• Ultimate Q&A Health Guide

    Ashley in England asks:

    “I recently had an operation after breaking part of my Tibia in the ankle. I have had two pins placed into the bone. The injury was to the inside of my ankle and I have now had a cast on for 3 weeks. I am due to have another cast put on next week. I understand it is normal for a cast to stay on for about 8 weeks depending on how well the bone fuses. The doctor said the best physio would be to move my foot around myself and get the joint functional again. As a keen footballer I just wanted to know whether you have dealt with cases like this before and the time scale involved in building my ankle back to full strength and the best techniques for that.”

    David Wales, Clinical Specialist Physiotherapist responds:

    “Obviously we can’t give a specific reply to your injury and we recommend that you follow the advice of your orthopaedic consultant and Chartered Physiotherapist. The good news is that you should make a full recovery following this type of injury, provided you follow the advice of your treating doctor. In high level soccer players the average time out is about six months.

    “Generally it takes about 3 months of immobilisation in a cast for the bone to heal adequately to do full weight bearing activities. You should wait for the go ahead to do this from your orthopaedic doctor. During the immobilisation period your ankle will get stiff and your Calf and Thigh muscles will waste. These problems can be addressed by physiotherapy treatment. To give a rough guide of the rehabilitation:

    • 8 – 12 weeks in plaster and using crutches until the orthopaedic doctor is satisfied there is sufficient healing. Once your doctor is satisfied that there is a sufficient degree of bone healing he may allow you to wear a removable plastic cast , instead of a plaster cast. Once out of the plaster cast hydrotherapy (exercises in the swimming pool) will help to restore ankle range of motion and general fitness. Pool running using a bouyancy belt is an excellent non impact form of exercise. Once you have been given permission to put partial weight through the injured leg then an exercise bike can also be used for fitness work.
    • 3 – 4 months. So long as there is evidence of fracture healing on x-ray, your doctor will give you permission to begin full weight bearing activities such as walking without a removable plastic cast or crutches. It is usually possible to begin strengthening and proprioception exercises.
      Exercise 1This exercise strengthens the muscles at the front of the shin that pull the foot back towards the knee.

    Sitting on the floor, a low resistance band is tied around the foot, with the other end attached to a fixed object that is out in front of the foot.Slowly the foot is pulled back towards the knee. 20 repetitions, 5 times daily.

    As this becomes easier, the resistance band is changed to one that provides more resistance.Tip: doubling up the elastic is an easy way to achieve more resistance.Exercise 2Sitting on the floor, with the legs out straight, a resistance band tied around the foot, and the other end held in the hand. Slowly, the foot is pushed forward and then relaxed.20 repetitions, 5 times daily.

    As this becomes easier, the resistance band is changed to one that provides more resistance.Exercise 3This exercise is a progression of the previous Calf strengthening exercises.

    The patient stands with their hands resting against a wall so that it is taking some of their body weight. With both feet, the patient pushes up on the toes so the heels rise up off the floor. This position is held for 2 seconds and then the heels are slowly lowered.20 repetitions, 5 times daily.

    Once this becomes easier, the same exercise is done but without any hands against the wall. Once this has been mastered, the patient progresses to doing the exercise with the toes positioned on a block, so that the heels have to come down lower before pushing up.

    The final progression to this exercise is to do it on the affected ankle alone.

    “Strength can be progressed using a Calf press resistance machine and Thigh strengthening should be progressed under the supervision of your physiotherapist. Muscle strength should be equal to the unaffected side before plyometric exercises (jump training) and running are resumed.

    “Proprioception exercises enhance neuromuscular control around a joint and are very important if you would like to return to sporting activities.

    Avoiding Back Pain and Neck Pain Whilst Working at a Computer

    Karim in London asks:

    “Could you provide some advice to prevent back and neck pain while I’m working on the computer?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London, replies:

    “Preventing back and neck pain whilst sitting is not an exact science, as there are always new ideas and differing opinions. There are various recommendations as to the ideal distance between your eyes and the monitor, or the perfect angle for your elbows and knees. Depending on which study you read, you will be given different recommendations.

    “When it comes to prevention, there are some common denominators on which most experts agree:

    • take regular breaks,
    • prevent your back and neck from stiffening,
    • sit in a good adjustable chair that provides lumbar support,
    • your feet should be on the floor or a footrest,
    • your desk should be large enough to allow your forearms to rest on it when using the keyboard,
    • be certain that your keyboard and monitor are at a comfortable height,
    • and avoid glare from the screen.

    “Whilst you are sitting using a PC there are a number of things you can do you prevent back and neck problems. If, for example, your neck and shoulder on the side that you use the mouse gets sore, it’s probably due the position of your arm when you use the mouse. When muscles become fatigued, they ache.

    “A good stretching exercise for these neck and shoulder muscles is shown here. This should be done intermittently throughout the day to help prevent those muscles from aching.

    “If you get soreness across the base of your neck and across your shoulder blades, it is likely that you start to slump forwards as the day goes on. Tiredness and poor posture causes your pelvis to tilt backward, your lower back flattens, and your head comes forward, in other words you become ‘C’ shaped, or sit in a ‘slumped’ position.

    “This ‘poking chin’ posture creates a lever system in the neck, with the pivot point of the lever being the base of the neck, in this ‘poking chin’ position the force through the neck is multiplied 3 x, and so your neck and shoulder muscles have to work 3 x harder to hold your head up.

    “The average weight of an adult head weighs between 8-12lb, so 12lbs of force need to be generated by the neck and shoulder muscles to hold your head up. If your head falls forward as described, the muscles now need to generate 36lbs of force to hold your head up. After a period of time, this amount of force generation will cause fatigue and pain.

    “To prevent this from occurring, move your chair in close to the PC to avoid over reaching, sit back in your chair properly. This will prevent your pelvis from tilting backwards as the backrest opposes it. If your feet cannot reach the floor comfortably, either lower your chair or use a foot rest.

    “Another very good neck exercise to stretch is neck ‘retraction’ or the chin tuck. This is performed by looking straight ahead and pulling your head straight back in, like trying to give yourself a double chin. This stretches the muscles at the base and back of the neck and opens and lubricates the neck joints. This is a particularly good stretch to do throughout the day. If this exercise causes pain discontinue it and consult a chartered physiotherapist.     

    “If sitting for too long causes back pain or soreness, it may be due to the forces that occur in the spine. When you sit in the ‘slumped’ position as described above, the normal curve of the spine is lost and the lower spine straightens. In so doing, the force distribution is lost. For example, when sitting in the ‘slumped’ position there is approximately 1.5 times the amount of compressive force through your spine than in standing. This increased force may, over a period of time, fatigue the spinal muscles and cause pain, or may lead to early degenerative changes.

    “When you sit, it is best to sit in an upright neutral posture as shown in the diagram. This maintains the natural curve of the spine and so preventing excessive loading of the lower back.

    “To prevent stiffness of the lower spine in sitting, you can gently rock the pelvis forwards and backwards – sit upright and then slowly allow the pelvis to drop backwards, and then slowly sit upright again. Then can be done whilst sitting, but you must move away from the chair backrest to allow you to drop your pelvis backwards.

    “It is also beneficial to stand frequently (every hour say) to ‘re-set’ the spinal tension that has built up over the last hour of sitting, and to allow the spine to regain it’s normal curvature. Gentle extension exercises may help the spine to regain its normal curve.

    “However, should this or any other exercise provoke any increase in lower back pain, discontinue it and consult a Chartered Physiotherapist.”

    Note – In the UK, workplace ergonomics and the use of visual display units are governed by legislation in Health and Safety (Display Screen Equipment) Regulations 1992. All employers must comply with this. It is the employers’ responsibility to undertake a risk assessment of the workplace to ensure that it is a safe working environment.

    Back Pain & Sciatica caused by Spinal Stenosis

    R. H. in Glossop, UK, asks:

    “The specialist has said that my mother’s back pain is caused by spinal stenosis. She has had sciatica for some years now. What is the treatment – will she need an operation?”

    Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

    “Most back pain is caused by disc degeneration and facet joint disease. As we get older the discs become ‘de-hydrated’ and as a consequence they lose their height. This closes down the spaces from which the nerve roots emerge from the spinal cord. This is known as spinal stenosis. Due to impingement on the nerve roots, spinal stenosis can cause pain and pins and needles in the buttocks and down the legs.

    “You and your mother’s surgeon need to be absolutely clear what the main problem is. If it is purely back pain, the source and site need to be established. A detailed examination and diagnostic investigations such as MRI scans can help to establish this. Once the definitive diagnosis has been established and if the pain is sufficiently severe, operative treatments should be considered ONLY if all non-operative treatments have been tried. These include physiotherapy (particularly core stability exercises), pain killers and injection therapy. The operations that might be considered include spinal fusion or total disc replacements.

    “If the pain is in the legs and on exercise, a simple disc decompression may be the correct operation, although full non-operative treatment must have been tried first. With regard to operations, a simple disc decompression has good results; however if either the spine shows signs of instability or if back pain is an important feature, then a fusion might be required.

    “As with all surgical treatments, these must be discussed with your surgeon and the risks and benefits discussed in detail.

    Alfie in London, UK, asks:

    “I have back pain which my doctor has said is due to degenerative disc disease. He also said that I may require surgery later. Could you explain more about this please?”

    Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

    “Degenerative disc disease (DDD) is an ongoing process that can be present in individuals who do not have symptoms of low back pain. In those who do complain of symptoms, the causes range from mechanical back pain to nerve root compression, (caused by stenosis (narrowing of the spinal canal) or a prolapsed intervertebral disc) as well as several other causes within that spectrum of conditions.

    “With such wide ranging clinical entities and causes, there is no simple answer to the question of ‘What surgical treatment should be used in DDD?’

    “In an attempt to answer the question there are several pre-requisites that should be fulfilled:

    1. Patients should have exhausted all conservative therapies and be on maximal medication.

    2. If, in spite of this, the symptoms are still sufficiently severe to limit activity to the point where quality of life is compromised, then surgery can be considered.
    3. The surgery should be directed at the pain generator and not simply an MRI abnormality!

    “These three axioms may seem straight forward enough, but they are often ignored.

    “The table below can often be used as a diagnostic chart:

    Pain Source Diagnosis Supplementary Investigations Surgical Treatment Options Alternative Treatments
    Nerve root compression Prolapsed intervertebral disc – slipped disc. MRI scan Decompression (to relieve pressure on the nerve root) and discectomy (to remove the disc) Laser foraminotomies (minimally invasive opening of the passage through which the spinal nerve roots and blood vessels pass)
    Nerve root claudication (compromise of blood supply to the nerve root) Spinal Stenosis (narrowing of the spinal column) MRI scan Spinal Decompression (to relieve pressure on the nerve root)  
    Mixed root and axial back pain Stenosis plus mechanical instability MRI scan and provocative discography Spinal decompression and stabilisation using screw fixation Wallis stabilisation ligament
    Mechanical low back pain DDD without compression MRI scan and provocative discography Spinal fusion of two vertebral levels Disc replacement

    “Essentially, for those who exhibit neural compression, MRI scan be used to confirm the diagnosis and direct the treatment. However, it should be remembered that in the case of a prolapsed intervertebral disc, there has been a major failure of a large avascular structure in the spine. Back pain and ongoing symptoms are extremely common. In some studies it has been estimated that up to 66% complain of ongoing leg and back pain, even 10 years after surgery that has been reported as being technically successful from the surgeons view point.

    “For those who complain of central back pain, the problem of spinal instability has to be addressed. The surgical method of addressing this falls between fusion of two vertebral levels or maintaining movement between these vertebral levels. The results of spinal fusion for back pain are dogged by poor quality research papers and misleading articles. The results of a Swedish study suggest that in the majority of patients who undergo fusion, there will be reduced pain although the operation is obviously a major undertaking.

    “Total disc replacements have been around now for over 15 years and the results in selected studies appear encouraging, although the long term behaviour of the disc is as yet unknown.

    “As back pain affects over 65% of the adult population at some time in their lives, and is the major cause of sickness and disability in the working population, the search for ‘cures’will continue. Unfortunately, some devices meet with more media interest than scientific proof and as such should be carefully examined both by patients and those healthcare professionals involved in the treatment of such conditions.

    “Back pain can be viewed as a lifelong condition which has to be managed wisely, using all of the evidence available to us, both on an individual patient basis and from a critical review of the scientific evidence that is published in the journals and the press.

    Back Pain Relief with Trigger Point Injections

    Andrew in Sheffield, UK asks:

    “A pain specialist suggests Trigger Point Injections or Intramuscular stimulation for my longstanding back pain. Could you explain more about this before I have it done?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London replies:

    “Muscle shortening can produce pain. It can often be felt in the muscle as tight ropey bands or as small points within a muscle. Small areas of muscle tightening associated with tenderness when palpated are often known as trigger points. A shortened muscle can be released by either injection of a chemical into the shortened area or by ‘desensitising’ the tight area by using sterile acupuncture needles. When a shortened muscle is released, pain which is caused by the shortened muscle is also eased.

    “Trigger point injection is when a pain specialist or rheumatologist injects these trigger points with some sort of anti-inflammatory medication or muscle relaxant. The idea is to release the tension within the tight muscle and to relieve the pain associated with it. There are obviously side effects with any injection therapy.

    “Intramuscular stimulation works by releasing the tight muscle areas by needling the trigger point with thin acupuncture needles. As the acupuncture needle is solid it tends to be a lot smaller in diameter than a hollow needle used for injections, so there tends to be less discomfort. When a needle is inserted into a normal muscle, there is minimal resistance felt. When a needle is inserted into a trigger point, there is more resistance felt and often the needle is grasped or held by the tight muscle fibres. Sometimes the tight trigger points actually twitch as the needle is inserted, if this occurs, there tends to be immediate muscle relaxation of the trigger point, and so relaxation of the muscle. Multiple trigger points can be needled in one session allowing a large muscle to be treated. Alternatively many different muscles can be treated in one session.

    Biceps Tendon Tear Surgery & Recovery

    Bob, Choctow, Oklahoma asks:

    “I was lifting a very heavy weight and heard a pop in my lower bicep area. I’ve been told that it is probably a tendon tear. I can still move my arm up and down, but I have lost a significant amount of strength.  There was a small amount of swelling at the crook of my arm and there was bruising from my wrist to mid upper arm. Will this require surgery to repair? How long is the recovery? I work out with free weights about 3 times a week.”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “From the description you have given, it would appear that you have suffered a distal biceps tendon tear. This injury is most commonly caused by a vigorous eccentric contraction (lengthens whilst contracting) of the biceps muscle, similar to the mechanism you have described.

    “The symptoms you have reported are textbook for this injury:

    • a popping felt at the elbow;
    • localized swelling and bruising at the area;
    • and a significant loss of strength in elbow flexion and supination.

    “The more severe the injury, the easier it is to diagnose. When the tendon is completely ruptured, the biceps muscle will retract towards the shoulder, resulting in a ball-like appearance ½ – ¾ of the way up the arm. The tendon can be partially torn, which appears to be the case in your situation .

    “The surgical decision depends on the severity of the injury and the activity level of the patient. In most cases, complete ruptures of the tendon require surgical correction, which involves reattaching the tendon to its insertion site.

    “The decision regarding partial tears is a little more involved. The activity level of the patient (low demand vs. high demand) will be one of the primary determining factors. Low demand patients (minimal labor-intensive activities) will typically do well with conservative treatment (rehabilitation). High demand patients will usually require surgery to allow them to return to labor-intensive activities or athletic competition.

    “This surgery involves reattaching the torn portion of the tendon. If most of the tendon is torn and is functionally deficient, the surgeon may detach the remaining intact fibers, and perform a complete surgical correction.

    “The recovery after reattachment of a complete rupture is a very gradual process, and the speed at which the rehabilitation can be progressed is based on the healing process. Very basic exercises for ROM (Range of Movement) are performed initially for the first 6-8 weeks, followed by light strengthening exercises. These are started with 1 pound weights and gradually increased as strength and symptoms allow. Light weight training can be performed (bench press, shoulder press) at the 3 – 3 ½ month post-op mark. Generally speaking, strength becomes normalized anywhere between the 6-9 month post-op period, which includes a return to full unrestricted function.     

    “The recovery after a partial tear can be significantly less, but is heavily dependent upon the size of the tear and how much had to be reattached. The physician will typically dictate the post-op progression based on the surgical findings.”

    Can a Torn Meniscus Heal without Surgery?

    Josh in NSW Australia asks:

    “I have torn my meniscus. Is there any way that this can heal without having surgery?”

    Marc Bernier and Douglas Palma, at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), reply:

    “As recently as 1970, the meniscus was thought to be a vestigial structure with little function. However, our knowledge has since expanded and we now realize their importance in the normal function of the knee. The functions of the meniscus include load bearing, shock absorption, and joint stabilization, all of which are vital characteristics in preventing deterioration of the joint, which is very vulnerable in the sport of soccer due to the nature of the game (extensive cutting, pivoting, etc).

    “The meniscus is composed of two semilunar fibrocartilaginous disks that are found between the distal femoral condyles and tibial plateau. They both are approximately c-shaped with a thick peripheral rim that taper to a thin inner edge, which in cross section appear as a triangle. Each one has a distinct shape and features. The medial meniscus is semicircular, approximately 3.5 cm in length, and is wider posteriorly than anteriorly. It has an average excursion on flexion and extension of the knee of 5mm, which is less than the lateral meniscus. It is also continuously attached to the joint capsule and at its midpoint to the deep medial collateral ligament. The lateral meniscus is circular and covers a larger portion of the tibial plateau than the medial meniscus. It has loose peripheral attachments to the joint capsule and an average excursion of approximately 11mm during flexion-extension movements of the knee.

    “The annual incidence of injury to the meniscus ranges from 60 to 70 per 100,000, with an estimated 850,000 meniscal procedures performed each year. There has been found a male-to female ratio of approximately 2.5-4 to 1. Higher incidences of meniscal injuries have been found with anterior cruciate ligament injuries (lateral meniscus more commonly affected) and tibial plateau fractures.

    “A thorough history and physical are essential to diagnosis. Most injuries are sustained from a twisting injury with the knee flexed and the foot planted on the ground. A pop could have been felt but is not always the case. A history of catching, locking, or popping may aid in the diagnosis of a meniscal tear. On physical exam, joint line tenderness and provocative testing (i.e. McMurray or Apley tests) are essential to confirm the pathology. MRI can be confirmatory, but is not 100% sensitive or specific.

    “Once the diagnosis has been made and confirmed, a treatment plan can be implemented. The decision must be made to either perform an excision of the torn fragment of the meniscus (partial menisectomy), or perform a repair of the tear. Many years ago, total menisectomies were the treatment of choice; however, it has since been found that removal of the entire meniscus resulted in a 200% increase in contact pressure within the joint. As a result, the technique of performing partial menisectomies was developed.

    “Initial research indicates that even with partial menisectomies, contact pressures increase by approximately 65%. This has lead to attempts at repairing meniscal tears, in which the “loose ends” of the tear are sutured or anchored together, and allowing healing to occur similar to that seen in skin lacerations. Unfortunately, research indicates that a small minority of all meniscus tears are amenable to repair.

    “Tears that occur in the vascular zone of the meniscus (“red-red” zone, outer 20-30%) have the greatest potential to heal, while tears at the vascular boundary (“red-white” zone) have somewhat less healing potential. Tears located entirely within the avascular zone (“white-white” zone) have limited potential to heal; nutrients are supplied by the synovial fluid. However, some physicians have advocated repairs of meniscal tears in this avascular region, with reports of acceptable success rates.

    “Other determining factors in the ability to repair meniscal tears include the size, type and location of the tear, degree of degeneration within the joint, and complexity of the tear. If the characteristics of the tear are not conducive to repair, partial menisectomy is the next treatment option in the soccer athlete.

    “Rehabilitation in the post-operative phase and return to play differ depending on the surgical procedure performed. In the case of partial menisectomies, weight bearing is allowed to tolerance, with an accelerated progression to closed kinetic chain and proprioceptive exercises. Typically, the rate of progression is dependent upon pain and effusion, with a usual return to play in 4-6 weeks. If a meniscal repair is performed, a much slower program is followed, with a more restricted weight bearing gait pattern that is gradually increased. Progression to closed chain activities occurs more slowly, with a goal of a return to play in 5-6 months.

    Can Spondylolysthesis cause Complications During Pregnancy?

    Sue in Dorset, UK asks:

    “After suffering with back pain since my teens I was recently diagnosed with Grade III spondylolisthesis. My husband and I are thinking of starting a family. Could my injury cause any complications during the pregnancy?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London replies:

    “Spondylolisthesis is a fracture of the lumbar vertebra with a forward slippage of one of the fracture fragments – the front most aspect of the vertebra, the vertebral body. Apart from local low back pain this condition can cause referred pain in the legs, due to impingement of the spinal nerve roots.

    “The answer to your specific query about pregnancy is yes on two counts.

    “Firstly, if your Spondylolisthesis is a Grade III, it means that the forward slippage of the front part of the vertebra is 75% or above, relative to the normal spinal alignment. This can cause difficulty with vaginal birth. Your obstetrician should be consulted BEFORE you get pregnant. He or she will then be able to assess the shape and size of your pelvis, to see whether it would be possible to have a trail of labour, or whether it would be simply be best to opt for a caesarian section.

    “One method of pain relief can be achieved when TENS acts as a physiological inhibitor of impulses from the pain receptor, in a process often referred to as the ‘Pain Gate Mechanism’. This occurs because, when set at a higher frequency, the TENS unit stimulates different pain receptors which override the painful stimulus. This is the electrotherapy equivalent of rubbing your knee after you’ve fallen on it. The counter stimulation provides pain relief.

    “Secondly, depending upon the level of pain that you have at present, it is likely that the level of pain during and after pregnancy will increase. You should be physically as well as you can be before becoming pregnant to minimize the potential risks to you and your baby.

    “Always remember that planning BEFORE the event is the best option, and if you are in any doubt, your treating doctors should discuss things with you and ideally should discuss things between themselves at an early stage.”

    CAT Scan, MRI Scan and Myelogram for Back Pain & Leg Pain

    Simon in Aylesbury, UK, asks:

    “I have just returned from long awaited appointment with a neurosurgeon – I have had back pain which goes down my leg for nearly two years. He is sending me for an MRI scan and CT scan, and a myelogram. He didn’t explain exactly what these were and I felt a bit stupid asking as he seemed to be in a hurry. Could you tell me more about these tests?”

    Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

    “An MR, MRI, magnetic resonant scan or a magnetic resonance image are one and the same thing. It is a scan that doesn’t use x rays and allows the spine, the nerves and the soft tissues (i.e. intervertebral discs) to be seen clearly. There are two types, an open one which is used for claustrophobic patients and a closed scan that is for the majority of patients. YOU MUST NOT BE PREGNANT, HAVE PACEMAKERS OF ANY SORT OR METALLIC OBJECTS IN YOUR EYES OR BRAIN – IF IN DOUBT ASK! Occasionally, if you have had a previous operation, an additional MR scan using dye injected into your vein may be performed.

    “A CT or CAT are the same things. It stands for Computerized Tomogram or Computerized Axial Tomogram. It does the same as an MRI but uses x-rays instead of a magnet. This scan shows better definition for bones, but less good definition for the soft tissues, such as nerves and discs. YOU MUST NOT BE PREGNANT, AND MUST NOT BE ALLERGIC TO IODINE FOR THIS TEST – AND YOU SHOULD LET YOUR DOCTOR KNOW IF YOU ARE..

    “A myelogram is perhaps the oldest method of imaging the nerves and involves injecting dye (which is clear to our eyes but shows up on x-ray, into the spine. X-rays and or a CT scan is then taken to see where the dye might be held up. (Rather like seeing a traffic jam on a road and then seeing a few cars going through the road works). YOU MUST NOT BE PREGNANT, AND MUST NOT BE ALLERGIC TO IODINE FOR THIS TEST.

    “I would like to add that you should not feel silly when you ask your doctor questions. I ask my mechanic what he is going to do to my car and he explains it nicely as he knows I know nothing about “cam belts” and HT leads. In fact he enjoys answering the easy questions. Please ask your doctor – we do understand. After the scans it is VERY important that you ask your doctor what the results are and that you understand this before coming to a joint decision on treatment – it is your body after all.

    Conservative Treatment of Disc Prolapse & Back Pain

    Verantha in Chandigarh, India asks:

    “I have been told I have a disc prolapse that should improve with conservative treatment. Could you explain what this means? Will I always have back pain?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London replies:

    “Conservative treatment is a common term used for describing treatment that is non-surgical. As most people who have low back pain don’t need surgery, conservative treatment plays a major role in treatment and should always be the first option when you have lower back pain that is not caused by major trauma.

    “Lumbar discs are composed of two main parts: a tough fibrous outer layer (annulus) and a jelly like inner part (nucleus). The discs act as shock absorbers and dissipate the force through the spine. All discs have sensory nerve endings in the outer portion of the disc and are known to be a potential source of back pain – normal discs do not cause pain. Abnormal discs with either tears of the outer layer or a prolapse (a leaking) of the jelly like inner part of the disc will cause pain. If the disc is ‘bulging’ because it is slightly degenerate or the prolapsed material is touching a spinal nerve pain will often be felt into the buttock and down the leg.

    “Early intervention by a qualified healthcare professional is vital to help prevent further ‘leaking’ of the nucleus and to minimise the likelihood of further episodes of lower back pain. Studies have shown that after the first episode 90% of people improve and do not have another episode of low back pain. After a second episode of lower back pain, 90% improve and 50% of these have a relapse at some future stage. Following a third episode, 90% improve and 10% relapse.

    “This means, of 100 people with a disc prolapse 90 will improve and have no pain again, while 10 will have further problems. Of the 10 people who have a second episode of pain, 9 will improve but 5 will have another episode of pain in the future. Of the 5 people who have a third episode of pain, 4.5 will improve and 0.5 will not, but all 5 are likely to have further episode of lower back pain.

    “Basically, the more episodes of low back pain that you have the less chance you have of improving and there is an increase in the likelihood of repeated episodes of pain. This is why early intervention by a qualified healthcare professional is vital.

    “Physiotherapy treatment aims to relieve pain and inflammation, prevent further damage and also re-train muscles that provide stability to the spine and help ‘absorb’ the forces put through the spine. A Chartered Physiotherapist is also able to give specific advice regarding posture and recommend changes to work and sporting practices which will help prevent back problems. Generally, positions of flexion such as bending over and sitting exacerbate the disc prolapse and should be avoided. An understanding of the causes of low back pain can be explained by the Chartered Physiotherapist. In most cases poor posture and a lack of muscular stability are usually implicated.

    “In the very acute phase (first 48 hours) of a disc prolapse, various anti-inflammatory procedures can be used to reduce inflammation and pain. Acupuncture and ultrasound may be helpful although Non Steroidal Anti Inflammatory medication have been shown to be most effective for pain relief in this stage.

    “Once the acute period has passed physiotherapy treatment aims to minimise joint stiffness. This is achieved using passive joint mobilisation, manipulation of the spinal joints and self mobility exercises/postures. Usually, the main exercise you will be asked to do is that of extension which is leaning backwards by propping yourself up on your elbows when lying on your front. This mobilises the joints but more importantly closes the area of the prolapse and reduces the disc prolapse. If the disc prolapse is reduced the tear in the disc can heal.

    “After the initial pain has subsided, remedial exercises to strengthen the spine are very important to restore normal spinal movements and muscle strength. The main aim of exercise is to encourage mobility, reduce muscle spasm, prevent further deterioration in the muscles and speed recovery.

    “A Chartered Physiotherapist will tailor your exercise program for you and it normally depends on the type of condition, its severity and your fitness level. Exercises should be performed in all planes of motion, that is forward/backward, side/side and twisting as these are the motions that occur during everyday activities. There are now specialised clinics that specialise in ‘Spinal Rehabilitation’ such as the back2normal clinic in London. Not only do these clinics have spinal specialist staff, but also unique equipment which is able to very accurately measure, re-train and improve spinal function.”

    Dislocating Knee (Subluxing Patella)

    Sarah in Mirfield, England asks:

    “I have a condition called subluxing patella. I also have a torn meniscus cartilage. My problem is not due to an injury as I have been able to ‘dislocate or sublux’ my knee from an early age. Over the past five years this has got extremely worse (it also comes with a very loud cracking sound, which freaks many a hospital staff out, apparently they have not seen a case as extreme as mine). My knee will dislocate anything from 15-30 times a day. Such as when I’m bending down, pivoting, using stairs or after I walk too far (running is out of the question). I have Hypermobility syndrome although I have no other real problems but the knee. It’s the right knee that’s affected. Occasionally my left knee will dislocate but only once or twice a week.

    My knee is totally unstable, and restricts everything I do. I am currently waiting my second arthroscopy to fix my meniscus, although my consultant said this is unlikely to make much of a difference.

    I have some questions about this and was hoping you could help.”

    David Wales, Clinical Specialist Physiotherapist responds:

    “Will physiotherapy help? “

    “As a physio I am always inclined to say that it is worth doing physiotherapy rather than not, although considering that you have had your problem for quite some time and have seen no improvement then I have to say that physiotherapy treatment will not cure your problem.”

    “If my meniscus is torn due to the subluxing, will this happen again in time? “

    “The menisci and knee joint generally are susceptible to further damage whenever there is knee joint instability. Hyper Mobilty Syndrome represents extreme instability so if you are repeatedly suffering these injuries then you may suffer further damage.”

    “What are my chances when it comes to arthritis?”

    “Arthritis tends to be accelerated secondary to joint damage. Because you are subluxing or dislocating over 15 times each day then the chances of developing arthritis are increased if your situation is not addressed. However, damage to joint surfaces from dislocation and subluxation tends to be less in individuals who have lax joints and Hypermobility Syndrome. In these individuals the joint pops out so easily there may be little or no tissue damage.”

    “What is the best knee support/brace that I could get to help support my knee?”

    “The most appropriate knee brace for Patellofemoral Instabilty is the Donjoy Hinged TRU PULL Advanced Knee Brace. However this brace is designed for people who have suffered one or two subluxations or for those with pain around the knee cap due to Patellofemoral Pain Syndrome. I don’t think that this brace will be effective in your case, due to the very severe symptoms and the way that Hypermobility Syndrome is affecting your knees. Patella subluxations tend to occur when the knee is bent, or when there is rotation of the knee so it is worth asking your orthopaedic doctor if a hinged knee brace that limits the amount of knee bend, such as a good quality Hinged Knee Brace would be suitable for your right knee.”

    “Will my left knee eventually do the same in time?”

    “Due to the fact that you have Hypermobility Syndrome then your left knee may also become more affected, but it is impossible to predict with certainty.”

    “What other damage could be caused in the future?”

    “As you’ve alluded to earlier, meniscal damage and general joint damage may precede osteoarthritis of the affected joints. However, damage to joint surfaces tends to be less in individuals who have lax joints and Hypermobility Syndrome, where the subluxations are relatively less painful and the joint goes back in place easily.”

    “Is there anything I should avoid that might make this worse?”

    “Try and avoid all the specific movements which you know tend to cause a subluxation. However I understand that this may be very difficult in your case, due to the subluxations occurring during such trivial, everyday activities.”

    “Overall I would recommend that you consult an orthopaedic consultant who specialises in knee problems, particularly Patellofemoral problems. They will be able to give you specific advice following a thorough history and physical examination of your knees. There are many factors to consider related to Patellofemoral Instability and the orthopaedic consultant will be able to explain these to you following his assessment of your knees. The orthopaedic consultant will also be able to let you know if a non surgical or surgical approach is indicated. There are several surgical approaches to Patella Instability, with the more modern techniques having a particularly good degree of success.”

    Exercises for Ankle Strengthening

    Phil in Kent, England asks:

    “Since a young age I have always had weak ankles due to repeated sprains. This problem seems to have persisted. What sort of excercise can I do to strengthen the ankles?”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “Contrary to popular belief, ankle sprains are not necessarily ‘minor’ injuries. While it is true that most athletes recover relatively quickly from these injuries, it is not uncommon for them to turn into chronic pathologies that result in significant residual physical deficits. Proper rehabilitation is required to ensure that all physical deficiencies are addressed, especially in athletes with a history of multiple injuries.

    “The traditional treatment of ankle sprains, as with most other injuries, has focused on the following objectives:

    • reducing pain and swelling;
    • restoring joint range of motion and muscular flexibility;
    • increasing muscular strength and endurance.

    “In many instances, the strengthening programs that were implemented involved resistive exercises using surgical tubing and calf raises using either the athlete’s body weight or weight machines. Once an athlete was able to progress through these exercises, a return to play ensued.

    “In recent years, more attention has focused on the benefits of functional, sports related strengthening of the entire lower extremity in the treatment of ankle injuries. During these types of programs, more emphasis is placed on single leg balance activities and exercises that force the athlete to stabilize the involved lower extremity against some form of external resistance.

    “In performing these types of exercises, the athlete is simulating movements and body positions that he will encounter while playing (additional benefits include re-training some of the neuromuscular pathways that are disrupted after injury, but are beyond the scope of this article). Functional strengthening is much more challenging to the muscular system, and helps to resolve the residual deficits that can lead to chronic injuries.

    “The initial phase of strengthening will still involve the use of surgical tubing for resistive exercise (Figure 1). This is performed in all planes of movement, with the most important being the inside and outside (inversion and eversion) planes. Calf raises are also performed, starting from a standing position and progressing to weight machines which allow additional external resistance.

    Figure 1

    “The next phase involves single leg balancing activities. Initially, these are performed with the foot flat on the floor, and progress to a ‘heel raised’ position (Figure 2). The ‘heel raised’ position forces all of the stabilizing musculature of the ankle to become activated simultaneously to avoid either rolling the ankle over or the athlete falling down. Once this is mastered, the same exercises are performed with the athlete standing on an unstable surface such as foam or a balance disc (Figures 3-4).

    “The next progression incorporates some form of sport-specific skill into the exercise program. For instance, soccer players will perform volleying while standing on an unstable surface (Figure 5); basketball players will catch and pass a ball.

    Figure 5

    “The final progression introduces plyometric exercise to the program. This is accomplished via single leg hops or jumps in multiple planes. Initial emphasis is on the ability to “stick the landing” after a jump, with subsequent emphasis on endurance.”

    Exercises for Knee Pain caused by Patello-Femoral Syndrome

    Miranda, in London, England asks:

    “I get knee pain when I attempt to exercise and my physio says it is Patello-Femoral syndrome. She has tried taping it, but I still get pain. Are there any exercises that will take my pain away?”

    Marc R. Bernier, MPT CSCS responds:

    “Patello-Femoral Stress Syndrome (PFSS) is a generic term that is often used to describe generalized knee pain that centers around the kneecap (patella). The pain that is associated with this condition is thought to be the result of either abnormal tracking (movement) of the patella during flexion/extension of the knee, or excessive stress being placed on the patello-femoral joint during functional activities. Over the years, many theories have been proposed as the primary cause of this condition:

    1. Quadriceps / Vastus Medialis Oblique (VMO) muscle weakness
    2. Muscular tightness
    3. Iliotibial band (IT Band) tightness
    4. Hyper-pronation of the foot
    5. Bone structure abnormalities

    “As a result, treatment methods typically focused on the following:

    1. Strengthening of the quadriceps (more specifically, the VMO)
    2. Stretching of the quadriceps, hamstrings and IT Band
    3. Orthotics to control hyper-pronation
    4. Patellar taping to correct abnormal tracking of the patella

    “Unfortunately, despite our best efforts, the above treatments seemed successful only 50-60% of the time.

    “The latest research into this condition has led to an increased focus on the proximal (anatomy closer to the trunk) influences on the patello-femoral joint, mainly the role of the Gluteus Medius muscle of the hip. This muscle is located at the top of the buttocks and can usually be palpated just above the back hip pocket. This muscle is responsible for both abducting (raising out to the side) and externally rotating the leg. However, it’s more important function is its role when the leg is in a weight-bearing position. During running, cutting and planting maneuvers it prevents the thigh from ‘buckling’ and rotating inwards, which is the ‘position of danger’ for knee injuries (especially Anterior Cruciate Ligament injuries). It is also a position that causes significant stress to the patello-femoral joint, as the Patella will have a tendency to be pulled laterally (towards the outer side), causing stress to the Patello-Femoral joint and soft tissue that surrounds it.

    “Several studies have shown that weakness of this muscle may be a primary cause of PFSS, especially in females. A study performed on long distance runners with Ilio-Tibial Band syndrome revealed a 90% success rate by implementing a Gluteus Medius strengthening program alone. I have also seen a very high correlation between hip weakness and PFSS incidence in females, and implementation of a hip strengthening program has resulted in a drastic increase my success rate in resolving this condition.

    “The program I implement with my patients (especially the female athletes) is a two phase program, and is based on the premise that the hip will control the position of the knee. The first phase focuses solely on Gluteus Medius strengthening. Strengthening of this aspect of ‘the core’ will better enable the patient to control the lower extremity and keep the knee out of the ‘position of danger’. Once this baseline strength has been established (2-3 weeks minimum), the second phase of Quadriceps/Hamstrings/Gastrocnemius strengthening can be initiated. It must be emphasized that implementing a general lower extremity strengthening program before resolution of the hip weakness will result in continued knee pain.”

    Side Lying Abduction

    Side Lying ‘Clamshells’

    Prone Hip External Rotation

    Single Leg Bridging

    ‘Donkey Kicks’

    Standing Abduction with Surgical Tubing

    Exercises for Wrist Pain and Thumb Pain

    Geoff, in Leeds, England asks:

    “I have had pain on the inside of my wrists and thumbs for many years and an x-ray has shown there is degeneration in the joints. Are there any exercises I can do that will help me?”

    Chris Smith, Occupational Therapist, HealthSouth Sports Medicine and Rehab Center, Birmingham, Alabama responds:

    “Carpo-Metacarpal degenerative joint disease (CMC DJD) is the most common condition in cases of wrist degeneration. As the thumb is involved most during gripping activities it is usually the CMC joint of the thumb that suffers from degeneration. Pain at the base of the thumb can be a considerable problem, with the patient frequently unable to unscrew jars and bottles.

    “Degeneration can be due to systemic disease such as Rheumatoid Arthritis, or due to ‘wear and tear’ which is medically classed as Osteoarthritis. Osteoarthritis of the CMC joint of the thumb is more prevalent in older people, and affects women at a much higher rate than men (approximately 5 to 1).

    “The thumb CMC joint complex is comprised of the Scaphoid and Trapezium (two of the eight ‘carpal’ bones of the wrist), and the thumb Metacarpal (the long bone of the base of the thumb).

    “Due to the large range of movement required at the base of the thumb, several ligaments, and the boney structures mentioned above, are relied upon to maintain stability while also allowing extensive movement in all planes of motion. Damage or overuse of these structures can place high loads through the base of the thumb and lead to degeneration.

    “Studies have shown that thumb tip pressures are multiplied by around 6 times during pressing activities, so if the pressure through the thumb tip is 2kg of force, then there is around 12kg of force going through the CMC joint. Rotational forces during gripping activities also place large stresses on this joint. In cases of CMC degeneration of the thumb, the bone that has degenerated is most commonly the Trapezium, although the Metacarpal is also affected.

    “Specific x-ray views ordered by a doctor can be helpful in ascertaining the extent of the degeneration. Even if the x-rays confirm degeneration, other conditions such as Carpal Tunnel Syndrome will have to be ruled out, although in some patients the two conditions exist concurrently.

    “The most advantageous treatment intervention for thumb CMC joint degeneration is immobilization of the thumb joint with splinting. This can be accomplished by simply purchasing an off-the-shelf hand based thumb spica splint or having a custom splint made (shown below). The splint should be worn at all times excluding showers and while performing the designated home exercise program.

    “The patient needs to remove the splint numerous times throughout the day (5-8) to perform thumb range of movement exercises to prevent muscle wasting and the formation of scar tissue that can limit range of movement. These exercises are very straightforward, simply moving the thumb through it’s available range – touching each of the other fingers in turn with the thumb, then circling the thumb several times.

    “Attempts to strengthen the muscles around the thumb in cases of thumb degeneration only exacerbate the symptoms and prolong the necessity of splint use. If there is pain, modalities such as icing for 15-20 minutes can be used under the supervision of a physiotherapist in conjunction with the splint wear to decrease acute symptoms.

    “If a reduction in pain is not noticed within 1-3 months, the patient should consult an orthopedist. Surgical options are available in more advanced cases.”

    Exercises to Strengthen the Rotator Cuff Muscles in the Shoulder

    Brian, in Wiltshire, England asks:

    “Since childhood I have had frequent subluxations in both shoulders which I can pop back in. An orthopaedic specialist told me that my rotator cuff muscles were extremely weak and advised me to strengthen these with the physio. Could you suggest some exercises that might help me?”

    Marc Bernier, Senior Physical Therapist, Director of Healthsouth Soccer International, replies:

    “In cases of congenital instability of the glenohumeral joint of the shoulder complex (as appears to be the case in your situation), the primary treatment option is rehabilitation that focuses on strengthening of the rotator cuff musculature. The rotator cuff is a group of relatively small muscles that are located deep in the shoulder and surround the joint. The primary function of these muscles is to provide dynamic stability to the joint. The goal during rehabilitation is to enable the rotator cuff to provide enough dynamic stability to compensate for the lack of static stability that is usually provided by the ligaments in the joint (these ligaments become either stretched or torn during subluxations).

    “There are many excellent exercises that can be performed to focus on the rotator cuff. These exercises consist of movements that must be performed with perfect form to ensure that the proper muscles are being isolated. In our facility, we also place a heavy emphasis on strengthening the scapular (shoulder blade) stabilizers; weakness of these muscles will result in a shoulder blade that tilts downward, further contributing to instability of the shoulder. It is also important to note that the rotator cuff is an endurance type of muscle group, and therefore requires the use of lighter weights and high repetitions. I typically start my patients with 3 sets of 15 repetitions, and will progress to 5 sets of 30 repetitions depending on the particular exercise being performed.

    “The following are a sample of some of my favorite exercises for rotator cuff strengthening:

    Sidelying External Rotation

    Lie on side with arm resting on stomach and a small rolled up towel under the arm. Slowly rotate arm upwards and stop when forearm is in a position just above horizontal. This exercise can be initiated using a 2-3 pound dumbbell.

    Prone Horizontal Abduction

    Lie on stomach with arm hanging over side of table and the thumb facing forward. Slowly raise arm straight out to the side and stop when arm is parallel to the body (going higher can cause excessive strain to the front of the shoulder).

    Prone Elevation in the plane of the Scapula

    Begin in the same position as in the exercise above, except rotate your hand so the thumb is rotated 45° out to the side. Slowly raise arm in a plane 45° forward and stop arm just below parallel to the body (going higher can cause impingement of the rotator cuff).

    Prone Row with External Rotation

    Begin in the same position as above, except rotate your hand so the thumb is facing towards the body. Perform a rowing motion with the elbow in the same plane as the shoulder, and stop when the elbow is even with the shoulder. After achieving this position, rotate the arm upwards until the forearm is just below parallel with the body. Next, rotate the forearm back down to the previous position, and then lower the arm back down to the starting position.

    External Rotation with Thera-tubing (surgical tubing)

    Stand while holding the tubing across your abdomen, with a rolled towel between your arm and body. Slowly rotate arm out to side until hand is pointing straight forward, and hold for 3 seconds. Slowly return to start position. It is important that the elbow is kept at a 90° angle throughout the motion; the motion should simulate sliding your forearm on top of a table.

    Horizontal Abduction with Thera-tubing

    Stand facing toward the attachment site of the tubing, with the arm extended straight out in front of you. Slowly pull arm backwards and out to the side, keeping the arm at shoulder height. As you perform this motion, try to pinch the shoulder blade backwards/inwards.

    Rows with Thera-tubing

    Hold ends of tubing in each hand. Perform rowing motion backwards, keeping elbows elevated at least 60° away from body. When elbows are approximately ½ of the way to the body, complete the motion by pinching the shoulder blades together.

    Standing Elevation in the plane of the Scapula

    Stand with dumbbells in your hands, with hands rotated 45° out to the side. Slowly raise arms at 45° angle approximately ¾ of way above head.

    “It must be stressed that all exercises performed with dumbbells must be performed with light weights (2-3 pounds); using heavy weights will strengthen the larger muscle groups more (deltoids, lats) resulting in a possible muscular imbalance.

    “These are just a small sample of exercises that can be performed. While all of these are very good at isolating the rotator cuff, not all may be appropriate to perform initially during the program.”

    Fitness Tests following Calf Strain Injury

    Griffo, in Sydney, Australia asks:

    “I have a star point guard who has been out for 5 weeks with a calf strain and he believes he is ready to return. I have been told I need to put him through a skills test to see if he can return to play. Can you suggest a suitable test?”

    Marc R. Bernier, Senior Physical Therapist responds:

    “Functional testing is an integral component of the rehabilitation program that will help determine when an athlete is prepared for a return to the basketball court. The testing protocol used can vary significantly from one clinician to another and will vary depending on the sport. However, it is important to ensure that the key physical attributes that are inherent to the particular sport are tested in a sport-specific manner. Therefore, the use of one test will not be sufficient in these regards.

    “Before a functional testing program can be implemented, we must first examine the sport-specific movements that will be necessary in order to compete in basketball:

    1. Explosive power
      This is required to achieve maximum jump height or when changing direction.
    2. Acceleration/deceleration
      :This is required during sprints and slowing down to stop or change direction; the ability to control body weight when landing from jumps.
    3. Agility/footwork
      Being able to move the feet quickly while carrying out basketball skills .
    4. Muscular endurance
      The ability to maintain repeated high intensity workloads while resisting fatigue .

    “Each test recommended below will determine an athlete’s capabilities in at least one of the abovementioned components of basketball-specific fitness. It is important to note that the tests include both qualitative and quantitative assessments of the player’s ability:

    1. Shuttle Run
      The athlete runs successive sprints starting at baseline, increasing the distance on the court each time (i.e. to foul line and back; to midcourt and back; to opposite foul line and back; to opposite baseline and back). This test is commonly used as a fitness assessment, but the purpose here is to qualitatively evaluate the player’s ability to accelerate, decelerate and change direction. The clinician will look for signs of limping or compensations in running pattern or an inability to push off with sufficient power when changing direction

      This test can also be used as a cardiovascular or muscular endurance test by having the athlete perform multiple repetitions of the shuttle run.
    2. Yo-Yo Runs
      The athlete runs repetitively forwards and backwards over a predetermined distance (I prefer 10 meters) with an emphasis on a rapid, explosive change in direction. This also is a qualitative assessment of the player’s ability to change direction by generating power through the legs, particularly the calf musculature.
    3. Single Leg Vertical Hops
      The athlete repetitively hops off one leg for 30 seconds, with a qualitative assessment being performed in regards to overall height, fatigue and jumping/landing ability between each leg.
    4. Single Leg Jump for Distance
      The athlete jumps as far forward as possible, jumping and landing on the same leg (the athlete must ‘stick’ the landing and not lose his/her balance). This is done on each leg, and a percentage comparing the injured to the uninjured side is calculated. A passing score is 85% of the uninjured leg.
    5. Timed Single Leg Hop for Distance
      The athlete hops off one leg as fast as they can over a 10 meter distance. The time taken to cover the 10 meters is documented, and a percentage comparing the injured leg to the uninjured leg is calculated. Again, a passing score is 85% of the uninjured leg.

    “The above tests will give you a qualitative and quantitative assessment of the player’s physical ability, and a more accurate determination of his/her readiness for clearance to unrestricted participation in functional basketball activity.”

    Football Team Fitness Training

    Tony in Sussex, England asks:

    “My football team is getting ready for the new season. What sort of training should we be doing to make sure we are fit?”

    Marc Bernier, Senior Physical Therapist at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “Conditioning for the sport of football has transformed from the days of performing long distance running at moderate paces, to more dynamic approaches that incorporate all components of athleticism. In order to optimally train for football, it is imperative that the training approach be specific to the demands placed on the athlete during matches. Interval circuit training can be an ideal approach to both enhance a player’s fitness and also improve his athleticism.

    “The goal of any conditioning program should be to make the player a better athlete, not a better long distance runner. The most effective training sessions will emphasize the following components:

    1. Anaerobic fitness (sprint recovery)
    2. Acceleration and deceleration
    3. Agility and footwork
    4. Core strength
    5. Lower extremity power
    6. Aerobic fitness (Interval circuit training)

    Anaerobic fitness

    “The nature of the sport of football dictates that players must be able to perform repetitive series of sprints at maximal intensity, with the ability to recover quickly between each sprint being the critical factor. Shuttle runs and multiple sprints (i.e. 10 x 30 meters) are appropriate methods to use, with emphasis on decreasing rest times between repetitions.

    Acceleration and deceleration

    “Although speed is an ideal trait in any athlete, the ability to accelerate over short distances is more important in football. A player’s 40 meter sprint time is not as vital as how quickly he can accelerate during the first 10-20 meters. It is not unusual to find players on a team with the fastest 40 meter times have the slowest 15 meter split. The player who can accelerate quicker is more likely to get to the ball first, which is obviously a key indicator for success during a match. Additionally, the ability to decelerate must also be emphasized so that players can ‘stop on a dime’to gain possession of the ball and set up their next move.


    “The ability to perform changes of direction quickly and powerfully cannot be emphasized enough in any football training session, as this is one of the most vital components of athleticism needed for success in the sport. Sprint patterns that incorporate rapid transitions between multiple planes of motion (forward, backward, diagonal, lateral, 180º turns, etc.) should be integrated into the session. Additionally, one of the prerequisites for agility is proper footwork that is quick and coordinated in nature. The use of ‘agility ladders’ can be very beneficial for training proper footwork techniques, and also for muscular endurance work by having the player perform repetitive series of footwork patterns in sets of 2-3 minutes continuously.

    Core strength

    “All athletic movements begin with a reflex stabilization of the ‘core’of the body, which consists of the abdominal, low back and pelvic musculature. This core stability provides a firm base from which explosive movements can occur at the extremities. Without this stability a player’s ability to accelerate and change direction with power will be significantly diminished. However, to be most effective, the activities performed must be functional. Some common techniques include the use of medicine ball throws from a variety of positions (seated, standing) and can also be performed in a more dynamic manner while jogging.

    Lower extremity power

    “One common misconception among youth coaches is that strength training in a gym using weight machines will improve a player’s performance by making him stronger. It must be understood that in most sports the key to success is not strength, but power. Power in athletic terms is the ability to perform maximal work over a short time period (milliseconds). The need for power in football can be seen throughout a match: shooting; jumping for a header; tackling; etc. The most effective manner in which to train for athletic power is through the use of plyometrics. Examples of plyometrics include box jumps, vertical jumps, bounding, single leg hops, etc.

    Aerobic fitness – Interval Circuit Training

    “When each of the above is performed in isolation, it is unlikely that an optimal training effect will result for the football athlete. The conditioning programs that I conduct integrate all of the previously mentioned components into a circuit training format. Each session lasts approximately 45 -60 minutes in duration, and consists of 4-6 stations. Each station emphasizes at least one of the above components of athleticism in a manner that is specific to the sport of football. An example of a typical circuit includes:

    • Station 1
      Continuous agility ladder pattern for 2 minutes.
      3 sets.
    • Station 2
      Seated / kneeling medicine ball throws.
      3 sets of 8-10 repetitions.
    • Station 3
      Acceleration – deceleration runs: sprint 20m, decelerate within 3-5m, backward jog to back to the start position.
      2 sets of 8 repetitions.
    • Station 4
      Recovery station: juggling, light continuous jog, etc.
    • Station 5
      Combination runs: various patterns that include sprinting slaloms around flags, over mini-hurdles, through agility ladders, etc.
    • Station 6
      Plyometric box jumps: sprint 10m, perform series of 3 box plyometrics, jog 20m, perform 10 vertical jumps over hurdle, sprint

    “Appropriate rest periods are given between each station. The ultimate benefit of this form of conditioning is that it addresses all the key components of athleticism, but it also incorporates an aerobic component that is extremely important late in matches.

    “The interval circuit training program is an ideal manner in which to condition the football player, as it will not only enhance his fitness level, but it will also work towards making him a better overall athlete.

    “The drills described in this article are those typically used by experienced soccer players, who have a good base level of fitness. All fitness programs should be supervised by a qualified conditioning coach or trainer. Consult your doctor before undertaking a fitness program.”

    Knee Pain when Running

    Carol in Glasgow, Scotland asks:

    “I have a hole on the weight bearing part of my knee in my articular cartilage. I love running three to four times a week, but when I try to run faster it flares up so bad that I can not put any weight on it for days. When it settles I can run again. Could you tell me what treatment options I have? Should I give up running for good to prevent long term damage?”

    Dr Christopher Piller, MD, Orthopedic Fellow, American Sports Medicine Institute and Dr Lawrence Lemak, MD reply:

    ” It sounds like this is most likely a full-thickness defect in the articular cartilage, with exposed underlying subchondral bone. There are several options of treatment.

    “Conservative treatment options include weight control or loss where the individual is overweight, in order to reduce load bearing stress on the joint; avoidance of activities that cause pain and swelling (this may be over exercising or conversely remaining too sedentary); changing to low or no-impact aerobic exercises (such as cycling); using impact-absorbing running shoes and a lateral heel wedge if the damage is within the medial compartment of the knee (in order to transmit forces elsewhere throughout the joint).

    “Other non-surgical treatment options include the use of unloader-type custom knee braces; medications such as acetaminophen, traditional non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors such as rofecoxib and celecoxib; viscous supplementation injections with hyaluronic acid (this increases lubrication within the joint); corticosteroid injections (for pain relief); and the use of oral supplements like glucosamine and chondroitin sulfate (substances involved in cartilage production and repair).

    “Surgical treatment of symptomatic partial-thickness defects includes arthroscopic shaving to smooth and theoretically stabilize the damaged cartilage to prevent further degeneration. Some full-thickness articular cartilage lesions may not get worse, depending on the size and location in the knee. However most will, especially with continued high-impact aerobic activity.

    ” Surgical treatment options for full-thickness defects include arthroscopic abrasion or ‘microfracture’ arthroplasty. These techniques involve the surgeon carefully ‘insulting’ the joint surface tissue in order to promote a healing response from the body. Another technique involves transplanting round ‘plugs’ of cartilage and underlying bone from a non-weight bearing part of the knee to the area of the defect.

    “Open surgical procedures include the use of autologous chondrocytes (the patient’s own cartilage cells) cultured outside the body and replanted inside the knee under what is called a periosteal flap (on the surface of the bone). This requires two surgeries; one to harvest the healthy chondocytes with a cartilage biopsy, and the open transplantation 6 to 8 weeks later. Some surgeons are doing these procedures in conjunction with a staged osteotomy (operation to re-align the bones and thus change the loading characteristics of the joint) to permanently change the alignment of the leg, in order to unload the damaged compartment of the knee.

    “These surgical procedures are more successful when the defect is small and still surrounded by healthy cartilage, so it might be best to consider surgery sooner than later if you wish to continue an active lifestyle and running. The type of procedure that is most appropriate for your injury can often only be determined at the time of arthroscopy, once a surgeon has had the opportunity to visualize the lesion.”

    Knee Pain when Running

    Carol in Glasgow, Scotland asks:

    “I have a hole on the weight bearing part of my knee in my articular cartilage. I love running three to four times a week, but when I try to run faster it flares up so bad that I can not put any weight on it for days. When it settles I can run again. Could you tell me what treatment options I have? Should I give up running for good to prevent long term damage?”

    Dr Christopher Piller, MD, Orthopedic Fellow, American Sports Medicine Institute and Dr Lawrence Lemak, MD reply:

    ” It sounds like this is most likely a full-thickness defect in the articular cartilage, with exposed underlying subchondral bone. There are several options of treatment.

    “Conservative treatment options include weight control or loss where the individual is overweight, in order to reduce load bearing stress on the joint; avoidance of activities that cause pain and swelling (this may be over exercising or conversely remaining too sedentary); changing to low or no-impact aerobic exercises (such as cycling); using impact-absorbing running shoes and a lateral heel wedge if the damage is within the medial compartment of the knee (in order to transmit forces elsewhere throughout the joint).

    “Other non-surgical treatment options include the use of unloader-type custom knee braces; medications such as acetaminophen, traditional non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors such as rofecoxib and celecoxib; viscous supplementation injections with hyaluronic acid (this increases lubrication within the joint); corticosteroid injections (for pain relief); and the use of oral supplements like glucosamine and chondroitin sulfate (substances involved in cartilage production and repair).

    “Surgical treatment of symptomatic partial-thickness defects includes arthroscopic shaving to smooth and theoretically stabilize the damaged cartilage to prevent further degeneration. Some full-thickness articular cartilage lesions may not get worse, depending on the size and location in the knee. However most will, especially with continued high-impact aerobic activity.

    ” Surgical treatment options for full-thickness defects include arthroscopic abrasion or ‘microfracture’ arthroplasty. These techniques involve the surgeon carefully ‘insulting’ the joint surface tissue in order to promote a healing response from the body. Another technique involves transplanting round ‘plugs’ of cartilage and underlying bone from a non-weight bearing part of the knee to the area of the defect.

    “Open surgical procedures include the use of autologous chondrocytes (the patient’s own cartilage cells) cultured outside the body and replanted inside the knee under what is called a periosteal flap (on the surface of the bone). This requires two surgeries; one to harvest the healthy chondocytes with a cartilage biopsy, and the open transplantation 6 to 8 weeks later. Some surgeons are doing these procedures in conjunction with a staged osteotomy (operation to re-align the bones and thus change the loading characteristics of the joint) to permanently change the alignment of the leg, in order to unload the damaged compartment of the knee.

    “These surgical procedures are more successful when the defect is small and still surrounded by healthy cartilage, so it might be best to consider surgery sooner than later if you wish to continue an active lifestyle and running. The type of procedure that is most appropriate for your injury can often only be determined at the time of arthroscopy, once a surgeon has had the opportunity to visualize the lesion.”

    Medial Knee Ligament Tear

    William in Belfast, Northern Ireland asks:

    “I’ve torn my medial ligament and stretched my anterior cruciate ligament on the inner part of my knee. I was wondering if I will tear my cruciate now that I have stretched it?”

    Dr Christopher Piller, MD, Orthopedic Fellow, American Sports Medicine Institute and Dr Lawrence Lemak, MD reply:

    “The diagnosis of a ‘stretched’ or partially torn anterior cruciate ligament (ACL) is controversial. This diagnosis is difficult to make accurately based solely on physical exam findings or an MRI scan. Increased knee laxity with a soft endpoint found in an ACL on manual testing after an injury almost universally means a complete tear. Increased laxity with a solid endpoint (the so called ‘stretched’ ACL) can be due to a portion of the fibers being torn while some remain intact, or result from a complete tear that has managed to scar down or heal in such a way that it can still provide some stability in preventing abnormal forward movement of the tibia (shin bone).

    “Many surgeons base the diagnosis of a partial ACL tear on the findings at arthroscopy, and the incidence in published studies ranges from 10 to 50% of all ACL injuries. The incidence is most likely closer to 10% if all diagnostic tools are utilized, including consideration of injury mechanism and concurrent injuries, objective manual laxity testing, MRI results, examination under anesthesia and arthroscopic findings. An exam under anesthesia, demonstrating abnormal pivoting (where the knee joint virtually subluxes due to instability), and anterior translation of a knee, is probably the single most accurate way to distinguish a partial tear from a complete tear.

    “Injuries to the medial collateral ligament (MCL) occur in approximately 20% of all ACL injuries. Initially, depending upon the severity of the injury to the MCL, the knee will be more prone to instability than if the ACL was torn by itself. However, with proper rehabilitation and management, even completely torn MCLs have been shown to heal well without surgery and should not affect the long term stability and functional abilities.

    “That being said, there are few studies that tried to predict the risk of residual instability and further knee injury with a half torn ACL found at arthroscopy. One study found a 50% incidence of instability and a 75% incidence of further knee injuries with a partial tear. Another study, however, demonstrated a very low incidence of instability, limitations with sports or work activities, or the development of arthritis. Out of 21 patients, none went on to require ACL reconstructive surgery. This discrepancy is most likely due to a difference in the demands and expectations of the patients studied.

    “Although it is very difficult to predict the likelihood of completely rupturing your partially torn ACL, general guidelines have been established for addressing a situation such as yours. For the person who has sustained a true partial ACL tear, treatment must be customized. If the tear is estimated at greater than 50% of the ligament fibres; if there are symptoms of instability present (buckling or ‘giving way’ of the knee); or the patient is in a high-risk or high demand category (athlete, manual laborer) then early ACL reconstruction should be considered to prevent later problems of re-injury or arthritis. Patients with a tear less than 50% of ligament fibres, or patients with a sedentary lifestyle and no symptoms of instability, can be treated conservatively. Of this group, perhaps 10% of patients may later go on to require ligament reconstruction due to re-injury or onset of instability.”

    Osteoarthritis of the Hip and Hip Replacement

    Angela in London, England asks:

    “I am sixty years old and have been diagnosed as having osteoarthritis of the hip. I would like to put off having a hip replacement for as long as possible. Which exercises will be best for my condition?”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “Osteoarthritis of the hip can be a very debilitating condition that significantly restricts the performance of normal activities of daily living. These restrictions are primarily the result of pain which inhibits the ability to bear weight through the involved hip. As the pathology progresses, a subsequent loss of motion can occur which can place more stress on the joint and interferes with the ability to attain certain bodily positions.

    “Surgical intervention in the form of a total hip replacement is usually the last option considered, primarily because of the “life expectancy” of the implanted prosthesis. It is generally believed that the prosthesis will last anywhere from 10 to 15 years, depending on the patient’s age and activity level. Patients are encouraged to delay the surgery for as long as they can tolerate the pain or until their ability to perform normal activities is significantly compromised; this will minimize the possibility that a revision hip replacement will have to be performed due to a wearing out of the prosthesis.

    “Therefore, patients are commonly sent to our facility to educate them on appropriate exercises that can be performed to delay the need for this surgery. In my experience, there are 4 activities that seem to provide the most relief of symptoms:

    1. Gentle hip stretching.
    2. Hip range of motion exercises in non-weight bearing position.
    3. Stationary bicycling.
    4. Aquatic therapy.

    Gentle hip stretching

    “In patients with osteoarthritis of the hip, there is a progressive decrease in mobility of the hip, which will result in tightness of the muscles surrounding the hip joint. This tightness will result in more pressure being placed on the joint, causing more pain. Gentle hip stretching will alleviate some of this stress, thereby decreasing pain.

    “It is important to note that the stretching exercises should be non-painful, and internal rotation of the hip should be avoided due to the joint compression that occurs during this motion. Emphasis can be placed on hamstring stretching, as this can be performed with relative ease as it it usually symptom free.

    Hip range of motion exercises

    “The performance of pain-free range of motion exercises will help modulate pain from a neural perspective, and will also act as a non-strenuous method of muscular strengthening. These exercises are performed in a standing position with the involved leg in a non weight-bearing position so as to minimize the joint compression that would occur during weight-bearing. The patient should hold lightly onto a fixed object in order to maiantain balance.

    “The first exercise is ‘Hip Flexion’, in which the knee is slowly raised up towards the chest, held for 2-3 seconds, and then slowly lowered. The patient is instructed to raise the leg only as far as they can without pain. The second exercise is ‘Hip Abduction’, in which the leg is raised out to the side with the knee straight. Once again, this is performed pain-free. The third exercise is ‘Pendulums’, in which the leg is gently swung forward and back through a very small range. The leg should be relatively relaxed and limp (like a piece of cooked spaghetti) with momentum being responsible for most of the movement.

    Stationary bicycling

    “Stationary bicycling can be a tremendous benefit for patients with this condition. The cycling motion will also modulate pain, and it will also ‘loosen up’ the joint which will decrease the patient’s symptoms. It is important to note that it is vital that the patient use a bicycle that is comfortable for them, and in patients with advanced arthritis, range of motion restrictions may prohibit use of a bike. It is best to check this with your doctor or physiotherapist.

    Aquatic therapy

    “The final exercise that is suggested, aquatic therapy, is the most highly encouraged activity for several reasons. Patients are encouraged to obtain a membership to a local pool (preferably an indoor heated pool) where they can perform independent exercises that focus on range of motion and gentle strengthening. Various walking patterns (forward, backwards, side-stepping, high knee walking) and other exercises (knee to chest, cycling, lunges, squatting) are prescribed.

    “The reasons this form of exercise is so beneficial are numerous: the heated water helps relax tense muscles; the buoyancy of the water reduces the patients bodyweight, allowing the performance of weight-bearing strengthening exercises; and the ability to perform pain-free exercise that can assist in weight loss (to name a few).

    “One last concept that is stressed to patients relates to the ultimate goal of this program. While it has been known on occasion to completely alleviate all symptoms associated with osteoarthritis of the hip, complete resolution of symptoms is not the norm. The more realistic expectation is to help reduce the pain encountered during the day to allow the performance of normal activities as much as possible, and delay the inevitable need for total hip replacement surgery.

    Pain Relief for Lower Back Pain

    Paul in Merthyr Tydfyl, Wales asks:

    “I have a sports injury to my lower back. My chiropractor tells me that my symptoms present as classic SI joint trouble. I have been having treatment for several weeks which involves manipulation of the SI joint and related soft tissue and while this certainly helps, the relief is short-lived – the piercing pain always returns with a vengeance. Should I continue with the treatment? What are the alternatives?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London replies:

    “If you look critically at the region your chiropractitioner has diagnosed the problem, there are two other anatomical structures that can produce similar symptoms that are very close to the SIJ, namely the L5/S1 facet joint and the L5/S1 disc.

    “It is very common for people who have been diagnosed with SIJ problems, who fail to respond to treatment, to then subsequently be diagnosed with problems related to the L5/S1 segment.

    “If the treatment that you are receiving has failed to help, either the treatment is wrong, the diagnosis is wrong or the problem is not curable with chiropractic treatment.

    “The next stage would be to ensure that the diagnosis is correct by obtaining an MRI scan of the Lumbosacral spine. This can be used to diagnose the problem and redirect the treatment appropriately.

    “It should be noted that treatment to any of these regions is often only partially successful and a holistic approach is often required using the combined expertise of a specialist sports trainer, a physiotherapist, a chiropractitioner and an Orthopaedic Surgeon before appropriate treatments can be instituted.”

    Pars Fracture Healing & Surgery

    Jo in Washington, USA, asks:

    “Could you give me some idea of how long it takes for a stress fracture in the pars L5 to heal? My daughter has been out of soccer since 2/23 (3 months) and the Doctor said it may never heal. Does this happen? Is there any type of surgery that is commonly successful if it does not heal?”

    Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

    “This is a significant problem and requires accurate diagnosis and treatment to be instituted.

    “Pars fractures can be of several types depending on their region and can either be old or new. These types and the age of the fracture can be differentiated using specific tests such as a CT scan and bone scans.

    “If the pars fracture is fresh and does not heal within 2 to 6 months consideration of a surgical pars fusion should be at least discussed. For old pars fractures (older than 6 months), there are typical features and treatment options are to rest patients from sports for up to 12 months until it hopefully heals, (which it often does not), or to proceed to a formal fusion.

    “The starting point for all cases is an accurate history and examination. Tests including plain xrays, CT scans, bone scans and MRIs are useful. Treatment then starts with pain killers, physiotherapy and possibly injections BEFORE surgical options are discussed. The majority of patients do not end up having surgery, but it should be remembered that for most patients, simply reducing activities may reduce the level of pain to an acceptable level. This must be balanced with the options of surgery – which does not guarantee a return to high level sporting activities.”

    Physical Therapy for Repeated Shoulder Dislocation and Weakness

    Tim in Sapparo, Japan asks:

    “I play football and am a goalkeeper. When I was 14 I dislocated my shoulder. Ever since then it has been extremely weak and regularly comes out of joint during minor activities. I can’t have an operation as I am currently living abroad in Japan but I would like to start playing football again and start Karate. Is there any way that I can regain full usage of my shoulder with physical therapy?”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “Before responding to your current situation, a brief lesson in anatomy is in order. The shoulder joint (otherwise known as the glenohumeral joint) consists of the junction between the humerus (upper arm bone) and the ‘glenoid fossa’ of the scapula (shoulder blade). As with all joints of the body, the stability of the glenohumeral joint is dictated by 3 anatomical components: the shape of the joint itself (how the bones fit together); the integrity of the ligaments and capsule which surround the joint; and the dynamic stabilization provided by the muscles that surround the joint.

    “The shape of the shoulder is such that you essentially have a ‘ball’ (humeral head) coming in contact with a slightly concave ‘socket’ (glenoid fossa). Unfortunately, this structural make-up does not provide much stability to the joint. Consequently, the other 2 components (ligaments/capsule and muscles) must therefore compensate for this deficiency in structural integrity.

    “In a situation where there are multiple episodes of dislocations and/or subluxations (partial dislocations), the ligaments become either stretched or torn. The ligaments are then unable to provide sufficient passive support to prevent a reoccurrence of shoulder dislocation, leaving the muscles as the prime stabilizing component of the shoulder.

    “Physical therapy after a single episode of shoulder dislocation or recurrent subluxations can be effective at minimizing the risk of future injuries. Rehabilitation focuses on strengthening the rotator cuff muscles (which stabilize and rotate the humeral head), scapular stabilizers (which fix the shoulder blade during movements) and prime movers of the shoulder (which as their name suggests provide the muscular force for large shoulder movements – Deltoids, Pecs, Lats, etc.). Particular attention is paid to the rotator cuff musculature, as their primary role is that of stabilizing the joint, whereas the larger muscles such as the Deltoid are responsible for large upper extremity movements.

    “Rotator cuff strengthening involves very specific movement, with an emphasis on perfect form, to ensure maximum involvement of the proper muscles. Many of the exercises are performed with surgical tubing type material (Theraband), which makes this type of program very easy to perform at home. Rehabilitation is very effective in allowing a return to previous levels of athletic activity (depending upon the sport and position involved) in the single dislocation episode or 2-3 episodes of subluxation.

    “Unfortunately, your situation appears to be a good bit more severe than the scenario described above. A shoulder that truly dislocates with minor activities would indicate that the ligamentous structures are significantly damaged, and unable to provide adequate contribution to stability of the shoulder. Additionally, in shoulders that chronically dislocate, a defect can form on the head of the humerus called a ‘Hill-Sachs Lesion’. This lesion presents as an indentation in the humeral head which is believed to be caused by repetitive impaction of the glenoid during chronic dislocations. It is believed that this indentation may actually make it easier to dislocate the shoulder, to the point that dislocations can occur with minor activities.

    “My recommendations for you would be to consult with an orthopedist to evaluate the extent of damage in your shoulder. Once that has been determined, I would request a few visits with a Physical Therapist to establish a proper home exercise program to focus on strengthening the musculature described previously. Perform the strengthening program for a minimum of 6-8 weeks before attempting higher level athletic activities such as karate, as it takes approximately that long to see an increase in true strength once a program has been initiated.

    “Based on the brief description you provided, the severity of the injury to your shoulder seems fairly significant. This severity may make it difficult for you to return to higher level activities without surgical intervention. However, performing a properly prescribed rehabilitation program may allow a return to lower level activities until you are able to consider surgical correction of your injury.”

    Physio Treatment for Knee Pain from Ilio Tibial Band Syndrome

    Nick, in Sheffield, England asks:

    “I am a keen runner and have recently completed a couple of marathons. During the training for the last one I noticed a pain over the outside of my left knee which the doctor has said is Ilio Tibial Band Friction Syndrome. He has advised me to rest. What is the physio treatment for this?”

    Marc R. Bernier, Senior Physical Therapist responds:

    “The Ilio-Tibial Band (IT Band) is a thick fascial structure that extends down the lateral aspect of (furthest from the mid-line of the body) the leg from the hip to the knee. The distal aspect of the IT Band is often a site of irritation in athletes involved in repetitive flexion-extension movements of the knee, such as in running and cycling.

    “Initially, the acute symptoms of the condition must be treated to decrease the patient’s pain and inflammation. This is typically accomplished via modalities such as ice, heat, ultrasound, electric stimulation and gentle massage for inflammation.

    “As the acute symptoms subside, further evaluation and treatment is required to establish the underlying reasons for the cause of this condition. There are many potential contributing factors, and more than one may be present. Therefore, it is highly recommended that anyone with this syndrome seek the treatment of a physical therapist, so that a thorough evaluation can be performed and the appropriate treatment can be prescribed. If the underlying causes are not addressed, the symptoms are likely to reappear.

    “In my experience, patients with this condition usually fall under one (or more) of the following clinical presentations: :

    1. Biomechanical abnormalities of the foot/Improper footwear
    2. Gluteus Medius weakness
    3. Iliotibial Band tightness

    Biomechanical abnormalities of the foot/Improper footwear

    “From a biomechanical perspective, the knee is highly influenced by the foot. Hyperpronation of the foot (excessive inward rolling of the foot during running) will cause a resultant increase in Tibial internal rotation (the shin bone rotating inwards), which can place excessive stress on the IT Band. This stress can result in soft tissue inflammation and subsequent pain. Treatment can include the prescription of an ‘orthosis’ (special insole which supports the foot and prevents too much inward rolling of the foot) and proper footwear prescription to ensure that the athlete is using shoes appropriate for his/her foot type and activity.

    Gluteus Medius weakness

    “The knee is also highly influenced by biomechanical abnormalities or muscular weakness of the hip and core muscles of the trunk and pelvis. Research has indicated that weakness of the Gluteus Medius muscle was prevalent in long distance runners with this condition. This muscle is located at the top of the buttocks, and can usually be palpated just above the back hip pocket. This muscle is responsible for both abducting (raising out to the side) and externally rotating the leg. However, it’s more important function is its role when the leg is in a weight-bearing position. During running, cutting and planting maneuvers it prevents the thigh from ‘buckling’ and rotating inwards.

    “A therapy program that specifically targeted Gluteus Medius strengthening resulted in an elimination of symptoms in most cases. Strengthening of this aspect of ‘the core’ will better enable the patient to control the lower extremity and help prevent the thigh ‘rolling in’ during running.

    1. Side Llying Abduction

    2. Side Lying ‘Clamshells’

    3. Prone Hip External Rotation

    4. Single Leg Bridging

    5. ‘Donkey Kicks’

    6. Standing Abduction with Surgical Tubing


    Iliotibial Band tightness

    “The ability to truly ‘stretch’ the IT Band is a source of significant controversy. Many therapists have prescribed ‘IT Band stretches’ as a part of the therapy regiment. However, it must be understood that the IT Band is not a muscle, but a very thick piece of fascia that cannot be stretched, especially at the lower part, around the knee joint.

    “The stretches that have been used will actually stretch the Tensor Fascia Latae (TFL) muscle in the hip. While this may result in a slight increase in IT Band length indirectly due to it’s attachment to the TFL, it will not address the fascial tightness that is present at the lower part of the IT Band. The treatment for this situation consists of extensive soft tissue mobilization and massage to the lower part of the IT Band, and fascial stretching using foam rolls at home.”

    Physiotherapy Exercises following a Broken Wrist (Scaphoid Fracture)

    Stuart, in Norwich, England asks:

    “I broke my scaphoid bone. It’s healed but I still dont have full mobility in it. Could you advise on any physio exercises I can do.”

    David Wales, Clinical Specialist Physiotherapist responds:

    “The Scaphoid bone is the most commonly fractured of the eight wrist bones that make up the wrist complex. These fractures occur relatively commonly following a fall onto an outstretched hand. Because of the poor blood supply to the Scaphoid, there are often problems with fracture healing, but other complications related to a lack of mobility and residual stiffness are also quite common.

    “The traditional management of Scaphoid fractures is to immobilise the wrist using a plaster cast. As with all cast immobilisation this produces short term stiffness around the wrist. In most patients this stiffness can benefit greatly from physiotherapy treatment such as massage, moblisation of surrounding joints and exercise, although symptoms remain in some wrists.

    “Recent advances in surgical techniques have changed the management of Scaphoid fractures. In patients where conservative treatment using immobilisation has failed to produce a healed fracture, where the fracture fragments are displaced (not in close proximity) or where the patient’s occupational demands require a more swift, certain outcome, then surgical treatment is indicated.

    “Conventional open surgery involves a small screw being inserted into the Scaphoid in order to unite the fracture fragments. This may be followed by 6 weeks of wrist immobilisation in a cast or immediate mobilisation, depending on the preference of the surgeon.

    “New surgical techniques using wrist arthroscopy are now becoming more popular. The arthroscope allows the surgeon to inspect the bones and soft tissues of the wrist, giving more useful information than x-ray films. Arthroscopy has an advantage over ‘open’ surgery in that it is less invasive and there is less associated soft tissue damage. This means the duration of rehabilitation is reduced.

    “Recent studies have reported the findings in patients who have undergone arthroscopic surgery for the treatment of Scaphoid fractures. These findings have shown that more than a third of patients suffered wrist ligament and cartilage injuries, in addition to their Scaphoid fractures. These injuries have been described as ‘Combined Wrist Injuries’ (Wong et al, 2005) and would explain why wrist symptoms continue in patients who have had a Scaphoid fracture that has been shown to have healed on x-ray.

    “Without arthroscopic surgery it may not be possible to diagnose Combined Wrist Injuries, even with investigations such as MRI. Once found, management of these injuries is dependent upon exactly which soft tissue is involved. Torn ligaments can be re-attached to the wrist bones using surgical wire. This is usually followed by immobilisation in a plaster cast for six to eight weeks, at which point the wires are removed and physiotherapy treatment begins.

    “Another common finding in Combined Wrist Injuries was damage to the fibro-cartilage disc, which is known as the Triangular Fibro Cartilage Complex (TFCC). The TFCC sits between the Ulna (one of the forearm bones) and the bones of the wrist area and its function is to increase the stability of the wrist. Damage to the TFCC can be repaired with arthroscopic surgery, where the articular disc is either repaired using sutures or partially shaved off.

    “If you are still experiencing symptoms in your wrist then you should return to your orthopaedic doctor for their opinion. If the Scaphoid is fully healed then it may be possible that you have a Combined Wrist Injury, and soft tissue lesions are producing your symptoms. Degeneration is also relatively common following Scaphoid fractures, so your doctor will have to review this.

    “If you do have a Combined Wrist Injury then the latest evidence suggests that arthroscopic surgery is the most effective treatment in the long term. Physiotherapy treatments, such as hot wax baths and mobilisations may be effective in relieving the symptoms of wrist pain and stiffness in the short term, but ultimately a surgical approach may be necessary.”

    Rehabilitation Exercises following a Calf Strain

    Caroline in Bromsgrove, England asks:

    “I am a tennis player and have strained a muscle in my calf (inner side rather than outer), which is sufficiently painful to make me unable to put my heel down when I walk. My questions are: How will I know when to start the stretching exercises? What stretching exercises should I do? How will I know when to start taking weight bearing exercise?”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “Following a Calf strain gentle stretching can usually be performed within the first few days (so long as it is pain free) in the form of active range of motion (AROM) exercises. In order to ‘stretch’ the calf muscles in this fashion, simply sit on the floor with your knees straight and bend your foot towards you using the muscles on the front of your shin. Hold this position for 5-10 seconds, and perform 30 times. This should be done in a pain-free manner throughout the day as a way to maintain some flexibility during the acute phase of the injury. Once you are comfortably able to do this exercise without pain, it should be safe to progress to more specific flexibility activities.

    “In order to understand how to stretch the Calf complex it is helpful to know about the anatomy.

    “The calf complex consists of two main muscles: the Gastrocnemius muscle (which crosses the knee joint) and the Soleus muscle (which doesn’t cross the knee joint). These muscles are stretched in a similar manner, with one modification: to emphasize the Gastrocnemius, the knee must be in a straightened position; to emphasize the Soleus, the knee must be in a bent position.

    “So long as the AROM stretches are pain free, the first stretches I recommend are ‘towel stretches’, which allow you to control the intensity of the stretch easily. This is performed with the knee extended and flexed to stretch both muscle groups.

    “The next stretches are ‘wall stretches’ which entail leaning into a wall while keeping the heel on the ground. Once again, this is performed with the knee extended and flexed. Additionally, it is recommend that you place a very small rolled towel under the inside part of your foot to allow the stretch to be performed in a “neutral” position, preventing the foot from pronating (turning inwards). This provides for a more efficient and functional stretch for the calf musculature.

    “The final stretches are performed on a ‘slantboard’. A variation of this stretch is to perform it by placing the foot up against a wall in a standing position. While performing the slantboard stretch, it is also recommended that a small rolled towel be placed under the length of the inside part of the foot.

    “Weightbearing exercise for strengthening can be initiated once the acute pain has subsided, usually within 3-10 days, depending upon the severity of the injury. The key to the strengthening program is to ensure it is a gradual program that begins with seated heel raise activity, progressing to full weightbearing exercises, and finally sport-specific training.”

    Strengthening Exercises for a Broken Leg

    Gerry, in Kent, England asks:

    “I broke my tibia and fibula just above the ankle almost nine months ago. It was fixed with an intermedullary nail. I had some x-rays at six months and my surgeon has given me the OK to return to football. However, I feel like I can’t push off so strongly on the leg that was broken. Could you suggest some exercises to help?”

    Marc Bernier, Senior Physical Therapist, Director of Healthsouth Soccer International, replies:

    “When devising a program to rehabilitate an injury such as yours, it is important to ensure that the first phase addresses both the loss of mobility and strength that accompanies the injury. The second phase will address balance, proprioceptive, and coordination deficits. Once all of the above components have been normalized, the initiation of football-specific functional training may begin. It is during this phase that an emphasis is placed on footwork, agility and power of the lower extremity. In many instances, the ability to push-off improves to pre-injury levels as the player progresses through his football training; however, this is not always the case, and may require more strict training to address this need.

    “One of the deficits I have noticed in athletes that had difficulty in pushing off was an inability to stabilize the ankle while in a dorsiflexed position. Without stability in this position, the ability to efficiently push off into plantarflexion will be significantly diminished. One of my favorite exercises to address this is noted in Figure 1. The athlete is in a single leg stance position on a piece of foam, in a dorsiflexed position. While maintaining this position, the athlete will simulate a push-off from the foot with the heel unweighted, and push into the ball with his hands. To increase the stabilizing effort, the therapist can apply a perturbating force at his pelvis, increasing the need for dynamic stability on behalf of the athlete.

    Figure 1

    “The next two exercises involve the integration of light plyometrics, with the focus of the movement being on the ankle. “Ankle plyometrics” (Figure 2) are performed with the knees kept in a slightly flexed position, and having the athlete jump repetitively as high as he can by using a forceful plantarflexor force (pushing off using only the calf muscles). “Quick taps” (Figure 3) are performed by quickly alternating feet on top of a step. Start with one foot on the ground and the other on top of the step, and simultaneously switch feet. To make this more challenging, hold onto dumbbells while performing.

    ” ‘Sportscord plyometrics’ (Figure 4) are performed to retrain the ability to decelerate body momentum and instantaneously perform a powerful push off manouvre. The athlete starts with significant tension on the sportscord (which is secured around his waist), and standing on the uninvolved leg. The athlete then hops backward onto the involved leg, and instantly pushing off and propelling the body forward back to the starting position. ‘Lateral cone plyometrics’ (Figure 5) involve jumping laterally over a cone, off one foot onto the other. Emphasis is placed on the height of the jump, progressing from slow (stabilizing for 2 seconds upon each landing) to fast (rapid jumps without pause).

    “The final series of exercises are performed on the field. ‘Yo-yo runs’ are repetitive forward and backward sprints in which an emphasis is placed on the transition from the backwards movement to the forward sprint. This transition requires the ability to decelerate the body at the ankle, and then perform a powerful push off to quickly change direction. This exercise is initially performed over short distances (3 meters) and progressing to longer distances (10-15 meters) which would allow faster speeds and would require more power to change direction. The final exercises in the progression are ‘high knee skipping’ (emphasizing the push off at the ankle) and ‘bounding’ (jumping as far as possible from one leg to the other).

    “It is important to note that the exercises should be progressed as outlined, to ensure that too much stress is not placed on the site of your fracture, and so the body can become accustomed to the ballistic types of movement. All of this is recommended assuming that you have been cleared for unrestricted athletic activity from your physician.”

    Surgery for a Lower Back Stress Fracture

    Rena in North Carolina, USA, asks:

    “My son is a fifteen year old baseball player. He was playing the position of shortstop in the fall. His back began to hurt and he started taking anti-inflammatories. As it got worse, we decided to go to a doctor.

    “He was given a bone scan which showed a lower back stress fracture. He was fitted for a custom brace which he wore for 6 weeks. It didn’t get better so he wore it longer for 23 hrs a day. Despite this my son never got better and a CT scan was ordered to rule out anything else. Again a stress fracture was confirmed. He saw a sports physical therapist, but gave up on this as his pain did not settle. He tried playing with the team again this spring but the pain came back. We are now scheduled to see the surgeon for a consult on an operation.

    “Is it wise to have an operation at this stage?”

    Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

    “A stress fracture of the lumbar vertebra is known as spondylolysis. It is a common injury in keen sports participants and presents as back pain. It can also be a long standing defect that occurs as a child and remains asymptomatic until they become very active in their teenage years. The treatment requires a correct diagnosis. Based on the history and investigations you have described, spondylolysis has been confirmed.

    “Conservative treatment is always attempted first and surgical treatment is seen as a last resort. It should only be considered when extensive conservative treatment has failed.

    “A typical treatment protocol for this condition includes:

    1. Rest for six weeks, as this is the usual time for bone healing. If pain is still present then the stress fracture hasn’t healed and another scan may be needed. If the scan indicates there is still no healing, then a further period of rest should be considered (I personally do not immobilize as the evidence for this treatment is inconclusive).
    2. Specialist Physiotherapy – Intensive core stability rehabilitation. Poor muscle stability in the lumbar spine has been implicated as a contributory factor in spondylolysis. Core stability exercises aim to recruit the Transversus Abdominus and Multifidus muscles. In order to understand how these exercises are effective it is necessary have a brief introduction to how the back is supported by muscles. The first muscle we are concerned with is called Transversus. This muscle arises from the middle of the tummy and goes right around the trunk, attaching itself to the spine.
       The Transverus Abdominus muscle acts as a natural corset and provides stability for the lower back. The second muscle involved in this exercise programme is the Multifidus. This muscle lies deep in the spine and attaches in between each vertebra. When it contracts it increases the stability of the spinal column.

      If you can contract the Transversus muscle, the Multifidus muscle is also contracted automatically. This improves spinal stability and can relieve back pain.

      The most effective way to learn how to contract these muscles is to kneel on all fours. Once in position, relax and allow the stomach to sag down with gravity. To contract Transversus now, all you need to do is very gently pull in your tummy so your belly button moves closer to your spine.

      It is important not to contract too hard, otherwise you will be using muscles other than the ones we are concerned with – don’t contract your ‘six pack’ muscles. Also, don’t confuse this exercise with breathing in and sucking your tummy in – you should be able to hold the contraction while continuing to breath and have a conversation.

      It is difficult at first but once you have mastered the technique it should become second nature. The contraction should be held for 4 seconds and repeated 20 times. Then, as your technique improves, increase the contraction hold to 10 seconds. Eventually you should be able to hold the contraction indefinitely.

      At this stage you should be able to move to different positions, such as sitting in a chair or standing up, and still be able to contract the deep stabilising muscles. Although it seems strange at first, once the muscles have been recruited, you will not have to concentrate on them and they will contract automatically – thus improving your posture and spinal stability.
    3. Once core stability in the lumbar region has been improved, it is time to gradually resume activities under the supervision of a chartered physiotherapist.
    4. If pain is still a problem that prevents sport and the patient considers the risks of surgery are worth taking – then surgical intervention is appropriate.

      Surgery can be of the form of a screw across part of the vertebra called the Pars Inter-articularis and a bone graft is used to help healing.

      Other surgical approaches include intertransverse fusion with bone graft and instrumented fusion with pedicle screws. Your doctor should explain these procedures for you in more depth, before deciding which, if any is most appropriate.

    “If the lesion is simply a stress fracture I would suggest intensive 1, 2 and 3. There should be careful consideration before surgery.”

    TENS Units for Back Pain Relief

    Frank in Fort Lauderdale, Florida asks:

    “I have been told that a Transdermal Electrical Nerve Stimulation Unit can help with my back pain. Could you explain how these things work?”

    T J Salih, Senior Chartered Physiotherapist at the back2normal back and neck clinic, London replies:

    “Transcutaneous or transdermal electrical nerve stimulation (TNS or TENS) is an electrotherapy modality used to relieve pain. Back pain is just one of the conditions that can benefit from this modality, which is used in the treatment of many chronic pain syndromes. Research has shown it to be an effective pain relief treatment in over 60% of patients.

    “It is a non-invasive treatment which uses the application of a pulsed electrical current via surface electrodes applied to the skin. There are many types of TENS unit on the market. They are normally pocket sized and battery operated. Most have controls for pulse width (or duration measured in microseconds), pulse shape (usually rectangular), frequency (the rate of electrical pulse delivery, measured in Hertz) and intensity (which indicates the strength of the current, measured in milli Amps).

    “To understand how TENS works, one has to have a basic understanding of pain. For pain to be perceived there is usually a stimulation of a type of sensory nerve called a ‘pain receptor’, by a noxious physical or chemical agent. This stimulation is passed up via nerve impulses in the spinal cord, to the brain where the pain is appreciated at the conscious level. If the pain stimulation to the brain is modulated using a TENS unit, then pain relief can be achieved.

    “One method of pain relief can be achieved when TENS acts as a physiological inhibitor of impulses from the pain receptor, in a process often referred to as the ‘Pain Gate Mechanism’. This occurs because, when set at a higher frequency, the TENS unit stimulates different pain receptors which override the painful stimulus. This is the electrotherapy equivalent of rubbing your knee after you’ve fallen on it. The counter stimulation provides pain relief.

    “The other mechanism of action of TENS, when set on a lower frequency, is that the brain will produce its own natural painkillers, known as endorphins. By setting the TENS machine to alternate between higher and lower frequencies, you not only get a local ‘nerve block’ but also a general endorphin release which both help with pain reduction.

    “Once switched on the patient experiences a gentle tingling or buzzing sensation from the electrodes. Unlike drug treatment, there are few side effects with TENS treatment and the pain relief mechanisms are completely natural. One problem may be patient allergy to the electrodes, but this is quite rare. Pain relief provided by TENS frequently outlasts the treatment period by a few hours and in some cases up to a few days. This can allow patients to complete their physiotherapy exercises and facilitate a complete recovery.”

    Weight Training for Young Football Players

    Todd in Newport, Virginia asks:

    “I am the coach of a youth soccer team. Could you tell me when the best time to start using weight training is for young players?”

    Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

    “The question of when it is safe to implement a weight training program in youth football players is a very common inquiry that I receive from coaches and parents. Although there are no definitive guidelines, many strength and conditioning professionals agree that it is safe for youth athletes to perform supervised, low weight resistance programs in the early adolescent years (11-12 years of age). However, I personally believe the more appropriate question that should be answered is: Will a weight training program make my son/daughter a better athlete and will it help prevent injuries?

    “There are several reasons why I do not recommend weight training programs to the youth athletes in the clubs I work with:

    1. Concern regarding proper adult supervision and safety.
    2. Cost and limited access to fitness centers with a full complement of weight training equipment.
    3. Athletes involved in a highly dynamic sport such as football become quickly bored by and lack motivation to perform activities limited by weight machines.
    4. Weight training programs will indeed make youth football athletes stronger, but is the increase in strength functional? Meaning will it have a carryover to performance on the field? Additionally, weight training will increase muscle mass and result in increases in body weight; will the youth athlete be able to dynamically control the concomitant increase in momentum that will be generated due to this increase in mass, when performing football specific movements? In my opinion, the answer to both of the above questions is no.

    “The goals that many parents and coaches hope to achieve with strength training for their youth players is to enhance performance and prevent injuries. I have found that many youth athletes exhibit significant deficits in functional strength (being able to control their own body), balance, and core strength. Consequently, the training programs I recommend to help achieve these goals focus on the following:

    1. Functional strengthening of the lower extremities.
    2. Balance training.
    3. Core and pelvic strengthening.
    4. Agility/footwork/coordination training.

    Functional strengthening and balance enhancement are accomplished via body weight exercises performed while in a single leg stance position. These exercises are augmented by incorporating medicine balls, resistance bands, and unstable surfaces which will not only increase the strengthening component of the lower extremities, but will also integrate core strengthening and balance. An added benefit of these activities is the emphasis on controlling body momentum (if performed correctly), which is an essential component for carryover to football specific movements. The program begins with isolated, static exercises and progresses to dynamic exercises that emphasize stabilization of the lower extremity and body during athletic movement.

    Core strengthening is vital (especially for female athletes) in preventing knee injuries such as ACL tears, as it helps maintain proper alignment of the knees during functional activities such as cutting and landing from jumps. Several muscle groups are targeted during this aspect of the program. Abdominal strengthening is performed via core stabilization training using gym ball, medicine balls and resistive tubing. Crunches and sit-ups may be performed as an initial method to establish a baseline abdominal strength, but are not stressed during the program due to the non-functional nature of these exercises. Hip strengthening (abductors and extensors specifically) is addressed via the use of resistive tubing while performing exercises such as lateral lunge walking, abduction movements and single leg stance hip hinges with a medicine ball.

    Agility and coordination training is integral in that it retrains the youth athlete how to properly utilize the newly acquired strength attained from the training program. External forces in the form of momentum will have increased compared to pre-training levels due to the increased muscle mass, and it is important for the athlete to learn how to control this during football specific movements. Agility ladders and running movement patterns (power skipping, bounding, grapevines) are performed while on the field.

    “The above program will be a more effective mechanism for enhancing performance and preventing injury in youth players.”

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