Return to Play Predictors for Hamstring Strains

Not sure where I found this, but it adds another dimension to the return to play discussion.

The following have been found to be significant predictors of length of recovery:

 Higher V.A.S at the Time of Injury: high correlation (r=0.77) between pain, measured by visual analog scale, and days lost from competition. Interestingly, in this study pain was a more accurate prognostic indicator than clinician’s assessment.

Recent Past History of Hamstring Injury (Within 12 Months): within the last 12 months were 4.2 times more likely to take greater than 3 weeks to return to play.

Time to Walk Pain Free: athletes that took longer than 24 hours to walk pain-free with a normal gait pattern where 4 times more likely to take longer than 3 weeks to return to play than those who did not.

Location of Strain (Medial vs. Lateral): site of injury i.e. biceps femoris, was a significant predictor of longer recovery time. Biceps femoris strains being 2.3 times more likely to take longer than 3 weeks to recovery.

Return to play strategies for sports injuries

I was doing a bit of research about assessing players for return to play after injury and came across an article from the Clinical Journal of Sports Medicine in 2005 looking at return to play after muscles strains. In my first year as a therapist with a local rugby club I've found myself having to deal with muscle injuries and helping a player decide when they are ready to return to play.

Every player and every injury is subtly different, but there are of course some general principles that apply. Normally I assess muscle strength and pain-free ROM as the basic tools for the decision. Of course some players make their own decisions, as do many athletes!

The approach you take to return to play strategies will broadly speaking be either a conservative approach, i.e. erring on the side of caution to avoid recurrence of the injury, or looking for an earlier return without being reckless. The paper I was reading provided a table looking at the factors that could affect early return or a more cautious approach.

Factors Indicating a More Conservative Approach	Factors That May Allow More Rapid Return to Play
Persisting strength deficit	Strength equal to uninjured side
Persisting flexibility deficit	Flexibility equal to uninjured side
Inability to complete full training without pain or limping	Ability to do all functional activities at training
Large area of abnormal signal on imaging	Normal ultrasound and/or MRI scan
100-m sprinter or team player in high-risk position (Australian footballer, rugby outside back, wide receiver, outfield soccer player)	Team sport player in low-risk position (e.g., offensive lineman, goalkeeper, rugby forward, basketball player)
Older player	Younger player (but with experience of playing with injury)
Early stage of season	Playoff or must-win game with no adequate replacement player
Strain in high-risk location (biceps femoris, central tendon of rectus femoris, medial head of gastrocnemius, adductor longus or magnus)	Strain in low-risk location (semimembranosus, vastus muscles, lateral head of gastrocnemius, gluteal muscles)

Some of the points are quite interesting. For example, the difference of approach depending on the position in a team setting, or the location of the strain.

The table suggests that simply taking into account strength, flexibility and functional activity should not be the only things to consider. 

As a therapist I'm often under pressure from both the player and coach to pass them fit as soon as possible, but this table gives some weight to choosing to be more conservative when other criteria are applied.

I found the original article here: Return to play following muscles strain

 

Identifying SLAP Lesions

Here's an interesting short piece about the usefulness of some clinical tests for SLAP Lesions.

If like me, you see a range of shoulder injuries, then knowing some of the basic clinical tests you can do to get an idea of what's going on is always helpful. This article on the The Sports Pysiotherapist's website is a useful discussion of some, but not all, the tests.

As a Sports Massage practitioner I'm not a clinician, but that doesn't mean I can stop learning about these things!!

Injuries and recovery in sport: The impact of smoking

I'm coming to the end of my first season looking after an amateur rugby club and I have to say it's been an interesting 9 months so far! We've had a few blood injuries, two that needed stitches. One of those was a quite spectacular nose injury that required 14 stitches.

Most injuries were less dramatic and were a mix of impact, overuse and over-exersion. Ligaments, tendons and muscles all came in for a fair battering and as the season unfolded the amount of tape on shoulders and ankles seemed to expand exponentially.

I've been trying to read as much as I can about injuries and recovery and rehabilitation. I've been looking for courses too, but to no avail. The only short CPD courses I can find run at the weekend and I'm pitch-side on those days.

One of things that I've been thinking about a little is the impact that smoking might have on recovery and rehabilitation. A number of the players smoke, and I was wondering what effect this was having on their ability to avoid injury and to recover from injury.

There are obviously a lot of studies that have demonstrated the various links between smoking and diseases such as cancer and cardiovascular issues. As yet I haven't found a lot of data about smoking and injury recovery, although I did come across a couple of studies that show that both bone fractures and ligament sprains take significantly longer to heal in smokers than in non-smokers. That's not unexpected given the impact smoking is known to have on general health.

Bone fractures can take up to 25% longer to heal and the risk of non-union occurring is 2.3 times higher for smokers. A study of the effect of smoking on recovery after medial ligament surgery in mice indicated a slower recovery process.

Everyone knows that smoking is bad for you, but if you're involved in sport at any level, then the impact smoking has on your general health is only one factor you should consider alongside the effect it has on your performance and your potential to recover quickly from injury and therefore return to the field of play.

The two reports I found were:

Blowing Smoke: A Meta-Analysis of Smoking on Fracture Healing and Post-Operative Infection

and

Cigarette smoking impairs ligament healing, researchers find

There's obviously a lot more reading to do, assuming I can find the information, but it is at least a potentially useful place to start when suggesting that maybe a player should give up smoking if they want to avoid longer than necessary times out of the game.

The Vital Glutes: A Review

It was the second or third week working with a local rugby team that one of the prop forwards came to me by the side of the pitch and asked if I had anything I could put on his aching back. It was a late summer day and the ground was dry, so I told him to lie down on his back and I'd have a quick look. I did a simple stretch of his hamstrings and glutes and asked him to stand up and tell me if anything had changed. To his surprise the pain had gone and he announced to all the other players that it was wonderful, I'd put him on his back, bent him over and fixed his back! It took a while for the laughter and suggestions to die down from that one!

I did this simple stretch because ever since I trained as a therapist I'd become aware of the connection between lower back pain and tight muscles around the hip. I've seen a number of client respond well to working through this chain of muscles.

John Gibbons's book "The Vital Glutes" confirms the importance of these muscles in addressing not just power back pain but many other issues that may have a connection to weak or inhibited, misfiring gluteal muscles.

The book looks at the functional anatomy of both GMax and GMed after exploring muscle imbalance and myofascial slings. There are some really helpful insights for both understanding what might be at the root of a presenting issue and for clinical practice.

The book also has quite a detailed discussion of the gait cycle in the context of the role of the glutes. At the end of the book there is a section showing a wide range of progressive exercises that can be used with clients in rehabilitation.

As a Sports and Remedial Massage Therapist I found this book accessible and definitely worth the read. I shall go back through it, picking out useful points and ideas for my practical work with clients. Yes, there are parts that will tax your brain as you try to get your head around things like force and form closure and the gait cycle if you haven't done that sort of stuff before. But it's certainly not beyond the scope of most massage practitioners who studied at a reasonable level and know their way around the anatomy and physiology they learnt as a student.

For most therapist anatomy is learnt in terms of origins, insertions and action of individual muscles, but muscles don't work in isolation. This book should convince you that understanding the wider picture of movement and the influence of one muscle on another is something in which you should invest some thinking time.

PFP Event

This popped up on my Twitter feed the other day. I was wondering about going, but haven't decided yet. Given the number of people who complain about knee pain, it might be 3 hours well spent!

Here's a link to the Eventbrite booking page for the seminar.

ITB Pain

Came across this article on ITB Pain, its sources and solutions.

I remember having a difference of opinion with a few folk when I was doing my PT course about whether you could stretch the ITB or not. I'm glad to say I argued the case for not and this article agrees with me!

The article looks at friction and compression as the potential sources of ITB pain and favours compression arguing that it's simply not possible for friction to be the culprit. Sadly there's no discussion of adhesion as a possible factor and I wonder if that's because it's not considered to be significant. Anyway, it's worth a read.