Month: June 2022

Research Review:
Strong, steady and straight: UK consensus statement on physical activity and exercise for
osteoporosis

https://bjsm.bmj.com/content/early/2022/04/24/bjsports-2021-104634

This paper aimed to set up guidelines for exercises, clarify the safety of exercise in the osteoporotic population
and promote consistent advice for health professionals and amongst those clients with osteoporosis. Focus
areas were collected from a stakeholder group of individuals with osteoporosis. These were then passed on to
an expert panel to guide the content for a consensus statement. The current literature was then reviewed by
this expert panel and an updated guideline was published.

From the stakeholder discussion it was found that osteoporosis sufferers believed that exercise was beneficial
for their bone health and general well-being, they reported frustration regarding mixed messaging from health
professionals and were unsure about which exercises were safe. There was also desire for more specific
exercise regimes across all functional levels.

The following diagram was made as part of the consensus statement. The diagram lists specific exercises and
dosages as well as sports and activities that are applicable for the following categories.
– The strong exercises are aimed at promoting bone strength and preventing fractures.
– The steady exercises are aimed at reducing falls risk.
– The straight exercises aim to reduce risk of vertebral fracture, improve posture and manage
symptoms after vertebral fracture

**It is important to note that those with vertebral fractures will only be appropriate for lower impact
activities, the impact equivalent of a brisk walk. There should still be elements from each area of the
program as exercise for these individuals will improve quality of life, mobility and reduce pain.

Popliteal Artery Entrapment Syndrome (PAES)

Popliteal Artery Entrapment Syndrome (PAES) is an obscure cause of exercise induced calf pain.
Posterior calf pain is a common presentation in the young athletic population, and so it is important
to recognize that PAES is an uncommon presentation. Therefore, it is important to consult your
regular Physio if you are experiencing ongoing pain, they can perform a thorough assessment to
correctly diagnose your issue. However, our interest today lies in PAES and how its presentation is
very similar to chronic exertional compartment syndrome (compartment syndrome), commonly
referred to as shin splints or calf cramps. This article looks to detail the specific differences between
the two conditions and explore potential treatment options that can be explored.

PAES typically affects a young 20-40yo athletic population and is up to 15x more common in males
than females. PAES is where the popliteal artery becomes dynamically compressed by the medial
gastrocnemius (gastroc) head through exercise. Causes are either anatomical variance in the medial
gastroc insertion or excessive hypertrophy of the muscle. The popliteal artery dilates as the blood
pressure increases in the vessel causing a dynamic compression against the medial gastroc head.
Patients with PAES will typically present with intermittent claudication (posterior calf pain/cramping)
and/or paraesthesia during exercise or exertion. This presentation is almost identical to the typical
compartment syndrome where the calf muscles swell from increased blood perfusion and become
compressed against the fascia. The main subjective difference is that PAES is more specifically
exacerbated by exercise intensity rather than volume. Whereas compartment syndrome requires a
certain duration of exercise to present, PAES can present almost instantly under the right
circumstances i.e running uphill, repetitive jumping, sprinting. Another difference is that athletes
with compartment syndrome will have decreased tolerance to exacerbating factors as a game
progresses whereas PAES symptoms remain consistent relative to intensity.

Differentiation between the two conditions can be determined therefore with a few clinical tests
and confirmed on imaging. Exercises such as repeated hopping on one leg or running can be used to
induce symptoms in the clinic. PAES will present sooner than compartment syndrome with a loss of
the dorsalis pedis or posterior tibial pulse, symptoms also settle a lot quicker as they settle with the
recovery of the athlete’s heart rate and blood pressure. If PAES is suspected, diagnosis can be
confirmed with a dynamic MRAngiogram, where the patient performs their provocative activity and
then the scan is performed. A positive test will show decreased blood flow through the popliteal
artery as it intersects the proximal medial gastroc head.

Early detection and intervention is important as prolonged stenosis of the vessel can cause scarring
and atherosclerosis of the inner vessel wall. If left untreated PAES may require invasive procedures
to stent the vessel open and can significantly impact an athlete’s career. Therefore, early detection is
key. Standard treatment of PAES involves relocating the medial gastroc head, optimizing the
popliteal artery tract. However, botulinum A toxin (botox) injections used locally to the site of
constriction in the medial gastroc head has gained traction in recent literature and is showing
promising results. The procedure is far less invasive than traditional measures and has been shown
to effectively reduce the muscles constriction of the vessel during exercise. Another benefit is that
recovery time is significantly reduced, the player can return to sports almost immediately as function
and pain allow.

Physio management is involved in retraining the muscle to promote muscle atrophy in the medial
gastroc head and guide successful return to sport. Long term management involves educating the
patient to avoid excessive training of calves that would promote increased medial calf bulk which
would encourage the condition to return.

Take home, is that this condition is quite RARE. Your exercise induced calf pain is far more likely to
be a result of the more common diagnoses, such as compartment syndrome. However, the purpose
of this piece is to explore this interesting albeit rare condition and raise awareness of potential
differential diagnoses that exist with exercise induced calf pain. If you are concerned about pain that
you experience whilst exercise, it is best to discuss this with your local physio. They are experts in
diagnosing your pain and providing you with a plan for management and recovery.

Muscle strains, torn muscles, pulled muscles, DOMS?!?!

Part 2.

After reading Part 1 you should be feeling a bit wiser on what muscle strains/DOMS can feel like and why they happen. In Part 2 we’ll cover some basics of what to do and how to best kick-start your rehab journey.

Early stages of physiotherapy rehabilitation for muscle strains and DOMS.

Often we find ourselves stuck with questions such as “How long will this take to heal?” or “When can I go back to playing competitive sports?” or “Should I ice it or put a heat pack on it?” Firstly let’s state that there is no miracle cure, no magic wands or special pills that replace healing time and hard work. But that doesn’t mean you can’t make things as comfortable as possible in the meantime. And it also doesn’t mean that you can’t do other things to keep you physically active and happy.

DOMS recovery

When looking through research literature, the jury is still out when it comes to what works best in minimising DOMS/recovery time. Interventions can include cryotherapy (ice or cold exposure), massage, compression, stretching, massage guns, creams, and a whole plethora of other knick knacks you can think of. Be cautious with anything that promises or sells miracure cures (remember there aren’t any). The evidence that does exist suggests that most of the aforementioned interventions may provide some pain relieving effects short term, but anything past that is still not 100%.

For many individuals with DOMS, management may simply mean getting back to some light mobility work or gentle exercise, or even just exercising another part of your body. This is one reason why many individuals like to isolate body parts (think leg day, arm day etc) during gym sessions, that way they allow rest days during the DOMS recovery period.

To hot pack or cold pack?

I find heat packs and ice packs are hugely personal preference (some people love heat packs, some people love cold packs). If we are getting technical and looking at the physiological mechanisms then usually a heat pack for muscle relaxation and to increase blood flow, and ice packs to help hinder swelling and inflammation. A recent study by Jerrold Petrofsky and his colleagues in 2015 looked at heat and cold therapy both immediately after exercise and 24 hours after exercise, and its effects on strength, pain levels and several other measures. Their results indicated that both were useful for different things at different times.

Imaging or no imaging?

Imaging is not required for DOMS, however if soreness does persist for more than several days even with resting then a quick visit to your physiotherapist may be warranted. With strains, mild strains don’t often require imaging unless symptoms are persistent. Given imaging can be expensive and findings of imaging may not actually change rehabilitation management, many healthcare professions would recommend against imaging for low grade strains early on. Moderate strains may require imaging again depending on the recovery process so far, as well as the site of strain.

Severe strains typically do require imaging, as this will help clarify whether further referral to an orthopaedic specialist is necessary.

It should be noted that imaging is a great tool to rule out any nasty pathology, but doesn’t tell you where pain is nor how capable you are. Use imaging sparingly.

The above picture shows an MRI of a low grade hamstring muscle strain, where the muscle fibres show some oedema (swelling) but fibres are predominantly intact.

Courtesy of Aspetar Sports Medicine Journal (https://www.aspetar.com/journal/viewarticle.aspx?id=28#.YmnEDNpByUk)

Strains

For mild muscle strains the recovery process may take several days to several weeks, but you may be able to continue light or gentle exercise. It’s often a good idea to ease off intense sport or the specific exercise which caused the muscle strain to begin with, as you don’t want to keep hammering that same injured muscle whilst it’s healing. Maintain mobility and movement, but keep effort low, simply easing back the intensity/effort can do the trick with mild strains.

Moderate muscle strains will take longer, we are talking several weeks to potentially months. As mentioned before this will be influenced by the location of the injury. For these injuries there may be a period of relative rest, and usually you will have to “baby” the injured area for a good while before going back to your exercise. Mild analgesics (such as paracetamol) or anti-inflammatories may be required to help with symptoms. If there is some muscle tension or tightness after the healing process is complete, gentle stretching may be introduced but avoid this during the early days of recovery.

Severe muscle strains will take the longest, and recovery can be months if that. In these cases imaging is usually advised to help determine if surgical input is required.

Anti-inflammatory medication or not?

There is discussion amongst healthcare professionals nowadays regarding the use of anti-inflammatory medication during early stages of soft tissue injuries. It is argued that disrupting the inflammatory process during early stages of a soft tissue injury may interrupt the body’s natural physiological reaction to an injury. What happens is during the inflammatory stages (usually lasting for several days after an injury) the body floods the injury site with cells that limit further injury and kick-starts the healing process. Thus stopping this would appear counterproductive to healing and optimal tissue repair.

HOWEVER, given inflammatory pain can be quite significant and limit the amount of active recovery/rehab you may partake in there should always be a balance between using medication for symptom relief when needed, and avoiding it if possible.

Courtesy of Dubois & Esculier (doi.org/10.1136/bjsports-2019-101253)

TIPS FOR DOMS AND MILD TO MODERATE MUSCLE STRAINS.

Exercise:

• Early loading and movement is key! Talk to your physiotherapist and find movements that your body likes or can tolerate, and avoid the ones that aren’t so great for the time being. This may include targeting all your muscles apart from the affected one (but may also include targeting the affected one in a reduced manner).

• We know your body heals best and feels best when you move, gone are the days of absolute bed rest!

• Mobilise early and avoid stretching until later stages of the healing process if necessary.

Pain relief:

• Medications can be a great way to make the healing process a little more comfortable (think paracetamol and ibuprofen, always consult your GP or pharmacist for medication information).

• Heat/cold therapy.

• Creams/sprays – Topical creams can provide temporary pain relief (think brain distraction), with some topical creams also having anti-inflammatory properties as well.

Diet:

• Keeping a balanced diet that is nutrient rich and contains adequate protein will help fuel the body for recovery.

Protection:

• In some cases taping, bracing or splints may be used during early stages of an injury, but remember you want your muscles and body to do the work in the long run and not the tape/braces/splints. Chat to your physiotherapist about best taping/bracing/splint options for your specific injury.

Later stages of physiotherapy rehabilitation

A common mistake with muscle strain rehabilitation is stopping when pain has fully resolved, after all pain is a great motivator! However, by the time muscles have healed and you are pain-free it is likely the muscle has weakened or deconditioned to a degree. Often we prematurely return to a high level of activity without doing the necessary work to get our injured muscle back to its former strength, if not further. As you can imagine this alone is a risk factor for a repeat muscle strain, and so the vicious cycle starts. Take your rehab a few steps further to really set yourself up brilliantly for the long run.

Making sense of all this and putting all the rehab principles into practice can definitely be a daunting task. To get your rehab on track for the best outcomes possible, book in to see your local friendly physiotherapist.

Part 2 SUMMARY

• For DOMS, don’t worry! Keep going with gentle exercise, avoid high intensity stuff involving the sore muscles.

• After being cleared for a severe strain, GET MOVING! Start low and slow and work within low/no pain movements.

• Medications can help make the process more comfortable, but healing takes time. Be patient.

• Keeping active will best help the healing process, and help retain muscle flexibility/range, cardiovascular endurance and muscle function.

• Fuel your body with adequate protein and a variety of nutrients/food groups.

• Imaging only when necessary.

• Once you think you’re out of the woods, take it several steps further for re-injury prevention.