intervention all individuals performed 4 athletic tests and were encouraged to perform all out. the plyometric group were then instructed on the plyometric drills. the groups were then retested at the end of the 6 weeks. The study found a significant improvement in performance in the plyometric group compared to the control (3x) in all 4 performance tests. the results of the Ramirez-Campillo et al (2014) study demonstrated that including as little as 60 mins of explosive strength training per week (i.e plyometrics) will have a positive impact on running performance without taking anything away from overall training intensity and frequency. the results of this study support the inclusion of a plyometric based intervention alongside a running schedule to improve performance, it is important to seek professional advice before beginning any form of strength training to ensure proper form, reducing the risk of injury.

Ramirez-Campillo, R., Alvarez, C., Henriquez-Olguin, C., Baez, E. B., Martinez, C., Andrade, D. C. and Izquierdo, M. (2014). Effects of plyometric training on endurance and explosive strength performance in competitive middle and long distance runners. Journal of strength and conditioning research, 28(1), 97-104

Foam Rolling during the warm up: an added benefit or waste of workout time?

Over the last decade self myofascial release has become a popular modality to relieve muscle soreness following exercise. Recently it has begun to appear in the warm up, with individuals postulating the potential benefits following the restoration of the normal length tension relationships. Despite the increase in popularity there appears to be a lack of clinical evidence to support the claims. A recent study by Healey et al (2014) evaluated the effects of myofascial release with foam rolling on performance, using healthy recreationally active (Exercises 3-5x week) college individuals. Participants were split into 2 groups (group 1: foam rolling for 30 secs each muscle group, and group 2: planking for the same time as the foam rolling group). Following warm up individuals performed 5 athletic tests and commented on levels of muscle soreness and fatigue. The study found no significant differences between both groups with respect to the 5 athletic tests, there was no improvement in performance found in either test group. with regard to levels of fatigue the foam rolling group noted significantly lower levels than the planking group. ultimately individuals are looking for the most effective way to improve performance, with regard to foam rolling it was not found to be of any additional benefit to performance, however if the individual is suffering from muscle soreness and fatigue the addition of foam rolling may give them a psychological edge, allowing them to perform a little longer during the session.

Healey, K. C., Hatfield, D. L., Blanpied, P., Dorfman, L. R. and Riebe, D. (2014). The effects of myofascial release with foam rolling on performance. Journal of Strength and Conditioning Research, 28(1), 61-68

Back and Core Stretching

Lower Back Stretch

Stretching should form an integral part of any training regime. Research suggests the best time to stretch is after exercise, making sure the muscles are warm. stretching a cold muscle can lead to potential muscle damage.

Attached is some stretches focusing on the main muscles of the Back and Core.

Back Stretching Program

Core exercises

A strong core is essential to optimal performance and the reduction of injury.

Attached is a beginners program to strengthen the core.

Core training program

Upper body Stretches

Sports Injury Scotland

 

 

 

 

 

Stretching should form an integral part of any training regime. Research suggests the best time to stretch is after exercise, making sure the muscles are warm. stretching a cold muscle can lead to potential muscle damage.

Attached is some stretches focusing on the main muscles of the upper body.

Upper Body Stretching Program

Stretching programs for the lower body and core can also be found on the website.

Initial Management of an Acute Injury

Once an injury occurs, whether to muscle, bone or ligament, it is imperative that you seek the most appropriate treatment for this. Injury often varies in severity, and therefore symptoms will differ. The most common signs of inflammation are heat, redness, swelling, pain and loss of function, not all of these symptoms may be present and some may even appear at a later date.

When you suspect you have sustained an injury to soft tissue (Muscle or Ligament) you must first minimize the symptoms of inflammation. The first 24 hours following the initial injury are critical in management. The following acronym is designed to control the bleeding and thus reduce inflammation and scar formation.

R: Relative Rest

I: Ice

C: Compression

E: Elevation

Relative Rest

Following any musculoskeletal injury, depending upon the severity, may require some immobilization, generally research suggests that a short period of reduction in motion can result in a stronger scar, which will be able to withstand more force, thus improving tissue regeneration and promotion of parallel alignment (Brukner and Khan 2012).

It is important however not to rest the injured area for too long, extended periods of immobilisation can weaken not only the injured tissue but also the surrounding areas, making return to activity a slow process.

Ice

One of the most important components of inflammation recovery, is the application of ice, Ice has been thought to reduce tissue metabolism, thus reducing blood flow and accumulating fluid, which results in reduction of swelling. Application of ice should happen as soon after injury as possible and should continue for the first 48 hours.

Two application procedures have been suggested, continuous and intermittent.

Continuous: 20 mins every 2 hours

Intermittent: 10 mins, with 10 mins rest then another 10 mins ice every 2 hours.

There are a number of ways to apply ice, with the most common being reusable packs (which can be kept in the freezer and used when required), Chemical ice packs (these are one use, disposable packs which are good for travelling, can be an expensive long term option tho), and frozen veg (frozen peas** have been found to be a good alternative to ice, as they conform to the body easily and can be re frozen for further uses).

** Mark bag with do not eat.

Prolonged exposure to ice can cause burning or nerve damage.

Compression

To reduce bleeding and swelling compression should be applied to the injury site, this should be used during and after ice application. The pressure should be firm but not to tight that it causes pain.

When using a bandage pressure should be initially applied distal to the injury and with slight overlap move proximal to one handbreadth above the injured area.

Elevation

The injured limb should be, where appropriate be raised above the heart, to reduce the pressure within the injured structure. This will also help in reducing the accumulation of fluid into the area, which will therefore reduce swelling.

Precautions in the Acute Stages

During the initial 72 hours there are a number of things that the injured person should avoid

Heat: Which will increase blood flow to the injured site, therefore increasing swelling,

NO hot baths, showers, saunas etc

Alcohol: this can mask the level of pain and severity of the injury

Aggravating Activity: Can result in worsening of the injury or re-injury

Massage and aggressive manual therapy: can increase blood flow, thus increasing swelling and risking further injury.

Medial Tibial Stress Syndrome

Medial Tibial Stress Syndrome: Common Cause of Shin Pain

What is it?

Medial tibial stress syndrome (MTSS), commonly referred to as “shin splints” has received a lot of attention within the literature, often found to be a difficult condition to manage. Shin Splints is a term which has been used to encompass all causes of shin pain including, compartment syndrome, stress fractures and MTSS. It is therefore understandable why such a term can become misleading as to the nature of such a complex and painful condition. The tibia (shin) is the larger of the two long bones located at the front of the lower leg.

Causes

MTSS is a chronic overuse syndrome, extremely common in activities, which involve weight bearing such as running. It has also been described as a common source of shin pain in military personnel. Pain associated with MTSS is often as a result of the following:

  • Over pronation: during the stance phase of gait the foot pronates to absorb shock and to adapt to uneven terrain, it is the soleus muscles job to resist unwanted pronation, therefore when the foot over pronates it places a repetitive stress on the tendons insertion on the tibia.
  • Training Errors: New training programs, sudden changes or increases to training, and inadequate recovery can all impact the repetitive overuse placed on the shinbone. Gradual progression and training increases will allow the musculoskeletal system to adapt to the loads imposed on them.
  • Muscle imbalances in strength and flexibility: It is all too common in runners to focus solely on their running and to neglect the strength and flexibility of their muscles. Tightness and weakness of the lower limb muscles can cause improper mechanics increasing the likelihood of developing MTSS.
  • Inappropriate footwear:  Appropriate running shoes should be the most important purchase by any runner, altered foot mechanics such as over pronation can cause internal rotation of the tibia, and fibula, which causes all structures to be forced into unwanted positions.

Symptoms

  • Pain due to MTSS is typically of gradual onset, pain is typically only associated with activity which often goes away once warmed up, that can often return when activity has stopped. The longer the injury goes untreated the more chronic the issue becomes, individuals may begin to notice pain during normal daily activities.
  • Pain is usually diffuse felt along the medial (inside) border of the tibia (shin bone). When a more focal area of tenderness is felt there may be a possibility of a stress fracture.
  • The pain felt can often be quite sharp, which may often be too painful to continue activity

Management

Early management of this condition is essential, initial reduction of the aggravating activity is important to reduce the stress on the tibia and leg musculature. The following are self-management strategies, which can be adopted.

  • In the initial stages when pain is present you may benefit from ice application (15mins every 2 hours) and some non-steroidal anti-inflammatory medication (NSAIDS).
  • Initiation of flexibility and strengthening programmes for the gastrocnemius/soleus complex and the anterior shin muscles. Beginning a proprioceptive training program will assist in regaining stability in the foot and ankle.
  • Correcting any training errors, following a guided program may ensure you don’t take on too much too soon. Altering the direction of your routes to ensure you are not running on the same cambered pavements.
  • Self massage with a foam roller.
  • Wearing the correct footwear, visiting a specialist footwear store such as Run 4 It will ensure you are measured correctly for the most appropriate shoe for your running style.

Sports massage and mobilisations have been found to be an effective method of reducing the pain associated with MTSS, increasing the mobility at the joint and improving the muscles flexibility, will enable the individual to perform the necessary strengthening exercises which are essential to ensure a speedy return to running. Sports Injury Scotland will provide diagnosis and treatment of any musculoskeletal injury offering advice on not only the management of pain, but direction on how to avoid recurrence.

 

Plantar Fasciitis

Plantar Fasciitis

What is it?

The plantar fascia is a broad band of connective tissue, which not only supports the arch of the foot, but also plays an important role in normal foot biomechanics. The fascia is designed to support the longitudinal arch of the foot. It attaches at the base of the heel bone and runs the length of the foot to insert into the bases of each toe. The plantar fascia is placed under tension during preparation for toe off during gait; the fascia is designed provide static support by tightening to stiffen the foot to allow affective propulsion.

Causes

Plantar fasciitis is a common overuse injury, particularly seen in runners with research indicating can account for 8-10% off all running injuries. This has been though to be due to repetitive microtrauma at the point of insertion. Some of the most common risk factors include:

  • Pes Planus (Flat feet): this causes excessive mobility in the foot, placing additional strain on the fascia due to increased stretching forces and reduced arch support. (Over pronation)
  • Pes Cavus (High arch): generally causing increased stiffness within the arch, and subsequently reducing the shock absorption properties of the foot. (Excessive supination)
  • Training errors: increases in mileage, changing terrain and inadequate recovery can place the individual at increased risk of developing plantar fasciitis, new runners who take on too much too soon are particularly at risk.
  • Muscle imbalances in strength and flexibility: research has suggested that tightness in the posterior muscles (hamstrings, gastrocnemius and soleus) may contribute to developing this condition. Poor strength and conditioning of the hip flexors, abductors and tibialis anterior muscles have been found to possibly contribute to the development of plantar fasciitis.
  • Inappropriate footwear: Appropriate running shoes should be the most important purchase by any runner, altered foot mechanics such as over pronation can cause excess stress on the plantar fascia. Wearing adequate footwear will enable the foot to function more effectively, which will subsequently reduce the impact on the more proximal structures.

Symptoms

  • Pain associated with plantar fasciitis is usually of gradual onset; it is typically painful at the beginning of activity, which often eases, only to return once activity ceases. If left untreated the pain increases to the point where weight bearing is painful and made worse with activity.
  • Pain is usually described as being worse in the morning, this is due to the foot being held in a plantarflexed position which when standing this movement is rapidly reversed.
  • Pain is typically felt on the medial (inside) aspect of the heel at the insertion to the calcaneus.

Management

As with any overuse injury, early management is essential, the longer it goes untreated the more difficult treatment would be.

  • In the initial stages it’s best to avoid any aggravating activities, any activity, which doesn’t cause pain, can be performed, for example swimming, cycling and cross trainer.
  • Anti inflammatory medication and ice may be beneficial in the early stages
  • Initiation of a strength and flexibility program, with particular emphasis placed on stretching the posterior muscles and strengthening of the hip flexors and abductors.
  • Wearing the correct footwear, visiting a specialist footwear store such as Run 4 It will ensure you are measured correctly for the most appropriate shoe for your running style.
  • Self massage to the plantar fascia with a massage ball.

Sports massage and mobilisations have been found to be an effective method of reducing the pain associated with plantar fasciitis, increasing the mobility at the joint and improving the muscles flexibility, will enable the individual to perform the necessary strengthening exercises which are essential to ensure a speedy return to running. Sports Injury Scotland will provide diagnosis and treatment of any musculoskeletal injury offering advice on not only the management of pain, but direction on how to avoid recurrence.