In focus

Fu’s theory of failed healing

admin April 17, 2014 home, In focus, Technique Geek, Technique Physiotherapy healing, injury, pain, physiotherapy, rehab, sports, sports injury, tendon, treatment

Fu’s theory of failed healing (that’s a mouthful!), stems from the belief that there is release of pro-inflammatory mediators causing relevant metallpotonise release and hence collagoynic injuries. A tendon that was previously damaged therefore may not have healed adequately prior to an external load being added/increased . At this point Fu believes mechanical weakness and pain are not significant and therefore the tendon still has the ability to heal spontaneously. This is different from the reactive stage described by Cook and Purdum, where the cells are activated but no damage is described.

The failed healing stage occurs when the cells are not able to repair the collageniylic injuries and the exact cause of this is unknown. It is widely appreciated that tendon healing requires many sequential process’s in order to repair damaged tissue.

These include:

Inflammation,
neovasulrisation,
neural ingrowth,
recruitment of healing cells,
proliferation and
aptosis.

Somewhere along this process disturbances occur. Either the tendon has not received significant rest in order for these processes to happen, or the initial inflammatory process is disturbed by the prescription of NSAIDS causing an increase in pro-inflammatory cytokaines and not the ordinary inflammatory infiltration into the damaged tissue. Fu also surmises that depending on the location of the pathology, there could be a peritendious reaction which may lead to a restrictive fibrosis due to increased innervations and vascular in-growth may also occur from the paratendon.

Symptomatic tendons are diagnosed by activity related pain and medical imaging. Rupture will occur due to mechanical weakness in the tendon. The pain mechanisms in this phase are now non-phlogstic such as agitation to periteninous nerves by nocioceptive substances and swelling. Due to the failed healing response previously mentioned, tendons will not be homogenious in their presentation, depending on which stage of the healing has been distrupted. Fu suggests that new treatments could be based on this failed healing model,” to override on the failed healing tissues and restart the healing process”.

The Iceberg Theory

admin April 3, 2014 home, In focus, Technique Physiotherapy injury, pain, physio, recovery, rehab, swelling, tendionpathy, Tendons

If our tendons are not loaded progressively they are likely to become pathological/diseased/unhealthy. This is known as a tendinopathy. We are likely to develop a tendionpathy, which is described in the literature as a pain and impaired function to a tendon with associated swelling. This used to be described as a tendonitis, but there is a wealth of evidence to suggest the absence of inflammatory cells which is the fancy medical suffix “itis”, is not actually present.

There are number of current the theories to try and explain the pathology of a tendinopathy. Cook and Purdam describe the “tendinopathy continuum”. This involves a reactive, disrepair and degenerative phase of the injury. Fu has described a “failed healing theory” with Abate taking this one step further and coining “the iceberg theory”. This theory involves a tendinonic healing process with failed healing. Pain in this case is the tip of the iceburg and occurs when the degeneration outweighs its ability to self heal.A healthy tendon subjected to exercise will undergo some degradation and synthesis, with synthesis prevailing and the tendon becoming stronger.

However, when damage develops 2 phases are recognised:

(i) asymptomatic and;

(ii) symptomatic phase.

If recovery is too short and the blood supply is inadequate the repetitive strain loads will cause micro damage inside the tendon. The iceberg theory explains the frequent relapses of a profession athlete when rehab periods are too short but pain has diminished but the neo-angiogenesis (growing of new blood vessels) and neural in growth (growing of new nerve cells) can still cause the tendon to be pathological.

Overuse is the initial disease factor with micro-disruption of the tendon fibers. From their research they believe that noxious mechanisms are activated with increased expressions of inflammatory mediators. This then stimulates the synthesis of MMP’s and enzymes that increase the degradation of the extra cellular matrix and promotes neo-angiogenesis. This results in degeneration and weakening of the normal tendon structure. Neural in-growth accompanies the neo-vessels which leads to over expression of glutamate and other chemicals which explain the occurrence of pain and possibly triggers neurogenic mediated inflammation.

In my next blog 2 blogs I will describe the Cook and Purdam “continuum model” and the Fu “failed healing” response.

Load your tendons – they like it.

admin March 18, 2014 home, In focus, Technique Physiotherapy injury, long distance running, muscles, running, sports, Tendons, training

Tendons are great, they connect muscle to bone and allow us to produce unbelievable force and attenuate weights of up to 8-10 times our own body weight. It’s pretty difficult to rupture a tendon but if you step on that football pitch, squash court or pogo up and down at a One Direction gig – without any recent exposure to these sort of activities. whilst enjoying beacoup de French cuisine and carafes of red wine, you just might!

Tendons like to be loaded with tensile force, but this has to be done progressively. The biggest risk factor other than excess central adipose tissue (expanding waist lines from over indulgence minus regular exercise) is unaccustomed, excessive load through your tendon (the former activities mentioned). We have all decided that we suddenly like 1D, let’s be fair they are musical genii and will soon overtake the Beatles as the most influential band to have graced these shores. However if you decided to jump up and down on 1 or 2 legs for 2 hours having not done it for some time you are likely to stimulate a “reaction” in your tendon.

If you’re a runner, avoid any sharp spikes in training load (hill sprints or a long run without graduated build up). If you haven’t played squash for a while, go for a couple of gentle jogs before going down to your local court and have a knock by yourself, before thrashing around for 40mins at a club night against people you think you could have beaten “back in the day”. Build up to every event/activity, increase your training load by 5-10% per session and your tendons will love you! They will gradually become conditioned and your will avoid developing a tendonopathy (you may know this as a tendonitis) or worse still a tendon rupture.

If this advice comes too late for some, I will be presenting the current research in my next blog for treating tendionpathies and rehabilitating tendon ruptures.

Right I’m off to practice my pogging, and get ready for the 1D’s headline Wembley show on June 6^th, I should have enough time to build things up!

The Importance of Good Landing Mechanics

admin March 4, 2014 In focus, Technique Geek, Technique Physiotherapy athlete, injury, landing mechanics, long distance running, running, sports, sports injury

Possessing good landing mechanics is important for the majority of athletes in todays world, from MMA athletes, to Basketball players.

However, due to the demands of their sport, the importance of landing effectively in long distance runners is critical. Landing with bad technique can place a great deal of stress throughout the kinetic chain and can end careers prematurely if this is not corrected.

Key points to focus on when landing:

Soft Landing – the aim is the land as silently as possible.
Feet – we want to land on our mid-foot. This ensures that the weight is centred and balance s optimised. This also allows us to absorb impact effectively, to then go on and produce force.
Knees – we must make sure that our knees and toes are lined up straight in order to minimise the risk of injury, with the knees slightly bent. Should the knees draw inwards upon landing, this could increase the risk of injury by placing unwanted stress on ligaments such as the ACL and MCL.
Hips – flexing the hips is vital in order to minimise the risk of injury and land effectively. As well as staying balanced, landing with our hips flexed will ensure some of the impact is absorbed through muscles such as the hamstrings and gluteals.
Torso – the torso should be slightly flexed, but with the chest facing upwards. Just think if you had something written across your chest, you should be able to read it in the mirror upon landing.

All of these points are critical, as they ensure the body is able to land both safely, and effectively as well as being prepared for the next jump. It creates a solid base in which to generate the most amount of power, in the shortest amount of time when looking further ahead to plyometric and power drills.

Jamie Grange BSc (hons) GSR MSc CPT.

Physiotherapy treatment of low back pain – 1

admin February 28, 2014 In focus, Technique Physiotherapy acupuncture, back pain, low back pain, physiotherapy, treatment

The aim of treatment is to re-establish normal movement at both a physiological and accessory level, while desensitising the nervous system and resolving pain. The physiotherapist must take into account the full picture of the patient’s symptoms. Critical to this is an accurate assessment. While it is not always possible to ascertain the exact cause of LBP the assessment should provide a reasonable theory as to the cause of the pain and aim to target the offending tissues or indeed pain syndrome.

Imaging may be used to help in the diagnosis but should not be relied upon to explain the whole picture as to why symptoms occur.

Manipulation, acupuncture, mobilisations, soft-tissue-release, nerve glides and rehabilitative exercises are among the techniques used. Should the therapist find that a certain level of the spine, a particular muscle or nerve are the root of the pain, the treatment can focus on returning normal movement and function to these areas. Here we discuss the first two interventions:

Manipulation

Manipulation may take place at the end or mid-range of a joints movement. What all manipulations have in common is that they are a high velocity and low amplitude thrust. While most of us would associate manipulation with an audible click or ‘cavitation’ of the joint, this is not a requirement in order to gain the effects. As with all manual therapy manipulations should never be seen as the sole treatment, rather they provide a window of opportunity during which rehabilitation exercises can take place. The three main mechanisms of manipulations are:

– Biomechanical effects – joint gapping leading to possible improved available accessory movements and therefore range

– Muscular reflexogenic effects – a reflex reduction in pain and muscle hypertonicity leading to improved functional ability

– Neurophysiological effects – pain-gating may occur through a barrage of non-nociceptive input. Opioid release has been shown to take place through stimulation of the periaqueductal grey matter in the brain leading to descending inhibition. The effectiveness of the neurotransmitter Substance P is decreased by the release of β-endorphins

(Potter et al 2005).

Acupuncture

Western Acupuncture is known to help with pain relief and muscle tension, which itself is often the cause of LBP. The National Institute of Care Excellence (NICE) recommend acupuncture as a possible treatment in the management of non-specific LBP. Possible mechanisms of therapeutic acupuncture pain relief include:

– Through axon reflexes, the release of neuropeptides with trophic effects, dichotomising nerve fibres and local endorphins

– Spinal mechanisms, for example, gate-control, long-term depression, propriospinal inhibition and the balance between long-term depression and long-term potentiation.

– Supraspinal mechanisms through the descending pain inhibitory system, the sympathetic nervous system and the HPA-axis.

– Cortical, psychological, “placebo” mechanisms from counselling, reassurance and anxiety reduction.

Pain relief has been shown to facilitate muscle function and with it tissue healing. If acupuncture can decrease the discomfort felt, through any mechanism, then a functional improvement should be seen. (Furlan et al 2005)

References:

Furlan AD, van Tulder MW, CherkinD, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1.

Potter L, McCarthy C, Oldham J. Physiological effects of spinal manipulation: a review of proposed theories. Physical Therapy Reviews 2005; 10:163-170

Syndesmosis Injuries

admin February 26, 2014 In focus ankle injuries, ankle pain, ankle sprains, recovery, strength, twisted ankle

As a big rugby union fan, particularly the six nations, I was sad to see Billy Vunipola limping off mid way through the first half on Saturday, in England’s clash against Ireland.

We haven’t had number 8s like him and Ben Morgan for a long time, those that actually make decent yardage when they run with the ball and strike fear into the heart of opponents as they bear down on them.

Billy’s injury was atypical for an ankle injury in that he twisted it in the opposite direction to 90% of most ankle sprains. So what does this mean?..

My differential diagnosis without actually having the fortune of assessing him would be that he has most likely injured the deltoid ligament and quite possibly disrupted the syndesmosis of his ankle +/- the anterior distal tibiofibular ligament (ADTFL).

The deltoid or medial ligament is often the first tissue to be disrupted and in more severe cases this disruption continues through into the ADTFL and then into the syndesmosis.

So what is the syndesmosis I hear you ask? Well the syndesomosis is a very stable group of ligaments that hold the tibia and fibula together from the ankle all the way up to the knee. They cross over each other in a lattice type formation making them very strong. To disrupt these ligaments often takes a lot of force, so when you do disrupt them you know you have done some damage.

So how do I know if I did my deltoid ligament and syndesmosis?

Well the first thing is to think about how you did it. Most sports people have injured their ankles once or twice and understand mechanisms of injury to a degree. So if you have twisted it in an atypical way and you have pain around the medial aspect of the ankle instead of the lateral then the deltoid ligament is a possibility. Identifying the syndesmosis is more tricky, but most people describe a feeling of instability above the ankle with pain when walking, possibly radiating higher up into the mid shin between the tibia and fibula.

If in doubt and you are in pain when walking consult a specialist, either via A&E or contact one of our team for an assessment. They will be able to identify the injury and recommend the next steps for you to make the most optimal recovery.

Pelvic Fractures

admin February 6, 2014 0 comments In focus

I read recently in the Guardian with great interest that Angela Merkel had been diagnosed with a pelvic fracture. The story read along the lines that she had a fall whilst skiing and having struggled to walk around for a few days with severe bruising down her thighs realised something wasn’t right. She subsequently booked in for a specialist review and a fracture of her deep pelvic bones was found.

This triggered off a memory from earlier in my career whilst working in private clinics in and around London. Your natural assumption would be that this type of injury is rare and probably only limited to those doing extreme sports. Well one of these assumptions is correct they are relatively rare injuries, however all of the incidences of the injury I diagnosed were found in cyclists that had been knocked off or fallen from their bikes and impacted onto their sides.

The characteristics of the injuries were the same:

A fall from a bike onto hard concrete impacting onto the greater trochanter
Immediate pain and discomfort, but when first x-rayed no fractures were found
Within one week the patient noticed severe bruising down into the thighs
Difficulty walking for up to 12 weeks
The fracture was on the contralateral side to impact and was diagnosed by MRI, this was found to be the superior pelvic rami
Deep seated pain on adductor squeeze testing (straight leg)

The pelvic ring is a seriously strong structure it takes serious force to disrupt it, in most of the literature you’ll find that the pelvic rami are often injured in car crashes or falls from a great height. If you think about falls from a bike at speed, the forces involved could be similar to those of falls from a great height.

These injuries were often stable fractures, meaning the bones were not displaced and intervention from a surgical perspective was not required. We managed each case with relative rest and gradual build up of leg and core strength. Bear in mind that it took these cases up to 6 months before they were pain free.

So if you are an active person and have had a fall onto your side with some force, still struggling to walk after 6 weeks, have bruising down both thighs and a deep seated pain between your legs. Maybe go and say hello to your local health professional.

Core Strength for Modern Day Footballers

admin January 30, 2014 0 comments In focus

We have all been told about the importance of having a good level of core stability, and the role it plays in maintaining a good posture and preventing conditions such as lower back pain (LBP) in our later years in life. But for footballers in particular, from Cristiano Ronaldo to non-league players, the benefits of having good core stability are huge with regards to enhancing performance.

The “core” involves muscles responsible for holding the torso in place; the abdominals, lower back, and the hip muscles, which should position the spine and pelvis neutrally. By making these muscles strong and “switched on”, it can vastly improve an individuals performance by improving:

Strength,
Power,
Coordination,
Endurance,
Prevention of injury.

There are a number of different exercises in which to do to improve someone’s core strength, and by progressing the exercises on a weekly basis, the individual will constantly feel challenged.

Exercises can be held for 20 seconds (beginners) up to 30 seconds (advanced) for three to four sets. Examples of these exercises include:

Planks,
Side Planks,
Hamstring Bridges
Leg Raises,
Prone Cobra’s.

Throughout my time working with the academy players at Leyton Orient Football Club (under 13’s-under 16’s), I have managed to implement some of these exercises into their daily routines through stressing the importance of good core strength within football, and how it will develop their game at this crucial stage of their young careers. These exercises can all be progressed by the use of swiss balls, theraband’s, use of a partner, or an unstable surface.

In football, it’s the small things that count, and it may be from getting that extra yard of pace, to holding your own in a 50/50 and not being bullied off the ball. But ultimately, it’s a game of margins, something core strength can win you.

Jamie Grange BSc (hons) GSR MSc CPT.

In focus: Core strength

admin January 23, 2014 0 comments In focus

Hello from Technique.

This month we are going to be looking at the core muscles and their role in supporting our spine, protecting us against injury and also in improving performance in sport.

So what are the core muscles? Well essentially they are a group of muscles that work in tandem to support us day to day in an upright posture. Sounds simple right? For the most part these muscles are activated subconsciously when we move and play sport, although we do have conscious control of them.

As we develop movement patterns from a young age, we learn how to recruit these muscles effectively or ineffectively to allow us to move from A – B efficiently. One thing is for sure, a strong core equates to better movement patterns and a certain amount of protection from load being transferred directly to the spinal support structures such as discs and ligaments.

As discussed in previous blogs, somewhere this support network becomes inefficient and stops’ doing the job it is designed to do. This is particularly true in conditions such as lower back pain.

The following muscles are those commonly associated with spinal stability:

Rectus Abdominus
Internal/External Obliques
Transverse Abdominus

Here are some that are less well known but still have a part to play in stability around the spine:

Multifidus
Erector Spinae
Quadratus Lumborum

Our expert knowledge could be the difference you need to put back pain behind you. Over the next few weeks we will be highlighting how to target the core and develop the strength needed to over come conditions such as lower back pain.

Our physiotherapist’s in Wimpole St, Vauxhall, London Wall and Earl’s Court have extensive experience from many different backgrounds. If you are an aspiring athlete or someone who has played sports from a young age, we will be able to help you improve your current level of strength. Book an appointment at one of our London clinics and we will get you from A – B in a more efficient and pain free way.

Make the Move.