Author: Michael Ranger

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Rugby – Ankle sprains and balance – Melissa Martin

A study by Martin et al.(2021) was conducted to examine differences in objective dynamic
balance outcomes of female rugby players with and without a history of lateral ankle sprains.
The Noraxon myoPressureTM (Zebris) pressure plate was used for this study to measure
objective dynamic balance during 3 sport specific tasks, namely single-leg catch-and-throw,
single-leg jump landing and side stepping with statistically significant differences noted.

Women’s rugby is growing in popularity worldwide (King et al.,2019) The most common type of
ankle injury in female rugby players was identified as lateral ankle sprains, mostly involving the
rupture or tear of the anterior talofibular and calcaneofibular ligaments (Gribble et al.,2016).

Ankle sprains mostly occur in rugby due to impact or collision of players when the ankle twists
inward (Richie & Izadi,2015). The tackle is considered the most dangerous phase of play as it
contributes to 61% of all injuries in rugby, with joint sprains more common to the ball carrier (
Matthewson & Grobbelaar,2015). However, ankle sprains may also occur spontaneously in
rugby during running and cutting manoeuvres particularly on uneven field surfaces. During
cutting manoeuvres, players are required to run, change direction and leap away for other
players at a high velocity. The ankle moves through extreme ranges of movement from
dorsiflexion and inversion to plantarflexion and inversion which stresses the plastic restraint of
the lateral ankle ligaments, resulting in a high risk of inversion sprains (Vijam et al.,2015).

An ankle sprain often results in loss of postural control, leading in turn to loss of proprioception,
nerve conduction and reduced strength as well as range of movement (Richie & Izadi,2015).
Optimal dynamic balance is important for rugby players as they need to be able to avoid falls
whilst performing and executing highly skilled sport specific tasks such as tackling, kicking,
passing and catching (Chiwaridzo et al.,2016). Technological advancements in balance
assessment over time have led to the utilization of pressure or force platform systems to
quantify dynamic balance ( Duarte & Freitas,2010; Mancini &Horak,2010; Schubert &
Kirchner,2014). These systems can objectively assess balance and provide quantitative
feedback to guide clinicians in assessing and monitoring proprioceptive retraining during
rehabilitation before return to play and during the implementation of preventative programmes.

At Physio Plus Cheltenham, we are able to provide a comprehensive assessment of your sport injury utilising
the Strength by Numbers AxIT testing system. The AxIT system can measure the force that you
produce and absorb when completing different exercises, such as Single leg balance, Squat,
Jumps and calf raises to name a few. This system helps to set goals and subsequently
motivates you to keep up with your rehabilitation and exercise plans, even once the pain from
your injury has subsided.

If you need help with your injury rehabilitation, get in contact with us today!

Rehab framework for the calf

Estimating prognosis
Positive:
– First time calf injury
– Not high energy mechanism eg not
running/accelerating
– If there is a disconnection between capacity
and pathology on MRI
– Good calf baseline
– Good calf strength

Negative:
– Recurrent injury
– Running or high energy mechanism
– PHx of calf, ankle or knee injury
– Older age
– Poor calf baseline profile
– Poor calf synergists both local and
upstream

Acute rehab examples (completed ~3 x day)
– Theraband plantarflexion
– aROM + isometric
– Isometric standing straight knee heel raise
– Isometric seated bent knee heel raise
– Focus on proximal synergists early – hip and knee strength

Early rehab examples:
– Body weight heel raise → Neutral position – aim for around 60bpm on metronome
– Isotonic seated calf raises in neutral position
– Body weight isometric switches → Monitor heel drop
– Smith machine isotonic standing heel raises
– Early locomotive
– Lunges
– Heel to toe walking
– Stair walking

Locomotive exercise progressions:
– Stair ascents
– Walking – start at ~90bpm on metronome
– Weight vest/waterbag
– Jogging – ~170bpm
– Lunges
– Walking lunges
– Lunge arabesque
– Lunge doubles
– Progressing to using barbell/medicine ball

Intermediate to end stage rehab examples:
– Bodyweight single leg heel raise → Progressing into dorsiflexion
– Isotonic seated calf raises → Progressing into dorsiflexion
– Smith machine isometric switches → Increase load
– Smith machine isotonic standing heel raises → Increase ROM
– Plyometrics
– Start with vertical and progress to horizontal
– Once comfortable with above progress to lateral/rotation
– Running drills → A + B walk/skip variations
– End stage locomotive
– Triple extension onto box from hinged position → Add weight with dumbbells/barbell
– Prowler progressions

Plyometric progressions
– Double leg
– 1 on 1 off
– 2 on 2 off
– Single leg

Combat sports – where the athlete puts it all on the line to break down his/her opponent, either physically or mentally. Due to the nature of the sports, it is inevitable that injuries will occur. Therefore, it is imperative that medical practitioners have a comprehensive understanding of the training and competition combat athletes participate in, as well as the injury characteristics to be prepared for the most pertinent injuries and its rehabilitation course.

There are many components to the combat athletes training regime. The martial arts gym is where the athlete develops skills and tactics to ensure they are well equipped in their ability to defend and attack in their sport. The weights room is where the athlete develops and enhances their general physical qualities (e.g strength, power and speed).  And lastly, the cage/ring/mats, are where the athlete puts it all together in competition, to display their unique style of martial art against their opponent.

When an athlete becomes injured, whether in training or in competition, it is imperative that their rehabilitation is guided by a qualified health professional (such as a physiotherapist/physical therapist), as the biggest risk factor for injury is previous injury to the site. It is also crucial that the practitioner understands the biomechanics and demands of the sport, as it will allow for a specific and effective rehabilitation program. Musculoskeletal injuries usually occur when an internal/external stress is applied to the bones, tendons, ligaments, joints and cartilage which is beyond the normal tissue capacity. This can be either acute or chronic.

In 2020, the UFC (Ultimate Fighting Championship) developed a cross-sectional performance analysis and projection of the UFC Athlete. They found that the most common injuries sustained from grappling were diagnoses’ involving the neck, low back and shoulder. The most common striking-related injuries involved knee pain, wrist/hand pain, concussions and foot pain. Finally, the most common injuries involved in submission techniques included knee and elbow injuries that involved ligament sprains.

Physiotherapists are experts in musculoskeletal rehabilitation, as well as prehabilitation. They are proficient in assessment and treatment, exercise prescription, manual therapy, and concussion/vestibular rehabilitation. And whilst there are many other physiotherapy clinics you can receive treatment from, Physioplus has practicing martial artists, who train and compete in mixed martial arts, wrestling, jiu-jitsu and muay thai. They understand the demands of the sport and what is required to make a full return to the mats, which makes them the most qualified to help you return to/optimise your martial arts journey.

Balance is a complex process that relies on the integration of sensory information from proprioception, vision, and the vestibular system. These three systems work together synergistically to maintain postural stability and enable smooth, coordinated movement. Understanding their combined effect sheds light on how optimal balance is achieved.

1. Proprioception:

• Definition: Proprioception refers to the body’s ability to sense its position, movement, and forces acting upon it.
• Role in Balance: Proprioceptors in muscles, tendons, and joints provide continuous feedback to the brain about the body’s position in space. This information is crucial for maintaining balance, especially during static and dynamic activities.

2. Vision:

• Definition: Vision provides information about the environment and the body’s position relative to external reference points.
• Role in Balance: Vision helps in orienting the body and adjusting posture based on visual cues. It provides additional information to supplement proprioception, especially in situations where proprioceptive input is limited or conflicting.

3. Vestibular Function:

• Definition: The vestibular system, located in the inner ear, detects head movements and provides information about spatial orientation and movement.
• Role in Balance: The vestibular system helps in maintaining gaze stability and detecting changes in head position, which are critical for balance and spatial awareness, especially during rapid movements.

4. Combination Effect on Optimal Balance:

• Synergistic Interaction: Proprioception, vision, and vestibular function work together to provide a comprehensive picture of the body’s position and movement in space. This integration allows for precise adjustments in posture and movement to maintain balance.
• Compensatory Mechanisms: When one sensory system is compromised, the other systems can compensate to maintain balance. For example, if visual input is reduced, proprioception and vestibular input become more critical for balance control.

Optimal balance is achieved through the synergistic interaction of proprioception, vision, and vestibular function. These sensory systems work together to provide the brain with accurate information about the body’s position and movement, allowing for precise adjustments to maintain stability. Understanding the combination effect of these systems is crucial for improving balance and mobility, especially in clinical settings where balance impairments are common.

Rest is a crucial component of any fitness or training regimen, but the type of rest one chooses can significantly impact recovery and performance. While complete rest, or the absence of any physical activity, is often the go-to for many athletes and fitness enthusiasts, relative rest, which involves engaging in light sport/activity specific, low-impact activities, may offer several advantages.

1. Enhanced Recovery:

• Blood Flow: Relative rest, such as gentle stretching or light walking, helps maintain blood flow to muscles without causing additional stress. This can aid in the removal of waste products like lactic acid, which can accumulate during intense exercise and contribute to muscle soreness.
• Muscle Repair: Light activities can stimulate the production of growth factors and hormones that support muscle repair and regeneration, potentially speeding up recovery compared to complete rest. (Crampton et al., 2017)

2. Injury Prevention:

• Maintaining Mobility: Engaging in low-impact activities during rest periods can help maintain joint mobility and prevent stiffness, reducing the risk of injury when returning to full activity.
• Muscle Activation: Light activities keep muscles active without overloading them, which can prevent deconditioning and reduce the risk of strains or tears when resuming regular training. (Sato et al., 2015)

3. Psychological Benefits:

• Mood Enhancement: Physical activity, even at a low intensity, can stimulate the release of endorphins, improving mood and reducing feelings of fatigue or burnout often associated with intense training. (Biddle et al., 2018)
• Maintaining Routine: Relative rest allows athletes to maintain a sense of routine and discipline, which can be beneficial for mental well-being and adherence to long-term training goals.

4. Performance Maintenance:

• Skill Retention: Engaging in light activities that mimic sport-specific movements can help maintain skill proficiency and muscle memory, reducing the need for reconditioning when returning to full training.
• Cardiovascular Fitness: Light aerobic activities can help maintain cardiovascular fitness, reducing the cardiovascular detraining effects of complete rest. (Mujika et al., 2018)

While complete rest has its place, especially in cases of severe injury or overtraining, incorporating relative rest into a training regimen can offer numerous benefits. By maintaining blood flow, supporting muscle repair, preventing injury, enhancing mood, and preserving performance, relative rest provides a balanced approach to recovery that can help athletes and fitness enthusiasts stay healthy and perform at their best.

College President report

Submitted by: Tom McMillan FACP
College President

I trust this message finds you in good health and high spirits. As we commence the year with the first edition of the College e-communications for 2024, I am thrilled to share some exciting developments within our College.

New registrars joining the Specialisation Training Program (STP)

I am delighted to announce that we have four new registrars set to commence their STP journey in April 2024. We extend our sincere gratitude to all those who are supporting them on this transformative path. Your mentorship and guidance will undoubtedly play a pivotal role in shaping the future of these physiotherapists.

Welcome Vice President Wendy Nickson APAM

A warm congratulations and heartfelt thanks are in order for College Council member Wendy Nickson, who joins the College executive as Vice President. Wendy will be joining Vice President Gen McGlashan FACP and myself at the helm, bringing a wealth of experience in education and dedication to our leadership team. Together, we are poised to lead the College towards new heights of excellence.

Andrew Webster FACP joins College Council

We are pleased to welcome Andrew Webster, FACP to College Council and as the newly appointed Specialisation Training Program (STP) chief examiner. Many of you will know that Andrew has more than six years of experience on the College Council and has most recently been serving as Musculoskeletal group NSW chair. His expertise and insights will be invaluable as we navigate the challenges and opportunities that lie ahead. We look forward to his contributions.

Revised Specialisation Training Program (STP)

I am pleased to report that work on the STP is progressing diligently. This initiative aims to enhance the STP to ensure it evolves with the landscape of physiotherapy. The program design is underpinned by the Physiotherapy Competence Framework to ensure the highest rigour and standards are maintained.

Accreditation of the revised STP by the Australian Physiotherapy Council (APC)

We are excited to share that an expression of interest application for the accreditation of the revised STP was submitted and accepted by the Australian Physiotherapy Council in December 2023. The accreditation process is well-resourced, and we remain steadfast in our commitment to achieving accreditation for the revised STP.

Evidence Portfolio Pathway roll-out

In 2024, we will witness the rollout of the Evidence Portfolio Pathway (EPP) to titling, creating more opportunities for College membership titles with equitable access and the opportunity for flexible and individualised learning.  It is important to note that this currently does not alter the existing academic pathway to titling and we want to reassure universities on the APA-recognised list, that there will be significant consultation and lead-in time before any changes are implemented.

Acknowledgement to the Board of Censors

I would like to take a moment to express our sincere gratitude to the Board of Censors. Debra Shirley FACP has been confirmed as chief censor in 2024, with Anne Daly FACP serving as deputy chief censor. We extend our deep thanks to Alisa McLachlan FACP and Marg Sherburn FACP for their dedication and service in acting positions during 2023. Your commitment has been invaluable in ensuring the smooth functioning of our critical processes, and we are grateful for your support.

As we embark on another year of excellence, let us continue to uphold the College values. Together, we can achieve great things and elevate the practice of physiotherapy to new heights.

Warm Regards,

Tom

• Tom McMillan FACP, Specialist Musculoskeletal Physiotherapist (as awarded by the College of Physiotherapists in 2010)
• Gen McGlashan FACP, Specialist Women’s, Men’s and Pelvic Health Physiotherapist (as awarded by the College of Physiotherapists in 2010)
• Andrew Webster FACP, Specialist Musculoskeletal Physiotherapist (as awarded by the College of Physiotherapists in 2015)
• Debra Shirley FACP, Specialist Musculoskeletal Physiotherapist (as awarded by the College of Physiotherapists in 2007)
• Anne Daly FACP, Specialist Pain Physiotherapist (as awarded by the College of Physiotherapists in 2021)
• Alisa McLachlan FACP, Specialist Musculoskeletal Physiotherapist (as awarded by the College of Physiotherapists in 2019)
• Marg Sherburn FACP, Specialist Women’s, Men’s and Pelvic Health Physiotherapist (as awarded by the College of Physiotherapists in 2010)