Author Archives: DCInjuryClinic

About DCInjuryClinic

I am a practicing Sports Therapist, based in Swindon, Wiltshire offering a full rehabilitation service, from injury to return to full health, dealing with all manner of soft tissue and joint injuries. My aim through working together with you is to relieve pain, regain movement, improve health and – importantly – prevent injury reoccurring, regardless of your age, occupation, or sporting activity (or lack of!).

Evidence-Based Practice

If you have ever visited my clinic, or attended one of my Workshops, you will have heard me talk of “what the evidence says”, and “evidence based practices” until the words become almost meaningless, and so I thought I would take a few minutes to describe what exactly I mean by that, and why I feel it is such an important part of what I do.

I came across a clinic recently offering a ‘Scientific Knowledge and Experience’ based approach, swiftly followed by advertisements of treatments with evidence that is at best inconsistent, and at worst non-existent. I saw another clinic advertising;

….which – and I cant sugar-coat this I’m afraid – is complete drivel.

For a treatment to be offered, I fully believe that the therapist offering said treatment must be able to stipulate exactly why this treatment will move your rehabilitation forwards. There are of course limitations to most treatment modalities, but to offer the service, the research must show benefit to the client, or else we get into the realms of an ethical debate; can a service be offered if the research does not support its use?

It would be incredibly easy to do so, as often a therapist is seen as the authority in the room, and the client can feel pained, desperate and even vulnerable, so will take whatever advice or treatment is offered.

I believe good therapists choose the harder route; good therapists refuse to stick to the oft repeated party lines of the unchallenged past  – such as bending over is bad for your back, when “…research suggests that back pain is twice as common in the developed world compared to less developed nations..” ….(Ref 1)

….or the new in vogue conditions…

The honest therapist has to work harder, because they can’t rely on age old myths of poor posture being to blame for everything; or a “weak” core causing pain; or advising stretching to everybody, for every ailment.

An honest therapist makes their own job harder, so that you can improve quicker.

A less honest therapist can hide behind regression to the mean because – hey, sometimes, things get better no matter what you do, so lets utilise placebo and discuss a 10 week treatment plan…

Cupping (Ref 2) and acupuncture (Ref 3, 4, 5, 6) are great examples of treatment modalities that are growing in availability at roughly the same rate as the indifferent or negative research coming out regarding their efficacy. They are obviously popular, but if the (paying) public were offered the treatment with the research, would they still be? I genuinely don’t know.

Foam Rolling and Kinesiology tape are a little more interesting as the research goes both ways, but, again, is it ok to recommend a treatment with such divisive results?

There is a battle between giving people what they want – as there is, again, obviously a demand for such treatments – and giving treatments which peer-reviewed scientific study suggests will move them forward. Of course the research is more important to me, on my side of the couch, but should we not, as therapists, be the ones communicating the evidence to the other side of the couch, to allow collaborative decision making?

We therapists and health professionals spend fortunes on courses learning new skills, but what is the reasoning behind theses skills? Just because the course was expensive, we should be able to acknowledge that not all is as it seems, regardless of how uncomfortable it is to do so, should we not?

Even if you don’t always want to know why, or even how a treatment modality works, surely you would want to know if it works?

I would be very interested to hear your thoughts; feel free to email Dan@DC-InjuryClinic.co.uk.

REFERENCES

  1. The epidemiology of Lower Back Pain in the rest of the world, Violonn E, 1997
  2. http://www.imr-journal.com/article/S2213-4220(15)00359-5/abstract
  3. https://www.painscience.com/biblio/acupuncture-treatment-for-pain-review.html
  4. https://www.painscience.com/biblio/best-acupuncture-evidence-shows-only-trivial-effects-on-pain.html
  5. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005319/abstract;jsessionid=BEF08C0098B706BF5374B983683DF8C4.d04t02
  6. https://www.painscience.com/bibliography.php?ee16

 

Warm-ups

In my recent blog about Posture I mentioned the most common things that we blame for injury; core stability, over-training, not stretching enough, the wrong shoes. One other recurring theme that people come back to is “not warming up properly”. So let us look at what warming up is, if it is as important as we think, why it is important, and how to do it effectively.

What is a warm-up?

Warm-ups are essentially the preparation for physical exertion, carried out by exercising or practising gently beforehand, generally including a combination of cardiovascular exercises, stretching and strength drills. This should gently prepare the body for exercises by gradually increasing the heart rate and circulation; the warm-up is also an opportunity for an individual to prepare themselves mentally, and for a team to work together prior to the start of the game. Warm-ups can also be used to practice skills and team drills. Moreover, one of the aspects of a warm-up is “simply to stir cellular content so the sarcoplasm [part of muscle fibre] becomes liquefied” (Ref 1)

Is it important, and why?

While the influence of warm-up on injury prevention is fairly inconclusive, there is certainly research that suggests that there are no negative effects to (a sport relevant) warm-up, and the psychological impact can be huge – getting your ‘Game Face’ on, as it were.

FIFA released their own recommendation for a football specific warm-up, and research there did suggest that the “…program reduced overall risk and severity of lower extremity injury ”  (Ref 2). The British Journal of Sports Medicine also found that the FIFA 11+’ effect was “substantial injury prevention…… reducing football injuries by 39%” (Ref 3).

Similarly, looking at the sport of rugby, research published in the British Journal of Sports Medicine :-

“… found overall injuries fell by 72% when players completed the newly devised exercise session at least three times a week, either just before a match or before training. Concussion injuries were also reduced by 59%” (Ref 4)

  • As an aside, for anyone who follows/plays rugby or football, you will have noticed that teams will go through a specific warm-up on the pitch, before disappearing for 15-20 minutes back into the changing rooms, only to reappear and start playing. I have always questioned this model and personally feel that a far better approach would be to start the warm-up 15-20 minutes later and gradually build the warm-up intensity up to the beginning of the match – and so starting at full speed. There doesn’t seem to be any reason for the current model other than those most dangerous of words; we’ve always done it that way. I believe that it would only take one team to take a different approach and we would see everyone following suit. I’d be interested in opinions from team coaches.

How to warm-up

To start with, I think we should acknowledge that old cliché of no one size fitting all. This goes for both person, and sport/activity. No one warm-up will suit everybody and every sport, and so we have to keep things relevant, and sport specific. Would a rugby player and a gymnast benefit from the same routine? We need to understand the demands of your chosen activity to fully understand the requirements of your warm-up.

For runners  that I work with, everything is dynamic – there is no static stretching. Research consistently tells us that “…the Static Stretching of the lower limbs and hip muscles had a NEGATIVE effect on explosive performances for up to 24 hours post-stretching …. Conversely, the Dynamic Stretching of the same muscle groups are highly recommended 24 hours before performing” (Ref 4) and that “static stretching for 30 seconds neither improves nor reduces muscular performance and that dynamic stretching enhances muscular performance” (Ref 5). Running – like most sport- is a dynamic activity, reliant on elastic recoil of muscles. Stretching them, and potentially dampening that ability to recoil, prior to setting off makes no sense. The dynamic movements should work through the range of motion required for the activity, and so slow running is a great warm-up for fast running, and many runners will use mile/km 1 as theirs.

No no no no no. No.

Gymnasts, dancers, divers, however – activities that rely on increased flexibility – may well benefit from static stretching as part of a structured warm-up. Horses for courses. Know your sport; understand the requirements; reverse engineer your warm-up.

Fine

So warming up is a good idea, but the key thing is always, always, always specificity of task. The best warm-ups – in my humble opinion – are the ones that most closely replicate the upcoming task, at a much lower intensity than required for said task.

How does your running club/rugby club/football team warm-up? Does it fit the research? If not, maybe get them to have a read of this blog; I’d be interested in opinions.

REFERENCES

  1. Basics of Strength & Conditioning, NSCA, p.15
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867089/
  3. http://bjsm.bmj.com/content/bjsports/51/7/562.full.pdf
  4. https://www.theguardian.com/sport/2017/may/17/rugby-union-research-exercise-plan-injuries
  5. https://www.ncbi.nlm.nih.gov/pubmed/23615481
  6. https://www.ncbi.nlm.nih.gov/pubmed/16095425

As part of my Strength & Conditioning for Runners Workshops, I provide my one-stop warm-up for runners. To find out more, please see here

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldn’t be seen as such. They are merely guides to a better understanding of how our bodies work.

Cramp & Stitch

Everybody knows what a stitch is, right? And everybody knows what it feels like to get cramp? Strangely though, we actually don’t know too much about what these two phenomenon’s are, or what causes them…

Lets look at what we do know;

STITCH

Side stitches are a very common problem among runners. They are mostly felt in the side, and make it difficult to breathe when exercising as it feels like someone is stabbing you in your side! Occasionally, they will be accompanied by pain at the tip of the shoulder on the same side. But as I have said, the actual cause of a stitch is still uncertain.

There are various ideas and opinions, all of which have some evidence to support them…and some to dispel them. Traditionally, it was thought that a lack of blood flow to the diaphragm can cause irritation and pain. However, studies have shown this not to be the case (Ref 1).

Another explanation for cause of stitch is irritation of the ligaments and soft tissues which connect all of the various muscles, bones, and organs inside the abdomen. The theory goes, impact during activity pulls the organs in your abdomen downwards, tugging on the ligaments in the upper abdomen and eventually creating irritation. This would make sense of why eating a meal too close to exercising seems to correlate with a stitch. However, this doesn’t stand up to research either! (Ref 2).

So how can you avoid getting a stitch? Studies have established that eating a large meal or drinking concentrated, sugary fluids like fruit juice close to the time of the exercise will increase your risk of developing a stitch, and they certainly seem to correlate with when you eat. If you are a chronic sufferer of the dreaded stitch, try keeping a food diary before exercise.

Diaphragmatic Breathing exercises may help to strengthen your breathing, as the diaphragm is a muscle (albeit involuntary), and how hard you are exerting yourself certainly seems to correlate with  getting a stitch; you may also want to consider incorporating some S&C for your hip flexors and extensors, ensuring a good, strong upright position of the trunk.

CRAMP

Cramping is a common and usually harmless condition where muscles suddenly involuntarily contract, or shorten, and become tight. Harmless they may be, but they are (often) extremely painful. Most common in the legs, any runner will know the feeling well!

Similar to a stitch, the research into the cause of cramping is largely inconclusive. There are again, however, a couple of things at play.

Most often blamed is dehydration, or an electrolyte imbalance. However this seems to stem from marketing (of sports drinks) more than scientific research. Research has actually found no relation of any kind between an athlete’s electrolyte levels and their risk of cramping (Ref 3).

Exercise induced cramps seem to stem from neural mechanisms, which are designed to inhibit muscle contraction, being depressed and the chemical and electrical synapses that fire the muscle fibers being enhanced. The result is an intense, sustained involuntary muscle contraction – cramp!

How do we avoid this cramping? Hydration is important; our muscles are around 80% water, and a 2% drop in hydration level can result in a 10-20% decrease in performance. A 5% drop can lead to a 30%+ decline. Committed athletes will weigh themselves pre- and post-workout, and measure the weight loss. For every Kg lost in weight, we would ideally be replacing that with between 1 and 1.5 litres of fluids. There are companies that will measure your electrolyte loss too, but as discussed, the science is sketchy at best.

You would have to consider exactly which muscle groups are cramping, and look to what the output expectations of that muscle group are, compared to its capabilities. Involuntary contraction of a muscle (Muscle A) can often be traced to a different muscle group (Muscle B) not being strong enough to cope, and so sending workload to a muscle (Muscle A) with an ever lower capability. Ergo, strengthen Muscle B, and ease the workload of Muscle A, resulting in lower chance of cramping.

Taking a holistic approach, other things to consider are diet – are you eating enough vegetables, greens, fruit etc? There is some research (again, fairly inconclusive…) into potassium deficiency being at play with cramps, so dietary potassium could help.

There is also some discussion on magnesium deficiency. The theory here is that as magnesium plays a role in neuromuscular transmission and muscle contraction, deficiency may predispose to muscle cramps

With both Stitch and Cramp, it will take a little trial and error on an individual level to find the exact cause (if there is a singular cause) – let me know how you get on!

REFERENCES

  1. Morton, D.; Callister, R., Spirometry measurements during an episode of exercise-related transient abdominal pain. International Journal of Sports Physiology and Performance 2006
  2. Morton, D.; Aragón-vargas, L.; Callister, R., Effect of ingested fluid composition on exercise-related transient abdominal pain. International Journal of Sport Nutrition and Exercise Metabolism 2004
  3. Brouns F, Beckers E, Wagenmakers AJ, Saris WH. Ammonia accumulation during highly intensive long-lasting cycling: individual observations. Int J Sports Med. 1990

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldnt be seen as such. They are merely guides to a better understanding of how our bodies work.

For more information please visit www.dc-injuryclinic.co.uk

Recurrent “Stiff Shoulders/Neck”; the same old Trap

Shoulder and neck pain is one of the most common complaints I come across in clinic. Often, there is no acute “injury”, as such, rather it is reported as a long, gradual onset to the point where people will feel as though their shoulders are creeping further and further upwards, towards their ears, often at times of stress or tiredness. I often hear them explaining how they can feel or see – or that they have been told previously – that these muscles are knotted or tight, and they will explain how it needs to be released, loosened or stretched.

But the structures test very differently to these descriptions. Most painful upper traps/shoulders I see are weak and long, not tight and short. The sensation of tightness or stiffness felt is because they are constantly being overloaded in a position of stress, and the muscles simply do not have the capability to endure. As we looked at in my blog about posture, muscles are designed to move, and being placed in this position of length for prolonged periods of time can, and often will, lead to a level of discomfort. How long do you sit at a desk, arms in front of you, lengthening these structures? How long do you sit in a car in the same position? And this is where I see a lot of treatment falling down, focussing too much on lengthening a muscle that is already long.

Anatomically, the Trapezius muscle is a large diamond-shaped muscle, described as lower-, mid-, and upper- portions, that is found down the side of your neck and top of your shoulders. Its the most superficial muscle of the upper back and runs from the base of your skull, along to the tips of your shoulders, and down to the middle of your back, as seen in the image below. So far so good.

The complication comes from the commonly held belief of the actions of the 3 parts of the trapezius muscles. It was commonly though that the lower-, mid- and upper-traps all had isolated functions, but we now know that to not be the case. For example, we know that the actions of the trapezius muscle is insufficient to rotate or elevate the Scapula (shoulder blade) alone, instead it is its combined action with the Serratus Anterior that does this job. The action of the Serratus Anterior pulling the shoulder blade outward around the back, at about 30° of arm elevation, is ultimately when the upper trapezius muscle assist in its upward rotation and elevation.

So what does this mean? First and foremost it means that anyone in the gym doing “shrugs”, are not really hitting the upper traps, if you are not incorporating that 30° of arm elevation. There is a muscle underneath the upper-traps called the Levator Scapula, which – brilliantly – does exactly what is says on the tin; elevates the scapula (shoulder blade) – the shrug movement. So what are we strengthening exactly?

The majority of the Upper Trapezius muscle fibres attach to the end of the collarbone; when they contract they rotate the collarbone inward. This causes compression of the sternoclavicular  (collarbone-sternum) joint, and allows forces and loads from the arm and shoulder to be transferred away from the neck – a pretty amazing system to protect the neck, and a system we would like to be strong and robust.

As mentioned, most painful upper traps/shoulders I see are weak and long, not tight and short. Soft tissue therapy, massage, joint mobilisation, and taping can be a hugely effective, if somewhat transient, component of treatment for your recurring shoulder issues – hence the monthly visit to your massage therapist. But the key word in all of this is “recurrent”. Why is it coming back? Why isn’t it being “fixed”? What can you do??

There is a way to build a sustainable treatment plan, achieving long term benefit, whilst empowering you to self manage. To find out how, contact Dan@DC-InjuryClinic.co.uk

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldnt be seen as such. They are merely guides to a better understanding of how our bodies work.

 

 

 

GUEST BLOG; What Sport did for my Child, by Debbie Gunning

Really pleased to have GB Runner Debbie Gunning’s great blog about what sport has done for her and her children – it’s a great read!

When I became a Mother, I wanted my Children to reach their potential, aim high and learn to be proud of their achievements whether in academic studies or on the Sporting field.

As a former International Athlete I wanted to get the balance right – my pet hate was and still is pushy parents, so I let my two boys go in the direction they were passionate about. Eldest Son breezed through School, although always worked hard, Sport – he chose Swimming, not the best in his Club but his work ethic soon paid off getting to a District Standard before opting to try his hand at Track and Field, gaining County Standard in his 1st year and hoping for more improvements now settled at Uni and increasing his training.

Then along came my youngest Jack, 6 and half years after my 1st born. Life was a bit tough from the moment he tried to take his 1st breath. He struggled with basic things, like trying to pedal a bike, walking up and down the stairs, catching a ball, As a parent you know they develop differently so there was no concern, his older brother was and and still is his Idol, so he tried swimming, coordination was a problem, football he had some success, making best improver for 2 years.

Then the bullying started, last year at Primary School, was a tough year, didn’t fit in struggled in every aspect. Left Primary School as a outsider with few friends. My little boy’s smile which would light up any room was rapidly disappearing. I was concerned as he entered Secondary School.

Then he was asked to have a go at running around Lawn woods with Swindon Harriers, he loved it, he came back said he wanted to do a bit more. Bryan his Coach, put him with a Group of slightly older Girls and a friendship developed that will never be broken. The Group was renamed ‘Spice Girls plus one,’ Jack was named Spice Boy. Each week he improved, getting fitter and getting more confident, joining in more sessions , he was included and accepted. I saw a trust in Bryan, that he never had with an adult outside the Family.

Running was becoming his saviour. Track Season soon came and he smashed through the targets both his Coach and myself had set him, and when he won a league Match, an 800m race, all his Club Mates cheered him on down the home straight. The smile that day shone through on a Cold Grey And Wet Day in Newport. On a Friday afternoon in October I received a call from him , he had won his Cross Country Race at School – no big deal , loads of Kids do that, but this was a Child who had been bullied, had no self esteem, and has also been diagnosed with Dyspraxia just 12 months earlier. Going on to make it through the Swindon Schools, to run in his County Schools, reserve for his County Team for South West and English Schools , but wherever running takes him his life has turned around. He is dreaming big, believing in himself, confident and happy teenager.

So when other Parents ask me why I drive around him to training or spend all Sunday at a race, stand waiting for him to finish his sessions in the freezing cold:-

It’s not about where he finishes, or how fast he has run

Sports gives him confidence.

Sports gives him the inclusion he lacks at School.

Sport gives him the interaction with Adults and Other Children.

It teaches him to follow his dreams.

It teaches is ok to fail – just get back up and try again.

It lets him be himself.

It teaches him self discipline

It teaches the importance of a Healthy Life,

It teaches him to be the best HE can be.

And the Smile… That is absolutely priceless.

About Debbie: I didn’t start running until I was 20, joined a gym, ran a half marathon, I realised I wasn’t too bad. Joined Swindon Athletic Club, trained hard, gave up a full time job and worked part-time to achieve my ambition of earning a GB vest…managed 12 – including European Championships in 1996. Very much a rollercoaster ride, lots of failing and picking myself back up again. Became a mum and within 6 months was back running well – but didn’t make it to Commonwealth Games, went onto the roads and won the Bath And Fleet Half Marathon. Trained as a PT, had another child, started working as a full time PT in DW Sports, training everyday people to reach their goals, whether it be weight loss, sub 30min 5k, but hopefully inspire people no matter what life throws at you – be the best you can be, and just be you…

Also fitted in 5 marathons – London 2017 looks to be on the cards!

On Being Injured

“Its not the strongest species that survive, nor the most intelligent, but the ones most responsive to change” Charles Darwin

Here’s a little secret; everyone gets injured. Everyone. That person on the start line every weekend? They get injuries. Your gym instructor that is 11 out of 10 on the energy dial all the time? They get injured. Your sports therapist/physiotherapist? They suffer the same as you. With the best will and practices in the world, injuries, aches and pains are one of life’s inevitabilities, alongside death and taxes.

How we deal with injuries, however, is in many ways unique to the individual, with their own aims, goals and commitment levels. Sure, initially it can be frustrating, particularly if you have an event, or a holiday on the near horizon but the key is to take an interest in your rehabilitation. Pain & rehabilitation are not your enemy; this is not wasted time. Pain is our friend – it’s our body trying to protect us; our first line defence system without which we would not survive. Congenital analgesia is a condition where sufferers can not feel pain, and which often leads to a reduced life expectancy. So – whilst it is all relative – knee pain isn’t actually that bad.

When injured, the sensitivity level of this defence system is turned right up. Your rehabilitation is designed to start turning this dial down, by graded exposure to what your nervous system has deemed as perceived (but not always actual) threat. See, those exercises and movements prescribed aren’t always just about stretching, or strengthening.

It can feel lonely, as your friends and colleagues continue with their gym routine, classes, or training, and in some cases there can be cases of comorbidities setting in, such as depression or anxiety, even at a low level. In A Leg To Stand On, Dr Oliver Sacks describes his injury as a “fearful sense of … aloneness”; that he “could not hurry — could only hope”. In his autobiography, Back From The Brink, ex-professional footballer Paul McGrath says of being injured that “the first thing you lose is the capacity to be hopeful”, and that you “crave the open spaces of training…the aggression, even..”.

But getting back training after injury can be hard physically, and also mentally. We should never underestimate the power of apprehension. Avoidance can be damaging in the long term, as we psychologically build what was once a daily occurrence into a terrifying prospect. Gardening changes from a pleasant way to spend an afternoon, to something which could lead to your back “going” again. Your regular running route seems full of threat. Those weights look far more menacing than they did pre-injury.

Your hardest opponent is your own mind; research shows that a happy you will be able to recover from injury far quicker than a stressed you – and a positive attitude goes a long way, as seen in this paper, The Relationship Between Expectations and Outcomes in Surgery for Sciatica, which found that “More patients with favorable expectations….. had good outcomes than patients with unfavorable expectations” (Ref 1). So smile as you go ( 🙂 ); trust in the process; commit to the process; reap the rewards.

Rehabilitation is a road that is rarely linear; we start with what you can do today – post injury – and we end with what you could do before your injury. It can be slow, it can be arduous, and there will almost definitely be setbacks. This is completely normal.

In ‘Legacy’, by James Kerr, the author discusses 4 stages of change, which ties in nicely with rehabilitation;

A Case for Change This is often a need for change; something is causing your discomfort, or pain. If we want this pain to go, we need to change, or address, ‘something’.

A Compelling Picture of the Future To do what we love without the repercussions of pain. People will often say they are prepared to “do anything” to get back training, or be pain free. To paraphrase Nietzsche, “He who has a why, can bear almost any how”.

A Sustained Capability to Change This is where we create an environment that is empowering, engaging and fun. When Rehabs fun, Rehab gets done.

A Credible Plan to Execute Alongside your rehabilitation therapist, this is the development and deployment of a self-reflective, self-adjusting plan that is safe, and graded, taking you from injured, to where you were pre-injury.

So, yes, the secrets out; we ALL get injured.

And here’s another secret; it’s ok. We are robust and adaptable creatures. To go back to Oliver Sacks, “We would have no idea of the resources which exist in potentia, if we did not see them called forth as needed.”

For more information contact Dan@DC-InjuryClinic.co.uk

REFERENCES

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496858/

P.O.L.I.C.E

For decades it has been known that if injured, you follow the R.I.C.E (R) protocol! But times change, evidence moves on, and good therapists admit that patient information needs to change with it!

So what has changed?

R.I.C.E.(R) is;

R for REST. I for ICE. C for COMPRESSION. E for ELEVATION. (R) for REFERAL.

P.O.L.I.C.E is;

P for PROTECT. Protection involves may include use of crutches, casts, braces, taping etc. to help protect the injured area as it heals. This part is designed to prevent excessive loading in the early stages, and so replaces out and out “rest”, which is completely subjective –  we have to be realistic with this and accept that most of us aren’t full time athletes, and so “rest” unfortunately will be relative to your job/daily activities etc. If you are struggling to weight bear you need to make sure you’ve had your injury checked out. Rest should be of limited time, ideally restricted to immediately after trauma. Undue long rest can have negative effects, producing “adverse changes to tissue biomechanics and morphology” (Ref 1).

OL for OPTIMAL LOADING. Research shows that “Progressive mechanical loading is more likely to restore the strength and morphological characteristics of collagenous tissue. Indeed, early mobilisation with accelerated rehabilitation is effective after acute ankle strain. Functional rehabilitation of ankle sprain, which involves early weight-bearing usually with an external support, is superior to cast immobilisation for most types of sprain severity” (Ref 1). What this means is that by optimally loading injured tissue, we can stimulate the healing process as bone, tendon, ligament and muscle all require some loading to start the healing process. Anyone that has been in my clinic will know this fits my biases quite nicely! But what is “optimal”? Of course – as is life – its about finding a balance –“Optimal loading means replacing rest with a balanced and incremental rehabilitation programme where early activity encourages early recovery. Injuries vary so there is no single one size fits all strategy or dosage. A loading strategy should reflect the unique mechanical stresses placed upon the injured tissue during functional activities, which varies across tissue type and anatomical region” (Ref 1).

Do we want to load a broken bone on day one? Maybe not. If in doubt, seek professional medical help to form a structured loading plan.

I for ICE. People are always surprised to hear that the research behind the use of ice is far, far from conclusive – see my blog here. There is certainly a lack of quality research and very little guidance in terms of how ice can be best utilised but as seen in the aforementioned blog, there is evidence for its use. Most of us have a personal experience of using ice, and it can be highly effective for reduction of pain post injury. A bag of frozen peas is my weapon of choice (a tin doesn’t work anywhere near as well….).

C for COMPRESSION. Again, very limited quality evidence to fully support compression, but putting pressure on the injured area can help in reducing swelling. This can be quite a fine line; the more pressure applied, the lower the amount of blood that can pass to the injured limb. However, cutting off the blood supply to the extremity of a limb completely can have negative effects. If the limb goes numb at all, the bandaging should be released. A tubi-grip is your safest bet.

E for ELEVATION. Place the injury so that it is higher than the heart, where possible. Can be combined with non weight bearing movements.

So as you can see, the last 3 have changed very little, other than to admit we know less than we thought we knew. As for pain management, and anti-inflammatories, certainly for the initial acute period (48-72 hours) I do not recommend the need for NSAIDS. If pain relief is needed, then paracetamol and ice should suffice. Impress your mates by telling them you are carrying out Cryotherapy!

If you are suffering from an acute or chronic injury, please contact Dan@DC-InjuryClinic.co.uk.

REFERENCES

Ref 1 http://bjsm.bmj.com/content/46/4/220.full.pdf

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldnt be seen as such. They are merely guides to a better understanding of how our bodies work.

 

 

 

Posture

In the Story Of Being Injured, there are many villains that we blame; core stability, over-training, not stretching enough, the wrong shoes(!!), as a few examples. One of the most commonly blamed of these bad guys, is Posture, and there are infinite posture correction therapies and courses out there. So how fair is it to blame our posture? What does the evidence say about the link between “bad” posture, and pain? What exactly is bad posture?

Firstly, it is very tough to blame any issue in the body as being the cause of anything else, usually pain, without a good base of evidence. However, evidence based practice is a game of probabilities and the probabilities are – unfortunately – well stacked against posture being a cause of many musculoskeletal problems. The key reason behind this is that there is simply no gold standard for what is good and bad posture. So what we are basing our “correction” on can actually be a rather arbitrary measure, as we can see here, for Lower Back Pain, and here, for Shoulder Pain, where no link between posture and pain can be found.

Your body’s soft tissues are amazing at adapting to load. When we go to the gym this is precisely what we are asking our tissues to do; adapt to an increased load. These weights/loads will be much greater – and in more extreme joint ranges – than the loads placed upon your soft tissue under the traditional model of “bad” posture. We have an amazing ability to adapt and self-repair. Ergo, surely over time a muscle would adapt, like with the gym work, to the level of endurance required to meet the demands of the task?

So do I think posture is important at all? Yes I do. The key point of our posture, is our time in that posture. For example, the office worker who drives for 2 hours, to sit in an office for 8-10 hours, to drive 2 hours home, and then sit on the sofa for a couple of hours. You may think this is an extreme example, but try keeping a Sitting Down Diary –  it can be pretty terrifying! In the above situation, the long hours in a flexed hip position could easily cause issues somewhere along the line. But this is actually a problem with lack of movement, as much as the posture the body is under.

The saying goes your best posture is your next posture, i.e. keep moving. Research supports this, as seen in this paper, where it is seen that in actual fact, rehab programs designed to change posture can help people out of pain without changing their posture. Again, its the movement that is the “magic”. So don’t sit still for 16 hours straight. If you work at a computer, and bench press in your spare time, try getting those shoulders back for a change. We have almost infinite postures – certainly more than in the graphic at the start of this blog.

As King Julien Says;

For more information, please contact Dan@DC-InjuryClinic.co.uk

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldn’t be seen as such. They are merely guides to a better understanding of how our bodies work

 

 

 

 

 

 

Do you Ice right?

People love a fancy name for something, and injury treatment is not different. Why have knee pain if you can have Patellofemoral Pain Syndrome? Why have a modest bruise if you can have a hematoma? And so I often – facetiously – tell people that if they want to jazz up their bag of frozen peas, why not tell your friends that you are partaking in a touch of cryotherapy?

Ice (I mean cryotherapy 😉 ) has always been seen as the go to treatment for decreasing tissue damage, inflammation/swelling and pain after injury. But what does current research say about the efficacy of this?

The application of ice does reduce tissue temperature, which decreases cell metabolism in the area surrounding the injury, and decreases the amount of secondary damage in the tissue surrounding the injury. However there is evidence that ice DOES NOT reduce swelling. The main effect of ice is actually to decrease nerve conduction speed (Ref 1), meaning a reduction in pain from soft tissues. A by product of this analgesic, pain relieving response, is that it allows you – the patient – to perform exercise/movement – and so muscle contraction – which in turn reduces swelling.

For this decrease in nerve conduction speed to take place, the tissue temperature needs to reach 10 degrees (Ref 1). Taking this in to account it seems that the best protocol for application of ice is directly on the skin, completely against the traditional method of wrapping the bag of crushed Ice, or bag of frozen peas in a towel. It goes without saying, that this is only applicable to those who have ruled out any contraindications such as open wounds, circulation issues, DVT etc. (contact me for more information on this; details below). And so because of this lack of insulation, our skin temperature can be reduced to our goal temperature within 5 minutes. There are many variables to this however, for example the depth of the target soft tissue and the build of the patient. There will be injuries at such a depth that no amount of ice will penetrate deep enough. As a rule of thumb, 10 minutes should suit for most.

Interestingly, this paper, Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury (Ref 2) says that “RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of DOMS than does cold therapy”.

So heat or cold? Both have positive effect, it seems. Maybe it depends on what season you get injured – Heat in the Winter, Ice in the Summer? It seems you cant really go wrong…

…as long as you keep moving.

REFERENCES:

  1. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. https://www.ncbi.nlm.nih.gov/pubmed/17224445
  2. https://www.ncbi.nlm.nih.gov/pubmed/25526231?dopt=Citation

For more information, please contact Dan@DC-InjuryClinic.co.uk

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldn’t be seen as such. They are merely guides to a better understanding of how our bodies work

Stretching

Stretching: A form of physical exercise in which a specific muscle or tendon (or muscle group) is deliberately flexed or stretched in order to improve the muscle’s elasticity. The result is a feeling of increased muscle control, flexibility, and range of motion. Stretching is also used therapeutically to alleviate cramping.

Alternatively;

Stretching: the most divisive, emotive and inconclusive part of the Exercise Universe.

Because of the second definition, by yours truly, I have put off writing a blog on stretching for as long as I have been writing a blog. But here goes;

In 2015, a paper in Research in Sports Medicine called “Impact of stretching on the performance and injury risk of long-distance runners” came to the conclusion that;

“….the literature suggests that stretching poses no significant advantage to endurance runners. Acute stretching can reduce running economy and performance for up to an hour by diminishing the musculotendinous stiffness and elastic energy potential. Chronic stretching additionally appears to have no advantageous effects. In regards to DOMS, it has been reported consistently in the literature that stretching cannot reduce its longevity or intensity. In relation to injury risk, stretching shows little significance for endurance runners to chronic injury. Endurance athletes are at high risk of overuse injuries such as illiotibial band syndrome, stress fractures and plantar fasciitis,and the literature suggests that stretching cannot reduce the prevalence of these injuries. It appears stretching may hold significance for certain exercise disciplines;
however, it can be concluded that it holds no advantage for endurance runners and is not the solution to improving performance or reducing injury prevalence”

Of course this very much focusses on Running, but is pretty damning stuff. It found no benefit to stretching, and actually some negative effects of stretching. Everyone stop stretching!

But wait….

A study in 2016 called “Acute bouts of upper and lower body static and dynamic stretching increase non-local joint range of motion” found – unsurprisingly if you read the title in full – that stretching had a positive effect, and not just locally. It concluded that lower body stretching increased flexibility in the upper body at the same time – and vice-versa. Praise the lord!

 

 

I’m always asked about stretching, and people will always ‘confess’ to “not stretching enough”. On my Strength and Conditioning For Runners Workshops, we focus almost entirely on Dynamic Stretching, as running is a dynamic activity. This does NOT mean I am anti-static stretching, at all, far from it. Stretching has its place in physical therapy – of course it does.

We can see from the evidence, that science can’t agree completely on its validity as a treatment. However, for some of the people, some of the time, it is essential. But of course, much the same as everything in the fitness and health world, it is not a panacea.

My advice is always to critically appraise your routine; What are you stretching? Why are you stretching it? Is it relevant to your daily activities, or sport? Is the muscle “tight” because it is short, or tight because it is already too long…? If you stretch something, and stretch it, and stretch it, and the symptoms remain, did it need stretching?

For more information, please contact Dan@DC-InjuryClinic.co.uk

N.B. There are no ‘one size fits all’ style quick fixes in most injury scenarios, so these article shouldn’t be seen as such. They are merely guides to a better understanding of how our bodies work