Do you have a good knee and a bad knee? Do your knees snap, crackle and pop? Do you ever wish you could walk for longer without pain or not be worried about how your knees will feel in the morning if you were living your life to the fullest?

Knee pain is a very common condition that affects people of all ages. Typically knee pain is the result of an injury on the sporting field when we are younger but tend to be more degenerative in nature as we age.

Different knee injuries tend to have differing symptoms. Common symptoms include:

Aching, sharp, stabbing and/or catching painsLarge amounts of swelling or sometimes pockets of swellingWarm to touchFeelings of grating, grinding or even giving wayPops and crunching noisesUnable to full bend or straighten the knee

The structures of the knee that are often implicated in knee pain are the patellar or quadriceps tendons, cartilage, meniscus, bursas, and even major ligaments such as the anterior cruciate ligament, otherwise known as the ACL.

Common injuries to the knee can be:

OsteoarthritisTendinopathy / TendonitisBursitisKnee cap pain (patellofemoral pain) Meniscal tear (degenerative and acute tears) Dislocated knee capIliotibial band friction syndrome

Regardless of your symptoms and presentation, our highly trained Praxis physiotherapists have expertise in this area and will help identify the problem and work with you so that you will feel empowered to fix the problem. At Praxis Physio this is our point of difference, we promise to take the time to fix you using a range of modalities including advice, hands on manual therapies and of course strength and conditioning programming. In addition, we work in close collaboration with leading knee surgeons if this course of action is required. There is no need to accept knee pain as 'normal'. Call us now on (07) 3102 3337 or book onlineto have one of our physios develop a plan to reduce your pain and restore your function!

To read more about how running can help your knees (that's right - running!) check out our related posts on running written by our published principal physio, Stephen.

Team Praxis,

PREVENT | PREPARE | PERFORM

FACT OR FICTION FRIDAY || All rotator cuffs tears need surgery..

Answer: FICTION. The devil is in the detail!

The rotator cuff is a group of 4 muscles that aid in providing stability through range for the shoulder joint, particularly overhead. There are multiple risk factors for RC tears, but most are down to overactivity of the shoulder joint decreased conditioning of the shoulder complex, which comes with age. In fact, cuff tears are common in individuals over the age of 40 with linear increase in incidence as we get older.

Pain with movement and function is one of the biggest symptoms of a rotator cuff tear. However, it is important to know that a sizeable portion of RC tears are actually asymptomatic and don’t cause the person any pain or discomfort! A study by Minagawa and Yamamoto in 2013 found that in a screening of 664 village residents, 147 subjects had RC tears on a medical imaging screening. Surprisingly 65% of them had no symptoms at all and didn’t have any shoulder complaints.

The two main ways of treating a cuff tear is either through conservative management with your physiotherapist or down the surgical route, which is also then followed by physiotherapy rehabilitation.

SO, back to the original question: "Do I need surgery?". As always - it is a case by case decision!! There is no definitive evidence for supporting one over the other generally speaking!

However, it is vitally important to note that each option comes with their own pros and cons. Furthermore, it is important to remember that just as every person is different, each case of rotator cuff tear is different. Young vs old, acute vs degenerative RC tear, current and desired future function, pain levels, radiographic findings, previous history of shoulder trauma and the patient's wishes are only some of the questions that aid in the decision process.

The best way to decide would be to contact us to asses you and discuss both options and what your goals of rehab are so that a tailored plan can be developed WITH you. To read more about RC tears, read our blog here

To get your shoulder back on track, book online or give us a call on (07) 3102 3337.

Team Praxis

PREVENT | PREPARE | PERFORM

FACT OR FICTION FRIDAY || Overuse injuries need rest and are because I'm doing too much.

ANSWER: FICTION (Mostly - stay with us here) 🙊

Do you keep getting injured when you get back into your usual training after a period of rest 😤? The first graph shows a 65-day cycle of an Olympic athlete. The red lines indicate when the athlete was injured. Looking at the multi-coloured line, you can see that the injuries both occurred when the acute to chronic workload ratio was at its peak. Essentially that means that the loads that preceded the injury were too high relative to the longer term loading of the tissue 😫. This is typically called an overuse injury!

Then along comes Mr/Ms physio and looks at the above cycle and says to the Olympian, "Come on mate, we can do better than this…" 😎

Ta da. The second graph shows the yellow section outlining the above 65-day period.

As you can see, training following this period is much more frequent and at higher intensities. So do we still assign the original injuries to overuse injuries given the athlete was able to handle much more relatively quickly after?! A better term would be a training load error and something that a sporting physio can help you with 👌. This is a particularly important thing to know given the holidays are just around the corner 🎅!

Get in touch with us if you want to train more with less injuries, or are looking to return to training! 📞(07) 3102 3337 or book online at www.praxisphyio.com.au 💻

Team Praxis

PREVENT | PREPARE | PERFORM

Drew, M. K., & Purdam, C. (2016). Time to bin the term ‘overuse’ injury: is ‘training load error’ a more accurate term? Br J Sports Med, 50(22), 1423. doi:10.1136/bjsports-2015-095543

SUMMARY:

Stingers are essentially a tractioning of the neural systemThis can cause pain, movement and sensation changesChronic traction to the nervous system can have a cumulative effect on nerve functionThe more damage to the nerve, the more serious the outcomeWe shouldn't be as dismissive of "stingers", particularly if they are recurrentPhysiotherapy has a role to play

STINGERS || Stingers have been the catch cry of many contact sports over the years. Often dismissed as 'just a stinger', trauma to the nervous system should probably be taken a little more seriously, as we delve into detail today.

Stingers are most commonly experienced in contact sports whereby the shoulder of a players is forcefully depressed, as experienced with a tackle in NRL or union. A large range of motion over a short period of time can result in a 'traction' of the Brachial Plexus (a network of nerves formed from exiting branches of the spinal cord in the neck that transverse to the shoulder and arm). Thus network of nerves sends signals from your spinal cord to your shoulder, arm and hand and thereby providing feeling and movement to these regions.

Background:

To understand a stinger injury, a clear understanding of nerves and nerve related injuries is required. A nerve is an enclosed, cable-like bundle of nerve fibres called axons, in the peripheral nervous system. A nerve provides a common pathway for the electrochemical nerve impulses that provide a number of functions, including getting our muscles to move!

Seddon and Sunderland present a five-grade classification scale for nerve related injuries[1-4]. Figure 1 illustrates the physiological changes that occur through each grade of injury. Essentially it outlines the greater amount of disruption to the anatomy of the nerve.

The more damage to the nerve, the more serious the outcome. Table 1 outlines the three different grades of stinger injuries.[4, 5] The most common stinger is a grade 1 injury, which represents a neurapraxia, or nerve stretch injury, without axonal disruption.[4] In an acute setting, this can result in motor and sensory loss/changes, which usually resolve within minutes.[1, 4] Grade 2 and 3 involve a higher degree of nerve injury, usually involving a crush, transection or compression mechanism.[1]

Chronic traction to the nervous system can have a cumulative effect on nerve function. This is termed “chronic stinger syndrome” and represents a distinct entity from acute stingers that may reflect long- standing structural changes of the subaxial spinal canal and chronic irritation/degeneration of the exiting nerve root complex.[4, 6]. This sounds complex but essentially means

A Clinical Example from Zac

"During a Gridiron match, a player was injured whilst making a tackle. I reviewed the player on field and he was unable to utilise his right upper limb (full paralysis) from shoulder down to his hand. The player was removed from the field immediately to be further assessed and monitored. A complete neurovascular assessment was performed, assessing motor function/strength, sensation, reflexes, and vascular status, as well was the cervical spine. Motor and sensation changes were the only deficits noted and were reviewed frequently. After roughly five minutes, the player demonstrated full upper limb motor strength and sensation, with nil lingering symptoms. In collaboration with the patient, it was decided he would return to match play immediately. The patient was monitored throughout the game and reported no further symptoms."

Figure 2 shows a proposed decision tree when managing stinger injuries.[4] This clinical example outline above fits the Grade 1 Mild category as he was able to return to competition with nil lingering symptoms. Despite the lack of symptoms during the game, it is recommended the patient be reviewed again both after the game and weekly for two weeks to ensure a full resolution of symptoms.[4, 7]

The role for neural mobilisation?

Current non-surgical management involves rest, pain control and resistance training[4]. Though not explored within the literature, neural mobilization may have an important role in patients with persistent symptoms, such as Grade 1 moderate to severe, and more recurrent neuropraxias. Though not assessed in this specific population, there is evidence for neural tissue management being superior to minimal intervention for pain relief and reduction of disability in nerve related chronic musculoskeletal pain.[8] It is biologically plausible that recurrent neuropraxias may respond in a similar way, utilising neural mobilisation (tensioning or sliding) and mobilisation of surrounding structures.

Management of persistent Grade 1 injuries may differ slightly, specifically if the suspected mechanism of injury was through traction rather than compression. The nerve structures may have a heightened sensitivity to tensioning based techniques due to the similar mechanism of injury and may respond better acutely to sliding techniques which limit the strain on the nerve and focus on excursion. Tensioning techniques may be important in the sub-acute phase by loading the patient’s nervous system (i.e. increased strain) in preparation for return to function (i.e. tackling with acute traction on the brachial plexus).

In summary, perhaps we shouldn't be as dismissive of "stingers", particularly if they are recurrent for you! If you have any questions or would like to see one of our physios regarding your injury, feel free to contact us on (07) 3102 3337 or book online on our website

Till next time, Praxis what you Preach

Team Praxis

Prevent | Prepare | Perform

REFERENCES:

Menorca, R.M.G., T.S. Fussell, and J.C. Elfar, Nerve physiology: mechanisms of injury and recovery. Hand clinics, 2013. 29(3): p. 317-330.Tsao B, B.N., Bethoux F, Murray B, Trauma of the Nervous System, Peripheral Nerve Trauma. 6th ed. In: Daroff: Bradley's Neurology in Clinical Practice. 2012.Sunderland, S., A classification of peripheral nerve injuries producing loss of function. Brain, 1951. 74(4): p. 491-516.Ahearn, B.M., H.M. Starr, and J.G. Seiler, Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers. J Am Acad Orthop Surg, 2019.Feinberg, J.H., Burners and stingers. Phys Med Rehabil Clin N Am, 2000. 11(4): p. 771-84.Presciutti, S.M., et al., Mean subaxial space available for the cord index as a novel method of measuring cervical spine geometry to predict the chronic stinger syndrome in American football players. J Neurosurg Spine, 2009. 11(3): p. 264-71.Aldridge, J.W., et al., Nerve entrapment in athletes. Clin Sports Med, 2001. 20(1): p. 95-122.Su, Y. and E.C. Lim, Does Evidence Support the Use of Neural Tissue Management to Reduce Pain and Disability in Nerve-related Chronic Musculoskeletal Pain?: A Systematic Review With Meta-Analysis. Clin J Pain, 2016. 32(11): p. 991-1004.

FACT OR FICTION FRIDAY || I'm no spring chicken so I should no longer lift weights, or I'm too old to start! 🏋️ ❌

Answer: FICTION 🙊

Progressive strength training in the elderly (>60 years) is efficient, even with higher intensities, to improve bone health, pack on muscle and retain function. And not surprisingly, side effects are rare!

Strength training increases muscle strength by increasing muscle mass, and by improving the recruitment of motor units, and increasing their firing rate. This is no different between younger and older gym goers.

It all comes down to how you train! Training with higher loads generally provokes marginally larger gains in muscle size. Intensity corresponding above 85% of the individual maximum voluntary strength can also illicit improved rate of force development compared to 60-80%. This is imperative for reducing frailty as we age.

It is now recommended that healthy old people should train 3 or 4 times weekly for the best results; persons with poor performance at the outset can achieve improvement even with less frequent training.

So if you are using age as an excuse - STOP! Don't let your age be a barrier to trying new things or feeling strong. We are here to help with supervised sessions, a great network of PTs as well as our clinical reformer pilates classes which are a great way to start (or return) to strength training!

To book for a clinical pilates 1:1 session or to chat with a physio about how strength training can help you, head to our website or give us a call on (07) 3102 3337

Team Praxis

PREVENT | PREPARE | PERFORM

References:

Mayer, F., Scharhag-Rosenberger, F., Carlsohn, A., Cassel, M., Müller, S., & Scharhag, J. (2011). The intensity and effects of strength training in the elderly. Deutsches Ärzteblatt International, 108(21), 359.

Lopez, P., Pinto, R. S., Radaelli, R., Rech, A., Grazioli, R., Izquierdo, M., & Cadore, E. L. (2018). Benefits of resistance training in physically frail elderly: a systematic review. Aging clinical and experimental research, 30(8), 889-899.

Do you have a 'good' and 'bad' shoulder? Have you been putting up with that grumbly shoulder for weeks, months or even years? Shoulder pain can but a real dampener on your activity levels - but it doesn't need to!

We at Praxis, pride ourselves on taking the time to listen, assess and accurately diagnose your shoulder pains. Some of the more common complaints we hear are:

Sharp, dull, deep, aching pains around the shoulder‘Popping’ or ‘crackling’ sounds or feelings in the shoulder jointPain in the mornings after lying on that side A feeling of the arm ‘separating’, 'popping out', 'slipping' or feeling unstableLosing power when doing overhead tasks such as swimming, throwing or gym workPains, pins and needles and numbness down the arms or pain up into the neckThe shoulder feeling stiff and sometimes even "frozen"

So whether your symptoms are as a result of wear and tear or an acute trauma from sport, general life or occupation, we are here to help. The shoulder needs to be strong AND mobile so if yours isn't, then contact us today on (07) 3102 3337 or book in online via www.praxisphysio.com.au. We are located at 4 convenient locations around Brisbane. Teneriffe, Woolloongabba, Bowen Hills and Carseldine.

Team Praxis,

PREVENT | PREPARE | PERFORM

FACT OR FICTION FRIDAY || A scan will always give me an accurate diagnosis for my knee pain... Answer: FICTION 🙊 “Osteoarthritis” is a common term that gets used by our patients as an explanation of their knee pain. But is this always the case 🤔?

🔍In a recent systematic review estimates of osteoarthritis feature prevalence on MRI among asymptomatic uninjured knees were up to 14% in adults < 40 years, and up to 43% in adults > 40 years!

Whilst features on MRI imaging such as cartilage defects, meniscal tears and osteophyte lesions can potentially play a role if you have pain, this should always be interpreted in the context of your clinical presentation by a health care professional as these changes can be normal in an asymptomatic population - just like grey hair as we age 👴👵!

If you have knee pain and have resigned yourself to a 'life sentence', come and have a chat to one of our physios to ensure you aren't robbing yourself of a full functioning future 🕺🏃🏌️🏄🏋️🏊🚴🏂🎾! Call 07 3102 3337 or book online simply at www.praxisphysio.com.au

#kneeoa #praxisphysio #factorfictionfriday #preventprepareperform #kneepain #kneeosteoarthritis #mri #fullfunctionfuture

Reference:

Culvenor AG, Øiestad BE, Hart HF, et al Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis British Journal of Sports Medicine 2019;53:1268-1278.

Are you a weekend warrior who is plagued by injury or an aspiring athlete trying to find that extra 1% or somewhere in between? We know how frustrating it can sitting on the side lines and not being able to be involved in the things that make you happy. All the Praxis team have (or still do) play sport of some description and understand the anguish that goes hand in hand with injuries. That is why we do what we do!

Praxis has an expert team who have been fortunate to travel the country and even the world with various sporting teams. Whether it is Stephen with Cricket Australia teams, Cam with the ICONZ Rugby, Zac with Netball or Emma with AFL Praxis has you covered.

We separate ourselves from other therapist because we know that specific, personalised and evidence based physiotherapy is the most effective and efficient method to getting you back to what you love doing quicker and better. Combine that with our years of experience in treating all athletes from the elite to the weekend warrior, and there is no sport we can't help with!

In summary, we believe that specific, personalised and evidence based physiotherapy is the most effective and efficient method in

If you are looking to Prevent future dysfunction, Prepare for your activity and Perform at your best, the Praxis Team has you covered and will get you achieving your goals sooner! See one of expert team members today by giving us a call on (07) 3102 3337, emailing admin@praxisphysio.com.au or booking online at www.praxisphysio.com.au

Team Praxis

PREVENT | PREPARE | PERFORM

Team Praxis,

PREVENT | PREPARE | PERFORM

SUMMARY

Shin splints are essentially an overuse injury Numerous factors contribute to symptoms but mainly involving the poor control of force through the lower limbsImportant to stop symptoms to avoid developing stress fracturesCorrective strengthening exercises, relative rest, and a graduated running program all seem to be the mainstay with treatmentPhysiotherapy has a significant role to play in getting back to running

SHIN SPLINTS || Shin splints, or as it’s referred to as in the literature, medial tibial stress syndrome (MTSS), is a common injury seen in the recreationally active and army populations. Symptoms typically consist of an aching pain to the lower medial (inside) part of the shin, that can be sharp when running or when inflamed. There can also be some pain and stiffness when you first walk around in the morning, or when you first start your activity.

Risk Factors:

Over 100 potential intrinsic risk factors of MTSS were identified in a recent systematic review [1] involving 21 different studies. Of those risk factors, nine were identified as having a moderate to strong occurrence in clinical practice. Out of these nine, the risk factors that result in the greater loads on the body (such as body mass index) or poorer acceptance of load with running were the most important.

A number of range of motion parameters were also identified. For example, larger plantar flexion range of motion (the movement of pointing your foot down) was identified. It has been hypothesized that the increased plantar flexion results in a greater likelihood of the individual landing on their forefoot rather than their rearfoot while running, possibly increasing the strain on the rear inside leg (posteromedial tibia). Forces on the inside of the shin bone explain the why pain may be present in that area.

Treatment:

Most people tend to simply rest which may decrease symptoms in the short-term, but it doesn’t address the direct cause! The condition is very commonly seen in recreational runners and not as much in your higher-level athletes. Why is this? It’s quite simple! As mentioned in our previous running blogs, the adherence to well-planned running workloads is what separates recreational runners from the competitive or non-injured. Planned training leads to adequate adaptation of the body to the demands placed upon it.

One of areas patients with shin splints focus on is poor “foot posture”. It is very common to hear the same old story, “I have shin splints because my feet are flat, I need orthotics to correct that”. The biggest problem with that approach is that not a lot of people realise that the reason that they are flat footed is not necessarily because of a defect in their feet! It may be because they have strength and control of their hips which is in turn is causing over pronation or flattening of their feet.

The diagram below demonstrates that perfectly!

As the hips cannot stay level during running, this may cause the knees to fall inwards and in turn causes pronation or flattening of the foot. Then, voila! You have increased tractional stress on the medial aspect of the tibia/shin bone. Yes, there is some evidence that poor foot posture can cause the problem, but only in combination with extrinsic risk factors such as over-training and rapid increases in workload.

Poor hip control and strength is also a precursor for many other musculoskeletal conditions such as lower back, hip, knee and Achilles pain. So if we could reduce the risk of these outcomes occurring in the future, why wouldn’t we try!

It is possible that MTSS is a condition where the simple treatment of rest is enough to reduce symptoms. Until proven otherwise, relative rest remains the number one treatment option for reducing your symptoms. However, If addressed early, MTSS can be managed with the combination of targeted strength routines, running workloads, manual therapy and ensuring adequate recovery time between training sessions.

If you are experiencing shin splints or are looking to prevent such injuries from reoccurring, please feel free to book online or give us a call (07) 3102 3337. You’ll receive an in depth assessment and treatment plan to help you achieve your goals and run better for longer!

Till next time, Praxis what you preach.

The Praxis Team.

PREVENT | PREPARE | PERFORM

References:

[1] Winkelmann, Z., Anderson, D., Games, K., & Eberman, L. (2016). Risk factors for medial tibial stress syndrome in active individuals: An evidence-based review. Journal of Athletic Training, 51(12), 1049-1052. 10.4085/1062-6050-51.12.13

FACT OR FICTION || Preseason training will help to reduce my injury risk next season.

Answer - FACT

With preseason training just around the corner, this blog is a timely reminder that turning up to preseason training consistently will give athletes the best chance of being able to play most games next year.

Murray et al (2017) reported that AFL players who completed <50% of pre-season training were 2x more likely to sustain in-season injury than those who completed >85%! This is not just relevant to elite AFL, it is relevant to all sports of all levels (even more so)! So what's the take home message? For the best chance to be able to play week in/week out during the competitive phase of the season, consistency during preseason is vital.

If you had injuries last season or are trying to make this your best season yet, see us to make sure you are ticking all the boxes!

#praxisphysio #preventprepareperform #factorfictionfriday #preseasontraining #praxispwhatyoupreach #afl #sportsphysio #preventprepareperform

References:

Murray NB, et al. Relationship Between Preseason Training Load and In-Season Availability in Elite Australian Football Players. Int J Sports Physiol Perform. 2017.

FACT OR FICTION FRIDAY || I’ve been doing my exercises for two weeks religiously and I’m no stronger! This will never work!

ANSWER: Fiction

How long does it take to have strength gains? The answer is actually in two parts. Increasing muscle size (hypertrophy) takes a minimum of 6 weeks, and repetitive exposures to fatiguing loads. BUT, neural adaptations can occur over the first 1-2 weeks.

What the heck is neural adaptations? Imaging you have a small car battery trying to start a truck. It will struggle to do a good job again and again and fade easily. Now try using 10 of those same smaller batteries, which makes the engine start easier. A similar type of thing happens with our nervous system as we train. We become much more efficient with our neural firing to the muscle.

As you can see in the picture below, you have a long way to go in your strengthening after those first two weeks. That is often why we often need to see beyond when the pain goes away as we know that there is so much more work to be done!

If you have been troubled by niggles and pains, don't hesitate to contact us to ensure we can help you prevent prepare perform! Book online at www.praxisphysio.com.au or call us on (07) 3102 3337.

#factorfictionfriday #praxisphysio #physioeducation #knowledgeiskey

Sale, D. G. (1988). Neural adaptation to resistance training. Med Sci Sports Exerc, 20(5 Suppl), S135-145. doi:10.1249/00005768-198810001-00009

FACT OR FICTION || I need to get an MRI to help with the management of my lower back pain

Answer - FICTION

In a recent narrative review, Wang and colleagues (2018) concluded that MRI imaging in the early stages of lower back pain can have detrimental effects including more pain, less improvement, higher risk of surgery and worse overall health status. In fact, one study reported that patients that received an MRI within the first month had an 8x greater risk for surgery and 5x more medical costs!

If you do NOT present with severe neurological deficits, signs of a serious or specific underlying condition or have persistent pain >6 weeks which is unresponsive to conservative treatment then there likely isn’t a need for further investigation!

To get help with your long standing back pain or even that acute flare up, give us a call on (07) 3102 3337 or book online at www.praxisphysio.com.au so we can sort you out.

#praxiswhatyoupreach #praxisphysio #factorfictionfriday #physioeducation #preventprepareperform #pain #backpain #lowerbackpain #MRI #patienteducation

Wang Y, et al. Informed appropriate imaging for low back pain management: A narrative review. Journal of Orthopaedic Translation. 2018.

GROIN PAIN || Groin pain, referred to also as athletic pubalgia, is a common problem for a number of athletes, particularly those who engage in sports that require specific use (or overuse) of lower abdominal muscles and the proximal muscles of the thigh. Predominantly, these activities centre around kicking sports such as AFL and soccer, as well as long distance running. Ice hockey is also a well renowned sport in which chronic groin pain occurs. All these sports involve repetitive energetic kicking, twisting, turning or cutting movements, which are all risk factors for causing pubalgia.

SUMMARY:

Understanding which of these four structures is causing your pain is key in effective managementExercise therapy and activity modifications should be the mainstay of treatmentAbsolute rest has been shown to be ineffectiveSteady gradual progressions through strength and function, tailored to your goals, is key to successful management

ROLE OF HIP ADDUCTORS (groin muscles)

Similar to other joints in the body, the hip relies on muscular control for stability and movement. At the hip, there are five key planes of movement; flexion, extension, abduction, adduction and rotation.

The adductor muscles are a large group of muscles located on the inner side of the thigh, attaching from below the knee, along the shaft of the femur and into the pubic bone of the pelvis.

While acute tears of the adductor muscle is common, more long standing pain is usually the result of an overload of the adductor tendon that attach to the pelvis. This is called an adductor tendinopathy. Adductor enthesopathy is common disorder which effects the bony attachment point of the tendon, with a slight structural difference from tendinopathy, however, management is similar in both cases

MANAGEMENT OPTIONS

Exercise:

Strength and functional based exercise are the core management strategies for adductor tendinopathy, and have been shown to increase function, decrease pain and reduce likelihood of injury [4].

Activity Modification:

Activity modification, especially in the acute phase or when symptoms are significantly affecting function, is key in reducing load on the affected structures and allowing tissues to adapt. [1]

Rest:

While activity modification is important, absolute rest has been shown to be ineffective in the management of adductor tendinopathy, and does not promote adequate tissue repair. [1,2]

Other:

Other conservative measures such as manual therapy, electrotherapy and stretching have been [1] explored, with reduced effect compared exercise prescription. Surgical management is also a potential option, with some positive results emerging for groin pain, though specific evidence [10] around adductor tendinopathy is limited. [10]

WHY IS EXERCISE IMPORTANT?

Exercise has been shown to increase tendon turnover, meaning in the first 24-36 hours there is a reduction in tendon integrity, but after that there is an overall increase in integrity and strength. Other benefits include: increased blood flow, increase in growth factors, and a reduction in altered pain processes in the brain [14].

WHAT'S THE BEST EXERCISE?

Isometric exercise has been shown to be effective in short term pain relief. Current evidence is unclear as to the best long term exercise strategies, with evidence supporting both eccentric and heavy-slow isotonic exercise. [12]

EXERCISE PLAN

The Copenhagen Adductor Program [9], with the below dosage, has been shown to significantly improve adductor strength, as well as being effective in groin injury prevention. It is important to note that though the program is eight weeks long, most effective tendon[12] adaptations take ≥ 12 weeks, and a tailored dosage should be discussed with your physiotherapist towards the end stage of rehabilitation.

Depending on how the symptoms affect your function, a reduction in training, running and kicking may also be required. Example progressions are noted below in the running program, in order of loading on adductors.

ADDITIONAL STRENGTH AND PROGRAMS

While targeted strengthening to the adductors is key, global strengthening around the hip may also aid in a reduction of loading to the tendon. Thorough assessment of your strength through all five movements noted previously is needed, as well as a tailored training program to resolve any discrepancies.

As symptoms reduce and function improves, part practice of painful activities, can be beneficial to reload structures, for example, banded kicking movements in preparation for return to soccer.

SUMMARY

In chronic adductor tendinopathy, tendon adaptations take time. It is important to understand this as you begin your rehab journey and not progress more than your body can tolerate. Steady gradual progressions through strength and function, tailored to your goals, is key to successful management.

As always, if you have a history of groin pain or are concerned about performance in your chosen sport, contact us today and chat to one of our friendly and knowledgeable physiotherapist to ensure you can Prevent. Prepare. Perform. Alternatively you can book online here

Till next time, Praxis what you Preach

Team Praxis

References:

1. Almeida, M.O., et al., Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain. Cochrane Database of Systematic Reviews, 2013(6).

2. Bohm, S., F. Mersmann, and A. Arampatzis, Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports Medicine - Open, 2015. 1(1): p. 7.

3. Brukner, P., Brukner & Khan's clinical sports medicine / Peter Brukner ... [et al.]. Sports medicine series, ed. K. Khan. 2012, North Ryde, N.S.W: McGraw-Hill Australia.

4. Charlton, P.C., et al., Exercise Interventions for the Prevention and Treatment of Groin Pain and Injury in Athletes: A Critical and Systematic Review. Sports Med, 2017. 47(10): p. 2011-2026.

5. Frizziero, A., et al., The role of eccentric exercise in sport injuries rehabilitation. Br Med Bull, 2014. 110(1): p. 47-75.

6. Griffin, V.C., T. Everett, and I.G. Horsley, A comparison of hip adduction to abduction strength ratios, in the dominant and non-dominant limb, of elite academy football players. Journal of Biomedical Engineering and Informatics, 2015. 2(1): p. 109.

7. Haroy, J., et al., The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med, 2019. 53(3): p. 150-157.

8. Harøy, J., et al., Infographic. The Adductor Strengthening Programme prevents groin problems among male football players. British Journal of Sports Medicine, 2019. 53(1): p. 45.

9. Haroy, J., et al., Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players: A Randomized Controlled Trial. Am J Sports Med, 2017. 45(13): p. 3052-3059.

10. Jorgensen, S.G., S. Oberg, and J. Rosenberg, Treatment of longstanding groin pain: a systematic review. Hernia, 2019.

11. Kohavi, B., et al., Effectiveness of Field-Based Resistance Training Protocols on Hip Muscle Strength Among Young Elite Football Players. Clin J Sport Med, 2018.

12. Lim, H.Y. and S.H. Wong, Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int, 2018. 23(4): p. e1721.

13. Machotka, Z., S. Kumar, and L.G. Perraton, A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes. Sports Med Arthrosc Rehabil Ther Technol, 2009. 1(1): p. 5.

14. Magnusson, S.P., H. Langberg, and M. Kjaer, The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol, 2010. 6(5): p. 262-8.

15. Rio, E., et al., Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine, 2016. 50(4): p. 209.

16. Thorborg, K., et al., The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med, 2011. 45(6): p. 478-91.

17. Wei, A.S., et al., The effect of corticosteroid on collagen expression in injured rotator cuff tendon. The Journal of bone and joint surgery. American volume, 2006. 88(6): p. 1331-1338.

PODCAST || Something a little different for Praxis Physio recently with our principal physio Stephen, having a chat with Matt from Back Yourself fitness.

The latest episode is all about rehab, recovery, Praxis Pilates and physio assessments.

Some interesting stories about all things Praxis, footy with Aspley Hornets and cricket all done on location at our Club Coops clinic.

If you think Stephen is the physio to help you navigate your aches and pains, feel free to give us a call on (07) 3102 3337 or book online today at www.praxisphysio.com.au

The BACK YOURSELF PODCAST is available on all podcast platforms 🔥🎧.

FACT OR FICTION FRIDAY || All meniscal tears need surgery 🤔🔪🔪🔪🔪

ANSWER: FICTION

In a recent meta-analysis (multiple studies combined), Kise and colleagues concluded that a small but inconsequential benefit is seen from treatment interventions that involve arthroscopy.

However, this small effect is of short duration and absent one year post surgery. Only 1 in 5 randomised controlled trials found greater pain relief 12 months after partial meniscectomy compared with non-surgical treatment! Further, the supervised exercise therapy showed positive effects over surgery group in improving thigh muscle strength, at least in the short term🙌

If you do NOT have mechanical symptoms (locking specifically), these results should encourage individuals with degenerative meniscal tears and no definitive radiographic evidence of osteoarthritis to consider supervised exercise therapy as a treatment option. Translation: Get strong and get moving under the care of a skilled physio like us at Praxis 💪🏃!

If your knee pain is holding you back, put a spring back into your step with Praxis Physio. We can accurately diagnose your issues, highlight where we can help, and get back on the path to improved function. To make a booking, call (07) 3102 3337 or book online via our website www.praxisphysio.com.au

#praxisphysio #kneepain #meniscus #mensicaltear #preventprepareperform #praxiswhatyoupreach #praxisblog #degenerativemeniscus #evidencebasedpractice

Reference

Kise N, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. Br J Sports Med. 2016.

That age old question in which the answers seems to be becoming increasingly more difficult to answer. We have looked over the research and tried to simply things for those who are unsure about what to do with their shoulder.

Summary:

A rotator cuff (RC) tear is a common cause of pain and disability among adults.There are multiple risk factors for RC tears, but most are down to overactivity of the shoulder joint decreased conditioning of the shoulder complex, which comes with age.Most common in individuals over the age of 40 with linear increase in incidence as we get older.A well-constructed strength program and active lifestyle is pivotal for preventing RC tears.Diagnosis of a RC tear is done through first a physical examination, which is then followed by a positive finding on medical imaging.To two main ways of treating a RC tear is either through conservative management with your physiotherapist or down the surgical route, which is also then followed by physiotherapy rehabilitation.There is evidence for both choices and the decision between the two is down to many factors and the well-trained and experienced physiotherapists at Praxis Physiotherapy can greatly assist you in making the decision!

ANATOMY

The rotator cuff (RC) muscles are a group of four muscles that act as rotators and stabilisers of the shoulder. These are supraspinatus, infraspinatus, subscapularis and teres minor. Supraspinatus is the most frequently torn of this group.

These muscles work to help raise and rotate your arm for everyday activities such as putting on a t-shirt, combing your hair or putting away dishes on a high shelf. In sport the cuff works as a dynamic stabilisers of the shoulder to help cope with the forces associated with overhead activities such as swimming, tennis serving, throwing or weight lifting. Simply put, the cuff aids in keeping the ball (head) of your upper-arm bone (humerus) in your shoulder socket with movement.

CAUSES, SYMPTOMS & RISK FACTORS

The cause of RC tears is multifactorial. Degeneration (which comes with age), impingement and overload, may all contribute in varying degrees to the development of rotator cuff tears.

This disease is primarily of middle aged and older patients with observational data reveals a nearly linear increase in the frequency of rotator cuff tears with age. Pain with movement and function is one of the biggest symptoms of a rotator cuff tear. However, it is important to know that a sizeable portion of rotator cuff tears are actually asymptomatic and don’t cause the person any pain or discomfort! A study by Minagawa and Yamamoto in 2013 found that in a screening of 664 village residents, 147 subjects had RC tears on a medical imaging screening. Surprisingly 65% of them had no symptoms at all and didn’t have any shoulder complaints.

Why is this important? Well if you end up going to a GP and he/she send you for a scan and finds a torn RC, most will assume that it is the cause of them pain, but as seen in the study this is definitely not always the case. Before it can be decided whether the RC tear is the causes of the pain there are numerous structures in and around the shoulder that have to be examined and “crossed off the list” of possible causes of the pain. This can only be done by a physical examination of the shoulder which can be done by an experienced physiotherapist.

TREATMENT: CONSERVATIVE OR SURGICAL

The decision of treatment for rotator cuff tears is dependent on many factors. The current literature on the topic states three main modalities of treatment for a symptomatic RC tear; these being:

Use of a corticosteroid injection Physiotherapy interventionSurgical management

The use of corticosteroid injections is commonly recommended by GP’s for treatment of pain in RC tears. They may provide pain reduction in some patients but is important that you talk to your GP about both the pro’s and con’s of these injections as the current evidence does support that these injections do in fact have a detrimental effect on tendon health and strength.

In addressing whether a surgical or conservative route should be taken, there is currently very limited literature and evidence to support one modality over the other. A study by Lambers and van Raay in 2015 looked at comparing the effectiveness of surgical versus conservative management of 56 patients with rotator cuff repairs. They followed up over a year and the results showed no significant difference in pain and disability in favour of either modality.

However, a study by Moosymayer and colleagues collected data from 103 patients with RC tears, with half having surgical repairs and half being treated conservatively with physiotherapy. They were followed up over 10 years at 6 months, 1, 2, 5 and 10 year marks. The first three follow up saw no difference in results between both modalities. However at the 5 and 10 year follow ups they found preferable outcomes for surgical repair over conservative treatment, with a small proportion of the conservative management patients opting for surgical treatment at the 5 and 10 year marks due to decreased satisfaction in results from conservative management.