One of our primary concerns when treating our athletic clientele is further injury prevention.  We are very conscious of what we do within our treatment program that will help our athletic clients decrease their risk for other common yet traumatic injuries.  A common athletic injury that we frequently rehabilitate and work to prevent is an anterior cruciate ligament (ACL) tear. 

The ACL prevents the anterior (forward) movement of the tibia (shin bone) in respect to the femur (thigh bone) during walking, running, recreational and sports related activities.  ACL injuries occur as a result of both contact and non-contact  situations where the increase in force of movement is too much for the ligament to hold.  These movements place increased stress on the knee joint, typically with forces in the rotational and horizontal planes in respect to the knee, which causes the ACL to tear.

Research has shown that athletic women suffer this type of injury an average of 3 times more that men competing in the same sports.  It has been suggested that women are more likely to ACL tears due to the changes in hip and knee alignment they go through during adolescence.  As a result, women are more susceptible to the rotational and horizontal forces mentioned above during sports participation.  These forces are highest during cutting movements, quick direction changes, and when landing from a jump. 

A recent study by Imwalle et al., published in the Journal of Strength and Conditioning Research looked at the possible link between cutting movements and non-contact ACL injuries using a subject sample of high school female soccer players.  The study compared rotational forces placed on the hop and knee during 45 degree and 90 degree cutting movements.  The researchers found that hip and knee internal rotation were increased more during the 90 degree cut versus the 45 degree cut.  As a result, the subjects' knee abduction increased during a 90 degree cut putting the subjects at greater risk for an ACL injury.  The researchers concluded that targeted neuromuscular strength training to the trunk and hips may improve the athletes' ability to control knee and hip internal rotation during cutting movements, and therefore decrease their risk for ACL injury.

Our rehabilitation programs and strength and conditioning plans fall in line with this research. Our programs focus on core strength with targeted training for the low back, gluteus maximus, gluteus minimus, and abdominals.  Targeting these muscle groups improves the participants' ability to control hip and knee internal rotation during cutting movements.  Our therapists look at our clients' form during agility and plyometric (jumping) activities that put greater stress on the knees and correct that form as needed. 

Our Physical Therapists and Fitness Staff are experts at working with athletes during all stages of ACL injuries, from prevention to post operative rehabilitation.  Contact us if you have questions about how All Access can help you rehabilitate or prevent an ACL injury. 

 Reference: Relationship Between Hip and Knee Kinematics in Athletic Women During Cutting Maneuvers: A Possible Link to Non Contact Anterior Cruciate Ligament Injury and Prevention.  Lauren E. Imwalle, Gergory D. Meyer, Kevin R. Ford, and Timothy E. Hewett: Cincinnati Children's Hospital Research Foundation Sports Medicine Biodynamics Center and Human Performance Laboratory, The University of Cincinnati College of Medicine, Cincinnati, OH, and Graduate Program in Athletic Training, Rocky Mountain University of Health Professions, Provo, Utah.  Journal of Strength and Conditioning Research: Volume 23, Number 8, November 2009, pgs 2223-2230. 

The Facet joints are located at the back on either side of the spinal column, between the discs and the vertebral bodies. Each vertebra has bony prominences on each side that form a facet joint with the vertebra above and below. The role of the facet joints is to limit excessive movement and provide stability for the spine.

Facet joints are a potential source of pain which can affect the neck, middle back or lower back. Poor posture is commonly implicated in the development facet joint pain. Prolonged sitting and bending postures places an increased load on the facet joints which then become inflamed and painful. The muscles surrounding the spine also become affected. When considering how poor posture can affect the neck and thoracic spine (middle back) we can see that the thoracic spine becomes round, the shoulders hunch and the head pokes forwards; this leads to tightness of the muscles at the front of the chest and overload of the muscles around the shoulder blades and neck. The paraspinal muscles (long muscles which run the length of either side of the spine) in particular become knotted and tender ⁽¹⁾. 

How can foam rollers help with cervical and facet joint injuries?

A foam roller is a firm solid cylinder which is about 6 inches in diameter and 3 feet long. A roller can be used to isolate specific injured areas of the body and treat restrictions in the soft tissue⁽²⁾as well as perform balance training exercises, core activation exercises and stretching.

Stretching exercises on the foam roller for neck and thoracic facet joint pain.

This exercise is great for extending the middle back and neck and opening out across the front of the chest.

Lie on your back with the roller placed vertically along the length of the spine, feet on the floor and knees bent. Try to keep the spine in contact with the roller and open the arms out to the side. Feel the stretch across the front of the chest, lengthen the neck by tucking the chin inwards.

Muscle release techniques for the middle back using the foam roller

This exercise is to release tension in the muscles either side of the spine, it may feel a little uncomfortable initially but this does ease the more you do it.

Lie on your back with the roller placed horizontally between you and the floor. Your feet should be on the floor with your knees bent. Use the legs to push the body up and down the roller (like a rolling pin) to release tension within the muscles either side of the spine.

By improving your posture, the alignment of your spine is more efficient and the loads placed on the facet joins are reduced.

One of the major benefits of using a foam roller is that it is a relatively inexpensive way to treat injury on your own. It can be used to maintain joint alignment and muscle flexibility in between treatment sessions or for prevention of recurrence of symptoms.

For more information about the use of foam rollers to treat back and neck pain or to purchase a foam roller contact us at (508) 845-3500. 

References

1. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Fukui S, Ohseto K, Shiotani M, et al.  1996, Pain, Vol. 68 (1), pp. 79-83.

2. A comparison of the pressure exerted on soft tissue by 2 myofascial rollers. Curran, PF, Fiore, RD and Crisco, JJ. 2008, Journal of sports rehabilitation, Vol. 17, pp. 432-442. 

The urge to “fatten up” and “hibernate” in winter is strong, even for us humans. However, you are better off staying in shape than struggling to catch up come spring. Winter exercise benefits more than just your physical fitness: it is also a powerful antidote for the winter blues.

Options for winter workouts vary by your interests and your location. People who live in warmer, sunnier climates have the outdoor advantage over those of us in the Northeast who have to live with the cold temperatures and snow. But being outdoors in the winter can be exhilarating. Look at Rocky Balboa…all he needed was 2-3 feet of snow covered wasteland, a pile of wood to cut and throw around, a cold barn to workout in, a “Paulie” weighted sled, a few trees to chop down, and a snow covered mountain to climb (watch this if you need a visual: http://www.youtube.com/watch?v=W8xHjC27YvM&NR=1). If it worked for him, it can work for you. And look at how much fun he had!!!

There are many causes of low back pain; it can be the result of a range of conditions that affect the muscles, joints, ligaments, discs or nerves. Regardless of cause, back pain has a negative effect on the muscles which support and stabilize the lumbar spine (these muscles are collectively known as ‘the core’). This phenomenon is known as pain inhibition.

Counteracting the negative effects of pain inhibition by strengthening the core is essential to overcome chronic low back pain and return to normal function. Core exercise progression, balance activities and dynamic movement exercises all contribute to this cause.

The ‘core’ is a group of muscles which include the Transversus Abdominis, Multifidus, Internal Oblique, Paraspinal, and pelvic floor. Initially it is a big enough challenge to learn how to activate the ‘core’ muscles when lying down still! But for maximum effect therapeutic exercises must go beyond this and the muscles have to be taught how to control the position of the lower back during dynamic, everyday, movements.

It is not just the ability of these muscles to contract that is important, but also the way in which they contract; the order in which they ‘fire’. Transversus Abdominis and Multifidus in particular are what are known as pre anticipatory muscles; this means that their job is to switch on just prior to dynamic movement in order to stabilize the spine in preparation for movement.

Core Exercise Progression

Like any training program, core training needs to be within the capabilities of the individual becoming more challenging in line with improvements. Initially volitional activation of the core muscles should be practised; this is normally done in lying encouraging the Transversus and Multifidus to return to its role of stabilization prior to movement .

Once the muscles are ‘awakened’ this should be transferred to more functional positions. Functional progression is vital, there is no blue print of exercises; a ‘one size fits all’ prescription is useless. Exercises need to be individualized to meet the needs of the individual. All programmes should incorporate exercises in sitting, standing and walking ⁽¹⁾.

Balance Activities

Training using an unstable surface has been shown to increase core muscle activation ⁽²⁾. Examples of such unstable surfaces that are commonly used in recreation and rehabilitation are: physio balls, BOSU’s, foam rollers and wobble boards.

Dynamic Movement Exercise

Everyday activities involve movements which are side to side, front to back and up and down. To complete a rehabilitation programme, the core needs to be challenged in all these planes and at different speeds. Faster movements change the centre of gravity relative to base of support. This means that the muscles are required to make quicker adjustments in order to maintain stability and control of the spine.

By mastering the ability to control the lumbar spine through the application of a progressive and individually tailored exercise programme, full resolution of back pain can be achieved. The negative effects of pain inhibition can be countered and future episodes of back pain can be minimised or even eliminated.

References

1. Core Strengthening. Akuthota, V and Nadler, SF. 2004, Archives of physical medicine and rehabilitation, Vol. 85, pp. S86-92.

2. What I always wanted to know about instability training. Fowles, JR. 2010, Applied physiology nutrition and metabolism, Vol. 35, pp. 89-90.

Physical Therapy Treatment of Ankle Injuries using Joint Mobilization

The ankle joint is susceptible to sprains or fractures which often result in restricted movement.  Mobilization with movement is a treatment technique which can be used to try and restore range of motion (ROM) at a joint. It is used in the rehabilitation of ankle injuries with reported positive results.

Anatomy of the Ankle Joint

The ankle joint consists of four bones, the tibia, fibula, talus and calcaneus. These four bones have three ‘articulations’ which are contained within the ankle joint. The three articulations are:

Talocrural Joint

This is a hinge joint formed by the distal (far) ends of the fibula and tibia and the talus. It allows dorsiflexion (pulling the toes up towards you) and plantarflexion (pointing the foot).

Inferior tibiofibular Joint

This is strong joint between the lower surfaces of the tibia and fibula. This is re-enforced by a ligament (ligaments attach bone to bone) called the inferior tibiofibular ligament.

Subtalar Joint

The subtalar joint is the joint between the talus and the calcaneus.  It provides shock absorption and the movements of inversion and eversion (inward and outward ankle movements respectively) occurs here.

Ankle Injury and the use of MWM

The ankle is fairly susceptible to injury, sprains and fractures are commonly seen at the ankle joint. Both these types of injury can result in a restriction of dorsiflexion. A limited ability to dorsiflex the ankle has many implications for normal function and can lead to chronic pain and instability. It has been suggested that following such injuries positional faults can occur within the articulations of the ankle joint (1).

Mobilization with movement (MWM) techniques can be used to help restore dorsiflexion. MWM is a manual therapy technique where a manual force is applied to a part of the body and sustained while a previously restricted and/or painful movement is performed. The aim of MWM is to restore normal range of motion, and reduce pain (2) by correcting positional faults.

The exact mechanism of how MWM’s help to improve range of motion and levels of pain are not fully understood; however what is clear is that by stabilizing one joint or body part whilst allowing another to move, appears to correct positional faults which have occurred as a result of injury. Several studies have shown MWM has a positive effect on ankle range of motion (particularly dorsiflexion) (3) (4). Due to the success of MWM to restore full range of motion at a joint, MWM’s are recommended as part of a thorough treatment plan for ankle sprains or fractures (5).

References

1. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Kavanagh, J. 1, 1999, Manual Therapy, Vol. 4, pp. 19-24.

2. Mobilisations with movement (MWM's). Mulligan, B R. 4, 1993, The journal of manual and manipulative therapy, Vol. 1, pp. 154-156.

3. The initial effects of a Mulligan's mobilization with movement technique on osiflexion on dorsiflexion and pain in subacute ankle spraind. Collins, N, Teys, P and Vicenzino, B. 2, 2004, Manual Therapy, Vol. 9.

4. Mulligan's mobilization-with-movement, poistional faults and pain relief: Current concepts from a critical review of literature. Vicenzino, B, Paungmali, A and Teys, O. 2, 2007, Manual Therapy, Vol. 12, pp. 98-108.

5. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Vicenzino, B, Branjerdporn, M and Teys, P. 7, 2006, Journal of orthopaedic and sports physical therapy, Vol. 36, pp. 464-471.

The Best Rehabilitation Approaches for Overcoming Shin Splints.

During this time of year when people are running more outdoors for exericse, shin splints are an extremely common problem. Anyone who has ever suffered from shin splints will tell you how frustrating and painful it can be.

Shin splints are a general term used to describe pain at the front of the lower leg. There are a number of different causes of shin pain, the most common of which is due to irritation of the lower leg muscles, (particularly Tibialis Posterior and Soleus) at the point where they join onto the shin bone (1). This type of problem is sometimes also known as medial tibial stress syndrome (MTSS) and should be differentiated from other causes of pain which may be due to stress fractures of the tibia or neural/vascular problems.

Symptoms should be checked by an appropriately qualified health professional for clarification of diagnosis. The evidence to support or contest the recommended treatments for shin splints is poor.  A recent critical review of the available literature concluded that rest was as effective as any other treatment tested (2) . It could be argued however that this conclusion is more a reflection of the quality and range of studies undertaken as opposed to the actual value of treatments. 

Physical Therapists offer number of treatment options to patients in an effort to cure shin splints which include:

• Massage
• Ice
• Orthotics/Insoles
• Strengthening
• Calf Stretching
• Surgery (via referral to orthopedic surgeon)
• Rest

The primary aim of treatment is to relieve the inflammatory changes that have occurred at the muscular attachment of the lower leg muscles. Massage, ice and rest are all used to help achieve this goal. Stretching and the use of insoles/orthotics aim to decrease the load placed on the muscles and thus reduce the traction forces at their point of attachment onto the shin.

Strengthening can be used to increase the body's ability to cope with the stresses placed upon it. Strengthening should focus not only on those muscles local to the area, but also on those further up the leg and the ‘core'.

In extreme cases surgery can be useful to reduce the pain associated with shin splints. This however is not an option to be considered lightly full uninhibited return to sport is not always achieved (3).

Prevention is better than cure (and often is the cure!)

Whichever treatments are utilized the recurrence rate of shin splints is high. Unfortunately too many people stop running and enjoying the exhilaration of exercise because of their shin pain, this is often an outcome of poor advice and a failure to completely rehabilitate their initial injury. There is no ‘blueprint' for exercises to correct the causes of shin splints; an individualized programme is required. Positive results have been demonstrated in the use of custom made orthotics (2) (4).

Despite mixed reports in the literature regarding the ‘best' interventions for the treatment of shin splints, what does seem to be clear is that a multi-faceted approach should be taken (5). Not only should the treating clinician aim to reverse the inflammatory changes causing symptoms, it is also important to identify and correct the causative factors to prevent recurrence and increase recovery time.

With a methodical and graduated approach which includes structured training plans, education and advice regarding appropriate selection of footwear and training surface alongside manual therapy, it is possible to cure shin splints and prevent recurrence.

References

1. Bradshaw, C, Hislop, M and Hutchinson, M. Shin Pain. [ed.] P Brukner and K Khan. Clinical Sports Medicine. 3rd Edition. Sydney : McGraw Hill Medical, 2006.

2. Medial Tibial Stress Syndromme - A critical review. Moen, M H, et al. 7, 2009, Vol. 39, pp. 523-546.

3. Outcome of surgical treatment of medial tibial stress syndromme. Yates, B, Allen, MJ and Barnes, MR. 10, 2003, Journal of bone and joint surgery - American Volume, Vol. 85, pp. 1974-1980.

4. Medial Tibial Stress Syndromme - Evidence based prevention. Craig, D I. 3, 2008, Journal of athletic training, Vol. 43.

5. Comprehensive management of medial tibial stress syndromme. Knenner, B J. 3, 2002, Journal of chiropractic medicine, Vol. 1.

Recent current or former professional athletes on the show include former NBA player Dikembe Mutombo, former NFL lineman Mark Schlereth, MLB pitcher Steve Sparks, and professional golfer Stacy Lewis to name a few.  Here is a link to view the episode with Mark Schlereth which I really enjoyed: 

Athlete 360 on facebook - http://www.facebook.com/Athlete360TV
Athlete 360 on twitter - http://twitter.com/Athlete360TV

If you are like me and wonder what it takes for professional athletes to overcome their injuries, I think you will really enjoy the show.  Thanks for your consideration.

Useful Manual Therapy Techniques to Improve Shoulder Impingement Outcomes

The shoulder gives the most degrees of freedom of any joint in the body. The rotator cuff is an extremely important structure in providing a vital balance between mobility and stability. The rotator cuff consists of the tendons (a tendon is an extension of a muscle which attaches that muscle onto a bone) of 4 different muscles: Infraspinatus, Teres minor, Supraspinatus and Subscapularis. These structures are vulnerable to injury. One of the most common of all shoulder injuries is impingement.

Impingement occurs when the rotator cuff tendons get pinched in the space between the arm bone and the arch of the shoulder blade, which is known as the sub acromial space, as they pass from their muscle to their attachment at the front of the shoulder. This causes a mechanical stress to the tendon which results in swelling and/or damage. This pain is usually felt when lifting the arm up straight in front of you or out to the side as this is when the sub acromial space is at its smallest.

Rotator cuff impingement can be difficult to cure. Stretching or strengthening exercises and non steroidal anti inflammatory (NSAID's) are often prescribed as treatments for impingement. Another valuable treatment option is manual therapy. Manual therapy has been shown to improve the outcomes for rotator cuff impingement treatment ⁽¹⁾. Manual therapy helps to relieve the mechanical stress on the tendon which causes the damage and helps the damaged tendon to recover more quickly.

What is Manual Therapy?

Manual Therapy is a term used to describe a ‘hands on' treatment approach where joints, muscles ligaments and other soft tissues are mobilized or manipulated by a therapist to achieve a therapeutic benefit.  The benefits for the shoulder and rotator cuff muscles in using these techniques includes increased flexibility, increased tissue healing, improved muscle function without impingement, and a patient's increased tolerance to performing functional activities without impingement pain following treatment.

There are a range of techniques which fall into the category of manual therapy, those most commonly used for the treatment of rotator cuff impingement are:

• Soft Tissue Massage
• Friction massage
• Manipulation
• Mobilization

Soft Tissue Massage

Soft tissue massage is the systematic application of pressure and movement on the soft tissues of the body with the intention of facilitating normal range of movement.

Friction Massage

Deep  tissue friction massage is the application of a massage technique whereby superficial tissues are rubbed against deeper tissues. It is useful in assisting the body's own healing mechanisms and as such can help to speed up the healing of injured tendons.

Manipulations

Manipulation is a passive joint movement performed with the aim of increasing joint mobility. It incorporates a small amplitude quick thrust movement at the end of the available joint range.

Mobilizations

Joint mobilization involves the application of a passive force to increase joint range of motion. Mobilizations are performed up to the end of available joint range, but always within that range.

Although manual therapy has been proven to improve rotator cuff impingement recovery, it is not clear which of these manual therapy interventions is better ⁽²⁾. It would seem logical to assume that a combination of these treatments would prove to be of benefit in promoting recovery from rotator cuff impingement.

References

1. The effect of manipulation on the structures of the shoulder girdle as additional treatment for symptom rekief and for prevention of chronicity or recurrence of shouder symptoms. Bergman, GJD, Winters, JC and G, Heijden. 2002, Physical Therapy, Vol. 25, pp. 543-549.

2. Comparison of conservative treatment with and without manual physical therapy for patients wth shoulder impingement syndrome: a prospevtive, randomized clinical trial. G, Senbursa., Baltaci, G and Atay, A. 2007, Knee surgery sports traumatology and arthroscopy, pp. 915-921.