Tag: Health

What makes a sports physiotherapist special?

Last week my boss asked me to write a small piece about sports physiotherapy. I want to share it with you as the task has enabled me to reflect a lot on what I’ve learned and continue to learn doing what I do every day. It has been a big year in growth for me, as I continue to pursue my personal goals and develop towards the health provider I want to be in the future. So here it is!

With an ever growing choice of treatment providers here in New Zealand, sometimes it can be a difficult decision choosing where to go for help. Have no fear, as all the answers you are looking for, are right here.

For the average human to enjoy life, we must think of ourselves holistically. High schools and undergraduate university programs up and down the country teach this by incorporating the four pillars of health, our Hau Ora; the physical/taha tinana; the spiritual/taha wairua; the social/taha whanau; and the mental and emotional/taha hingenaro. With this in mind, it is therefore important that whoever you choose has a strong understanding for how all these pillars of health fit.

“Whare tapawha” image, credit https://www.researchgate.net/figure/Maori-Health-Model-Te-Whare-Tapa-Wha-developed-by-Mason-Durie-image-reproduced-with_fig2_274713827

The sports physio has the upper hand as being involved in sports also requires an in-depth understanding of these four pillars.

The physical goes without saying, as physiotherapists are movement specialists by trade. But it’s not good enough to get people moving, a physio needs to get you moving well. The sports physio needs to have a deeper level of biomechanics, where getting a sports person back performing at the highest level they can becomes a habit of practice. It puts pressure on understanding the injury in its entirety, starting with an accurate diagnosis so the physio can tailor a rehab programme specific to what you need. This means that the sports physio won’t be satisfied with just getting you back to work or running 3 times a week. They will want you to do that effortlessly, so you can enjoy what you are doing.

The spiritual is, by nature, more difficult to see. But athletes have to embody all of who they are to perform at their best and the sports physio knows and respects this. This means that the sports physio will work with your beliefs and cultural needs intimately and incorporate these elements into your rehab programme. It helps to build trust in the physiotherapist, something vital in having the best outcome possible with the rehab plan. 

Sport is social. At one stage, most sports physios were sportspeople. The others usually still are. What this means is that they know how important it is to get patients back to regularity as being injured can have a big impact on your social life as well. It’s a common trend to find that a sports physio decided to take up the occupation following a positive experience with their own physio, who helped them return to sport, activity and being able to be around like-minded people.

That just leaves the mental well being. Let me start by saying up front that all activity we engage in has an element of risk that it could do more harm than good. As previously mentioned most sports physios were (or are) avid sportspersons. This means that the sports physio, more often than not, has been exactly where you are. Upset, frustrated, worried, and everything else that comes along with being injured. With this experience comes understanding, not just of what it feels like to be injured, but also what it feels like to lose a part of who you are. Sports is so much more than playing a game once a week. Its socializing with like-minded people, it’s the rush of achieving something challenging, it’s the community that you are a part of when you are tied to a club. Having someone guide you who has been exactly where you are adds an air of reassurance. They’ve been through it, they know there are good days and bad, times of optimism and others of feeling totally defeated. It is all of these elements that make the relationship between a patient and a sports physiotherapist so special.

So, should you ever find yourself injured or unable to complete the things you want to in life, seek out a good sports physio. And tell ‘em I sent ya. 

Teej

A LisFranc Fracture: The next rare injury to add to the collection

I am convinced I must have done some terrible things in a previous life.

I’m writing this from my hospital bed following surgery for a Lisfranc foot injury I sustained 5 days ago playing a club rugby. For the record, a Lisfranc fracture is one of the most commonly missed injuries in primary care, and mine would have fallen into this category had I ignored my gut instinct and followed the advice of the urgent doctors.

But this post is not a gripe about the sometimes sub-par treatment delivered for musculoskeletal injuries in after-hours care, they have a really difficult job with patients that are often in immense levels of pain and discomfort. In this post I’m going to take you through how to not miss a lisfranc fracture, with a first-hand account of what it felt like to sustain it, and what my next steps are on the road to recovery.

Lisfranc Fracture

The Lisfranc joint involves the tarsometatarsal (TMT) joint complex. The injury is usually sustained with the foot in full weight bearing and plantarflexion, with a translational or torsional external force applied to the foot. This causes the small ligaments between these bones to tear and sometimes avulse, resulting in displacement and therefore unstable joints under weight bearing.

Previously, I have seen one case which presented to me after 4 weeks of being in a moonboot and foot pain that was not improving. The mechanism was simple, the patient had stepped down from a curb and stumbled forwards while crossing a road. She felt/heard a popping/crunching sensation at the time and her main complaint was that her foot felt like it was separating under her own weight, pretty much a 1, 2 and 3 of key things to look for should someone present to you with mid-foot pain.

One thing I’ve learned with Lisfranc injuries, is that appropriate radiographs need to be taken as soon as possible. To pick this injury up, it is almost empirical that weight bearing x-rays are obtained as well as non-weight bearing views. This is because the radiologist looks for widening of the Lisfranc joint, which will not be shown in non-weight bearing views.

So it seems pretty simple doesn’t it: A plantarflexed foot under translational/torsional load, popping and cracking sensation through the midfoot (NOT THE ANKLE) and a sensation of separation or the foot being unstable after the injury will make you suspicious of a Lisfranc fracture, with the logical next step being to obtain weight bearing comparison radiographs to rule in/out a Lisfranc fracture.

How I knew I’d broken my foot

It all happened very quickly, but I feel like I had a good handle on the sequence of events. I was stepping a player pushing of my right foot, the tackler made contact so I looked to offload to my left. As I came down in the tackle, I felt the toes of my right foot stick into the ground, and the middle part of my foot roll inwards, with multiple clicks and crunches as I came down. It hurt immediately, and as I went to stand and run to the next phase of play, I felt my foot give way and the bones in the middle of the foot did not feel like they were sitting in the right place. It was a deeply sickening sensation. Even before getting my rugby boot off the swelling had already started, and within 15-20 minutes my foot had ballooned completely with swelling. Putting two and two together, it was obvious that I’d seriously damaged my foot.

I went to urgent doctors as that was the best care available where I was, and they took non-weight bearing x-rays. The initial impression was that there were no obvious misalignment or fractures of my foot, but the radiologist report recommended the weight bearing views be obtained as there was evidence of subluxation of the second metatarsal on the lateral view. Two days later after waiting 5 or so hours in accident and emergency I got the weight bearing views which confirmed a lisfranc fracture. A CT scan shortly followed and 3 days later here I am with two plates and a screw holding the middle part of my foot together. Overall, this is a really good outcome compared to my previous patient that had been walking around for four weeks with a broken foot that was not going to heal by itself.

What comes next?

I’m currently waiting on final x-rays, after which I’m hoping to be discharged to go home. I’ve been told that I will be 6 weeks in cast, and then a further 4 weeks in a moonboot before progression to full weight bearing. Thankfully, a progression of rehabilitation following a lisfranc surgery has already been published by Porter et al. 2019. I’ll leave the link at the bottom of the page but unfortunately the paper is not free to view. I’ll briefly explain the four phases of rehabilitation: (these have been taken from table 4 of the paper by Porter et al. 2019)

Phase 1: 1-6 weeks post-op

Clinical goals:

  • Full ROM ankle – dorsi, plantar, inversion and eversion
  • Full ROM MTP joints (toes)
  • Control swelling
  • Desensitize foot

Exercise

  • NWB for full 6 weeks
  • Toe curls – active and passive
  • Achilles tendon stretching with towel
  • Strengthening with theraband at 2 weeks all directions of the ankle
  • All upper extremity lifting
  • Body weight leg extension and curls, seated calf raises in non-weightbearing

Phase 2: 6-12 weeks post-op

Goals:

  • Strength comparable to opposite side
  • Bilateral double to single toe raise
  • Wean out-of-boot into carbon fiber plate and orthotic/athletic shoe
  • Proprioception retraining activity in shoe
  • Wean off crutches over 10-14 days

Exercise

  • Stationary bike in boot until 8-10 weeks post-op
  • Proprioception retraining in boot 6-10 weeks post-op and in shoe 8-12 weeks post-op
  • Bilateral standing toe raise work to single toe raise

Phase 3: 12-16 weeks post-op

Goals:

  • Full ROM, strength and flexibility
  • Restore normal proprioceptive retraining at rest/standing
  • Begin running, and sports-specific training

Exercise:

  • Advanced proprioceptive retraining
  • Increase from biking to stair-stepper/elliptical/AlterG to running
  • Can begin leg press when able to do stair-stepper/elliptical
  • Can do squats/clings/lunges after can run

Phase 4 – 3.5-9 months post-op

Goals:

  • Removal of hardware typically at 3.5-5 months post-op
  • Return to sport is 4-6 months for high school, 5-8 months for college and 6-10 months for professional athletes

Exercise:

  • Sports specific performance exercises and conditioning for full play

https://scholar.google.co.nz/scholar?hl=en&as_sdt=0%2C5&q=Injury+Pattern+in+Ligamentous+Lisfranc+Injuries+in+Competitive+Athletes&btnG=

If you have made it this far, thank you and stay tuned for updates on my progress via my instagram @theinjuredphysio. Let’s get back to rehabbing together!

References:

Mora, A., Lunz, D., & Kao, M. (2018). Return to sports and physical activities after open reduction and internal fixation for Lisfranc injuries in recreational athletes. Foot & Ankle Orthopaedics, 3(3), 2473011418S0036. doi: 10.1177/2473011418s00361

Porter, D., Barnes, A., Rund, A., & Walrod, M. (2018). Injury pattern in ligamentous Lisfranc injuries in competitive athletes. Foot & Ankle International, 40(2), 185-194. doi: 10.1177/1071100718802264

Singh, S., George, A., Kadakia, A., & Hsu, W. (2018). Performance-based outcomes following Lisfranc injury among professional american football and rugby athletes. Orthopedics, 41(4), e479-e482. doi: 10.3928/01477447-20180424-03