Stuart Baptist

No pain, no gain

No Pain No Gain??

One of the most common things we get asked is how much pain is acceptable?

We watch images of pro athletes pushing it to the limit and we hear stories of people smashing themselves day in day out…but the question always remains…how do we know when to push and when to hold back?

The question is an interesting one and the answer (of course) is not a simple one.  There are many contributing factors….I’ll try to explain the most common ones.

  1. How used to this kind training are you?

If you have gone from a relative couch potato to captain motivation overnight you are HIGHLY likely to get injured.

Sudden changes in exposure of our bodies to unfamiliar movements means that we are often poorly prepared to cope.

SOLUTION:

Engage in a progressive demands system

Start light and easy and progress your exercise demands slowly

If you are completely new to exercise it may even be worthwhile in the long run to be assessed by a physio/exercise physiologist for identification of biomechanical ‘risk factors’ (e.g. tight calfs, flat feet, poor lumbopelvic stability) and integrate some preventative training into your actual training.

  1. The pain disappears when you are actually running, only to stiffen up again after you’ve rested

WHAT THIS MEANS:

Unfortunately pains that settle with more activity can often mean the tendons are struggling with the change in load.

SOLUTION:

You may have to reduce your training load if this is happening, identify what tendon is causing the trouble and treat it locally with ice and targeted exercises.

In extreme cases you can use GTN patches to reduce the tendon pain but you will have to talk to your physio/GP/sports physician to make sure that this approach is right for you.

 

  1. The pain comes on with training and then just gets worse and worse until I physically have to stop.

SOLUTION:

Stop

This is not ok pain.  If the pain is in your legs it can be a compartment syndrome (where the muscles swell and are compressed within the fascial outer casing of the muscle) or it could even be a stress reaction in the bone.  Either way you need to get this looked at by someone who knows their stuff.

 

  1. My muscles are sore for up to 3 days following activity, but then they feel fine.

WHAT THIS MEANS:

Well Done

You are experiencing delayed onset muscle soreness…this is the no pain no gain they talk about.

You have exercised just enough to cause damage to the muscles, but it will be repaired and new, improved sarcomeres (the building blocks of muscles) will be laid down.

It is however a good time to rest for a day or two while you are sore, or cross train by doing something different (go for a swim or hit a few tennis balls gently).

Overall some discomfort is a acceptable with training, but if it is impacting your ability to perform regularly you must get it checked out.

Stuart Doorbar-Baptist | Senior Clinician and Research

Groin Strain

The title of this blog should really read  Groin PAINtemp

rather than groin strain.

A groin strain is a simple bone-muscle -tendon lesion brought on by overload, for example training as a runner and then playing a game of touch football.  Your muscles become good at what you practice and if you practice running at a consistent pace in a relatively straight line you are not adequately prepared for rapid changes in pace and direction.  This is an example of a training error, and should be addressed upon recovery.

These groin strains are managed with rest and ice in the early stages, then progressive stretching (including dynamic stretches like this and this), local massage and a progressive return to running.

Groin PAIN however is a whole different kettle of fish!  It often starts very similarly to a groin strain but it fails to recover appropriately.  These groin pain syndromes are often referred to as ATHLETIC PUBALGIA or a SPORTS HERNIA.

Pain in the groin can be referred from the lumbosacral spine, sacroiliac joints, urological causes (see our previous post on Chronic Pelvic Pain Syndromes) and active myofascial trigger points in abdominal and hip muscles. In other words a careful examination is needed to isolate the source of the problem.

MRI can also be used to evaluate whether there is any intrinsic hip pathology (for example a labral tear) and to assess the extent of damage to the conjoint tendon, abdominal muscles and connective tissues around the region. (the white stuff on the image below!)

If extensive tears are noted surgery is often a good option, provided it is followed by a careful and considered rehabilitation period.

Flexibility and core strength are vital in preventing the adductor and abdominal muscles from developing excessive tension so will form the mainstay of rehabilitation.

Chronic groin strains, or sports hernias will often present as significant post event stiffness and pain.  But it is best not to ignore it and push through.

Achilles Tendinopathy

achilles-tendinitis-pain

Achilles Tendinopathy is a degenerative condition characterised by pain and stiffness in the Achilles tendon.  It is different from it cousin Achilles Tendinitis because in a tendinopathy there is an absence of an acute inflammatory response and therefore it is often poorly responsive to Non-Steroidal AntiInflammatory (NSAID) medications.

A misconception is that as a tendon degenerates it becomes thinner and more prone to tearing like a cartoon rope imagesbut this is an inaccurate image and one that can lead to chronic pain behaviours.  Degenerative tendons look more like old rope which has thickened.  Micro tears have occurred but the overall effect is that the tendon is thicker

Screen Shot 2016-03-09 at 1.55.24 PM

Thats often why the tendon feels thicker than on the non affected side and may contain focal nodules.

It’s important to realise that this does not mean that your Achilles is going to snap…far from it, in fact there is no evidence that shows that achilles tendinopathy progresses into tears.

So…thats all well and good….but what to do about it?

Well..lets look at it from a microscopic perspective…if we want the tissues to heal and recover we have to cease irritating it.  ACTIVITY modification is therefore an important step….In other words REST…take it easy.   Even the use of heel raises can offload the tension in the system, this can be especially useful in the more painful early stages.

Kinesiotape (stretchy elastic tape) can be used…and it looks so cool too!! (thats me being sarcastic!).  Use it if it creates at least a 50% reduction in symptoms, if it doesn’t don’t worry.fa5b3b1f18c3edffd54f1061ba772d47

Application of ice and ice cube massage has been shown to cause a local vasoconstrictive response which can reduce neovascularisation (or the creation of useless small blood vessels that impede the healing process).  It’s worth a try.

Current evidence supports the use of extracorporeal shockwave (ESWT) therapy (a machine that works like a mini jack hammer!) and eccentric exercise.  Although the link just posted shows the patient dropping from a normal step,  new research indicates there may be additional benefit from having a rolled towel placed underneath the toes to further increase the windlass effect of the foot.  There appears to be benefit in adding loading to the exercise, even if it induces some pain.

Dynamic calf stretching and foam rolling have also been shown to have some beneficial outcomes for some so they are worthwhile adding into  management program, but the mainstay of management still needs to be eccentric exercise.

Despite implementing these strategies some people may suffer from persistent or recalcitrant pain.  For these it may be worthwhile discussing with their doctor whether glycerin trinitrate (GTN) patches would be a worthwhile addition.  The jury is still out as to whether injections should play a role in management with a 2015 Cochrane Review reporting that there was little evidence to suggest injection therapy (including Cortisone and Plasma Rich Protein (PRP) injections) was worthwhile. It seems the key is

1. let it settle

2. address any biomechanical dysfunction

3. load it progressively over time.  But the most important thing?….

Be patient and be positive.

A final note from a Sports Physician John Orchard who has a special interest in tendons

The body – eventually – does a good job of curing the pain of Achilles tendinopathy itself in the vast majority of patients, probably with the help of the patient being advised or stumbling upon the formula of moderately loading the tendon just enough to strength it but not enough to overload it.

Recovering From Surgery

Be a Beacon!

Recovering from surgery can be quite a lonely time. People often have family and friends around them, but the pain, and loss of function is not easily visualised and sometimes men internalise their feelings and suffer in silence.

Once a ‘person’ becomes a ‘patient’ they loose a sense of being in control of their situation and their self-belief begins to suffer. They allow themselves to bob around in the rough waters of their ‘health’ with well meaning practitioners poking at them to get them to move through this rough patch and back towards smoother waters.

As clinicians we are good at analysing data and planning pathways. We are great at dishing out advice, but we often lack in one key area… Encouragement.

Encouragement can provide people with the strength to look ahead, move forward, and strive for the next goal. It’s like infusing them with courage or giving them a paddle so they feel like they can play a more active part in their recovery journey.

To be able to lift someone’s spirits so that they can see over the crest and regain a sight of their goals is a vital part of any rehabilitation process. It can be done in many ways, from a simple smile to loud applause but it is something that is often left out of treatment sessions.

Of course we need to instruct, educate and give feedback to improve performance…it goes without saying that errors need to be corrected. To infuse courage into your patients and to praise their progress will undoubtedly increase compliance and improve outcomes.

Encouragement shines light into patients’ lives. Be a beacon!

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Hip Pain – Labral Tear

The hip is a ball and socket joint.  A very big ball and quite a deep socket.anatomic-hip-620x380-zc-ns

But to help deepen the socket, and increase the joint stability,  there is a fibrocartilaginous ring around the outside of the socket. (coloured blue below)

images

If the ball is not centred in the socket optimally, abnormal wear patterns set up and, like any fibrocartilage in the body, degenerative wear patterns can appear.  These can progress into tears of the labral tissue which may cause significant catching type deep hip pain.

It was once thought that if a labrum is torn that surgical intervention (arthroscope and debridement (clear out) and/or repair) was the only solution.  However with rest and anti-inflammatory medication we can settle the acute inflammatory response and then try to evaluate whether there is a biomechanical causation.

Tight adductors (groin muscles), weak gluteals, overactive hip flexors can all have a significant effect in altering where the head of the femur (ball) sits in the acetabulum (socket).  Careful analysis of the deepest layer of muscles (the deep hip stabilisers – kind of like the rotator cuff of the hip!) using real time ultrasound may reveal timing deficits or poor control which can also have an effect on increasing labral stress.

Once the specific causation is worked out a plan of rehabilitation can be started and surgery may be able to be averted.   However if the labrum is being pinched by bony outgrowths (a condition called FemeroAcetabular Impingement – FAI – see image below)- it can be much harder to completely alter the biomechanical components.

FAI

One thing is for certain…a deep pinching pain in your hip or groin region needs investigating…so don’t put it off…get it checked out.

Erectile Dysfunction

In order for men to have good penile health, for the tissue to stay healthy, men need to get erections.

There can be many reasons for men to develop erectile dysfunction but they can be largely broken down into 3 main categories.

Psychological erectile dysfunction.  Depression, anxiety and stress all have adverse effects on erectile function.  The solution?  clinical psychologists, sex therapists, even simple strategies like meditation and relaxation time.

Medical erectile dysfunction. Vascular issues, neurological issues (such as occurs following prostate surgery), hormonal issues…all of these complex factors have to be assessed and evaluated by an experienced GP or sexual health doctor.  Treatments of these issues can range from surgery and medications to counselling that patience and time should improve matters.

Physical dysfunction.  Erections occur when blood moves into the penis and is held there.  Pelvic floor muscles can act as both a pump to move blood in, and as a tourniquet to keep it in there.  Pelvic floor muscles can become weak as we age, which is one reason that erectile dysfunction becomes more prevalent as we get older.  But like all muscles that we have voluntary control over, we have the ability to target them specifically and then expose them to progressive training.  Thats where we mens health physios come into play.

RTUS led training of pelvic floor muscles has started to become the gold standard to show men how to isolate their muscles more effectively, and once you know where they are there are now gadgets like the private gym, a US based product (that has now got early scientific evidence behind it) to help men with pelvic floor muscle training.pg-complete-product-main  Lifting weights has never been so much fun!!!

Real Time Ultra Sound (RTUS)

When learning a task the most useful thing is to have a great teacher….why??  To watch what you are doing and give you the best feedback on your performance.

In physiotherapy we often have to teach exercises for muscles located deep within our bodies (our core muscles – abdominals, pelvic floor, diaphragm).  These muscles have stabilising role within our bodies and as such have a principal function of damping down unwanted movements.  This in turn means they are hard to observe working in real time.

Ultrasound scanning is not a new phenomenon, we have been looking at babies in the womb and checking their health and development since the 1950’s.  It is only in the last 10 years that physiotherapists have started to utilise it in their clinical care.

Real time ultrasound is a tool that therapists use to give the best feedback as to whether patients are turning on the right muscles deep inside themselves.  It’s an important part of learning a new skill and enables the therapist to teach exercises more efficiently and accurately.  It does not replace hard work on the part of the patient to perform the exercises but it can accelerate the outcome by ensuring that the skill acquisition phase occurs optimally.

More recently still, therapists are starting to learn how to perform musculoskeletal scans, to be able to observe tendinopathies, muscle tears, swelling within joints…and this is further helping them optimise the therapy intervention and refer on for more thorough investigations as needed.

All in all RTUS is a very valuable tool and in the hands of skilled and thoughtful therapists can be a tool that can assist in yielding optimal patient outcomes.

RTUS

Real Time Ultrasound

Incontinence

Incontinence is the involuntary release of urine.

It’s common in men following prostate surgery as their urinary sphincter has been surgically traumatised and may be weakened.  So when they cough, sneeze or move suddenly the internal pressure within the bladder can exceed the closure pressure of the sphincter and urine exits the body.  This is called stress urinary incontinence and can be treated effectively with pelvic floor exercises to develop sphincter strength over time.

For some however the picture of incontinence is different;  they may have never had a prostate issue.  Instead they develop an overwhelming urge to urinate.  When this occurs regularly they start to develop a behavioural pattern of urinating all the time (frequency).  This can result in the bladder never being stretched and like any muscle it gets less compliant and less able to store large volumes.  A vicious cycle then develops where the bladder volume gets smaller (less able to store for as long)…the sphincter working overtime to try to stem the urge can become tight and weakened…and the sufferer tends to wee ‘just in case’ to prevent incontinence episodes…The cycle can peak with the sphincter unable to cope as the bladder starts to pre contract and the urge itself causes leaking (usually on the way to the toilet).incontinence

The solution for urgency and frequency issues is a little more complex than just pelvic floor muscle strengthening.  It may involve relaxed breathing exercises, fluid balance changes, utilising deferral strategies and even neural stimulation techniques, so its important to be well assessed prior to commencing rehabilitation.  For some people with frequency issues pelvic floor muscle strength training makes things worse.

Whichever way you look at things, incontinence is a major issue that needs urgent and specific attention.  So don’t put off getting assessed, man up and get it checked.

 

 

Arthritis in my knee – should I run, will I wear out my knee joints?

We live in a world with gravity.  This means as we move, our load bearing joints are compressed and frictional forces applied to the joint surface, and just like a car’s brake discs when we continue to use them in this fashion they will eventually undergo erosion. (a.k.a. arthritis)

Unlike brake discs though articular cartilage is a live tissue, requiring food and nutrients to stay optimally healthy.  As the blood supply within cartilage is not great, joint surface nutrition occurs by gentle compression and release of the cartilage layer (movement).

And that is the dichotomy….we need movement to create an optimally healthy environment for the cartilage….too much though and we risk erosion.  So how are we supposed to know what to do? Run? not run?

patella-femoral-syndrome

In my opinion the best option is to look at things from a number of avenues…Firstly make sure you are a healthy weight.  Knee joint loading is exactly proportional to how heavy you are…if you stay in control of your body weight and strive to keep a healthy BMI you will minimise the excessive force through the knee.  Eating well also maintains optimal internal health to help recover from the microtrauma stress and strain of running.

Secondly… learn your craft.  Running is not a simple activity, it requires a great deal of muscular coordination and effort.  Poor technique will increase the loading at the knee and can accelerate degeneration.  Get your running assessed and perform corrective exercise to get the most out of your body.

and lastly…be sensible…thrashing yourself doesn’t allow time for tissue recovery.  If you are looking at increasing your fitness…do this in a number of ways rather than just relying on one discipline.  If you are training for a specific event ramp up slowly and listen to your body.  Look at your family tree…if arthritis has been an issue in the family be cautious about embarking on an intensive running program.

We need to move to maintain joint health, run smart and enjoy longevity…be a candle not a firework!