Author: Michael Ranger

Sinus Tarsi

Sinus Tarsi Syndrome is a condition that occurs commonly in the athletic population but is often missed and treated as a peroneal muscle disfunction. Which is a real shame, because when treated appropriately, Sinus tarsi syndrome is easily managed and requires minimal adaptations to workload.

The sinus tarsi refers to an anatomical tunnel that runs between the two bones of the heel (Talus and Calcaneus, called the subtalar joint). Typically, this joint is very stable and experiences little to no movement during weightbearing activities. However, in an ankle that has experienced trauma to the lateral ligaments from an inversion sprain the sinus tarsi can become acutely inflamed. This is due to increased shearing forces that occur in the subtalar joint when the ankle lacks stability. Therefore, this condition can occur alongside an acute ankle sprain or because of recurrent ankle instability. Inflammation of the sinus tarsi causes localised lateral and/or medial ankle pain over the site of the sinus tarsi in weightbearing positions typically walking/running on uneven surfaces.

Sinus tarsi syndrome responds well to heel lock taping and anti-inflammatory treatment, allowing an athlete to minimise their training deload whilst managing their symptoms. Longer term management may involve proprioceptive retraining of your affected ankle. Your local physio will be able to provide you with relevant advice and management of your condition, tailored specifically to you, so if this sounds like you, book an appointment to have them take a look!

Lockdown #5 survival tips

Physio Plus Footscray’s Lockdown Hero tips.

Lockdown’s can get pretty dull and it can be hard to find ways to entertain yourself. Our Footscray team have had plenty of practice with extended periods stuck inside and wanted to share their top 5 ways to manage and liven up lockdown life.

  1. Uber eats

Lockdowns are hard on our favourite restaurants and cafés, why not kill two birds with one stone and treat yourself to a fun lunch while supporting local?

 

  1. Peanut brittle

Welcome to your new obsession. Ridiculously Delicious is our go to brand, we can’t get enough. If you can’t get your hands on a pack why not try making your own?

https://www.taste.com.au/recipes/peanut-brittle-2/acb7563a-0ecd-4a29-8ad7-d2942d1ac09f

 

  1. Binge watching

It’s a great time to catch up on all those shows, and movies people have been telling you to watch. Mick promises you can’t go wrong with the Sopranos.

 

  1. Exercise

Whether its zoom Pilates, a backyard HIIT session or a run within your 5km radius, moving your body this lockdown is a great way to break up your day. Nothing like a nice walk to boost your mood and get some vitamin D while you’re at it.

 

  1. Coffee Friday

Our ultimate favourite thing this lockdown is a takeaway coffee to kick off the weekend. Instant gets us through the week but nothing less than a cup from our local West 48 will do on a Friday.

@west48

 

#lockdownlife #comeonaussie #supportlocal #keepsmiling

Mastering the rehabilitation of calf strains in runners

The calf complex consists of two muscles: The gastrocnemius and soleus. Both muscles share the common insertion (combining to form the Achilles tendon) at the posterior aspect of the calcaneus. They perform plantar flexion of the foot during toe off and provide eccentric control during dorsiflexion in mid-stance during running.

 

We know from Dr. Rich Willy (2019) that the calf complex is extremely important, attributing up to 50-60% of force production when running.

 

EMG studies have shown the soleus in particular is the powerhouse for runners, finding it produces up to 6.5-8 times body weight of force during running. Studies have also found soleus force production remains largely consistent throughout low, moderate and high running speeds. This is unlike the hamstring muscle which is required more as running speed increases (Dorn et al., 2012).

 

This should highlight why building the strength capacity of the calf complex to meet the demands of running is essential for all recreational or elite runners when completing rehabilitation.

Mastering your calf strain rehabilitation program:

Before I discuss individual exercises for the calf complex, it is important to acknowledge muscle strains are mostly due to extrinsic factors (training loads). It is estimated 60% of all running related injuries could be attributed to training errors – load vs capacity mismatch – increases in frequency of sessions, intensity, volume or elevation i.e. running too far, too fast and too quick (Hein et al., 2014 & Hreljac, 2005).

 

A structured return to running program should be a part of a detailed rehabilitation plan to initially adequately reduce and gradually increase running loads as calf capacity increases.

 

How to build calf complex capacity:

At the 2021 Australian Physiotherapy Association Sports Symposium finding the edge – optimising athletic performance, 6 components were outlined to consider when completing a detailed calf rehabilitation program, these include: vertical strength, horizontal strength, stiffness, intrinsics, endurance and technical.

Vertical strength

  • Progressively loading calf raises:
    • With the knee straight in standing (targeting the gastrocnemius) and with the knee bent in standing or sitting (targeting the soleus).
  • Goals for vertical strength:
    • Single leg
    • Add weight, start low, progressively increase, aim up to 50-100% of body weight (this can be done with a smith machine/barbell, seated calf raise machine at the gym or giving the kids a piggie back/ sitting on your knee if in lockdown).

Horizontal strength

  • Horizontal strength is often neglected, however we don’t run on the spot, we run forwards.
  • Examples of horizontal strengthening exercises:
    • Walking lunges
    • Sled push
    • Forward hops
    • Hill/stair repeats (start walking, then progress to running when ready, following your return to running program).

Stiffness

  • Think of your calf complex as a spring, a stiffer spring will produce more recoil.
    • Heavy weighted single leg isometrics (set and hold calf raises).
    • Walking on toes + add weight (via dumbbells, barbells or wearing a backpack/carry shopping bags if in lockdown).
    • Walking on toes up a hill or stairs.

 

Plyometrics have also been showed to improve tendon stiffness, running performance and economy (Foure et al., 2010 & Garcia-Pinillos et al., 2020).

  • Plyometric exercises include:
    • Skipping
    • Progress to single leg hopping.

Intrinsics

  • Arguably I believe this is probably the least important component of the group and would constitute as the 1%’ers.
  • There is limited, low level of evidence finding increased medial arch drop and pronation when the intrinsic foot muscles are fatigued (Cheung et al., 2015 & Headlee et al., 2008).
  • Furthermore, it may be inferred that strengthening the intrinsic foot muscles could improve medial arch stiffness, which was found to be associated with improved running performance (Garcia-Pinillos et al., 2020).
  • We will discuss specific intrinsic foot muscle exercises in an upcoming blog.

Endurance

  • Building endurance of your calf complex could include:
    • Progressively increasing walking duration (progress to running when ready, following your return to running program).
    • Performing lighter weight with more repetitions until fatigue.
    • Increase skipping duration.

 

Technical (Sport specific technique and leg speed drills – A, B skips)

  • Introducing sport specific technique and leg speed drills such as:
    • A skips and B skips.
    • High knees and heel to bum flicks.
    • Fast feet drills.

Note: no components are prioritising stretching or flexibility.

 

Considering all the aspect above to optimise calf capacity and manage extrinsic training loads will help decrease return to running time, reduce the risk of re-injury and return the runner to optimal performance.

 

References:

Cheung, R. T. H., Sze, L. K. Y., Mok, N. W., & Ng, G. Y. F. (2016). Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. Journal of Science and Medicine in Sport, 19(9), 713-715. https://doi.org/10.1016/j.jsams.2015.11.004

 

Dorn, T. W., Schache, A. G., & Pandy, M. G. (2012). Muscular strategy shift in human running: Dependence of running speed on hip and ankle muscle performance (vol 215, pg 1944, 2012). Journal of Experimental Biology, 215(13), 2347-2347. https://doi.org/10.1242/jeb.075051

 

Fouré, A., Nordez, A., & Cornu, C. (2010). Plyometric training effects on achilles tendon stiffness and dissipative properties. Journal of Applied Physiology, 109(3), 849-854. https://doi.org/10.1152/japplphysiol.01150.2009

 

García-Pinillos, F., Lago-Fuentes, C., Latorre-Román, P. A., Pantoja-Vallejo, A., & Ramirez-Campillo, R. (2020). Jump-rope training: Improved 3-km time-trial performance in endurance runners via enhanced lower-limb reactivity and foot-arch stiffness. International Journal of Sports Physiology and Performance, 15(7), 927-933. https://doi.org/10.1123/ijspp.2019-0529

 

Headlee, D. L., Leonard, J. L., Hart, J. M., Ingersoll, C. D., & Hertel, J. (2008). Fatigue of the plantar intrinsic foot muscles increases navicular drop. Journal of Electromyography and Kinesiology, 18(3), 420-425. https://doi.org/10.1016/j.jelekin.2006.11.004

 

Hein, T., Janssen, P., Wagner-Fritz, U., Haupt, G., Grau, S. (2014). Prospective analysis of intrinsic and extrinsic risk factors on the development of achilles tendon pain in runners. Scandinavian Journal of Medicine & Science in Sports, 24(3), 201-212. https://doi.org/10.1111/sms.12137

 

Hreljac, A. (2005). Etiology, Prevention, and Early Intervention of Overuse Injuries in Runners: a Biomechanical Perspective. Physical Medicine and Rehabilitation Clinics of North America, 16, 651-667. doi:10.1016/j.pmr.2005.02.002

 

Willy, R., Parquette, M. (2019). The Physiology and Biomechanics of the Master Runner. Sports Medicine and Arthroscopy Review, 27(1), 15-21. doi: 10.1097/JSA.0000000000000212

Iselin’s Syndrome

Description

  • Iselin disease is a painful inflammatory condition of the apophysis (growth plate) of the 5th metatarsal (little toe bone), where the peroneus brevis inserts.
  • The growth plate is the area that bone grows from in children.
  • The growth plate is made up of cartilage, which is softer and more vulnerable to injury than mature bone. This growth plate also serves as an attachment site for the peroneus brevis muscle and the plantar fascia.
  • Iselin disease is most often seen in physically active boys and girls between the ages of 8 and 13 years of age but it can occur in younger children who are particularly active.
  • This condition is most common in those that participate in soccer, basketball gymnastics and dance.

Causes

  • Iselin disease is an overuse injury caused by repetitive pressure and/or tension on the growth center at the base of the fifth metatarsal.
  • Running and jumping generate a large amount of pressure on the forefoot.
  • Change of direction activity and heavy plyometric exercises are risk factors for Iselin disease because they increase the tension at the insertion of peroneus brevis.

Signs and Symptoms

  • Pain is most commonly found along the outer edge of the foot and is worsened with activity and improved with rest.
  • A limp on the affected side is likely to be present.
  • The child may walk on the inside of the affected foot to decrease tension through the insertion of peroneus brevis into the base of the 5th
  • The skin overlying the base of the 5th toe bone may be swollen, red, and/or painful to touch.

Diagnosis

  • The diagnosis of Iselin Disease is made primarily by clinical presentation and physical exam. Pain with palpation at the widest part of the lateral foot is the most common sign.
  • Xray or ultrasound are generally not required to diagnose the disease, but they may prove useful in assessing for displacement of the growth center and excluding other causes of foot pain.

Treatment

  • A short period of rest from aggravating activities to reduce inflammation and allow release of pressure on the tendon insertion is recommended.
  • Applying ice for 10 to 15 minutes every 2 to 3 hours is helpful to reduce pain and swelling. Ice is only really required to minimise pain as it won’t improve healing.
  • Non-steroidal anti-inflammatory medications such as ibuprofen or naproxen may also be beneficial in relieving inflammation and pain in the early stages.
  • Tension on the growth plate can be relieved by gentle massage of the calf and lateral shin muscles.
  • Properly fitting running shoes and/or arch support inserts are very helpful in decreasing pain on return to explosive activity.
  • If the individual fails a trial of massage, gentle stretching, rest, ice, and pain medications, the affected limb may be immobilised in a cam/walking boot for a short period until pain has decreased.

Return to Activity and Sports

  • Despite having a goal to return the patient to his or her sporting activities as quickly as possible, playing with pain will not only inhibit healing of the affected growth plate but may further injury the affected foot.
  • Activity however is best continued but guided by pain rather than completely resting and then reloading too rapidly.
  • The longer the individual has been plagued by the injury, the more time is required for symptoms to resolve.
  • Symptom minimisation and healing, if completely detached at the growth plate, typically takes anywhere between 3-12 weeks and is likely nearing completion when the patient can meet the following:
    • Completing full range of motion without ankle pain
    • No pain at rest
    • Ability to walk, jog, and sprint without pain
    • Ability to jump and hop on the affected side without pain
  • If pain recurs upon returning to sporting activities don’t despair, the individual should rest, ice, massage and gentle stretch until the pain has resolved before trying to return to play again.

Prevention

  • A dynamic and gradually increasing warm-up before starting any activity. A warm up regime such as the Fifa11+ is a great, researched warm up regime that can minimise risk of injury to the entire body.
  • Wear shoes that fit well and are appropriate for the activity. Replace worn-out shoes as regularly as practicable.
  • Stretch or massage tight muscle groups. A dynamic warm up will go a long way to loosening muscles appropriately.
  • Do not play through pain. Pain is a sign of injury, stress, or overuse. Decreased load or rest is required to allow time for the injured area to heal. If pain does not resolve after a couple days of rest, consult your physiotherapist. The sooner an injury is identified, the sooner proper treatment can begin. The result is less time not being able to play and therefore a faster return to life and sport.

 

Nutrition and performance

Running food

Adequate fuelling is essential to ensure optimum training and performance for any athlete, or person in general. This can also be said for ensuring a timely recovery from injury or illness. Post-injury nutrition is an important part of the healing process and will complete a good rehabilitation program.

After an injury, our body has an increased nutrient requirement to help the healing process, however given the reduction in activity/training load and therefore energy requirements, most people will reduce their dietary intake and may even lower the quality of the food they consume. One goal during this important recovery period is to prevent, or at least reduce the likelihood of, the loss of lean body mass. Intake of adequate protein that is spread evenly across the day can help with this. This can be from foods such as beef, chicken, egg, legumes or beans.

During rehabilitation it is important to take in required amounts of vitamins and minerals which play a role in boosting our immune system, assisting in collagen formation (important for healing of muscles, tendons and ligaments) and contributing to bony healing. An easy way to do this is to include fresh fruits and vegetables regularly as part of your diet.

Carbohydrates and fats are other important nutrients to consider during recovery. Wholegrain carbohydrates such as oats, brown rice or wholegrain pasta will be higher in fibre which helps with our hunger levels. Omega-3 fats play an important role in mediating the inflammatory process and can be found in foods such as salmon, chia seeds and walnuts.

It is also important to monitor consumption of sugars, fried fatty foods and alcohol during this time as these foods can affect the inflammatory process and reduce our body’s ability to synthesise protein and adequately repair tissue.

For specific information regarding dietary intake and performance talk to your physiotherapist, exercise physiologist or contact your local sports dietician.

 

 

Tendons and tendinopathy

Tendons and Tendinopathy.

There is a lot we do not know about tendinopathy, but there are some evidence-based truths that are not common knowledge and should be for best treatment of tendon pain.

Summarised below are some of the most important findings:

  1. Tendinopathy does not improve with rest – the pain may settle but returning to activity is often painful again because rest does nothing to increase the tolerance of the tendon to load.
  2. Although there are some inflammatory biochemical and cells involved in tendinopathy, it is not considered to be a classic inflammatory response. Anti inflammatories may help for very high pain levels but it is unclear what effect they have on the actual cells and pathology.
  3. Tendinopathy can be caused by many different risk factors. The main factor is a sudden change in certain activities – these activities include 1) those that require the tendon to store energy (i.e. walking, running, jumping), and 2) loads that compress the tendon. Some people are predisposed because of biomechanics (e.g. poor muscle capacity or endurance) or systemic factors (e.g. age, menopause, elevated cholesterol, increased susceptibility to pain, etc). Predisposed people may develop tendon pain with even subtle changes in their activity.
  4. Exercise is the most evidence based treatment for tendinopathy – tendons need to be loaded progressively so that they can develop greater tolerance to the loads that an individual needs to endure in their day-to-day life. In a vast majority of cases (but not all) tendinopathy will not improve without this vital load stimulus.
  5. Modifying load is important in settling tendon pain. This often involves reducing (at least in the short-term) abusive tendon load that involves energy storage and compression.
  6. Pathology on imaging is not equal to pain – pathology is common in people without pain. ‘Severe pathology’ or even ‘tears’ this do not necessarily mean a poorer outcome. Further, we know that even with the best intentioned treatment (exercise, injections, etc) the pathology is not likely to reverse in most cases. Therefore, most treatments are targeted towards improving pain and function, rather than tissue healing, although this still is a consideration.
  7. Tendinopathy rarely improves long term with only passive treatments such as massage, therapeutic ultrasound, injections, shock-wave therapy etc. Exercise is often the vital ingredient and passive treatments are adjuncts. Multiple injections in particular should be avoided, as this is often associated with a poorer outcome.
  8. Exercise needs to be individualised. This is based on the individual’s pain and function presentation. There should be progressive increase in load to enable restoration of goal function whilst respecting pain.
  9. Tendinopathy responds very slowly to exercise. We must encourage patience, ensure that exercise is correct and progressed appropriately, and try and resist the common temptation to accept ‘short cuts’. There are often no short cuts.

Please note that these are general principles and there are instances when injections and surgery are very appropriate in the management of tendinopathy.

REFERENCES
Abate M, Gravare-Silbernagel K, Siljeholm C, et al.: Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy. 2009, 11:235.
Cook J, Purdam C: Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine. 2012, 46:163-168.
Littlewood C, Malliaras P, Bateman M, et al.: The central nervous system–An additional consideration in ‘rotator cuff tendinopathy’and a potential basis for understanding response to loaded therapeutic exercise. Manual therapy. 2013.
Malliaras P, Barton CJ, Reeves ND, Langberg H: Achilles and Patellar Tendinopathy Loading Programmes. Sports Medicine. 2013:1-20.

Women’s NRL National Championship

Last weekend in Redcliff, Queensland, Matt provided his expertise working with the Victorian Under 19s and Open team at the Women’s NRL National Championship.

The tournament was a fantastic opportunity for the best of Victoria’s talented ladies to compete against the Australia’s best players, including the perennially strong rugby league states of Queensland and New South Wales.

The women put in a tremendous effort playing 4 games across the 4 days with a lot of tape used as a preventative measure on knees and ankles, concussion the most common injury amongst a thankfully small injury list. For Matt, a physiotherapist who has predominantly worked in the male elite sport system, this experience afforded a great insight into top level competition and Women’s Rugby.

Matt looks forward to seeing the continued improvement in the game in Victoria while seeing the sport grow with more women given the chance to represent their state at National level. 

Injury prevention in community sport

Jump and land

Injury prevention in community sport.

Given return to competition in 2021 after a year without the majority of community sporting competitions in 2020, incidence of injuries to all parts of the lower limbs are unfortunately more likely than ever before.

Injury to the knee, hamstring and ankle can be debilitating due to the enormous number of varied forces that are put through the lower limb while weight bearing through the joints required for all upright locomotion.

Injuries to these areas account for the biggest lost time injuries in the AFL as well as most twist and turn sports played in Australia and around the world.

Traumatic knee injuries caused by impact, twist and turn mechanisms while working or playing sport include ligament and cartilage injuries. Sports such as football, netball, rugby, lacrosse and hockey are sports that tends to have a high incidence of ACL and other ligament injuries. Cartilage can also be impacted through excessive use and awkward positions under load.

Patellofemoral joint pain (PFJ) tends to cause significant pain particularly with deep knee flexion positions such as landing to getting up from the ground.

The Footy First training program has been developed considering the latest and best recent scientific evidence by the AFL, in conjunction with Monash University and Griffith University, the Victorian and NSW governments and Sports Medicine Australia, as an injury prevention program designed to prevent, at the least reduce, the prevalence of leg injuries in community Australian Football is a fantastic resource available to everyone as free PDF document via: http://www.aflcommunityclub.com.au/fileadmin/user_upload/Coach_AFL/Become_a_Coach/Accreditation/FootyFirst_-_Manual.pdf

The program includes ideas for the most appropriate warm up regimes, progressions as players become more proficient at each exercise or dynamic stretch as well as being formulated considering the exact movement patterns required for safe completion of a sport with such high demands as Australian rules football.

By implementation of programs such as the footy first program at all levels of community sport, we can cost effectively do our bit in preventing lost time injuries and the associated heartache of missing games. Let’s make the 2021 the best season in memory by keeping as many players as possible available for every game.

If you’d like more specific injury information, click here to return to our home page https://physioplus.com.au/ to read more about any injury that you may be suffering or to book an appointment with one of their fantastic team today.