Posts Tagged ‘prevention’

Shoulder Injuries, Part I

Tuesday, June 30th, 2009

Shoulder injuries are far too prevalent in many sports.  These injuries tend to fall into two groups.  The least common are those injuries caused by a sudden traumatic force, as seen with the football player being tackled and landing oddly, causing a dislocation or separation of the shoulder.

The more common injury type is the overuse injury that occurs in athletes who are involved in weightlifting, throwing, swimming, swinging clubs or racquets.  The majority of these injuries are preventable with a program of specific shoulder exercises and an understanding of the workings of the shoulder joint.

The shoulder is the most mobile joint in the body.  The shoulder joint looks like a golf ball sitting on a tee.  The humeral head (ball) sits in the glenoid (socket) which is shaped like a shallow dish.  A circular structure of soft tissue, the labrum, deepens the dish.  The stability of the shoulder joint is provided by the labrum and the tendons of the rotator cuff.  The rotator cuff is comprised of four small but very powerful muscles.  They wrap around the humeral head to keep it located in the glenoid.  The rotator cuff also internally and externally rotates the upper arm (humerus).  Above the rotator cuff tendons is a water-filled sac or bursa that reduces friction and cushions the rotator cuff tendons as they slide under the cowl of bone on top of the shoulder, the acromion.

The shoulder works in a balancing act, a force couple, between the deltoid and the rotator cuff. As you raise your arm the deltoid contracts to bring your arm up.  The rotator cuff muscles contract in synchrony to depress the humeral head ointo the glenoid. If your rotator cuff muscles are weak or your deltoid overpowers them, then the shoulder subluxes (partially dislocates) and rides up against the acromion.  This in turn pinches the tendons and bursa between the two.  This is called impingement.  Repeated often enough and the tendons and bursa become irritated and swell.  This leads to tendonitis, bursitis or even a small tear in the rotator cuff tendons.

Part II will discuss factors which predispose you to rotator cuff pathology, ways to reduce the likelihood of injury, and treatment options.

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Knee Pain, Part II.

Thursday, June 11th, 2009

Depending on the extent of the tear and location, some meniscal injuries can be treated without surgery.  Physical therapy to increase muscle strength around the joint and increase your range of motion along with anti-inflammatory medication, knee sleeves, activity modification and time are the regimen.  However, you should have significant improvement within 2-3 months if this approach is working for you.  If little or no improvement is felt, then surgery to remove the part of the meniscus is indicated.  In younger athletes, surgery is generally the better option if the meniscus can be repaired.  Repairing the meniscus can prevent further deterioration of the joint and help to prevent arthritis later in life.

Surgery for meniscus tears is an outpatient procedure which can generally be done in under an hour.  It is performed through two small poke holes in the knee.  One hole is for the arthroscope, a lighted tube connected to a television screen, which is used to visualize inside the joint.  The other hole is for the instruments which are used to either repair or trim the torn meniscus.  If the meniscus is repairable, an additional small incision on the side of the knee may be used to retrieve the sutures and protect the nerves that travel in the skin around the knee.  You are generally allowed to go home within 2-3 hours following the surgery.

Recovery from meniscal surgery varies for different people depending on the extent of other damage to the knee structures and the person’s age.  Some athletes have arthroscopic surgery and are back playing in 2-3 days; however, most people take 2-3 weeks to regain their strength and get rid of their swelling.  If the meniscus was repaired, then you will usually have to be on crutches for 4-6 weeks to allow the meniscus to heal properly.  This is a great improvement over what was the norm 15 years ago when open surgery was done through a large incision and you were out of competition for 3-6 months.

The meniscus is an important structure in the knee joint and as much of it as possible should be preserved.  The meniscus cushions the knee joint and prevents the ravages of arthritis.  Through modern surgical techniques and improved rehabilitation, a quicker return to sports or work is possible for this bothersome condition.

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Ankle Sprains, Part III

Wednesday, April 15th, 2009

Prevention of ankle sprains
It is estimated that 30 to 40% of all ankle inversion sprains end in re-injury. To avoid being one of the 30 to 40% it is important not to stop the rehabilitation process but continue with it until full fitness is regained. It is a common complaint that once an athlete goes over on the ankle they become prone to doing the same thing again. If the original sprain is a bad one and joint laxity has resulted, then it may be for certain sports where fast changes of direction are required that strapping of the ankle or wearing a brace is necessary to prevent re-injury.

If the sprain does not result in joint laxity then a recurrence may be avoided by the following:
1. Re-establish proprioception. This involves lots of balancing exercises on one leg which is essential to avoid re-injury. If you start to turn the ankle over then you will find you automatically right it without even thinking about it. If the proprioception is damaged then you lose this ability.
2. You need to strengthen the ankle in order to provide a far more stable joint. Then, if the ankle does start to turn and the proprioceptors work as they should, the ankle muscles should contract quickly to hold the joint stable
3. For a severe sprain (one you can not put weight on), you may need a visit a physician to make sure you don’t have a fracture, ligament tendon damage or another serious ankle injury.

In general, you should avoid putting weight on the joint as long as you have swelling. When possible, you should keep your foot elevated. Within a couple of days, your pain should decrease enough to allow moderate weight bearing without pain. As you are able to tolerate more weight, you can begin a walking and gentle stretching program to increase your flexibility.

Proprioception exercises or balance exercise can help you recover more quickly and should actually be preformed as part of a prevention program. Poor balance is a good predictor of future ankle sprains. After an ankle injury, balance training is essential to recovery. In addition to our eyes and inner ears, there are special receptors in our joints (proprioceptors) that provide information about our position in space.

By balancing on one leg, you can reinforce and strengthen those receptors in the ankle. Balance on the affected leg and hold steady for 15 seconds. Continue to challenge your ankle by balancing with your eyes closed, or with your head turning from side to side. If you play soccer, balance on your sprained ankle and kick a soccer ball against a wall. If you play basketball, balance and shoot or practice bounce passes. Get creative with your exercise to match your sport.

Ankle sprains can be prevented by using appropriate equipment for your sport. However, sport-specific shoes and protective gear are just the start. To avoid ankle sprains, you need to strengthen your ankle joint and develop a highly refined balance system. Don’t forget to keep your first aid kit nearby.
• Range of Motion Exercises
Some simple exercises can help maintain ankle motion, and stretch the injured ligaments in the ankle joint.
• Achilles stretches
Achilles tendon stretching can easily be started soon after sustaining an ankle sprain. While seated or lying down, take a towel and loop it around your toes. Pull the ends of the towel, pulling your toes upwards, and feel the stretch in the back of the ankle. Perform this 3-4 times a day for several minutes.
• Alphabet writing
While seated or lying down, write the alphabet in the air with your toes. Make the letters as big as possible. Get creative by trying all uppercase, then lower case, then cursive, etc…
• Strength Exercises
The next step in recovery from ankle sprains is strengthening the muscles that surround the ankle joint. By strengthening these muscles, you can help support the ankle joint and help prevent further injury. Some exercises to perform after an ankle sprain include:
• Toe raises
Stand on a stair or ledge with your heel over the edge. Stand up on your tip toes, then in a controlled manner, let the heel rest down. Repeat 10-20 times (each foot), 4 times a day.
• Heel and Toe Walking
Walk on your toes for one minute, then on your heels for one minute. Alternate walking on your heel and toes, and work up in time to a total of 10 minutes, repeating 4 times each day.
• Activity-Specific Training
Activity specific exercises may include simply walking or jogging, or may be more intense for athletes who participate in basketball, soccer, or other sports. The key, no matter what level (recreational or competitive) athlete you may be, is to progress slowly. Begin at very low intensity, and very low duration of activity, and slowly work up–never suddenly increase either the intensity or duration of your activity.
Here is a sample progression for a soccer player
• Jogging
Begin at 50% intensity. Jog 100 yards, walk 100 yards. Repeat 4 times. Increase intensity and duration over 2-3 weeks
• Figure of Eights
Jog in a figure-of-8 pattern around cones. Begin with the cones near each other. Each day, spread out the cones and increase the speed.
• Box Runs
Make a box of cones. Jog forward the first side, side shuffle to the right, run backwards, then side shuffle to the left. Again, increase the size of the box and the speed of the running each day.

Once these activities can be done at full speed with no pain, patients can resume their sport. More sport specific exercises can be given to you by a coach or trainer if needed.

What if the pain continues?
The most common cause of persistent pain following an ankle sprain is known as incomplete rehabilitation. This means that patients either don’t complete the right type of rehabilitation, or they don’t progress properly (i.e. too fast or too slow). If you feel that your progress is not going along properly, make sure you seek advice such as speaking to your doctor or working with a physical therapist or athletic trainer. Most causes of chronic ankle pain are due to a lack of full rehabilitation and returning to play before all healing has occurred.

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Ankle Sprains, Part II

Monday, April 13th, 2009

Phase 2 – Rehabilitation phase
The rehabilitation phase begins when swelling stops increasing and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress.

Improve mobility and flexibility
Seated foot tapping may be beneficial for an ankle that has reduced mobility. Initially plantar flexion (down) / dorsi flexion (up) and then progress to inversion (in) / eversion (out) as pain allows.
For the first 2 to 7 days after injury you can start to move the ankle straight up and down but do not turn it in or out. This will help increase mobility and start to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps while the ankle is iced and elevated and increase as you can.
As swelling and pain lessen, you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and outwards and upwards). This will start to put more stress on the damaged structures, so be careful not to do too much.
Stretching the Achilles tendon regularly is important. Have available a specific Achilles stretching board throughout the day (or lean into a desk or counter, keeping heels on the floor) to ensure a few minutes of stretching daily.

Strengthening the ankle joint
Again as the ankle improves you can start to do strengthening exercises where you pull the foot and toes up and hold for 10 sec’s and then push down and hold for 10 sec’s This can also be done for inversion and eversion as pain allows. Try 3 sets of 10 reps twice a day and build on that. Begin using your hand to resist these ankle movements.
Continue to apply cold therapy to the joint regularly – at least 3 times a day for 20 minutes.
If you see no further improvement with ice then start to apply heat in the form of a hot bath / bucket or via a specialist with ultrasound.
Strapping and taping may still be beneficial here.
You should be able to maintain fitness by swimming or cycling if pain allows.

Re-establish co-ordination and proprioception
Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. Early weight bearing is thought to help reduce proprioception loss. Try balancing on one leg with your eyes closed. This will improve proprioception (the neuromuscular control you have over your muscles). This will have been damaged when you injured the ankle. Aim to be able to balance for 1 minute without wobbling.
Return to full fitness / functional training
In order to start the functional rehabilitation phase (activity and sports specific training), it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity.
Cardiovascular exercises is important and should begin the first day after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
Running may begin as soon as walking is pain free. It is a good idea to tape the ankle before starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.
Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves.
Speed should be gradually increased over time to a sprint.
Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.

In the final article, Ankle Sprains Part III, we will discuss ways to reduce the liklihood of ankle sprains.

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Ankle Sprains, Part II

Monday, April 13th, 2009

Phase 2 – Rehabilitation phase
The rehabilitation phase begins when swelling stops increasing and pain lessens. This means the ligaments have reached the point in the healing process where they are not in danger of being re-injured from mild stress.

Improve mobility and flexibility
Seated foot tapping may be beneficial for an ankle that has reduced mobility. Initially plantar flexion (down) / dorsi flexion (up) and then progress to inversion (in) / eversion (out) as pain allows.
For the first 2 to 7 days after injury you can start to move the ankle straight up and down but do not turn it in or out. This will help increase mobility and start to strengthen it up. Do as much as pain will allow. Try 2 sets of 40 reps while the ankle is iced and elevated and increase as you can.
As swelling and pain lessen, you can start to invert and evert the ankle (move the soles of you feet inwards and upwards and outwards and upwards). This will start to put more stress on the damaged structures, so be careful not to do too much.
Stretching the Achilles tendon regularly is important. Have available a specific Achilles stretching board throughout the day (or lean into a desk or counter, keeping heels on the floor) to ensure a few minutes of stretching daily.

Strengthening the ankle joint
Again as the ankle improves you can start to do strengthening exercises where you pull the foot and toes up and hold for 10 sec’s and then push down and hold for 10 sec’s This can also be done for inversion and eversion as pain allows. Try 3 sets of 10 reps twice a day and build on that. Begin using your hand to resist these ankle movements.
Continue to apply cold therapy to the joint regularly – at least 3 times a day for 20 minutes.
If you see no further improvement with ice then start to apply heat in the form of a hot bath / bucket or via a specialist with ultrasound.
Strapping and taping may still be beneficial here.
You should be able to maintain fitness by swimming or cycling if pain allows.

Re-establish co-ordination and proprioception
Proprioception exercises are thought to be important in avoiding recurrent ankle sprains. Early weight bearing is thought to help reduce proprioception loss. Try balancing on one leg with your eyes closed. This will improve proprioception (the neuromuscular control you have over your muscles). This will have been damaged when you injured the ankle. Aim to be able to balance for 1 minute without wobbling.
Return to full fitness / functional training
In order to start the functional rehabilitation phase (activity and sports specific training), it is important the athlete has full range of motion and 80 to 90% of pre-injury strength. When you can comfortably do all of the above then you are ready to start phase 3 and begin your return to activity.
Cardiovascular exercises is important and should begin the first day after injury depending on what pain will allow. It is important that the athlete maintain some kind of CV exercise not just for the physical benefits but for psychological well being as well. Stationary cycling, running in water and swimming are all possibilities depending on severity of injury and what pain will allow.
Running may begin as soon as walking is pain free. It is a good idea to tape the ankle before starting running training particularly during early sessions until confidence, proprioception and strength has returned. A laced ankle brace can also provide support and is less expensive in the long run, particularly if laxity in the ligaments means a support needs to be worn permanently.
Running should begin on a clear flat surface such as a running track. Grass or bumpy surfaces will increase the risk of re-injury. Jog the straights and walk the curves.
Speed should be gradually increased over time to a sprint.
Sports specific drills using cones can be introduced. Changing direction, running in a figure of 8 pattern and zig zagging between cones.

In the final article, Ankle Sprains Part III, we will discuss ways to reduce the liklihood of ankle sprains.

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