Acromioclavicular joint injuries

ac-injury

The acromioclavicular (AC) joint is a diarthrodial joint that anchors the clavicle to the scapula and shoulder girdle, it helps distribute forces from the upper extremities to the axial skeleton.[1-4] Static stability at the AC-joint is achieved via the AC-ligaments, capsule, and coracoclavicular (CC) ligaments, whilst dynamic stability is provided by the Deltoid and Trapezius muscles.[1-5] As the AC-joint lies relatively subcutaneously there is little protection from soft tissues, and as such is prone to injury; specifically within contact sports,[2,5-6] i.e. via trauma.  It is reported that AC-joint injuries comprise 9-12% of all injuries to the shoulder girdle,[2-4,6] with males in their 20’s having the highest rate of injury.[2-3,6]

 

As with most traumatic injuries, the AC-joint can be injured by direct or indirect trauma. Direct trauma to the AC-joint is caused when a person lands on the point of their shoulder, as seen in multiple collision sports; which forces the acromion inferiorly and medially.[2-4] Indirect trauma is caused when a person falls on an outstretched hand (FOOSH), and the force is transmitted up the arm forcing the humeral head into the acromion.[1-3] Whether the injury was cause by direct or indirect trauma matters not, the classification is based on structural involvement and displacement present; therefore higher levels of force involved will lead to a higher classification.

There are many methods of classifying ligament or muscle injuries throughout the literature, [7] with the research surrounding AC-joints’ being no different. The most commonly recognized classification is known as the Rockwood classification[1,4] (Table 1). The Rockwood grading system is based on physical and radiographic findings,[1-6] whereas in the clinic it would be down to the level of visual displacement and painful areas upon palpation. Throughout the classifications, the higher classifications of injury are shown to have greater ligamentous involvement and a greater displacement present.

Table 1: AC-joint injury – Rockwood classifications[1,4]

Best treatment for injuries I, II, and IV-VI has been clearly established within the literature.[1-6] Type I and II injuries are treated conservatively with treatment commencing as comfort allows, as for type IV-VI injuries the literature states that open reduction and internal fixation with ligament repair/reconstruction is the treatment which provides best prognosis. However, these authors all agree that type III injuries must be taken on a case-by-case basis. Current trends exist in the literature to show that conservative management provides an earlier return to work and sport[4] with Bontempo and Mazzocca[3] stating that: at a 2 year follow up, non-operatively versus operatively treated type III injuries had no difference in strength after 2 years. That being said Bannister et al. (1989) as cited by Lemos[1] state that those with a displacement greater than 2cm did better with operative intervention, while Bontempo and Mazzocca[3] go on to say that surgery may be indicated in those whose symptoms persist after a full course of rehabilitation.

The primary aim of rehabilitation for an AC-joint injury is to restore pain free Range of Motion (ROM), how quickly this happens will depend on the type of injury and whether this is the first or a subsequent injury. Rehabilitation programs involve modification of the patients’ work and daily activities in the initial phase before gradually introducing and progressing exercises.[1-6] For non-operative treatment, Bontempo and Mazzocca[3] proposed an algorithm (Figure 1), which showed that athletes should go through a 3-month functional rehab program before surgery is considered.

Non-operative-treatment-algorithm-proposed-by-bontempo-and-mazzocca.png

Figure 1: Non-Operative treatment algorithm proposed by Bontempo and Mazzocca[3]

Case Study

As an example, we will take a patient with a Grade II injury: they have a decreased ROM across all shoulder movements, an associated decrease in strength, with pain and laxity present. After assessment the patient would be advised to continue with the P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression, Elevation) principle[8] and to reduce the amount of overhead and heavy work conducted,[1-6] whilst avoiding competitive sport and heavy lifting until cleared.[6] Initially the patient would be placed in a broad arm sling and advised to wear it regularly over the first 1-2 weeks; this advice would be accompanied by passive ROM exercises to prevent the shoulder from becoming stiff whilst in the sling.

 

When pain starts to subside, patients would be advised to wean themselves out of the sling by trying to use their arm for light daily activities. Whilst increasing their ROM exercises, and to begin replacing passive ROM with active assisted exercises and isometric holds throughout range;[2,5] this would include hold-relax proprioceptive neuromuscular facilitation (PNF) patterns for the upper limb.[9]

Once full pain-free ROM has been achieved the patient would begin an upper limb rehabilitation program to strengthen the AC-joint and surrounding structures; to provide additional pain relief during the early stages of the rehab program the AC-joint may be taped.[5-6,10-11] Strength exercises primarily focus on the trapezius and deltoid muscles (table 2), while elements of neuromuscular control (NMC)[5,12-13] would be introduced to strengthen the rotator cuff and additional musculature about the scapulae (table 3).

Table 2: examples of strength rehabilitation exercises

Table 3: examples of NMC rehabilitation exercises

 

To summarize, the AC-joint is a very superficial joint prone to traumatic injuries, for example in contact sports, the higher the levels of force in the injury will generally lead to a higher classification of injury; with it comprising 9-12% of all injuries to the shoulder girdle,[2-4, 6] and males in their 20’s having the highest rate of injury.[2, 4, 6]. The primary method for classifying AC-joint injuries involves both physical and radiographic findings, however in the clinic the grading will rely on the level of visual displacement and painful areas on palpation with Higher levels of force generally leading to a higher classification of injury. The primary aim of rehabilitation for an AC-joint injury is to restore pain free ROM, how quickly this happens will depend on the type of injury and whether this is the first or a subsequent injury. Although type III injuries provide an area of contention within the research, the majority of rehabilitation programs follow a conservative approach similar to that of type I and II injuries. For an injury to the AC-joint, a rehabilitation program will include: modification of the patients’ work and daily activities in the initial phase, before gradually introducing and progressing exercises. This along with NMC and dynamic stabilising exercises would assist in not just rehabilitating the primary injury but assist in preventing further injuries to the AC-joint.

 

References

 

  1. Lemos, M.J., 1998. The evaluation and treatment of the inured acromioclaviculae joint in athletes. The American Journal of Sports Medicine, 26(1), pp. 137-144.
  2. White, B., Epstein, D., Sanders, S. and Rokito, A., 2008. Acute acromioclavicular injuries in adults. Orthopaedics, 31(12), pp. 1219-1226.
  3. Bontempo, N.A. and Mazzocca, A.D., 2010. Biomechanics and treatment of acromioclavicular and sternoclavicular joint injuries. British Journal of Sports Medicine, 44(5), pp. 361-369.
  4. Wright, A.P., MacLeod, I.A.R. and Talwalker, S.C., 2010. Disorders of the acromioclavicular joint and distal clavicle. Orthopaedics and Trauma, 25(1), pp. 30-36.
  5. Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
  6. Fraser-Moodie, J.A., Shortt, N.L. and Robinson, C.M., 2008. Injuries to the acromioclavicular joint. The Journal of Bone & Joint Surgery, 90(6), pp. 697-707.
  7. Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., Van Dijk, C.N., Kerkhoffs, G.M., Schmasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P., 2013. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine, 47(6), pp. 342-350.
  8. Bleakley, C.M., Glasgow, P. and MacAuley, D.C., 2012. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), pp. 220-221.
  9. Kwak, D.H. and Ryu, Y.U., 2015. Applying proprioceptive neuromuscular facilitation stretching: optimal contraction intensity to attain the maximum increase in range of motion in young males. Journal of Physical Therapy Science, 27(7), pp. 2129-2132.
  10. Shamus, J.L. and Shamus, E.C., 1997. A taping technique for the treatment of acromioclavicular joint sprains: a case study. Journal of Orthopaedic and Sports Physical Therapy, 25(6), pp. 390-394.
  11. Kneeshaw, D., 2002. Shoulder taping in the clinical setting. Journal of Bodywork and Movement Therapies, 6(1), pp. 2-8.
  12. Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
  13. Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.

Ankle ligament injuries: Assessment and Rehabilitation

Ankle-Ligament-Injuries

Lateral ankle ligament sprains are the most common injury affecting both general and athletic populations.[1-7] Within the UK and the US approximately 5,000 and 27,000 injuries respectively occur per day,[1] with research showing that the anterior talofibular ligament (ATFL) is injured most frequently.[1-2] The ATFL connects the lateral malleolus to the neck of the talus, forming part of the lateral ligamentous structure of the ankle joint; alongside the calcaneofibular and posterior talofibular ligaments (PTFL).[1,5,9] Due to the biomechanics of the ankle joint, as plantar flexion (PF) increases the soft tissues are more susceptible to strain/injury;[1] with most sprains occurring in PF, adduction and inversion, leading the ATFL to be injured before any other ligament;[1,5] the classic ‘rolled ankle’ or ‘going over on your ankle’

 

In the acute setting, to assess the ankle, simply placing the ankle into: PF, abduction and inversion will be sufficient to elicit pain in the ATFL – this is if the patient will let you. This in conjunction with the anterior draw test[2] and palpation can lead to the diagnosis of an injury to the ATFL. In addition to this assessment a clinician should also check the syndesmosis, via the syndesmosis squeeze test,[9] and assess for creptius at the foot/ankle: for possible Lisfranc injury or a 5th metatarsal fracture, and for crepitus at proximal fibula: attempting to rule out a Maisonneuve fracture. In the acute setting the Owatta ankle rules [1,5,10,11] can be applied to help the clinician decided if an ankle x-ray is required. Research suggests, that due to the bodies healing mechanisms initial soft tissue injury management, P.O.L.I.C.E (Protection, Optimal Loading, Ice, Compression and Elevation),[12] should be commenced and a more thorough assessment should be completed 4 days post injury.[1,4] There are several grading systems available,[1,13] for musculoskeletal injuries and are dependent on the clinician present as to which is used.

 

As research suggests,[1,3-5,14] the treatment of choice for this type of injury should start with P.O.L.I.CE, to reduce pain and swelling; continuing with exercises when able. These early mobilisation exercises should take the form of gentle active range of motion (ROM) exercises e.g. plantar flexion, dorsiflexion, inversion, and eversion.[1,3-5] Early mobilisation provides controlled stresses to the ankle joint and has been shown to speed up the recovery of acute ankle injuries.[1] My personal favourite to say to patients for ROM exercises, is to get them to write the alphabet or spell their name with their foot. To maintain cardiovascular fitness and to help work the ankle functionally, although in a controlled manner, one can use the stationary bike or elliptical.

 

When the patient is able to progress with their exercises, the progressions should always be functional in nature, with an element of proprioception/neuromuscular control (NMC).[1,3-5] Due to the importance of restoring NMC,[3,5] NMC exercises should be afforded their own time slot; as insufficient NMC is a contributing factor to both initial and secondary injuries.[15] Functional treatment is based on the healing process of a ligament: during the first 3 weeks as new collagen tissue forms it is necessary to prevent unwanted inversion as this will lead to a weaker collagen being laid down, after 3 weeks the collagen begins to mature and responds to controlled stresses by correcting fibre alignment.[1] The collagen will continue maturing, with a return to activities expected at approximately 4-8 weeks.[1] Manual mobilisations, ultrasound, laser and electrotherapy were shown to have limited/no added value to ankle ligament rehabilitation.[4]

 

Rehabilitation exercises, no matter their guise; be it strength, flexibility, or NMC, are always commenced on a stable surface. During a NMC session, the goal is to provide greater kinesthesia through better communication between the neural and muscular systems. Therefore to progress NMC exercises from a stable base, the exercise could include external perturbations (catching/throwing an object), be conducted on an unstable surface (foam pad/mat/beam), having a flight phase included,[16-17] or by combining progressions. An example here would be a single leg stand; this can be progressed by: throwing and catching a ball (reaching out of the base of support), standing on an unstable surface, and standing on an unstable surface whilst throwing and catching a ball.

 

An example rehabilitative exercise for the ATFL is the Step-up; whilst this may primarily be used for strength, it can have a great NMC adage. The step-up should only be commenced once the patient is: 1) fully weight bearing, 2) able to take their full weight on a single leg, and 3) is confident in stepping up through their injured side. Initially the step-up can be conducted onto a shallow box (Figure 1), which can be made higher (Figure 2) as the patient progresses.

Figure-1- Shallow-box
Figure 1: Shallow box
Deeper-Box
Figure 2: Deeper box

Stages

  1. To start, the patient will stand facing the box (Figure 3), before stepping onto it leading with the injured side (Figure 4). The patient will stand up achieving full extension (Figure 5), before stepping back down in a controlled manner.
    Figure-3-Start-position
    Figure 3: Start position
    Figure- 4-Stepping- onto- box
    Figure 4: Stepping onto box
    Figure 5: Top position
    Figure 5: Top position

2.Adding a foam pad/mat onto the top of the box to create an unstable surface (Figure 6), then continuing as in 1.

 

Figure 6: Foam pad progression
Figure 6: Foam pad progression

3. Stable box; upon stepping up onto the box, adding in a hip/knee drive of the contralateral leg (Figure 7)

Figure 7: Hip/knee drive progression
Figure 7: Hip/knee drive progression

4. Foam pad/mat on box; stepping up onto the box with a hip/knee drive of the contralateral leg (Figure 8)

Figure 8: Foam pad + hip/knee drive progression
Figure 8: Foam pad + hip/knee drive progression

5. Stable box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 9)

Figure 9: Flight phase progression
Figure 9: Flight phase progression

6. Foam pad/mat on box, hip/knee drive of the contralateral leg: achieving flight phase (Figure 10)

Figure 10: Foam pad + flight phase progression
Figure 10: Foam pad + flight phase progression

In addition to the foam pad/mat to progress the exercise the therapist can add in perturbations, these could be visual or physical perturbations. Visual perturbations could be advantageous for athletes, as they have to take in a lot of external information whilst remaining focused for their task at hand. The step-up is a very versatile exercise; in that it can be altered to conduct a side step-up (Figure 11), a step-up with an eccentric step down (Figure 12), a weighted step-up (Figures 13 and 14) +/- an eccentric step down

Figure 11: Side step up
Figure 11: Side step up
Figure 12: Eccentric step down
Figure 12: Eccentric step down
Figure 13: Weighted step up
Figure 13: Weighted step up
Figure 14: Weight step up
Figure 14: Weight step up

In summary, from the available research lateral ankle ligament sprains are the most common injury to affect both the general and the athletic populations, with the ATFL is injured most frequently. An increase in pain when placing the ankle into: PF, abduction, and inversion, combined with an increase in pain during the anterior draw test, and pain on palpation over the ATFL is sufficient to point towards an ATFL injury. Although it is very important for the clinician to still think about concurrent injuries: Ottawa ankle rules, Syndesmosis injury, Maisonneuve fracture, Lisfranc injury, 5th metatarsal fracture etc. An acute injury to the ATFL responds well to the P.O.L.I.C.E principle and early mobilisation, and should then be fully assessed 4 days post injury. This early mobilisation will provide the basis for sport specific training i.e. strength and NMC. NMC is one method by which the ankle can be made more stable; and as such reduce the likelihood of recurrent sprains/ankle instability.

 

Opinions expressed by physiogramworld contributors are their own.

References

  1. Lynch, S.A. and Renström, P.A.F.H., 1999. Treatment of acute lateral ankle ligament rupture in the athlete: conservative versus surgical treatment. Sports Medicine, 27(1), pp. 61-71.
  2. Tohyama, H., Yasuda, K., Ohkoshi, Y., Beynnon, B.D. and Renström, P.A.F.H., 2003. Anterior drawer test for acute anterior talofibular ligament injuries of the ankle: how much load should be applied during the test? The American Journal of Sports medicine, 31(2), pp. 226-232.
  3. Gutierrez, G.M., Kaminski, T.W. and Douex, A.T., 2009. Neuromuscular control and ankle instability. PM & R: The Journal of Injury, Function, and Rehabilitation, 1(4), pp. 359-365.
  4. Kerkhoffs, G., Van Den Bekerom, M., Elders, L.A.M., Van Beek, P.A., Hullegie, W.A.M, Bloemers, G.M.F.M., De Heus, E.M., Loogman, M.C.M, Rosenbrand, K.C.J.G.M., Kuipers, T., Hoogstraten, J.W.A.P., Dekker, R., Ten Duis, H.J., Van Dijk, C.N., Van Tulder, M.W., Van der Wees, P.J. and De Bie, R.A., 2012. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), pp. 854-860.
  5. Brukner, P. and Khan, K. 2013. Clinical sports medicine. 4th Australia: McGraw-Hill Education.
  6. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016a. A 2016 consensus statement of the International Ankle Consortium: Prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp.1493-1495
  7. Gribble, P.A., Bleakley, C.M., Caulfield, B.M., Docherty, C.L., Fourchet, F., Fong, D.T.P., Hertel, J., Hiller, C.E., Kaminski, T.W., McKeon, P.O., Refshauge, K.M., Verhagen, E.A., Vicenzino, B.T., Wikstrom, E.A. and Delahunt, E., 2016b. Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. British Journal of Sports Medicine, 50(24), pp. 1496-1505
  8. Platzer, W. 2009. Color atlas of human anatomy: Locomotor system. 6th Stuttgart: Thieme.
  9. Sman, A.D., Hiller, C.E., Rae, K., Linklater, J.L., Black, D.A., Nicholson, L.L., Burns, J. Refshauge, K.M., 2013. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. British Journal of Sports Medicine, 47(10), pp. 620-628.
  10. Bachmann, L.M., Kolb, E., Koller, M.T., Steurer, J. and ter Riet, G., 2003. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal, 326(7386), pp. 1-7.
  11. Beckenkamp, P.R., Lin, C.W.C., Macaskill, P., Michaleff, Z.A., Maher, C.G and Moseley, A.M., 2016. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. British Journal of Sports Medicine, Online First, pp. 1-8
  12. Bleakley, C.M., Glasgow, P. and MacAuley, D.C., 2012. PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine, 46(4), pp. 220-221.
  13. Mueller-Wohlfahrt, H.W., Haensel, L., Mithoefer, K., Ekstrand, J., English, B., McNally, S., Orchard, J., Van Dijk, C.N., Kerkhoffs, G.M., Schmasch, P., Blottner, D., Swaerd, L., Goedhart, E. and Ueblacker, P., 2013. Terminology and classification of muscle injuries in sport: The Munich consensus statement. British Journal of Sports Medicine, 47(6), pp. 342-350.
  14. Hossain, M. and Thomas, R., 2015. Ankle instability: presentation and management. Orthopadeics and Trauma, 29(2), pp. 145-151.
  15. Herrington, L., Myer, G. and Horsley, I. 2013. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.
  16. Paterno, M.V., Myer, G.D., Ford, K.R. and Hewett, T.E., 2004. Neuromuscular Training Improves Single-Limb Stability in Young Female Athletes. Journal of Orthopaedic and Sports Physical Therapy, 34(6), pp.305-316.
  17. Coughlan, G. and Caulfield, B., 2007. A 4-week neuromuscular training program and gait patterns at the ankle joint. Journal of Athletic Training, 42(1), pp. 51-59.

Musculoskeletal injuries associated with “underuse” mechanism.

I recently received an e-mail from a supplement company telling me to ‘start my summer prep’, which lead me to think about the stereotypical summer holiday preparation. You have just booked yourself a beach holiday, or a hotel getaway to lounge by the pool, and you begin making preparations: someone to watch the house, someone to look after the cat or dog, you purchase new clothes, and you feel the need to hit the gym to feel more comfortable. Whilst making healthier nutrition choices or becoming more physically active would be sufficient, the subconscious bombardment of the ‘ideal beach bod’ on TV commercials and e- mails such as the one I received, lead people to take up more intense exercise to achieve their goal. This article is going to focus on the injuries associated with the uptake in physical activity (PA) due to an underuse mechanism.

PA has been defined by the National Institute for Health and Care Excellence (NICE) as the full range of human movement, including hobbies such as walking or cycling, and any activities of daily living such as walking up stairs, gardening, or housework.3 PA has been associated with numerous health benefits, such as a reduction in the incidence and mortality associated with: cardiovascular disease, diabetes, obesity, hypertension, and cancer.4,6 As such, there are guidelines published across the world regarding the minimal amount of physical activity that should be achieved by various age groups to attain these associated health benefits.

High levels of physical inactivity are of global concern,7 with many countries

facing an epidemic of physical inactivity8 for example, out of 85 countries, 50%

or less of adolescents achieved the minimum recommendations.9 Physical

inactivity has prompted a rise in diseases (obesity, diabetes etc) and the number

of musculoskeletal injuries (MSKI’s) amongst children and adults.9,10

The World Health Organization (WHO) classifies physical inactivity as the 4th

leading risk factor of global mortality.1 Evidence has shown that those with lower

levels of PA had the strongest association with overall MSKI risk,11,12  with Body

Mass Index (BMI) being significantly associated with injuries of the lower

extremity and the odds of injury increased 6-10% for each unit increase in BMI.5,10,13

Numerous authors have proposed possible mechanisms by which physical inactivity contributes to an increased MSKI risk, some theorized that this was due to low levels of strength and decreased cardiovascular fitness.4,14 Whilst others postulated that increased weight during childhood combined with physical inactivity, affected bone development in load-bearing bones contributing to

skeletal malalignment and/or changes in muscular function.10,13 Essentially, those who were more physically inactive tended to underuse their body.

The idea of the bodies’ susceptibility to injury from underuse is not completely new. As part of a new model for tendinopathies, it was proposed that the underloaded tendon does not receive appropriate physiological stresses; leading to degradation.15 Therefore once the tendon is subjected to activity that is higher in level than that which is normally placed upon it, this will subject the tissues to overload; starting the degenerative cascade of tendinopathies.15 This idea seemed to be a further contribution to the small body of evidence,8 where the authors detail how research typically classifies MSKI’s as ‘acute’ or ‘overuse’ due to reports interpreting that the preceding movement caused a persons MSKI. However the underlying cause for many MSKI’s in a physically inactive population is in fact ‘underuse’; whereby the body is required to move in an unfamiliar method.8

The literature has shown trends that those who are more physically inactive tend to underuse their body, and once they start a period of activity above that which their body is used to, their body cannot adapt and tissues are overloaded causing an injury. Is it then possible to prevent or reduce the likelihood of acquiring an MSKI? In short yes, but how can one go about this?

First lets address previous injuries, so as to start fresh. Previous injuries have been shown to be a significant risk factor for sustaining an injury16,20 due to the incomplete recovery of the earlier injury.18 Research has shown17,19 that those who have had a previous ankle sprain have a 30-50% higher chance of sustaining another ankle sprain, these authors further state that these repetitive injuries are location specific, i.e. a previous ankle injury has the potential to cause another injury to the same ankle.17 So in the lead up to the summer holiday and before beginning any new exercise program, especially if it has been a sufficient time period since the last formalized training period, any previous injuries should be fully rehabilitated. Proper injury rehabilitation can be achieved through a qualified Physiotherapist, Physical Therapist, or an Athletic Trainer

Next up is periodized training; to periodize ones training means to deliberately adjust or manipulate the training volume and intensity over time.21 It is one method of reducing the sudden and abrupt load exerted on the body,22 optimizing performance whilst mitigating injury risk.23 The body has the ability to adapt to any new form of training, however this process takes time,22 as such periodized training is normally formed around macro-, meso- and micro-cycles; ≈ 1-year, ≈ 6-12 weeks, ≈ 1-day respectively.21,23 These cycles allow for greater variety in ones training, changing up the stimuli (types of exercises, reps, sets, rest etc)23,24 received by the body allowing it to adapt, and therefore progress21,23 e.g. to lift a heavier weight, run a longer distance, or run a quicker time. A qualified Sports Physiotherapist, Sports Physical Therapist, Athletic

Trainer or a qualified Strength and Conditioning Coach will be able to assist with training periodization.

The final tip is centred on the warm-up; the multiple benefits of a well-designed warm-up are well known, such as: Injury reduction, faster muscle contraction, increased blood flow and therefore improved oxygen delivery, etc.25-30 Warm- ups will vary dependent on the physical activity about to be undertaken but will generally last 10-30 mins,25 and typically consist of a pulse raiser, stretching and sport specific movements.25-26,31 Warm-ups will typically follow a protocol such as the Raise, Activate and Mobilize, and Potentiate system – aptly named the ‘RAMP’ system.25 Sports governing bodies have listened to the research and recognize the benefits of a well-designed warm-up; as such organizations like Fédération Internationale de Football Association (FIFA), have produced an easy to follow / administer, standardized warm-up: the FIFA 11+.27,30 The research has shown the FIFA 11+ to reduce injuries in young female football players by approximately one third and all severe injuries by half,27 with significantly fewer training and match injuries in amateur players.28

In summary, the MSKI risk is higher in those who are physically inactive, when undertaking PA; due to an underuse mechanism. The evidence has shown that those who are classified as ‘obese’ have a higher MSKI risk than those who are ‘overweight’ or ‘normal weight’, as the risk increased 6-10% for every unit increase in BMI. The greatest risk is for the lower extremities/load bearing bones, which is of particular importance for children and adolescents due to the increased stresses placed on their developing body.

For these more physically inactive populations, while PA may cause the injury, it is due to the underuse of the body. The underuse has led to weakening of the body in general, whereby it cannot cope once the body begins to move in intensities above that which it can handle; especially if in an abnormal pattern. This article provides three simple building blocks to help reduce the likelihood of suffering from an underuse injury in the lead up to the summer. These three building blocks should form questions you should ask yourself prior to starting a new workout or fitness regime, especially after a prolonged period of inactivity or reduced activity:

  • Do I have any injuries I need to sort out first?
  • How am I going to structure my training?
  • What will my warm-up consist of?

References

  1. World Health Organization, 2010.Global recommendations on physical activity for health. WHO Library Cataloguing-in-Publication Data, pp. 7
  2. National Institute on Aging 2016. Exercise and Physical Activity:Your Everyday Guide. Department of Health and Human Services: National
    Institute on Aging Publication No. 17-AG-4258, pp 18
  3. National Institute for Health and Clinical Excellence,2015. Preventing excessive weight gain. NICE guideline (NG7)
  4. Hootman,J.M., Macera,C.A., Ainsworth,B.E., Addy,C.L., Martin,M. and
    Blair, S.N., 2002. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Medicine and Science in Sports and Exercise, 34(5), pp. 838-844.
  5. Janney,C.A. and Jakicic,J.M., 2010. The influence of exercise and BMI on injuries and illnesses in overweight and obese individuals: a randomized control trial. International Journal of Behavioral Nutrition and Physical Activity, 7(1), pp. 1-11.
  6. Mendes,R., Sousa,N., Reis,V.M. and Themundo-Barata,J.L., 2016. Prevention of exercise-related injuries and adverse events in patients with type 2 diabetes. Postgraduate Medical Journal, 89(1058), pp. 715-721.
  7. Gray,C., Gibbons,R., Larouche,R., Sandseter,E.B.H., Bienenstock,A., Brussoni, M., Chabot, G., Herrington, S., Janssen, I., Pickett, W., Power, M., Stanger, N., Sampson, M. and Tremblay, M.S., 2015. What Is the Relationship between Outdoor Time and Physical Activity, Sedentary Behaviour, and Physical Fitness in Children? A Systematic Review. International Journal of Environmental Research and Public Health, 12(6), pp. 6455-6474.
  8. Stovitz,S.D. and Johnson,R.J., 2006.“Underuse” as a cause for musculoskeletal injuries: is it time that we started reframing our message? British Journal of Sports Medicine, 40(9), pp.738-739
  9. Draper,C.E., Grobler,L., Micklesfield,L.K. and Norris,S.A., 2015. Impact of social norms and social support on diet, physical activity and sedentary behaviour of adolescents: a scoping review. Child: Care, Health and Development, 41(5), pp. 654-667.
  10. Shultz, S.P., Anner, J. and Hills, A.P., 2009. Paediatric obesity, physical activity and the musculoskeletal system. Obesity Reviews, 10(5), pp. 576- 582.
  11. Nauta, J., Martin-Diener, E., Martin, B.W., van Mechelen, W. and Verhagen, E., 2015. Injury risk during different physical activity behaviours in children: a systematic review with bias assessment. Sports Medicine, 45(3), pp. 327-336.
  12. Bloemers, F., Collard, D., A Paw, M.C., van Mechelen, W., Twisk, J. and Verhagen, E., 2012. Physical inactivity is a risk factor for physical activity-

related injuries in children. British Journal of Sports Medicine, 46(9), pp.

669-674.
13.Adams, A.L., Kessler, J.I., Deramerian, K., Smith, N., Black, H.B., Porter,

A.H., Jacobsen, S.J. and Koebnick, C., 2013. Associations between childhood obesity and upper and lower extremity injuries. Injury Prevention, 19(3), pp. 191-197.

  1. Trudelle-Jackson, E., Jackson, A.W. and Morrow, J.R., 2011. Relations of meeting national public health recommendations for muscular strengthening activities with strength, body composition, and obesity: the women’s injury study. American Journal of Public Health, 101(10), pp. 1930-1935.
  2. Lewis, J.S., 2010. Rotator cuff tendinopathy: a model for the continuum of pathology and related management. British Journal of Sports Medicine, 44(13), pp. 918-923.
  3. Opar, D.A., Williams, M.D. and Shield, A.J., 2012. Hamstring strain injuries: Factors that lead to injury and re-injury. Sports Medicine, 42(3), pp. 209-226.
  4. Zambraski, E.J. and Yancosek, K.E., 2012. Prevention and rehabilitation of musculoskeletal injuries during military operations and training. Journal of Strength and Conditioning Research, 26(7), pp. S101-S106.
  5. Jacobsson, J., Timpka, T., Kowalski, J., Nilsson, S., Ekberg, J., Dahlström, Ö. And Renström, P.A., 2013. Injury patterns in Swedish elite athletics: annual incidence, injury types and risk factors. British Journal of Sports Medicine, 47(15), pp.1-13.
  6. Fulton, J., Wright, K., Kelly, M., Zebrosky, B., Zanis, M., Drvol, C. and Butler, R., 2014. Injury risk is altered by previous injury: A systematic review of literature and presentation of causative neuromuscular factors. The International Journal of Sports Physical Therapy, 9(5), pp. 583-595.
  7. Saragiotto, B.T., Yamato, T.P., Hespanhol Junior, L.C., Rainbow, M.J., Davis, I.S. and Lopes, A.D., 2014. What are the main risk factors for running-related injuries? Sports Medicine, 44(8), pp.1153-1163.
  8. Nindl, B.C., 2015. Physical training strategies for military women’s performance optimization in combat-centric occupations. Journal of Strength and Conditioning Research, 29(11S), pp. S101-S106.
  9. Sharma, J., Greeves, J.P., Byers, M., Bennett, A.N. and Spears, I.R., 2015. Musculoskeletal injuries in British Army recruits: a prospective study of diagnosis-specific incidence and rehabilitation times. BMC Musculoskeletal Disorders, 16(106), pp. 1-7.
  10. Kraemer, W.J. and Szivak, T.K., 2012. Strength training for the warfighter. Journal of Strength and Conditioning Research, 26(7), pp. S107-S118.
  11. Lauersen, J.B., Bertelsen, D.M. Andersen, L.B., 2014. The effectiveness of exercise interventions to prevent sports injuries: A systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48, pp.871-877.
  12. Jeffreys, I., 2007. Warm up revisited – the “ramp” method of optimising performance preparation. Professional Strength and Conditioning, 6, pp.15-19.
  13. Woods, K., Bishop, P. and Jones, E., 2007. Warm-Up and Stretching in the Prevention of Muscular Injury. Sports Medicine, 37(12), pp. 1089- 1087.
  14. Soligard, T., Mykleburst, G., Steffen, K., Holme, I., Silvers, H., Bizzini, M., Junge, A., Dvorak, J., Bahr, R. and Anderson, T.E., 2008. Comprehensive warm-up programme to prevent injuries in young female footballers: clustered randomised controlled trial. British Medical Journal, 9(337), pp. 1-9.
  15. Junge, a., Lamprecht, M., Stamm, H., Hasler, H., Bizzini, M., Tschopp, M., Reuter, H., Pshch, D., Wyss, H., Chilvers, C. and Dvorak, J., 2010. Coutnrywide campaign to prevent soccer injuries in Swiss amateur players. The American Journal of Sports Medicine, 39(1), pp. 1-7.
  16. Soligard, T., Nilstad, A., Steffen, K., Mykleburst, G., Holme, I., Dvorak, J., Bahr, R. and Andersen, T.E., 2010. Complience with a comprehensive warm-up programme to prevent injuries in youth football.
  17. Herman, K., Barton, C., Malliaras, P. and Morrissey, D., 2012. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC Medicine, 10(75), pp. 1-12.
  18. Fletcher, I.M. and Jones, B., 2004. The effect of different warm-up stretch protocols on 20 meter sprint performance in trained rugby union players. Journal of Strength and Conditioning Research, 18(4), pp. 885-888.

Opinions expressed by physiogramworld contributors are their own.