How to safely return to running postnatally.

How to safely return to running postnatally

Jen Vardy, Pelvic Health Physiotherapist

Having a baby is a time of incredible joy and exhilaration and a time to adjust to motherhood, sleep deprivation and the amazing changes a woman’s body has undertaken in growing, carrying and birthing a little one.  New mums are usually keen to return to exercise and all the activities they loved doing before baby but are often unsure how to safely begin.

Runners are often a different story. They are usually itching to get back on the trails for both the exhilaration of the run and the mental break from newborn life. However, they may not be aware of the impact of running on their recovering bodies both in the now and also in the future. Fortunately, to help support postnatal women to return to running safely there are new guidelines based on the best available current evidence (1). The guidelines have been produced by three passionate UK based Physiotherapists who have sought extensive collaboration from leading international Health Professionals. They recommend that there is no one size fits all approach and that most women should wait until at least 12 weeks postnatally before a graduated return to the pavement.

Some women will cringe at waiting this long but consideration must be given to the high impact loads of running and the physical, psychological and hormonal factors of postnatal recovery.

Running produces a sudden rise in intra-abdominal pressure and acknowledged increased ground reaction forces of around 1.5-2.5 times bodyweight. Postnatal women have weakened lower limb muscles following pregnancy and childbirth and poor ability to absorb such dramatic elevations in pressure. Abdominal and pelvic floor muscles are also recovering post both birth and if such forces are transferred to these vulnerable muscles they will struggle to maintain continence and organ support.  No new mum wants to encounter bladder or bowel leakage or an onset of prolapse symptoms.

The stakes are high for a mum wanting to return to running. Throw in sleep deprivation as the new norm which causes a reduction in muscle protein synthesis. And breastfeeding and its increased energy requirements and no wonder the guidelines recommend every mother should access a pelvic health and physical assessment with a specialist Physiotherapist. Until Medicare funds such a postnatal screening assessment for every new mum this may not always be achievable. Best practice should at the very least include starting an appropriate exercise program early which includes specific pelvic floor and abdominal muscle training and education to ready the running mum for herappropriate time to return to running.

  • Goom, T., Donnelly, G., & Brockwell, E. (2019). Returning to running postnatal – guideline for medical, health and fitness professionals managing this population.

 

https://www.researchgate.net/publication/331608702_Returning_to_running_postnatal_-_guideline_for_medical_health_and_fitness_professionals_managing_this_population

Is Running Bad for My Knees?

Running is a highly popular, easily accessible physical activity that provides a number of physical and mental health benefits including reduced risk of mortality and chronic health conditions.

Despite this, for many years there has been a stigma attached to running from many health professionals and those in the community that running is bad for your knee joint and causes osteoarthritis (OA). For quite a few people this has meant that they been advised to reduce or stop running in order to protect their joint, yet there is little evidence to support this approach.

 

However, there is a growing amount of research that demonstrates recreational running in distances up to a marathon has a protective effect against the development of knee OA compared to non-runners. Runners should understand that there are other risk factors more likely to increase the risk of OA including higher body mass, previous knee injury, previous knee surgery and heavy occupational workloads rather than running alone.

Management and progression of training loads, strength training, adequate recovery (including sleep) and running technique improvement are important to consider to minimise the risk of knee injury.

Cross-training with appropriately guided strengthening, Pilates, non-weightbearing activities and other associated remedial therapies such as joint mobilization, massage, dry needling and myotherapy can assist to improve recovery and reduce injury risk.

Pain and injury are likely to develop when the body is pushed passed it’s capacity, such as when training loads are too heavy or not increased gradually, and also when biomechanics of gait are sub-optimal. This is where seeking guidance from a physiotherapist can be invaluable – to assess what can be improved and how. This may be as simple as planning training loads, looking at key muscle groups to strengthen or assessing foot and lower limb biomechanics.

To summarise, the total running an individual can tolerate will vary from person to person and will depend on factors previously mentioned. Be sure though that running at an appropriate level for yourself will not cause you any damage to your knees, and instead likely help them.

Prevention of the ACL epidemic in female sports

Another ACL injury! Fremantle AFLW player Alex Williams clutches her knee this week, courtesy of The Advocate.

ACL (anterior cruciate ligament) knee injuries in female sports has increased dramatically in Australia in recent years, correlating positively with the huge uptake of AFL by girls and women. In fact, there have been up to 43% (74% under 25 years) more ACL injuries over the past five years!

The peak rate of these injuries occur during the age of 15-19 years old & are likely due to increased participation levels and changes during puberty, plus a range of other physiological factors.

The ACL attaches to the area in front of the intercondylar eminence of the tibia (lower leg), it extends backwards and laterally, to attach to the posterior part of the inside of the lateral condyle of the femur (thigh bone).

Its primary role is to resist excessive anterior translation and medial rotation of the tibia, in relation to the femur.

The ligament is stretched or torn in 70% of all serious knee injuries (Tortora & Grabowski (2000).

It is more commonly torn in women than men for a number of reasons:

– ligament is smaller and less strong in female
– less thigh muscle strength means there isn’t as much muscular protection to the ligament
– the increased elasticity in females means that there is more of a delay in hamstring firing, which will protect the ACL less (particularly with hormonal changes during the menstrual cycle)

– Greater Q angle due to wider pelvic compared with males (see diagram below) which places increased stress on the ACL

– Narrower intercondylar notch (which has an increased shearing effect when knee is under stress)

The good news however is that there are effective measures to help reduce the incidence of injury. Injury prevention programs have been shown to decrease severe injuries (including ACL) by up to 74% and all other lower limb injuries by 55% (including ankle, other knee injuries and muscular strains).

These programs focus on improving strength and control of movement (including balance and agility) that can easily be incorporated into routine warm-ups for training and games. Not only do these programs reduce the risk of injury, but they also performance of players completing the program (increased strength, improved movement patterns and balance/agility).

These programs have been implemented in both female and male community and elite sport throughout the world for different sporting codes. In Australia such programs include; the FIFA 11+ for soccer, FootyFirst for AFL and the netball KNEE program for netball.

The physiotherapy team at Dandenong Ranges Physio have developed our own abridged version of these

preventative training regimes assist local coaches, parents and trainers in the implementation of these programs. One downside of the above programs is that they often take 20-25 minutes to complete, and when coaches only have their players for 1-2 hours of training they are reticent to spend this time on preventative training. Perversely it is the younger and mid-teen girls teams which have shorter trainings yet are the demographic that would benefit most from preventative training.

So far we’ve presented this to local youth and adult football, soccer and netball clubs coaches, trainers and player with great uptake.

If you or your local club is interested you can get in contact by emailing info@drphysio.com.au or calling us on 97510400.

Overuse Knee Injuries

There are a number of common knee pain complaints that we see every day that are labelled as ‘overuse’ injuries. Overuse doesn’t necessarily mean that you as a person have overused that joint or body part (though it could well do!), rather than a soft tissue or connecting structure has been overloaded. In fact the cause may be from a change or increase in training, poor foot biomechanics, and often gluteal or hip weakness. The symptoms can be sharp, acute pain or a dull ache that lingers after activity – it varies depending on the condition.

Remember that pain is not equivocal to damage, rather it is a signal, and the more chronic the pain the more the signal may be interpreted abnormally by our brains!

This month’s blog article looks at the causes, symptoms and treatment for three overuse conditions that often cause knee pain:
– Patellofemoral Joint Pain Syndrome (PFPS or PFJ syndrome)
– Iliotibial Band Friction Syndrome (ITB syndrome)
– Patella Tendinopathy (Jumper’s knee)

Plus Knee osteoarthritis, which often underlies soft tissue changes in people over 40 years of age (yes, only 40!).

Patellofemoral pain syndrome (PFPS or PFJ syndrome):

PFPS is pain arising from the tissues within or surrounding the knee cap (patella) and the femur (thigh bone).

Pain is typically a vague, overall tenderness at the front aspect of the knee and can be hard to localize. It is usually aggravated by activities that involves a high amount of knee bend (eg. up/down stairs, running (especially downhill), squats, lunges, sitting in a car, plane or cinema for prolonged time).

There are a number of risk factors that may increase the stress placed on the patellofemoral joint including lower limb muscle weakness, abnormal patellofemoral joint alignment, increased foot pronation, increased Q angle at the hip, weak external rotator of the hip (gluteals), change in training load.

Patella tendinopathy (jumpers knee):

Patella tendinopathy is a diagnosis of pain and dysfunction in the patella tendon. This condition presents with well localized pain in the patella tendon, usually at the attachment to the patella. Typically people with this condition have aggravation with activities that increase loading on the patella tendon such as running and jumping.

Risk factors for this condition are similar to that of PFPS, however the most common trigger is an increase in training volume and frequency and reduced quadriceps muscle strength and length.

Iliotibial band syndrome (ITB Syndrome):

The ITB is a thick structure called fascia that runs from the outside of the hip to the outside of the knee. ITBS is an overuse condition where pain is felt on the outside aspect of the knee. It was previously thought that this was caused by increased friction of the ITB on the bone outside the knee, with excessive knee bending movements causing inflammation and pain. Recent literature suggests that there is a highly innervated layer of fat between the ITB and bone that is responsible for the pain felt.

Common causes of ITBS are once again rapid increases in training volume and intensity, thigh muscle weakness particularly gluteal and quadriceps, increased foot pronation, poor movement control and poor tissue flexibility of the ITB and glutes.

Treatment:

The treatment of these issues involves addressing lower limb biomechanics that may be contributing to increased pressure on the injured structure including lower limb muscle weakness, increased foot pronation and poor movement control.

Soft tissue techniques including dry needling and massage can be effective in order to reduce sensitivity of tight muscles contributing to the injury.

Taping can also be effective in the initial phase of rehabilitation in order to offload injured areas and enable easier return to activity.

Load management is also a key component that needs to be addressed, as rapid increases or decreases in activity often lead to these injuries developing.

Your physiotherapist will be able to guide you through a specific rehabilitation program and which of these methods of treatment will be suitable to you.

Knee osteoarthritis (OA):

Knee OA is another condition not to forget when considering overuse injuries around the knee. This condition typically arises when people have changes in activity level (either too much or too little). Common symptoms are pain with weight bearing, reduced range of joint motion, sensation of the knee giving way and joint line tenderness.  Our recent article discussing the latest evidence for knee OA and the GLA:D program will detail the appropriate treatment strategy in greater detail.

 

 

Christmas and Holiday Period Trading Hours

Xmas 2018 and new year Holiday trading hours for 2019

 

 

 

GLA:D® Program at Dandenong Ranges Physiotherapy, Olinda

In December 2018 we launch our participation in the worlds best first treatment for knee and hip arthritis – GLA:D®. And to celebrate we are offering our first 10 participants $50 off GLA:D® 12 or 18 session programs! Get in quick to reserve your discount.

Read all about GLA:D® here or contact us directly to join one of our free Knee and Hip Osteoarthritis information sessions.

GLA:D™ Australia is a program for all individuals who experience any hip and/or knee osteoarthritis symptoms, regardless of severity.

 

Do topical creams and gels help with pain relief?

Tim Hardiman, Musculoskeletal Physiotherapist, November 2018.

Physiotherapists are often asked about the potential benefits of the various creams that are purported to help people with pain or movement problems. Because of the expanding knowledge of adverse side effects of many medicines, people wonder about the benefits of the creams we see advertised and whether they may be safer than tablets.

Anti-inflammatory medicines and creams are an interesting example. Non-steroidal anti-inflammatories (NSAIDS) have a long list of serious side effects including stomach ulcers and bleeding as well as heart attack and stroke risks.

All NSAIDS work to interrupt the production of inflammatory hormones called prostaglandins. Since their introduction in the late 1800’s these drugs are among the most commonly used worldwide.

Unfortunately, a direct consequence of the action of these drugs on prostaglandins results in weakening of the lining of the gut, and consequently ulcers. Routine consumption of NSAIDS has been shown to cause around 3 events per 1000 patients per year of heart attack or stroke (x4 above usual levels). 20-40 per 1000 per year may experience a stomach bleed. When treating short-term conditions for people without cardiovascular disease, the risks of these events associated with taking NSAIDS are probably very low.

New research suggests that substantial pain relief can occur with the use of topical anti-inflammatory creams. The suggestion is that because the active ingredients are able to penetrate to the affected tissue (superficial joints or tissues such as the ankle, knee, wrist and elbow, rather than deeper joints such as the shoulder, hip, spine) there is less exposure of the active ingredient to the whole person (including their gut).

Studies comparing the benefit of these creams to placebo (the same cream, without the active medicine in it) suggest that about 10% more people will report a significant reduction in their pain than those using the placebo cream. Of note in a study of one of these creams was that there is moderate quality evidence suggesting that 6 in 10 people using an anti-inflammatory cream reported improvements in arthritis symptoms after 6-12 weeks use. The group using the placebo cream had 5 in 10 reporting similar results!

Another way of expressing this is that for every 6 people using the cream, one person has a benefit greater than placebo, and that the placebo response is strong when it comes to these creams.

There is little to no evidence suggesting that anti-inflammatory creams work for certain types of pain such as low back pain, headache or neuropathic pain. Creams likely present a safer risk profile for people needing pain relief for superficial structures than oral NSAIDS.

It is much more difficult to assess the myriad of alternative creams and gels, since they do not need to pass the rigours of validated trials that pharmaceutical products do. They are often marketed aggressively despite weak or non-existent evidence and quality controls during the manufacturing process are lax compared to medicines.  

You can walk into many chemist shops and see posters about the miraculous magnesium oil sprays that penetrate the skin, bypassing the gut and targeting your sore muscles directly (assuming you are low in magnesium obviously). Most products quote the same weak evidence from quite a few years ago that blood serum magnesium levels slightly increased after bathing in magnesium chloride, said to mimic the therapeutic benefits bathing in the Dead Sea. What they don’t tell you is that urine levels didn’t change, a raft of other blood markers also rose, levels only rose in ‘non-athletes’, the sample size was tiny and over a two-week period levels returned to normal. Also, a comprehensive literature review in 2017 found that there is no evidence to suggest magnesium oil can be absorbed topically & concluded that any benefit from using magnesium oil is likely due to a placebo effect.  

Pain relief for musculoskeletal conditions can occur with appropriate exercise too. Which is why physiotherapists will often prescribe safe and specifically targeted exercise to speed recovery, prevent recurrence and improve functional outcomes for people with pain or movement problems. So whilst there is room for topical NSAID’s for specific and superficial pain in the short term, developing good behaviours, awareness and routine with respect to exercise and movement is likely the best way forward. 

To book a session with one of physiotherapists, please , myotherapists or Exercise Physiologist, please call us on 9751 0400 or book online.