General Rehabilitation

Ice Massage

Ice massage is a therapeutic technique that can benefit both acute injuries and chronic tendon and ligament problems.

There is evidence that massaging in non-steroidal anti-inflammatory gels (like Voltaren Emulgel) can benefit inflammatory conditions in tissues that are immediately under the skin. These gels can be purchased over-the-counter from most pharmacies, without prescription. (Unfortunately there is little proven benefit for using these gels on deeper structures like the rotator cuff in the shoulder).

Instructions
  • Take a polystyrene coffee cup (like McDonald’s serve their coffee in)
  • Fill it with water and freeze it solid
  • Peel off about 2cm of the rim, so that 2cm of ice-block is exposed - this gives you a solid block of ice that you can hold without freezing your fingers
  • Apply a blob of anti-inflammatory gel (about the size of a 20-50 cent piece) to the affected area
  • Massage this in for 10 minutes by the clock!

For an acute injury, massage gently. For a longer standing problem, massage firmly enough to be uncomfortable, but not so hard as to cause pain. If it is getting painful, move the zone of massage away – nerves in particular don’t like ice massage. Keep peeling the cup away as needed. Return the ice-block to the freezer when you have finished. You may need to wrap it in gladwrap if you have a frost-free freezer

Ice massage can be performed as often as comfortable, but should be done at least once each evening If there is swelling, an ice-pack for 10 minutes every waking hour will be of use.

Do not Ice Massage if
  • There is increasing pain
  • You develop a skin rash
  • You are making any swelling get worse
  • You are about to exercise – always ice massage after exercise and in the evenings
Some tips
  • You might like to freeze 2 or 3 cups at any one time, or keep one in the freezer for emergencies
  • A small “coke” bottle filled with water and frozen, or a frozen golf ball can be used as foot massagers for things like plantar fasciitis

Walk - Jog Program

This programme is a graduated rehabilitation programme that is used for certain lower limb problems, for example stress fractures, and for regaining fitness after a period of rest. The starting level is intentionally gentle. Progression in duration and intensity should be guided by comfort. The aim is to gradually increase the load that is being applied to the body at a rate that allows all of the tissues to adapt to the load without deteriorating.

If at any time you get pain (during exercise, on cooling down, or first thing the following morning) have one day of rest and drop back by one level.

walk
  • Comfortable walking pace
  • Start at 15 minutes per day
  • Increase by 5 minutes every second walk
  • When you have performed two 40-minute walks without problems progress to Walk-Jog
walk-jog
  • Walk a lamppost, jog a lamppost; walk 30 sec, jog 30 sec; walk 30 paces, jog 40 paces
  • Come back to 15 minutes per day
  • Increase by 5 minutes every second walk-jog
  • When you have performed two 40-minute walk-jogs without problems, progress to Jogging
jog
  • Comfortable, “conversation” pace
  • Come back to 15 minutes – but now only train every second day
  • Increase by 5 minutes every second jog

When you have jogged for 40 minutes on two occasions without problems, you can return to your normal training – if this involves explosive sprints, you should increase this type of training gradually over 2 weeks.

If you are training for a long-distance event, you can return to your training programme when your weekly training load matches the mileage and intensity of your current training programme.

If you are unable to progress past a certain point, you should return to discuss this, bringing your training diary with you. This programme is designed to retrain muscle, tendon, bone, and to a lesser extent the cardiovascular system. In order to maintain aerobic fitness it is important for patients recovering from injuries such as stress fractures to perform extra aerobic exercise – either in the pool (aqua-jogging or swimming), or on an exercycle if painfree.

Aqua Jogging

It is relatively common for athletes suffering from lower limb injuries to be advised to rest their painful limb. This is obviously very frustrating. Aqua-jogging (or water running) allows an athlete to remain active and maintain their cardiovascular fitness despite being injured. Running in the pool is the exercise which most closely simulates running. It is used widely by many elite athletes both when they are injured and as a cross-training tool. A number of studies have shown that athletes can maintain their aerobic conditioning for more than eight weeks using this type of regime.

You can aqua-jog in any depth water although we generally recommend that you start suspended in the deep end using a foam belt. This removes most of the effects of gravity on your injured limb and allows you to get exercising. As your injury progresses you may decide to add some weight-bearing. Running in waist deep water removes about half your body weight while running in chest deep water reduces your weight by about 90%

If you are used to monitoring your heart rate during your training sessions you may find that your heart rate is about 10-20 beats slower than you would normally record during your normal land-based sessions. This does not mean that you are not training hard. When the body is suspended in water the venous return (blood flowing back to the heart) is greater and so the heart does not have to pump as hard. The cooling effect of the water also means that your body temperature does not increase as much also limiting the heart rate elevation.

Aqua-jogging can be boring. A training partner is a good idea as is making a clear plan before you head to the pool. Have a good idea of what you are trying to achieve before you head to the pool. Interval sessions generally work best.

The basic idea is to try and simulate your running position in the water. You want to adopt an upright position leaning forwards slightly. Attempt to run as you would on land flexing your ankles, knees and hips as well as driving your elbows. You will not make much forward progress but this is not important. You may try cupping your palms to add more of an upper body workout. You will quickly find a position that will feel comfortable for you.

As with any training regime pain is bad. This is particularly true when you are using aqua-jogging to recover from injury. Always train within the limits of comfort. Aim to build up slowly starting with about 20 minutes of jogging. Once you are confident in the pool build up your intensity and duration of training. Be guided by time rather than distance and try to match the normal effort you would put into a given running session. Remember your heart rate is not a reliable indicator of intensity.

There are a variety of internet resources which illustrate different exercises and techniques which you can use in the pool. In general interval training (mixing slow easy running with periods of fast and hard running) is probably the best method to increase the intensity of your training and to reduce boredom.



If you would like more advice about whether aqua jogging would be a suitable part of your injury rehabilitation book an appointment with one of our team.

Autologous Blood Injections

Tendinopathy is the name for a range of conditions that affect tendons – the connective tissue that connects muscle to bone. These conditions can cause pain, weakness and stiffness. The most common tendons affected are in the elbow, the heel and the knee.

There are a variety of treatment options available to people with tendinopathy. The mainstay of treatment is a progressive eccentric strengthening program. Autologous blood injections are an adjuvant treatment which can be used to help assist the tendon to heal. The idea is that the blood contains growth factors and other substances which promote a healing response. Essentially we are artificially creating a bruise about a tendon which has failed to heal and attempting to stimulate tendon healing. We have used these injections over the last five years and have had some good success with them.

What is Involved?

Blood is taken from the patient's arm (like a routine blood test). In general 2-5mls of blood is taken. The blood is mixed with local anaesthetic before the procedure. Using a sterile technique the mix of local anaesthetic and blood is then injected into the area around the damaged tendon. Patients are encouraged to take some simple pain relief - paracetamol or ibuprofen - and to ice the area following an injection. The injection is often repeated a month after the initial proceedure.

How well does the procedure work?

Anecdotally this procedure works well to treat tendon pain. Between us we have performed approximately 1000 autologous blood injections. There is also some limited scientific evidence to support the use of this technique. In one study pain was assessed in 15 patients who were injected with their own blood and 5 who were just injected with anaesthetic. After 8 weeks the pain had decreased by 60% in the blood injection group and by 16% in the anaesthetic group. At just over 2 years, pain in the group injected with their own blood had decreased by 93%.

Three studies involving a total of 83 patients treated for ‘tennis elbow’ also looked at the severity of pain. On a scale from 1 (mild pain) to 7 (worst pain), pain scores decreased from 6 to 0 or 1 at 6 months and from 6.5 to 2.0 at 9.5 months after patients were injected with their own blood.

Two other studies have also illustrated an imporovement in other tendons. Knee function improved in a group of 44 patients (47 knees) who had problems with their patella tendon. In another study of 15 patients, elbow function had improved by 72% 6 months after the procedure.

Risks and possible problems

Pain was one of the main problems reported. In one study of 35 patients, 25 had pain and stiffness after the procedure, which went away within 2 days. Most patients reported that the pain was similar to the pain they had after steroid injection. Other potential complications include infection, injury to structures near the tendon and bruising at the injection site.

The FIFA 11+

The 11+ was designed by FIFA's medical research unit F-MARC. It is a complete warm-up program for football (soccer) which has been scientifically proven to reduce the risk of injury in men and women.

Cycle Rehab Program

This program is a graduated rehabilitation program that is used for some knee and lower limb conditions. The starting level is low intentionally. Progression, duration, intensity (and seat height) should only be attempted if there are no problems.

Problems
  • Pain while cycling
  • Pain after cycling (on cool down or the following morning)
  • Stiffness that increases after cycling
  • Swelling that increases after cycling

If you have any of these problems drop back one level. If you still have problems have a day off and drop back one further level

Starting Level:
  • Seat a little higher than normal - your leg should be straight at the bottom of the stoke when the forefoot is on the pedal
  • If you are unable to fully extend your knee (because of your injury) you may need to have your seat lower than normal
  • Zero resistance
  • Start with 15 minutes each day
Progression
  • Increase by 5 minutes/day if there are no problems
  • Build up to 30 minutes/day
  • When you can cycle for 30 minutes/day without pain, stiffness or swelling lower the seat height to normal - knee straight with the heel on the pedal
  • If you develop pain, stiffness or swelling reduce the load by 5 minutes/day until it settles then gradually build back up to 30 minutes/day
  • When you can do 30 minutes/day at this seat height without problems gradually increase the resistance
  • Keep building up until you can do a heavy workout for 30 minutes without any problems - at this stage you are ready to gradually return to weight-bearing exercise

This is a rehabilitation program for the knee. You also need to exercise in the pool if you want to maintain your aerobic fitness. Upper body weights may also be important depending on your sport.

Acupuncture

Many Physiotherapists offer acupuncture as a treatment modality in conjunction with traditional physiotherapy management. Acupuncture refers to the insertion of fine, solid needles into the body for pain relief, healing and general well being. It has been used by the Chinese people for over 3000 years.

What to expect?

Acupuncture needles are disposable, single use, pre-sterilised needles. A number of needles may be used at each treatment and these are may be left in for up to 30 minutes. You may feel a pin prick as the needle is inserted into the skin followed by warmth or an achy sensation.

How does it work?

Acupuncture utlises specific points throughout the body but applies it to scientific reasoning with particular consideration to neurophysiology and anatomy. Acupuncture is used to achieve pain relief via the stimulation of the nervous system, including the brain and spinal cord to release the body’s own pain relieving chemicals, such as endorphins. These chemicals assist the body's healing process and offer pain relief in conjunction with other manual or manipulative therapy or home exercise programme. Dry Needling or Trigger Point Acupuncture is a form of short term needling to altered or dysfunctional tissues in order to improve or restore function.

Which conditions can be treated with Acupuncture?

A large range of conditions can be treated successfully by Acupuncture within Physiotherapy. Some are shown below:

  • Acute Injuries
  • Sports Injuries
  • Trigger Points
  • Back and Neck Pain
  • Chronic Injuries
  • Osteoarthritis
  • Joint Pain
Does acupuncture have side effects?
  • Drowsiness can occur after treatment in a small number of patients, and, if affected, you are advised not to drive
  • Minor bleeding or bruising can occur in about 3% of treatments
  • Pain during treatment can occur in about 1% of treatments
  • Existing symptoms can get worse after treatment (less than 3% of patients)
  • Fainting can occur in certain patients, particularly at the first treatment
  • If you would like to learn more about this treatment please feel free to arrange an appointment with one of our physiotherapists

Proprioception

Proprioception refers to the body's ability to sense movement within joints and joint position. It is important in everyday movements but especially in complicated sporting movements, where precise coordination is essential.

What is the Proprioceptive System?

The proprioceptive system is made up of receptor nerves that are positioned in muscles, joints and ligaments around joints. The receptors can sense tension and stretch and pass information to the brain where it is processed. The brain then responds by signalling to muscles to contract or relax in order to produce the desired movement

What are the Benefits?

Once a joint has been damaged, or a ligament has been torn or partially torn, there will be a deficit in a person’s proprioceptive ability. This can leave the person prone to re-injury, or decrease their coordination during sport. Proprioception also helps speed an athlete's return to competition following injury.

Proprioceptive Re-Education Program

Please consult your physician or physiotherapist before commencing the program to ensure it is appropriate for your condition. Factors which can influence this include pain, swelling, loss of range of active and passive movement. Full assessment is required to enter the program safely so you are doing the right things at the right time and not disrupting tissue repair. It is possible to commence advanced exercises too early, which can be detrimental to your rehabilitation outcome.

Level One
  • Transfer weight on to affected limb
  • Walk with support/crutches ensuring correct heal-toe pattern
  • Seated with floor on unidirectional balance board – rock back and forward
  • Stand on one leg – eyes open, maintaining stationary position
  • Stand on one leg – eyes closed, maintaining stationary position
Level Two

Standing on one leg

  • Small knee bend keeping kneecap over second toe
  • Catch ball thrown by friend – vary height, distance, speed of throw
  • Maintain position while being pushed off balance
  • Hop and land – sideways, forward, backward, ½ circle
Level Three

Multi-directional balance board/air cushion/Bosu ball – maintaining stationary position:

  • Both feet – eyes open then closed
  • Add – cross arms, arms in front of body, knee bends, swing other leg, catch ball
  • Lunge forward on to board
  • Stand on one foot – eyes open then closed
Level Four

Start with hopping on ground then progress to rebounder/mini-tramp

  • Hop and land in patterns
  • Lateral glides – sliding sideways on polished floor. Add catching ball
  • Walk and then run over flat surface then progress to uneven ground
Level Five
  • Walk then run across steep hill each way
  • Run sideways up/down hill each way
  • Sideways step-ups gradually increasing height of step
  • Running drills: straight, backwards, sideways/carioca, circle, figure 8, cutting. Progress to uneven surface, eyes closed, speed

Compartment Pressure Testing

Your doctor or physiotherapist has diagnosed a probable exertional compartment syndrome and is requesting some pressure measurements in your leg muscles after you exercise to help confirm this diagnosis. This may happen in the fronts of your shin, the calf region or in both places.

This procedure involves injecting some local anaesthetic into the affected area of your leg so that the pressure monitoring needle can be inserted without pain. After the anaesthetic you will either hop for 1-2 minutes, or move your foot up and down, depending on where the problem is, to build up the muscle pressure. The pressure monitoring needle will then be inserted and the pressure is measured over the next 10 minutes.

What are the risks of this procedure?

We have done 3 to 4 hundred of these tests with very few problems. There is however a potential risk that one of the needles may touch a nerve or artery in your leg and cause some bleeding in your shin muscle. If this was severe it may require an urgent operation to release the bleeding, but this has not been necessary in any of our previous tests.

In preparation for the pressure test
  • Try to continue to exercise, within the limits of your pain, as this makes the test more accurate for your condition
  • Bring someone with you to drive, as there is a chance that your foot may be numb, and you cannot drive home
After the test
  • You should not plan to exercise for at least 3 days, or until your leg has fully recovered.
  • You should avoid baths or spas for 2 days until the needle holes fully heal; you may have a shower with no problems.
  • You shouldn’t drive on the day of the test, and not until you are sure your leg is fully recovered – usually the next day.
  • There may be a mild ache when the anaesthetic wears off, and this usually responds to elevation of the leg, ice packs, and simple pain relief such as Panadeine or Voltaren– this is not unusual.
Warning

But if you should experience increasing pain increasing swelling increasing throbbing increasing numbness this may be a sign of bleeding into the muscle. This is an emergency and you should contact the clinic or seek an assessment from your local hospital emergency department immediately. You should explain to them that you have had a compartment pressure test and that there is a chance you may have bleeding in the muscle (ie acute compartment syndrome). This is fortunately very rare and has never been a problem in the past. It is however important to get it checked by a Doctor to exclude an acute compartment syndrome where a prolonged increase in pressure can damage muscle.