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BONE STRESS INJURIES AND THE EFFECTS ON BONE MINERAL DENSITY

By Ali McGill

25/06/2024

People with BSIs generally have pain that develops gradually and worsens with weight-bearing activities, and sometimes have swelling and tenderness at the injury site.

BSIs in runners commonly are in the tibia. These injuries often require a prolonged recovery period, and there is a high rate of reinjury. Popp et al. (2021) investigated the effects of a tibial BSI on the Bone Mineral Density (BMD) of female athletes. They evaluated 30 female athletes aged 18-35 years, all diagnosed with a tibial BSI. The athletes all underwent an initial period of reduced weightbearing, such as walking with crutches or a pneumatic walking boot.

From time of BSI diagnosis to 12-weeks post diagnosis, all measures of BMD declined by between 60%-95% in both the injured and uninjured legs, indicating that reduced weightbearing associated with the initial management of a BSI affects the BMD in all weightbearing bones. Weightbearing physical activity was at its lowest during the first 8 weeks of the study then steadily increased, while BMD continued to decrease until 12 weeks before beginning to increase again. This finding indicates that reintroducing higher level weightbearing and impact loading of bones takes some time to begin to produce noticeable changes in BMD. Therefore, the critical time to ensure safe and cautious progression of weightbearing is at least the first month, as re-loading in this period involves increasing the impact load on bones that may be briefly continuing to decline in BMD.

By 24 weeks, bone measurements returned to near-baseline values, and had surpassed baseline values by 1 year post-injury. 10 of the 30 participants (1/3) experienced a subsequent BSI during the re-loading period of the study. Participants of a younger age, who’d had a later age of menarche, and who’d had previous BSIs were more likely to sustain a second BSI.

To summarise, bone density declines in both legs post-BSI and does not return to baseline for 3-6 months. It’s vital to cautiously re-load impact and weightbearing to avoid overloading bones that may continue to have reduced BMD for 4 weeks. Please see your physiotherapist if you have any running-related pain or injuries.

ROTATOR CUFF TEARS AND TENDINOPATHY

By Ali McGill

29/02/2024

Structural changes in muscle tendons:

• Type 1 collagen is the most abundant connective tissue in tendons, but these can degenerate over time, in response to injury or due to metabolic conditions (such as diabetes). This phenomenon is termed “tendinopathy, and this process can affect a tendon’s:

• tensile strength ie. the ability to transmit force from muscle to joint

• shock absorption

• innervation and blood supply, leading to a potential increase in sensitivity and increased risk of tears

MRI and ultrasound are the preferred imaging modalities for imaging and evaluating tendon tears. Important to note however, is that tendon abnormality seen on imaging does not always diagnose the cause of your pain, as many people with asymptomatic pain-free shoulders demonstrate rotator cuff tears or tendon abnormality on imaging. In adults over the age of 60, 66% of rotator cuff tears found on imaging are asymptomatic. The use of routine scanning for cuff tears therefore remains debated in terms of efficiency. Your physiotherapist can refer you for necessary imaging as they see fit to assist in the diagnosis and management plan for your painful shoulder condition.

Management of rotator cuff tendinopathy

The two treatment pathways for rotator cuff tendinopathy are; Non operative management such as lifestyle changes, physiotherapy and injections or shockwave therapy; and operative management, which consists of a subacromial decompression surgery to increase the available anatomical space for the tendons to pass through.

Management of rotator cuff tears

In the case of an acute rotator cuff tear, urgent referral to a specialist surgeon is advised to discuss the potential for surgical management and repair. Indications that support surgical tendon repair are:

• High energy traumatic injuries

• People in high performing roles that require shoulder use for their sport or hobby

• People under 50

• In the case of non-traumatic tears: where non-operative management including physiotherapy for >3 months has failed and patient has persistent pain and dysfunction

Non-operative management - physiotherapy

Physiotherapy for rotator cuff tears involves manual therapy and exercise, focusing to ameliorate modifiable risk factors such as strength of deltoid, pectoral muscles, glenohumeral internal rotation deficit, weak stabilizing, core muscles and weak and tight pelvic girdles. Exercise therapy is especially useful in the elderly population where surgery prognosis is poor.

Non-operative management - injections

Corticosteroid injection is an option for those with shoulder pain that is restricting rehab. It improves short term outcomes such as pain, function, insomnia and allow the development of deltoid muscle function. It may however increase the risk of tendon tears, which has been suggested by some studies. 

Mechanical loading on bone can improve your Bone density.

Specific exercises can make you develop stronger bones by ‘building bone'.

Strengthening muscles helps bone density which helps in Prevention of stress fractures.

Osteoporosis only gets worse with age, However exercise can slow this down and improve bone density,combined with good nutrition including foods containing Calcium and maintaining good levels of Vitamin D.

Physical activity causes an increase in loading bone and with extra exercises, it loads up more to adapt the bone to remodel and lay down strong bone.

You are never too old to exercise, even with  osteoporosis.

To prevent falls and fractures you need supervised exercises by your Physiotherapist. Balance,

functional and resistance training can result in a 60% reduction in falls resulting in fracture.

Good resources:
Healthy Bones Australia ‘
Garvan Institute 
Healthybones.org.au
Australian Institute of Sport 
LIFTMOR trial 
Medexop trial

Photo ref: The bone and joint centre

01.08.22

RUNNING AND OA

Is Running good for Knee Osteoarthritis?

The latest research into the benefits for knee health are very positive in terms of  moderate distance running [up to 10 km 3 x per week]. The perception from some of the research  suggests that the public believe ‘running is bad for knees and causes them to wear out ‘.This just isn’t the case .  La Trobe Exercise and Sports Medicine Research   Centre ,suggests that moderate running may have a protective effect on knee health ,promoting an increase in synovial fluid nutrients, which help the  cartilage and joint surfaces .The fact is too little exercise increases our risk of OA[ osteoarthritis]. Moderate distance running protects our knee joints , however elite and professional long distance running or too much exercise increases the risk of OA.

Studies have shown that ‘leisure-time  running ‘ is not associated with increased knee pain, increased radiographic O.A., or increased symptomatic O.A.

Our knee articular joint surface ,is made up of the  superficial  zone, Collagen fibres [ sponge like ],mid-zone Proteoglycans[central core proteins]and  the deep zone ,Chondrocytes and then the Subchondral bone .

The effect of exercise and physical activity  walking and moderate running ,on the joint surface ,is that it nourishes the joint with synovial fluid  via ‘dynamic load’.

Physical Activity and Exercise Therapy , also has a positive effect on Chronic  Systemic Inflammation .Osteoarthritis is an inflammatory condition.Lack of exercise can lead to an accumulation of visceral fat  which affects our immune cells  which can have an effect on brain cells [Alzheimer’s disease]Insulin resistance [type 2 Diabetes ]and Osteoarthritis .The research also now suggests  Physical Activity and Exercise Therapy including running may prevent 35 different chronic medical conditions .

The facts:

* Recreational Running is not harmful on knee joint articular joint cartilage without symptomatic knee osteoarthritis .

*Participation in recreational running may have a protective effect against the development of knee and hip osteoarthritis .

*Higher rates of knee and hip osteoarthritis  have been reported in non-runners and runners exposed to sustained elite-level training loads .If a runner already has OA they should continue to feel safe to continue running .Running does not appear to accelerate  the progression of exisiting OA in runners > 50 years old .

Load management is the key !

Avoid /minimise consecutive days 24 hours review symptoms [they need to be settled within 24 hours ]Assess running patterns Running cadence and heel strike [take shorter faster steps]Footwear changesstrength and resistance exercises for lower limb to help absorb loadSpeak to your physiotherapist if you have any questions .

04.08.22

RECURRENT ANKLE SPRAIN

Ankle injuries are a very common presentation to  Physiotherapy ,Sports Medicine  &  GP Clinics .  Ankle sprains are the most common injury in recreational physical activities and  sports .  Some people are more  predisposed to  recurrent ankle sprains and this maybe due to  more  intrinsic and extrinsic  factors outlined below .  Reducing the risks of developing  Chronic ankle instability is where your physiotherapist can really help .

Lateral  ligament sprain [ the ligaments on the outside of ankle ] in 40 % of cases can  cause  Chronic Ankle Instability , which can go on to   Post-traumatic Osteoarthritis.

Chronic Ankle Instability is defined by:

Repetitive episodes or perception of the Ankle ‘ giving way ‘

Ongoing symptoms : Pain , weakness, limited Range of motion

Diminished self reported function

Recurrent ankle sprains for > 1 year after initial event

Internal Risk factors

Age: highest ankle sprain incidence female between 10-14 years , male 15-19 years . The highest incident rate of ankle sprain overall was between 15-19 years and individuals between 10 and 24 years of age sustained more than half of all ankle sprains .Interventions to reduce the risk of ankle sprains should be targeted at preadolescents and early adolescents .

Sex:among the general population no difference between male and female in incidence of ankle sprains[considering the substantial ankle sprain incident rate between male and female high school and university age athletes ,players of both sexes should be exposed to risk- reduction interventions .

Body Composition :the risk of sustaining an ankle sprain is affected by body composition .Both body mass and body mass index [BMI]were independent predictors of non contact ankle sprains .

Health: History of Previous Injury

Studies have shown that participants  in studies with a history of ankle sprain  have shown 2 x more likely to incur a subsequent ankle sprain.

Ankle sprains have one of the highest re-injury rates of all musculoskeletal injuries .A history of ankle sprain is a  primary risk factor for recurrent injury .Individuals with a history of  ankle sprain who participate  in physical activity and sports should  pursue specific , targeted , and ongoing exercise -based  injury risk-reduction  programmes . Ankle bracing also has been supported by the research .

Skill Level: Postural Balance -Decreased postural balance [static and dynamic ]has been associated with increased risk of ankle sprain .Postural balance exercises on a regular basis should be part of the prevention programme.

Joint Anatomy and Psychological factors [e.g. competitiveness, motivation, perception of risk]are included in risk factors.

Extrinsic Risk factors 

Indoor and Court sports highest incidence : mens basketball ,women basketball, women’s volleyball, women’s soccer and netball. Athletes who participate in court sports are at a heightened risk of sustaining recurrent ankle sprains and should participate in an on -going exercise based risk- reduction programme and wearing an ankle joint brace to reduce the risk of injury

Physiotherapy Assessment:

Ankle Joint pain

Ankle joint swelling

Ankle joint Range of motion

Ankle joint arthrokinematics

Ankle joint muscle strength

Static postural balance

Dynamic postural balance

Gait

Physical activity Level

Ankle Joint specific patient -reported outcome measures (e.g single leg calf raise, jump, hop)