To some, winter means cold mornings and nights, shorter days and rugging up inside with a hot chocolate and some Netflix.
But to others on the Northern Beaches, it means Ski and Snowboarding season has begun. Whether you’re off to Thredbo, Perisher, Charlotte Pass, or somewhere else; it’s important to ease into it.
Statistically, sports injuries peak in the months of May, June and July. This is not surprising because cold muscles, tendons and ligaments increase the risk of sustaining injury and team sports are in full swing.
Snowboarding and skiing might seem like a couple of fun activities to just ‘do’ on vacation, but they are also intense whole-body activities. This means they can be pretty hardcore to go gung ho straight into after a year of sitting at an office desk or working from home.
Don’t overexert yourself
One of the most common causes of injury during winter sports is overexertion.
While you’re out having a blast and full of endorphins, it can be hard to recognise how tired you are and miss the fact that your knees are burning or that your arm fell off on the last run.
Take regular breaks, drink lots of water, eat a good healthy lunch and keep an eye on your energy levels, if you start to feel fatigued – call it a day.
What are some common winter sports injuries to look out for?
The knee is the most commonly injured joint by skiers due to the increased twisting and turning demands. In particular, ACL, MCL, PCL and LCL injuries can occur due to a sudden twisting movement at the knee with your foot planted, along with a lovely popping sound which may or may not be followed by extreme pain and instability in the knee.
Head, neck, shoulder and wrist injuries also commonly occur as a result of falls, which tend to be more common among snowboarders. In particular, wrist sprains, clavicle fractures, shoulder dislocations, whiplash, and concussions are common.
If you have had winter sports injuries in the past, or have some current niggles then it would be a good idea to consult your physiotherapist before you go and hit the slopes.
A musculoskeletal physio will be able to give you the right piece of advice to avoid recurring injuries in the future and tips on how to properly warm up and warm down.
If you’re concerned about injury during the winter sports season and would like to find out more about injury prevention Call Fixio today on 8964 4086 or Email info@ﬁxio.com.au to organise an appointment with one of our Physios.
One of the best things about living at Dee Why is being spoilt for choice when it comes to which Northern Beaches paradise to enjoy on a beautiful summer’s day. Whether you’re catching waves at Curl Curl or hitting the Manly Lagoon Reserve outdoor gym, the Northern Beaches offers up plenty of outdoor activities that also have great physiotherapy benefits.
One of my favourite activities is feeling the soft sand between my toes during a steady jog. Don’t get me wrong, I hit the pavements regularly on my morning jogs, but a soft surface like sand can be a great way to add diversity to your regular training routine.
Running exclusively on hard surfaces, especially without proper technique and supportive shoes can increase your risk of impact-associated injuries like stress fractures.
Is running on the beach good for joints?
Studies have shown that mixing up your running routine and adding in some sand runs can help to put less stress on weight-bearing joints such as your hips, knees, and ankles. A 2017 study in the European Journal of Sport Science compared women who ran on soft sand and those who ran on grass and found that the sand runners experienced less muscle damage and inflammation than those who ran on grass.
Running on the beach isn’t easy
The softer sand also causes many of your ankle, hip and knee stabilisers to work harder than they would on a surface like concrete or bitumen. The Journal of Experimental Biology found that running in sand actually causes 1.6 times the energy expenditure of running on firmer surfaces.
This can make beach runs the perfect antidote for when you need a lower-impact session on the body but still want to have a workout that’s going to make you sweat.
However, because different muscles are working harder in the sand, beach running can potentially increase overuse injuries of the of the foot, knee and ankle if you do too much too soon, don’t have the correct foot support or have inefficiencies in your running technique.
Should I see a physio about my running technique?
In-depth biomechanical assessments and running technique analysis aren’t just for the professionals.
Research indicates that biomechanical running assessments can not only help runners improve their times and run more efficiently but it can also help prevent common running injuries such as:
- Runners knee
- Iliotibial band friction syndrome
- Plantar fasciitis
- Patellofemoral pain syndromes
- Shin pain
- Low back pain
If you have had a previous injury such as plantar fasciitis, Achilles tendinopathy, ankle sprains, or recent calf strains, these injuries may flare up if you start training on a beach surface. Lower back niggles might also flare up if you may have an underlying back complaint combined with weak core muscles
Beach and sand running also puts varying levels of stress on different parts of the body and can exacerbate other existing conditions or lead to overuse injuries if your biomechanics are sub-optimal.
At Fixio, our musculoskeletal physiotherapists are experts in working with novice and experienced runners who want to improve their technique, biomechanics, performance, efficiency and ultimately prevent running injuries before they occur.
If you need help with a running injury, or would like some more information on biomechanical assessments we’d love to help you. Call us on 8964 4086 or email to info@ﬁxio.com.au.
 Brown, H., Dawson, B., Binnie, M. J., Pinnington, H., Sim, M., Clemons, T. D., & Peeling, P. (2017). Sand training: Exercise-induced muscle damage and inflammatory responses to matched-intensity exercise. European Journal of Sport Science, 17(6), 741-747. https://doi.org/10.1080/17461391.2017.1304998
 Mechanics and energetics of human locomotion on sand. T M Lejeune, P A Willems, N C Heglund Journal of Experimental Biology 1998 201: 2071-2080;
 Chan, Zoe & Zhang, Janet & Au, Ivan & An, Winko & Shum, Gary & Ng, Gabriel & Cheung, Roy. (2017). Gait Retraining for the Reduction of Injury Occurrence in Novice Distance Runners: 1-Year Follow-up of a Randomized Controlled Trial. The American Journal of Sports Medicine. 46. 036354651773627. 10.1177/0363546517736277.
It’s been estimated that up to half of the Australian workforce is now working from home due to the effects of COVID19. That means that unless you’re fortunate enough to have a home office setup with a full-size desk, desktop computer and comfortable chair, you’ve probably built a makeshift workstation out of the closest materials.
If that’s you, you could be at risk of developing aches and pains or worse.
Your neck might not notice responding to emails at the kitchen table or browsing Instagram on the couch every now and then, but full work days of hunching and slouching are going to catch up to the musculoskeletal system after a while.
How can I make my home office a safe and healthy place to work?
If you’re new to working from home due to COVID19, the good news is that you don’t need to go out and buy thousands of dollars of ergonomically designed knick knacks to save your body from developing chronic pain.
You can set up your workspace to be safe and comfortable with a few simple tips.
You don’t need to go out and buy an expensive office chair
Yes, some office chairs look really cool and will feel super comfortable, but you also need to think about how your feet sit on the floor, whether your wrists are bent when you type or use the mouse, and other factors. Most of these adjustments can be made using items from around the house or with inexpensive purchases from Amazon or Ebay.
Be conscious of your head and neck angle while working
Keeping your neck, shoulders, and back free from injury relies heavily on putting the least amount of strain on them. This means keeping your head directly vertical and neutral to your neck.
Impossible with that laptop sitting on the kitchen table or holding your Iphone low in front of you I’m afraid. To keep neck pain and upper back pain at bay, try mounting your laptop on something that props it up and consider using an external keyboard and mouse. If you have a PC, use some books if you have to raise it to a comfortable height at eye level, keeping your head and neck in that neutral position.
It’s a myth that you should be sitting at a 90 degree angle
Most musculoskeletal and sports physios have spent years trying to tell people that’s not how you should be sitting. Find a comfortable posture where you can see the screen while sitting back in a way that provides lower back support. You might find feels like sitting in the driver’s seat of a car, slightly leaning back.
If you don’t have a fancy pants office chair that reclines back, try placing a pillow, travel cushion or towel behind your lower back for lumbar and neck support.
Take frequent but short breaks
It takes time to get used to working from home and one of the biggest adjustments can be the work schedule. At home, it can be easier to get sucked into sitting in an uncomfortable position for hours on end only to wake up the next morning with a kinked neck.
We all need to take breaks and ensuring you get up and walk around and have a stretch every 30 minutes is a great way to keep your energy and productivity levels up while also looking after your body.
Building your ergonomic office can feel like putting together the pieces of a puzzle and plenty of people opt for buying expensive easy products over making a few small adjustments.
If you are unsure whether your workspace is right for you, contact a Fixio physio on (02) 8964 4086 or book an appointment online.
Hamstring strains (a.k.a. “doing a hammy!”) are one of the most common injuries seen by Northern Beaches physiotherapists. Hammy strains are most prevalent in sports that use a combination of dynamic movements like sprinting, Australian Rules football (AFL), soccer, dancing, surfing, rugby league and other activities where quick eccentric contractions, when the leg is being straightened and the hamstring is working hard, occur frequently such as slowing the leg down after kicking a ball. In AFL hamstring strains are the most common injury with a rate of 6 injuries per club per season combined with the highest rate of re-injury at over 30%. Musculoskeletal physiotherapists know that it is perfectly normal for two people to tear exactly the same muscle but recover at different speeds. Recovery time is dependent on the grade of the injury with a grade 1 injury possibly healing in only a few days, while a grade 3 injury could take months and, in extreme cases, even require surgery.
“My hamstring is ok but derogatory and sexist comments aren’t”
Most hamstrings will have torn well before this point so all can admire the incredible strength and flexibility of Tayla Harris during the AFLW 2019 season.
What are the hamstrings and what do they do?
The hamstrings are a group of muscles and their tendons at the back of your upper leg. They are made up of three different muscles: the biceps femoris, the semitendinosus and the semimembranosus. You use your hamstrings for all kinds of things: walking, running, dancing and jumping. They enable you to flex your knee and extend the hip at the beginning of each step you take. Your hamstrings play a large role in many movements of the legs and hips which is why physiotherapists have spent so long studying them and how to reduce the occurrence and length of injuries.
How do hamstring injuries occur?
Like most injuries, hamstring strains or injuries can be classified as being caused by either primary or secondary factors.
- Primary factors include:
- Poor timing coordination in the hamstring (the swing phase of the leg in sprinting)
- Lack of strength and stiffness in the hamstring
- Muscle imbalances
- Increased neural tension through the sciatic nerve
- Common secondary factors include:
- Overstriding or poor pelvic control when running
- Improper warm-up to prepare hamstring muscles
- Lower back problems
- Prior hamstring injuries
What are the symptoms of a hamstring strain?
The nature of hamstring strains means that symptoms can vary greatly between injuries. Mild hamstring strains could present as tightness or a mild ache in your hamstring. While a severe strain can be extremely painful, with some people describing it like being shot in the back of the leg even making it impossible to walk or even stand. If you have any of the following symptoms get in to see your Dee Why physio ASAP:
- Hamstring tenderness
- Pain or difficulty running, walking or standing
- Pain in the back of the thigh or lower buttock
- Bruising or swelling
- Sudden severe pain while exercising, with a popping sound or snapping feeling
How physiotherapy helps treat hamstring strains
If you have had a hamstring injury your best course of action is to consult with a physiotherapist that has an expert knowledge of sporting and musculoskeletal injuries. Due to the high rate of reinjuring your hamstring, there is no substitute for high quality initial care and rehabilitation. Physiotherapy helps patients with a hamstring injury to speed up the healing process and ensure the best outcome. They will be able to assess and treat your strain and help you to minimise their recurrence in the future.
- Acute or initial phase of a hamstring injury
Your physio will likely recommend the trusty RICE (Rest, Ice, Compression, Elevation) method for the first few days. This will help to reduce swelling and minimise pain. I like the saying ‘the early bird gets the worm’ and when it comes to intervention for hamstring injuries the early bird getting treatment always recovers quicker and more effectively. An expert sports physio will also get you loading your hamstrings in a variety of different ways, even in the early stages!
- Your physio will then comprehensively assess:
- Your range of motion
- The strength and mobility of your lower back
- Your gait
- Your flexibility
- If possible, your running, jumping and sporting techniques
How to prevent another Hamstring Strain
If you’ve ever had a hamstring strain I can pretty much guarantee you won’t want another one, they certainly don’t tickle. Dealing with a hamstring injury once it’s already happened is much harder than preventing it. Here are some tips:
- Stretch before and after physical activity
- Increase the intensity of your physical activity gradually
- If you feel pain, stop exercising (it’s not all ‘no pain, no gain’)
- Stretch and strengthen hamstrings as a preventative measure
Whether you have recently suffered a hamstring injury and are in need of immediate physical therapy or you have suffered a hamstring injury in the past, a physiotherapist is able to assess and recommend the best activities and stretches to help speed along your recovery and reduce the likelihood of experiencing further strains.
 Sutton G. Hamstrung by hamstring strains: a review of the literature*.J Orthop Sports Phys Ther. 1984; 5(4):184-95.
 Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, season 1997–2000. Br J Sports Med2002;36:39–44.
 Schunke M., Schulte E., Schumacher. Anatomische atlas Prometheus: Algemene anatomie en bewegingsapparaat. Nederland: Bohn Stafleu Van Loghum, 2005.
We’re an active bunch on the Northern Beaches and you’ll find that injury prevention and recovery are 2 major aspects of sports physio clinics in Dee Why. Chances are at some point you’ve experienced an injury, whether you tore an ACL, strained a hammy or twinged your neck and if you’re one of the unfortunate many you’ve probably reinjured it at least a couple of times. Recurrent injuries aren’t confined to AFL players and other professional athletes. Computer programmers are more susceptible to a recurrence of tennis elbow than tennis players, remember? Unfortunately prevention can’t always prevent a hammy strain, but once an injury has occurred you have the power to start the prevention cycle all over again.
There are a number of factors that influence the statistical probability of suffering an injury recurrence; if you watch a sport regularly you can probably name 1 or 2 athletes that seem to suffer the same injury over and over again. NRL player Tautau Moga for instance is only 25 years old and has torn his left ACL 4 times, having a full reconstruction and rehabilitation after each occasion. Researchers are getting better at injury prevention and management every day and sports and musculoskeletal physiotherapists are experts in getting to the things that increase injury recurrence:
Insufficient rehabilitation from previous injury
Call it youthful exuberance in wanting to get back into it too quickly, call it being lazy and not completing your full rehabilitation but one of the most common reasons for suffering a recurrence of an injury is failing to rehab properly. Overloading is a great short term principle and is part of effective programming to allow for super-compensation and increase fitness and strength, but IT DOES NOT APPLY DURING INJURY RECOVERY. Any professional level athlete in any sport will tell you their recovery is just as important as their training when it comes to performance. Failing to follow your physiotherapist’s full rehabilitation program for your sore hammy is only going to end one way. Your guessed it – a pain in the butt!
Neglecting symptoms of pain
Speaking of pain, one of the next most popular reasons people reinjure themselves is failing to heed your body’s best warning signal; pain. “I’ll just run it off” doesn’t cut it as an effective treatment strategy for managing most musculoskeletal injuries but it’s still one of the most common things that people like to do for some reason. Most chronic back, neck, knee, hip, groin, ankle and hamstring injuries will usually give you some warning sign before they completely give up. Don’t treat that shooting pain in your leg like the check engine light in an old car and just put some tape on it either. Strapping and taping is good in some instances, but it can’t keep a hamstring in place for long.
Poor conditioning or fitness
Coming back from long term injury can be tough and it’s common to let fitness levels slip while injured which can often lead to poor performance or additional musculoskeletal injury upon returning to physical activity. Every bit of physical activity outside of your physically repetitive job is going to lower your chances of suffering a repetitive strain injury as well. While you are recovering from an injury, try and do all you can to keep moderately active, whether it be short walks, dumbbell curls or simple sit-ups.
Poor technique and movement control
Poor technique and movement control are probably the 2 most important factors that cause injuries in the first place and they continue to play a part in injury recurrences. I don’t know how many times I’ve seen someone load up weights to the max at the gym, lifting far too much and trading technique for weight. This principle can be applied to most physical activities. Most injuries occur when you go too hard, are fatigued and are using movements that you are not at the unconscious competence stage of performing yet.
Poor or no warm-up/warm-down
Be honest, do you spend 10 minutes warming up and down every time before and after sport and physical activity? A well performed warm-up before a workout is going to dilate your blood vessels, ensuring your muscles are supplied with enough oxygen while also raising your muscles’ temperature aiding in achieving optimal flexibility and efficiency. Cooling down after physical activity is every bit as important as warming up. Stretching while you’re cooling down is the way to go because your muscles, limbs and joints are still warm. Stretching is going to reduce the build-up of lactic acid, which is the leading cause of muscle cramp and stiffness.
If you have suffered an injury, don’t shirk your recovery. Speaking with an expert in sports and musculoskeletal physiotherapy and undertaking a custom made rehabilitation program is going to shorten the length of your recovery, minimise your risk of a recurrence of your injury and also help provide you with the knowledge you need to continue to prevent injury independently.
Going for my early bird swim at Dee Why pool this weekend it took a few minutes longer than usual for my muscles and joints to really get going. I couldn’t quite put my finger on it until I got out of the pool and a fresh gust of wind reminded me… Winter Is Coming. Checking the weather and in 2 days the minimum temperature has dropped 7 degrees. Did you know that May, June and July are the busiest months for sport and exercise related injuries in Australia? While you can attribute some of that rise to the winter contact ball sports, a contributor to the rise in muscle and tendon related injuries is the drop in temperature. The muscles and ligaments of the body function and perform better when they are warmer. It’s also easier to get out of bed and actually go on that early morning run too when it’s not 5 degrees. Let’s look at how the cold affects the performance and injury rate of the muscles and tendons and how you can lower your chances of a cold related injury.
Can cold weather make joints and muscles hurt more?
My Dad is one of those people who say that his joints can predict the weather, “a cold front is coming through” he’d say on a 30 degree day and it did seem like he picked it once or twice (little did I know at the time that he constantly consulted the Bureau of Meteorology as much as Gen-Y checks Facebook). But let’s just say science is far less convinced than he and a few other patients of mine who are convinced that their arthritic conditions can predict the weather. Over the years a number of studies have looked at the correlation between temperature, weather and barometric pressure with none being totally conclusive. That being said, some studies have shown a plausible link between barometric pressure and cold weather on some specific arthritic conditions or under less strict conditions. If you believe your joints hurt more in the cold, I’m not going to not believe you.
Increase your warm-up time and quality
This is probably the single most important piece of advice if you are undertaking any physical activity during the winter months. Cold muscles and ligaments mixed with physical activity are going to equal a lot of pain. Cold muscles, tendons and ligaments are more likely to lead to muscle sprains and joint strains due to decreased flexibility and elasticity. If you normally warm up for 5 minutes, extend it to 10 as it gets colder, if you normally don’t warm up, extending that to 10 minutes is fine too. A good warm-up:
- Prepares the body and mind for the activity
- Increases the body’s core temperature
- Increases the heart rate
- Increases breathing rate
- Stimulates flexibility and power
Don’t skimp on the cool-down either!
Many musculoskeletal physiotherapists will agree that failing to cool down adequately is a major contributor to muscular and tendon injuries. I don’t know why but it doesn’t seem like it’s cool to cool down. After physical exercise the body needs time to slow down and recover, so cool down immediately after your activity for at least 5 to10 minutes. Sports and exercise physiotherapists recommend your cool-down can be the same sort of exercise as the warm-up with low intensity body movement such as jogging or walking substituted for running.
Can stretching help to reduce injuries?
Stretching before and after physical activity helps to promote maximum flexibility, relax the muscles, return them to their resting length and promotes recovery by assisting in the body’s natural repair process. When stretching it is important to:
- Stretch all muscle groups that will be or were involved in the activity
- Stretch gently and slowly
- Don’t bounce or try and stretch too quickly
- Only ever stretch to the point of mild discomfort – PAIN DOES NOT EQUAL GAIN
- Don’t hold your breath – breathe slow and easy
Don’t forget to stay hydrated
While it may not be scorching hot outside your body is still going to need a healthy dose of water daily. Dehydration is one of the major causes of muscle cramps and the winter months are an easy time to lost sight of drinking a couple of litres of the good stuff every day. Please don’t think a couple of shots of something harder will warm you up either, alcohol will only impair your coordination and your body’s ability to regulate your temperature which could lead to an injury. Caffeine drinks also cause dehydration, so steer clear of excessive coffee and energy drinks too if you can.
 The influence of weather on the risk of pain exacerbation in patients with knee osteoarthritis – a case-crossover study. Ferreira, M.L. et al. Osteoarthritis and Cartilage , Volume 24 , Issue 12 , 2042 – 2047
 Deall C, Majeed H (2016) Effect of Cold Weather on the Symptoms of Arthritic Disease: A Review of the Literature. J Gen Pract (Los Angel) 4:275. doi: 10.4172/2329-9126.1000275
 Woods K, Bishop P, Jones E. Warm-up and stretching in the prevention of muscular injury. Sports Med 2007;37:1089-1099.
 Scott, E E F et al. “Increased risk of muscle tears below physiological temperature ranges.” Bone & joint research vol. 5,2 (2016): 61-5. doi:10.1302/2046-3758.52.2000484
Sever’s disease, aka calcaneal apophysitis to musculoskeletal physiotherapists is the most common cause of heel pain in growing athletes. Sever’s Disease isn’t really a true disease per se and was actually first identified by Patrick Haglund in 1907, but it was James Sever’s characterisation of the disease in 1912 that led to it being named after him. Maybe it just had more dramatic ring to it? Sever’s disease is the inflammation of the calcaneal apophysisa, located on the heel close to where it connects into the Achilles tendon. Sever’s Disease most commonly occurs before or during a child’s peak growth spurt and is often seen when they begin a new sport or footy season. It is most common in boys between the ages of 8 and 12 and quite frequently in girls between the ages of 8 and 10 years old who are also active in sports.
How is Sever’s Disease diagnosed?
For your physio to find the cause of your child’s heel pain and rule out more serious conditions, they will ask some thorough questions about their medical history and ask questions about recent activities or injuries. There is rarely the need for any blood tests or x-rays, your physiotherapist will perform what’s called a squeeze test and some other tests to confirm the diagnosis of Sever’s Disease. During the squeeze test (which is exactly what it sounds like) if the child’s medial and lateral sections of the heel are tender and there are no symptoms such as red skin or swelling, almost always indicates a diagnosis of Sever’s disease.
- Pain in the back or bottom of the heel
- Walking on toes
- Difficulty running, jumping or participating in usual activities or sports
- Pain when the sides of the heel are squeezed
What causes Sever’s Disease?
When children (especially boys) are going through a growth spurt, the bones will grow first and the muscles and tendons can take a while to catch up. In Sever’s disease, the area around the heel bone can become quite sore and swollen where the Achilles tendon attaches to it. Children who participate in running and jumping sports such as AFL, soccer, Basketball and athletics are more likely to end up with Sever’s disease. Research has also shown that wearing boots with studs or spikes increases the risk of developing Sever’s disease.
Factors contributing to Sever’s Disease in children include changes to:
- Height and weight – high BMI children have higher rates of the disease
- The frequency of physical activity – AFL carnivals over a few consecutive days
- The type of physical activity – Changing sports or starting new ones eg. Netball, gymnastics
- Shoes and equipment – Many football boots have a lower heel that can add pressure to the apophysis by stretching the Achilles tendon slightly. Lots of barefoot running and even walking in thongs on the soft sand at Dee Why can cause the same increased load.
How is Sever’s Disease treated?
As with most soft tissue injuries, in the first stages of recovery your physio will recommend the R.I.C.E method – Rest, Ice, Compression, and Elevation. Unfortunately, no one treatment method has been definitively proven to be better than others in the long-term management of Sever’s disease. During the early phase your child will probably be unable to walk pain-free, so the first aim is to prescribe your child with some active rest activities and keep away from pain-provoking activities for the time being. Your physio will use and teach your child a range of pain relieving techniques including joint mobilisations for stiff ankles and give the area a good massage in order to restore full Range of Motion, reduce pain and regain full foot biomechanics. A good musculoskeletal physiotherapist will also want to see your child’s biomechanics and technique in action and if they have injured themselves playing AFL or another sport, getting your physio to check it out will help reduce flare ups in the future.
How does Sever’s Disease affect my child’s sport?
Sever’s disease is a self-limiting condition and will fully heal with the right treatment. The first important step is to seek treatment when early signs of Sever’s become apparent. Sub-optimally treated Sever’s disease can cause a permanent bone deformity at the rear of the heel bone which can be painful and annoying. For the time being, seeing a physio will be be helpful to learn ways to stretch the Achilles tendon and keep pain under control. Limit your child’s sport load during the initial period and monitor their return to sport closely afterwards.
If your child is between the ages of 8 to 12 and is complaining of heel pain with no exterior causes, you should suspect Sever’s disease until proven otherwise. Sever’s Disease is a common issue seen by your local Dee Why physio due to the high number of active kids on the Northern Beaches (a positive and a negative there) and they are the best people to speak to if your child is complaining of a sore ankle.
 HAGLUND P: Ueber fractur des epiphysenkerns des calcaneus, nebst allgemeinen bemerkungen ueber einige
aehnliche juvenile knochenkernverletzungen. Archiv fur
klinische Chirurgie 82: 922, 1907
 SEVER JW: Apophysitis of the os calcis. N Y Med J 95:1025, 1912
 Sever’s Disease: What Does the Literature Really Tell Us? Rolf W. Scharfbillig, PhD* Sara Jones, PhD† Sheila D. Scutter, PhD May/June 2008 • Vol 98 • No 3 • Journal of the American Podiatric Medical Association
All physiotherapists want the best for their patients and we aim to provide the most effective treatment for each and every person on the Northern Beaches that walks through our doors. But how do we know that our physiotherapy is making a difference and that it is the best care for every individual’s circumstances?
Everybody and every body is different, which means there are going to be nearly an infinite number of ways to treat individuals suffering from chronic pain, musculoskeletal disorders and muscular or ligament injuries. It is up to physiotherapists to identify the best methods for each individual client and implement them in a broader strategy to meet their goals. This is where utilising evidence based practice techniques and taking a results based approach to treatment and injury management can shave weeks from your recovery period and result in less pain and a decreased risk of suffering a re-injury.
What is evidence based practice?
Evidence based practice (EBP for short) isn’t a new concept, it has been utilised in the medical world for a number of years now and has become a popular method of treatment for physiotherapists around the world over the last decade.
EBP utilises ‘the integration of best research evidence with clinical expertise and patient values’ in order to shape the treatment of patients and include them in the processes of treatment in order to prevent pain and injury in the future.
The goals of evidence based practice are:
- To improve the care for clients, resulting in more effective treatment and injury recurrence
- To use evidence from high quality sources to help shape physiotherapy practice
- To challenge treatment views based on anecdotal evidence
- To integrate patient preferences into the treatment and decision making processes
- To take the guess work out of treatments, using education to shape future activities
What are the 5 steps of evidence based practice?
Because evidence based practice relies on consistency and clinical fact in order to make diagnoses and frame the best treatment, a framework of steps has been outlined in order to help physiotherapists design and implement and evidence based approach to treating musculoskeletal conditions.
Step 1 – Ask an answerable and measurable question
One of the fundamental skills needed by musculoskeletal physiotherapists in designing an evidence based program is the asking of to the point clinical questions. By asking the right questions you can focus your efforts specifically on the areas needed, instead of non-important matters.
Step 2 – Acquire relevant research evidence
With the easy part out of the way, your physiotherapist will move onto extrapolating the answers to their questions in order to find relevant, recent and scientifically proven methods for treating your specific condition. Physiotherapists will use a combination of their own data collected over years of practicing in the field and scientific studies located in databases specifically designed to provide a workflow in order to come to the right conclusions.
Step 3 – Analyse the evidence
This is where the expertise and experience of your physiotherapist is really going to come in handy. For example, a Titled Musculoskeletal Physiotherapist has likely spent over a decade studying and practicing in the field and has gained an advanced insight into what evidence is important and what evidence may not be supported by clinical practice and other data. By critically analysing the scientific data your physio is already piecing together your treatment plan in their head and focusing on your goals in relation to the evidence for treatment techniques.
Step 4 – Implementation of the evidence
Now that your physio has conducted their full body assessment, questionnaire and compared data with high quality evidentiary sources, the real fun is ready to begin. Physiotherapists will implement their treatment plans usually by combining the best available evidence with their clinical expertise and their patient’s values and goals. During the implementation phase, your physio will be documenting and assessing your treatment and recovery in order to make any adjustments to your program and to ensure your recovery is progressing. Implementation isn’t a single process; it is the sum of all their experience and knowledge that can be altered and updated to suit your progress.
Step 5 – Evaluate the outcome
If your original treatment plan isn’t getting results, this is where your physio has the knowledge and flexibility to alter what’s required to get you back to 100% health. By documenting your progress and implementing evidence based methods, your physio is able to alter your treatment based on results and at the end of the day, that’s exactly why you see a physio in the first place. To get results. If it’s not working, fix it.
Evidence based practice in physiotherapy is a constantly evolving concept and allows for a flexible and science based approach to combating common musculoskeletal problems. Find yourself a Northern Beaches physio with the expertise and experience to create and implement an evidence based, patient-centred and results focussed program and you’ll be on the right track to a pain free future.
 Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
Australians in general and those of us on Northern Beaches especially are an active bunch. Unfortunately, activities that are great for the waistline can spell trouble for the musculoskeletal system when injuries occur. More people are playing sports, running or participating in some kind of physical activity than ever and that means more injuries. Aussies are world leaders in most sports and unfortunately we’re also world leaders in ACL injuries and that rate has been climbing consistently.
Between 2000 and 2015 nearly 200,000 ACL reconstructions were performed in Australia with men aged 20 to 24 years and women aged 15 to 19 years the most common patients, but the fastest growing demographic was 5–14-year-old children. Apart from being painful and ongoing, ACL repair can also be painful to the back pocket, costing on average over $8000 including hospital fees.
What, if anything can physiotherapists do to help prevent ACL injuries, and how do we make sure that a full recovery after ACL surgery occurs?
What is an ACL, what does it do and how are they injured?
Ligaments are strong bands of tissue connecting bone to bone and are among the most commonly injured part of the musculoskeletal system. Your anterior cruciate ligament or ACL for short is one of the four ligaments in your knee that keep your knee joint stable. Your medial and lateral collateral ligaments stop your knee from moving side to side, while your anterior and posterior cruciate ligaments keep the knee from sliding front to back.
ACL injuries can occur at some pretty random and innocuous times but usually are a result of rapid changes in direction at speed, typically in non-contact sports or events. ACL tears also commonly occur during sports that involve sudden stops, jumping and landing such as soccer, AFL, basketball and netball.
It’s common to hear a “pop” in the knee when an ACL injury occurs accompanied by some pretty rapid swelling, instability and an unbearable pain that won’t let you put weight on it. Depending on the severity of your ACL injury, treatment is likely to include a good chunk of time on the sidelines and probably some surgery.
What does ACL surgery involve?
A surgeon chops out a piece of another tendon (usually the hamstring), removes your damaged ACL (because it can’t heal itself) and replaces it with the new tendon. Your new replacement tissue is called a graft which will be attached to your bones with screws (airport security just got more fun) or other fixation devices and serves as the point where new ligament tissue can grow. Fun fact, if the tissue is taken from you, it’s called an autograft but if it was donated by another person it is known as an allograft.
How long until I can play sport after ACL surgery?
The recovery period after ACL reconstruction surgery varies from one person to the next and there are many factors that determine how quickly and adequately you will recover and how low it will take until you can get back into the full swing of things.
One of the biggest factors influencing how long ACL surgery recovery takes is whether you have an orthopaedic pre-habilitation and rehabilitation plan and you stick to it. A well designed pre ACL surgery body strengthening regime can shave weeks and pain off your post-surgical recovery. The physical shape your affected area is in is one of the strongest predictors of the chances of a fully successful recovery. It is likely that you have pain and weakness operating in tandem leading up to surgery, but you’re going to need every ounce of strength you’ve got to recover fully. In prehab your local physio will help you build strength and stability where you need it most to ensure you get the most out of your rehabilitation.
Your surgeon and musculoskeletal physio will be able to advise you when you’re good to go for most activities, but this is usually only once you have adequate flexibility, strength and fitness.
Can physiotherapy prevent an ACL injury occurring?
Because ACL injuries have been becoming increasingly common, more time and research is being devoted to understanding the mechanisms behind ACL injuries and what steps can be taken to reduce the possibility of an ACL tear happening. Prevention is much better and less painful than a cure.
Over the last two decades multiple randomised controlled trials have shown that anywhere between 50–80% of ACL injuries can be prevented by regular neuromuscular agility training programmes. A number of these studies have shown that many ACL injuries are caused by faulty mechanics during dynamic movements performed under fatigue.
These prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training designed to teach the body to perform movements deliberately and with precision even under fatigue. A trained musculoskeletal physiotherapist will be able to observe your technique and address the faulty movement patterns in a personalised injury prevention program.
 Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495–501.
 Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015 David Zbrojkiewicz, Christopher Vertullo and Jane E Grayson Med J Aust 2018; 208 (8): 354-358. || doi: 10.5694/mja17.00974
 Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996
 Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003–10
Whether you’re a novice runner or a seasoned veteran, chances are you’re well acquainted with pain. Right from the get-go we’re taught to run through the pain to push through it to get to that next PB. When you’re new to running long distances it’s normal for your body to take some time to adjust and being a regular runner is all about dealing with those niggling aches and pains. My right knee certainly lets me know all about it for a few days if I run too many stairs between Manly and Dee Why.
But how much pain does it take to gain and when does pain point to an injury? While pain and injuries go hand in hand, pain doesn’t necessarily mean you’ve got an injury and there are plenty of injuries that sneak by without causing pain where you’d expect it. Minor running “injuries” can be treated with a bit of good old fashioned R’n’R but more chronic or serious injuries require the expert guidance of a musculoskeletal physiotherapist.
Assessing pain: am I sore, or am I injured?
Before you can get to the treatment stage for those aches and pains, we’ve got to work out what we’re dealing with. At an initial consultation with a physio they will usually ask you a number of questions regarding your pain/injury to get a better idea of its causes and how best to treat it.
- Did the pain start abruptly or come on over time?
It is normal for your body to feel sore after a big run or a workout; delayed muscles soreness (DOMS) is a common occurrence and normally improves after a few days, whereas an injury will likely cause you pain for weeks or more at a time. If you heard a pop or snap and felt a twinge or an abrupt sensation of pain during your run, chances are you have suffered an injury. Around 70% of all running injuries are caused due to overuse, but they often show themselves in a straw breaking the camel’s back fashion.
- Is the pain persistent or does it only come on during certain activities?
Unfortunately, what your pain is trying to tell you isn’t always clear cut and chronic or persistent pain is notoriously difficult to pinpoint and treat. That being said, when muscle or joint soreness hangs around for longer than a few days, is accompanied by sharp pains or aches and is persistent even when not engaging in a physical activity it’s likely you’ve done yourself an injury.
- Is the area swollen, sore to the touch or bruised?
When you tear a ligament or cause substantial soft tissue damage, the body usually (not always) reacts by causing some pretty obvious external symptoms. It may not happen immediately, but swelling and bruising commonly accompany major injuries and can be more easily diagnosed by comparing one side to the other and checking for differences.
- Is there a loss of function?
Loss of function tests are one of the most common methods musculoskeletal physiotherapists use to identify the nature of pain. One of the biggest indicators of an injury as opposed to regular pain is the presence of a loss of function independent of any sensation of pain or an inability to complete certain movements due to severe pain.
Preparation is the first step to avoiding a running injury
- See a physio to identify potential musculoskeletal and health problems that may contribute to injury
- Always warm up and cool down by jogging slowly
- Injured runners should consult a professional about how to prevent re-injuries
- Hydrate prior to running and consider taking water on longer runs
- Get a running assessment if niggles persist
Use the R.I.C.E method to treat running soreness
If you’re suffering from the DOMS or you’ve just pushed yourself a little hard and feeling it, you can’t go wrong erring on the side of caution and giving your body a bit of a recovery pamper session.
Rest properly and resist the temptation to down a number of celebratory alcoholic beverages. If you must go out, keep hydrating, don’t party too hard and let your body recover.
Ice – this will help constrict the blood flow to sore areas and help to reduce inflammation and soreness. If you feel up to it, you can always take your second ice bath as you likely already took your first one during the race.
Compression of the legs and arms will help flush out the lactic acid that has accumulated. Wearing compression gear will work great for this. Pairing compression and icing will ensure they work symbiotically and will shorten your recovery period.
Elevate your legs as you lie in bed thinking about how awesome and tough you looked covered in mud, running through electroshock stations, carrying logs and kicking butt.
If you have a persistent ache or pain whether it be the result of running or another physical activity, it needs to be identified and addressed. Nobody likes being injured, but allowing something as simple as shin splints to go untreated with continued overtraining, can cause tibial stress fractures, which will put you on your butt for at least 6 weeks. The moral of the story is from little things, big things grow; this includes injuries.
Visit a pain and injury clinic on the Northern Beaches for more information on identifying the difference between pain and injury and how to treat those niggling aches and pains before they progress to something more serious.