"Dead Leg"

Posted 14 May, 2013 

A dead leg of the most common injuries in field sports where player contact arises. The correct name for this type of injury is a Quadriceps Contusion. The direct blow causes the muscle to be compressed against the femur which leads to primary damage of myofibrils, fascia and blood vessels. Secondary tissue damage may occur due to the decrease in oxygen being supplied to the surrounding muscle as bleeding from the broken blood vessels will increase tissue pressure in the damaged area.

The contusion may be either intramuscular or intermuscular. The intramuscular hematoma is the more painful and restrictive of the two. Bruising in many cases is not noticeable as the damage to the muscle is contained within the muscle sheath. An intermuscular hematoma on the other hand is more likely to be visible. This is because there has been a tearing of the muscle and part of the sheath surrounding it, which leads to the blood escaping through the fascia and dispersing in between the compartments of the thigh. Contusions in the lower third of the thigh may lead to the blood tracking down into the knee and irritating the patellofemoral joint.

A direct blow to the front of the thigh is usually more serious and disabling than a blow to the outside of the thigh due to the difference in muscle mass present in the two areas. When the injury occurs, pain, a decrease in the working of the quadriceps muscle group and a decrease in the amount of knee flexion may be present. The injury can be either; Mild (Grade I), Moderate Grade II), or Severe (Grade III). Grade I: Can usually continue activity, sore the next morning, 5-20° decrease in full stretch, tender to touch, minimal loss of strength. Grade II: May be able to continue activity but stiffens up with rest, 20-50° decrease in stretch, pain on contraction of muscle, tender to touch, person may limp. Grade III: May not be able to continue activity, may not be able to control rapid onset of bleeding/swelling, severe loss of movement (50%), difficulty walking, tender to touch over a large area, obvious bleeding, noticeable loss of strength. 

The most important period in treating a quadriceps contusion is in the first 24 hours. Following the injury the RICE (Rest, Ice, Compression, Elevation) regimen should be implemented as soon as possible. It is important to apply the ice to the contusion in a position of maximal pain free stretch. This may help decrease the amount of range of motion that may be lost. Crutches should be used if full weight bearing is painful. Excessive activity, heat (hot bath etc.) and alcohol should be avoided. 

The type of treatment depends on the Grade of the injury. All grades involve RICE in the early stages. Pain free stretching in the early stages is important and over time strengthening exercise will need to be introduced. Electrotherapy may be used to decrease the swelling and ultrasound may be used to speed up the healing process. Sometime you hear of sports message being carried out a few days after an injury, this should not happen as aggressive treatment may lead to myositis ossificans (calcification within the muscle). This may also occur with repeated injury to the same area or when trying to play through Grade II or III quadriceps contusions. 

This injury can be quite serious and in severe cases may lead to several months away from your sport, so it is important that you take the injury seriously. Assessment, treatment and the correct rehabilitation program will help you return to your sport as quickly as possible.

"Lateral Ankle Sprain" 

Posted 6 May, 2013

Last week we had a look at shin splints, which, judging by the feedback, is something that a lot of people have suffered from and/or continue to suffer from. I had a few runners into the clinic this week and they asked me to do a piece on ankle sprains. You don’t have to be very active to have had one of these as we have all ‘gone over’ on our ankle at some point in time.

When we say ‘gone over’ we are usually referring to having injured the outside of the ankle, this is called a lateral ligament injury or an Inversion sprain. Eversion and syndesmotic sprains may also occur but we will deal with them in a future article. The usual mechanism of injury is inversion and planterflexion, which is basically rolling over on your ankle while you are attempting to walk/run. As you can see from the picture, there are 3 ligaments on the lateral side of the ankle; ATFL, CFL and PTFL. The ATFL is usually damaged before CFL as the ATFL is tight when downward pressure is being applied by the foot. The greater the inversion force applied the more likely it is that the CFL and PTFL will be injured. 

In some cases there is an audible crack, snap or tear which may not be as worrying as it sounds. Depending on the severity you may continue on or may have to rest immediately. Swelling may rapidly appear in the region but occasionally it may take a number of hours. On examination the extent of the injury can be determined and categorised as a Grade I, II or III type tear. Grade I; no abnormal ligament looseness. Grade II; some degree of looseness but have a firm end point. Grade III; abnormal looseness without a distinguishable end point. All 3 Grades are associated with pain and tenderness. In Grade III cases where conservative treatment is unsuccessful surgical reconstruction of the ligament may be required. 

Initial management of the injury requires RICE treatment; Rest, Ice, Compression and Elevation. This is important as limiting the amount of swelling in the area will decrease the potential for irritation of other structures and decrease the loss of joint range of movement. Hot showers, heat rubs, and excessive weight bearing should be avoided in the first few days. Initial work should be concentrated on restoring full range of motion to the area. Muscle conditioning will help strengthen the muscles in the area so as to help avoid reoccurrence. Proprioception exercises are important as the body’s awareness of where the foot is positioned will have become impaired following injury to the ligaments. For those involved in sport, functional exercises can be prescribed when the athlete is pain free, has full range of motion and adequate muscle strength and proprioception. Taping of the ankle is advisable if playing sport but over time you should aim to not have it strapped if possible. 

Approximately 75% of people who sustain an ankle ligament injury will have had a previous injury. This is down to the fact that people usually just rest the ankle and resume playing without carrying out a rehabilitation program. If you don’t do something to strengthen up key areas of potential weakness the likelihood is that you will injure yourself again.

"Shin Splints" 

Posted 29 April, 2013

Shin pain is a common complaint among athletes and the term ‘shin splints’ is commonly used as a way of describing pain in that region. When people say that they have ‘shin splints’ they are usually referring to Medial Tibial Stress Syndrome (MMTS).  While MMTS is the most common cause of shin pain it can also be caused by : 1) Stress fracture of the tibia; usually more common for athletes in impact, running and jumping sports.  Stress fractures usually present as pain that is pin point or that is specific to an area of the tibia. It usually hurts when walking as opposed to easing after you warm up. 2) Chronic exertional compartment syndrome; this is the most serious of the conditions where there is an increase in pressure in one of the 4 compartments in the lower limb which leads to reduction in blood flow and a reduction of the transfer of blood to the capillary beds in the muscle.

By far the most common cause of shin pain is MMTS, which has been defined as ‘a specific overuse injury producing pain over and along the posterior-medial border of the tibia’, which is basically pain along the border of the bone on the inside of your leg. The pain is due to muscular and fascial traction on the bone which causes inflammation of the periosteum, a layer of connective tissue which surrounds the bone. MTSS is thought to be down to the interaction of internal risk factors (e.g. muscle imbalances, flexibility, biomechanics) and extrinsic risk factors (training volume, footwear, training type, surface). In the beginning the area may be sore after and intense work out but over time the condition may worsen to the point where it may be painful when walking and morning pain and stiffness may be present.

Rest, ice and anti-inflammatory medications may reduce the symptoms in the early stages of treatment. Switching to pain free training such as cycling or swimming may help maintain fitness levels while avoiding weight bearing training. When treating MMTS a therapist will need to examine what are the main causes of the condition occurring. With many people it is due to an increase in training coupled with poor flexibility and excessive pronation (flat foot). Orthotics may be needed to help stop excessive pronation while soft tissue therapy will be need to be carried out on the calf muscles, especially the soleus muscle which has been implicated as one of the muscles causing the pain as it may repeatedly be over worked when trying to resist pronation. Abnormalities in the tibialis posterior muscle may be addressed by relaxing the overlying muscles. Increasing the flexibility of the muscles in the calf region is important as is addressing any muscle weakness that may be present.

A return to full activity should be made when there is boarder of the shin is not tender to touch, when flexibility and biomechanical issues has been addressed, and when the patient has completed a gradual running program and a sport specific functional program without an increase in symptoms.

"Lower Body Posture"

Posted 15 April, 2013

Last week we looked at one of the most common upper body postures that people have due to staying in the same position for a prolonged period of time. This time we are going to look at lower body posture, in this case Lower Cross Syndrome. Both upper and lower crossed syndrome can occur at the same time, especially with people who spend a lot of time sitting throughout the day. 

As mentioned in the previous article, when you have a muscle that is tight it causes another muscle to become lengthened and in turn this muscle becomes weak and dysfunctional. If you spend a lot of the time sitting at a desk or adopting a poor posture then muscle imbalances will occur. Chances are that you are sitting down while reading this. You will see that your hip flexor muscles are in a shortened position as are erector spinae muscles which are located around the arch in your lower back. If this is maintained for a prolonged period of time it will lead to these muscles adapting a shortened position. This tightness will then have an effect on the opposite muscles by lengthening them, hip flexor tightness will see the glut max lengthening and tightness in the lower back region will see lengthened abdominal muscles. Figure 1 shows the muscles affected by Lower Cross Syndrome. 

These muscle imbalances can lead to a number of complaints. Tightness of the hip flexors can lead to pain and discomfort in the groin region as well as the knee, as the rectus femoris muscle crosses the hip and knee joint. Tightness of the muscles in the lower back can lead to pain in that region as well as referred pain in to the hip area. An excessive curve in the lower back may also lead to compression of joints in the lumber vertebra which may cause pain, restrict movement and if left untreated it will lead to a degeneration of the joint. Disk issues may also occur which may lead to pain in the lumbar region and/or radiating down the leg as well as possible weakness or numbness in the affected limbs. 

Weakness in the gluteal muscles decreases stability in the region. It can lead to hamstring issues, particularly in athletes, as the glut max is firing after the hamstrings when the hip is extended which places added pressure on the hamstring muscle group. Glut medius and minimus, which are located on the side of the hip, may also become inhibited and weak which may lead to painful trigger points with in the muscle as well as having a knock on effect on structures further down the chain.

If left untreated strength and flexibility will decrease over time, while degenerative changes in the lower back will also occur. However, if you do get treatment and are willing to follow a program that strengthens key areas, such as the glut muscles, while stretching others, then you will see the benefits. Muscle balance is important and it can stop your body functioning at its best so if you are maintaining a position, such as sitting, for a prolonged period of time then break the cycle even if it’s only for a few minutes.

"Upper Body Posture" 

Posted on April 11, 2013

A sizeable amount of the people that are coming into the clinic have postural issues due to prolonged sitting, especially people who work at a desk or drive long distances. Prolonged sitting usually leads to upper back/neck and lower back problems. Today I am going to focus on the upper back region. 

We have all been told over the years to sit up straight or not to slouch which usually had an effect for a while but 5 minutes later you found yourself back in the same position. This slouching posture leads to your head being in a more forward position that what it should be and with the chin protruding. A typical patient will have reduced thoracic extension, rounded shoulders, tight pec muscles, restricted shoulder movement and forward carriage of the head. This is clinically referred to as Upper Cross Syndrome (figure 1). This posture is common among production line workers, hair dressers, painters, basically people who have to maintain the same body position for a prolonged period of time.

This prolonged posture leads to muscle imbalances. As you can see from figure 1, if the head is in a forward position it leads to the neck flexor and shoulder/mid back muscles being in a weak and lengthened position while the upper neck and chest muscles are in a tight and short position. With the chest being tight this leads to the back and rear shoulder muscles becoming lengthened, if they become lengthened they become weak which leads to them not functioning correctly and this can lead to muscle pain in that region. This posture can also lead to a decrease in movement in the lower C Spine and upper T Spine with pain arising in the upper neck due to tight muscles. 

When muscle imbalances occur it can lead to pressure on other muscles to do the work that the week muscles should be doing. One of the muscles that can be most affected by the Upper Cross Syndrome posture is the infraspinatus muscle which goes from the shoulder blade (scapula) to the humerus. This muscle works with 3 other muscles to form the Rotator Cuff which is responsible for stability and smooth movement in the shoulder region. If the shoulders are rounded this leads to the infraspinatus muscle being elongated and then it becomes weak. This can lead to pain in the region and in more severe cases pain down the arm due to referred pain from trigger points in the muscle. A dysfunctional infraspinatus muscle can lead to other muscles compensating, such as the middle trapezius muscles, and this leads to that muscle being over worked which in turn leads to tightness. So as you can see imbalances between a group of muscles can have a knock on effect on other muscles which leads to a cycle of dysfunction in a particular area. 

Treatment includes a multimodal approach, with therapeutic exercise, manual therapy, ergonomic advice and postural retraining. While treatment will bring relief only you can stop reoccurrence by carrying out a program of strengthening and stretching exercises while looking at changing your working habits.

 "Choosing Running Shoes"

Posted on March 8, 2013

While athletics has always been popular in this country it’s hard not to notice the increase in numbers to athletic clubs and the rise in the amount of meet and train groups popping up in every county. One of the benefits of running is the relative low cost; all you need runners, training gear and a road. Today I am going to talk about running shoes and some of the myths surrounding them. 

Road running shoes can be generally split into 3 groups; motion control, stability, and neutral/cushioned shoes. It is generally perceived that there are 3 main foot types; the ‘flat’ (pronated) foot, the ‘normal’ (neutral) foot, and the ‘high arched’ (supinated) foot. This is an oversimplification that has led to the misconception that a certain foot type should be matched with a certain type of shoe (fig 1.1). This model of shoe selection is thought to have been created following an army foot survey in 1947 and it has more or less remained thanks to its inclusion in runner’s magazines over the years. 

Pronation (flat) is word that most runners will have some across. Although shoe companies like to push the angle that the more pronated the foot the more likely you are to occur an injury, very few studies actually back this up. Some studies conclude that there is no relationship between foot type and injury while two studies show that pronation may protect against injury. In fact a number studies suggest that lower limb injury may be due more too training errors (excessive or incorrect training methods) or dysfunctional hip muscles (usually weak glut muscles). 

‘Normal’ or ‘neutral’ alignment is talked about when mentioning foot positioning even though studies show that the ‘norm’ may in fact be mild to moderate pronation. It is unlikely that a mass produced product can achieve a ‘normal’ position for the subtalar joint (joint in the foot that controls pronation and supination), especially when individuals are shown to have varying anatomy at the joint. The reality is that each individual had an optimal position for peak performance. 

Cushioning is big selling point when it comes to reducing the amount of force the foot is subjected to when running. This may also be subject to further questioning as there is evidence to suggest that as the cushioning of the shoe decreases the runner changes foot strike to maintain a constant load on the outside of the foot. Running shoe technology also centres around ‘anti-pronatory’ shoes by making the mid sole of the shoe stiffer. While stiffer mid soles in stability and motion control shoes do decrease the amount of pronation and the speed to reach maximum pronation there is evidence to suggest that they decrease sensory feedback which may increase the risk of injury.

Shoes do seem to generally achieve what they do in regards to foot positioning but our understanding of whether or not they need to achieve these variables is poor at present. The future of shoe manufacturing probably lies in technology that changes midsole stiffness by tuning into the requirements of the individual and puts their foot in a position where injury risk is minimised and performance is maximised. 

With selecting the correct running shoe it can little bit of a trial and error process, if you have found one that you are comfortable with then it’s probably best to stick with it. It’s not all about the shoe you wear at the end of the day. Sensible training habits, a strong core and taking care of your muscles will also play a huge part.

This article is based on review of studies by Ian Griffiths MSC BSC(HONS) MCHS. The original can be found atwww.sportspodiatryinfo.co.uk/blog

"Foam Rolling" 

Posted on February 26, 2013

Hey there. I am going to start posting advice/information on this page. I will try to keep it simple and if you have any questions or thoughts on the subject then please post away! Today I am going to talk about foam rollers which are a cheap and cost effective way of massaging muscles yourself. 

If you take part in a sport or if you work in an office all day one of things you should have is a foam roller. Sitting for longs periods of time causes certain muscles to adapt a shortened position i.e. quads, hip flexors, hamstrings, calves. The repetitive nature of sport will cause certain muscles to become tight. Tight muscles are muscles that are not working correctly and a tight muscle means that another muscle is lengthened beyond their correct length which also leads to that muscle not working correctly. Basically, if a muscle is not at its correct length then it is not working to the best of its ability. While stretching the muscles will give you some relief it will not loosen the taut bands or the trigger points that will have formed. 

One of the cost effective ways to get some relief is to use a foam roller. Foam rolling works as a form of self-massage where you use your own body weight to work the muscles. Most rollers are made of foam while some are made of plastic and as you can see from the video below they are easy to use. On the bigger muscles such as the quads, calves, hamstrings you can massage the muscles by carrying out long sweeping strokes. If you find an area that you notice is particularly tight apply direct pressure to the area for 30 seconds or so until the muscle relaxes and then roll some more. This process may need to be carried out a number of times. Direct pressure works best for muscles such as TFL, glut medius, glut minimus which are located on the side of the hip area. You can also use a golf or hockey ball to release these muscles if you find that the foam roller is not going deep enough. 

Foam rollers may also be used on the lower back, upper back and shoulder muscles. A particular area that many people have trouble with is around the shoulder blade area, this is mainly due to the muscles being in a lengthened position and is particularly common among office workers and people who drive long distances. 

While some injuries or muscle dysfunctions will require treatment by a therapist a foam roller will lessen the chance of the injury reoccurring in the future. But as they say ‘prevention is better than cure’ so I would advise that you get one today.