Is the Outcome of ACL Surgery really better than Conservative Management?

August 28, 2010

If you have sustained an ACL ( Anterior Cruciate Ligament of the knee) tear and is considering an ACL surgery, you would find it useful to know more about the latest research discussion on ACL surgery versus Physical therapy management.

Written by lenia.teo · Filed Under Knee, Latest Research Findings, Treatment Option | View Comments

Knock Knees – Can I reverse it? (Part 2)

August 19, 2010

In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.

The Problems of this condition

The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.

How do I get rid of it?

External aids:

1. Orthotics

The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.

2. Knee braces

These can help prompt correct alignment of the knee joint, but may create a degree of dependency.

3. Strengthening

A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.

4. Stretching

Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.

Written by Jessica Ellison · Filed Under Hip (NonSport), Injury Prevention, Knee (NonSport), Peripheral (NonSport), Treatment Option | View Comments

Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome

July 29, 2010

Do you have heel pain? And think it is Plantar Fasciitis?

Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.

What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?

Source: AAF
click for larger view

As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).

While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.

Plantar Fasciitis

Plantar fasciitis is an overuse condition of the plantar fascia.

Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.

Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.

Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.

Heel Fat Pad Syndrome

Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.

Contributing factors: Increased age and weight decreases the elasticity of the fat pad.

Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.

Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.

References:

Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3^rd edition, Tata McGraw Hill, Australia .
Cole, C, Seto, G & Gazewood, J 2005, 'Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy`, American Family Physician, vol. 72, no. 11, pp. 2237-42.
Thomas, JL, Christensen,, JC, Kravitz,, SR, Mendicino, RW, Schuberth, JM, Vanore, JV, Weil, LS, Zlotoff, HJ, Bouche, R & Baker, J 2010, ´ The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010`,The Journal of Foot & Ankle Surgery, vol. 49, pp. 1-19.

Written by Mathias Puhr · Filed Under Ankle & Foot (NonSport), Injury Prevention, Peripheral (NonSport), Treatment Option | View Comments

Management for ITB friction syndrome

June 16, 2010

Follow up to our last ITB article, we have identified three conditions that contributes to the tightening of the ITB. They are weak outer hip muscles, incorrect training methods and bio-mechanical gait issues. In this edition, we seek to address these three main problems, looking at strengthening those weak hip muscles, rectify those poor training methods and biomechanical issues, outlining the practical management of iliotibial band friction syndrome (ITBFS) associated with running athletes.

Weak outer hip muscles

Early stage of rehabilitation aims to redress muscle weakness in the hip which may be considered as a major factor in the development of this condition. Thus, strength and conditioning exercises should focus on the muscle called gluteus medius. The reason why we target the gluteus medius is because it functions as an important stabilizer to control and decelerate adduction of the thigh during running. Poor endurance and control of the gluteus medius leads to gait alteration and ultimately ITBFS. Furthermore, to decrease tension along the ITB, the use of a foam roll and performing isolated stretches for tight muscles can be particularly effective in releasing myofascial restrictions. Below are some recommended exercises.

ITB Proximal Stretch click for larger view	ITB Proximal Stretch To stretch the IT band of your left leg, stand with your left side facing the wall. Cross your left leg behind your right, while using your left hand to help balance. Put your weight on the right leg and lean against the wall by pushing your left hip towards the wall. You should be able to feel the stretch in your left hip and down the IT band
ITB distal stretch click for larger view	ITB release with Foam Roller Rest the side of the thigh on the foam roller, positioning the foam roller just above the knee. Support yourself with your right arm and right foot to keep your balance. Roll yourself down the mat, rolling the foam roller from the knee up to the hip and then down to the knee. For a trigger point release, you can sustain pressure on the painful spot for 30 seconds.
Clam shell 1 click for larger view Clam shell 2 click for larger view	Clam shell in side lying Lie on left side to work on the right gluteus medius muscle. Keep spine in neutral and not sagging down towards the mat Keep the heels together and the knees at a right angle Lift the right knee up without rotating the pelvis and back. You should feel it on the muscle behind the hip bone
Side Planks click for larger view	Side planks To work on your right, lie on your side with your right hand on the ground or use an exercise mat. Lift your trunk and pelvis up to form a plank Maintain a straight trunk and pelvis alignment Hold for 30 secs

Training methods

Having re-established muscle balance around the hip, you should now be ready to take full bodyweight on the affected leg while maintaining optimal body alignment. To start getting back to running, we recommend running every other day for the first week, starting with easy sprints on level ground. It is important to note that studies have shown that ITBFS occurs mainly at, or at slightly less than, 30 degrees of knee flexion. Thus, it is necessary to avoid downhill running because the knee flexion angle at footstrike is reduced, causing strain on the ITB. Biomechanical studies have also shown that faster-paced running is less likely to aggravate ITBFS. This is because as the foot strikes the ground, the knee is flexed more than 30 degrees, avoiding the range where the strain occurs. Incorrect training practices can also contribute to the condition, such as starting a demanding routine of sport or exercise immediately following a return from injury, or otherwise expanding your training too rapidly.

A gradual increase to your training mileage (e.g. 2-3km per week) cannot be over emphasized. Your body won't get used to running long distances, unless it has run those distances on a regular basis. As the body needs rest between those runs, thus it is recommended that there should be no more than two long runs per week and moderate distance on the other days. Long training runs should be conducted at an aerobic capacity where you can talk and run at the same time. After a run, stretch and then ice the outside of the knee for 5-10 minutes. Last but not least, always train at an appropriate intensity. Training at higher intensities (>80% of Max. Heart rate) will lead to lactic acid production, which will fatigue the muscles and increase the chance of injury. To monitor the level of training intensity, a heart rate monitor may be a useful device.

Biomechanical Gait issues

Always wear appropriate shoes that give you proper support. A wet footprint test is a common method for determining your foot type. Get your feet wet and stand on a flat surface that will allow your footprint to be shown. Compare your footprint to the images below.

foot

Now that you know your foot type, approach a knowledgeable salesperson at a running specialty store and they will be able to help you find the right shoes for you. A semi-rigid orthotic may also be useful for someone who have excessively flat feet or high arches, in bid to improve function by supporting the foot segments during gait. The orthotic is worn in the shoe and it helps by changing the position and time sequences talking place in the foot during running so that no one muscle or group of muscles have to work longer and harder than it should.

Formthotics

Written by Admin · Filed Under Hip, Injury Management, Injury Prevention, Knee, Running, Treatment Option | View Comments

Heat or Ice? When to use which?

February 17, 2010

When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.

If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.

This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.

There are 2 common scenarios that cause pain, making you reach for that heat/ice pack. One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal). Each scenario requires a different approach to reducing your pain and speeding up your recovery.

Acute Injuries

It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand. All these are examples of acute injuries and will show the following signs:

Sharp, severe pain
Swelling
Redness
Increased warmth
Restricted joint movement
Unable to put weight through the structure (e.g. leg, ankle, wrist etc).

Flickr: Kyle May

For these types of injuries, we recommend managing the pain, inflammation, and swelling immediately with the use of ice. The ice cools the tissues, reduces tissue metabolic rate and constricts the blood vessels helping reduce further damage from occurring.

There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!). The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.

How does ice work?

1. Decreasing the pain

There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.

Decreased nerve transmission in pain fibres
Cold reduces the activity of free nerve endings
Cold raises the pain threshold
Cold causes a release in endorphins
Cold sensations over-ride the pain sensations

2. Reducing swelling

Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels. This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling. After a few minutes, the blood vessels re-open allowing blood to return to the area. The narrowing and opening repeat in cycles.

The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury. Pain is also reduced as pressure from the swelling lessens. Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.

3. Decreasing metabolic rate

Ice reduces the metabolic rate and oxygen requirements of the cells. Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened. This prevents further injury.

Sub-acute phase

A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury. However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively. This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.

How does this work?

Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues. The increased blood flow to the area provides proteins, nutrients and oxygen for better healing. It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique. That means that the area should not be red, and should not be warm to touch.

Chronic Injuries

Flickr: Capture Queen

These are injuries resulting usually from overuse where some tissues are tight and inflexible causing aches. Examples include tennis elbow, golfer’s elbow, patella tendinitis and Achilles tendinopathy. Symptoms include pain when performing activities, a dull ache at rest and swelling. Occasionally, an acute injury is not allowed the time to heal properly and muscles spasm to protect it.

In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area. Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.

Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs. If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns. The heat should be applied for 15-20 minutes.

How does heat work?

Heat applied on the skin increases the temperature of the skin and the underlying tissues. This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.

Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly. Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.

Written by MCR · Filed Under Treatment Option, Treatment Options | View Comments

Ladies! Stronger Thighs, Lesser Knee Pain

September 30, 2009

Knee pain is one of the most common, if not the most common complain of pain in the elderly. In the USA, nearly 4 million sufferers of knee pain above the age of 45 are ladies.

Why are females more prone?

There are quite a number of reasons why ladies are more pre-disposed to developing knee pain. The reasons range from wider hips to increased Q-angle, tighter ilio-tibial band (ITB) to weaker physique. However, what is the most common cause of knee pain? The answer lies in the weakness of the quadriceps or thigh muscles. Read more

Written by MCR · Filed Under Injury Prevention, Knee, Knee (NonSport), Treatment Option, Uncategorized | View Comments

What can i do for a hamstring “pull”

August 31, 2009

Pulling one’s hamstring is one of the most common soccer injuries and the most common cause is the lack of proper stretching before playing. When one says that they pull their hamstring, what it means is that one has strained or slightly torn their hamstring. Most soccer players think that by just resting for about 2-4 weeks without playing is all that is required to recover. However, this is not true. If you do nothing about the strain, you are at a higher risk of sustaining the same injury.
Read more

Written by MCR · Filed Under Exercises/Tools, Injury Prevention, Rugby, Running, Soccer, Sports Injury, Thigh, Treatment Option | View Comments

How to tell the difference between an ankle sprain and a fracture

July 27, 2009

This is a brief video on how to tell the difference between an ankle sprain and an ankle fracture. If you are thinking of taking an X-ray to confirm if it is a fracture, the Ottawa Ankle Rules has a guideline to check if you need an x-ray.

Written by chyetuan.chng · Filed Under Ankle & Foot (NonSport), Ankle and Foot, Treatment Option, Video | View Comments

Simple Exercises For Plantar Fasciitis Sufferers

June 26, 2009

In an earlier post, we discussed on what plantar fasciitis is about, including the causes, symptoms and treatment options available. If you think you might be sufferring from plantar fasciitis, read on and find out more about the exercises that you can do to help ease the pain in your foot!

Written by MCR · Filed Under Ankle & Foot (NonSport), Ankle and Foot, Injury Management, Injury Prevention, Peripheral (NonSport), Sports Injury, Treatment Option | View Comments

Arthroscopic Rotator Cuff Repair

April 16, 2009

A rotator cuff tear is a common injury of the shoulder. It can be due to a traumatic event where the tendon gets torn in a fall or due to overuse where repetitive overhead activities causes wear and tear of the tendon. Pain is the most significant symptom with a rotator cuff tear followed by loss of range of movement in the shoulder. Arthroscopic rotator cuff repair, which involves minimally invasive surgical techniques, helps to heal the tendon back to the bone. Such surgeries are usually done as a day operation. Rehabilitation of the shoulder post operation takes about 6 months before patients return to functional activities.

Written by chyetuan.chng · Filed Under Injury Management, Peripheral (NonSport), Shoulder, Shoulder (NonSport), Sports Injury, Treatment Option, Uncategorized | View Comments