Flexor Hallucis Longus tendon injuries

What?

Flexor Hallucis Longus muscle (and subsequent tendon) runs down the medial border of the tibia past the malleolus and inserts into the plantar surface of the foot and into the base of distal phalanx of hallux. Its role is to move the big toe downwards. FHL pain is usually characterised by medial ankle and foot pain. Sometimes, the discomfort can run up into the medial calf.

How?

Tendon pain can occur due to an overload or an acute injury causing a tear. Typical activities of overload include running and jumping. It can be irritated in end of range plantarflexion eg calf raise or in a stretch position e.g. knee’s over toes with heel down.

When?

Not necessarily typical of a certain age group. Can commonly be seen in dancers (who spend a lot of time in the aggravating positions mentioned above). Can also be seen in those with calf insufficiencies, either transient or permanent e.g. post-surgery like an Achilles repair or after a traumatic injury like an ankle sprain

How does it resolve?

·       Avoiding aggravating positions/activities until it settles

·       Progressively building load capacity

What is the treatment?

The focus of treatment is to reduce pain levels and restore the capacity of the tendon. This can be done in a few different ways including:

-       Manual therapy (eg muscle massage)

-       Taping to offload the tendon

-       Exercises to strengthen key areas eg calf

-       Implementation of load management strategies (eg mapping out impact activities)

-       Voltaren gel wrap at night time

If you would like your injury reviewed by one of our physiotherapists, then don’t hesitate to book an appointment.

Relative Energy Deficiency in Sport (RED-S)

Are you unable to recover between training sessions? Experiencing severe wide-spread muscle ache/DOMS? As a female athlete, has your menstruation ever been affected by your training? These can all be signs of energy deficiencies and overtraining. Our blog explores what energy deficiency is, how to identify it and how to treat it.  

What is RED-S? 

Relative Energy Deficiency in Sport (or RED-S) is due to low energy availability in athletes. This means the fuel going into the body from food is less than the energy burnt during exercise. This energy balance should be at least equal and is additional to the normal calories consumed during the day. When energy input is at a deficit, RED-S can have significant impact on many body systems, affecting both injury risk and performance. 

RED-S used to be known as the ‘female athlete triad,’ terminology which is no longer used as it affects ALL athletes. The most well-known consequences of poor energy availability are bone stress injury and female athletes losing their period. These are both extreme consequences of RED-S, however there are much earlier signs and symptoms which are lesser known. 

Signs and Symptoms 

·      Poor sporting performance 

·      Inability to recovery between sessions

·      Poor wound healing 

·      Regular cold and flu sickness

·      Irregular/cessation of menstruation/periods (see below; ‘The female athlete’)

·      Poor bone health/osteopenia/bone stress response

·      Mood changes 

·      Iron deficiency 

·      Arrythmias (in severe cases)

Why does it matter? 

1.     Adverse effect on performance 

·      Quicker onset of fatigue from less energy available to skeletal muscles

·      Reduction in muscle strength/size due to impaired testosterone production and compromised neuromuscular control  

·      Impaired recovery increasing the risk of overtraining 

2.     Impact on health and wellbeing 

·      Increased the risk of chronic fatigue 

·      Low energy availability decreases the ability to heal from injury. Strains, sprains, cuts and bone injuries will take longer to heal

·      Impaired growth and development from inadequate cell turnover

The good news is most effects of RED-S are reversible if picked up early.

Athletes are often worried increasing food intake can result in weight gain. This is not the case for most athletes. Nutritionists and sports science professionals understand the energy demands of sport and ensure the balance between energy input and output is correct. 

The female athlete

1.     Menstruation 

If an athlete has low energy availability, their body is unable to produce normal levels of hormones. This can affect the menstrual cycle in female athletes. Periods may become irregular, or even cease altogether. Although the female menstrual cycle is variable between individuals, an individual’s cycle should be quite consistent. Irregularity or cessation of periods for longer than 6 months, or not getting a period by 16 years of age should be reviewed by a doctor. 

2.     Contraception 

Female athletes may be advised the oral contraceptive pill can treat symptoms and normalise their menstrual cycle. The combined pill produces a synthetic estrogen the body can not process and therefore does not assist with improving bone health. This can mask hormonal problems, without assisting in bone health. Athletes using contraception that contains estrogen may also be screened for risk factors of RED-S. Athletes using contraception that alters the normal production of a period (e.g. Mirena, Implanon) must also be monitored for RED-S symptoms.

How can physio help?

Physios can help review your training program and lifestyle to assess energy availability. If an athlete is at significant risk of RED-S, a Sports Physician should be involved to identify any hormonal/nutritional deficiencies and directly address them. This is commonly done through a blood test. 

After any nutritional deficits have been addressed, a physio can help modify training loads and aid with recovery techniques.

Who else can help? 

Sports doctor – Vital for initial diagnosis and hormonal/nutritional testing. Depending on severity, medical intervention may be needed (e.g. iron infusion)

Nutritionist – Eat the right food… and enough food, is vital for good energy availability   

Strength and conditioning coach – Clever programming results in efficient training and decreases the risk of overtraining. 

Costochondritis - A real pain in the chest

There can be many medical reasons for chest, rib and upper back pain including heart and lung conditions, infections and trauma incidences like fractures.

However, once that has been ruled out a diagnosis to be considered is costochondritis. 

 What?

The condition is classified as inflammation of the costochondral junction of the ribs (where the bone and cartilage meet) or of the costosternal joints (where the ribs connect to the chest bone). The issue is normally unilateral (one sided) but can sometimes be bilateral.

 Signs and symptoms:

-       Chest pain that can radiate into the upper chest near the shoulder, down the rib into the area under the armpit and even into the back near your shoulder blade

-       Pain can be sharp with certain movements and a dull ache at rest

-       Sometimes there is visible swelling over rib joints

-       Neck and shoulder range can be affected

-       Pain with laughing, coughing, sneezing and deep breathing

 Why?

The exact reason for an individual developing inflammation of that particular area is yet to be determined. However, there are a few mechanisms that have been anecdotally found to trigger costochondritis symptoms including:

-       Trauma to the area (eg. Direct fall/pressure or injury to the pec muscle)

-       Intense exercise of the area

-       A bout of illness with lots of coughing

 Diagnosis methods

The condition is primarily diagnosed with clinical tests including:

-       Palpation of the costochondral and costosternal joints (usually ribs 2-5)

-       Assessment of thoracic, cervical and glenohumeral joint range

-       Cough/sneeze/laugh test

-       Deep breathing test

Scans would only be beneficial if you needed to rule out any of the below alternate diagnoses. Potentially a blood test would be beneficial if a multi joint inflammatory condition is suspected. 

 Examples of differential diagnosis

-       Coronary artery disease (or other heart conditions acute or chronic)

-       Pulmonary embolism or pneumothorax

-       Rib fractures or subluxations

-       Costovertebral sprain

-       Tietze syndrome

-       Pectoralis muscle injury

-       Infections (e.g., pneumonia)

-       Xiphoidalgia

Treatment

-       A review with a physiotherapist can be helpful to accurately diagnose

-       Ice over the joints or heat over the muscles

-       Speak to your pharmacist regarding pain relieving medication

-       Modification of aggravating activities

-       Gentle massage to the neck, shoulder and chest muscles can be helpful in some cases

-       Gentle stretches and strengthening exercises once the pain has reduced

If you believe you are suffering from costochondritis then book an appointment to see one of our friendly physiotherapists today! 

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

Common Adolescent Conditions – Part One: Ankle

This topic seems somewhat timely given these particular injuries are normally load related.

As discussed in my previous blog about Load Management, the last 6 months have played havoc with people’s Acute Chronic Workload Ratio and children/adolescents are no exception. 

The conditions I will be discussing are usually related to a big spike in activity which has been the case this year with most sporting organisations eager to recommence their seasons. These spikes will be somewhat amplified in young athletes who participate in multiple sports or who are already specialising in their chosen sport which can mean numerous training sessions/games per week.

 Sever’s Disease

 What?

An irritation of the insertion of the Achilles into the calcaneus. This differs from adult Achilles tendinopathy due to the immaturity of the adolescent skeleton which means it affects the actively remodelling trabecular metaphyseal bone.

How?

As mentioned previously, it is usually due to the area’s inability to deal with an increase in activity (particularly activity that uses that area eg running or jumping sports).

 When?

More common in boys and usually between the ages of 10-15 compared with girls which is usually between the ages of 8-13.

How does it resolve?

Usually self resolves with time (6-24 months) however the reason it’s best to seek treatment/advice is due to the pain that accompanies the condition which can affect sports performance and most importantly day to day activities. 

What is the treatment?

The main focus of treatment is to reduce pain levels. This can be done in a few different ways including:

-       Manual therapy (eg muscle massage)

-       Heel raises for footwear to offload the tendon

-       Taping to offload the tendon

-       Exercises to strengthen key areas 

-       Implementation of load management strategies (eg RPE scale)

-       Advice regarding recovery (eg icing)

The main takeaways about the condition are:

-       The adolescent will grow out of it

-       It can still be quite painful however so there should be a focus on pain relief

-       Load management with guidance from a physiotherapist can allow the continued participation in sport without compromising day to day function 

If you would like your injury reviewed by one of our physiotherapists, then don’t hesitate to book an appointment. All of our physiotherapists specialise in sport and have had extensive experience with adolescent athletes.

Achilles Tendinopathy - What you need to know

What is a tendinopathy?

Tendinopathy simply means that the tendon has failed to adapt to loading, doing “too much, too soon”. 

Whether you have increased your load by volume, intensity or frequency… this amount was greater than the tendons capacity to cope and recover.

Load > Capacity

How did I get an Achilles Tendinopathy?

 You may be more prone to a tendinopathy if you are a…

o   Running / jumping / landing athlete i.e. distance running, basketball, AFL and netball.

o   Weekend warrior who over exercises on weekends and under trains during the week.

o   Older person with a history of poorly rehabilitated and/or grumbly tendon.

Where does it hurt?

Do you pinch your heel and feel your pain? 

People tend to have a very specific site that is the source of their symptoms and can put their finger right on it.

Do I need a scan of my Achilles?

No.

In 90% of cases this should be easily diagnosed by your physiotherapist or sports physician. If you aren’t getting results with your treatment and rehab then you may be referred for a scan.

What should I avoid doing?

-       Don’t rest

Staying off it completely will only increase the time it takes to rehabilitate the tendon.

-       Don’t stretch/massage the tendon

Stretching and massaging the tendon won’t get it stronger. Muscle massage however, is ok. Stretch may feel good temporarily, however can make the tendon more irritable.

-       Don’t train through high levels of pain

Low or mild discomfort can be ok during activity, but if you are still sore 24-72 hours later then you have done too much, too quickly.

 I’ve been having physio and not getting better, what should I do?

Ask yourself;

-       ‘Do I have the correct loading amount in my work out?’

… not too much or too little.

-       ‘Am I sticking to the program?’

… over committing/loading or too many days between rehab sessions won’t help the tendon to strengthen and repair.

 If you’re doing all these things right then discuss with your health practitioner where to go to next.

What’s the best treatment for Achilles Tendinopathy?

Best practice for tendon health is a combination of…

-       Regular progressive loading, and

-       Pain monitoring

-       A short period of staying off the grumpy tendon may also be necessary.

-       Your GP or health professional will be able to advise regarding anti-inflammatory use. 

Speak to your physiotherapist who will assess and prescribe the optimum amount and intensity of exercises for you.

Author: Peter Gangemi - Master of Physiotherapy

Most Common Injuries in Martial Arts

 Most Common Injuries in Martial Arts

Being a martial artist has its pro’s and con’s and injuries are a major risk of the job.  The following are some common injuries that fighters can expect whether training for fun and fitness or aiming to become the world champ.

1.     Lacerations

The most common injury in the MMA and martial arts world. Australia’s most decorated Muay Thai fighter John Wayne Parr currently counts a total of 346* stitches from 146 professional fights (Muay thai and boxing).

General rules for whether you need stitches are;

-       If the cut is greater than 1-inch in length or depth

-       If you can see fat, muscle or bone

-       Is the cut easily exposed to infection i.e. on the hand or fingers

-       Difficulty with clotting i.e. prolonged bleeding >15mins

-       Is it in a sensitive area i.e. the hands or face where reducing scarring is integral.

See your GP or present to your nearest emergency department if you fit any of the above categories.

Good luck JWP in your next fight against Anthony ‘The Man’ Mundine. 

2.     Cork / Contusion / Haematoma

Is an impact on the muscle with sudden, heavy compressive force i.e. opposition players knee. These can present either within a muscle (intra-muscular) or between muscles (inter-muscular).

Inter-muscular corks are sore to touch, can bleed down the limb i.e. thigh towards the knee.

Intra-muscular cork are also tender, and stiff to touch where stretching is difficult and movements like walking can be difficult without a limp. These can sometimes lead to solidification of blood within the muscle if not resolved, known as ‘myositis ossificans’.

Management;

-       0-48hrs: involves rest, ice, compression and elevation post game.

-       2-3days: see a physio/doctor for assessment and whether anti-inflammatories will be of use. Start some gentle stretching and movement i.e. exercise bike or light training.

-       3-4 days: gentle massage around cork and training as tolerated.

-       5 days: stretching and foam rolling around the sore spot and gentle heat packs may be useful.

3.     Concussion – Knock Out aka ‘the Big Kaboosh’ aka ‘goodnight Irene’

The risk of concussion is significant in MMA due to high volume of punches, elbows, knees and kicks to the head. However, many fights are stopped due to submissions as opposed to head injury. In February 2019, the Australian Institute of Sport, Australian Medical Association and Sports Medicine Australia released a joint Position Statement on the management of confirmed concussions in athletes. (https://ama.com.au/position-statement/concussion-in-sport-2019 ). This states that athletes over the age of 18 should not return to contact activity sooner than 7-days, and 18-year-olds and under should refrain from risk of contact for 14 days or more and once cleared by a doctor with no signs of concussion still present.

A player should be immediately removed from the sport if any of the following occurred;

-       Loss of consciousness

-       A fall to ground without protection

-       Seizure or tonic (rigid) posturing

-       Impaired memory (date, location)

-       Severe headache and other symptoms (below)

-       Vomiting

-       Deteriorating consciousness

-       Vision loss/changes

-       Non-typical behaviour

Signs of concussion may include;

-       Loss of consciousness, headache, drowsiness or feeling like ‘in a fog’ or ‘slow’

-       Dizziness or balance problems

-       Confusion, sadness, irritability, nervous, anxiousness or emotional

-       Blurred vision or sensitivity to light or noise

-       Trouble sleeping

If any of the symptoms above are severe then the person should be taken directly to emergency and/or immediately be assessed by a doctor.

4.     Fractures

a.     Boxers Fracture

           i.     Occurs when a closed fist impacts with another hard object (head/floor) causing fracture at the head of the metacarpal (typically the 5th metacarpal).

           ii.     Signs: Swelling, redness, tenderness or crunching (crepitus) over the affected area.

           iii.     Diagnosis: Doctors or physiotherapist physical exam and X-Ray

          iv.     Treatment: Non-surgical cast and immobility or surgical pins and immobilisation cast.

          v.     Prognosis: up to 12 weeks

Others – can include any part of the body due to the high forces of usually bone on bone impact.

5.     Cervical Disc Pathology – i.e. Neck cranks, rear-naked chokes.

Causes hyper flexion/extension or rotation to the neck. These often result in the fighter ‘tapping out’ prior to any serious damage. However multiple drilling, sparring and then fighting can place excessive stress on the neck discs, joints, ligaments and muscles.

Talk to your physiotherapist or GP immediately if you notice any of the following;

-       Severe central neck pain

-       Inability to move the neck >45° left or right

-       Pins & needles, numbness or tingling into the arms and hands

-       Severe shooting pains, electric shock or burning sensations in the arm and hands

-       Strength loss in the upper limbs

Hot Tip: Learn your limits when training and ‘tap out’ early!

6.     Dislocations / sub-luxations

The art of Brazilian Jiu Jitsu is designed to uncover the weakness at a joint and apply force so that the opponent taps before the trauma occurs. All dislocation/subluxations involve traumatic forces applied to a joint beyond its capability, leading to instability. Continuous micro-trauma may also lead to a joint becoming vulnerable over time.

A history of trauma puts you at increased risk of a repeat injury and continued clicking/locking/catching and instability indicates that the joint needs proper assessment and treatment. Never try to relocated a dislocated joint without a medical professional present.

Tip for young players… TAP EARLY

Author: Peter Gangemi - Master of Physiotherapy

Shoulder – Kimura / Americana

Shoulder – Kimura / Americana

Elbow – Arm bar

Thumb Dislocation