An ankle sprain is a common injury that occurs when the ligaments around the ankle joint are stretched or torn when the ankle is twisted, turned in (inverted) or turned out (everted).

Ligaments are tough bands of tissue that help connect bones together. The most commonly injured ligaments when you ‘roll’ your ankle are the three ligaments on the outside of the ankle. These are called;

• anterior talofibular ligament (ATFL)
• calcaneofibular ligament (CFL)
• posterior talofibular ligament (PTFL)

Normally, the ATFL keeps the ankle from gliding forward & inward, & the CFL keeps the ankle from rolling inward on its side. When the ankle joint is forced into these positions these ligaments are overstretched & can tear.

Initially the ankle joint will become swollen & may bruise. The ankle will be painful to move & depending on the severity of the injury, you may or may not be able to put weight through it. Certain areas, most commonly the outside of your ankle, may be tender to touch.

The best results after an ankle sprain occur when treatment begins straight away. If the ankle ligaments do not heal adequately the ankle may become unstable, causing the ankle to give way & feel untrustworthy on uneven surfaces. This is because the ligaments become weaker after the injury (even when the pain goes away) & without proper rehabilitation re-straining the ankle is very likely. People who have had several mild ankle sprains or one severe sprain may develop irritation & thickening of the ligaments that were sprained causing them to get pinched near the edge of the ankle joint on certain movements.

Studies show that the recurrence of ankle sprains can be as high as 80% & the incidence of developing a chronic ankle sprain between 20-40%. This is important because each sprain creates more scarring & increases the risk of more significant problems such as fractures (broken bones) & cartilage damage, so preventing recurrent sprains is essential. The 2 main reasons for these ongoing problems are;

• persisting weakness in the peritoneal muscles which help stabilise the outer ankle
• a loss of balance feedback (called proprioception) from your ankle to your brain.

Research shows that retraining these 2 components can dramatically reduce the risk of recurrent sprains. Your Physio can help you achieve this, as well as greatly speeding up your recovery from the original pain & inflammation. This lets you get back to your normal sports & activities a lot faster, & also reduces the risk of more inconvenience & damage through repeated injury.

Your knees play a big role in many of your daily activities such as walking, getting in & out of cars, using stairs, & getting up from sitting in a chair. If you have problems with them then they can even make it hard to sleep or sit for long periods. Medical research shows that doing the right exercise can help keep your knees healthy by protecting them from injury & can also significantly improve many common problems that you may already have. Your knees rely a lot on the muscles of your hip, quads (front of thigh), hamstrings (back of thigh) & calf to support them & make them move well. If these muscles get weak then your knee loses some of it’s stability and this can cause pain, increase your risk of developing or aggravating arthritis, & make your leg feel weak like it won’t support your weight. Making sure your muscles are strong and the right length makes your knee stable, prevents injury & reduces pain. This is especially important for your quads & hamstrings to keep the right strength balance between the front & back of your knee. Both aerobic (cardio) & resistance (weights) exercises have been shown to bring many benefits for your knees. These include;

• reducing pain & improving your ability to do daily tasks such as walk, drive & use stairs
• promoting weight loss, which reduces the stress & strain you put on your knees
• improving your balance & strength which helps prevent falls
• helping fight osteoporosis by increasing bone density
• reducing the risk of secondary problems with your ligaments, cartilage & kneecap

If you already have knee problems then exercise can be very good for you however you should consult your trainer or physio to make sure the exercise is right for you. Research shows that in conditions such as knee osteoarthritis the benefits of exercise are further improved when the exercise is done together with physio treatment & appropriate weight loss. The general recommendations for knee exercises for most people are;

• start gently and progress gradually. Have supervision if you are unsure or have any underlying problem or injury. You should not feel any knee pain as you exercise.
• use a mix of cardio & weights exercises
• keep to low-impact exercises initially eg exercise bike, cross-trainer, shallow squats (avoid deep squats as they stress your knee & your kneecap)
• make sure you wear appropriate shoes (trainers) because they absorb shock & help keep your whole leg in the right alignment
• keep the amount of strengthening you do for the back of your knee (eg hamstring curls) in balance with your exercises for the front (eg knee extensions). This balance is important for knee stability & preventing pain.

Following these few simple rules will get you on the right track to enjoying all of the great benefits that regular exercise can bring for your knees.

Summer is rapidly approaching, and with global climate changes, the summers are getting hotter and what better way to cool down than to hit the beach or pool for a swim!

Unfortunately though, as with many sports there are always associated injuries and in swimming it is often the shoulder. One of the most common conditions that can occur is shoulder impingement.

Lets have a quick chat about the muscles and their function in the shoulder. There are 4 major muscles which make up your rotator cuff. Theses 4 muscles work to stabilise the shoulder as it moves through range.

If one of these 4 muscles are weak or there is tightness in the muscles controlling the shoulder blade then the top of the arm bone (humerus) can jam up under the roof of the shoulder blade (acromion). This can cause the tendons or the bursa (pocket of fluid) to become inflamed and painful.

Shoulder impingement usually occurs when your arm is up close to your ear in backstroke, freestyle, butterfly. It can also be when you are in a streamline position where your arm is slightly rotated inwards (internally rotated).

So think of the shoulder like a canoe and paddle – the swimmers hand is like a paddle and the rotator cuff muscles work like a fulcrum to stabilize the shoulder as the arm comes in and out of the water.

So how does shoulder impingement happen?

Shoulder impingement usually occurs when your arm is up close to your ear in backstroke, freestyle, butterfly. It can also be when you are in a streamline position where your arm is slightly rotated inwards (internally rotated).

This position causes friction of the head (ball) of the arm against the ligaments and the tendons.

This occurs due to:
• Poor swimming technique
• A large amount of training which can cause the muscles to fatigue and therefore work inefficiently or be overworked and fail
• Your hand crossing your bodys midline when it enters the water in freestyle or butterfly
• Your thumb pointing down and the palm facing outwards as your hand enters the water
• Unilateral breathing (ie only breathing on 1 side), as it can cause the opposite shoulder to become overworked
• The use of a kick board and streamline positions with the palm facing out can place the shoulder in a position of impingement
• The use of hand paddles or paddles without holes can increase the pull-through load, again placing increased strain on the shoulder muscles

Here are a few common swimming stroke problems to take note of to help avoid having a painful shoulder this summer!

Things NOT to do!

Butterfly:
• entering the water with your arms too far outside the shoulders or too close together (too close to midline)

Backstroke:
• pulling through with elbows extended (fully straight) which results in a straight arm pull through instead of an S shaped pull through.
• inadequate body roll

Freestyle:
• pulling through beyond the midline
• reaching out too far or aiming for too much length ahead
• inadequate body roll

Breaststroke:
• Excessive elbow straightening in the streamline position.

So have a think about your technique, have a think about the few technical problems mentioned above, and have a safe and painfree swimming season!

Getting your bike ready for spring cycling!

As the warm weather comes through there is no greater way to soak up the sun and enjoy spring but on your bike.

Cycling is a great way to get active for the recreational or competitive cyclist whether it be around the bay, through the park with your kids, through the bush or up and down dirt tracks on rugged terrain.

But before you get started here are a couple of tips on how to pedal and set up your bike properly to minimise injury and maximise your effort!

Firstly lets talk about seat height.

What is the optimal seat height?

Having a straight knee when the heel is resting comfortably on the pedal when you are sitting down on the bike. This means the knee will still be slightly bent on the maximum down stroke of your pedal.
Studies have shown that a forward seat tilting of 10-15 degrees will reduce the incidence of low back pain.

What happens if the seat is too high?

• Your hamstring (muscles as the back of your thigh) efficiency is reduced increasing the risk of hamstring strains.
• Your pelvis will tilt to the side thus causing your back to bend sideways too, causing jarring forces through your back and pelvis on that side.

What happens if the seat is too low?

• Your knee will bend more through the cycle which will increase forces onto your knee cap causing anterior knee pain (“patellofemoral pain”).
• Your hip will also go through greater ranges of bending potentially causing hip pain. Also, your back will have a tendency bend forward more increasing the load through the joints.

What is the ideal Handle bar position?

• When sitting on your bike, your spine should always be flat to reduce strain on your back
• the optimal trunk flexion (bend in your back) should be 20 degrees from horizontal, however, for recreational cyclists, 40-60 degrees of flexion is more comfortable and it will also reduce the strain on your back and neck as you have to look up to see the road ahead!
• Make sure the bend forward comes from your hips as much as possible rather than from your back.

Have you got the right pedalling technique?

• A good pedalling technique involves your ankle being at 90 degrees on the down stroke.
• When you ride too much with your toes you put more forces through the knee which can result in knee pain.

A good cycling revolution is:

• Push down using your buttock muscles, thigh, and calves pull across as you hit the bottom of the revolution then just relax on the up-phase of the revolution as the other leg starts to pedal down- do not try to pull the leg up! Its unnecessary work and will slow you down!
• Try to cycle without jolting when transitioning between the right and left leg; try to smooth it out.
• Concentrate on keeping your pelvis stable.

What can cause knee pain in cycling?

• The seat is too low or too far forward which increases the amount knee bend.
• Your bottom muscles are too weak! If they are too weak your quads will have to work extra hard to compensate.

What can I do if I have knee pain?

• tape up your knee – your local physio can show you how
• knee pain also commonly results from some muscles being too tight (eg your ITB) and others being too weak (eg your VMO and gluts (butt) muscles) – once again, your local physiotherapist can assess you and show you how to correct these problems

Check your program! Have you :

• Iced it for 20 mins post ride and relative rest i.e. reduce the intensity of your ride e.g less hills etc.

Well, this has been a whirlwind tour of how to get out and start pedaling in our beautiful Sydney weather. If you would like more information about cycling then check out http://www.topbike.com.au/physio.htm for heaps of information.

Well, the Aussie ski season is well and truly here now. Fantastic amazing scenery, loads of fun, lots of adrenaline, heaps of speed – and unfortunately, lots of knee injuries.

Each year around this time we start getting a steady stream of injuries from skiing, with many of them being knee ligament problems. The information below gives you an easy-to-understand background of why the knee is a problem area for skiing, and a run-down of the common ligaments that are injured. We’ll just stick to ligaments for this post, as cartilage & bone injuries are another whole story that we may look at another time.

Knee injuries account for about 1/3 of all skiing injuries, and the majority of these are related to ligament damage. Ligaments are like pieces of rope that cross over joints to hold the bones together in the right place.

As you can see in the diagram there are 4 main ligaments in the knee, one on each side (the medial and lateral collateral ligaments) and 2 that form a cross through the middle of the knee (the anterior and posterior cruciate ligaments).

Different ways of falling and twisting the knee predispose you to injure different ligaments, and more than one ligament may be injured in a single fall. Also, because treatment will vary depending on the degree of ligament damage, we use a system for grading the degree of injury;

• Grade 1 – minor sprain with no laxity (excess movement). Less than approx 30% of ligament fibres torn. Usually mild swelling and pain that often resolves in under a week.
• Grade 2 – moderate sprain with some laxity (excess movement) but still a firm “end feel” (a nice solid block that limits the movement). Approx 30-80% of fibres torn. There will be significant swelling and pain, and treatment is definitely required to ensure strong and durable healing.
• Grade 3 – severe sprain or rupture. Excessive laxity with no real end feel – effectively the joint will just keep moving the more you push it. 80% – 100% of fibres torn, which effectively means that the ligament has completely ruptured and does not hold the joint in position any more. Usually marked swelling and pain, although complete ruptures may present more as pronounced instability rather than pain as the 2 torn ends of the ligament are not joined any more and therefore do not get stressed with tension in the ligament.

Most Grade 1 & 2 ligament injuries respond well to physio and a full recovery is made. Grade 3 injuries need full investigation (eg MRI, orthopaedic review) to determine not just the full extent of ligament damage but also the usual damage to other structures like cartilage that often accompany Grade 3 knee ligament injuries.

Signs that you have a significantly damaged a knee ligament can include;

• Swelling, especially if this occurs rapidly eg within a few hours. Aggressive swelling, i.e. a large amount within 1-2 hours, strongly suggests a haemarthrosis (bleeding into the joint) and this should be investigated & treated ASAP.
• The knee does not seem to be aligned in it’s normal position
• You hear a “popping” sound or similar during your fall
• You are unable to take at least a moderate amount of weight through your knee due to pain &/or instability (just feels like it will give way)
• You aren’t able to fully straighten your knee
• There is sharp localised tenderness over 1 or 2 areas of your knee

If you have these signs then you should start RICE treatment straight away & go to see a physio or doctor ASAP. Getting treatment as early as possible is enormously beneficial to prevent secondary problems such as excessive swelling, muscle tightness, further injury due to more pressure through the knee, and muscle wasting due to reduced knee function.

As mentioned before you may injure more than 1 ligament in a single injury, &/or may injure other structures such as knee cartilage and bone. Below is a summary of the 2 most common knee ligament injuries – the medial collateral ligament (MCL) & the anterior cruciate ligament (ACL). Please remember that this info is for general advice only – please see your physio for an individual assessment of your knee.

Medial Collateral Ligament (MCL) Sprains

This is the commonest ski injury & accounts for around 25% of all ski injuries. It is often associated with the snow-plough position (ie skis wider apart & pointed inwards) & so is common in beginner skiers. It can also be caused by “catching an edge” as you start to go faster, so is also seen in intermediate skiers.

The mechanism of injury is a “valgus” force which is where the lower leg is taken out to the side so your foot moves outwards compared to you knee. This can be associated with an outwards rotation of the ski as well, so the front of the ski moves outwards twisting the knee out with it.

A diagnosis can be made based on the description of the fall (as above), and physical examination. There is usually at least some swelling in the knee, the inside of the knee will be tender to touch, it is often hard to fully straighten or bend the knee or take weight on it, and a valgus stress test whereby the lower leg is moved outwards relative to the knee reproduces pain.

The degree of movement and the “end feel” (ie how the ligament feels at the end of it’s stretched position) helps indicate the degree of injury, although often a full test is impossible initially due to acute pain.

Treatment includes techniques to reduce inflammation as quickly as possible, joint mobilisations (movements) to restore full movement, graded exercises to maintain and restore muscle strength, and proprioception exercises to restore your full balance and reaction times to your knee. These will be tailored later in your program to be specific to skiing & any other type of exercise you wish to return to.

Combining this end-stage proprioception retraining with specific strengthening is vital to ensure a full recovery and reduce the risk of re-injury. Most MCL injuries do not need further investigation (x-ray, MRI) or orthopaedic referral, however if your physio is concerned about the extent of injury further investigation will be arranged.

Anterior Cruciate Ligament (ACL) Sprains

ACL sprains account for about 15% of skiing injuries. They are one of the more serious knee injuries, partly because a full ACL rupture produces a very unstable knee that requires surgical repair (a “knee reconstruction”), and also because a fall that is bad enough to produce an ACL injury will often also injure other ligaments, bone or cartilage.

ACL injuries mainly occur when the tibia (shin bone) is sheared forwards on the femur (thigh bone), or when the knee is hyperextended (instead of bending backwards the shin bone is rotated forwards).

Because of the angle of the ski boot and the fact that the ankle is in a fixed position, if the back of the ski catches or hits first then the back of the ski boot drives the upper calf forwards, shearing the tibia forwards on the end of the thigh bone and damaging the ACL. The ACL also plays a role in controlling rotation of the knee so if this forward shearing is also associated by a rotation force then the ACL is very prone to injury. Hyperextension may occur if you catch an edge and the ski slows and changes direction and you effectively go forwards over towards the front of the ski.

There are 2 classic things that people report with ACL injuries. The first is hearing a “pop” during the fall (this may sometimes also be loud enough to be heard by other people nearby), and the second is a large swelling that appears rapidly (within 1-2 hours). This aggressive swelling is called a haemarthrosis, which means bleeding directly into the joint.

Other common things that people report after an ACL injury are moderate to severe pain (interestingly, sometimes complete ACL ruptures are not very painful because the 2 torn ends have no tension through them), inability to put weight through the knee, instability and feeling like the knee may just give way underneath them, and loss of range of movement.

Assessment in the clinic includes a thorough history and then several specific tests to check for the integrity of the ACL. If an ACL injury is suspected then you will be referred for orthopaedic assessment and usually an MRI. The earlier this is done the better especially as associated cartilage injury is relatively common, however some current schools of thought advocate delaying surgical ACL repair until the acute inflammation has resolved. Either way, early physio to reduce swelling, restore range and maintain/improve quads muscle function are extremely beneficial.

Partial tears of the ACL are treated in similar ways to partial tears of other ligaments, however complete tears routinely require surgical repair, especially if you plan to continue skiing and most other sports. Following surgical ACL repair physio is vital for progressing back to full function and minimising the risk of future problems. Depending on the surgery performed, any associated injuries, and your individual recovery pattern, return to full sporting activity is usually from 9 to 12 months and you may require a brace to help support your knee when skiing.

So, now you have a little background on the common ligament injuries encountered when skiing. Basically if you have a knee injury that limits your weightbearing or movement, produces some swelling or any feelings of instability then you should be assessed by a physio as early as possible. This is important not just for a speedy recovery from this injury, but is also vital for preventing secondary problems and potentially more injuries in the future due to incomplete recovery. Enjoy your time on the slopes

Shoulder pain can be one of the most debilitating injuries for people to live with. If you are experiencing a sharp catch of pain when taking you arm above your head you may be suffering from a shoulder injury known as rotator cuff tendinopathy.

The rotator cuff muscles are a group of muscles that sit around the shoulder. Their primary function is to stabilize the shoulder in its socket. If a person is participating in regular overhead activities such as swimming or tennis and these muscles are not properly conditioned the shoulder loses it overall stability and the tendons of these muscles can become pinched against the bony surfaces. Over time this leads to the tendons becoming inflamed, thickened and weakened. If shoulder pain is left untreated the symptoms can increase in both severity and frequency.

The first line of treatment for settling this condition is to reduce the inflammation in the tendons. This is best achieved through a combination of electrotherapy devices administered by a physiotherapist and regular icing and anti-inflammatory medications.

Once the inflammation has settled correcting the causative factors is critical to ensuring long term recovery of the shoulder. Two of the most common factors affecting correct shoulder function are muscle tightness and rotator cuff weakness.

The most common area where muscle tightness predisposes a person to rotator cuff tendinopathy is at the back of their shoulder. Excessive tightness in this area changes the resting position of the shoulder so that the shoulder sits slightly elevated and slightly forward. This change in the resting position of the shoulder means that the tendons of the shoulder are more likely to become pinched by the bony surfaces when attempting any arm movement.

If weakness is apparent in the rotator cuff muscle groups the shoulder is less stable and movement will not be as well controlled. Repeated overhead work or repetition of a specific task that requires the rotator cuff muscles to work predisposes a person to rotator cuff tendinopathy. Individuals are unable to control their shoulder movement leading to pinching of the tendons against the bony surfaces. Over time the repetition of shoulder movement and the pinching of the tendons will lead to thickening and weakening and increasing overall recovery time.

Early diagnosis and management of shoulder pain is essential to ensure recovery time is minimized. Physiotherapy can assist in also correcting any predisposing factors contributing to the condition to ensure long term recovery of your shoulder.

I hope you don’t mind another article primarily about running injuries today, but with the onset of the Sydney running festival upon us, but we’re seeing an awful lot of them at the minute!

But this one isn’t just for runners, it’s about using custom made orthotics and is relevant for anyone with pain in their foot, ankle, Achilles, shins and knees.

First up, rather than me re-writing a whole load of info, just check out  for some great background reading on common leg and foot conditions.

Custom made orthotics are inserts made specifically for you that fit in to your shoes to correct your foot position. Correct foot position is vital for efficient functioning of the joints and muscles not just in your feet, but of your whole lower limb and can also affect your pelvis and spine.

It’s important to note that although you can buy orthotics off-the-shelf from many pharmacies and sports stores, these “one-size-fits-all” orthotics are not designed specifically to be right for your foot and therefore are much less likely to be effective. It’s kind of like buying a one-size-fits-all T-shirt – if you happen to be the right size then it’ll be great for you, but most people won’t be the “standard” size so it won’t fit well at all.

As well as runners, other groups of people who we regularly treat that benefit from custom made orthotics are;

Sports groups:

• team sports which involve a lot of running and pivoting such as rugby, football, hockey & netball
• racquet sports
• gym users who do a lot of classes such as Pump and Body Attack
• people who use personal trainers for boxing, boot camps etc…

Occupational groups:

• people who are on their feet a lot such as retail sales
• people who are on their feet all day in work boots such as store-men, pickers-&-packers, labourers
• people who have to wear more

Often if you have problems that initially respond to treatment but then plateau and persist at a low level, or settle for a while and then recur in the future, it’s because there’s something going on in the background that is causing the imbalance within your body to keep coming back. In the case of leg and foot problems, poor foot position (or poor foot biomechanics) is often the culprit.

So custom made orthotics is a valuable treatment option not just to help your current problems fully settle down, but to minimise the risk of them coming back in the future. Check the rest of the website through the link above to get lots more information about how poor biomechanics can cause a multitude of problems, and also how orthotics can help you.

I hope you find this information really helpful. Please feel free to email me through any questions you have, or suggest topics for future posts that would help you out.

Cheers, Chris

With the upcoming Sydney Morning Herald half marathon fast approaching many of you would have started to develop little aches and pains as a result of your training schedules.

Recently, we have seen a lot of people complaining of sore shins and knees, and these are two of the most common areas to be injured while running. Both areas can cause severe pain and interfere with training schedules but the good news is they are both very treatable and with proper management you shouldn’t be sidelined for too long.

First of all, what causes shin pain? The most common area to develop shin pain is on the inside of the shin roughly 5-10cm above the inside ankle bone. This type of pain is classically termed ‘shin splints’. The muscles on the inside of the shin are not very strong and if they are overloaded through a sudden increase in training, running too frequently on harder surfaces or through poor foot biomechanics then the muscles can become very tight and begin to pull on the bone at the front of your leg called your tibia.

If we continue to run through this tightness the lining of the bone called the periosteum begins to become inflamed and tenderness and pain develops. The best approach for treating this condition involves an initial rest period including regular icing and anti-inflammatory medication. Soft tissue work to the muscles on the inside of your shin should also be commenced to reduce any tightness that exists to reduce the chances of the muscles continuing to pull on the bone.

To prevent the pain returning a thorough biomechanics assessment should be completed to ensure any factors contributing to the cause of your pain can be addressed and corrected by your physiotherapist. Effective long-term correction is really important because chronic over-stress of the tibia in this way may lead to stress fractures and much more extended periods off running.

Similar to shin pain, knee pain is often caused by a sudden increase in training, running too frequently on harder surfaces, or because of faulty leg biomechanics. The muscle of the inside of our knee is called our vastus medialis oblique, or VMO. This muscle acts to keep our knee-cap in the correct position. If this muscle has become weakened or is not strong enough to withstand regular running then the kneecap can be pulled out of position, causing rubbing on the back of the kneecap and producing pain.

The good news is that rapid short-term relief can often be achieved by taping your kneecap to hold it in the right position. This minimises training disruption and time out of running, but remember it is only really a temporary fix and must be combined with a proper assessment to find and correct the real cause of the problem.  An effective long-term fix usually includes core stability to improve hip biomechanics, VMO strengthening, biomechanics correction, and focussed stretching.

Basically, once you have sorted out all of these factors then they will hold your kneecap in the right place and you will no longer need the tape. However, if you just tape and don’t fix these other things then once you stop taping then your kneecap will start to shift out of position again and your problems are likely to recur.

Like most things that go wrong with our bodies both of these conditions are so much easier to treat when they are at their initial “niggle” stage, rather than at their full-blown painful stage. So a big key for anyone in a training program for an event is that if you have a “niggle” get it checked early – your relief will be faster, your training will be less disrupted (if at all!), and it will often be good for your wallet because early intervention usually means less visits to the physio.

So good luck to all of the people getting out there this Sunday in the Sydney ½ marathon, and also those in training for the Gold Coast marathon in July!