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Hip dysplasia

Hip pain is one of the most common causes of lower limb musculoskeletal pain. Not only do hip injuries have the potential to cause issues later in life, there are often times when younger adults are also burdened by hip pain. This can affect you at a time when sporting, work or family commitments can be physically demanding. Depending on the severity of your hip pain, it can be overcome so you can continue to perform everyday activities without discomfort.

What is hip dysplasia

A common cause of hip pain is hip dysplasia, which is the leading condition of early-onset hip osteoarthritis. Hip dysplasia refers to the misalignment between the ball and socket with issues regarding the shape, size or orientation of the bones. This can lead to instability and overloading of certain structures. Some adults have leftover problems from childhood hip dysplasia but often they don’t realise there is a problem until their hip starts hurting.

Are you at risk

Hip dysplasia is most commonly associated with females (though certain sub-types are more common in males), first born, breech birth and family history. The first sign of hip dysplasia in an adolescent or young adult is hip pain and/or a limp. Pain is usually felt in the groin area, but can also occur on the side or back of your hip. Often there is a sensation of catching, snapping or popping in addition to pain with activities.

Overcoming hip dysplasia

Treatment for hip dysplasia varies depending on many factors including your age, the exact structural formation, and how much it is affecting your daily activities. There is emerging research showing that a tailored strengthening program can be effective in managing this condition and reducing pain and limitations. Other effective treatment strategies can include lifestyle modifications (e.g. changing workplace setup), monitoring specific loads during sports, cross-training to maintain or improve general fitness, and manual therapy for pain relief. In severe cases surgical procedures, such as a Periacetabular Osteotomy (PAO), followed by a period of rehabilitation may be required.

Hip & Groin Clinic at Lifecare

Effective treatment requires the correct diagnosis. Adults with hip dysplasia on average see more than three healthcare providers and have symptoms for five years before receiving an accurate diagnosis. You may want to consider getting a second opinion if your hip pain is getting worse for no apparent reason.

See how Lifecare Malvern’s speciality Hip and groin service can help you diagnose and manage your hip pain.

How to return to running after becoming a mum

With the running season in full swing, we need to turn our attention to new mothers who are wanting to return to running after giving birth. New research has been published which outlines the safe return to running postnatal. Olivia Clarke, Northern Sports Physiotherapy Clinics physiotherapist, with a special interest in women’s health has summarised the new guidelines.

So you’re a new mum and you’ve settled into a routine and are keen to get back into running?

So what next? How fast do you progress the run? How do you prevent ongoing prolapse or incontinence symptoms?

Running is a high impact exercise that places high levels of load on the body. Recent research states that in order to maximize your postnatal recovery that only low impact exercise should be carried out in the first 3 months and running should start between 3-6 months postnatal.

This is a generalised guideline and is also affected by the following risk factors:

  • <3 months postnatal
  • Hypermobility
  • Breastfeeding, especially timing of breastfeeding with runs
  • Pelvic floor or lumbopelvic dysfunction
  • Obesity, BMI >30
  • C-section or perineal scarring
  • Relative energy deficiency in sport
  • Diastasis rectus
  • Sleep deficiency

In addition to this, women should not have the following symptoms when return to running, unless instructed by a specialised physiotherapist or doctor:

  • Prolapse symptoms such as vaginal heaviness or dragging
  • Incontinence or leaking urine
  • Pelvic or lower back pain
  • Ongoing blood loss that is not linked to your cycle

The return to running criteria can be assessed via a vaginal examination and functional testing:

  • Pelvic floor strength, speed of contraction and endurance
  • Able to complete functional exercises: walking, single leg balance, single leg squat, jogging, bounding, hopping
  • Able to complete specific strength exercises with good technique: single leg calf raises, single leg bridging, single leg sit to stand and side lying abduction

Ideally, return to running should be done via a graduated loading program which can be given to you by your physiotherapist. They can also advise you about additional support items which can make the return easier such as supportive clothing or a pessary.

If you require a postnatal assessment or simply need information relating to return to exercise with pelvic floor issues then call 9901 400 to speak to us today.

Ankle Taping

The Best Treatment for Knee Pain

Knee pain is a common reason people book an appointment with a physiotherapist. There can be plenty of reasons for this knee pain to occur and over the years I’ve seen an amazing amount of solutions. However recently it has become apparent that if your physiotherapist is not starting you on some form of graded exercise program then something is not quite right.

 

Studies from around the world are highlighting the benefits of supervised exercise more and more:

  • Exercise reduces pain and does not cause increased inflammation or the loss of cartilage (Bricca et al., 2019).
  • Surgery does not give superior results to exercise in patients with degenerative meniscal tears (Kise et al., 2016).
  • The costs of physiotherapy and likely beneficial results mean it should be considered ahead of surgery for non-obstructive cartilage tears (van de Graaf et al., 2019).
  • A recent editorial in the British Journal of Sports Medicine further supported this with the unequivocal statement “there is convincing evidence that exercise therapy works.” (Crossley & Cowan, 2019).

 

This would all appear reasonable and yet out in the community this level of care is not always common place.

 

An article in 2016 found that physiotherapists still spent time with patients with osteoarthritis performing low value care options such as electrotherapy and ice (Spitaels et al., 2016). Furthermore it has recently been reported that the use of imaging, recommendations for surgery, prescription of opioid medication and failure to provide adequate education remain common problems in the management of musculoskeletal pain (Lin et al., 2019).

 

So the next time you visit your doctor or physiotherapist with a sore knee ask yourself if you are receiving high value care. Were you;

 

  • Given a graded exercise program and offered supervision to assist?
  • Educated on the reasons for your knee pain and ways to improve it?
  • Discouraged from receiving a scan unless there was unsatisfactory improvement in conservative management or unexplained progression of symptoms?
  • Advised not to take opioid medication?
  • Encouraged to continue work and exercise in some capacity?
  • Felt that the care and treatment provided was specific to you and your goals?

 

If any of these questions cause you to reflect then maybe it’s time to consider, are you receiving high value care?

 

References

Bricca, A., Roos, E. M., Juhl, C. B., Skou, S. T., Silva, D. O., & Barton, C. J. (2019). Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation. British Journal of Sports Medicine, bjsports-2019-100727. https://doi.org/10.1136/bjsports-2019-100727

Crossley, K. M., & Cowan, S. M. (2019). VMO retraining or graduated loading programme for patellofemoral pain: different paradigm with similar results? British Journal of Sports Medicine, 0(0), bjsports-2017-098736. https://doi.org/10.1136/bjsports-2017-098736

Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. British Journal of Sports Medicine, 50(23), 1473–1480. https://doi.org/10.1136/bjsports-2016-i3740rep

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, bjsports-2018-099878. https://doi.org/10.1136/bjsports-2018-099878

Spitaels, D., Hermens, R., Van Assche, D., Verschueren, S., Luyten, F., & Vankrunkelsven, P. (2016). Are physiotherapists adhering to quality indicators for the management of knee osteoarthritis? An observational study. Manual Therapy, 1–12. https://doi.org/10.1016/j.math.2016.10.010

van de Graaf, V. A., van Dongen, J. M., Willigenburg, N. W., Noorduyn, J. C. A., Butter, I. K., de Gast, A., … Poolman, R. W. (2019). How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study. British Journal of Sports Medicine, bjsports-2018-100065. https://doi.org/10.1136/bjsports-2018-100065

 

The Best Treatment for Knee Pain

Knee pain is a common reason people book an appointment with a physiotherapist. There can be plenty of reasons for this knee pain to occur and over the years I’ve seen an amazing amount of solutions. However recently it has become apparent that if your physiotherapist is not starting you on some form of graded exercise program then something is not quite right.

 

Studies from around the world are highlighting the benefits of supervised exercise more and more:

  • Exercise reduces pain and does not cause increased inflammation or the loss of cartilage (Bricca et al., 2019).
  • Surgery does not give superior results to exercise in patients with degenerative meniscal tears (Kise et al., 2016).
  • The costs of physiotherapy and likely beneficial results mean it should be considered ahead of surgery for non-obstructive cartilage tears (van de Graaf et al., 2019).
  • A recent editorial in the British Journal of Sports Medicine further supported this with the unequivocal statement “there is convincing evidence that exercise therapy works.” (Crossley & Cowan, 2019).

 

This would all appear reasonable and yet out in the community this level of care is not always common place.

 

An article in 2016 found that physiotherapists still spent time with patients with osteoarthritis performing low value care options such as electrotherapy and ice (Spitaels et al., 2016). Furthermore it has recently been reported that the use of imaging, recommendations for surgery, prescription of opioid medication and failure to provide adequate education remain common problems in the management of musculoskeletal pain (Lin et al., 2019).

 

So the next time you visit your doctor or physiotherapist with a sore knee ask yourself if you are receiving high value care. Were you;

 

  • Given a graded exercise program and offered supervision to assist?
  • Educated on the reasons for your knee pain and ways to improve it?
  • Discouraged from receiving a scan unless there was unsatisfactory improvement in conservative management or unexplained progression of symptoms?
  • Advised not to take opioid medication?
  • Encouraged to continue work and exercise in some capacity?
  • Felt that the care and treatment provided was specific to you and your goals?

 

If any of these questions cause you to reflect then maybe it’s time to consider, are you receiving high value care?

 

References

Bricca, A., Roos, E. M., Juhl, C. B., Skou, S. T., Silva, D. O., & Barton, C. J. (2019). Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation. British Journal of Sports Medicine, bjsports-2019-100727. https://doi.org/10.1136/bjsports-2019-100727

Crossley, K. M., & Cowan, S. M. (2019). VMO retraining or graduated loading programme for patellofemoral pain: different paradigm with similar results? British Journal of Sports Medicine, 0(0), bjsports-2017-098736. https://doi.org/10.1136/bjsports-2017-098736

Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. British Journal of Sports Medicine, 50(23), 1473–1480. https://doi.org/10.1136/bjsports-2016-i3740rep

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, bjsports-2018-099878. https://doi.org/10.1136/bjsports-2018-099878

Spitaels, D., Hermens, R., Van Assche, D., Verschueren, S., Luyten, F., & Vankrunkelsven, P. (2016). Are physiotherapists adhering to quality indicators for the management of knee osteoarthritis? An observational study. Manual Therapy, 1–12. https://doi.org/10.1016/j.math.2016.10.010

van de Graaf, V. A., van Dongen, J. M., Willigenburg, N. W., Noorduyn, J. C. A., Butter, I. K., de Gast, A., … Poolman, R. W. (2019). How do the costs of physical therapy and arthroscopic partial meniscectomy compare? A trial-based economic evaluation of two treatments in patients with meniscal tears alongside the ESCAPE study. British Journal of Sports Medicine, bjsports-2018-100065. https://doi.org/10.1136/bjsports-2018-100065

What is Concussion?

What is a concussion?

A concussion is a brain injury caused by acceleration or deceleration of the brain within the skull following a significant impact to the head or elsewhere on the body. The impact causes a biochemical imbalance within the brain cells, resulting in decreased blood flow and temporary energy deficits within the brain. Symptoms may include loss of consciousness, headache, pressure in the head, neck pain, nausea or vomiting, dizziness, or balance problems, among others. It is also important to note that symptoms often ease prior to complete brain recovery, so caution needs to be taken with returning to sport or an environment where you may suffer another injury to the head.

What do I do if I have a concussion?

Following a concussion, you may experience a drop in energy levels over the next few days. However, with proper management, your energy levels can be restored. After a concussion, it is recommended that you see a Complete Concussion Management Provider as the symptoms you may be experiencing may be related to other conditions caused by your injury such as whiplash and injury to the muscles in your neck.

Concussion treatment and rehabilitation:

Pain Management After Surgery

Commonly following any operation regardless of the extent of the work there is an inflammatory response. This may be a response to the incision site or tissues that have been moved or cut in the process of the surgery.

Inflammation is an important part of the healing process, however, it can cause many unfortunate side effects. Pain and alterations in muscle recruitment are two of these.

Pain is the body’s interpretation of signals sent from an area. With inflammation, there are increases in chemical and pressure signals. Minimising these signals without removing them entirely will often help reduce pain levels, while not interrupting the healing process. This consequently improves the recruitment of postural muscles while decreasing compensatory strategies.

Like asking a sprinter to run a marathon, these compensatory strategies often fatigue much quicker than the normal postural/ control muscles. As muscles fatigue, they can also become a source of pain. For example, if I asked you to lift your arm up straight in front of your body and hold it. For a certain length of time, your muscles are very happy with this task but after a few minutes, you may start to feel an ache in your neck or shoulder as a result of the muscles fatiguing.
A very simple way to minimise this post-operative effect of swelling, with minimal side effects, is icing!

Icing is a very commonly overlooked option for both pain reduction and swelling management post-operatively, regardless of the site. Swelling also persists to some degree for weeks to months following surgery meaning ice may be used for pain relief for a very long time following surgery.

Usually, we will advise someone to apply ice to an area for 10-15mins. If it is also possible to provide compression to the area and elevation (until the affected area is higher than the heart) at the same time, this is also of benefit. After the 10-15mins, remove the ice and wait for the area to return to normal temperature before reapplying. Always ensure there is a layer of material directly between your skin and the ice, and be extra careful if you have any medical conditions which mean you have decreased sensation in that area to best protect the skin. This may be repeated multiple times in a row or throughout the day. Usually in the earlier days post-operatively this should be more frequent and then as the weeks are going on, apply ice following exercise or increased activity levels for pain relief.

Range of movement exercises, as well as gentle and moderated return to activity levels, may also help to modulate the inflammatory response and some of its negative side effects. If you require further information regarding your specific operation please seek advice from your local Physiotherapist or medical professional.

Exercise Tips for Summer Bodies

They say summer bodies are made in winter, but sometimes it can be a bit daunting to get back into the routine of exercising, particularly if you have been sedentary for a while. Below are some tips and tricks to get you started, and keep you on track to reaching your goals, without reaching for the ice pack.

1. Wear Supportive Shoes –

When working out, make sure that you are wearing supportive and comfortable shoes. For most foot types, your chosen shoes should have good arch support and stability around the heel and back of the ankle. Keep in mind that your shoes won’t last forever, so if you are experiencing foot pain while exercising it might be time for an upgrade! Nb. depending on your activity levels this may need to happen anywhere between every 6-18mths.

2. Start Slow –

When getting back into exercise, you should start with low impact exercises such as walking, then up the ante by including high impact exercises like running and jumping as your fitness and strength improves. Likewise, you should also start with a short duration and slow pace, and gradually build up.

3. Warm-Up and Cool Down –

An effective warm-up will increase blood flow to your muscles and will typically consist of sort of cardiovascular exercise (e.g. cycling, walking) and movements you plan to do in your workout. After you finish your workout, you should spend 5-10 minutes completing gentle cardiovascular exercise and stretching to cool down.

4. Set Realistic Goals –

Setting goals is a great motivational tool. Not only is it a great way to keep you accountable, but it also helps you to track your progress. When setting your goals, you want to make sure they are specific, measurable, achievable, realistic and time-bound (SMART). Try breaking up your larger goals (e.g. lose 5kgs) into smaller, more attainable goals (e.g. lose 0.5kg per week for 10 weeks).

5. Don’t Push Through Pain –

While it is common to feel some post-exercise soreness for 2-3 days after a workout, you shouldn’t be feeling any pain while completing (or directly after completing) an exercise. If you do feel pain, make sure you stop that exercise, and if the pain persists, book in an appointment with your physiotherapist

Exposing the truth about lower back scans

Ever had lower back pain (LBP), gone to a chiropractor or doctor, had a scan done on your lower back and been told you have a bulging disc, degenerative changes, slipped vertebrae or something else weird going on with your spine? Well you’re definitely not alone. Approximately 80% of people with LBP want to be sent off for a scan and (not so coincidently) 80% of GPs will refer a LBP patient for imaging. If you go to a chiropractor you will almost certainly get a full spinal x-ray. And I can almost GUARANTEE that something abnormal will show up.

But what does it mean if your spine is not perfect? What does it mean if your vertebrae is “out of place”? What should you do if your spine is degenerating?

In most cases, absolutely nothing! But before we delve into why you’ve probably just needlessly handed over your hard earned money, let’s quickly go through some basic lumbar anatomy.

Lumbar spine anatomy 101

Your lower back (or lumbar spine) is made up of 5 vertebrae (the bony bits), the discs in between each vertebrae (to provide a bit of cushioning and allow more movement), ligaments to provide  support and nerves that come out in between the vertebrae on either side. When you move in certain directions, different structures are squished or stretched. For example, when you bend backwards or lean to the side, the hole that the nerve comes out of will get smaller which can cause a bit of irritation. When you bend forward, the disc tends to get squished backwards a little bit. All these structures are incredibly strong and can cope easily with a lot of load and like any part of your body, you usually have to put a fair amount of force through your back and move in the wrong direction to significantly damage one of these structures. 85% of the time it is the way you move (either having too much or too little movement in your back) that is the cause of the problem rather than damage to a specific structure.

 

Why an abnormal spine is normal

Asymptomatic imagaing features.jpg

BP is present in 15% of people at any given time and will affect almost every single person in their lifetime. Although this seems like a massive problem, the good news is most LBP is fairly mild and will pass within a month. 55% of people won’t even have to get treatment for it and 72% will be fully recovered within one year. These stats haven’t changed much in the last 20 years yet incredibly for a scan that costs upwards of $350, the use of MRIs for LBP in America increased 300% from 1994-2006!

As I mentioned at the start, if every single person went off and had a scan of their lower back right now, almost everyone would have something weird going on. As illustrated in the table above, Brinjikji and some of his colleagues last year trawled through heaps of studies who had imaged people without pain and recorded any abnormal findings. As you can see, even at 20 years old there is a good chance you’ll have something wrong with your disc. By the time you’re in your 50s, 80% of people without symptoms (eg. pain, stiffness) will have disc degeneration, and in your 80s having a degenerative spine is nigh on inescapable. Remember these findings are in people who DO NOT have any symptoms! Those that do have pain are have a very slightly higher chance of having abnormal features come up on their scans than those who don’t but the amount is inconsequential.

Based on this, if only 15% of people have back pain at any given time and most people have something structurally wrong with their spine, its pretty obvious that the weird findings in the spine probably aren’t the cause of the problem.

Still not convinced?

There have been multiple studies comparing the relationship between abnormal imaging results and LBP. The following list is just some of the features which have been found to have NO DIFINITIVE RELATIONSHIP with LBP: Spina bifida occulta, transitional vertebrae, facet arthritis, spondylolysis, Spondylolosthisis, Scheuermann’s Disease (lumbar), disc signal changes, annular fissures, disc degeneration, disc herniation, vertebral endplate changes, and general degeneration in athletes.Some of these may be problematic if severe enough but around 30% of people WITHOUT pain have SIGNIFICANT abnormalities… so even someone with a really bad looking spine could well be pain free!

On top of this, the amount of degeneration in your spine does not predict how bad your future LBP will be, how many episodes of LBP you will get, how quickly you will get better or the presence of sciatica. There is also no correlation between further degeneration and worsening symptoms.

Having your back scanned will often make you worse

As well as not being able to predict the severity or presence of current or future LBP, having your back scanned will often result in poorer outcomes. Being told that your spine has degenerated or a vertebrae is out of place is reason enough to feel quite worried and anxious that something serious is going wrong, and if not properly explained can lead to slower recovery times and poorer quality of life (how generally happy you are).

Interestingly, psychological factors such as anxiety, depression and understanding of pain are actually BETTER at predicting whether someone will get better or not than the results of any physical (amount of movement, muscle spasm, pain etc) or radiological testing (X-Ray, MRI, CT etc).

Health practitioners can also be negatively affected by imaging results. If they are choosing their treatment technique based on the results of an X-Ray or MRI, they are probably treating the wrong thing which will only result in wasted money and frustration for everyone involved.

Another scary fact is that there is a poor relationship between imaging findings and surgical outcomes. One study followed the progress of patients who had a scan to identify the problematic disc, fused the level above and below together and only 30% of these people got any better. That means that only one in every three people who went under the knife would show any signs of improvement

Not only will you probably be made worse by getting scanned, it can actually KILL you.

All xrays and CT scans expose you to a degree of radiation, however the amount of exposure required to see everything in your lower back is so high the standard front and side view x-ray is the equivalent of having a chest x-ray EVERY DAY FOR 1 YEAR. In the UK alone lumbar x-rays cause 19 deaths a year… this is 10 times higher than the amount of people who are taken by sharks each year in Australia!  In the US, CT scans of the lumbar spine result in 1200 additional cancers.

So why would you get a scan?

Although most of the time a lower back scan won’t be very useful, there are a few scenarios where it is very important to have one done. These include things like a suspected fracture/broken bone, tumour/cancer, infection, compression of the lower spinal cord and a few other nasties. Although these are very serious conditions they are also VERY rare and are responsible for less than 5% of back pain.

The other time scans are useful is when there are signs of significant nerve compression/squishing like numbness, loss of strength and reduced reflexes. Nerve pain is responsible for around 10% of LBP and only a small proportion of nerve pain is due to severe compression.

When you go and see your physio/doctor, they will be listening out for certain things (called red flags) that may indicate that something isn’t quite right and you should be asked some quick screening questions to determine whether you are at risk of these. If they decide you are at risk, then, and ONLY then, should you be sent off for a scan to exclude a serious problem. Chou and colleagues in 2009 reviewed 4 studies where 400 people who medical professionals didn’t think were at risk of a serious condition were scanned and none of them displayed evidence of the above conditions, so the screenings on the whole are very effective.

Conclusion

Almost everyone will have changes in their spine and on the whole it is nothing to worry about.

There is a commonly held belief in both society and among many health professionals that the source of pain can be found on a scan and that LBP can be resolved by treating the abnormality. This belief is resulting in poorer outcomes for LBP sufferers and health practitioners alike. There is a massive amount of evidence now demonstrating the hazards of lower back scanning and the clinical guidelines for medical professionals strongly discourage the use of imaging as an assessment tool for LBP. There are of course exceptions to every rule and in 5-10% of cases the person should be sent off for a scan only if the referring doctor or physio is concerned that something serious is going on.

Lower back pain on the whole is just like any other injury. It DOES get better quickly with the appropriate treatment. It ISN’T something to be overly concerned about, even if your spine has some weird stuff going on. And it SHOULDN’T be a condition that you have to put up with for the rest of your life.

***If you have lower back pain, are worried about what you see on your scan or have any other physio related questions feel free to call the LifeCare Point Walter clinic on 9438 3444 or email bicton@lifecare.com.au and have a chat to one of our very friendly and knowledgeable physios.***

 

REFERENCES:

  • Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., Owens, D. (2007). Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 147(7). 478-495
  • Towards Optimized Practice. (2009). Guideline for the Evidence-Informed Primary Care Management of Low Back Pain. Retrieved from www.topalbertadoctors.org. 1-21.
  • Brinkikji, W., Luetmer, B., Bresnahan, B., Cornstock, B., Chen, L., Deyo, R., Halabi. S., Turner, J., Avins, A. James, K., Walk, J., Kallmes, D., Jarvik, J. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Merican Journal of Neuroradiology. Vol36, 811-816
  • Wand, B. (2014). Structural and Mechanical Basis of Lower Back Pain (Lecture). University of Notre Dame
  • Chou, R., Fu, R., Carrino, J., Deyo, R. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis, The Lancet. Vol373. 463-472
  • Dagenais, S., Galloway, E., Roffey, D. (2014). A Systematic Review of Diagnostic Imaging use for Low Back Pain in the United States, The Spine Journal. Vol14, 1036-1048

Stretching the limit of injury prevention

Stretching, or the forceful lengthening or a muscle in order to reduce its tightness, has been around for thousands of years and is hardwired into the makeup of humans and animals alike. The first thing most people do in the morning (after pressing snooze on the alarm 5 times) is to let out a great yawn and stretch out all the muscles that have been dormant while you sleep. It is so instinctual that even the family dog and cat will do it!

Stretching as an injury prevention strategy dates way back to the ancient Greek and Roman armies who would stretch before battle to improve their flexibility in order to avoid winding up on the wrong end of a blade. In more recent years it has utilised by modern day warriors as they wage war on their chosen battle field, whether it be a football oval, soccer pitch, netball court etc. Regardless of the age, skill level or activity, stretching has embedded itself as an integral component of warm up and cool down routines around the world in an attempt to optimise performance and reduce injury.

But does it actually work?

Before we address this controversial question, let’s have a look at a few different types of stretching and their supposed benefits…

Types of stretches

Static stretching

Static stretching is arguably the most common form of stretching in the general community. It involves moving into and holding a position that stretches a muscle, resulting in an improved length and greater flexibility. The optimal amount of time to hold a stretch is approximately 30 seconds; too little will not allow time for changes to occur in the muscle and too long can actually reduce muscle performance and increase the likelihood of injury.

Ballistic stretching

This “old school” method of stretching involves moving to the end of a muscle’s limit and then performing small bouncing movements to try and get further. This is often associated with a reflexive muscle tensing in response to the sudden stretch and can result in an injury before you even get onto the field!

Dynamic stretching

Dynamic stretching is gaining more and more popularity within the sporting world because it improves flexibility and, unlike static stretching, hasn’t been proven to significantly reduce performance. Dynamic stretching is the rhythmic movement through a joint’s range of motion, gently pushing into the limits of a muscle’s flexibility. It is generally performed 10 times, gradually increasing the speed and amount of movement.

Proprioceptive neuromuscular facilitation (PNF) stretching

Proprioceptive neuromuscular facilitation stretching is the most effective of the four at improving muscle length. It is usually done with a partner and involves contracting the muscle for 5-6 seconds before relaxing and performing a static stretch. This can be repeated multiple times. However, like static stretching, it has been shown to decrease muscle strength and is not recommended before performing explosive sports.

THE BIG QUESTION

So, if 3 of these 4 stretches have been shown to reduce performance or increase the risk of injury and the jury is still out on the other, why is stretching still so widely used as an injury prevention strategy?

The answer is quite simple. If you have tight muscles and restricted range of motion, you are more likely to sustain an injury.  On the flip side, if your muscles are too loose and not performing as well as they should be, you are again more susceptible to an injury. The classic “Catch 22”.

If by this point you’re feeling exasperated and wondering if there is anything you can do to before exercising to limber up and reduce the risk of injury, don’t despair! The solution: Sport Specific Warm-Up Routines.

THE SOLUTION

Sport specific warmups are a vital component of an effective pre-game ritual and is actually something your team probably already does. They involve a combination of static and dynamic stretching, aerobic work (i.e. running), jumping and balance exercises, usually integrated into sport-related drills. The effect of the sport specific warm-up is “preconditioned muscles”, which is the body’s equivalent of warming up the engine of your car. If you jump into your car on a cold winter’s morning, start it up and try to take off Fast and the Furious style, there’s a good chance you’re going to blow something up. As you progress through the warm-up (or run your engine for a while), your muscle fibres (engine pistons) start firing more efficiently which improves your coordination and response time, allowing you to take off quicker, jump higher, dodge more opponents and perform at your peak. The warm-up also increases the temperature of your muscles by 1° which may not seem like much, but this tiny change reduces the viscosity of the fluid in your muscles allowing it to stretch further before tearing.

So, why stretch?

Don’t get me wrong, I’m not trying to say that stretching is a complete waste of time because it does have its benefits and it is an integral component in many of my physiotherapy treatments. A lot of people who come to see me have pain or reduced movement due to an “active restriction,” which is a fancy way of saying that the muscles are tensing up too much and have shortened from working overtime. In these scenarios a combination of regular stretching and release work through the muscle throughout the day is an extremely effective way of calming it down and allowing it to work normally again.

Stretching also feels good, which is reason enough to do it in my books. After a big work out or intense training session, the muscles that have been working hard will be tense and full of lactic acid so going through and stretching all the major muscle groups will help relax them off and remove some of the waste products.

The take-home message

According to the evidence, stretching before activity doesn’t have much going for it in terms of injury prevention and has been shown to reduce muscle performance. On the same token however, going into the game with tight muscles with also predispose you to an injury. The best way to combat this is to perform a sports-specific warm up routine before the game involving minimal static stretching AND do a lot of stretching and muscle release (massage, foam roller etc) during the week so your muscles are at an optimal length going into game day to give yourself the best chance of being victorious in your battles!

*For more information on injury prevention strategies and stretching, drop by the clinic or call us on 9438 3444 to have a chat with one of our physios*

REFERENCES:

Sampaio, F., Rangel, L., Mota, H., Morales, A., Costa, L., Coelho, G., Ribeiro, B. (2014). The Effects of Passive Stretching on Muscle Power Performance, Journal of Exercise Physoilogists17(6). 81-89.

Lewis, J. (2014). A Systemati Literature Review of the Relationship Between Stretching and Athletic Injury Prevention, Orthopaedic Nursing. 33(6). 312-320