Overtraining syndrome, a common cause of persistent tiredness in sportspeople, seen by physio’s, frequently occurs in athletes who are training for competition or a specific event and train beyond their bodies ability to recover. Athletes often exercise longer and harder so that they can improve. However without adequate rest, recovery and nutrition, these training regimens can backfire, actually decreasing performance. Proper training and conditioning requires a balance between overload and recovery. The terms overtraining, overreaching, overtraining syndrome, burnout, and staleness have all been associated with overtraining syndrome and need to be clarified. Overtraining is excessive training with inadequate recovery. Overtraining has also been linked to glycogen depletion(Costill et al. 1988) when inadequate refuelling of muscles glycogen occurs due to low carbohydrate intake. The sooner carbohydrate is consumed following a bout of exercise, the more effective the replenishment of glycogen stores. Adequate quality protein intake would also be important in the case of strength athletes to help protect against overtraining syndrome. Sufficient iron intake is important for endurance athletes especially women.
The term overreaching describes similar symptoms(fatigue, performance decrements, mood state
changes) but is generally of a more transitory nature and is often utilised by sportspeople/coaches
during a typical training cycle to enhance performance. Intense training, in the short term can result
in a decline in performance; however when incorporated with periods of recovery, a
super-compensation effect may occur, with the sportsperson exhibiting enhanced performance
when compared with baseline level (Halson and Jeukendrup, 2004). Overtraining syndrome
develops when there is failed adaptation to overload training due to inadequate regeneration.
Unfortunately , many sportspeople and coaches, especially at amateur level, react to impaired
performance by increasing the intensity of training. This leads to further impairment of
performance, which may , in turn, result in the sportsperson increasing training even further. A
vicious cycle develops which leads overtraining syndrome.
Changes within the central nervous system seem to play an important role in the development of
chronic fatigue and many of the other common signs and symptoms that are frequently seen in
overtraining syndrome, such as disrupted sleep, changes in appetite and weight, irritability, impaired
concentration, decreased motivation, and depressed mood. It has been suggested that alterations in
levels of brain neurotransmitters(e.g. a reduction in serotonin levels) and an increased release of
inflammatory mediators(e.g. cytokines) are important factors in the development of overtraining
syndrome(Anish, 2005). Many of the signs and symptoms that characterize overtraining syndrome are remarkably similar to those of clinical depression. Unfortunately, no single test can detect overtraining in the sportsperson. Probably the simplest and most effective means of monitoring overtraining is self analysis by sportspeople themselves. Daily documentation should include sources and ratings of stress, fatigue, muscle soreness, quality of sleep, irritability, and perceived exertion during training or standardized exercise.
Blood parameters such as red and white blood cell counts, haemoglobin, hematocrit, urea, and
ammonia are usually normal during overtraining. Changes in exercise blood lactate concentration
and blood lactate threshold however have been shown to be good indicators of overtraining but are
influenced by many other factors and are probably only useful if assessed repeatedly.
The initial symptom of the overtraining syndrome is usually fatigue but in time, other symptoms
develop.(Mackinnon and Hooper, 2000) Indicators of overtraining include; decreased performance
despite continued training, persistent fatigue, increased early morning heart rate or resting blood
pressure, frequent illnesses such as upper respiratory tract infections, persistent muscle soreness,
loss of body mass, mood changes, loss of appetite, sleep disturbance, high self-reported stress
levels, irritability, depression , decreased maximal heart rate. Overtraining syndrome can also leave
an athlete more susceptible to injury.
Deep tissue massage and injury prevention advice is where or physiotherapists come in. Feel free to set up an appointment at our Tralee clinic to discuss things. For more details click here.
Mackinnon, L.T., Hooper, S.L. Overtraining and overrreaching: causes, effects, and prevention. In :
Garret, W.E., Kirkendall, D.T., eds. Exercise and Sports Science. Philadelphia : Lippincott, William &
Acceleration/deceleration injury to the cervical spine(neck) and back, also known as whiplash, is a common injury due to traffic accidents regularly treated by our physiotherapists in Tralee. Whiplash as it is commonly known may result from rear-end or side impact motor collisions. It can also occur with activities such as diving or due to a direct blow from an opponent etc. The impact of any of these may result in injury to the cervical spine(bones of neck) or soft tissues such as the muscles or ligaments of the neck/back. This in turn leads to what is called ”whiplash associated disorders” or WAD for short(Spitzer, W.O., 1995).
To simplify the mechanism of this type of injury, think of a whip snapping. This is basically what is happening with your neck during these incidents, the head jolts swiftly forward first, then snaps backwards. It is being propelled swiftly with great force in one direction, then there is a recoil swiftly in the opposite direction. The back may also experience similar trauma.
The most common symptoms of whiplash include neck pain, headache, back and shoulder pain with decreased mobility. The condition can be graded into WAD 1 – 4 depending on the degree on injury. With Wad 1 the patient complaints of pain, stiffness or tenderness only but no physical signs are noted. With Wad 2 the patient complains of neck pain and there is decreased range of motion and point tenderness in the neck. Where there are hard neurological signs, for example tingling and/or numbness down one or both arms WAD 3 is the grade assigned. Where there is a resulting fracture of the cervical spine, the term WAD 4 is used(Balla and Iansek, 1988, Stovner, L.J., 1996).
With whiplash the patient may not feel any pain immediately after the accident, however symptoms can increase gradually in the 48 hours after injury. Muscles, joints, ligaments and neural tissue can all be affected depending on the level of injury. Once an x-ray or Mri is performed to rule out serious injury to the bones, ligaments etc. of the neck , red flag signs also being ruled out, it is important that physical therapy is started as soon as possible. A multimodality approach to treatment as early as possible has shown good results in best evidence practice. This includes very specific therapeutic exercises, manual therapy, postural education and the use of drugs most notably non steroidal anti-inflammatories and muscle relaxants(Childs et al. 2008, 2009). It is extremely important to try to return range of movement to the neck as soon as possible after the accident once adequate safety checks have been performed. The neck stiffens up quite quickly when immobilized for even short periods of time. This current thinking is very different to years ago when neck braces and immobilization for long periods after accidents was standard.
Some symptoms associated with whiplash that can indicate the condition may be a little more serious, needing immediate review by a doctor or specialist include bilateral parasthesia(numbness on both sides of body), dizziness, feeling sick, a lump in throat when swollowing, progressively worsening neurological symptoms, signs of neck instability, unrelenting pain, increase in any of these symptoms with rotation or flexion of head. For more information on whiplash click here.
Balla J., Iansek, R., Headaches arising from disorders of the cervical spine. In : Hopkins A, ed. Headache. Problems in diagnosis and management. London: Saunders, 1988:241-67.
Childs, J.D., Cleland, J.A., Elliott, J.M. et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. Erratum appears in J. Orthop. Sports Phys. Ther. 2009 Apr;39(4):297, J. Orthop. Sports Phys. Ther. 2008;38(9):A1-34.
Spitzer, W.O., Skovron, M.L., Salami, L.R. et al. Scientific monograph of the Quebec Task Force on Whiplash Associated Disorders : redefining ”whiplash” and its management. Spine 1995;22(8suppl.):S1-73.
Stovner, L.J. The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine 1996; 21(23):2735-46.
A mobile thoracic spine allows you turn your back in many directions, enabling you to do everyday tasks with ease. Today’s sedentary lifestyle often contributes to reduced spinal mobility. Basically ”motion is lotion” and if you are inactive and also prone to poor posture, your thoracic spine can seize up. If it goes on long enough, say into old age portions of the spine may fuse and not move at all. A lack of thoracic spine mobility means that the lumbar spine, pelvis, shoulders and surrounding muscles have to compensate. Long term, these over-compensations can lead to overuse conditions and injuries, the lower back being particularly suceptable. This is because the lumbar spine is meant to keep us stable and is not very mobile, so when these joints are forced to overcompensate for the lack of movement in the thoracic area, it can place alot of pressure on the discs of the lower back. Possible consequences include inflammation, degeneration, herniation of the discs, generalized low back pain, compression fractures, muscles spasms, and spinal nerve injuries. Similar pressures and injuries can occur in the neck and shoulders. For example, if your thoracic spine isn’t mobile, anytime you have to do a movement overhead, your shoulders make up for that lack of mobility. If you have shoulder impingement or chronic shoulder and neck problems lack of mobility in the thoracic spine will make every thing worse.
Improving Thoracic Spine Mobility
Yoga, pre- and post-workout stretching, and mobility exercises are the best way of maintaining and improving thoracic spine mobility. These need to be done regularly and consistently, especially as you get older. Your physiotherapist will be able to guide you on the correct exercises and help correct your form and technique until you get used to them and can do them yourself. Here are a few exercises to get you started.
Chondromalacia patella, also known as ”Runners Knee” is one of the most common causes of knee pain in runners. The condition results from irritation of the cartilage on the under-surface of the kneecap. This cartilage is smooth and the kneecap normally glides effortlessly across it during bending of the knee joint. In some individuals however the kneecap does not track so smoothly due to poor alignment and the cartilage surface becomes irritated, resulting in inflammation and knee pain. In more severe cases there can be breakdown of the cartilage. Chondromalacia patella can affect athletes of any age but tends to be more common in women, most likely due to anatomical differences between the sexes ie. wider hips in females which results in a greater angulation between hip and knee, thus resulting in increased lateral forces on the patella.
Chondromalacia Patella – Causes
There are several causes both structural and dynamic which are linked to the condition. These include excessive foot pronation(feet turn out when running etc.), tight IT band, tight vastus lateralis(basically outer lower quad), weak or slow firing vastus medialis (basically lower inner quad), increased Q angle (simply put the angle between the outer hip and centre of the knee), a lateral femoral condyle that is not sufficiently prominent anteriorly (simply put the knee joint does not fit together properly),and a small or high riding patella(knee cap).(McConnell, 2002)
Chondromalacia Patella – Symptoms
The most common symptom is a dull, aching pain in the front of the knee, behind the kneecap. This pain is often worse when you go up or down stairs. It also can flare up after you have been sitting in one position for a long time. For example, your knee may be painful and stiff when you stand up after watching a movie or after a long trip in a car or plane. In some cases, the painful knee also can appear puffy or swollen. Chondromalacia can sometimes cause a creaky sound or grinding sensation known as ”crepitus” when you move your knee.
Chondromalacia Patella – Physio Treatment
Suitable treatment may involve 1. Soft tissue work to loosen tightened structures such as vastus lateralis muscle, IT band, lateral retinaculum etc., 2.Strengthening of weak structures such as vastus medialis, glutes , hip abductors etc., 3. Correction of overpronation using orthotics, 4. Non steroidal anti-inflammatories such as ibuprofen to reduce pain and inflammation, 5. Rest with gradual return to exercise, 6. Taping to correct tracking can be a short term solution.(Hertling and Kessler, 2006) while you strengthen the vastus medialis muscle. Also there are supports you can purchase to help correct patella tracking while exercising. These are a good short term solution while you correct the problems referred to above. Here is a good example.
If nonsurgical treatments fail, or if you have severe symptoms, your doctor may recommend arthroscopy to check the cartilage inside your knee. If the cartilage is softened or shredded, damaged layers can be removed during the surgery, leaving healthy cartilage in place .
Hertling, D., Kessler, R.M. ”Management of Common Musculoskeletal Disorders : Physical Therapy Principles and Methods.” Lippincott, Philidelphia 524-533, 2006.
Mc Connell, J. ”The physical therapist’s approach to patellofemoral disorders.” Clinical Sports Medicine 21:363-387, 2002.
For more information on chondromalacia patella see this video.
If you would like to get in touch to discuss your condition or make an appointment for physio in Tralee, please click
A Supraspinatus tear is a common area of injury in the rotator cuff complex. These are a group of muscles surrounding the humerus that help to keep the shoulder(humerous) in place. They are the supraspinatus, infraspinatus, subscapularis, and teres minor muscles. These muscles facilitate movement of the shoulder joint in different directions, ie. raising your arm overhead. Other supportive structures which help to stabilise the shoulder include the shoulder capsule and the ligaments of the shoulder. See video.
Supraspinatus Tear – Acute vs Degenerative
Acute tears to the rotator cuff muscles/tendons often occur due to sports or impact injuries. can occur alongside injuries like shoulder dislocation, clavicle fractures, or other rotator cuff injuries that can happen as the result of things like a fall on your outstretched arm or attempting to lift something too heavy; plus there are a variety of sports where the athletes are prone to shoulder damage like baseball, basketball, rugby, AFL Football, and tennis. Construction work and other high-risk physical jobs can also increase the likelihood of experiencing this type of injury.
Alternatively degenerative type tears can occur due to overuse and as a result of age and lifestyle. Instead of a single catastrophic episode or trauma to the shoulder, these tears are the result of damage and wear on the supraspinatus structure slowly over time. The likeliness of these issues increases with age and is more common in the dominant hand. In addition, if you experience a degenerative tear in one shoulder, you’re at a greater risk for a tear in the other shoulder. Men over forty are the most likely to have degenerative supraspinatus tears. Factors like smoking, hypercholesterolemia, weight and BMI, height, bone spurs, and other genetic factors increase the chances as well.
A Supraspinatus tendon tear can be full thickness (the entire muscle is affected) or partial thickness (incomplete tear). Tears can be symptomatic , where there is pain and your ability to perform basic everyday tasks is greatly reduced, or it can be asymptomatic, meaning that the tear causes very slight or no pain.
Difference between full and partial thickness Supraspinatus tear
You can partially or fully tear your supraspinatus muscle, and remember that these sorts of tears can be symptomatic (meaning they cause supraspinatus pain and inhibit your range of motion and ability to perform everyday tasks) or asymptomatic, meaning the tear is present but it not currently causing you pain or otherwise causing problems in your life. Partial thickness tears of the supraspinatus muscle are an incomplete disruption of muscle fibers.
If you have been diagnosed with a partial thickness tear and begin experiencing more pain you should talk to your orthopaedic surgeon. Sometimes partial tears can progress to full thickness tears. Full thickness tears can also occur spontaneously and are the complete disruption of the fibers of the supraspinatus muscle.
The supraspinatus tendon can also be the site of injury. Tendons have poor blood supply and will not heal themselves. The longer these tears are left untreated, the more chance the tendon tear will enlarge and retract which results in more difficult surgery to repair this damage.
Diagnosis of a Supraspinatus tear
Various orthopedic tests can help indicate the likelihood of a supraspinatus tear during a physical exam. Magnetic resonance imaging (MRIs), and ultrasound scans are all used to confirm diagnosis.
Depending on the severity of the tear, a surgeon may recommend starting with a non-surgical treatment like physiotherapy. For most tears this is rarely effective. Cortisone injections can give short term relief but cause more harm long term. They can be effective if the main cause of pain is a sub-acromium bursitis
For full thickness tears and more major tears there is significant damage to the tendon, various surgical procedures such as arthroscopic shoulder surgery are usually required. Full thickness tears will not heal without surgery. I have however seen cases where the supraspinatus muscle shrivels up after a full tear and basically withers away. In some such cases there is little or no pain at that stage and other muscles take over to a certain extent during shoulder movement, allowing the person to carry out normal daily activities.
To discuss your condition, make an appointment or get a second opinion please contact us.
Haemochromatosis is a inherited condition where iron levels in the body increase over many years leading to iron overload. If the condition is not treated, it can lead to damage in certain parts of the
body such as the liver, joints, pancreas and heart. Haemochromatosis most often affects people of white Celtic/northern European ethnicity such as from Ireland, Scotland and Wales.In advanced cases of haemochromatosis, the high levels of iron can also damage the joints. Many older people with longterm haemochromatosis experience arthropathy with associated joint pain. Haemochromatosis arthropathy, or joint disease(arthritis), can lead to progressive thinning and loss of cartilage within the joints. It can also result in bone bruising, damage and osteophyte formation around the edge of the joint causing pain.
The main symptoms of haemochromatosis are:
swelling (inflammation) in the joints
Treatments for haemochromatosis
There’s currently no cure for haemochromatosis. There are however treatments that can reduce the amount of iron in your body. This can help relieve some of the symptoms and reduce the risk of damage to organs such as the heart, liver and pancreas.
The most commonly used treatment for haemochromatosis is a procedure to remove some of your blood, usually about 500ml at a time, from a vein in your arm. known as a phlebotomy . The removed blood includes red blood cells which contain iron, thus reducing the amount of iron in your body.
There are 2 main stages to treatment:
induction – blood is removed on a frequent basis (usually weekly) until your iron levels are normal; this can sometimes take up to a year or more
maintenance – blood is removed less often (usually 2 to 4 times a year) to keep your iron levels under control; this is usually needed for the rest of your life
Chelation therapy may be used in a small number of cases where regular phlebotomies are not possible, because say for example, you have very thin or fragile veins. This treatment involves taking medicine that removes iron from your blood and releases it into your urine or poo. One such medicine is called deferasirox. It comes as a tablet that’s usually taken once a day. It’s unlicensed for the treatment of haemochromatosis, which means it has not undergone extensive clinical trials for this use. But your doctor may recommend it if they feel the possible benefits outweigh any risks.
Keep a generally healthy, balanced diet.
Avoid foods high in iron such as red meat, liver etc..
Avoid breakfast cereals/milk that have been “fortified” with extra iron
Avoid taking iron and vitamin C supplements together, as vitamin C increases iron absorption significantly when they are consumed together.
Avoid drinking excessive amounts of alcohol – Alcoholic drinks can be high in iron.
It may be possible to relieve the painful symptoms of haemochr0matosis with painkillers and steroid medicine. However, If significant damage has occurred, it may be necessary to replace the affected joint with an artificial one, such as a hip replacement or knee replacement.
To make an appointment, get a second opinion or discuss your condition contact us.
AC joint injuries occur where the acromion connects to the clavicle on the top of the shoulder. This joint helps maintain the position of the shoulder and is very important for shoulder control, motion, and strength. The joint is stabilized by a capsule and ligaments. Injury occurs when these structures get damaged. If severe the injury can lead to joint instability and pain. These type of injuries are usually the result of a sudden fall onto the shoulder. The AC joint is also a common place for arthritis to develop. This is usually the result of years of “wear and tear” on the joint and is common in weight lifters and laborers.
Sudden AC joint injuries (“sprains” or “separations”) typically occur by one of the following ways:
A fall onto the shoulder
Lifting weights or heavy objects
An impact injury to the shoulder
Pain at the AC joint
A noticeable bump at the AC joint
Shoulder tightness and loss of motion
Pain when lifting the arm up to the side or across the front of the body
Acromioclavicular joint separation is a fairly common injury among physically active people. Football players are often subject to AC separations. Many AC injuries don’t require surgery. Most patients recover with full function of the shoulder. The period of disability and discomfort ranges from a few days to 12 weeks depending on the severity of the separation. Disruption of the AC joint results in pain and instability in the entire shoulder and arm. The pain is most severe when the patient attempts overhead movements or tries to sleep on the affected side. There are certain situations ie. grade 4 or 5 separations, which may require surgery.
What is an AC joint separation?
AC joint separation injuries are dislocations of the clavicle from the acromion. The severity of these depends on which supporting structures are damaged, and the extent of that damage. Tearing of the acromioclavicular ligament alone is not a serious injury, but when the coracoclavicular ligaments are ruptured, the result is major instability in the shoulder area.
AC injuries are classified in three grades ranging from a mild dislocation to a complete separation:
Grade I – A slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint.
Grade II – A partial dislocation of the joint in which there may be some displacement that may not be obvious during a physical examination. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact.
Grade III – A complete separation of the joint. The acromioclavicular ligament, the coracoclavicular ligaments, and the capsule surrounding the joint are torn. Usually, the displacement is obvious on clinical exam. Without any ligament support, the shoulder falls under the weight of the arm and the clavicle is pushed up, causing a bump on the shoulder.
There are a total of six grades of severity of AC separations. Grades I-III are the most common. Grades IV-VI are very uncommon and are usually the result of a very high-energy injury such as one that might occur in a motor vehicle accident. Grades IV-VI are all treated surgically because of the severe disruption of all the ligamentous support for the arm and shoulder.
For more on acromioclavicular joint injuries click here.
If you would like to discuss your condition or get a second opinion, feel free to ring us for a chat on 0867700191 at Eddie O Grady Physiotherapy.
The term “back mice” is a rather cute description for a painful yet often overlooked condition, even by back pain specialists. The term “back mice” was first used to label the condition by Peter Curtis in 1993. Back mice present as small, firm, fleshy yet moveable nodules upon palpation over the sacral region. Firm pressure directly on the nodules usually produces pain and tenderness, which sometimes radiates into the sacrum and hip. Also, the back mouse seems to suddenly appear following trauma to the back as in a motor vehicle accident or perhaps following a lifting injury. The size of the nodules does not change and they remain the same regardless of the administered soft tissue treatment.
Perhaps a more descriptive term for the back mouse is “lumbar fascial fat herniation” . This occurs when the lumbar subfascial fat layer herniates through the overlying thoraco-dorsal fascia and gets trapped and inflamed. The mechanism appears to be due to an anatomical defect or weakened area in the fascia, which, when there is increased internal pressure, allows the fat lobules to push through the fascia. Once herniated, the fat becomes trapped and as an expanded, inflamed, herniation in an otherwise unyielding fibrous capsule. This creates a focus of pain. Pressure on the fat mouse does not push it back through the fascia but only inflames the torn fascia more. These herniations occur at predictable sites along the iliac crest and sacrum very close to the natural dimple area. They also are approximately three times more prevalent in women, particularly in moderately obese women.
A client usually presents with an episode of low back pain. There may be a history of pain with lifting or prolonged sitting and the pain is usually greater on one side more than the other. The pain may radiate into the buttocks and sacrum and perhaps to the lateral thigh and into the lower extremity. Medications usually do nothing. Many will have gone through the pain pill merry-go-round, taking a cocktail of pain and anti-inflammatory medications even though the pain never truly goes away. The client has often tried everything, been everywhere and you are their last hope. They may have had radiographs, MRI studies or nerve conduction studies, all with negative or minimal findings. They may even have a minor disc bulge without nerve compression, yet the pain exactly mimics a discogenic disorder. When asked to point to the area of the greatest pain, they will invariably point just above and lateral to the natural “dimple” where the back and buttocks come together, near the multifidis triangle. When the area is palpated, the most marked finding is one or several firm, mobile 1.3 cm nodules. When pressed, these nodules reproduce the client’s complaints of back pain as well as the “sciatic” pain.
Subcutaneous lipomas in the back region differ from back mice in that they present as moveable non-tender “speed bumps” that cause pain only when they compress the underlying soft tissue. Subcutaneous lipomas can be found anywhere in the body. They grow slowly over time and are only cosmetically important.
Fig 2. Overlying thoraco-dorsal fascia.
Fig 3. Iliac crest and sacrum.
There always seems to be a focus by back pain specialists upon the disc and nerves issues even though the fat mice are readily palpable. Many sufferer’s have had epidural injections without success. I have had clients who have had surgery for disc herniations yet who still point to the back mouse post surgery as the focal point of pain. It could perhaps be considered diagnostic for the presence of a lumbar fascial fat herniation if a local infiltration of anesthetic takes away the pain.
Treatment of Back Mice
A medical doctor can inject the back mouse with a local anesthetic. This usually only helps temporarily. Dry needling techniques by acupuncturists may help reduce the tension in the fibrous capsule. Good results may sometimes be obtained with local electrical stimulation techniques such as electro-acupuncture. Do not apply deep pressure to back mice during manual physiotherapy treatment. Doing so may only serve to aggravate the herniation. Release of muscular tissue tension around the back mouse may provide some relief by easing pressure on the area.
Perhaps the only permanent cure for the back mouse is its excision and removal. This could be performed by a hernia repair specialist. Once the fat herniation is excised and the fascial tear repaired, the client usually enjoys a more enduring and sometimes dramatic relief. One of the biggest problems is that so many medical doctors fail to recognize this condition; they tend to discount its existence, thereby limiting the treatment options. Icing the area may also provide temporary relief.
Achilles tendon ruptures will debilitate your lower leg completely, the moment they happen. The Achilles tendon is an important part of the leg. It is located just behind and above the heel, attaching the heel bone to the calf muscles. Its function is to help in bending the foot downwards at the ankle (this movement is called plantar flexion). If the Achilles tendon is torn/ruptured, the tear may be either partial or complete. In a partial tear, the tendon is torn but is still partly joined to the calf muscle. With complete tears, the tendon is completely torn and the connection between the calf muscles and the ankle bone is lost. If your Achilles tendon is ruptured you will be unable to stand on your tiptoes and you will have a flat-footed walk with a severe limp, along with considerable pain initially.
What causes Achilles tendon ruptures?
An Achilles tendon can tear when there is too high a load or stress placed on it. This can happen with activities involving a forceful push off with the foot – ie. running/sprinting in football, basketball, tennis etc. I have also seen it occur when somebody sprints off suddenly on a sandy beach, the sand giving way under the foot putting extra stress on the calf and the achilles tendon. The push off movement uses a strong contraction of the calf muscles maximally stressing both the calf muscles and the Achilles tendon . Injury to the achilles can also occur due to falls, if the foot is suddenly forced into an upward-pointing position, stretching the tendon. Another possible injury is a deep cut/laceration to the tendon.
Sometimes the Achilles tendon is weak, making it more prone to rupture. Factors that weaken the Achilles tendon are:
Corticosteroid medications (such as prednisolone) – mainly when used as long-term treatment.
A corticosteroid injection near the Achilles tendon.
Certain rare medical conditions, such as Cushing’s syndrome, where the body makes too much of its own corticosteroid hormones.
Tendinopathies of the Achilles tendon.
Other medical conditions which can make the tendon more prone to rupture; for example, rheumatoid arthritis, diabetes, gout and systemic lupus erythematosus.
Certain antibiotic medicines may slightly increase the risk of having an Achilles tendon rupture. These are the quinolone antibiotics such as ciprofloxacin and ofloacin. The risk of having an Achilles tendon rupture with these antibiotics is quite low and mainly applies to people who are also taking corticosteroid medication.
What are the symptoms of Achilles tendon ruptures?
You might hear a snap or feel a sudden sharp pain when the tendon is torn (ruptured)during a sporting activity or injury. The sharp pain usually settles quickly, although there may be some aching at the back of the lower leg. After the injury, the usual symptoms are:
A flat-footed type of walk. You can walk and bear weight but cannot push off the ground properly on the side where the tendon is ruptured.
Inability to stand on tiptoe.
If the tendon is completely torn, you may feel a gap just above the back of the heel. However, if there is bruising and swelling may disguise the gap.
An Achilles tendon rupture is usually diagnosed based on symptoms, history of the injury and a physio/doctor’s examination. An orthopedic test called Thompson’s test (also known as the calf squeeze test) may help diagnosis. In this test, you will be asked to lie face down on the examination bench and to bend your knee. The doctor will gently squeeze the calf muscles at the back of your leg and observe how the ankle moves. If the Achilles tendon is OK, the calf squeeze will make the foot point away from the leg (a movement called plantar flexion). This is quite an accurate test for Achilles tendon ruptures. An ultrasound or MRI may be used to confirm diagnosis and give a fuller picture of the injury.
Treatment and recovery
Treatment for a ruptured achilles tendon usually involves surgery to repair the tendon. The surgeon sews/sticks together the torn ends of the Achilles tendon, and may also use another tendon or a tendon graft to help with the repair. A plaster cast or brace is needed after the operation for about eight weeks, to keep the foot immobilized, allowing the tendon can heal. The plaster cast or the brace is positioned so that the foot is pointing slightly downwards, which takes the strain off the tendon.
Traditionally, crutches were used to keep weight off the leg during the first few weeks of treatment. Current thinking tends towards using the leg normally early on (early mobilization). This involves fitting a plaster cast or a brace which you can walk on. It is more convenient because you do not need to use crutches. Physiotherapy will also be needed, especially when the cast is removed. I have personally found instrument assisted soft tissue work(after about 8 weeks) to be very beneficial along with stretching/strengthening work and deep tissue work to the calf during recovery. Full recovery is greatly slowed when there is no hands-on work done during recovery, after the cast is removed once an ok is given by the surgeon to commence.
Depending on a person’s profession, some people may need several weeks off work after an Achilles tendon tear (rupture); the time taken to return to sport is usually between 4 and 12 months. Generally, the outlook is good. However, the tendon does take time to heal, usually about six to eight weeks. More time will be needed after this to allow the muscles and tendon to regain normal strength.
For more on rehabilitation on achilles tendon ruptures post surgery click here.
Plantar plate injuries are easily missed, probably because a lot of people don’t know what the plantar plate is. Quite they are diagnosed under the general term metatarsalgia. The plantar plate is a deep fibrocartilaginous structure that originates from the metatarsal head and attaches to the proximal phalanx through the joint capsule within the forefoot. Its role is to help stabilize the metatarsophalangeal joints (MTPJ), along with a couple of other structures. The plantar plate also acts as an attachment site for the plantar fascia, so if you load the foot, the medial arch lengthens, the plantar fascia tightens, this engages the plantar plate to plantarflex the proximal phalanx until the toe reaches the ground. This is a simplification of a complex process and is commonly known as the The ‘reversed’ windlass mechanism (with weight-bearing the longitudinal arch flattens, the foot lengthens, the plantar fascia tightens, the proximal phalanx becomes plantarflexed and the mechanism comes to a stop when the proximal phalanx presses against the ground).
What causes a plantar plate injury and how common are they?
There are many contributing factors. The first is any activity that exposes the MTPJ to repetitive and excessive dorsiflexion, so think about jumping and running especially in forefoot runners. There are a few biomechanical conditions that increase the load through the plantar plate such as hallux valgus (bunions). As the function through the 1st MTPJ(big toe) is reduced, then we get what is known as low gear propulsion and increased loading through lesser MTPJs, typically the 2nd, 1st, then 3rd and so on. Another condition like having say an irregular metatarsal length, for example, if you have a long 3rd metatarsal, can expose the plantar plate to increased load, as can external factors like high heels. Basically anything that will result in excessive dorsiflexion or ground reaction forces at the MTPJs may increase plantar plate loading.
How does a plantar plate injury present?..
The patient will complain of pain on the dorsal and plantar aspects of the MTPJ, usually described as an ache or bruising.
Mild oedema may be present along with an episode of trauma, however, trauma is not essential as plantar plate injuries are typically a chronic overuse injury
Reduced plantarflexion strength – The ‘Digital Purchase’ test
A quick way to do this, put a piece of paper under the apex of the affected toe and ask the patient to try and stop you pulling the paper away, in a plantar plate injury you will notice the paper is pulled away much more easily.
Pain, oedema and positive Digital Lachmans (Anterior Draw) / Vertical Stress.
Floating toe, if late-stage hammertoe, or Churchill sign may be present.
Diagnosis of plantar plate injuries
Digital Lachmans / Vertical Stress Test (Fig 1)
Same style of test to assess ACL tears, helps to assess the integrity of the plantar plate, it is quick, easy and a simple test to perform. Stabilise the head of the metatarsal with one hand, using the other hand stabilise the base of the proximal phalanx, apply a vertical force, we are looking for pain and any translocation, it is important to remember this is different from dorsiflexion of the digit.
There are 2 scoring systems one by Thompson and Hamilton and the other Yu and Judge
Thompson and Hamilton
Stage 0, there is no dorsal translocation present of the proximal phalanx.
Stage 1 the base of the phalanx, will not dislocate, however, may sublux
Stage 2 the base of the phalanx can be dislocated.
Stage 3 the phalanx base is in a fixed dislocated position
Yu and Judge
Stage 1 mild odema on the plantar MTPJ with dorsal odema often present as well. Tenderness is present on palpation, however no anatomical malalignment.
Stage 2 moderate odema is present with a noticeable deviation.
Stage 3 odema present around the entire MTPJ with deviation and possible dislocation/subluxation, the odema will reduce however the deformities will remain.
I think the best way to describe the 2 different methods of testing, would be that the Thompson and Hamilton test best describes the integrity of the plantar plate at any given time, whereas the Yu and Judge test describes different stages based on clinical findings on the time of examination.
MRIs, X-rays and Ultrasound
There is still some debate as to whether an MRI scan or ultrasound scan is best for detecting plantar plate injuries. As we know ultrasound is cheaper, however, it is user-dependent, whereas MRI scan is more expensive but we can also get an overall picture of the structures within that area as well. X-ray in weight-bearing (lateral or oblique views) will show subluxation dorsally of the proximal phalanx on the metatarsal head, an anterior-posterior view will show a transverse deformity as well. An x-ray will also rule out other bony pathologies.12
Treatment of plantar plate injuries
The aim of treatments, like most musculoskeletal pathologies, is about managing the load. Essentially we want to try and reduce the ground reaction forces under the affected metatarsal head and reduce the plantarflexion moment of the metatarsal and the dorsiflexion of the phalanx.
Treatment protocols include
No barefoot walking/activity modification
Footwear advice / Air cast boot – we want to look at using a stiff-soled shoe, or reducing the heel height of a shoe, so footwear like high heels and the flexible minimalist type shoes tend to aggravate a plantar plate injury, the same goes for open-toe shoes and flip-flops, as you must claw your toes to keep these on which again increases the ground reaction force underneath the metatarsal.
Stretching / Strengthening – thinking about the mechanics of the foot, if there is tightness within the calf muscles, in turn, could result in early and increased loading through the forefoot, and if you are unable to get adequate dorsiflexion due to calf tightness, then the foot may pronate to compensate for this, which in turn could increase the loading through the lesser MTPJ’s. It is important also to work on strengthening the muscles within the foot.
Strapping can be very helpful in reducing pain, using a rigid zinc oxide tape and pulling the toe into a plantarflexed position to help offload a plantar plate (Fig 2).
Orthotics can be a useful way to help offload the affected plantar plate. One of the best ways to treat Plantar Plate Injures with or without surgery is using an orthotic device that places the pressure into the archway and off of the ball of the foot. If manufactured and molded correctly, they can keep the tension off the injury and pressure when standing and walking. Combining the orthoses with taping and footwear advice can be quite an effective way of offloading the affected plantar plate, whilst the patient reduces sporting activities.
Steroid injections can be tried , however repeated intra-articular injections has been shown to result in dislocation of the MTPJ. It has also been suggested that injections into a ligament resulted in destruction of fibrocytes and reduction in tensile strength for up to 1 year which in turn may result in further damage a possible rupture.
A recent case study showing a patient with a plantar plate tear was managed using conservative measures, consisting of taping, activity modification and the use of a Darco boot over a 6 month period, and progressing to stiffed shoe and orthoses and stopped taping. At the 1 year mark, the patient was pain-free with no toe deformity, and on MRI the plantar plate has healed.
So what’s my treatment plan?
No barefoot walking for 6 weeks (minimum)
To wear stiff-soled shoes
Strapping of digit changing every 72 hours
Orthoses as described as above, plus any other modifications required
Stretching and Strength work – Distal and proximal
If conservative measures fail, then it may require referral to a surgeon.
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