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Shoulder Exercises: What are you strengthening?

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Shoulder Exercises: What are you strengthening?

Internal rotation of the shoulder

Strengthens: Subscapularis, Teres major

Position: Standing or seated elbow tucked into the side with elbows at 90 degrees flexion. Keeping elbow in, thumb on top. Rotate inwards taking the theraband away from your body.

Important: shoulder should be in ‘neutral position’ with activation of lower fibres of trapezius to avoid excessive protraction of the scapula.

External rotation

Strengthens: Infraspinatus, Teres minor,

 Position: Standing or seated elbow tucked into the side with elbows at 90 degrees flexion. Keeping elbow in, thumb on top. Rotate outwards taking the theraband away from your body.

Important: shoulder should be in ‘neutral position’ with activation of lower fibres of trapezius to avoid excessive protraction of the scapula.

 

Shoulder Abduction to 30 degrees

Strengthenens: Supraspinatus.

Position: Standing, keeping elbow straight, lift arm to side. It should not move forward or back.

Internal and external rotation can be progressed by moving into larger degrees of abduction.  A patient should be competent with exercises close into the side before progressing to longer lever arms away from the body to ensure good control. 10 exercises with perfect technique are better than 200 rubbish ones.

What a lot of patients find difficult to understand is that the shoulder needs to be kept in an optimal position, which is where your communication and coaching  skills are so important.

 

“Golden Nugget from Motivational Molly”

 

Before giving these exercises it is important to formulate a hypothesis on why they are getting their pain and therefore what needs to be strengthened or stretched to allow optimal position. If you give basic exercises to anyone/condition then you are no better than them looking on the internet and self diagnosing. It should not be a lottery. Find the muscle that is tight and stretch, test the muscles that are weak and strengthen and don’t forget to tap into myofascial, neuromuscular and movement patterns to reduce re occurrence.

 

As clinicians we should be giving clear advice and if you have asked a patient to complete exercises 2-3 x a day and they can’t. What are their barriers?  Are you not selling it enough? Break the barriers down. Not enough time – explain how to do exercises at work, stress the importance of the exercises in their recovery “traffic light exercises/ cup of tea exercises.” Do they truly not have time or are they prioritizing other things ie work/tv/hobbies. If we all ask can we fit 3 lots of 5 minutes of exercises in the day the answer is YES if we MAKE time.

 

People at home signed off can certainly achieve 15mins per day. So what motivates them? “You need to do these exercises so we can get you back to work, back to walking, back to golf”. You need to demonstrate their reward which may be as simple as reducing pain or improving function.

 

Physiotherapists need exceptional communication skills to be able to educate patients on the importance of exercise, stretches and compliance with treatments, which will improve results.

 

 

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Physiotherapy Interventions for shoulder pain: Cochrane review summary.

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The following offers a snippet of the freely available Cochrane Review which can be found here…

Unfortunately small sample sizes, variable methodological quality and heterogeneity in terms of physiotherapy interventions results, physiotherapy intervention employed and length of follow up of RCT of PT interventions results in little overall evidence to guide treatment.

Overview
  • Prevalence of Shoulder disorders 7-36% of the population. (Lundberg, 1969)
  • Athletic Shoulder Injuries: 8-13% (Hill, 1983)
  • Peak prevalence: 56-60 year olds (Allander 1974, Ingemar 1993)
Physio Aims in Shoulder Pain
  • The aim is to relieve pain
  • Promote healing
  • Reduce muscle spasms
  • Increase joint range and strengthen weakened muscles and ultimately to prevent and treat functional impairment (Lee 1973).
Summary
  • Pulsed Electromagnetic Field for rotator cuff disease in the short term (1 trial, Binder 1984)
  • Ultrasound and Pulsed Electromagnetic Field for Calcific tendinitis. (2 trials Ebenbichler 1999; Dal Conte 1990)
  • In general, ultrasound is of no additional benefit over and above exercise alone (1 trial Winters 1997/9)
  • For rotator cuff disease, corticosteroid injections are superior to physiotherapy interventions (4 trials, van der Windt 1998; Berry 1980; Winters 1997/9; Bulgen 1984)
  • No evidence that physiotherapy interventions alone is of benefit for Adhesive Capsulitis (1 trial Dacre1989)
  • Supervised exercise regime is of benefit in the short and long term for mixed shoulder disorders and rotator cuff disease (Brox 1993/7; Ginn 1997).
  • Exercise for rotator cuff disease with additional benefit from exercise plus mobilisation (2 trials, Bang 2000; Conroy 1998).
  • Laser for adhesive capsulitis in the short term, but not for rotator cuff disease (4 trials,Taverna 1990; England 1989; Saunders 1995;Vecchio 1993)

Learn. Share. Develop.

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The Hampshire Clinic – ACL/ Meniscal and Osteotomy update

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 “All acute knees should be referred “

Another great seminar presented last night by the likes of Mark Wotherspoon, Adrian Wilson and Mike Risebury.

The message they were bringing :

“We (first contact practitioners)  are failing acute knees”

The seminar was interesting, relevant and provided interesting incites on new surgery being developed by the Hampshire Clinic knee surgeons. A similar theme that developed throughout the talk is the huge wait between initial ACL rupture and a review by a surgeon. One chap shared his experience, a 25 year old who had waited one year from first injury to an MRI. There were also horror stories of an 18 year old with Grade IV arthritis because he had been mobilising on an unstable knee. Could we have done more? The simple answer is yes. I have to agree we are failing these patients. By the time the surgeons are reaching them they have significant damage that is much more difficult to ‘fix.’

So how can we do our part?

As physiotherapists we should be extremely familiar with the mechanism of injury: 

  • Usually non contact injury.
    Concussion in rugby
  • Immediate swelling.
  • Fell to ground, couldn’t play on.
  • Changing direction.
  • Heard a  POP.

 

Next patient usually:

  • Limping 3-4 weeks
  • Function returns.
  • Tries to return to sport but knee gives way. 

Usual route which we need to change

  • A and E – saw a triage nurse
  • X-Ray – Normal – Go home and if doesn’t resolve see your GP. (tries to return to sport gives way)
  • GP – Physio
  • Referred back to GP recommending ortho opinion
  • Referred to consultant.
  • Time lapse between each stage average in uk: One year injury to MRI.
Take home message from Adrian Wilson

  • Protect the knee
  • Any further twisting on the knee/giving way are likely to damage the cartilage and joint surfaces.
  • 60% ruptured ACL’s also damage meniscal.
  • Refer on the mechanism of injury before the secondary damage has occurred.

Recommendations after brain stormings::

Short flashcard/ sheet for GP’s/ sport physicians (Refer acute knee with ACL mechanism of injury).

5 bullet letter to GP’s – patient’s suitable for acute knee service.

Direct number to refer to: 01256 357111 ask for Jennie and ask for the acute knee service.

Patient education: “Protect the knee, educate that serious injury, potential ligament damage, protect your knee until we have checked with a surgeon, straight lines, don’t do anything silly”.

Anything more that a Grade I MCL needs to be assessed for brace, 30 degree bracing immediately.

Consider ACL repair in those older that 50.

Physio’s can refer directly to surgeon.

 

Osteotomies

They also discussed osteotomies and their use for the ‘younger patients (30-55)’ as an alternative for knee replacements.

This operation looks to offload the lateral compartment (depending on deformity) and aims to reduce pain and improve function in those who wish to be active. The surgeons aim to regain normal alignment by correcting through a wedge osteotomies. A large, strong fixation allows patients to weight bear from day 1 and patients can be expected to be off crutches and back at work at 6 weeks. Operation time is 30 mins

Most patients will partial weight bear as pain allows but can be back to activity relatively quickly. Can potentially return to impact exercise ie tennis etc. Consider this for those who are too young for a TKR who need something to reduce pain and improve function.

Summary

The advice that was given regarding the Acute Knee service was that patients could be seen in the first instance by:

  • The Consultants in Sport and Exercise Medicine, Drs Mark Wotherspoon and Mike Rossiter whose skill is in diagnosis (bringing years of relevant experience), including access to all the diagnostic tools on offer either privately or through the NHS (MRI, CT, xray and ultrasound).
  • If the patient needs surgical intervention, then they get referred to the Knee Surgeons, with all the appropriate investigations done – Mssrs Neil Thomas, Adrian Wilson and Mike Risebury, either privately or through the NHS
  • If the patient does not need surgical intervention, then they get referred back to the original physio with all the investigative information to hand and with a plan to work towards their recovery

Overall an informative evening and some great snacks too! 

 

Resources

Mr. Wilson – New ACL surgery  

Knee Problems..

The Hampshire Knee (Informative website)

The Hampshire Clinic

The Newbury Clinic – Phil Harris works closely with Hampshire Clinic knee surgeons to provide physiotherapy. 

Mark Wotherspoon offers his golden gems of advice in our consultant directory…..

All Sports medicine sec: Julie Fourt : juliefourt@allsportsmedicine.co.uk or 01256 377637

 

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An Inspirational Lady

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 Patient Stories: Jan Knight on Hip OA

Nicole Jones who is a physiotherapist based at The Newbury Clinic in Berkshire would like to share a patient story. Jan Knight started physiotherapy in February this year and has kindly taken the time to write an article on her experiences of her hip pain and changes that have helped her move forward and regain her life back.

My life has changed since starting to exercise regularly and completing physio.

My hip started to become painful about 2 years ago. As I got more pain I became less active, and there was also a lot of stigma that I’m 62 and you begin thinking “well perhaps I’m 62 and this is it’

After my consultant told me the hip was not bad enough to operate and that the pain might be coming from my back and that there was nothing he could do for me. I felt he didn’t care and had more important people to look after.

I thought “I’m over weight. I’ve got a bad hip. That’s my lot. There’s nothing else anyone can do for me”

But then I thought actually, I’m only 62, life isn’t over yet I can do this, I can change.  With guidance from my physiotherapist and great reluctance and embarrassment I joined the gym. I started off slowly with 2-3 times a week and slowly began to feel better.

Whereas initially I felt like the odd one out, there were other people my age but they were all slim and fit and this made me feel  embarrassed, now they have begun talking to me and I feel like part of the club. I now attend 3-4 times a week, even on the bank holidays!!

It only takes an hour out of the day and now I feel motivated with my diet, activities for the day and also it makes you feel good about yourself.

I began to realise that although perhaps there was nothing anyone could do for me there was plenty I could do for myself.  You should never give up on yourself and pushing yourself outside your comfort zone can be very rewarding. This can be lonely at times however when I become breathless and achy at the gym I think no pain no gain.

Turning your life around can be extremely difficult particularly if you are faced with barriers of being overweight or having low self confidence.

My treatment has included acupuncture to manage pain, range of movement exercises, specific strengthening exercises for the gluts and hip stabilisers, hydrotherapy, activity modification and progressive gym work.

My physio explained at the beginning of treatment that 60% would be purely down to me.  Its tough to motivate yourself but the rewards have been worth it.

Jan Knight,  March 2013

 

The Physiowizz team would like to thank Jan and other patients who have taken the time to share their experiences to help physiotherapists learn and inspire others.

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How can Ultrasound help fracture healing?

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 Low intensity pulsed Ultrasound (LIPUS) – How can it benefit Physio’s and patients?

 

Tim Watson and his research buddies have been hard at work once again providing us with an ever-growing evidence-base for electrotherapy.  He offers some interesting incites into electrotherapy products currently available to treat fractures and the evidence behind them.

Recent NICE guidelines have finally been published in Jan 2013 supporting the use of Exogen, which is one product used in the treatment of long bone fractures and non union fractures.

photo credit: Petra B. Fritz via photopin cc

What is EXOGEN?

Exogen is a device that delivers low intensity pulsed ultrasound. It is a mobile device that the patient uses daily to self administered treatment.  It has been shown to be effective to treat long bone fractures or those with non union that have failed to heal (over 9 months).

It has also been shown to accelerate healing in new long bone fractures. The transducer is simply placed along fracture site (or in hole/holder cut out of the cast if the patient is immobilized).

What makes Exogen different from ultrasound you use in clinic?

How how is been used so far?

So what does it mean for us as clinicans?

  • Reduced cost to the NHS by avoiding surgery that may otherwise be necessary in non union cases.
  • Edge as a private practitioner who can offer this service to athletes.
  • Improve customer satisfaction by getting them back to fitness/sport/work/playing sooner.
  • Reduced cost to the government/employers in time off work.

References

Want to hire an Exogen ? Rental available here…..

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How technology can help the elderly

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Growing up in the age of the internet, mobile phones and Ipads I can’t imagine how anyone lived without them. Watching Band of Brothers and films that document the horrors of war I find it difficult to put myself in those character’s shoes and imagine moving away from the city to the country to avoid bombs or ever experiencing a real threat of dying.

So if I find it so difficult to relate with a world where thousands were slaughtered in gas chambers, where family members dying was not unusual and where sugar was rationed, it is hardly surprising our elders find it difficult to relate to these new things emerging. The fear of the unknown is probably the strongest. But, despite this, on a day to day basis I see technologies that will not only benefit the young,  driven, city slicker but also provide company, mental stimulation and safety for the elderly.

 photo credit: Jamais Cascio via photopin cc

So how can technologies benefit the elderly? Below we look at the barriers to overcome the fears of modern day living and the new technologies that offer us solutions..

“I’m too old to learn all that”

 Are you to old? No of course not. Its not going to be easy but was learning to ride a bike, taking your first trip away or driving? Nothing is easy to begin with until you learn the skill! And now we have a fantastic resource from Age UK

Age UK Advice: 0800 169 6565

A message from my Nan after calling them “Wow, this lovely young man helped me. My TV was all fuzzy and he talked me through it step by step. Knew which button I needed to press! And do you know what? He didn’t even have to come over because I was able to follow his instructions and made it work myself!”

 

“I don’t want anyone changing anything”

This is usually the fear of losing control and the unknown. No one should be forced into anything. Try to show them the benefits and take something over to try.

“I don’t understand how it all works”

If this is the answer it is useful as a care giver or a physio to give advice and information sheets that the patient can have a browse through at their leisure.

photo credit: Public Places via photopin cc

Simple observations and Possible solutions 

Scenario One – Day Care Centre Entertainment

Wii  FIT  –

This can be used in sitting or standing (if appropriate for the patient)

The Benefits Include…….

Active games – Increase heart rate, endorphin release, laughter, mental stimulation, improve balance.

Mental Games – ‘Use it or lose it’ philosophy. Increased self esteem, mental stimulation.

photo credit: Luis Hernandez – D2k6.es via photopin cc

It is well known that physical exercise, balance exercises and fitness is useful for elderly patients to reduce the risk of falls, improve circulation, improve quality of life and confidence, particularly in a care setting. Get your patients involved and active to keep them fit and healthy.

Scenario 2 – Elderly patient wanders off in the night

Ever been worried that your patients will wander off and be unable to find their way home? According to the Alzheimer’s Society 800,000 people in the UK have Dementia and in our ever aging population this is growing.

Dementia is the term that refers to the symptoms such as memory loss, communication difficulties and mood changes. This can be the result of diseases where the brain becomes damaged.

The solution?

This nifty bit of kit from Fijutsi provides a walking stick with a difference. Its clever GPS downloads information on the walker’s location through Wi-fi,  3G or Bluetooth. Relatives can access an App or computer system to see where their relative is. Even better the stick can give direction so if your lost it can help you find your way home!! It can also measure heart rate to see if the patients are within normal healthy ranges. In the future they hope to develop an emergency button that could e used to call emergency services and provide their position. Finally!!

Scenario 3 – Loneliness

Can you imagine being 85? Your husband has passed on, your family have passed on and your dear friend Katherine lives down the road but you are no longer mobile enough to visit her except for once a week when you can get a lift? Being retired you have a lot of time to think and you can no longer get out and about as you used to.

Ipads

There are so many games on the Ipad which are becoming increasingly easy to use. Even better you can video call and catch up with Katherine for a quick catch up over mid morning tea.


Benefits

It’s light, easy to use (if provided education from grandchildren or physio techies!)

Provides mental stimulation, puzzles, quizzes, books, games, music, communication. For the younger 60-70 you can access fitness apps that set goals and provide advice on conditions and keeping healthy and active.

 

Useful Websites

http://www.nhs.uk/Conditions/Dementia/Pages/Introduction.aspx

http://www.alzheimers.org.uk/

 

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Case Study: Hamstring Grade II Tear

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Case Study: Hamstring Grade II Tear

The following case study gives you an idea of what treatments may be considered for this patient. This is a brief overview. Any CPD or case study for university would require much more depth and must be evidence based and demonstrate clear clinical reasoning. Many examples of these can be found through Pubmed and these should (alongside university guidelines)  be used as your outline for graded work.

Introduction

A 24 year old man presented with a one week history of right posterior thigh pain following a football injury at the weekend. He reports that he felt severe pain and a ‘twange/pop’ sensation after kicking a ball. He reports no swelling but has noticed a small bruise in the centre of the posterior thigh. He describes that symptoms are worse with activity and in the mornings he notices the muscles are tight but ease with gentle movement and stretches. He reports no history of back pain and no paraesthesia or pins and needles in the lower limbs. His GP advised NSAIDs to manage pain and advised resting from football for one week. There was no other past medical history and the patient had no history of previous hamstring tears.

Clinical Impression

The objective findings of the assessment fitted with a Grade II hamstring tear. The patient experienced tenderness on palpation of the right mid bicep femoris muscle 1cm superior to a small bruise (1cm x 1cm). Straight leg raise was limited to 40 degrees before onset of symptoms. Additional cervical spine flexion did not change symptoms in the leg during the straight leg raise suggested that there was not a neural component.

The patient demonstrated good ROM of the lumbar spine however flexion was limited due to ‘pain in the hamstring.’ There was reduced muscle strength of the right hamstring MMT 4/5 with knee flexion 90 degrees and MMT 4/5 with knee flexion 15 degrees. The patient had full AROM of the right knee however hyperextension elicited pain in the hamstring. On gait analysis he demonstrated reduced stride length on the right and reduced stance phase on the left.

No avulsion fracture was suspected and due to the available resources the patient was not immediately sent for MRI (Heidersccheit et al, 2010). Instead tissue healing times (Watson, 2006) were explained and the usual course of this type of injury.

Treatment Goals

  • Treatment goals were discussed and formulated with the patient.
  • Reduction of posterior thigh pain.
  • Restore optimal ROM and strength of the hamstrings.
  • Return to competitive football with 36 days ( Average duration of time lost in injuries resulting from kicking, Brooks et al, 2006)

 Treatment Plan “Tool box”

Hamstring injuries are not just prevalent in rugby and football. Dancers and kick boxers are also at risk dur to the excessive strain on the hamstring.

  • Initial PRICE guidelines: Protect, Rest, Ice (10-15mins x 2-3 daily), Compression, and Elevation.
  • Avoid excessive stretch of the hamstring (can result in excessive scar formation).
  • If using crutches avoid ‘hanging leg in flexion’ as this increases tensile load on the tendons.
  • ROM should be guided by pain limits (ie do not push into pain in early stages)
  • NSAIDs are controversial and should be avoided if pain can be controlled with ice and activity modification alone.
  • Acupuncture
  • Electrotherapy:
  • Tens for pain relief (over nerve root) – This is not widely used to practice but is a possibility.
  • Ultrasound
  • Massage (not immediately following injury of if a haematoma is suspected)
  • Gentle stretches.
  • Taping
  • Static(isometric) strengthening.

Treatment 1

  1. The patient was screened for contra indications for treatments
  2. Patient was educated on the condition, tissue healing times and then given a copy of:  Hamstring Rehabilitation and Prevention Protocol University of Delaware Sports and Orthopedic Clinic. and Heidersccheit et al, 2010 hamstring protocol.
  3. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  4. Home exercises program(HEP) : The patient was advised to begin phase 1 of the Heidersccheit et al, 2010 protocol. Patient was advised to reduce repetitions if experiencing increased symptoms/ pain.
  5. Advised ice 2-3 daily x 15mins.

P/ Review 1/52

Treatment 2

  1. The patient reported good progress and was able to complete more repetitions of the exercises from the protocol.
  2. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  3. Home exercises program(HEP) : The patient was advised to continue phase 1 of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  4. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  5. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia. The patient was unable to move to phase II because he was still unable to complete a pain free isometric contraction against submaximal (50-70%) resistance with prone knee flexion 90 degrees.

Treatment 3

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The criteria to move to phase II is as follows:
    1. Normal walking stride without pain
    2. Very low speed jog without pain
    3. Pain-free isometric contraction against sub-maximal (50-70%) resistance during prone knee flexion (90°) manual strength test.
  3. Following a test of these 3 things the patient was deemed fit to move on to phase II.
  4. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  5. Home exercises program(HEP) : The patient was advised to move phase II of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  6. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  7. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia.

Treatment 4

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The criteria to move to phase II is as follows:
    1. Full strength (5/5) without pain during prone knee flexion (90°) manual strength test
    2. Pain-free forward and backward jog, moderate intensity
  3. Following a test of these the patient was experiencing pain with maximal strength testing so advised to continue phase II for a further week..
  4. Ultrasound was applied to the tender area in the mid bicep femoris. Please see Tim Watson, electrotherapy for further information on settings to choose.
  5. Home exercises program(HEP) : The patient was advised to continue phase II of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  6. Deep transverse frictions were applied to the point of tenderness on the bicep femoris x 30 sec x 3.
  7. Clinical massage was applied to the right hamstrings to encourage blood supply, reduce myofascial trigger points and mobilise the fascia.

Treatment 5

  1. The patient reported good progress and feels he is ready to move on to phase II.
  2. The patient was able to demonstrate good muscle strength of the right hamstring 5/5.
  3. There was now minimal pain on palpation of the hamstring.
  4. Home exercises program(HEP) : The patient was advised to continue phase III of the Heidersccheit et al, 2010 protocol. Patient was advised to increase repetitions gradually and reduce again if experiencing increased symptoms/ pain.
  5. Exercises were demonstrated and completed with mild tenderness.
  6. The patient was advised to continue to follow the protocol before returning to sport which

Conclusions

  • The patient returned to sport at approximately 8 weeks following the injury. This is longer than the average ‘kicking’ hamstring tear within rugby union injury reports (Brooks et al, 2006), which averages 36 days lost. This was perhaps because compliance with daily exercises was limited due to the patients working life and difficulty getting to the gym to use a bike.
  • Unfortunately with NHS  demands, physiotherapists often are unable to see the patient through to return to sport however by providing this clear program physiotherapists can be a vital tool in assessing if the patient is ready for progression and minimising compensations.
  • The addition program was given to help protect the player from future injuries. It is important to highlight that hamstring re-injury rate is larger than those who have already experienced a hamstring tear therefore it is important to continue exercises within their training plan to prevent future problems.

References

Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6:237–248.

Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006 Aug;34(8):1297-306. Epub 2006 Feb 21. PubMed PMID: 16493170.

Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther.2010;40:67–81. [PMC free article] [PubMed]

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Jonny Sexton: Physiotherapy Injury Analysis

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 Jonny Sexton

Born: July 11, 1985 (age 27),

Height: 1.89 m

Weight: 92 kg

Country of birth: Dublin

Injury Update:

“Jonny’s scan revealed a grade two hamstring injury,” Ireland manager Mike Kearney said. “Progress has been good so far, but it’s too early to say when he will return to play.

What is a hamstring tear?

The hamstring muscle group is made up of three muscles (Semimembranosus, Bicep femoris and semitendinosus). The mechanism of injury is normally as the athlete is running or kicking. This is when the hamstrings are working eccentrically to decelerate the tibia. The moment just before the foot hits the ground (terminal swing phase of the gait cycle) is when the muscles are maximally activated and on end of range length, and thus at most risk of injury.

How are hamstring injuries graded?

Tears are graded on their severity.

Grade I consists of minor tears within the muscle.

Grade II is a partial tear in the muscle.

Grade III is a severe or complete rupture of the muscle.

How are hamstring injuries diagnosed?

  • Unless an avulsion fracture with bony fragment or apophyseal fracture is suspected, plain radiographs are of little use in the examination of an acute hamstring injury (Clanton and Coupe, 1998).
  • Ultrasound and MRI (MRI is thought to be more sensitive to subtle oedema).

Heidersccheit et al, 2010

What symptoms presentation would you expect from a grade II?

  • Gait will be affected.
  • Reduced performance.
  • May be associated with discomfort/pain during activity.
  • Palpation increases pain.
  • Hamstring strength test results in pain and reduced muscle power.
  • Reduced extension of the knee.
  • May notice swelling.

 

When will he be back? 

A study looking at rugby union players in 2006 found that:

  • The incidence of hamstring muscle injuries was 0.27 per 1000 player training hours and 5.6 per 1000 player match hours.
  • Injuries, on average, resulted in 17 days of lost time, with recurrent injuries (23%) significantly more severe (25 days lost) than new injuries (14 days lost).
  • Second-row forwards sustained the fewest (2.4 injuries/1000 player hours) and the least severe (7 days lost) match injuries.
  • Running activities accounted for 68% of hamstring muscle injuries, but injuries resulting from kicking were the most severe (36 days lost).
  • Players undertaking Nordic hamstring exercises in addition to conventional stretching and strengthening exercises had lower incidences and severities of injury during training and competition.

 

(Brooks et al, 2006)

 

Clinical Reasoning and return to play: Tissue Healing times

  • Bleeding (6-8 hours)
  • The Inflammatory phase ( 2-3 days- continuing to resolve over 2 weeks)
  • Proliferation Phase (2-3 days following injury to 2-3 weeks before reach its peak reactivity)
  • Remodelling (Recent evidence shows that this can begin 1-2 weeks post injury however 4-6 weeks is the general rule that a scar with enough tensile strength to begin withstanding higher loads is present.)
  • Treatment should be therefore targeted to optimise and complement the phase of healing.

(Watson, 2006)

 

Read more about these phases by an article written by Tim Watson, Electrotherapy Guru.

When can he return to sport?

  1. Full range of motion
  2. Strength, and functional abilities (eg, jumping, running, cutting) can be performed without complaints of pain or stiffness.
  3. When assessing strength, the athlete should be able to complete 4 consecutive pain-free repetitions of maximum effort manual strength test in each prone knee flexion position (90° and 15°).
  4. If possible, isokinetic strength testing should also be performed under both concentric and eccentric action conditions. Less than a 5% bilateral deficit should exist in the ratio of eccentric hamstring strength (30°/s) to concentric quadriceps strength (240°/s).
  5.  In addition, the knee flexion angle at which peak concentric knee flexion torque occurs should be similar between limbs.16,78
  6. Functional ability testing should incorporate sport-related movements specific to the athlete, with intensity and speed near maximum.

 

Listen to the following podcasts on advice regarding advising your athletes to return to sport:

Possible physiotherapy management of hamstring injuries

  • Initial RICE guidelines: Rest, Ice (10-15mins x 2-3 daily), Compression, and Elevation.
  • Avoid excessive stretch of the hamstring (can result in excessive scar formation).
  • If using crutches avoid ‘hanging leg in flexion’ as this increases tensile load on the tendons.
  • ROM should be guided by pain limits (ie do not push into pain in early stages)
  • NSAIDs are controversial and should be avoided if pain can be controlled with ice and activity modification alone.
  • Acupuncture
  • Electrotherapy:
  • Tens for pain relief (over nerve root) – This is not widely used to practice but is a possibility.
  • Ultrasound
  • Massage (not immediately following injury of if a haematoma is suspected)
  • Gentle stretches.
  • Static(isometric) strengthening.
  • Please read this brilliant article which takes you through appropriate exercises and the evidence behind them. (Heidersccheit et al, 2010)

 

Click here to view a comprehensive  hamstring rehab program. If any one who is reading this suspects they may have a hamstring tear be sure that you are guided by a physiotherapist to ensure correct diagnosis. A little knowledge can be a dangerous thing and these exercises will not be suitable for other conditions that can cause posterior leg pain. In particular it is important to rule out involvement of the back which may be causing neurogenic referral. Hamstring Rehabilitation and Prevention Protocol University of Delaware Sports and Orthopedic Clinic.

  

 

 References

Brooks JH, Fuller CW, Kemp SP, Reddin DB. Incidence, risk, and prevention of hamstring muscle injuries in professional rugby union. Am J Sports Med. 2006 Aug;34(8):1297-306. Epub 2006 Feb 21. PubMed PMID: 16493170.

Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6:237–248.

Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther.2010;40:67–81. [PMC free article] [PubMed]

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Physiotherapy Webinars

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Physiotherapy Webinars

WebinarsCheck out the fantastic series from ‘Hands on seminars’

Advanced Mobilization in Lumbar Spine Pathology 

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Wakeboarding – Sport Specific Series

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Wakeboarding – Sport Specific Series

Summer is coming! Different sports stress the body in different ways and its important to know your sport.
Task: 
1. Watch this video.
2. List the core stabilising muscles and are vital in co-ordinating the mid air twist of the ‘Whirley bird’.
3. List 2 functional restrictions which may make this trick more difficult to achieve (ie reduced strength of/reduced ROM of……)
4. List 3 exercises which may help benefit the athlete to achieve this trick.

5. Post answers. Do not be afraid of ‘wrong answers’ this is an opportunity to learn. Results will be formulated and put up into a new page which will be displayed in the ‘sports specific’ section of the website.

Big love to Carro Djupsjo who’s own website is   http://www.wakecarro.com/ she also coaches around the world in between competitions.

If you have any questions you would like to ask her about her sport or training regime let me know and I will try to get an interview!

Check out other peoples thoughts on our forum CLICK HERE!!!!!

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