How to classify muscle injuries on MRI using the British Athletic Muscle Injury Classification (BAMIC) system

Soft tissue injuries are very common in sport/physical activity and recovery timelines can take anywhere from 10 days – 16 weeks. These timelines are decided using physical assessment and understanding of muscle-tendon complex injury healing but, in the case of lower limb injuries, can be aided with an MRI of the area. The radiologists who interpret the scan results will often use the BAMIC system to identify the area and grade of the injury which can help in determining return to play timelines.

The area is typically divided into three parts of the muscle-tendon complex:

1.       Myofascial: Involves the periphery of the muscle, including the surrounding connective tissue layers (epimysium, perimysium, aponeurosis). The myofascial allows force transmission and absorption through the muscle-tendon unit.

2.       Myotendinous junction/muscular: A blend of muscle and tendon connection this is potentially the location of greatest force production within the muscle tendon unit.

3.       Tendon: The most serious of the three when the central tendon is involved as there are high re-injury rates if the person returns to high level physical activity too early. Tendons take longer to heal than muscle or fascia due to the less vascularity. Also important to note that intra-muscular tendon parts has less sensory neural innervation which means reported pain levels is not a good indicator of severity of injury with those athletes.

Classification system

grade 0a: focal neuromuscular injury with normal MRI

grade 0b: generalised muscle soreness with normal MRI or MRI findings typical of delayed onset muscle soreness (DOMS)

grade 1 (mild): high STIR signal that is <10% cross-section or longitudinal length <5 cm with <1 cm fibre disruption

grade 2 (moderate): high STIR signal that is 10-50% cross-section; longitudinal length 5-15 cm with <5 cm fibre disruption

grade 3 (extensive): high STIR signal that is >50% cross-section or longitudinal length >15 cm with >5 cm fibre disruption

grade 4: complete tear

Rehabilitation and return to play considerations

The health professional will typically take into account a myriad of factors to get someone back to exercise as quickly (and safely) as possible. These include (but are not limited to):

·       Previous injury history

·       Physical assessment findings

·       Current activity level

·       Goals of the patient

·       Response to treatment and rehab

·       Time of the season (eg finals etc)

Here at East Vic Park, we are experienced in treating soft tissue injuries. Book in to see one of your friendly physiotherapists today.

Plyometrics: Why Should They be in Your Gym Program?

Plyometric training is when we use exercises to make muscles exert a large amount of force in a short amount of time to improve our power output.

Plyometric exercises like jumping, hopping and landing causes the nervous system to develop reflexes to sudden high-stretch loads, improving the rate and scale of motor unit activation.

Key components of plyometric training are:

Focus on rapid movement between phases of muscle contraction (fast movement)

Typically body weight or light weights only (light weight)

These types of movements produce greater power than concentric only movements as more force is released in the plyometric action. This is because it allows the muscle-tendon complex to store more elastic energy which must be released. If we do these movements slowly, we lose this elastic energy (as heat) and therefore it is not efficient.

Research suggests that stretch-shorten cycle exercises should be implemented at the beginning of a training session (or on a separate day by themselves). This reduces the chance of poor technique due to fatigue and allows the athlete to maximize the velocity of movement. 

Examples of plyometric exercises

-       Drop jump

-       Box jump

-       Hopping

-       Lateral hop/skater

-       Split squat jump

Overall evidence based practice suggests the use of plyometrics with traditional strength training for best performance of an athlete.

Syndesmosis sprains : The high ankle injury

You may have heard various athletes suffering a high ankle sprain or injuring their syndesmosis. But what exactly is a syndesmosis injury? And how does it differ to a normal lateral ankle sprain?

The ankle syndesmosis is the joint between the distal (lowest aspect) of your tibia and fibula. It is comprised by three main supporting ligamentous structures – The anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous membrane (see Figure 1).  The role of the syndesmosis is to provide stability to the tibia and fibula and resist separation of these two bones during weightbearing tasks. It also plays a role in assisting with mobility of the ankle.

Figure 1: Syndesmosis anatomy

How does it differ to a common ankle sprain?

Generally, a lateral ankle sprain is a result of and inversion injury and will result in an injury to the outside ligaments of your ankle (ATFL, CFL, PTFL). These ligaments are positioned slightly lower than the syndesmosis and provide stability to the true ankle joint.

Figure 2: Inversion sprain mechanism

Mechanisms of injury:

The most common mechanism for injuring your syndesmosis is a forced dorsiflexion combined with an Eversion movement. Essentially the foot/ankle moves in an upward direction and to the outside of the leg (See figure 3).

Figure 3: Syndesmosis Mechanism - Dorsiflexion + Eversion

The syndesmosis can also be injured with a typical inversion or lateral ankle sprain (Figure 2) mechanism. This usually occurs when the incident is of high force and will result with an injury to the lateral ligaments as well.

Signs and symptoms:

·       Mechanism of injury consistent with a syndesmosis injury (forced dorsiflexion + Eversion)

·       Pain location may extend above the ankle and into the lower shin

·       Swelling may sit slightly above the cease line of the ankle joint

·       Difficulty weightbearing, particularly when the foot is in dorsiflexion (knee over toe)

·       Low confidence/feeling of instability

Gradings:

• Grade 1: isolated injury to the AITFL

• Grade 2: Injury to the AITFL and interosseous membrane

• Grade 3: Injury to the AITFL, interosseous membrane and PITFL

• Grade 4: Injury to the AITFL, interosseous membrane, PITFL and deltoid ligament

Immediate management:

As always if you have recently suffered an injury, please seek medical attention from your physio or doctor for accurate diagnosis and management.

If a syndesmosis injury is suspected acute management will initially involve offloading and protecting the tissues. This may be in the form of one or a combination of crutches, a cam walker (moon) boot and strapping.

Your physio or Doctor may also refer you for imaging such as an x-ray or MRI to assist with diagnosis and understanding the severity of the injury.

Following the acute period of offloading and protection a period of rehabilitation will be required to restore normal function of the foot and ankle. In more severe cases surgery may be required to stabilise the syndesmosis and therefore rehab will commence following a period of protection post-surgery.

If you have experienced an ankle sprain yourself, please book in with one of our physiotherapists for an individualised rehabiltation program.

Low Back Pain Myths

There is a lot of information out there on low back pain and injuries. Some of which is very useful but on the other hand there is a lot of misinformation which can sometimes lead us in the wrong direction. In this blog we will look to debunk some of the most common low back pain myths!

Myth # 1 : I Should brace my core or I will get pain

This is a very common thought and is a big reason why people seek help for their low back.  Although we have previously thought bracing can help relieve symptoms it can in fact increase the forces going through the back and in some cases lead to pain. The muscles around the trunk play an import role in movement and stability but trying to actively brace these muscles can often lead to stiffness and inefficient movements. The body is clever, our trunk muscles will naturally contract and work when required to assist in tasks such as lifting.

Myth # 2: My low back pain is cause by my back/pelvis being out

One of the most common myths when it comes to low back pain. The back is extremely strong and robust and without serious trauma or force the back and pelvis does not go ‘out’. Manual therapy techniques such as manipulations and adjustments DO NOT put these structures back in to place but they can however provide pain relief which is helpful in the short term.

Myth # 3: I have a disc bulge and degeneration and that is causing my pain

Disc bulges and degeneration are very common and have a high occurrence rate amongst people who don’t have low back pain. We consider these changes to be age related and are not necessarily linked to pain.  Approximately 30% of people in their 20’s will have a disc bulge in the absence of low back pain and this percentage goes up approximately 10% for every decade in life. Further to that disc bulges and protrusions have shown to recover on imaging over time. So, it is likely that a disc bulge that you may have previously had is no longer there!

Myth # 4 I need to stand and sit in “good” posture, or I will get pain

There is no such thing as good or correct posture! Despite what we have previously thought and what we may have been told as kids. Research has showed us that there is no direct link to how we sit and stand and pain. Instead, it is recommended to find a posture that you are comfortable with. This may differ from person to person but that is okay. Of course, it is always recommended to keep moving, so taking regular breaks to move around may help reduce the occurrence of discomfort from prolonged positions.

Myth # 5 Bending your back when lifting is bad for your back and you should lift with my knees

The spine holds some very important structures, and it would be a big design flaw if the back was not robust and strong to protect them. In fact, it is one of the strongest parts of the body and can handle large forces. When trained correctly the spine can comfortably handle loads in positions of lifting, squatting and twisting. We are often told to avoid bending the back when lifting however this can often create problems such as inefficient movements and fear avoidance.  Like all activities, we need to exposure our body to them for us to get better at it!

 Our physiotherapists at East Vic Park Physiotherapy can help answer all your low back related questions. If you would like more information or help with your low back do not hesitate to get in touch!

Dietary Supplementation

The dietary supplement and health food market is massive and is continuing to grow. To gain that extra edge it is not a surprise that athletes of all backgrounds find themselves drawn to additional dietary help to improve their physical output. Unfortunately, most of the supplements on shelves are not what they are made out to be and there is no substitute for good old-fashioned hard work. However, it is not all bad news, there are some foods and supplements that have been backed by science that can play a marginal performance enhancing role in sport and exercise.

Here we will briefly go over some of these health foods and supplements that may have a positive effect on performance directly. There are also many other dietary foods/supplements that claim to have an indirect on performance such as aiding recovery, assisting muscle development or improving immune function which we will not go into detail.

Caffeine:

One of the most commonly used supplements and widely used legal drug (in the form of coffee).  There is significant scientific for caffeine as a positive performance enhancement for some athletes in range of different types of activities.

Possible benefits are improved endurance capacity such as exercise time to fatigue and time-trial activities of varying duration (5-150min). This has been shown across activities such as cycling, running, rowing and various team-sports. Improvement in performance measures such as time-trial time have shown to range from 3-7%.

How does it work?

Caffeine is a stimulant which can enhance vigilance and alertness, perception of fatigue and exertion during exercise and improve neuromuscular function.  It can also stimulate an endorphin release which can assist in feelings of wellness.

A systematic review by Ganio et al (2009) has shown 3-6mg/kg of body mass consumed 60 min prior to exercise is sufficient to provide positive effects. However lower doses <3mg/kg of body mass has shown to also be effective. To put that in perspective the average cup of coffee has about 100mg of caffeine in it.

Possible side effects:

Larger doses of caffeine have shown not to further increase performance enhancement and in fact increase likelihood of negative side effects.

Possible side effects include; nausea, anxiety, insomnia and restlessness. Caffeine is also a diuretic which can increase urine flow but is small when consumed at the doses that have shown to improve performance.

Sodium Bicarbonate:

Sodium bicarbonate is a commonly occurring substance in most foods. In fact, most households will have this In their kitchen without even knowing as it is commonly known as baking soda.

How does it work?

It helps regulate PH in the blood which commonly increases in acidity during exercise. Sodium bicarbonate is naturally occurring in the body and helps buffer excess acid that accumulates during bouts of high intensity exercise. By keeping muscle PH level closer to its normal it can enhance exercise capacity.

Sodium bicarbonate has shown to enhance performance during short term, high-intensity exercise of approximately 60s in duration of approximately 2%. Improvements reduce as duration of effort exceeds 10 min.

Protocol of use:

According to the evidence various strategies of consumption have been suggested.

1.     Single dose of sodium bicarbonate of 0.2-0.4 g/kg of body mass, 60-150 mins prior to exercise

2.     Split dosage (i.e multiple smaller doses totalling 0.2-0.4 g/kg) over 60-180 min

3.     Serial loading with 3-4 smaller doses per day for 2-4 days consecutive prior to an event

Potential side effects:

It is well established that gastro-intestinal upset can be associated with sodium bicarbonate. Therefore, may not be appropriate for some athletes or ideal consumption strategies may be person dependant.

Creatine:

Creatine is naturally occurring substance in body where it is found in the substance creatine phosphate. Its use as a supplement has grown significantly over recent times. Creatine works by aiding resynthesis rate of the phosphocreatine energy system. In short aiding the use of the energy system in the body that is utilised in short, high-intensity bouts of exercise.

In term creatine has shown to have positive effects particularly in sports that involve repeated high-intensity exercise (eg. Most team sports). it has also shown to assist in increased gains of lean mass and muscle strength and power.

Potential side effects:

No negative health effects are noted with long-term use (up to 4 years) when appropriate consumption use is followed. However, a 1-2 kg of body mass increase has shown to be a possible side effect which is primarily the result of water retention. This is an important consideration as the possible detrimental effect of increase weight gain may outweigh the positive effect of creatine.

Nitrate or Beetroot Juice:

It may seem as an odd one to add in but nitrate which is readily found in beetroot has been shown to have positive performance enhancing benefits. High nitrate rich foods include leafy green and root vegetables, including spinach, rocket, celery and of course beetroot which accounts for one highest sources of nitrate.

How does it work?

Nitrate contributes to the production of nitric oxide in the body. Nitric oxide is a vasodilator which improves blood flow and oxygen delivery to muscles. It therefore can improve the muscle efficiency in utilising oxygen and can improve the performance and energy efficiency of type 2 or fast twitch muscle fibres.

Supplementation of nitrate has been associated with improvements of 4-25 % in time to exhaustion during exercise and 1-3 % in sport specific time trial events lasting less than 40 mins.

Protocol of use:

Nitrate consumption within 2-3 hours of activity as bee associated with improved performance. Prolonged use of nitrate also appears to be beneficial and has been suggested strategy for highly trained athletes where improvements from nitrate supplementation is smaller.  

Potential side effects:

There appears to be few side effects or limitations to nitrate supplementation. It is suggested that there is potential of gastro-intestinal upset and therefore suggested to be trialled in trainings before the use in competition. It also appears that performance gains and harder to obtain in highly trained athletes.

Beta-Alanine:

A naturally occurring amino acid, beta-alanine plays a role in the development of a carnosine.

How does it work?

Similar to sodium bicarbonate, carnosine acts as a acidity buffer in the muscle and therefore helps maintain an optimal PH level for muscular performance. It helps resist muscle fatigue and in term potentially assists performance.

Protocol of use:

Beta-alanine is commonly found in meat, poultry and fish and therefore most people can get enough beta-alanine through their regular diet.

Dietary supplementation however can further assist our daily intake. It is suggested a daily consumption of 65mg/kg of body mass taken in 3-4 smaller doses throughout the day.

Potential side effects:

Possible side effects include skin rashes and/or transient paraesthesia (tingling feeling in the skin) when taken with high single doses. This effect is temporary and harmless.

It should also be noted the effectiveness of supplementation appears to be harder to realise in well-trained athletes.

It should go without saying please seek professional medical advice whenever considering whether additional dietary supplementation is right for you.

If must also be noted that inadvertently consuming a known banned/prohibited substance should be risk considered when weighing up the decision to pursue dietary supplementation.  Please find some useful links below which can assist in determining whether a specific product is considered banned or has gone through the necessary batch testing to determine if it is safe for consumption under the anti-doping rules.

Useful resources:

https://www.informed-sport.com/

https://www.asada.gov.au/substances/check-your-substances

1.     Maughan R, Burke LM, Dvorak J et al 2018 IOC consensus statement: dietary supplements and the high-performance athlete. British Journal of Sports Medicine; 52 418-419. doi: 10.1136/bjsports-2018-099199

Load Management

I started writing this blog about 2 months ago as Winter Sports pre-seasons started to ramp up. What a difference 2 months can make right? Back then, my purpose was to focus on the consequences of increasing physical activity (too much load) too quickly. However, on further reflection, the focus can also be on not enough physical activity (under-loading) which is probably more topical.

 What is Load Management in sport?

Very basically it is the balance of physical activity and rest for an individual athlete.

This has two main purposes:

1.     Reduce injury risk

2.     Allow for Optimal Performance

From a physiotherapists perspective, we focus primarily on the first point whereas the coaching staff, club personnel and athletes are more involved with the second point. However, both groups work together to monitor an athletes load “ceiling” and “floor”.

 What is the ceiling and the floor?

This refers to the max load an athlete can tolerate (the ceiling) and the minimum load an athlete should be maintaining (floor). Very basically, if you don’t continue to load your body, it’s capacity/resilience will drop which means it will tolerate less and less load over time (lower the ceiling). If an athlete then tries to increase their physical activity (eg pre-season) then they are at risk of overload injuries like stress fractures and tendinopathies. The ceiling is important because that informs the coaching staff of an athletes current limitations so they can plan for that in their trainings/gym sessions. Luckily, the ceiling can be increased with pre-planned and monitored loading over time.  The main way this is monitored is through the Acute-Chronic Workload Ratio (ACWR).

What is the Acute-Chronic Workload Ratio?

Acute workload refers to the amount of loading over a week. Chronic workload refers to the average of loading over four weeks. Loading can be a number of factors eg kilometres per week which is applicable for marathon runner.

Optimal ratio is 1-1.25 so anything above or below can mean a large spike in injury risk.

Equation: (Acute workload) / (Chronic workload)

Eg week 1 40km, week 2 40km, week 3 50km, week 4 55km

So Acute workload is 55km (the latest week kms)

Chronic workload is average of four weeks ((40+40+50+55)/4) = 46.25

55/46.25= 1.2 (reduced injury risk)

As mentioned, ACWR can be built up over time. For example, the reason marathon runners can do 180km+ per week is because they have painstakingly built up their distance (and therefore ACWR) over years of training.

 How to monitor relative load:

• RPE Scale: Rate of perceived exertion times minutes per session

• Smart watch that monitors distance, speed etc

• GPS: electronic unit that calculates distance, speed, collisions etc

• Subjective Questionnaires (eg Smartabase)

How is Load Management applicable to Elite Athletes?

You may see that every now and again an AFL player is ruled out of a game with “general soreness”, this is most likely because a players load is too high and they are at a high risk of injury so to reduce the risk, they won’t play the game. The same goes with NBA players (eg Kawhi Leonard in the 2018/2019 season) and high profile soccer players. Usually this is done during the season to make sure the player doesn’t get injured before the important part of the season (finals). It also serves to make sure they are “peaking” performance wise. The focus is on winning and the teams chances infinitely increases if their best players are;

A - able to play (no injuries) 

B - optimally performing

How is it applicable to the everyday athlete?

Pretty much the same as above, just because they don’t get paid to play doesn’t mean they don’t want to perform well, remain injury free and win. However, it can be harder for everyday individuals to be able to monitor their loading as intensely as sporting clubs/elite athletes. So here are my top tips for monitoring loading if you don’t have a GPS etc:

• Record each exercise session in terms of duration and RPE 

• Monitor your ACWR (as explained above) by reviewing and planning your training 4 weeks at a

  time (at a minimum)

• Keep an eye on types of physical activity and alternate if possible (eg running/jumping, weights, swimming, bike)

• Apply the 10% rule: don’t increase distance, speed or weights more than 10% on your last session (especially if you can’t calculate your ACWR)

•  Lastly, listen to your body as it will most likely tell you when you need to “de-load”

Main points from this blog:

• You need to load (even if you’re in isolation) otherwise you lose capacity

•  Load a bit more each week if you want to increase your capacity (not more than 10% is a good start)

• Structure your physical activity to load manage which can reduce injury risk as well as improve performance 

• Listen to your body!

 A big thanks to Glenn Stewart, Tim Gabbett and Lauren Shelley for all their work thus far in understanding load management.

If you would like some help load managing, make an appointment (call us on 9361 3777 or click the Book Now button) and any one of our highly trained physiotherapists will be able to assist you.

Workstation Ergonomics: Tips to staying pain free

With a large percentage of people now working from home the team at East Vic Park Physio thought it would be a good idea to provide some simple but useful information on workstation ergonomics.

Previous to what we used to think, there is not one way to correctly sit at your workstation. Your set up should be able to accommodate for a range of comfortable positions that you can frequently change throughout the day. The optimal/most comfortable sitting position will change from person to person and will depend on:

• The type of work being done

• Visual demands

• Individual body shape

Figure 1: An example of an acceptable sitting position. It will allow for a range of supported postures that can be changed throughout the day.

Tips for setting up your home workstation:

• Sitting with body close to desk

• The head and neck are in a forward facing and in midline position (i.e no backward arching of the neck and or forward extension of the chin)

• The shoulders are relaxed and relatively symmetrical, elbows close to the side of the body

• The back is supported by the chair backrest. The curved lower part of the backrest should sit into the lower back

• Having an open angle of 100-120 degrees (slightly more than right angles) at the hip. This can be achieved by adjusting the seat pan tilt and the backrest

o   As a general rule have your knees at a height lower than your hip

• Ensuring a gap or 2-3 fingers widths between the front of the chair and the back of your knees

• Having feet flat on the floor or footrest

RECOVERY TIPS: WHAT DOES THE EVIDENCE SAY

In a world focused on optimal performance, adequate recovery is paramount in allowing consistent high intensity effort. Exercise in general uses various body energy systems in which the waste products (eg lactic acid) can hinder performance. The quicker the waste is processed and cleared out from the body, the quicker the body returns back to homeostasis. 

The head of Discipline at the AIS, Shon L Halson, reviewed different recovery techniques in a published article that sought to determine the most effective methods.

Firstly, she identified the different factors affecting athletic performance which included:

-       Environment (Temperature, altitude, humidity)

-       Training/Competition (volume, intensity, duration)

-       Health Status (Infection, illness, injury, muscle soreness)

-       Psychological stress (Stress and anxiety)

-       Lifestyle (Sleep, schedule, housing situation, leisure/social activities, relationships, job/school situation)

She then reviewed 6 methods that were thought to enhance recovery from the above factors and her findings are summarised in the table below:

She concluded that:

-       Sleep conditions are very important

-       Massage, 1-2 x per week can be helpful for elite athletes

-       Contrast therapy should be 1 min hot, 1 min cold x 7 (cold temp 10-15 deg, hot 38-40 deg)

Here at East Vic Park Physiotherapy, we can provide advice on stretching, active recovery and hydro therapy programs as well as providing massage for recovery. Click on the BOOK NOW button on the top of the page or call us on 9361 3777.