Tag: Recovery

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

The Crux of Crutches: the 1-2-3 step guide

Crutches… Crutches… Crutches

During my time as a sports enthusiast, I have unfortunately become well acquainted with crutches. They are essential for enabling mobility while keeping weight off injured tissue, allowing natural time to heal as well as possible without overloading it.

But at the time, they can suck.

Crutches are awkward, they make your palms sore, they fall over when you try to lean them against the bench top, they are with us for what feels like an eternity (yes six weeks can feel that long) – and it’s a shame that the safe use of crutches is often left to the user to work out themselves.

Whether young or old, the skill of using crutches efficiently can be learned using these simple concepts. But first, lets make sure they are set up properly.

Small disclaimer: As the axillary (under armpit) crutches are pretty much extinct here in New Zealand, I’ll be focusing on the elbow crutch in this post.

#1 – Setting up the crutches

Crutches must be set up for YOUR body, and typically they are set up too high. It puts unnecessary stress on your arms and shoulders, and when saddled with crutches for 6 weeks or more, this will take it’s toll on your body.

To set up the crutches, stand up straight with your arms relaxed by your sides. If your balance is not good, then do this close to a bench top so you can support yourself, or get a friend to help. Allow your arms to hang so there is a subtle but comfortable bend at the elbows. The handle of the crutch should be set to your palms at this height. Set the forearm cusps to wrap around the upper third of the forearm (closer to the elbow), NEVER above the elbow.

As a quick check, stand in front of a mirror with your crutches. Gently apply force downwards into the handles to take your weight – maintaining that slight bend at the elbows. If you feel/see your shoulders visibly rise, then it is likely the crutches are too high. If you need to lean forwards to apply the pressure through the crutches, then it is likely the crutches are too low.

#2 – Walking for your injury

The pattern of walking could depend a number of factors including type of injury, stage of injury and/or medical teams advice. I will split these into non-weight bearing, partial weight bearing and near-full weight bearing (NFWB).

Non-weight bearing (NWB):

This is usually in the early stage of recovery, following some surgeries or if you have been put into a non-weight bearing cast.

This is the hardest stage of using crutches both physically and mentally. Every effort to stand up, get out of bed, go to the toilet will test you. Factor in the pain you’re likely experiencing and some days might not feel worth it.

But,

There is a reason for this, and it is to give your body the best chance it has at healing. So turn those mini-challenges into mini-victories! Apply the following patterns to make things as easy as possible.

The concept is simple. And its based on simple geometry.

You are going to use a triangle as your guide. The two crutches in tandem will make up two points, and your good (uninjured) leg will be the third.

Place the two crutches one regular step ahead of yourself, and step through one step ahead of the crutches with the other foot, and repeat. Take your time, be methodical initially until it becomes natural

Easy – but be wary.

It’s possible to get caught out by putting the crutches too far ahead of yourself. This will mean that rather than stepping through with your good foot, you end up swinging your body through. Although quicker, more momentum simply increases the chance of you or the crutches slipping, or having to hop to regain control. Be smart and stay safe.

Partial weight bearing (PWB):

Perhaps the injury is on the low end of the severity spectrum, or you’ve gone an extended period of NWB and the doctor/physio/specialist has given you the green light to start loading gradually.

Awesome job! Celebrate this mini-victory!

The pattern here doesn’t change. Put your crutches out first as before, next step with your injured foot to the middle of the crutches and “weight-bear” within pain-free limits, step through with your good foot and repeat.

Near full weight bearing (NFWB):

You are nearly there! Graduation and the point of throwing those blasted crutches out the door is almost upon you. Once again, well done on getting this far!

The likely change here is that you will be wanting to only use one crutch. As easy as that sounds, it is super common for people to make this harder than it needs to be.

Make sure the crutch is on the OPPOSITE side to your injured leg. This is crucial. Having it the same side will cause a walking pattern similar to a pirate with a wooden peg leg. It results in overuse of the upper body on that side an “hitching” of the hip on the affected side. It also abolishes the triangle rule that has served you so well to this point. Why change something that isn’t broken?

Instead have the crutch on the opposite side to promote even weight distribution and a far more regular walking pattern. The crutch and the affected leg come forwards at the same time, followed by a step through with the good foot. If you don’t believe me, try both ways! One will feel far more comfortable than the other

#3 – Conquering steps

Steps and stairs are another challenge for someone fresh to using crutches. It can be scary, and fear of falling can be debilitating enough to keep people at home or even worse confined to the ground floor of their homes.

Steps are managed by remembering this: GAS goes UP, and SAG comes down.

G.A.S means Good, Affected and Sticks, and applies to scaling UP stairs.

  • First, place your GOOD leg up one step,
  • Next, bring your AFFECTED (injured) leg up to the same step,
  • Last, bring your STICKS (crutches) to the same step as well, and repeat.

S.A.G is the opposite, for when going DOWN stairs.

  • First, place your STICKS on the step below,
  • Next, bring your AFFECTED leg to the same step below,
  • Last, bring your GOOD leg to the same step below, and repeat.

It’s now up to you to put this into practice!

If you’ve made it this far, thank you for reading my blog. All the information covered is intended to help you through your injury, as it has helped me through mine.

If you did find this helpful, don’t hesitate to mention it to a friend who might benefit from it as well.

Take care out there, and lets continue to rehab and train together!

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

“How Do I Not Over-train?”

This is something I get asked a lot by patients in the physio room, and it seems an appropriate first topic as I get stuck in to power training for a half marathon at the end of Feb.

Training hard and over-training can be a very fine line, with one achieved at optimal loading for the physiology of the body and the other when you strain the body just enough to cause more net tissue damage (and injury) than net growth. It’s important to keep in mind that everyone is different, so there is no formula we can simply plug our height, weight, age, gender or goals into that will tell us exactly how much is too much. We can however, implement some reasonably straightforward principles into training to help us get things right.

  • Avoid Training on Consecutive Days

This one might seem pretty obvious, but its particularly important if you are starting a completely new sort of training or working your way back from injury. Training and recovery are both equally as important as each other, with the latter often not given the respect it’s due. Training is the breaking down of tissue, with recovery being the time you eat the right things and rebuild better, stronger and faster than what was there before. We can easily get sucked in to a boom-bust behaviour. What I mean by this, is you train very hard for a couple of days (the boom) and then find yourself so sore that you can’t walk for the next week (the bust). Training needs to be gradual, and having a day off in-between training days when you get started can be an easy way to make sure your body is given the time it needs to recover, especially as a beginner getting into physical exercise for the first time.

  • Have Variations in your Training

We can still be active while we recover. Keeping with the marathon training rhetoric, my personal goals are to be doing one decent run each week. Other days of the week, I’ll still be getting my Km’s in, but I’ll switch up whether I’ll getting these from the bike, or the rowing machine. Another option would be to get into the pool. All of these are great ways to train without the relentless pounding the body takes from running. It’s also important to respect the benefit that specific strength training can have on the body, and no, this does not mean that we need to go and get ourselves a gym membership to start pushing weights. To typically train for endurance strength, we want to keep the load low and the repetitions high, so body-weight exercises in sets of 12, 15 or 20 are perfect for achieving these parameters. Squats, lunges, step-ups, sit-downs, and floor exercises can all be easily performed in a small space in your own home.

  • Listen To Your Body

This last principle is often easier said than done, and is often accompanied with the question of “how do I know if I’ve done too much”. For this, I like to give my patients a traffic light guide model. A “Green Light” is given to an activity that may/may not be sore at the time, but the pain stops pretty much as soon as they stop doing the activity. They can do as much of that activity as they like, knowing that the pain/discomfort they feel is not physical damage to tissue. An “Orange Light” is given to an activity that again may/may not be sore at the time, but the pain/discomfort stays for a few hours before settling once again by that evening (within 24 hours). The patient can continue with this activity, but must pay attention that the activity does not become a “Red Light”. A “Red Light” activity is one that may/may not be sore at the time, but the pain or discomfort hangs around for a long time afterwards, and is also more sore the next morning (outside of 24 hours). It’s possible that this activity, if continued, could increase the chance of tissue injury and should be adjusted to be less strenuous moving forward, to limit this possibility.

If you’re interested in taking up a new sport or physical hobby, hopefully these three steps can give you the confidence to get stuck into things without the worry or doubt that the pain you feel training is actual damage to your body.

If you’re interested in reading a little bit more, here are some articles to g a little bit deeper into the science of training.

Teej

Over-training and Recovery: A Conceptual Model https://www.researchgate.net/profile/Peter_Hassmen/publication/13545392_Overtraining_and_recovery_A_conceptual_model/links/548199d60cf22525dcb6268c.pdf

Maximal Strength Training Improves Running Economy in Distance Runners http://sport1.uibk.ac.at/lehre/burtscher/efficiency-artikel,2008.pdf