Shannon Clinic

There is no worse feeling than rolling out of bed, putting your feet down, then taking your first few steps and feeling pain or tightness under the foot near the heel. This pain might last a few steps, a few minutes or can be more prevalent throughout the day. This is called “start-up pain” and is a hallmark feature of plantar fasciitis.

What is the Plantar Fascia?

The plantar fascia is a band of dense fibrous tissue or aponeurosis that runs from the medial (inner) aspect of the calcaneus (heel bone) to the forefoot. The fascia runs in three bands (lateral, medial and central) fanning across the sole (plantar aspect) of the foot.

The plantar fascia plays an important role in maintaining, stabilizing and controlling the longitudinal arch which is stressed during locomotion. As well as, aiding in the distribution of weight evenly across the metatarsal heads; while also assisting with efficient propulsion forces, by acting as a cushion for the soft tissues around the metatarsal heads. Therefore, any alterations impacting the fascias ability to maintain the longitudinal arch leads to increased stress loading of the fascial tissues.

What Causes Plantar Fasciitis

Plantar fasciitis usually presents with focal pain around the heel, accompanied by start-up pain first thing in the morning and/or after sitting for extended periods, as well as pain during walking/running. The pain associated with plantar fasciitis is due to degenerative changes in the fascial tissue, weakening the tissue as a result of excess stress loading. The most commonly involved fascial bands are the medial and central bands.

Excess stress loading can be multifactorial and can include, direct training or volume load increases, and/or biomechanical imbalances leading to increased tissue loading. Causes can include:

Acute load spikes (increasing walking/running load too quickly – a classic example being individuals who do not walk much day-to-day (i.e 5k steps per day) but then go on holiday and start walking 15-25k steps per day for 1, 2, 3, 4 weeks in a row.
Excessive foot pronation – collapsing of the longitudinal arch
High arches
Tight achilles, calf, intrinsic foot muscles
Poor fitting shoes
Poor gait mechanics – reduced great toe extension, reduced dorsiflexion of the ankle
High body mass index – placing higher loads over the plantar fascia

Treatment Options

There are a wide variety of treatment options available for plantar fasciitis, ranging from over the counter analgesics, to orthotics and night splinting, through to physical therapy, injection interventions and surgery. In this blog the focus will be on the more common treatment interventions.

Orthotics

Orthotics are commonly prescribed for plantar fasciitis with one study indicating they may help reduce pain associated with PF in the medium term. However, in the short and long term there is low quality evidence to suggest orthotics do not provide any improvement in pain. Furthermore, a 2018 systematic review and meta analysis found orthotics were not superior for improving pain and function when compared to sham and other conservative interventions.

Moreover, there is evidence indicating orthotics may lead to a weakening of the intrinsic foot muscles which may potentially augment the already weakened and dysfunctional tissue driving the degenerative changes associated with plantar fasciitis. It is for this reason Melbourne sports chiropractor Dr. Shannon does not advocate the use of orthotics as a front-line intervention for improving pain and function in patients with plantar fasciitis.

Shock-Wave Therapy

Shock-wave therapy is a treatment intervention which has been gaining some traction in recent years. There is evidence to suggest shock-wave therapy may improve pain and function and is ranked as a treatment option most likely to be effective at improving pain and function over the short, medium and long term. Shock-wave therapy is therefore a treatment option that could be considered, particularly in more chronic or recalcitrant cases.

Strengthening/Loading Exercise Programs

The research in this area is currently lacking. One of the difficulties at present is the lack of a standardized strength program which can be used for research purposes. However, in 2023 a consensus paper was released with 3 specific strengthening programs designed to be used in clinical trials. This is an area of most interest as individuals with plantar fasciitis exhibit reduced foot and ankle strength, muscle size and function.

In 2014, a randomized controlled trial comparing stretching and high load strengthening exercises reported a superior self report outcome after 3 months in the strengthening group. This is not surprising, considering plantar fasciitis is associated with degenerative change of fascial tissue, an appearance somewhat similar to tendinopathy which in the case of achilles and patellar tendinopathy, responds well to moderate to heavy strength loading programs.

It is for these reasons the cornerstone to Dr. Shannon’s approach to managing plantar fasciitis includes strengthening exercises, which are combined with load management and correcting any biomechanical imbalances in the lower extremity. As more studies are published exploring strength loading on plantar fasciitis pain and function, it is hoped the results will reflect what is seen in our Melbourne city sports chiropractic clinic.

Injection Interventions

At present the pathophysiology of plantar fasciitis is not well understood however, there is histopathological evidence indicating degenerative changes and atrophy of the muscle tissue, together with inflammation either in the fascia or muscle tissue. It therefore would be logical to assume that an intervention which potentially reduces inflammation and aids with tissue repair would perform superior to an intervention which solely focuses on reduction in tissue inflammation. The evidence comparing these two types of injection interventions leans towards supporting this assumption.

The two most prevalent injection interventions for plantar fasciitis are corticosteroid and platelet rich plasma (PRP) injections. Corticosteroid injections (CSI) are a powerful anti-inflammatory intervention that have shown to improve pain levels in the short-term (<3 months) in plantar fasciitis however, they come with risks of tendon ruptures, fat pad atrophy and there appears to be an absence of any medium to long term benefit.

PRP injections possess strong anti-inflammatory properties, in addition to high levels of cytokines and growth factors which are important in wound healing. Furthermore, PRP injections have not been associated with any adverse effects on the plantar tissue. Moreover, they provide better improvements in pain and function than CSI’s over 6 and 12 months and could be considered in chronic cases in conjuction with strength loading interventions.

Surgery

Surgery should only be considered in recalcitrant cases of plantar fasciitis that have failed to respond to conservative management. Procedures include plantar fasciotomy, gastrocnemius release, radiofrequency tenotomy, dry needling. All have been shown to be effective (improving pain and function) over the short and medium term.

Summary

Although futher research is needed to understand the true pathophysiological cause, plantar fasciitis appears to have similar characteristics to tendinopathy such as Achilles tendinopathy including degenerative changes of the tissue due to excess stress loading of the tissue. As the evidence currently shows, treatment interventions which aim to address the degenerative and inflammatory changes in the plantar fascia tissues appear to be more effective at reducing pain and improving function over the medium and long term (6-12 months) over interventions that focus primarily on symptompatic control.

It is for this very reason our approach to treating plantar fasciitis at the Shannon Clinic – Melbourne Chiropractic and Sports Care is to focus on improving the quality and strength of the plantar fascia tissue through a loading program, whilst also addressing any mechanical imbalances and training load problems which may be contributing to the excess stress loading of the plantar fascia. In recalcitrant cases that fail to adequately respond to exercise therapy and load management, we utilize PRP injections to assist with pain management to allow individuals to return to their rehabilitation program.

If you are experiencing plantar fascia pain and would like to make an appointment with Melbourne sports chiropractor Dr. Nicholas Shannon you can book below. If you found this blog of interest, you might enjoy our blog on elbow tendinopathy.

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Nicotinamide Mononucleotide (NMN) is a supplement that seldomly comes onto most people’s radar, yet it is a supplement that holds a promising future with some researchers suggesting NMN should become a staple supplement to help improve longevity. Melbourne sports chiropractor Dr. Nicholas Shannon takes a look at literature on NMN to see if it is something you should consider.

What is NMN and How Does NMN Work?

NMN is synthesized in the body via two pathways, the Salvage and Preiss-Handler pathways, with the former synthesizing NMN from vitamin B3. Once synthesized, NMN acts as a precursor to a metabolic coenzyme called NAD+ (nicotinamide adenine dinucleotide).

NAD+ is an important coenzyme involved in a variety of processes including cell death, aging, gene expression, neuroinflammation and DNA repair.

NMN is found naturally in plant and animal sources including soybeans, broccoli, avocado, tomatoes, cucumbers, mushrooms, raw beef and shrimp. The levels of NMN in these food sources vary from around .25mg/100g to 1.88mg/100g. For comparison, studies investigating the efficacy of supplementing with NMN range from 250mg to 2000mg per day.

Why is NMN and NAD+ important in aging?

As we age there is a reduction in energy production in the mitochondria (the power factory of cells) in a variety of organs including the brain, adipose tissue, skin, liver, skeletal muscle and pancreas as a result of decreased NAD+ levels. This depletion of NAD+ occurs naturally with aging, due to an increase in consumptions of NAD+ consuming enzymes. Additionally, the metabolic pathway which produces NAD+ can be inhibited by chronic inflammation, high fat diets and, oxidation which can further negate the levels of NAD+ in the body. This in part, leads to biological changes associated with aging such as, reduced endurance, strength, cognitive impairment and DNA damage.

Supplementation with NMN has been shown to boost NAD+ levels by 2-3 times. Furthermore, fasting, and reducing energy intake may also improve NAD+ levels. It is for this reason, NMN supplementation research has moved from NMN being a source of cellular energy and a precursor to NAD+, to it’s potential impact on other disease such as age-induced type II diabetes, obesity, cerebral and cardiac ischaemia, heart failure and cardiomyopathies, Alzheimer’s disease (AD) and other neurodegenerative diseases, corneal injury, macular degeneration and retinal degeneration and acute kidney injury.

Safety and Efficacy of NMN

NMN has been extensively studied in mice and rodents, where results have shown significant improvements across a variety of areas including AD, age-related physiological changes, as well as renal, cardiac, vascular and skeletal muscle function. However, impressive results in animal studies do not necessarily correlate to the same changes in humans.

The first step in the human trial process is to establish if an intervention is safe, efficacious (does it work) and if are there any adverse reactions. To this author’s knowledge, there are at least 9 randomized controlled human trials which have explored dosage ranges from 250mg to 2000mg per day, over various time periods ranging from 30 days to 3 months, across a variety of groups; healthy middle aged adults, healthy older aged adults, recreational athletes, obese and overweight, males and females.

These studies have consistently shown NMN is safe and well tolerated. The data is favourable to seeing an increase in NAD+ concentrations in the blood, however it should be noted there have been some studies which haven’t shown a statistically significant change. Furthermore, it should be noted that currently there is no agreed definition of what low, normal or high NAD+ levels are.

Reported Benefits of NMN

A 2023 randomized, controlled, double blinded placebo trial (the gold standard study design) investigating the effects of NMN at 300mg, 600mg and 900mg versus placebo on a cohort of 80 healthy male and female adults over 60 days, found increased blood concentrations of NMN, significantly improved 6 minute walking test (endurance), minimal to no change in blood biological age, and improved health scores (SF-36 questionnaire) in the NMN groups compared to placebo. In addition to NMN being safe and well tolerated across all doseage levels.

Additional clinical trial data has shown the following.

Sleep – no detectable changes in sleep quality scores
Physical activity (older adults) – significantly improved gait speed, grip strength, 30s chair-stand test indicating a potential prevention in age-related muscle decline
Physical activity (middle-aged adults) – significantly increased oxygen consumption in ventilation and energy consumption. In addition to significantly improved aerobic capacity when exercise and NMN were combined, suggesting NMN could be used to improve athletic performance
Nervous system-related – improvements in hearing in older adults, no change in cognition or vision
Diabetes – improved muscle insulin sensitivity which may improve impaired glucose tolerance
Anti-aging – significant improvement in telomere (a biomarker for monitoring aging)

Where To From Here?

The early human data for NMN looks promising, it’s safe, it is well tolerated, and there is evidence in adults that NMN may play an important role in anti-aging. The data specifically related to improvement in endurance and strength for older and middle-aged adults looks extremely promising, and this should be an area of great interest to those in the sports and exercise medicine field.

Overall, the early data suggests NMN might have a bright future, which will be solidified as more data comes out. Some of that data needs to provide clarity to understand the full impacts of NMN supplementation on the body; to establish agreed measurements of NAD+ to determine what are low, normal and high levels; to identify if there are specific age-related dosages; and to study the safety of NMN supplementation over the long term (years).

It is also important to note that supplementation is only one component to improving health and longevity. Additionally sleep, diet, fasting and exercise are essential to the process.

If you are interested in exploring the benefits of NMN for yourself, Melbourne sports chiropractor Dr. Shannon has analysed the market providers and prefers Renue by Science, as their products are third party tested to confirm their supplements purity, and their manufacturing plant is FDA approved. To read more about why third party testing is important for supplements have a read of our blog on sports supplements.

If you would like to book an appointment a chiropractic or massage appointment at our Melbourne city chiropractic clinic on Collins Street in the Melbourne CBD, click on the link below.

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Elite motor sport is fiercely competitive, driven by supply and demand economics with a tight supply of seats available, and high demand from drivers wanting to occupy one of those seats. This places significant pressure on incumbents to consistently perform week in, week out to maintain their seat. As Melbourne city sports chiropractor Dr. Shannon has discussed before, elite racing drivers endure a myriad of physical and mental demands throughout a race weekend. Making the pressure to perform just one source of stress elite drivers must contend with.

As we found during our research for the blog on the physical and emotional demands of elite motor sport, it became quite evident there is a paucity of literature looking at the mental demands and stress elite racing drivers endure. Coupled to this, is the lack of public attention and awareness to this area of elite motor sport. Where we routinely see the media and fans quickly criticize a driver for a bad performance, often with little apparent consideration for the internal and external stresses elite drivers face at race meets. Nor consideration to the everyday human stress an elite racing car driver faces outside of their job such as relationships, families, and/or business stress.

In light of this, and with the enduro rounds about to start as we build up to the Supercars Bathurst 1000, we talk with Bathurst winner and Supercars ace, Nick Percat to discuss how he handles the mental demands and stress of racing, to give readers an insight and appreciation into the mentally demanding world elite drivers like Nick endure.

Preparing For a Race Meet

Nick Percat Darwin Hidden Valley 2023 Friday Race Schedule with WAU — Nick Percat’s Darwin Race Meet Schedule 2023 – NP + ALL are events Nick is required to attend

Race meetings in their own right are stressful places, fuelled by environmental noise and pollution from the cars, long days, as well as driver nerves, anxieties and adrenaline. From our own experience working in Supercars with Nick and in other race categories, on a given race weekend drivers and crews can be at the track as early as 6am and leave as late at 9-10pm (sometimes longer for mechanics). On any given day during the race meet drivers can be under highly demanding schedules which is highlighted by the packed agenda Nick has kindly provided from one day of a Supercars race meeting. These additional commitments outside of the car place added stress on drivers, with Nick noting it “is difficult, I find some nights I am exhausted but the adrenaline keeps me sharp in the races.”

So how do drivers prepare for such challenging and demanding weekends? When we asked Nick he states “I use a sports psychologist, who I have worked with for 15 years now.” Together their objectives are to put strategies in place which allow Nick to be calm, relaxed and in the right mindset so he can focus on performing at his best across the race weekend. Furthermore, they work together on allowing Nick to be present time conscious and adaptable if unexpected events occur. For Nick, this approach of creating a comfortable mental space that keeps him relaxed, focused and flexible, allows Nick to prepare for a rigorous and demanding race weekend. Moreover, the successful deployment of this strategy has led Nick to multiple race wins including Bathurst 1000, Clipsal 500, and podiums.

Staying Focused Over a Race Weekend

Handling Pressure from the Team

Leading into and at the race meet, drivers and teams will have expectations of how they hope the weekend will unfold. These expectations will primarily be driven internally by the team, and the goals they set for both the driver and team. However, there can be added performance expectations from the team’s sponsors, media and the fans. This creates a multitude of mental demands and stress for the team, which often falls onto the driver who will ultimately feel responsible for the teams on track performance.

Elite drivers therefore need to manage both the expectations and goals set by the team for their own performance, as well as those expectations of the team. To mitigate the external distractions, Nick says Walkinshaw Andretti United works hard to create an environment that is “very focused personally and from a team perspective.” They do this by “setting realistic goals” for both the drivers and team, while fostering a positive yet accountable work environment. This allows Nick to understand the team’s expectations of his performance, and allows him to set his individual goals, all while knowing he is supported by his team.

This team approach of creating a space where the driver and team are positively congruent is consistent with the framework Nick and his psychologist have been building on at a personal level; creating that comfortable, calm space, easing the stress on the driver and team. On a more personal note, knowing Nick has the support of his team he says that “if I have a bad race or day, it’s about leaving that in the past and focusing on the next time (he) is in the car.”

Enduring Scrutiny From the Media and Fans

Both drivers and teams are not immune to the scrutiny of the media and fans, resulting in an additional source of mental stress, particularly in the 24/7 news cycle, and with the accessibility of drivers via social media. Sadly, in a world driven by “likes”, “page views”, and “clicks” media content, including consideration of an athlete’s health and wellbeing are disregarded for a clickable headline. More often than not the scrutiny athletes (drivers) are under from the media and fans is unjust and ignorant of the human aspect of the individual.

Having worked with many athletes, across different sports it is a fair statement to say the harshest critic of an athlete is the athlete themselves. Nick is no different, stating “the pressure I put on myself has been there since I was probably 16 years old”. Pushing him to be the best he could be, and to unwaveringly commit himself to achieve his goal of having a long career as an elite racing driver. It is no surprise that Nick chooses to “block out the noise of the media” knowing the only scrutiny that matters comes from himself. As Nick knows that “if (he) has done the work off the track, that the rest will be ok and that keeps the pressure off.”

Maintaining Concentration in The Car

Once all of the off-track demands and pressures have been dealt with there is the business of racing, which as Melbourne chiropractor Dr. Shannon has previously discussed, is a complex, multi-tasked activity undertaken in a physically demanding cockpit, resulting in both physical and mental stress demands.

To cope with the physical demands of racing in a cockpit where cabin temperatures can range from 32-58⁰, and to remain completely focused over anywhere from 45 minutes to 2 hours in the car, strength, condition and nutrition work is imperative. Nick’s approach to these demands has seen him partner with his long-term trainer Heath Meldrum, who keeps Nick’s body conditioned through endurance aerobic training which includes cycling, swimming and trail running, in addition to strength/resistance training.

To make sure Nick is adequately fuelled and hydrated while training, leading into and across a race weekend, Nick consults with a sports dietitian. Nutrition and hydration is particularly important during a race weekend especially in the car, as drivers have high calorie burn rates across a race. Added complexities for drivers to remain adequately hydrated and fuelled in the car comes from the limited and temperamental fluid reserves and fluid lines, as well as the challenges of eating in the car, especially over longer races.

Additionally, Nick says having a “routine with sleep is very important” to allow him to remain focused in the car. As we have previously discussed, having a good sleep habit is essential for maximizing athletic performance. Sleep is an area which is challenging for many elite athletes who can often be anxious or nervous the night before their event, and in Nick’s case can be impacted by the adrenaline of a race weekend, evening sponsor commitments, late night data analysis etc. To help switch off at night Nick likes to “watch a good tv show or movie”.

Once in the car, to maintain that calm, relaxed, present time conscious space, Nick works off the “keep it simple, stupid” mantra, which allows him to remain calm and focused when unexpected events occur, or if he is enduring a difficult weekend where the car is struggling with setup. This includes taking a corner-by-corner approach, where his attention remains fixed on the upcoming corner. Keeping grounded in the present, allows Nick to forget those frustrating, stress inducing incidents that may have occurred, while also avoiding any anxieties and nerves that may arise from thinking about how the future of the race may unfold. Sometimes though it is the simplest of things that allow an athlete to refocus, and for Nick it can be “as simple as looking at a photo of (his) dog”.

Wrapping It Up

The key theme that flows through Nick’s approach to managing the mental demands of elite motor sport is the importance of having the right team around you. For Nick to create that calm, relaxed space enabling him to remained centred and present regardless of what might get thrown at him over a race weekend, has been built from the work he has done with his sports psychologist, dietitian and trainer, in addition to the team environment Walkinshaw Andretti United has created, Furthermore, Nick’s partner Bayley, and his dog Nelson are there to provide a sanctuary and distraction from a physically and mentally draining race weekend. Nick’s wholistic approach to managing the physical and mental demands of racing is one young drivers and athlete’s should look to learn from.

Moreover, the media and fans need to understand athletes are human beings, who have good and bad days. As Nick stated, there is no-one putting more pressure on an athlete or driver to perform than themselves. Therefore, if an athlete or driver has had a bad performance or a string of bad performances, negative commentary will do little to help the mental health of that individual, and in some cases may actually be destructive to the individual’s mental health. If we want to see our athletes and drivers perform at their best, the media, sponsors and fans need to be a positive contributor within that team care approach to managing mental stress, building up and supporting our athletes and drivers.

To read more of the Shannon Clinic – Melbourne Chiropractic and Sports Care blogs you will find them here. If you would like to book an appointment with Melbourne city chiropractor Dr. Shannon or our Melbourne remedial massage therapist Paula Pena, you can book online below. Our practice is located on the corners of Collins and Swanston Streets, opposite the Melbourne Town Hall in the CBD.

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Athletes and coaches are consistently looking for ways to optimize peak performance, this can come through enhanced recovery techniques, strength and conditioning, skills and repetition training, sports nutrition etc. However, one area that is often overlooked is sports psychology which can include, mental skills training to help build mental toughness and develop strategies to cope with the stress and mental demands of sport, as well as mental imagery (MI).

What is Mental Imagery?

Although there are various definitions for MI, it essentially refers to an intentional mental representation of the motor skills used to perform a task without physically engaging in that task. In short, it is “using all the senses to create or recreate an experience in the mind“, this might be a free throw in basketball, a serve in tennis, a lap in motorsport, a maneuver on a wave in surfing, lifting a weight, or kicking a goal in football etc. Additionally, this process involves kinesthetic imagery; that is the process of imagining the physical movements, the weight, the forces and effort required to execute that moment. Mi is often performed from 2 different perspectives; internal or a first person perspective of actually undertaking the task/movement; and external or from a third person perspective such as watching a video of someone performing the task/movement.

MI is often used either as a replacement for training during periods of downtime due to injury, travel, a religious event, unavailability of appropriate training equipment/facilities etc or as a supplement to help rehearse or learn a new movement pattern. The power of MI is it allows one to visualize a movement perfectly every time, something that is not possible in real life as mistakes, even little ones will routinely be made.

As a melbourne sports chiropractor we have extensive experience working at the tennis Australian Open in Melbourne, we will show you how MI is performed using a tennis serve as an example. You would sit in a quiet calm place with eyes closed, imagining the feeling of the court surface beneath the feet, the flow of the air across the body, the weight of the tennis racquet in hand, the feel and texture of the ball, the force and specific movements of the muscles bending from the ankles, knees, hips, starting to rotate the body, lifting the racquet up and over head, while starting to the throw the ball into the air, picturing exactly where you want the ball toss to go, extending the back and then whipping the racquet through, contacting the ball at the exact right time and position, feeling the clean impact the ball makes with the racquet, hearing the crisp snap of the ball on the strings and the release of energy and air from the lungs as the body rotates and movements forward into the court and the racquet follows through, watching the ball fly just over the net tape, landing directly on the centre T line.

How does Mental Imagery Work?

There are several theories on the psychoneurophysiological mechanisms by which MI works however, some of the key themes underpinning MI include, neural changes in the primary somatosensory and motor areas, augmented spinal circuitry, and similar task-specific EMG patterns and subliminal muscle activity. Furthermore, there has been research showing internal MI results in improved strength performance as a result of higher muscle excitatory activity compared to external MI. Moreover, the neuromuscular responses evoked from MI are intensity and activity dependent.

Although there is not a clear association at present, it would appear that there are different scenarios were internal MI is superior to external MI and vice versa. External MI has been found to effective for form-based tasks, while internal MI has been shown to be superior to external MI for goal-directed tasks or motor skills involving changes in the visual fields. In simple terms, external MI works by promoting an association between movements and their effects (ie. by watching a top spin serve it is possible to see the movements required to execute the serve and to see how the ball moves across the net and court). Whereas internal MI creates a link between the movement and the tactile and kinesthetic sensations (ie. by performing a top spin serve in the mind, it is possible to recreate the muscle activation/movements, the energy required, the feel of the ball impacting the racquet etc).

Why Use Mental Imagery?

MI has been shown to be an effective tool for enhancing motor skills and motor performance with results seen after either one single sessions of MI training or after longer term MI training. Additionally, whether your are a novice or expert it is an effective way to learn or refine a new technical skill. To provide context for the benefits of MI use in sports performance, below is a short list of studies examining MI use across different sports.

Dance – MI is used by all ages and levels but is used more frequently in higher skilled dancers to enhance their movements and/or to help practice or develop a routine.
Tennis – a small study looking at elite youth players revealed MI with physical practice improved serve accuracy, velocity and consistency (higher % of successful first serves).
- a study of 38, young male players fasting during Ramadan showed MI improved serve accuracy, running speed and performance compared to a control group (no MI).
Golf – a study of 23 beginner golfers split into 3 groups (MI + practice, practice only, control) found participants in the MI + practice group were significantly more accurate with more balls landing closer to a target using an approach chip shot than the other two groups.
Soccer – a study of 69 elite soccer players showed improvements in successful pass rates in competition matches in the MI group when compared to the control group (no MI).
Basketball – a study of 38 elite basketball players revealed MI increased maximal strength and power motor performance compared to controls (no MI) over a 6 week training period.
- a study of 81 youth basketball players showed improved free throw accuracy in the MI group when compared to the control (practice only group).
Rehabilitation – a systematic review of MI on muscle strength in healthy participants shows MI with physical practice is more efficient or comparable to physical practice alone with respect to strength performance. Additionally, MI helped to reduce strength loss following short periods of immobilization. Furthermore, internal MI has a greater effect on strength than external MI.

When to Use Mental Imagery?

As the studies above show there are two key areas where MI can augment sports performance; during periods of immobilization or injury, where MI can help attenuate the strength loss associated with detraining or immobilization, enabling an individual to retain a higher strength base compared to someone who does not use MI, theoretically resulting in a faster return to play time. As well as being used to improve motor control and muscle memory skills, helping to improve performance whether that be a serve in tennis, a pass in soccer, a free throw in basketball, or a shot in golf.

Furthermore, MI can be used to help visualize an outcome or result. Motor racing pilot and author Ross Bentley discusses this in his book series “Speed Secrets” where he dedicates an entire book to the mental aspects of racing. In it he discusses MI and asks readers to visualise themselves on the starting grid of a race; where do you see your self, 5th, 3rd, 2nd? Are there cars in front of you? Are you on the inside or outside of the racing line? You always want to visualise yourself 1st, as visualizing anything else is only programming yourself to be less successful. Even if the likelihood of being winning looks impossible, visualizing it puts you in a position to perform at your best.

How to Implement Mental Imagery in Sport?

One of the difficulties in reviewing the literature on MI is the lack of a standardized MI protocol, with variance in the duration of the MI program, how many times per week MI was undertaken, for how long and when. Generally speaking programs in the studies above ran for 3 to 8 weeks, were undertaken 1-3 times per week and lasted for 5-15 minutes. Knowing that improvements have been noted even after 1 session of MI, at a minimum one 15 minute session per week of MI combined with routine physical practice if you are wanting to perform at your best. From our experience as a sports chiropractor working with athletes across a variety of sports MI is under utilized, so if you are looking for that extra advantage over your opponents or are wanting to improve faster, MI is a simple, fast and easy addition to your training program.

If you are looking for more information on the mental side of sport, you might find our blog on burnout of interest and if you would like to make an appointment to see one of our clinicians to help with your performance you can book a remedial massage or sports chiropractic below. Our practice is conveniently located on the corner of Collins Street and Swanston Street in the Melbourne CBD.

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Recently The Age / Sydney Morning Herald media outlet published an article titled “For decades, an ACL tear meant surgery. New evidence suggests that may be the wrong move.” The article highlights a recent publication in the British Journal of Sports Medicine which uses a systematic review (literature review) and a meta analysis to examine the various outcomes comparing surgery to rehabilitation following an ACL rupture. In short, the study found rehabilitation with the option for surgery performed similarly to surgery.

Surgery has been the primary treatment intervention for active individuals, especially for athletes; however rehabilitation without surgery has been a long viable option for less active individuals and in those that don’t participate in sports involving pivoting / rapid change in direction like cycling. Cadel Evans is a notable athlete who competed at a professional level without undergoing ACL reconstruction (ACLR).

What is the ACL?

The ACL or anterior cruciate ligament is one of two cruciate ligaments in the knee which provides stability to the knee. In the case of the ACL, it’s primary role is to prevent the tibia (shin bone) from sliding forward on the femur (thigh bone) which is called “anterior translation”. Additionally, it plays a role in limiting rotation at the knee, hence it is a key stabilizer of the knee especially when the knee is in a straightened position. When it is ruptured, instability of the knee during pivoting movements becomes apparent in many cases. Hence surgery is often required to reconstruct the ruptured ligament to restore stability to the knee.

Are We Wrong to Be Operating on ACL Injuries?

We need to put some context around the study The Age articles uses to support its narrative. Firstly, The Age article relies on only one study to support their claim, rather than a raft of papers indicating a similar outcome. The author correctly stated the quality of the data is low and hence the recommendations are also low quality. Secondly, on closer inspection the papers inclusion criteria include studies across all age groups, doesn’t exclude for surgery/rehab following re-ruptures, doesn’t stratify by age, sex nor surgical technique, graft type however, does includes randomized controlled trials which is a stronger methodology. Essentially though, this means we are mixing up different groups which can potentially influence the findings. This adds additional weight to suggest the findings of this study are by no means a gold standard even though the methodology was robust.

Further investigation reveals an earlier high quality systematic review which examined randomized control trials comparing surgery to conservative management. Again, the results of this review were low quality due to the high risk of bias. This study on the surface supports the articles claim that there is no difference between patient reported knee function at 2 and 5 years follow up between either group. However, when we dig deeper, we see that the most prevalent complication in the rehabilitation group was instability and by 2 years 39% went for ACLR and by 5 years this had increased to 59%. They also found that the ACLR group had higher return to sport (RTS) rates at 2 years than those in the rehabilitation group.

Return to Sport / Reinjury

The author further highlights the lower rates of RTS and risks of reinjury following surgery as additional arguments for why conservative management could be a viable alternative to surgery. It is important though, to understand what sits behind this data. A systematic review of 1342 recreational athletes found that only 59% returned to pre-injury levels of sport following ACLR, this is slightly higher than the 1/3 stated in the article but provides support for lower RTS rates post-surgery. Another systematic review and meta analysis examining 3744 patients found a similar number (61.8%) of athletes RTS following ACLR. To put context to these low RTS rates we need to consider the psychological impact such a devastating injury has on an individual. That same paper found those who RTS had higher psychological readiness, higher self-efficacy and lower kinesiophobia (movement/joint phobia) compared to those who did not RTS. Furthermore, reinjury risks for ACL ruptures include reduced psychological readiness to RTS. This highlights the importance of the psychological impact of an injury on RTS and may in part help to explain the lower rates of RTS especially in non-elite athletes, rather than associating it with a failure of surgery.

All Groups Are Not Equal

As mentioned earlier the study used to formulate the narrative for The Age article grouped all individuals together and it is known that there are specific subgroups of individuals with different risks and outcomes, males versus females, adolescent versus adults, recreational versus elite athletes etc This isn’t a critcism of the paper, as the data wasn’t available for the authors to undertake a subgroup analysis. However, in youth and adolescents a low quality systematic review and meta analysis comparing surgery to rehabiliation found 20 to 100% in the rehabilitation group experienced instability and only 6-50% in that group RTS. They found early ACLR over delayed ACLR resulted in reduced risks of meniscal tears and irreparable tears. While those in either surgical group had RTS rates of 57-100%. It is also well documented that females, especially soccer players are at greater risk of an ACL injury than males which is postulated to be due to anatomical differences (tibial slope angles).

What About Knee OA?

The author makes a claim that ACLR reduces the risks of osteoarthritis (OA), a claim which they provide no evidence to support. Again, this falls back into all things are not equal and so we cannot group everyone together. It is possible to rupture an ACL and preserve the meniscus. Furthermore, injuries can involve one or both meniscus, as well as the articular cartilage and damage to meniscus and/or cartilage are going to be relevant factors in whether an individual is likely to develop OA. A recent lower quality systematic review and meta analysis examining clinical outcomes and OA 22 years post ACLR found satisfactory outcomes but noted high levels of OA (2.8x compared to the individuals well knee) particularly in those with concomitant meniscal and or cartilage injuries, adding further weight to the argument that cartilage/meniscus injury may play a role in OA development following ACL ruptures.

Furthermore, knee OA following ACLR is a multifactorial process potentially involving factors associated with surgery like an incorrect femoral/tibial alignment but also factors not associated with surgery such as early return to sport, altered lower limb strength and balance. In that follow up study 12.8% had severe OA and only 1.1% went on for a total knee replacement. Melbourne sports chiropractor Dr. Shannon has spent time with orthopaedic knee surgeons in clinical practice and surgery in the US and it is their opinion based on personal experience that the risk of OA increases in patients who delay or do not undergo reconstruction due to the higher likelihood of cartilage injuries.

Where Are We Then?

The narrative for the article is that we have been potentially wrong to operate on those with ACL injuries and perhaps we need to look at alternatives. As has been clearly illustrated in this blog, strong, consistent data is clearly lacking to support a view that we shouldn’t be operating on ACL injuries especially in those active individuals. Injury management options are always weighed up and made based on the circumstances surrounding the individual. Does that mean operating on all individuals with an ACL injury? No. Should the current approach start shifting towards conservative management over surgery? No. More consistent and higher quality data is warranted to make that shift, as has been the case for Achilles tendon ruptures.

You can find out more information about Dr. Shannon and The Shannon Clinic here. If you would like to book an appointment to have your knee assessed, our Melbourne CBD chiropractic practice is centrally located on the corner of Collins Street and Swanston Street, opposite the Melbourne Town Hall in the Manchester Unity building.

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Common Injury Sites

Although bone stress injuries and fractures are not as frequent as other injuries seen in our Melbourne sports chiropractic practice, they are prevalent in active individuals and athletes. Stress fractures and bone stress injuries are more common in the lower extremity and include the bones in the feet (metatarsals and navicular), the leg bones (tibia and fibula), the thigh bone (femur), sacrum (pelvis), pars (lumbar spine). They can also occur in other less common areas like the humerus and wrist in tennis players and baseball pitchers.

Stress Versus Insufficiency Bone Fractures

When bone starts to fail there are two primary reasons for it. In the first instance normal healthy bone begins to fail under abnormal stress loading which is called a “stress fracture”. In the second instance there is abnormal bone which fails under normal stress loading called an “insufficiency fracture”. Insufficiency fractures occur when there is something systemically wrong within the body, resulting in abnormal bone health.

Bone Remodeling

Understanding bone health and how bones remodel is key to understanding why bone stress injuries and fractures occur. Two important cells in bone remodelling are osteoclasts and osteoblasts. Osteoclasts are like the demolition team who come in and break down old bone which is called “bone resorption”. Osteoblasts are the builders who come in a lay down new bone once the osteoclasts have removed the old bone which is called “bone formation”. This process is called “bone turnover” and in exercise is it vitally important, as bone turnover allows new bone to form and adapt to the stress loads that exercise is placing on the bone, helping the bone to adapt and become stronger. The entire process takes approximately 3-4 weeks under ideal conditions.

In the case of bone stress injuries and fractures the ideal conditions for bone turnover are compromised which can include alterations in bone nutrition; low vit d, low energy availability; rapidly increased training load; impaired endocrine function. Changes in these conditions ultimately leads to an imbalance between osteoclast and osteoblast activity, resulting in bone tissue break down occurring at a faster rate than new bone tissue can be laid down.

Bone Tissue Breakdown

To understand how this bone tissue breakdown process impacts bone health we need to think of bone health as a continuum. At one end of that continuum there is healthy bone and at the other end there is a fractured bone. Bone health can slide backwards and forwards along this continuum depending on those variables which impact bone health as mentioned above.

Let’s use an example to illustrate how bone moves down this continuum. For simplicity we will assume nutrition and endocrine function are normal. We will use a runner who is new to running with no prior running experience. Let’s assume they have a half marathon they are training for in 8 weeks. Because they have only a short period of time before the race, they start running 5 days a week. As they start running the osteoclasts begin breakdowning old bone so that new bone can be laid down to strengthen the bone as it adapts to the new impact loads going through the bone as a result of running. The more running, the more osteoclast activity occurs however, the osteoblast activity takes time to lay down new bone so an imbalance in the process begins to occur.

Initially this leads to microtrauma in the bone which will present clinically as a focal (specific) area of tenderness over the bone, mostly noticeable on impact activities like running, jumping, hopping etc This is called “bone marrow edema”. The runner notes this as ‘training pains’ as they are new to running. As they continue to run 5 days a week, bone tissue breakdown continues, while new bone formation is unable to keep pace due to the rapid increase in loading and lack of rest days. The microtrauma persists and the bone continues to slide down the continuum through the 4 stages of bone marrow edema finally resulting in macrotrauma to the bone tissue, creating a fracture site.

Clinically, this can present similar to an acute fracture where an instant acute pain is felt, or there can be continuously worsening acute pain which becomes present with simple activities like walking or weight bearing. Both force the individual to stop exercising and usually seek treatment.

Bone Stresss Injuries and Fracture Treatment

The way sports chiropractor Dr. Shannon at The Shannon Clinic – Melbourne Chiropractic and Sports Care treats bone stress injuries and stress fractures is through a complete and thorough work up which routinely includes other clinicians. The key questions that need to be established are “why has this injury occurred?” and “is this a bone health related injury or a training load injury?”. Our workups often include:

Looking at whether there is a prior history of bone injuries, as a prior stress fracture is a predictor of a future stress fracture injury.
Assessing bone health – DEXA, MRI, Vit D (serum 25) and Calcium blood tests
Assessing nutritional intake – energy availability
Assessing endocrine function
Assessing training load and volume
Assessing for biomechanical imbalances/weaknesses
Assessing for technique deficits

Fracture Healing Process

Once we have pertained the cause of the bone injury and have determined it is a training load injury and not a bone-related injury, we then move into treatment and education. Treatment to optimise bone health (nutritional and supplement support), strategies to allow the bone healing process to catch up, strengthening programs, education on training load management to mitigate the risk of reinjury, technique modification if required.

To book an appointment to have your bone pain assessed below and you will be in safe hands. Our sports chiropractic clinic is situated on Collins Street in the Melbourne CBD, opposite the City Square and Melbourne Town Hall.

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