Is running becoming a pain?

5 Jun 2017 10:10 AM - Shin pain, anterior leg pain, shin splints, knee pain, patellar pain, joint pain, aching, muscular fatigue.

Running is a complicated thing. Dr Christian Barton, a well-renowned Physiotherapist who specialises in running retraining, described the total irony of learning ball or bat/ stick skills, tactical plays and foot work but never getting taught how to run as kids or adults despite being a vital part of most sports. Dr Barton presented his approach and research at the latest South Australian Sports Medicine Association conference.

Running is truly a massive coordination of muscles and movements over the whole body: Foot strike, pre-loading, loading, mid-stance, terminal stance, push off, initial swing… And that’s just the feet. So what’re the best things you can do to prevent or reduce pain when running? Unanimously, physios and evidence agrees that for most pains in the lower limb you should try increasing your cadence. More steps per minute for the same speed results in a 10-12% decrease in loading forces through your joints and muscles. Beyond this we hit some specifics.

An astounding amount of research has been done in the last five years about forefoot running and minimalist shoes. In brief, the argument is that a shoe with a thick heel (your classic, big, padded running shoe) encourages a heel strike. The heel strike can increase loading through the knee, as opposed to shock absorption in the foot itself. But! For those of us who have run most of their life and not realised there was a different way you could put your foot on the ground, I wouldn’t jump to tell you that you should now run on your toes. A mid- and fore-foot strike will undoubtedly increase the muscular demand on your calf muscles. They will help to decelerate the foot on impact and push off again at terminal stance. Each time your foot lands you’ll essentially be doing a calf-raise at several times your body weight, due to landing forces etc. Tissues generally can only adapt to a 10% increase in load weekly. I would argue that, in most populations, this may be a bit of an overload to your tissues if you went straight from a heel to a forefoot strike pattern!

What else then? Step length. Something that comes hand-in-hand with cadence. Shorter steps can make a big difference. Landing out in front of your body is a predictor of anterior shin pain and knee pain. However, cueing to “run shorter” usually feels weird and can be addressed by looking at cadence first. Further; step width, hip position and foot biomechanics can hinder people from running better. These factors (as well as those above) may be impacted by muscle length and strength capabilities.

Take away comments:

If you’re suffering from any type of leg pain with running, consult with a physio to see if increasing your step rate is your ‘Get Out of Jail Free’ card. A Physio will properly assess all areas and potential issues, creating a  plan to relieve pain and discomfort while running. 

By Suzannah Michell

Physiotherapist

 

Tennis Elbow

24 Jan 2017 4:36 PM -

2017 is upon us, and with it comes a swathe of New Year’s resolutions timed perfectly with things like the Tour Down Under and the Australian Open. Been feeling like a pro with the tennis racquet, tennis whites and sweat bands this January? We really hope so! We’ll say it once and we’ll say it again- exercise is one of the best treatment tools in our toolboxes! But… Too much of a good thing can lead to disaster.

At Prevent, we’ve been seeing lots of ‘Tennis Elbow’ presentations in the last few weeks. It’s a very common term describing a pain on the outside of your elbow with gripping and lifting movements. It was cited as being as high as 40% prevalence in a tennis population and 15% in a non-tennis population in one study.

It can be caused by many things- and obviously tennis is one of them. The most aggravating activities we see at Prevent are gripping and twisting movements of the forearm; ironing, lifting heavy pans and pouring out contents, tennis- especially when applying spin, carrying heavy bags, opening stuck jars etc.

But why is it really caused? Most commonly, it is caused by doing too much (or too many) of the things that overload the muscles on the outside of your elbow (listed above), doing them with poor technique or rushing back into being a tennis pro after a long winter off!

Fair warning though: ‘Tennis Elbow’ is not always a true ‘Tennis Elbow’ (or lateral epicondylitis, to get technical). Very often there is some contribution of pain attributed to the nerves in the area, or more specifically, the radial nerve. Arm pain, neck pain, shoulder pain, numbness and pins and needles can all be signs that maybe the pain is being radiated to your elbow from somewhere else. Or, the old chicken or the egg scenario- the dysfunction caused by the muscles on the outside of your elbow could be causing some nerve irritation. Either way, Google Doctor isn’t always the best course of action.

Our top tips:

1.      If you’re looking to increase your tennis regime, aim for a 10% progression each week, no more. That will bring you inline with your body’s tissues ability to adapt.

2.      Exercise and rehab are a much better option than a cortisone injection- all of the best current evidence shows no difference in pain after 6-8 weeks between cortisone and active rehab, and an actual increase in pain for cortisone groups after 12 weeks in some studies.

3.      Don’t put up with elbow pain! It can be the kind of thing to resolve quickly and completely (within 5-6 weeks) or it can drag out for months. Because of the close proximity of your nerves to the typically-affected muscles, the area can become sensitised and more complicated to treat. 


     By Suzannah Michell 

    Physiotherapist


The art of efficiency in sport isn’t as easy as it looks

25 Oct 2016 4:40 PM -

Did you watch any Olympic events this year and think that the athletes were making it look too easy? Commenting on the rowing like “They would’ve placed better if they were sharper with their blade-work!”, the gymnastics with “She should have done a triple flip, rather than just the double!” or the table tennis “He should’ve added some more top spin to that last one”… Yeah, we might’ve been guilty of that too!

In most, if not all, sports there is a degree of skill acquisition that requires the athlete to be powerful, strong, accurate and/or fast whilst expending minimal energy. The outcome is that it looks easy, almost effortless. But it isn’t.

This is the art of sporting efficiency; using only the muscles absolutely required, the exact amount they are needed, no more. Using more than what is specifically required is not only a waste of energy but can also lead to decreased performance and even overuse injuries. It’s a trained skill to be efficient and accurate; it’s how Olympians make super-human feats look like a piece of cake!

We can think of it almost like a monetary budget: athletes should be aiming to cash in all their energy-budget for what is going to give them the biggest return for their investment, rather than wasting it on tense shoulders, excessive gripping or toe-curling, especially when the lactic acid or fatigue kicks in, for example. Most people require immense training to enforce this near-perfect muscle and nervous system relationship in a pressured system like elite sport competition. It takes time, feedback and a complete network of healthy muscle and nervous tissue working well to achieve that one perfect sporting moment!

At Prevent though, we often find that people forget that learning a new physical skill in adulthood in sports (or otherwise) is actually incredibly challenging. It is the same process you might have gone through in childhood trying to learn a musical instrument: playing the whole song may be out of your reach on the first try, but you can hit some of the notes right. In fact, it might take you several weeks of trying before you can play the entirety without making a mistake. Whilst piano playing is a coordination of your upper limbs and fingers, sporting activities are just big, whole-body movements and coordination feats of the same nature. Consider the theory of three stages of motor learning:

Image result for 3 stages of learning

table sourced from: http://www.alphaknightscrossfit.com/category/blog/

In this theory, let’s compare it to when you learnt to drive, and in particular turn the corner:

Cognitive stage: you needed prompts to indicate, place your foot over the brake, brake slowly, turn the wheel and then accelerate through.

Associative: you were able to consider the turn ahead, then simultaneously perform the above steps fluidly like a chain-reaction.

Autonomous: you left your house and arrived at your destination without consciously considering the cornering at all.

Every time we learn a new physical skill, we step through this same process. However, if we need to refine a certain skill or change it slightly we need to step back to the Cognitive Stage again. Repeating the cycle as necessary until we meet a new Autonomous Stage. This is why bad habits are hard to break: we need to un-write a whole series of neural patterning and muscular activation.

Our top tips for making a technical change, and moving through the cognitive and associative stages of learning are:

  1. Get feedback: have someone watch you, video yourself, get a mirror or use props (a wall, Theraband, tape or a seat) to feel when you have performed the task differently. Counterintuitively, If it feels or looks wrong, different, even unusual, then you’re probably doing it right! If it feels the same, it probably is the same…

  2. Part-practice: break big movements into little, bite-sized pieces. They are much easier to digest this way. It can also help you to hone in on what exactly is causing your technique to falter. This can be a good way to identify small muscle imbalances or tissue length issues too.

  3. Repetition is key: especially if you’re looking to break a bad habit! Do it once perfectly and then do it again and again. This is not so much challenging the muscles themselves, but more the muscle-brain relationship. Get that brain working hard to instil and maintain the change!

  4. Progression is vital: Once you feel confident, you are able to maintain form and you do not have any injury concerns- up it. Do more repetitions, make it heavier, slower or faster, further and higher. The body is fundamentally designed to be pushed; all our tissues respond to physical stress by getting stronger. Start with little progressions, keep a rest day between training days and make sure you can maintain form in the progression.

It’s Golf Month this month in Adelaide. So if you are having issues with performance or injury, consider where the fault may lie in your technique. Because Golf requires so much from the whole body, it really can be anything along any part of the system. And at first, it may not necessarily be an obvious technical or physiological change. Golf is all about efficiency and coordination.


By Suzannah Michell

Physiotherapist

PILATES AND PHYSIO

17 Oct 2016 11:46 AM - Why do they work together?

It's about this time of year that we all realise we've let our fitness and activity levels drop a little bit. Maybe there are some perceived barriers stopping you from exercising now: time, motivation, energy, travel or even pain? But the weather is getting warmer and there's no time like the present to make a change!

In fact, recent evidence suggests that exercise and exercise-based therapies are just as effective, if not better than having treatment for some pain conditions. Further, several studies, on ongoing low back pain indicate that a Pilates-specific program is the most effective treatment tool for reducing pain and disability in comparison to other exercise programs and therapy.

Pilates has a strong emphasis on control and strength around the pelvis and core, which we like to think of as our foundations in Physiotherapy. You can't build a building and expect it to last forever if you haven't invested time and effort into solid foundations. Not to mention exercise has also been clinically shown to increase your energy levels, improve cardiovascular health and circulation, up your mental well-being and boost your metabolism!

By Suzannah Michell

Physiotherapist

Get Moving!

Contact us on 8361 8182 if you'd like to hear more about our Pilates classes


World University Rowing Championships

8 Sep 2016 4:44 PM -

The World University Rowing Championships start today in Ponzan, Poland; it’s an opportunity for students rowing at an elite level to compete on an international stage without impacting their studies at University. Elite sport is more often a career choice than an add-on to a University degree. And for this we have a lot of admiration for their dedication and time management skills!


At Prevent, we work holistically: these rowers in Poland aren’t just students, nor are they just elite rowers, in fact they are much more than just those combined. It takes a global approach to provide care for a person and help them achieve their goals.


A study published in 2014 scrutinizing student-athlete behaviours at Harvard showed that hours of sleep was the highest predictor of injury, even more than number of hours of training per week! Students who slept <8hrs sleep were 1.7 times more likely to sustain an injury than those who got >8hrs. (http://www.ncbi.nlm.nih.gov/pubmed/25028798)


Treating the whole person will always take preference over just one part or another.


(Photo by Get-Shot Photography of Annabel Gibson, who will be representing Australia at the World University Championships with her doubles partner, Sophie Jerapetritis, in the lightweight double)

By Suzannah Michell

Physiotherapist


Women’s Health

12 Jul 2016 10:20 AM - Stress Urinary Incontinence (SUI)

Urinary Incontinence affects up to 37% of Australian women. That’s more than 1 in 3! (Australian Institute of Health & Welfare, 2006)

Stress Urinary Incontinence (SUI) is the leaking of small amounts of urine during activities that put stress on the bladder. “Stress” refers to an increase in pressure on the bladder; a physical stress. Increased pressure can be caused by coughing, sneezing, laughing and heavily lifting, and it can also be caused by jumping, running or any large downwards force on the body. All of these things are an increase in abdominal pressure, which translates to an increase in pressure downwards on the bladder and pelvic organs.

Risk Factors:

Pregnancy, childbirth and menopause are very common predisposing factors to experiencing SUI. As previously discussed, pregnancy and childbirth can cause stretching, weakness or incoordination in the pelvic floor muscles. In the case of menopause though, it is a lack of oestrogen that can lead to physiological changes in the urethral lining that causes some leaking. Elite sportswomen also suffer from SUI commonly due to jumping, running, heavy lifting, straining and/or decreased amounts of oestrogen. Trampolining, parachuting and base jumping have been identified as a sports with high incidences of SUI within their female populations.

SUI can be mild, moderate or severe;

For some women it can make them feel uneasy about their chosen sport, and others it can make a sneeze in public their worst nightmare.

So why does it happen?

Well firstly, we have to understand the fundamentals. Yes, it is linked to your deep pelvic floor muscles! But no, it is not because the deep pelvic floor constricts around your urethra! Following on from the last post- your pelvic floor helps to hold your abdominal organs up and in the most advantageous position. In the case of the bladder and urethra, this a position where the urethra and bladder neck (where the bladder turns into the urethra) are upright and supported.

As seen below, when the bladder neck is well supported and we have an increase in abdominal pressure the pressure is equally applied to the whole system. This causes a forced closure of the urethra equal to the pressure applied to the bladder, and hence there is no loss of urine. However, on the right hand side, when these structures are less supported, the force is not applied evenly and urine escapes. The pressure downwards may just move the urethra instead of stinting it closed up against a firm, contracted pelvic floor muscle (or fascia).



So what can we do about this?

Let’s not forget that the deep pelvic floor muscles are in fact muscles! And just like all other skeletal muscles in our body, they can adapt to loading. That’s right- if you want a strong bicep, you’d have to do bicep curls regularly to increase its strength, and it’s no different for the pelvic floor.

There are a few ways we can go about this strength training though depending on symptoms. So let’s think about these two different examples:

  1. you suffer from mild SUI only when you cough or sneeze 

  2. you suffer from mild SUI only when you go for a 5km run

In the first example, we would focus more on maximal strength and coordination of the pelvic floor (equivalent to a persons’ 1 rep maximum). And in the second example, we would focus more on the resting tone and endurance of the pelvic floor (more like, how many reps you can do at the same lower weight).

Why is this? Consider the time frame of each event: Even in running, we turn on and off our muscles in a rhythm, but we would never expect a single muscle to contract the entire time. Muscles don’t like to be turned on and kept on. So we would never try and train the pelvic floor to turn on and hold for 5km!! However, if it is a single, shorter event that you can predict that causes SUI, it makes sense that you need a very strong, effective contraction to make a change in leakage.

Some treatment ideas could be (corresponding to the different symptoms above):

  1. Frist of all we would teach the patient how to coordinate a strong contraction during a cough or sneeze. Interestingly, this reflex is usually lost after giving birth and it is more a coordination issue rather than a strength one. Depending on this efficacy then, we would prescribe pelvic floor exercises focusing on fast activation, maximal holds and/or pulsing holds towards maximum. Importantly these exercises are based at fatiguing your pelvic floor and should only be done at the end of the day in bed, before sleep.   

  2. In order to change the endurance and resting tone of your pelvic floor, we need to build muscle bulk in the pelvic floor. For this we would be aiming for 8-12 repetitions pushing the muscle to fatigue, and doing 1-2 sets per day. It is recommended that strength training occurs for three to four months. Additionally, for women with good strength, but lifestyles that exceed normal pelvic floor requirements (such as elite sportswomen, powerlifters or cross-fitters), vaginal weights can be excellent to increase resistance and hence build the needed muscle bulk.

But…

SUI symptoms may be caused by other pelvic floor or bladder issues, and it is always worth seeing a medical professional about your issues before attempting anything by yourself. A lot of women don’t contract their pelvic floor muscles properly, and are often pushing down instead of pulling up, hence worsening their problems, not making it better! Furthermore, severe SUI can be a sign of other issues in the pelvis and a multifactorial approach may need to be taken, not just pelvic floor retraining.

If you have any issues or you want to discuss anything further about any symptoms you may be experiencing you can call us on 8361 8182 to book an appointment today with Suzannah. Women’s Health is an area that only Women’s Health specifically trained professionals will be able to fully assess and treat, so give us a call to help you on your way.

Suzannah Michell

APA Physiotherapist- Women’s Health


Women's Health

24 Jun 2016 4:13 PM - The Pelvic Floor

When we are talking about Women’s Health we are generally talking about urinary, faecal and sexual health in women. And it sounds like a scary, taboo topic, doesn’t it? Well, of course, we are here to tell you that it really isn’t. And thinking about Women’s Health as such may be holding us back from big changes in wellbeing and health in Australia. This piece will be one of several to help debunk some myths around Women’s Health and hopefully educate and empower women facing these issues. And if you are someone who has problems, you are not alone!

Urinary incontinence affects up to 37% of Australian women (Australian Institute of Health and Welfare, 2006), however of those who reported they were suffering, only half reported seeking help from a health professional (Byles & Chiarelli, 2003).

Did you know that your uterus can expand to one thousand times its normal size when pregnant? And a placenta can create up to one thousand times the normal amounts of oestrogen and progesterone than the ovaries usually do when you’re not pregnant? Crazy, right? So why aren’t we taking about the other things that can happen to the female body with such respect?

A fantastic physiotherapist, Taryn Hallam, once described the pelvis to me like a soup can. The filling of all the soup in this analogy is your organs: uterus, bladder, intestine, stomach etc. However this tin of soup has no top and no bottom to the can. So what’s then stopping all the contents just falling out? The pelvic floor muscles and fascia; a genius, yet potentially flawed design of the female human body. In one regard, it’s great- muscles are stretchy and can be strengthened, so a baby can pass through a woman’s pelvis to give birth and recover afterward. But on the other, they can be forgotten about, weakened and altogether misunderstood.

Did you know at the end of pregnancy, the weight of the baby on the pelvic floor has been found to be equivalent to a 100kg man standing on a trampoline?

If that man stood on that trampoline for weeks or months, think about what that trampoline would look like when he got off. Or better yet, someone tried to push him through the fibres of the trampoline!

What really is the pelvic floor then?

The pelvic floor muscles span from your pubic bone to your sacrum, as drawn in in bright pink on this image:


(Adapted from www.fda.gov image, viewed 21/06/2016)

Note that this picture is from the side. Note the positions of the bladder, the uterus and the rectum next to each other. Your pubic bone is the hard bone you can feel at the front of your pelvis, and the sacrum is a continuation of your spine which ends in your coccyx bone.

What does it do?

The pelvic deep pelvic floor muscles sit a bit like a sling. So what do you think would happen when they contract? They get tighter and straighter, making the shortest line between the pubic bone and the sacrum. Whilst there are muscles around the anus and urethra that work by constricting around these exits to stop defecation and urination respectively, these are not your deep pelvic floor muscles. The pelvic floor muscles do not hold your urine and faeces by constricting around your passages. So why do physios go on and on about them?

Well, firstly, when they are weak you can see that they sag down. When the pelvic floor muscles are tight and taut, the weight of your organs is more evenly distributed. When it sags, you have an increase in pressure in the very centre, towards the vagina. Therefore, having weakened pelvic floor muscles puts you more at risk of a prolapse (which is where your bladder, uterus or rectum slips downwards, usually towards your vagina), as you can see below. Prolapses will be more closely discussed in further posts.

http://vibrancepelvictrainer.com/vibrance/wp-content/uploads/2015/06/pf_nice2.jpg

Just briefly and very simply, this sagging of the pelvic floor is one of the reasons that women experience loss of urinary and faecal continence as well. Because the organs are not well supported, their function can be altered. This is especially the case with Stress Urinary Incontinence (SUI), which is the loss of urinary continence when there is an increase in pressure (i.e. stress) on the bladder. This increase pressure is most commonly caused by coughing, sneezing, laughing, heavy lifting or jumping/running. We will continue to expand on this in coming posts.

So what can you do?

Well, unfortunately research has found recently that

Up to 50% of women perform a pelvic floor contraction incorrectly if only given verbal cues.

However, an appropriately trained physiotherapist with a special interest and training in Women’s Health can assess and treat pelvic floor weakness and dysfunction. At Prevent, we have private and confidential treatment rooms and specialised equipment to help you.

Want the good news though? According to the Incontinence Foundation of Australia:

80% of sufferers can be improved or cured with conservative treatment

Further, Pelvic Floor Muscle Training (PFMT) for people with SUI has been systemically reviewed to increase quality of life and have very few reported adverse effects (of which, none were serious) (Dumoulin & Hay-Smith, 2010).

So let us help you to improve your confidence, health and wellbeing. If you have any issues that you would like to discuss with our trained Physiotherapists regarding the pelvic floor or anything in this article, do not hesitate to call us on 8361 8182 or email physio@prevent.net.au

By Suzannah Michell

Physiotherapist


Acknowledgements:

Information, analogies and concepts from Taryn Hallam’s Introductory Course of Women’s Health Training Associates (WHTA) are used throughout this article.

Dry Needling

9 Jun 2016 2:35 PM - What exactly is it?

Dry needling is the insertion of very thin needles, exactly the same ones used in the practice of Acupuncture.   The needling is considered “dry” because the needles aren’t injecting anything into your tissues- like an anaesthetic, corticosteroid or other substance. They can be inserted into or in the vicinity of muscles, ligaments, scar tissue and even nerve tissues. This practice differs from traditional acupuncture in that it does not necessarily follow the meridians nor is it based on the traditional Chinese theories.

What should you expect?

Dry needling can be done many different ways; consequently it is very unlikely for any two practitioners to use this treatment tool in exactly the same way. It is almost always used in conjunction with other treatments and tools, such as massage, stretching and movement retraining. Some forms of Dry Needling can pain free, and others are aimed to elicit a muscle twitch and pain response. However, everyone can have a different experience because of the brain and body’s fantastic and ever-changing sensitivity. Needling has been known to even cause changes to mood, alertness and create other strange nervous system responses!

Does it actually work?

It has been well documented that Dry Needling can cause an immediate and long term reduction in pain, can restore range of movement to a joint and cause a physical and chemical change within tissues. In these studies, a range of conditions were considered, including lower back pain, osteoarthritis, tendinopathies and neural pain conditions with focal pain and radiating pain.

How does it work?

There has been a shift in thinking over the last ten years concerning the Pain Sciences, and hence how practitioners believe Dry Needling actually works is evolving and ever-changing. At Prevent, we use needling to try to address the cause or driver of your presenting problem.

In some cases, muscular dysfunction and overuse can lead to the production of trigger points in tissues. Trigger points usually feel like painful lumps or knots in muscle tissue and are believed to be caused by a response from the nervous system when a structure is under stress or not working in perfect harmony. Under a microscope these trigger points are, in fact, collections of sensitised C-fibre nerve bundles in a relatively hypoxic collection of muscular tissue.

Dry Needling has been shown to change what is happening physically and chemically at these trigger points and can lead to a ‘deactivation’ of them in the short- or long-term. Hence, by stimulating them we can cause a neuromuscular change in the entire muscle tissue. This may be represented by a change in range of movement, amount of pain or even the way a structure is moving.

In addition, there is some very good evidence that non-trigger point Dry Needling is effective in some conditions, such as arthritis and carpal tunnel syndrome. Practitioners predict this may be because of a strong nervous system reaction to the stimulation of small nerve endings in our tissues. So at Prevent we often Dry Needle where you are experiencing pain and sometimes in structures down the length of that limb, or in opposing muscles to elicit a change.

By Suzannah Michell

Physiotherapist


Sources:

Dommerholt, J 2011, Dry Needling- Peripheral And Central Considerations, ‘Journal Of Manual And Manipulative Therapy’, vol 19, no 4

Dunning, J Butts, R Mourad, F Young, I Flannagan, S Perreault, T, 2014, Dry Needling: A Literature Review With Implications For Clinical Practice Guidelines, ‘Physical Therapy Reviews’, vol 19, no 4