Posts tagged sports injury
How Does Exercise Heal Injured Tissues?
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Each day we meet with athletes, clients, and patients who present with an injury or condition involving an injury to a muscle, nerve, ligament, tendon, or bone.  One of the most powerful tools we have to accelerate the healing of this injury is exercise.  A previous post discussed the impact of Physical Therapy exercises on Achilles Tendinopathy.  This post described the impact on exercise on achilles tendinopathy and how exercise improves injured tissue a process called mechanotransduction.  Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses (Khan Br J Sp Med 2015).  

Khan et al. in a recent article used the term "mechanotherapy" to describe the benefits of Physical Therapy exercises on injured tissues in the body (Br J Sp Med. 2015).  These authors updated the definition of this term to include "the employment of mechanotransduction for the stimulation of tissue repair and remodeling".  Each day we utilize exercise parameters including direction of force, speed, intensity, frequency, duration, and others to optimally impact a patient's injured tissue in order to promote healing and restoration of function.  Each tissue in the body seems to have unique responses to loading from Physical Therapy exercise.

A common example of this phenomenon occurs in our bones.  Gradual loading of the bones through exercise improves bone density, but aging and a lack of weight bearing exercise can lead to osteoporosis.  Bone cells (osteocytes) are stimulated through loading in weight bearing and exercise to promote fracture healing in injured bones.  Research by Challis et al. examined the impact on loading in addition to standard fracture care in patients with forearm fractures (Aust J Phys 2007, J Bone Joint Surg Br 2006, Clin Orthop Relat Res. 2005).  The authors noted improved fracture healing, strength, and range of motion when fractures were exposed to low load, cyclical pressures from a pneumatic cuff wore under the cast.  This suggest gentle, controlled loading in addition to immobilization may accelerate fracture healing. 

Muscle and tendon offer us some of the best examples of exercise's impact on tissue.  The benefits of exercise on muscle are clearly known including increased size (hypertrophy) due to loading (weight training) and the loss of muscle size due to disuse or immobilization (cast).  After a brief period of controlled rest after a muscular injury (strain) exercise has been shown to positively effect the cellular healing and repair of these injured tissues (Jarvinen et al. Best Pract Res Clin Rheumatol. 2007).  Without proper loading these injured muscles may remain in a weakened state making them more prone to subsequent injury.  We often see this in recurrent injuries such as hamstring strains.

Ohberg et al. examined the impact of achilles tendon exercises on achilles tendinopathy.  These patients demonstrated quick improvements in pain and function, but they were also followed over the coming years to determine how their tendons healed from this exercise (Br J Sp Med 2004).  The authors noted improved tendon structure with 19/26 tendons returning to "normal" quality on ultrasound imaging.  As described in our previous blog post early pain relief and restoration of function is likely due to a different mechanism than tendon restructuring since these changes often take years to develop. 

In short, Physical Therapy exercise will always be a hallmark conservative treatment for the regeneration of injured tissues.  Utilize a Physical Therapist to learn how to best manage your injury and how to utilize specific exercise parameters in get back to life and sports. 

Injury Prevention Program Reduces ACL Risk by 38% in Female Basketball Players
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In our previous posts on ACL injury we have highlighted girls are 6-8 more likely to sustain an ACL injury compared to boys in the same sport.  Multiple research studies have attempted to reduce this risk by implementing sport specific strength, agility, and balance programs.  On average, these programs have a significant impact on injury rates with ACL injury by 1/3 to 1/2.  A recent long term study was conducted over a 12 year period studying the impact of a hip focused prevention program on girls basketball players.   

Omi and colleagues conducted a prospective intervention study on 309 college female basketball players (Am J Sp Med. 2018) over a 12 year period.  The girls were tracked and observed over the first 4 years of the study and sustained 16 ACL injuries (13 non contact).  Next the authors implemented an 8 year intervention program consisting of strengthening, balance, and agility exercises.  The authors reported ACL injuries were 1/3 as frequent during the intervention program compared to the observation period.  Dropping the risk of ACL injury by 38%.  Amazingly, the exercise compliance rate was 89% during the trial demonstrating the impact of focused, consistently performed exercises in this population.

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Early Physical Therapy for Muscle Injuries Accelerates Recovery and Return to Sport
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Muscle injuries (strains) are a common injury among both inactive and active people.  These injuries can become recurrent and lead to significant losses in function and sport participation.  Research has previously shown injections such as PRP (platelet rich plasma) are costly and ineffective to treat these muscular injuries.  Conversely, these injuries require Physical Therapy and early, progressive loading of the injured tissue to both promote healing and re establish its' pre injury tensile strength.  The main question remaining is how soon Physical Therapy should be started after an acute injury.

A recent study in the New England Journal of Medicine conducted a randomized controlled trial of 50 amateur athletes who sustained either a thigh or calf muscle strain (Bayer et al. 2017).  Athletes completed the same rehabilitation program but were randomized to either early Physical Therapy (2 days) or delayed Physical Therapy (9 days after injury).  The rehabilitation program consisted of 1 week of frequent stretching followed by 2-4 weeks of daily, progressive loading of the injured tissue.  The final phases of the Physical Therapy rehabilitation program consisted of dynamic loading with increased resistance 3 days a week and finally completed the return to sport phase in weeks 9-12 consisting of functional exercises and heavy strength training 3 days per week.

As expected, the authors showed a 25% faster return to sport in the early vs. delayed Physical Therapy group (62.5 vs. 83 days).  Importantly, the authors showed no increase in risk of injury among the athletes who completed the early vs. late rehabilitation programs.  Authors reported this study supports the importance of early loading compared to immobilization of injured tissue.  Previous research has shown immobilization impairs connective tissue cells and their ability to heal and return to pre injury composition.  Authors stated the "importance of regular and controlled mechanical loading early after trauma" to facilitate an optimal return to activity.

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Evidence Supports Not Using FMS To Predict Future Injury
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The functional movement screen was designed to screen athletes and individuals on both upper and lower body movement tasks in order to identify those at risk for future injury.  As participants move through the 7 movement tasks, Physical Therapists are able to identify areas of weakness, tightness, or decreased coordination.  Based on these results exercises or manual therapy interventions are provided to help improve an individual's performance on a test.  The FMS was initially shown to be a predictor of injury in both NFL draft prospects and firefighters, but has not held up as well in future research.

Previous review articles have called into question the validity of these tests for athletic performance and testing, as well as, their ability to predict injury.  A recent review article of the available evidence was conducted to determine if an individual's composite scores are predictive of future injury (Moran et al. Br J Sp Med. 2017).  The authors 24 studies on the FMS and found the relationship between a cut off score of 14 out of 21 and future injury was small.  Further their was moderate evidence to recommend not using the FMS as a prediction test in soccer and conflicting evidence for other sports.  This study adds to the existing literature moving away from using the FMS for injury prediction, but single tests may hold value for certain sports and patient populations.      

The Impact of Pre Operative Physical Therapy on ACL Recovery
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ACL injuries  are becoming more common among both recreational and professional athletes.  The majority of these athletes who sustain complete tears of their ACL ligament will undergo ACL reconstruction and intensive post operative Physical Therapy.  Often, the ACL surgery is delayed after the injury to allow the athlete to regain their lost range of motion and strength, as well as, reduce signs of swelling and inflammation.  This pre operative period is an excellent opportunity for the patient to work with a Physical Therapist to address these impairments and improve their post operative recovery.  An athlete's condition entering surgery has a significant impact on their condition following surgery.

A recent review article studied 8 previous articles on pre operative Physical Therapy prior to ACL reconstruction (Alshewaier et al. Clin Rehab. 2017).  The 8 studies included 451 patients who underwent pre operative Physical Therapy from 3 up to 24 weeks.  The authors reported pre operative Physical Therapy was effective for improving strength and function prior to ACL surgery.  They concluded pre operative Physical Therapy is beneficial to patients with ACL injury and should be utilized to improve recovery and functional outcomes. 

Sports Specialization and Injury Risk

With a changing in the seasons we also see a changing of the sports in our Boulder County student athletes.  Athletes previously focused on winter sports including swimming and basketball are now able to focus on spring sports including baseball and track.  Prior research shows athletes who change sports during the sports year have half the risk of injury compared to their peers who focus on one sport all year round.  Early sports specialization  in school sports places athletes at greater risk of overuse injuries during their seasons due to lack of recovery/rest periods, muscle imbalances, and repetitive sports movements such as pitching.  

A recent article in the American Journal of Sports Medicine adds further support to the risk of student athletes playing one sport year round.  Bell and colleagues studied over 300 athletes aged 13-18 from 2 high schools to determine the prevalence and impact of year round athletics (2016).  Athletes were classified in 3 groups including low, moderate, and high specialization based on their single sport participation.  Not surprisingly, athletes from larger high schools were more likely to specialize in one sport and these athletes reported greater rates of overuse injuries than their peers who played at smaller schools or multiple sports per year. Specifically, athletes playing one sport greater than 8 months per year were at greater risk of injury than athletes who participated in one sport less than 8 months of the year.  

Parents, coaches, and student athletes are advised to consider the risk of spending >75% of the year training for an individual sport.  Coaches and athletes are advised to schedule their training year based on periods of dedicated to both training and recovery.