Posts tagged sports injuries
Only 1/3 Of Patients Are Satisfied With Activity Level Following Surgery For Hip Impingement
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Hip impingement (FAI) is one of the fastest growing orthopedic surgeries, but much of this growth has outpaced our current understanding of this condition. A key question involves the additional bone development (cam and pincer lesions) found among athletes. Many of these athletes remain asymptomatic despite having positive findings of impingement on x ray and other imaging techniques. Other athletes with FAI who are symptomatic often return to sport and high function after undergoing Physical Therapy indicating some individuals are able to compensate and adapt for these structural changes or they may be a natural response to the sport itself.

Previous research has found equivocal long term outcomes between Physical Therapy and surgery for hip impingement. This data indicates a significant duration (8-12 weeks) of Physical Therapy should be attempted before surgical interventions. The majority of athletes undergoing hip impingement surgery will return to sport around 6-10 months post surgery, but many will be unable to return to their pre injury levels of activity. Prior studies have found only half are able to return to their previous sports and 1 in 5 will be able to return to the same sport with the same level of performance. A recent study sought to understand how these individuals function 6-10 months after surgery.

The Orthopedic Journal of Sports Medicine followed 33 patients who underwent hip arthroscopy for conditions involving hip impingement (Worner et al. 2019). On average, patients were reassessed at 8 months post op and their subjective history and objective testing were compared to their age matched peers. Authors reported decreased subjective function and ability to return to sport in the surgical group. Specifically, 46% and 18% were able to return the same sport at a lower or similar level, respectively. Consistent with prior research these individuals regained strength and range of motion after post operative Physical Therapy except continued to experience decreased hip flexion strength and range of motion compared to their peers.

This study adds to our existing knowledge on the recovery following hip arthroscopy for hip impingement. Despite being cleared to return to sport many athletes will require additional recovery time to regain participation in sporting activities.

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PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy
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Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

Short or Long Duration Isometrics Equally Effective For Patellar Tendinopathy
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Patellar Tendon pain, also known as jumper's knee, is a painful condition most commonly seen in athlete's engaged in jumping sports such as track and field, basketball, and volleyball.  Common causes of this condition include training errors (too much too soon) and underlying weakness in the quadricep and hip musculature.  The gold standard of treatment for this condition involves the application of sub maximal loading through Physical Therapy exercises to promote healing (remodeling) of the tendon.  In short, doing too little is as bad as doing too much.   Exercise begins to heal the injured tissue through a process called mechanotransduction and without it tissues remain in an immature, weakened condition.  In the knee, promising research is being conducted showing the immediate and short term benefits of isometric loading (45-60 seconds), but new research suggests patients may benefit from shorter loading times.  

In the Clinical Journal of Sports Medicine, Pearson and colleagues randomized patients with patellar tendinopathy to one of two groups (2018).  Patients were placed in either a short duration (24 sets of 10 seconds) or long duration (6 sets of 40 seconds) isometric loading program at 85% of their maximum voluntary contraction.  As you can see from the prescriptions time under load (240 seconds) was balanced between groups.  Authors reported the short duration isometric loads were as effective as the longer duration isometric loads as long as the time under tension was equalized.  This study provides more flexibility to both patients and Physical Therapists when treating patellar tendinopathy.  The take home message is one size does not fit all and tendons should be optimally and progressively loaded over time based on the individual.

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Strength and Balance Asymmetries Predict Future Athletic Injury
Photo Credit: charlieweingroff.com

Photo Credit: charlieweingroff.com

In our prior posts we have described the injury risks associated with athletic activities.  There will always be an inherent risk with athletic participation but current research is identifying Physical Therapy tests which can help predict future injury.  These test batteries involve movement assessments of functional positions such as squatting, jumping, and landing.  The information gained from these pre participation screenings allows the Physical Therapist to identify known risk factors for injury including weakness, instability, and balance impairments.  

The star excursion balance test is a function test assessing an individual's ability to maintain stability on one leg as they reach their opposite leg in multiple directions.  The distance reached is measured and compared from side to side.   Asymmetrical movement patterns and reach distances have previously been shown to predict future risk of injury.    In one study, athletes with a greater than 2 inch reach difference between legs were shown to be twice as likely to sustain an injury in the upcoming season.  

A recent article in the Journal of Orthopedic and Sports Physical Therapy examined the predictive ability of the star excursion balance test among NCAA Division I athletes (Stiffler et al. 2017).  147 athletes were retrospectively analyzed after the completion of their season for both pre season athletic performance and injury status.  20% of these athletes sustained a non contact injury to their knee or ankle during their athletic season.  Balance test measurements were analyzed in this group to determine the impact of pre season testing on the develop of a future non contact injury.  The authors reported asymmetries in forward reach distance during the star balance excursion balance test were able to identify injury vs. healthy athletes.  To learn more about pre season injury prediction testing visit your local Physical Therapist. 

Increased Risk of ACL Re Injury Among NSAID Users

In our previous posts we have detailed the risk factors for ACL injury and the effectiveness of Physical Therapy to reduce this risk especially among adolescents.  A percentage of athletes who return to sport will re injure their ACL leading to further surgeries and Physical Therapy.  A delayed return to sport allows the athlete more time to resolve muscle imbalances and coordination impairments leading to decreased re injury risk.  As we learn more about these athletes who re injure their ACL reconstructions we will have a better idea of how to prevent the injuries.

A recent large study in the The American Journal of Sports Medicine reviewed patient charts who underwent an ACL reconstruction surgery in the US Military over a 7 year period (Pullen et al. 2016).  Over 17,000 procedures were performed over this time period and 587 soldiers underwent revision surgery (3.6%).  The median time to re injury among these individuals was 500 days.  Athletes at greater risk of re injury included younger, active duty soldiers who took anti inflammatory medication during the perioperative period.  This study also identifies the potential harm of taking anti inflammatories during rehabilitation for ACL repair.

Reducing Knee Pain In Cyclists
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Cycling is one of the most popular outdoor activities in Boulder.  Cyclists we encounter in our Boulder Physical Therapy practice most commonly complain of pain on the front of their knee or anterior knee pain.  Research shows 1 in 2 competitive cyclists have experienced this knee pain resulting in lost training and competitions in over half of those affected (Clarsen et al. 2010).  A cyclists exposure to the impact of poor pedaling biomechanics is amplified by the volume of their training.  It is not uncommon for a competitive cyclist to flex and extend their knee over 5 million times per year during their training sessions and competitions (Callaghan et al. 2005).  In addition to training errors, bike biomechanics remain one of the key sources of an athlete's knee pain.

Athletes who have excessive movement in their lower bodies both reduce their cycling economy and performance, as well as, increase their injury risk.  In particular, the movement of the knee toward or away from the frame increases stress across the knee especially during the power portion of the pedal cycle.  The suboptimal mechanics change the alignment of the knee and the ability of the leg muscles to import forces on the foot and pedal.  Commonly, bike fitters use shoe orthotics or wedges to modify the relationship between the foot, shoe, and pedal.

Research has shown a rigid cycling shoe is the most economical and efficient interface with the pedal allowing cyclists to pedal at a lower % of their VO2 max for a given work load compared to a softer shoe.   Research regarding orthoses or wedges on cycling alignment and mechanics are fewer in number.  The limited research shows these orthoses or wedges 5-10 degrees can temporarily impact mechanics but their long term efficacy as a tool remains to be limited (Fitzgibbon et al. 2016).  They are most likely to benefit those athletes with true structural alignment impairments in the leg.  

Conversely, many of our patients's symptoms improve quickly with Physical Therapy interventions to correct impairments such as limited range of motion and muscle imbalances in the leg.  Once these are addressed an athlete is better able to use cuing and movement retraining to improve static and dynamic alignment of the knee while cycling.  In summary, athletes need the capacity to control the knee position through strengthening then the appropriate retraining to use that strength in an optimal cycling pedal cadence.