Tag: sports

Shannon Clinic – Melbourne Chiropractic and Sports Care Blog

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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Shannon Clinic – Melbourne Chiropractic and Sports Care Blog

Following on from the strong interest in the Shannon Clinic – Melbourne Chiropractic and Sports Care’s blog post looking at injuries in elite men’s football during the 2022 FIFA World Cup, and with the 2023 FIFA Women’s World Cup about to kick-off right on our doorstep here in Melbourne, Victoria; Melbourne city chiropractor Dr. Shannon dives into the prevalent injuries seen in elite women’s football to see what injuries might play out at this World Cup.

Women’s football has been growing at a rapid pace, with the number of semi-professional/professional players more than doubling from 1.68 million in 2013 to 3.57 million in 2017. It is now played in over 100 countries, with FIFA working on expanding the number of women participating in football around the world to ~60 million by 2026. But as the women’s game expands, so too should the medical and research support around the women’s game. However, currently there is a scarcity of literature focused on the women’s game, and concerningly 15% of players at the Women’s 2019 World Cup in France played at clubs with no permanent medical staff.

Risk Factors

Figure 1

Risk factors associated with an injury are complex and involve both intrinsic factors such as age, sex, BMI, physical fitness/strength and extrinsic factors like equipment, playing surface, weather (figure 1). Specific to elite women’s soccer, intrinsic factors predisposing players to injury include a previous injury, joint hypermobility, age over 25 years old, increased body mass. While specific extrinsic factors include playing position, where defenders and strikers have higher rates of injury than midfielders and goalkeepers.

Risk factors common to both men and women include trait anxiety and negative life events; increased exposure to large and rapid changes in athletic load; being a newly transferred player to a club; positional risks such as low back pain in goalkeepers. Additionally, there are risk factors nominated by elite women players themselves including low muscle strength, poor pitch quality, playing on artificial turf, reduced recovery, hard tackles.

Overall, female players appear to have a higher rate of moderate to severe injury risk than men, as they experience up to 20% more time lost to injury, with evidence suggesting women are at greater risk of ACL ruptures, ankle syndesmosis and quadriceps injuries than men. Additionally, women experience more frequent and severe concussions than their male counterparts.

Injury Data in Women’s Elite Football

As we have discussed in prior blogs injury incidence or risk rates, that being the risk of sustaining an injury over a specific time frame, can vary in its reporting and football is no exception. Incidence rates can be measured over various time frames including minutes, hours, halves, and matches played, which can make pooling injury data difficult. However, in women’s football per 1,000 hours is a standard exposure time to measure injury risks, and what will be referred to in this blog.

Irish Women’s National League Injury Rates

This paper analyzed injuries in the Irish Women’s National League across two seasons during the 2018 and 2019 seasons.

  • Overall injury rates – 7.9/1000
  • Injury rates during match play 19.2/1000
  • Injury rates during training 2.5/1000
  • 50.4% of injuries occurred during match play / 25.1% occurred during training
  • 75.6% of injuries had a sudden onset with 45.9% being non-contact in nature
  • Injury types – muscle injuries (35%), ligament sprains (30.1%), contusions (9%), meniscus lesions (7.5%), concussion (3.4%), fractures (3.4%)
  • Injury site – lower limb injuries accounted for 85% of all injuries
  • Injury site by location – ankle (24.4%), knee (21.8%), hamstring (12.4%), achilles/lower leg (7.9%), trunk/spine (6.8%), hip/groin (6.4%)
  • Most common injury – lateral ankle sprain (13.9%) and hamstring injuries (12.4%)
  • 15% of all injuries were re-injuries with 63% occurring with in 2 months of the initial injury
  • ACL injuries accounted for the longest time out with an incidence rate of .2/1000
  • 53.8% of injuries occurred in players aged 15-20 years old and 31.6% in players aged 21-25 years old

Systematic Review and Meta-Analysis of Injuries in Elite Women’s Football

This systematic review and meta analysis reviewed studies from 1991 and 2018 that documented injuries in elite women’s football including both play at domestic clubs and at tournaments like the Olympics and World Cup. This blog only references the data from the systematic review, as the meta-analysis had high heterogeneity limiting the quality of the meta-analysis findings (pooling the data together).

Domestic Play

  • Overall injury rates during domestic club play 8.4/1000
  • Injury rates during domestic club play during match play 30.3-12.6/1000
  • Injury rates during domestic club play during training 5.2-1.2/1000
  • Injury locations during domestic club play – lower limb accounts for 85% of all injuries. Knee (33%), thigh (21%), ankle (18%)
  • Type of injury – ligament sprains (37%), muscle strains (31%), blunt soft tissue trauma (contusions/hematomas) (15%)
  • Time lost to injury – 8-28 days (moderate) most common at 34%

Tournament Play – Medical Attention (pitch side)

  • Injury locations during tournament play for medical attention (being attended to pitch side) – lower limb accounts for 66% of all injuries. Ankle (24%), head, neck, face (17%), thigh (13%)
  • Type of injury – blunt soft tissue trauma (44%), ligament sprain (21%), muscle strain (16%)
  • Time loss to injury – 78% of injuries prevented play/training for up to 7 days

Tournament Play – Time Loss

  • Overall injury rates during tournament play 11.6/1000 (for time loss)
  • Injury locations during tournament play for time loss – lower limb accounts for 89% of all injuries. Knee (22%), lower leg (22%), thigh (17%), ankle (17%)
  • Type of injury – blunt soft tissue trauma (42%), ligament strain (21%), muscle strain (16%)
  • Time loss to injury – 1-3 days (minimal) most common at 58%

Overall

  • Types of injury – ligament injuries (37%), muscle strains (27%), blunt soft tissue trauma (21%)
  • Most common diagnosis – ankle ligament sprains (43%), quadriceps muscle strains (16%), knee ligament sprain (12%)

What Does This Injury Data Mean?

At a high level, more injuries occur during match play than training in elite women’s football, which follows a similar trend to men’s football. Furthermore, lower limb injuries consistently account for the largest number of injuries by region, at nearly 90% of all injuries which is again consistent with men’s football. With ligament injuries specifically to the ankle and knee, in addition to hamstring and quadriceps muscle strains making up the bulk of lower limb injuries. This profile is consistent with what we have seen in both elite male and female players.

Additionally, this injury pattern is reinforced by the high rate of sudden onset, non-contact injuries which are consistent with hamstring and quadriceps muscle strains and ligament injuries, especially ACL injuries. ACL injuries is an area warranting further research to understand why female football players have a 2.2 times higher incidence risk of an ACL injury compared to male football players, in addition to a higher reinjury rate, 27% compared to 10% in male football players.

With limited and low quality studies at present, it is unknown why women are at higher risk than men. Current hypothesis include, biological differences such as the menstrual cycle (hormonal changes during the menstrual cycle potentially lead to joint hyperlaxity and an increased risk of a non-contact ACL injury), increased femoral condyle ratio, posterior tibial slope, joint hyperlaxity, larger Q angle. Furthermore, a gendered environmental disparity theory has been raised in the last 2 years which postulates women have different access and experience to sports when compared to men; this include coaches, medical staff, training facilities, high performance programs etc which in turn may result in lower skill levels and conditioning, potentially leading to intrinsic risk factors such as higher BMi, weaker lower limb strength, poor neuromuscular control etc.

Injury Areas of Concern

Two areas of concern that stand out are the higher rates of documented head injuries / concussion 3.4% (Irish League) and 17% (medical attention) in women’s football, compared to men 2% documented. In addition to the high reinjury rates (15%). Where there is a high prevalence of injury to the same injured limb, with 63% occurring within 2 months of the initial injury.

It is likely that head injuries are under-reported in the men’s game, however, knowing female football players experience more frequent and severe head injuries than men, more needs to be done to understand why female players are at a higher risk (technique, neurophysiology, anatomy, neck strength? etc) so more can be done to help mitigate the risks, as well as improve the treatment and prevention of female players.

Additionally, the high rate of re-injuries coupled together with the lack of permanent medical support staff at club level, indicates female players are potentially receiving a lower standard of medical care than their male counterparts, resulting in players returning to play too early, and/or receiving inadequate treatment and rehabilitation.

Better Support Needed for Women’s Football

As women’s football rapidly expands and participation rates rise, so must the research literature and quality of medical support for women’s football, this includes encouraging women to take up careers in sports science, research and sports medicine as they are currently under-represented. Moreover, the literature on injuries in elite women’s football is sparse, especially in comparison to men’s football. It’s already known that literature on concussion in women is desperately lacking compared to men, and when coupled with women’s football players suffering more frequent and severe concussion than men, it becomes alarming how neglected our female athletes are.

This is further reinforced by a reported history of gender disparity access to permanent medical support staff in elite women’s teams, plausibily resulting indequate access to treatment, rehabilitation, structured injury prevention programs and appropriate return to play assessments, and therefore comes as no surprise that female players have high reinjury rates, often to the same limb. Let’s get behind our women’s soccer players and female athletes to help raise the support and awareness they deserve.

If you are looking for more information on ACL injuries we have blogs examining natural healing versus surgical repair and the risks of ACL injuries in female footballers. To make an appointment to see Melbourne city sports chiropractor Dr. Shannon or remedial massage therapist Paula Pena you can book below. The Shannon Clinic – Melbourne Chiropractic and Sports Care chiropractic practice is located on Collins Street in the Melbourne CBD, opposite the Melbourne Town Hall.

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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.

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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Shannon Clinic – Melbourne Chiropractic and Sports Care Blog

The COVID-19 pandemic created global disruption, uncertainty and with many countries enforced society into lockdowns, which made physical activity and exercise more onerous and challenging. However, one of the few exceptions to the lockdown rules was exercise, so Melbourne city chiropractor Dr. Shannon examines the evidence on exercise and immune function.

Does Acute Bouts of Intense Exercise Help or Hinder Immunity?

It is well known that regular bouts of exercise lasting up to 45 minutes of moderate to vigorous exercise is beneficial for immune defence, particularly in older adults and those with chronic diseases. This type of exercise is beneficial for the normal functioning of the immune system and is likely to help lower the risk of respiratory infections/illnesses. However, there is debate within the scientific community whether acute bouts of vigorous intensity exercise leads to a period of immune suppression post exercise.

There has been a long held concept in exercise immunology developed in the 1980s and 1990s called the “open window” hypothesis which proposes a J curve relationship between exercise intensity and infection risk. Which is supported by the belief that athletes who engage in high volume endurance training experience a greater incidence of Upper Respiratory Tract Infections (URTI) compared to those who are less active. Until recently this concept has remained relatively unchallenged.

The “open window” Hypothesis

The “open window” hypothesis suggests that following a prolonged (>1.5hr) and vigorous acute bout of exercise or following chronic intense training (>1.5hr on most days) there is an “open window” which results in an increased risk of opportunistic infections such as URTI’s. The three principles underpinning this concept are:

1). Infection risk increases after prolonged vigorous aerobic exercise

2). Acute bouts of vigorous exercise can lead to temporary reductions in salivary immunoglobulins resulting in higher risk of opportunistic infections

3). A period of post exercise reduction in peripheral blood immune cells resulting in a period of immune suppression.

J Curve – relationship between the risk of infection and level of exercise intensity

Is The “open window” Hypothesis Still Relevant Today?

Recently though there has been emerging evidence suggesting this concept may be outdated. There is evidence, albeit small that indicates international athletes suffer from less URTI than national athletes. This raises the likelihood that infection susceptibility is more likely multifactorial including genetics, sleep, stress, nutrition, travel, circadian misalignment and increased exposure risks due to close proximity of crowds rather than being directly attributed to acute or chronic bouts of vigorous training. This also indicates that international athletes are potentially better supported, have access to better education helping them to improve their life-style behaviours over national athletes resulting in lower risks of infection.

Secondary to this, evidence supports the opposite of the three principles upholding the “open window” concept. With no changes seen in mucosal immunity which has previously been flagged as an indication of immune suppression. The reduction in blood immune cells (primarily lymphocytes) 1 to 2 hours post exercise reflects a transient and time dependent redistribution of immune cells to peripheral tissues resulting in a heighten state of immune surveillance and regulation leading to enhanced antibacterial and antiviral immunity, not suppression of the immune system.

Moderate to Vigorous Exercise Is Beneficial for Immunity

Further research is needed to confirm or refute the “open window” concept however, it currently appears that the infection risk post vigorous exercise is more likely to be associated with a multitude of other factors rather than purely post exercise immune suppression. So for athletes and non-athletes the message remain the same, regular moderate to vigorous exercise is beneficial to enhance immune function to reduce the risk of bacterial and viral infections including URTI’s. And remember that good hygiene practices (washing hands regularly, not touching your face), physical distancing, getting good quality sleep, reducing stress levels and eating healthy wholefoods are the keys keeping your immune system in peak condition. To read more on the importance of sleep you can find the Shannon Clinic Melbourne Chiropractic and Sports Care blog on sleep and performance here.

As a Melbourne city sports chiropractor Dr. Shannon advocates to all his patients the important of regularly exercise and utilizes exercise therapy with all patients. To work out what exercise is best, moderate continuouse or high intensity interval training check out our blog. If you are looking for an active way to rehabilitate your musculoskeletal injury book an appointment today at our Melbourne CBD chiropractic clinic on Collins Street in the Manchester Unity building opposite the Melbourne Town Hall and City Square.

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