Australians in general and those of us on Northern Beaches especially are an active bunch. Unfortunately, activities that are great for the waistline can spell trouble for the musculoskeletal system when injuries occur. More people are playing sports, running or participating in some kind of physical activity than ever and that means more injuries. Aussies are world leaders in most sports and unfortunately we’re also world leaders in ACL injuries and that rate has been climbing consistently.
Between 2000 and 2015 nearly 200,000 ACL reconstructions were performed in Australia with men aged 20 to 24 years and women aged 15 to 19 years the most common patients, but the fastest growing demographic was 5–14-year-old children. Apart from being painful and ongoing, ACL repair can also be painful to the back pocket, costing on average over $8000 including hospital fees.
What, if anything can physiotherapists do to help prevent ACL injuries, and how do we make sure that a full recovery after ACL surgery occurs?
What is an ACL, what does it do and how are they injured?
Ligaments are strong bands of tissue connecting bone to bone and are among the most commonly injured part of the musculoskeletal system. Your anterior cruciate ligament or ACL for short is one of the four ligaments in your knee that keep your knee joint stable. Your medial and lateral collateral ligaments stop your knee from moving side to side, while your anterior and posterior cruciate ligaments keep the knee from sliding front to back.
ACL injuries can occur at some pretty random and innocuous times but usually are a result of rapid changes in direction at speed, typically in non-contact sports or events. ACL tears also commonly occur during sports that involve sudden stops, jumping and landing such as soccer, AFL, basketball and netball.
It’s common to hear a “pop” in the knee when an ACL injury occurs accompanied by some pretty rapid swelling, instability and an unbearable pain that won’t let you put weight on it. Depending on the severity of your ACL injury, treatment is likely to include a good chunk of time on the sidelines and probably some surgery.
What does ACL surgery involve?
A surgeon chops out a piece of another tendon (usually the hamstring), removes your damaged ACL (because it can’t heal itself) and replaces it with the new tendon. Your new replacement tissue is called a graft which will be attached to your bones with screws (airport security just got more fun) or other fixation devices and serves as the point where new ligament tissue can grow. Fun fact, if the tissue is taken from you, it’s called an autograft but if it was donated by another person it is known as an allograft.
How long until I can play sport after ACL surgery?
The recovery period after ACL reconstruction surgery varies from one person to the next and there are many factors that determine how quickly and adequately you will recover and how low it will take until you can get back into the full swing of things.
One of the biggest factors influencing how long ACL surgery recovery takes is whether you have an orthopaedic pre-habilitation and rehabilitation plan and you stick to it. A well designed pre ACL surgery body strengthening regime can shave weeks and pain off your post-surgical recovery. The physical shape your affected area is in is one of the strongest predictors of the chances of a fully successful recovery. It is likely that you have pain and weakness operating in tandem leading up to surgery, but you’re going to need every ounce of strength you’ve got to recover fully. In prehab your local physio will help you build strength and stability where you need it most to ensure you get the most out of your rehabilitation.
Your surgeon and musculoskeletal physio will be able to advise you when you’re good to go for most activities, but this is usually only once you have adequate flexibility, strength and fitness.
Can physiotherapy prevent an ACL injury occurring?
Because ACL injuries have been becoming increasingly common, more time and research is being devoted to understanding the mechanisms behind ACL injuries and what steps can be taken to reduce the possibility of an ACL tear happening. Prevention is much better and less painful than a cure.
Over the last two decades multiple randomised controlled trials have shown that anywhere between 50–80% of ACL injuries can be prevented by regular neuromuscular agility training programmes. A number of these studies have shown that many ACL injuries are caused by faulty mechanics during dynamic movements performed under fatigue.
These prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training designed to teach the body to perform movements deliberately and with precision even under fatigue. A trained musculoskeletal physiotherapist will be able to observe your technique and address the faulty movement patterns in a personalised injury prevention program.
 Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495–501.
 Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015 David Zbrojkiewicz, Christopher Vertullo and Jane E Grayson Med J Aust 2018; 208 (8): 354-358. || doi: 10.5694/mja17.00974
 Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996
 Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003–10
Whether you’re a novice runner or a seasoned veteran, chances are you’re well acquainted with pain. Right from the get-go we’re taught to run through the pain to push through it to get to that next PB. When you’re new to running long distances it’s normal for your body to take some time to adjust and being a regular runner is all about dealing with those niggling aches and pains. My right knee certainly lets me know all about it for a few days if I run too many stairs between Manly and Dee Why.
But how much pain does it take to gain and when does pain point to an injury? While pain and injuries go hand in hand, pain doesn’t necessarily mean you’ve got an injury and there are plenty of injuries that sneak by without causing pain where you’d expect it. Minor running “injuries” can be treated with a bit of good old fashioned R’n’R but more chronic or serious injuries require the expert guidance of a musculoskeletal physiotherapist.
Assessing pain: am I sore, or am I injured?
Before you can get to the treatment stage for those aches and pains, we’ve got to work out what we’re dealing with. At an initial consultation with a physio they will usually ask you a number of questions regarding your pain/injury to get a better idea of its causes and how best to treat it.
- Did the pain start abruptly or come on over time?
It is normal for your body to feel sore after a big run or a workout; delayed muscles soreness (DOMS) is a common occurrence and normally improves after a few days, whereas an injury will likely cause you pain for weeks or more at a time. If you heard a pop or snap and felt a twinge or an abrupt sensation of pain during your run, chances are you have suffered an injury. Around 70% of all running injuries are caused due to overuse, but they often show themselves in a straw breaking the camel’s back fashion.
- Is the pain persistent or does it only come on during certain activities?
Unfortunately, what your pain is trying to tell you isn’t always clear cut and chronic or persistent pain is notoriously difficult to pinpoint and treat. That being said, when muscle or joint soreness hangs around for longer than a few days, is accompanied by sharp pains or aches and is persistent even when not engaging in a physical activity it’s likely you’ve done yourself an injury.
- Is the area swollen, sore to the touch or bruised?
When you tear a ligament or cause substantial soft tissue damage, the body usually (not always) reacts by causing some pretty obvious external symptoms. It may not happen immediately, but swelling and bruising commonly accompany major injuries and can be more easily diagnosed by comparing one side to the other and checking for differences.
- Is there a loss of function?
Loss of function tests are one of the most common methods musculoskeletal physiotherapists use to identify the nature of pain. One of the biggest indicators of an injury as opposed to regular pain is the presence of a loss of function independent of any sensation of pain or an inability to complete certain movements due to severe pain.
Preparation is the first step to avoiding a running injury
- See a physio to identify potential musculoskeletal and health problems that may contribute to injury
- Always warm up and cool down by jogging slowly
- Injured runners should consult a professional about how to prevent re-injuries
- Hydrate prior to running and consider taking water on longer runs
- Get a running assessment if niggles persist
Use the R.I.C.E method to treat running soreness
If you’re suffering from the DOMS or you’ve just pushed yourself a little hard and feeling it, you can’t go wrong erring on the side of caution and giving your body a bit of a recovery pamper session.
Rest properly and resist the temptation to down a number of celebratory alcoholic beverages. If you must go out, keep hydrating, don’t party too hard and let your body recover.
Ice – this will help constrict the blood flow to sore areas and help to reduce inflammation and soreness. If you feel up to it, you can always take your second ice bath as you likely already took your first one during the race.
Compression of the legs and arms will help flush out the lactic acid that has accumulated. Wearing compression gear will work great for this. Pairing compression and icing will ensure they work symbiotically and will shorten your recovery period.
Elevate your legs as you lie in bed thinking about how awesome and tough you looked covered in mud, running through electroshock stations, carrying logs and kicking butt.
If you have a persistent ache or pain whether it be the result of running or another physical activity, it needs to be identified and addressed. Nobody likes being injured, but allowing something as simple as shin splints to go untreated with continued overtraining, can cause tibial stress fractures, which will put you on your butt for at least 6 weeks. The moral of the story is from little things, big things grow; this includes injuries.
Visit a pain and injury clinic on the Northern Beaches for more information on identifying the difference between pain and injury and how to treat those niggling aches and pains before they progress to something more serious.
At this very moment 1 in 6 people on the Northern Beaches is suffering from back pain due to a variety of different back problems. Back pain doesn’t discriminate and its causes are as varied as its symptoms. Back pain can be caused by sitting too much, by standing too much and by running too many loops of the Manly to Dee Why coastal walk. Back pain can affect your work, sports, mental health and especially your sleep. Getting a good night’s sleep is so important for recovery and back pain is notorious for being worse at night, creating a self-perpetuating loop of poor sleep that exacerbates the back pain.
What causes back pain?
Having spent my career as a musculoskeletal physiotherapist on the Northern Beaches, many of my clients suffering from back pain have injured a muscle in or surrounding the back. In fact, studies have shown that around 70% of all back pain is a direct result of muscular injury? Repeated heavy lifting and sudden awkward movements are the big causes of back pain and as we get older it gets easier to give it a twinge. Other common back pain causes we see here at Dee Why include:
- Arthritis – Nobody likes the A word but it’s something that will affect around 1 in 7 Australians during their lives. Lumbar arthritis pain is caused by movement and inactivity so you can’t win and affects the lower back and can extend to the pelvic area, sides of the buttocks and can even be felt in the thighs.
- Sporting injuries – Northern Beaches physios treat back pain every day that has been the result of an injury caused by playing sport. Sports like volleyball, gymnastics, surfing and running are the cause of plenty of sore backs between Manly and Dee Why, that’s for sure!
How do physiotherapists treat back pain?
How long have you got? Titled Musculoskeletal Physiotherapists can draw on years of study, observation and curing back pain of all varieties and use literally dozens of different techniques for treating back problems. First things first though, your physio will take you through an in-depth physical examination in order to determine the exact cause of your back pain – back pain can have a variety of root causes.
Titled Musculoskeletal Physiotherapists understand the complexity of lower back pain and use an evidence based approach to injury management in order to get results. Musculoskeletal physiotherapy is the most common form of intervention for chronic back pain and your back pain physio on the Northern Beaches will create and prescribe a bespoke program to not just combat the pain, but to protect and strengthen your back against future problems.
If you are suffering from back pain on the Northern Beaches and avoid seeing a physio you are increasing your chances of your back pain persisting longer and a recurrence of the injury in the future. Don’t wait until the pain becomes severe or chronic, give The Beaches Sports Physio a call on (02) 8964 4086 or email us to book at firstname.lastname@example.org.
Knee injuries are among the most common type of injuries treated by physiotherapists on the Northern Beaches and are also at the top when it comes to re-injuries. I don’t know how many times I’ve seen a patient who ended up having a serious knee injury and they said they just tried to ‘run it out’. If you are involved in physical activity or sports such as netball, volleyball, beach volleyball, soccer, AFL and rugby league, you are at a much higher risk of suffering a serious knee injury compared to the rest of the population. If you are suffering from pain or swelling in the knee, please don’t try and run it out, jump in the car and head down to your local Northern Beaches physio for some hands on treatment and get a plan for recovery so you don’t end up suffering ongoing pain or movement issues.
These are the most common types of knee injuries treated by musculoskeletal physiotherapists:
Torn ligaments and ligament strains
Like a lot of musculoskeletal injuries, it’s the most active people who get the wrong end of the stick when it comes to suffering them. Your knee contains a number of ligaments connecting bones to other bones in and around the knee joint that are susceptible to damage when you take a sharp change in direction, land wrong from a jump, or commonly from force directly to the knee, such as in soccer or footy tackle. The knee is made up of 4 ligaments that can all be torn or strained:
ACL – The ACL is the big daddy of knee injuries, the most painful and also the most common. The ACL connects the thigh bone to the shin bone and is most likely to strain or tear when pivoting or landing from a jump, around 80% of ACL tears are non-contact injuries.
PCL – The PCL is there to stabilise the tibia and prevent it from being bent too far backwards, commonly tearing or becoming strained due to forced hyperextension. It is the least common of the knee injuries, accounting for around 10% of them in total.
MCL – Your MCL is located on the inner side of your knee and connects the medial femoral condyle and the medial tibial condyle. MCL injuries usually take place during a sharp change in direction, when the knee is twisted while your foot stays in place, landing incorrectly from a jump, or from a hard direct hit to the knee, commonly in a footy tackle.
LCL – Like the ACL and MCL, your LCL helps control the sideways motion of the knee, connecting your femur to the fibula. LCL injuries only account for less than 5% of knee injuries, but they are known to be pretty darn painful.
Once your physio has conducted a thorough physical examination, they will be able to give you a good idea of the grading of the injury (1 being the lowest, 3 the highest) and begin treatment. Depending on whether you have suffered a strain or a tear, you may be required to undergo surgery and your physio will be able to design an in-depth prehab and rehab program for you that will aim to:
- Reduce pain and swelling
- Return the joint to its full range of motion
- Strengthen the area surrounding the knee such as hamstrings and quadriceps
- Improve your proprioception, agility and balance
- Improve your technique and function specific to any sports or your circumstances
- Get you back into your sport, regular activities and exercises
- Minimise your chance of re-injury
Fractures and dislocations
Musculoskeletal physiotherapists commonly see knee fractures and dislocations paired with ligament damage, they tend to go hand in hand unfortunately. Not only are patellar fractures relatively common, they are also painful and can take a good deal of healing time. A patellar fracture is a break in the patella, or knee cap which is a small bone sitting at the front of your knee. The knee cap acts like a shield for your knee joint and is vulnerable to fracturing if you fall directly onto your knee or cop a big hit in sport or commonly in a car crash.
A patellar fracture may be a clean and even two-piece break or the bone can break into many pieces (ouch). If you are lucky enough when suffering a patellar fracture and the pieces of bone are not displaced, you may not need surgery.  Because treatment for a patellar fracture includes a period of time where you need to keep your leg immobilized in a cast, it’s not uncommon for your knee to become stiff and your thigh muscles to shrink. During the rehabilitation your physiotherapist designs, will be given a number of specific exercises to help improve the range of motion in your knee, strengthen your leg muscles surrounding the knee cap and manual therapy in order to decrease stiffness.
The most painful part of dislocating the patella is the immediate time after; with most people having a sort of relief in the hours after it is re-located. Because a dislocation or fracture commonly occurs with a ligament strain or tear, your rehabilitation will take at least 8 to 12 weeks to successfully heal the area and decrease your chance of a recurrent dislocation.
If you have:
- Sudden or severe pain in the knee
- Heard a loud pop or snap during sport or exercise
- Swelling in the knee after feeling pain
- A feeling of looseness in the joint
- An inability to put weight on the joint without pain, or any weight at all
Get down to your local physio ASAP. You’re only doing yourself further damage and increasing your chances of re-injury by putting it off.
 Schuett DJ, Hake ME, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Current treatment strategies for patella fractures. Orthopedics. 2015;38(6):377-84.
Osgood-Schlatter’s disease (OSD) is a few things (on top of being a bit of a mouthful); it’s a growth plate injury in children, notoriously difficult to diagnose and commonly mismanaged. Osgood-Schlatter’s is characterised by swelling and irritation of the growth plate at the top of the shinbone. The growth plate is a layer of cartilage located toward the end of a bone where the bone’s growth occurs. This is why adults cannot suffer this “disease”.
When it comes to kids, two things are pretty much certainties; they’re going to grow and at some point they’re going to hurt themselves. When these two certainties occur simultaneously, children can end up with painful growth-plate injuries that can be difficult to treat and manage effectively. Growth plate injuries are quite a common cause of pain in children and adolescents and Osgood-Schlatter’s causes pain in the front of the knee. Boys are more likely to suffer the condition than girls, and playing in sports that involve lots of running, jumping and kicking increases the chances of it popping up too. Musculoskeletal physiotherapists classify Osgood-Schlatter’s disease as an overuse injury, not a disease!
HOW IS OSGOOD-SCHLATTER’S DIAGNOSED?
Because children’s bodies are physiologically different than adults, it is not uncommon for the Emergency Department or a GP to misdiagnose a child’s pain as another injury. Your child’s physiotherapist will conduct a thorough assessment which will include checking movement patterns of the hip, knee, ankle and foot, assessing muscle strength and muscle length in order to pinpoint the cause of pain. X-rays and other medical imaging are usually not required.
If your child has Osgood-Schlatter’s, they will normally have pain close to where the patellar tendon connects to the shin bone slightly below the knee cap. It can also cause a painful lump to form in that area. For your child, their pain will probably be heightened during physical activity and the pain commonly gets worse with running, jumping and walking up hills. The pain and swelling tends to improve relatively quickly (in the short term) with a bit of rest.
WHAT CAUSES OSGOOD-SCHLATTER’S?
Osgood-Schlatter’s is an overuse injury, which is exactly like it sounds. During a child’s growth spurt, the bones, muscles, and tendons all grow at different rates. In OSD, the tendon connecting the shinbone to the kneecap pulls on the growth plate at the top of the shinbone. Activities and sports such as AFL, soccer and athletics can cause this movement to happen over and over, causing injury to the growth plate. When undergoing physical activity with strong, repetitive muscle contractions in the thigh, micro-fractures can occur due to the immature nature of the joint and bones. Another possible cause of Osgood Schlatter’s in adolescents is the lack of growth of the quadriceps in comparison to the femur bone. During a child’s growth spurt, the slow lengthening of the muscle is unable to keep up with the rapidly lengthening femur, which causes increased tensile force on the tibial tuberosity and more pain.
HOW IS OSGOOD-SCHLATTER’S TREATED?
I’ve seen mild cases of Osgood Schlatter’s Disease resolve themselves within a few weeks, but severe cases must be professionally managed to avoid permanent growth plate damage. Fortunately for the unfortunate child, Osgood Schlatter’s disease is very successfully managed via physiotherapy. Osgood Schlatter’s disease is a self-limiting syndrome which means that with time, complete recovery can be expected with the closure of the tibial growth plate. If OSD hasn’t been treated effectively during childhood, it is not uncommon for there to be recurring discomfort in the knee while kneeling due to enlarged lumps as a result of the distorted growth plate. Although symptoms of Osgood Schlatter’s disease can hang around for months at a time, surgical intervention is hardly necessary.
The goal of the treatment is to control your child’s knee pain and prevent the condition from worsening. Treatment usually includes:
- The tried and true RICE method (rest, ice, compression, and elevation)
- Medications such as anti-inflammatories for discomfort and swelling
- Wrapping or compression of the knee
- Limit on activity
- Physiotherapy to help lengthen and strengthen the thigh and leg muscles
What not to do:
- Stretching! Multiple sources online speak about stretching out the quadriceps, to help lengthen the muscle and alleviate tension on the growth plate. With additional tensile force pulling on a growth plate that is constantly being pulled, no child will thank you for stretching out their quadriceps!
Your child’s physio will also prescribe specific exercises for your child to complete depending on their assessment findings. One of the common reasons adolescents develop Osgood Schlatter’s syndrome is tight quads, hamstrings and calf muscles. In that case, manual therapy and soft tissue release will assist pain and quicker recovery.
If your child has been complaining of a sore knee or has been limping or showing signs of discomfort, don’t let the issue linger for too long. Call one of our musculoskeletal physiotherapy experts on (02) 8964 4086 and get a diagnosis and treatment plan before any long term damage occurs.
I was down at Manly Beach the other day sucking in some big ones having been worked for 90 mins solid by my beach volleyball coach Martine and couldn’t help but overhear a conversation two men were having. As a long practicing physio there are a few buzzwords I can’t help but tune into and when bloke 1 said to bloke 2 “hopefully my back sorts itself out soon, I haven’t had a surf in months” I was instantly hooked. Unfortunately, it’s common for me to see new clients who have been suffering a form of chronic pain or immobility due to a condition or injury for months, even YEARS, but every time I’m still shocked. Look, I know not everybody loves seeing the GP or attending to annoying medical issues when there are other things going on in life, but chronic pain is not something anybody should be living with for any extended period of time. It’s not only uncomfortable at the time, but chronic pain and the underlying causes can eventually cause permanent physical and even neurological damage to parts of the brain if left undiagnosed and untreated.
What is pain?
The simple version of pain as endorsed by The International Association for the Study of Pain is that it is as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. But pain is not simple. Pain is not only a physical sensation, it can be influenced by a number of external factors such as personal attitude, personality, resilience and has the ability to negatively affect emotional and mental wellbeing. For example, take two people suffering the same ACL injury – they are experiencing the same condition, yet their experience of living with the pain will be vastly different and their recoveries will differ based on their physiological make-up along with their psychological attitudes.
There are two main categories of pain that physiotherapists see and treat: acute and chronic.
Acute pain only lasts for a short time but can be incredibly intense. Commonly occurs after surgery or due to physical trauma such as a motor vehicle accident or a sporting injury. Acute pain is the body’s warning alarm telling you to seek help. Although acute pain usually improves as the body heals, sometimes it doesn’t.
Chronic pain is the type of pain that stays with you long after surgery or an immediate injury and is commonly caused by underlying conditions. Conditions like migraines, osteoporosis, arthritis and other musculoskeletal issues are all commonly diagnosed chronic diseases that musculoskeletal physiotherapists see all the time. Just to keep us on our toes, chronic pain can exist without a clear reason or underlying cause. Remember the definition above of pain; actual OR POTENTIAL tissue damage. Yes, you can have pain without any damage! Chronic pain is commonly a symptom of other diseases but can actually be a disease in its own right, caused by changes within the central nervous system.
How does pain work?
Your lower back pain, knee pain, neck pain, ankle pain and every other pain all the way to your little pinky pain comes from the brain itself. Pain is the end result of your brain evaluating information and coming up with a best guess of how to translate that information and to where. Your body contains nerves called nociceptors that detect any dangerous changes in temperature, chemical balance or pressure in your body and send alerts to the brain, but the pain you feel is all in the brain and controlled by the brain. Thanks heaps brain.
Most of the time your brain gets it right, but sometimes it doesn’t. For example, referred pain in your leg is common to experience when it is actually your lower back causing the issue. Another example of the brain’s power is phantom limb pains commonly experienced by amputees in limbs that are no longer there. If that’s not the perfect example of the power of the brain, I don’t know what is. They have pain when the limb doesn’t even exist!!
How can ignoring chronic pain lead to more problems?
I’m sure other physiotherapists on the Northern Beaches are just as sick of hearing ‘no pain, no gain’ applied to every painful scenario as I am. Even during and after short term bouts of experienced pain, your brain increases stress hormones in your body, which can make it harder to think, cause anxiousness, lethargy, fatigue, slower recovery and lead to muscle tightness. Even that “dicky knee when it gets cold”, that “sore back” or “dodgy shoulder” is capable of causing long term physical and psychological effects. Pain affects the proper functioning, strength and efficiency of the human body. This often leads to altered movement patterns, compensatory tightness in other areas of the body, limb weakness and can cause chronic stiffness and exacerbate the pain.
It is imperative to address any pain as soon as you realise that it is not just going to disappear in a couple of days. Your GP will agree with musculoskeletal physiotherapists that the evidence supporting early treatment in almost any acute injury or painful condition is well documented.
Don’t let your pain today progress and evolve into more than something that can be relatively easily fixed with physio intervention. Instead of thinking “no pain, no gain” when you get an injury, focus on allowing yourself to understand that we need to heal, we need to relax and we need to look after ourselves because putting your body and brain through continuous pain is doing much more harm than good.
 McArdle S. Psychological rehabilitation from anterior cruciate ligament-medial collateral ligament reconstructive surgery: a case study. Sports Health. 2010;2(1):73–77. doi:10.1177/1941738109357173
Sever’s disease, aka calcaneal apophysitis to musculoskeletal physiotherapists is the most common cause of heel pain in growing athletes. Sever’s Disease isn’t really a true disease per se and was actually first identified by Patrick Haglund in 1907, but it was James Sever’s characterisation of the disease in 1912 that led to it being named after him. Maybe it just had more dramatic ring to it? Sever’s disease is the inflammation of the calcaneal apophysisa, located on the heel close to where it connects into the Achilles tendon. Sever’s Disease most commonly occurs before or during a child’s peak growth spurt and is often seen when they begin a new sport or footy season. It is most common in boys between the ages of 8 and 12 and quite frequently in girls between the ages of 8 and 10 years old who are also active in sports.
How is Sever’s Disease diagnosed?
For your physio to find the cause of your child’s heel pain and rule out more serious conditions, they will ask some thorough questions about their medical history and ask questions about recent activities or injuries. There is rarely the need for any blood tests or x-rays, your physiotherapist will perform what’s called a squeeze test and some other tests to confirm the diagnosis of Sever’s Disease. During the squeeze test (which is exactly what it sounds like) if the child’s medial and lateral sections of the heel are tender and there are no symptoms such as red skin or swelling, almost always indicates a diagnosis of Sever’s disease.
- Pain in the back or bottom of the heel
- Walking on toes
- Difficulty running, jumping or participating in usual activities or sports
- Pain when the sides of the heel are squeezed
What causes Sever’s Disease?
When children (especially boys) are going through a growth spurt, the bones will grow first and the muscles and tendons can take a while to catch up. In Sever’s disease, the area around the heel bone can become quite sore and swollen where the Achilles tendon attaches to it. Children who participate in running and jumping sports such as AFL, soccer, Basketball and athletics are more likely to end up with Sever’s disease. Research has also shown that wearing boots with studs or spikes increases the risk of developing Sever’s disease.
Factors contributing to Sever’s Disease in children include changes to:
- Height and weight – high BMI children have higher rates of the disease
- The frequency of physical activity – AFL carnivals over a few consecutive days
- The type of physical activity – Changing sports or starting new ones eg. Netball, gymnastics
- Shoes and equipment – Many football boots have a lower heel that can add pressure to the apophysis by stretching the Achilles tendon slightly. Lots of barefoot running and even walking in thongs on the soft sand at Dee Why can cause the same increased load.
How is Sever’s Disease treated?
As with most soft tissue injuries, in the first stages of recovery your physio will recommend the R.I.C.E method – Rest, Ice, Compression, and Elevation. Unfortunately, no one treatment method has been definitively proven to be better than others in the long-term management of Sever’s disease. During the early phase your child will probably be unable to walk pain-free, so the first aim is to prescribe your child with some active rest activities and keep away from pain-provoking activities for the time being. Your physio will use and teach your child a range of pain relieving techniques including joint mobilisations for stiff ankles and give the area a good massage in order to restore full Range of Motion, reduce pain and regain full foot biomechanics. A good musculoskeletal physiotherapist will also want to see your child’s biomechanics and technique in action and if they have injured themselves playing AFL or another sport, getting your physio to check it out will help reduce flare ups in the future.
How does Sever’s Disease affect my child’s sport?
Sever’s disease is a self-limiting condition and will fully heal with the right treatment. The first important step is to seek treatment when early signs of Sever’s become apparent. Sub-optimally treated Sever’s disease can cause a permanent bone deformity at the rear of the heel bone which can be painful and annoying. For the time being, seeing a physio will be be helpful to learn ways to stretch the Achilles tendon and keep pain under control. Limit your child’s sport load during the initial period and monitor their return to sport closely afterwards.
If your child is between the ages of 8 to 12 and is complaining of heel pain with no exterior causes, you should suspect Sever’s disease until proven otherwise. Sever’s Disease is a common issue seen by your local Dee Why physio due to the high number of active kids on the Northern Beaches (a positive and a negative there) and they are the best people to speak to if your child is complaining of a sore ankle.
 HAGLUND P: Ueber fractur des epiphysenkerns des calcaneus, nebst allgemeinen bemerkungen ueber einige
aehnliche juvenile knochenkernverletzungen. Archiv fur
klinische Chirurgie 82: 922, 1907
 SEVER JW: Apophysitis of the os calcis. N Y Med J 95:1025, 1912
 Sever’s Disease: What Does the Literature Really Tell Us? Rolf W. Scharfbillig, PhD* Sara Jones, PhD† Sheila D. Scutter, PhD May/June 2008 • Vol 98 • No 3 • Journal of the American Podiatric Medical Association
Going for my early bird swim at Dee Why pool this weekend it took a few minutes longer than usual for my muscles and joints to really get going. I couldn’t quite put my finger on it until I got out of the pool and a fresh gust of wind reminded me… Winter Is Coming. Checking the weather and in 2 days the minimum temperature has dropped 7 degrees. Did you know that May, June and July are the busiest months for sport and exercise related injuries in Australia? While you can attribute some of that rise to the winter contact ball sports, a contributor to the rise in muscle and tendon related injuries is the drop in temperature. The muscles and ligaments of the body function and perform better when they are warmer. It’s also easier to get out of bed and actually go on that early morning run too when it’s not 5 degrees. Let’s look at how the cold affects the performance and injury rate of the muscles and tendons and how you can lower your chances of a cold related injury.
Can cold weather make joints and muscles hurt more?
My Dad is one of those people who say that his joints can predict the weather, “a cold front is coming through” he’d say on a 30 degree day and it did seem like he picked it once or twice (little did I know at the time that he constantly consulted the Bureau of Meteorology as much as Gen-Y checks Facebook). But let’s just say science is far less convinced than he and a few other patients of mine who are convinced that their arthritic conditions can predict the weather. Over the years a number of studies have looked at the correlation between temperature, weather and barometric pressure with none being totally conclusive. That being said, some studies have shown a plausible link between barometric pressure and cold weather on some specific arthritic conditions or under less strict conditions. If you believe your joints hurt more in the cold, I’m not going to not believe you.
Increase your warm-up time and quality
This is probably the single most important piece of advice if you are undertaking any physical activity during the winter months. Cold muscles and ligaments mixed with physical activity are going to equal a lot of pain. Cold muscles, tendons and ligaments are more likely to lead to muscle sprains and joint strains due to decreased flexibility and elasticity. If you normally warm up for 5 minutes, extend it to 10 as it gets colder, if you normally don’t warm up, extending that to 10 minutes is fine too. A good warm-up:
- Prepares the body and mind for the activity
- Increases the body’s core temperature
- Increases the heart rate
- Increases breathing rate
- Stimulates flexibility and power
Don’t skimp on the cool-down either!
Many musculoskeletal physiotherapists will agree that failing to cool down adequately is a major contributor to muscular and tendon injuries. I don’t know why but it doesn’t seem like it’s cool to cool down. After physical exercise the body needs time to slow down and recover, so cool down immediately after your activity for at least 5 to10 minutes. Sports and exercise physiotherapists recommend your cool-down can be the same sort of exercise as the warm-up with low intensity body movement such as jogging or walking substituted for running.
Can stretching help to reduce injuries?
Stretching before and after physical activity helps to promote maximum flexibility, relax the muscles, return them to their resting length and promotes recovery by assisting in the body’s natural repair process. When stretching it is important to:
- Stretch all muscle groups that will be or were involved in the activity
- Stretch gently and slowly
- Don’t bounce or try and stretch too quickly
- Only ever stretch to the point of mild discomfort – PAIN DOES NOT EQUAL GAIN
- Don’t hold your breath – breathe slow and easy
Don’t forget to stay hydrated
While it may not be scorching hot outside your body is still going to need a healthy dose of water daily. Dehydration is one of the major causes of muscle cramps and the winter months are an easy time to lost sight of drinking a couple of litres of the good stuff every day. Please don’t think a couple of shots of something harder will warm you up either, alcohol will only impair your coordination and your body’s ability to regulate your temperature which could lead to an injury. Caffeine drinks also cause dehydration, so steer clear of excessive coffee and energy drinks too if you can.
 The influence of weather on the risk of pain exacerbation in patients with knee osteoarthritis – a case-crossover study. Ferreira, M.L. et al. Osteoarthritis and Cartilage , Volume 24 , Issue 12 , 2042 – 2047
 Deall C, Majeed H (2016) Effect of Cold Weather on the Symptoms of Arthritic Disease: A Review of the Literature. J Gen Pract (Los Angel) 4:275. doi: 10.4172/2329-9126.1000275
 Woods K, Bishop P, Jones E. Warm-up and stretching in the prevention of muscular injury. Sports Med 2007;37:1089-1099.
 Scott, E E F et al. “Increased risk of muscle tears below physiological temperature ranges.” Bone & joint research vol. 5,2 (2016): 61-5. doi:10.1302/2046-3758.52.2000484
We’re an active bunch on the Northern Beaches and you’ll find that injury prevention and recovery are 2 major aspects of sports physio clinics in Dee Why. Chances are at some point you’ve experienced an injury, whether you tore an ACL, strained a hammy or twinged your neck and if you’re one of the unfortunate many you’ve probably reinjured it at least a couple of times. Recurrent injuries aren’t confined to AFL players and other professional athletes. Computer programmers are more susceptible to a recurrence of tennis elbow than tennis players, remember? Unfortunately prevention can’t always prevent a hammy strain, but once an injury has occurred you have the power to start the prevention cycle all over again.
There are a number of factors that influence the statistical probability of suffering an injury recurrence; if you watch a sport regularly you can probably name 1 or 2 athletes that seem to suffer the same injury over and over again. NRL player Tautau Moga for instance is only 25 years old and has torn his left ACL 4 times, having a full reconstruction and rehabilitation after each occasion. Researchers are getting better at injury prevention and management every day and sports and musculoskeletal physiotherapists are experts in getting to the things that increase injury recurrence:
Insufficient rehabilitation from previous injury
Call it youthful exuberance in wanting to get back into it too quickly, call it being lazy and not completing your full rehabilitation but one of the most common reasons for suffering a recurrence of an injury is failing to rehab properly. Overloading is a great short term principle and is part of effective programming to allow for super-compensation and increase fitness and strength, but IT DOES NOT APPLY DURING INJURY RECOVERY. Any professional level athlete in any sport will tell you their recovery is just as important as their training when it comes to performance. Failing to follow your physiotherapist’s full rehabilitation program for your sore hammy is only going to end one way. Your guessed it – a pain in the butt!
Neglecting symptoms of pain
Speaking of pain, one of the next most popular reasons people reinjure themselves is failing to heed your body’s best warning signal; pain. “I’ll just run it off” doesn’t cut it as an effective treatment strategy for managing most musculoskeletal injuries but it’s still one of the most common things that people like to do for some reason. Most chronic back, neck, knee, hip, groin, ankle and hamstring injuries will usually give you some warning sign before they completely give up. Don’t treat that shooting pain in your leg like the check engine light in an old car and just put some tape on it either. Strapping and taping is good in some instances, but it can’t keep a hamstring in place for long.
Poor conditioning or fitness
Coming back from long term injury can be tough and it’s common to let fitness levels slip while injured which can often lead to poor performance or additional musculoskeletal injury upon returning to physical activity. Every bit of physical activity outside of your physically repetitive job is going to lower your chances of suffering a repetitive strain injury as well. While you are recovering from an injury, try and do all you can to keep moderately active, whether it be short walks, dumbbell curls or simple sit-ups.
Poor technique and movement control
Poor technique and movement control are probably the 2 most important factors that cause injuries in the first place and they continue to play a part in injury recurrences. I don’t know how many times I’ve seen someone load up weights to the max at the gym, lifting far too much and trading technique for weight. This principle can be applied to most physical activities. Most injuries occur when you go too hard, are fatigued and are using movements that you are not at the unconscious competence stage of performing yet.
Poor or no warm-up/warm-down
Be honest, do you spend 10 minutes warming up and down every time before and after sport and physical activity? A well performed warm-up before a workout is going to dilate your blood vessels, ensuring your muscles are supplied with enough oxygen while also raising your muscles’ temperature aiding in achieving optimal flexibility and efficiency. Cooling down after physical activity is every bit as important as warming up. Stretching while you’re cooling down is the way to go because your muscles, limbs and joints are still warm. Stretching is going to reduce the build-up of lactic acid, which is the leading cause of muscle cramp and stiffness.
If you have suffered an injury, don’t shirk your recovery. Speaking with an expert in sports and musculoskeletal physiotherapy and undertaking a custom made rehabilitation program is going to shorten the length of your recovery, minimise your risk of a recurrence of your injury and also help provide you with the knowledge you need to continue to prevent injury independently.
Hamstring strains (a.k.a. “doing a hammy!”) are one of the most common injuries seen by Northern Beaches physiotherapists. Hammy strains are most prevalent in sports that use a combination of dynamic movements like sprinting, Australian Rules football (AFL), soccer, dancing, surfing, rugby league and other activities where quick eccentric contractions, when the leg is being straightened and the hamstring is working hard, occur frequently such as slowing the leg down after kicking a ball. In AFL hamstring strains are the most common injury with a rate of 6 injuries per club per season combined with the highest rate of re-injury at over 30%. Musculoskeletal physiotherapists know that it is perfectly normal for two people to tear exactly the same muscle but recover at different speeds. Recovery time is dependent on the grade of the injury with a grade 1 injury possibly healing in only a few days, while a grade 3 injury could take months and, in extreme cases, even require surgery.
“My hamstring is ok but derogatory and sexist comments aren’t”
Most hamstrings will have torn well before this point so all can admire the incredible strength and flexibility of Tayla Harris during the AFLW 2019 season.
What are the hamstrings and what do they do?
The hamstrings are a group of muscles and their tendons at the back of your upper leg. They are made up of three different muscles: the biceps femoris, the semitendinosus and the semimembranosus. You use your hamstrings for all kinds of things: walking, running, dancing and jumping. They enable you to flex your knee and extend the hip at the beginning of each step you take. Your hamstrings play a large role in many movements of the legs and hips which is why physiotherapists have spent so long studying them and how to reduce the occurrence and length of injuries.
How do hamstring injuries occur?
Like most injuries, hamstring strains or injuries can be classified as being caused by either primary or secondary factors.
- Primary factors include:
- Poor timing coordination in the hamstring (the swing phase of the leg in sprinting)
- Lack of strength and stiffness in the hamstring
- Muscle imbalances
- Increased neural tension through the sciatic nerve
- Common secondary factors include:
- Overstriding or poor pelvic control when running
- Improper warm-up to prepare hamstring muscles
- Lower back problems
- Prior hamstring injuries
What are the symptoms of a hamstring strain?
The nature of hamstring strains means that symptoms can vary greatly between injuries. Mild hamstring strains could present as tightness or a mild ache in your hamstring. While a severe strain can be extremely painful, with some people describing it like being shot in the back of the leg even making it impossible to walk or even stand. If you have any of the following symptoms get in to see your Dee Why physio ASAP:
- Hamstring tenderness
- Pain or difficulty running, walking or standing
- Pain in the back of the thigh or lower buttock
- Bruising or swelling
- Sudden severe pain while exercising, with a popping sound or snapping feeling
How physiotherapy helps treat hamstring strains
If you have had a hamstring injury your best course of action is to consult with a physiotherapist that has an expert knowledge of sporting and musculoskeletal injuries. Due to the high rate of reinjuring your hamstring, there is no substitute for high quality initial care and rehabilitation. Physiotherapy helps patients with a hamstring injury to speed up the healing process and ensure the best outcome. They will be able to assess and treat your strain and help you to minimise their recurrence in the future.
- Acute or initial phase of a hamstring injury
Your physio will likely recommend the trusty RICE (Rest, Ice, Compression, Elevation) method for the first few days. This will help to reduce swelling and minimise pain. I like the saying ‘the early bird gets the worm’ and when it comes to intervention for hamstring injuries the early bird getting treatment always recovers quicker and more effectively. An expert sports physio will also get you loading your hamstrings in a variety of different ways, even in the early stages!
- Your physio will then comprehensively assess:
- Your range of motion
- The strength and mobility of your lower back
- Your gait
- Your flexibility
- If possible, your running, jumping and sporting techniques
How to prevent another Hamstring Strain
If you’ve ever had a hamstring strain I can pretty much guarantee you won’t want another one, they certainly don’t tickle. Dealing with a hamstring injury once it’s already happened is much harder than preventing it. Here are some tips:
- Stretch before and after physical activity
- Increase the intensity of your physical activity gradually
- If you feel pain, stop exercising (it’s not all ‘no pain, no gain’)
- Stretch and strengthen hamstrings as a preventative measure
Whether you have recently suffered a hamstring injury and are in need of immediate physical therapy or you have suffered a hamstring injury in the past, a physiotherapist is able to assess and recommend the best activities and stretches to help speed along your recovery and reduce the likelihood of experiencing further strains.
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 Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, season 1997–2000. Br J Sports Med2002;36:39–44.
 Schunke M., Schulte E., Schumacher. Anatomische atlas Prometheus: Algemene anatomie en bewegingsapparaat. Nederland: Bohn Stafleu Van Loghum, 2005.