Ankle and Knee Stability and Landing Exercises
These are slightly more advanced exercises to perform after any ankle or knee injury for those wishing to return to sporting activities.
A Runners Guide to Shin Splints
Medial Tibial Stress Syndrome (MTSS) or “shin splints” is one of the most commonly reported lower limb injuries by competitive and recreational athletes. Recent research has shown that shin splints affects approximately 20% of the running population, with the majority of sufferer’s partaking in long distance training/competition.
What causes the pain?
Currently, there is two widely accepted theories on the cause of shin splints:
- The bony bending/bowing theory
- The traction theory
The bony bending theory suggests that during running, the Tibia (shin bone) bends due to the stress placed upon it. This bending causes small amounts of strain in the bone that enables it to adapt and get stronger (a good thing!!). When this strain exceeds the adaption process the shin bone becomes overloaded (a bad thing!), subsequently leading to injury and pain.
The traction theory states that shins splints is caused by the continual contraction of the muscles (Soleus, Flexor Digitorum Longus & Tibialis Posterior) that attach to the inner border of the shin. As these muscles contract during running, they place a traction stress on the shin bone, which results in inflammation at their attachment onto the bone, causing pain.
Am I at risk?
Current research has identified several risk factors leading to an increased likelihood of developing shin splints. These include:
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A previous history of shin splints
- Prior orthotic use
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High Body Mass Index (BMI)
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Female gender
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Decreased running experience
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Decreased running cadence (step rate)
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Excessive pronation
- Over striding
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Crossover running style
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Increased vertical oscillation (ground clearance)
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Forefoot running
How do I know if I have shin splints?
To diagnose shin splints accurately, two symptoms must be present:
- Exercise induced pain along the distal 2/3 of the medial Tibial border
- Recognisable pain produced by pressing the medial Tibial border, which spans a distance of 5cm or more.
If you are experiencing symptoms not typical of shin splints such as cramping, pain spanning less than 5cm, burning pain, numbness or pins and needles, you should seek a thorough assessment by a physiotherapist to properly diagnose and treat your condition.
Treatment – Technique Technique Technique!!!
Arguably one of the biggest contributors to the development of shin splints in a runner is their running technique, particularly their lower limb mechanics. One of the quickest ways to reduce shin splints related pain is to address the technical aspects of running that can contribute to increased stress across the Tibia and associated musculature. What you should focus on is:
- Cadence – Normal cadence should be between 165-185steps/min. Decreased Cadence causes increased ground contact time resulting in prolonged pronation and excessive tibial torsion stress.
- Over striding – Excessive stride length results in poor tibia positioning upon heel strike, increasing Soleal traction and reducing force absorption ability.
- Cross Over Gait – Landing across the midline of the body causes excessive tibial torsion and pronation, reducing proper force attenuation.
- Vertical Oscillation – Increased vertical oscillation during running increases Tibial impact forces and often results in a loud foot strike.
How do I improve my technique?
Increase your cadence!! – This is by far the biggest bang for your buck. Increasing your cadence by approximately 10%:
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Reduces lower limb impact forces by 20%
- Reduces vertical oscillation
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Reduces ground contact time
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Reduces stride length
The best way to achieve an increase in your cadence is by using GPS watches, phone applications or by simply running on a treadmill.
Eliminate a crossover running style – On a track, run straddling a line across 2 lanes or alternatively, try and maintain a space between your knees with every stride.
How to beat shin splints using strength
Strength exercises for shin splints should aim to improve the localised muscular capacity of the calf complex as well as the bone load capacity of the Tibia. This is best addressed with weight bearing functional exercises that mimic running postures.
One of the most important and often forgotten muscles of the calf complex is the Soleus. The soleus muscle is vital for absorbing excessive loads placed on the Tibia during running by minimising excessive pronation as well as resisting the bending forces experienced by the Tibia due to ground impact.
The best Soleus exercise that runners can do is the Bent Knee calf raise (pictured above). To perform the exercise correctly:
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Bend your knee as far forward as possible, keeping your foot flat on the floor
- Keeping your knee bent, raise yourself up onto your toes
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Lower your heel back to the ground
Perform 3 sets of 15 repetitions in a slow and controlled manner.
As always, if you are having problems, please do not hesitate to contact one of our experienced physiotherapists.
Top 3 Injury Prevention Strategies + Lessons from Leicester City
About the authors.
Vas Krishnan is in his final year of Sports & Exercise Science at the University of Sydney.
Stephen Andreazza is a Titled Sports & Musculoskeletal Physiotherapist.
Lets face it, injuries are annoying and expensive. They result in lost hours of training and game time as well as dollars spent on physio, doctors and imaging, and in some cases, surgery. So what are the best ways to prevent injury? We highlight the key points taken from the most recent research as well as from Leicester City’s incredible Premier League Title in 2016.
The top 3 Injury Prevention strategies are:
- Measure/track your workload and training
- Gradually increase your training
- Be specific in your training
1) Measuring your workload
- Training/exercise load is emerging in the research as the most significant predictor of injury in the athletic population.
“Load” definition
Workload is all things affecting the body in a sporting context. This could be internal measures which are mainly physiological or external measures which are physical work performed. [8]
Internal Load Measures
- Rate of perceived exertion (RPE)
- Heart Rate (HR)
- Blood Lactate Concentration
- Stress/Arousal
External Load Measures
- Weight Lifted (total Kg)
- Total Distance (Km)
- Acceleration/Deceleration (m)
- Minutes on ground (training and game time)
When quantifying workload for usable data we usually use at least one Internal load to determine intensity (e.g. RPE) and one external load to determine physical work done (e.g. Total Distance) these together help us to quantify total load (Internal load x external Load = total load).
It was found that using an internal load and an external load measure was more effective in determining the actual load an athlete was undertaking compared to just the external load. [8]
An Example of weekly workload
Calculating Load for a soccer player could be as simple as Minutes on ground x RPE. If a soccer player trained 3 times per week and had 1 game on the weekend where the sessions went for 60min each and their game time on game day was 60min. For Training sessions RPE was 6 and game day RPE was 8.
Session 1 – 60×6 = 360 Units
Session 2 – 60×6 = 360 Units
Session 3 – 60×6 = 360 Units
Game 1 – 60 x 8 = 480 Units
Total Weekly Load = 360+360+360+480 = 1560 Units
2) Gradually increase your training. Use your load measurements to work out how much is too much.
Acute: Chronic Workload Ratio
The Acute: Chronic Workload Ratio is a way for athletes and coaches to determine the load their athletes should do for current and future training as to prevent injury. If load is considered to be km running/week. Acute load is Km over 1 week and Chronic load Km over 4 weeks. [5]
Using the Acute: Chronic Workload Ratio we can quantify expected and required load for decreased injury risk. [5]
It was found that when the Acute: Chronic workload ratio was greater than 1.5 there was an increase in the risk of injury. This can be clearly seen in the graph below. [5]
It was also found that >0.8 to <1.3 was the point of least injury risk. This was noted as the “sweet spot” and should be what all athletes are aiming to be in at all points of the season. [5]
>1.3 is where the risk of injury started to increase with a significant increase at 1.5 and an even greater increase at 2.0. [5]
Coaches and Athletes can use this as a guideline to determine the load that they should be using for transitioning season to season, coming back from injury or even coming back from holidays/time off. This can help the athlete and coach with injury prevention strategies, re-injury and further progression. [5]
Using the Acute: Chronic Workload Ratio
Below is a table illustrating what the likelihood of injury is for an athlete in accordance with the Acute:Chronic workload ratio. [1]
This table compares different scenarios of acute and chronic workloads using predefined equations to determine load as a percentage of normal training.[1]
The table grades each load percentage with a percent likelihood of injury. [1]
For example if an athlete has come back from a holiday and resumed normal 100% load (Acute workload) but over the past 4 weeks has only been training at 30% of their normal load (Chronic Workload) there can be an expected 61.4% increased likelihood of injury in the following week. [1]
Athletes and coaches can use this table to determine the load they should be working at or if they are at a greater risk of injury. [1]
So, how much is too much!?
-
Acute: Chronic workload ratio should not exceed 1.3 or go below 0.8 (>0.8-<1.3) – aka “the sweet spot”
-
Likelihood of injury increases when the Acute: Chronic workload ratio is >1.3
-
Danger Zone for Injury when Acute: Chronic workload ratio is >1.5
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Severe Danger Zone for injury when Acute: Chronic workload ration is >2.0 (greatest risk of injury)
The amount of “Load” that is too much is determined by how much you have been doing in the previous weeks.
An elite athlete training 6+ times per week will have a vastly different load to a high school athlete training 3 times per week, however we want their Acute: Chronic Workload Ratios to be the same!
Leicester City’s exercise scientists and coaches were meticulous about manage player loads. They used GPS tracking as one of a few tools to measure each players load.
If a player had spike in their workload, the coaches were notified and the player was pulled from the next session and sent for recovery work.
3) Be Specific in your training
This sounds so simple but we see people get it wrong all the time.
Athletes or Individuals wanting to compete in particular events must ensure they are training specific to that event. For example if you wanted to run a half marathon, you need to run! You don’t need to be in the pool swimming or doing reps on the bike.
You can start by running small distances and build your way up to 21 km. Using the Acute: Chronic Workload ratio and increasing your distance/load by 10% per week you can safely build your load and compete in the half marathon at your best.
Leicester City was specific in their injury prevention strategies. They identified that the most common injury was a hamstring strain and that these occurred in the last 20mins of a game when a player is trying to sprint under fatigue. They used 2 training methods to specifically address this.
- They made their players do repeat 40metre sprints at the end of every training session when they were fatigued.
- Every player had to reach and maintain a certain strength target of their hamstrings and this was measured using a device called the NORDBORD.
At the end of the season, Leicester City had the least number of injuries in the league and also had the greatest number of counter attacking goals in the league. [7]
If all of this is still confusing to you (you’re probably not alone!) then at least try to stick to these simple guidelines.
- Keep a diary of how much training you do.
- Increase your training loads gradually, particularly if your new to a sport, or coming back from a break. Keep your increases to around 10% per week.
- Be specific in your training. If you’re training for a run, then run!
If you’re still unsure, then please don’t hesitate to contact our friendly team at clinicalphysiostives.com.au
Key Evidence
-
Drew et al. (2016)
-
Load Management is Critical for all types of Injury Prevention. This was found in relation to both specific pathologies/injuries and in controlling injury risk factors.
-
Murray et al. (2016)
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Sudden increases in Acute workload were found to have a significant relation to injury in the current and subsequent weeks of increased load. High Chronic workloads were found to have a protective affect against injury. Hence the need for monitoring of both Acute and Chronic Load, and the Acute:Chronic Load Ratio.
-
Blanch et al. (2015)
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“The Acute: Chronic Workload ratio should be included in the return to sport decision-making process” (1. p.475)
Reference List:
- Blanch, P., & Gabbett, T. (2015). Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. British Journal Of Sports Medicine, 50(8), 471-475. http://dx.doi.org/10.1136/bjsports-2015-095445
- Bowen, L., Gross, A., Gimpel, M., & Li, F. (2016). Accumulated workloads and the acute:chronic workload ratio relate to injury risk in elite youth football players. British Journal Of Sports Medicine, 51(5), 452-459. http://dx.doi.org/10.1136/bjsports-2015-095820
- Drew, M., & Finch, C. (2016). The Relationship Between Training Load and Injury, Illness and Soreness: A Systematic and Literature Review. Sports Medicine, 46(6), 861-883. http://dx.doi.org/10.1007/s40279-015-0459-8
- Drew, M., Cook, J., & Finch, C. (2016). Sports-related workload and injury risk: simply knowing the risks will not prevent injuries: Narrative review. British Journal Of Sports Medicine, 50(21), 1306-1308. http://dx.doi.org/10.1136/bjsports-2015-095871
- Gabbett, T. (2016). The training—injury prevention paradox: should athletes be training smarterandharder?. British Journal Of Sports Medicine, 50(5), 273-280. http://dx.doi.org/10.1136/bjsports-2015-095788
- Murray, N., Gabbett, T., Townshend, A., Hulin, B., & McLellan, C. (2016). Individual and combined effects of acute and chronic running loads on injury risk in elite Australian footballers. Scandinavian Journal Of Medicine & Science In Sports, 27(9), 990-998. http://dx.doi.org/10.1111/sms.12719
- Leicester City: The science behind their premier League title, http://www.bbc.com/sport/football/36189778
- Weaving, D., Marshall, P., Earle, K., Nevill, A., & Abt, G. (2014). Combining Internal- and External-Training-Load Measures in Professional Rugby League. International Journal Of Sports Physiology And Performance, 9(6), 905-912. http://dx.doi.org/10.1123/ijspp.2013-0444
Stretching – Tackling the biggest myth in sport!
Should I be stretching before the big game?
Although stretching has long been promoted as an injury prevention method, recent systematic reviews conclude that there is no evidence to support its efficacy.
The Types of Stretching
Static stretching:
-
Static stretching involves moving the muscle or joint into an elongated position and holding the position for an extended period.
-
Historically, this type of stretching has been used to prepare the muscle for exercise.
Dynamic stretching:
-
Dynamic or ballistic stretching is when the muscles and joints are taken through their range of motion during movement. This type of practice is more specific to preparation for exercise and sports in particular
-
During the rehabilitation process care should be taken to not ‘bounce’ the muscle that is recovering from injury
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Dynamic stretches have been shown to significantly increase tendon flexibility and elasticity and have been promoted for end-stage rehabilitation for tendon injuries
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However, ballistic stretching involves eccentric contractions during the stretch phase, which may results in soreness or injury and therefore care should be taken when incorporating such stretches
Static stretching does NOT improve muscle length
-
Static stretching changes the muscle-tendon functions (range of motion and maximum voluntary contraction), which are related to mechanical changes of the muscle but not the actual tendon structure
-
In a 2019 study there was a decrease in muscle-tendon stiffness after static stretching observed immediately, but not 5 or 10min after stretching
Static stretching does NOT prevent injury
-
Warm-ups are typically composed of a submaximal aerobic activity, stretching and a sport-specific activity
-
The stretching portion traditionally incorporated static stretching
-
However, there are numerous of studies demonstrating static stretching induced performance impairments
-
A number of researches have concluded that stretching has no effect on injury prevention (Gleim and McHugh 1997; Herbert and Gabriel 2002; Small et al. 2008).
-
Sustained static stretching can impair subsequent performance;
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Maximal voluntary contraction
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Isometric force and isokinetic torque
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Training-related strength measures such as one repetition maximum lifts
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Power-related performance measured such as vertical jump (jump height)
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Sprints running economy (reaction, movement time and balance)
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Agility
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The acute negative effects of stretching seem to be associated with stretches at a duration of 60 seconds, while stretches of shorter duration may have less significant deficits
-
The most powerful injury prevention tool available is strength training, at increasing loads over a 6-8 week period.
What is safe stretching? When Should I be stretching?
-
It is important to differentiate between pre-exercise stretching (where stretching does not appear to prevent injury) and regular stretching outside periods of exercise (where there is some clinical and basic science evidence suggesting stretching may prevent injury)
-
Additionally, stretching does not seem to reduce the effects of DOMS (Delayed onset of Muscle Soreness)
-
Dynamic stretching which involves controlled movement through the active range of motion should be the choice pre-exercise.
The effect of stretching after exercise
-
Athletes often stretch after exercise in an attempt to improve range of motion and reduce the perception of musculotendinous stiffness. While it is a regular component of post-exercise regimens, there is limited evidence of the effect of stretching on various aspects of recovery
-
Lund et al. suggested that stretching following bouts of eccentric exercise may delay recovery. In a study investigating the effect of static stretching on DOMS following eccentric quadriceps of seven untrained females, they reported that recovery of strength was impaired in the group who stretched their quadriceps for three repetitions of 30 seconds each day after exercise caused further mechanical disruption and exacerbated muscle damage
-
In contrast, Torres et al. reported no effect of daily stretching on maximum voluntary contraction of the quadriceps following eccentric exercise in healthy untrained men .
Key messages
- Perform dynamic stretching before exercise.
- You can perform static stretches after exercise or at any other time to give you temporary relief of stiffness or pain.
References
Barbosa, G., Trajano, G., Dantas, G., Silva, B., & Vieira, W. (2019). Chronic Effects of Static and Dynamic Stretching on Hamstrings Eccentric Strength and Functional Performance. Journal Of Strength And Conditioning Research, 1. doi: 10.1519/jsc.0000000000003080
Bertolaccini, A., da Silva, A., Teixeira, E., Schoenfeld, B., & de Salles Painelli, V. (2019). Does the Expectancy on the Static Stretching Effect Interfere With Strength-Endurance Performance?. Journal Of Strength And Conditioning Research, 1. doi: 10.1519/jsc.0000000000003168
Brukner, P., Khan, K., Clarsen, B., Cook, J., Cools, A., & Crossley, K. et al. (2017). Brukner & Khan’s clinical sports medicine. North Ryde, N.S.W.: McGraw-Hill Education (Australia).
Konrad, A., Reiner, M., Thaller, S., & Tilp, M. (2019). The time course of muscle-tendon properties and function responses of a five-minute static stretching exercise. European Journal Of Sport Science, 1-9. doi: 10.1080/17461391.2019.1580319
Smith, J., Washell, B., Aini, M., Brown, S., & Hall, M. (2019). Effects of Static Stretching and Foam Rolling on Ankle Dorsiflexion Range of Motion. Medicine & Science In Sports & Exercise, 1. doi: 10.1249/mss.0000000000001964
Su, H., Chang, N., Wu, W., Guo, L., & Chu, I. (2017). Acute Effects of Foam Rolling, Static Stretching, and Dynamic Stretching During Warm-ups on Muscular Flexibility and Strength in Young Adults. Journal Of Sport Rehabilitation, 26(6), 469-477. doi: 10.1123/jsr.2016-0102
Williams, M., Harveson, L., Melton, J., Delobel, A., & Puentedura, E. (2013). The Acute Effects of Upper Extremity Stretching on Throwing Velocity in Baseball Throwers. Journal Of Sports Medicine, 2013, 1-7. doi: 10.1155/2013/481490
2021 Concussion Guidelines
With winter sport starting up again, it seems a perfect time to talk about concussion. Concussion seems to be the hot topic over the past few years: Sports commentators are talking about it far more than ever before and even Hollywood has shown the impact of concussion on people’s lives.
In this article we will cover:
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- What is Concussion?
- Signs and symptoms
- What do the latest guidelines say about assessment and treatment?
- When can a player return to sport?
- Post Concussion Syndrome and how physio plays an integral role in rehabilitation
Glutues Medius Strength – “Peeing Dog”
A great exercise to challenge both sides at the same time.