3 Weeks after a DIP Dislocation in a gymnastics injury, swelling, pain, and weakness remained in the PIP more than DIP of that digit. She was unable to grip or hang/swing on bars without pain. In order to restore threat free grip, compression plus lateral rotation held enabled full pain-free passive end range flexion of the PIP. For the DIP, which was also limited in flexion, end range repeated extension restored pain-free flexion. Just a little experimentation and you can easily find desensitizing repeated loading strategies. She was prescribed to do these resets hourly and gradually work on grip strength.
[UPDATE]: Just followed up, after 4 days of the reset and grip strengthening, she was able to complete a bars routine and prior she was unable to even hang from the bar. Swelling is down, but still present, and grip strengthening needs to continue.
I watch a lot of hockey….like A LOT of hockey. It seems like every offseason there are at least a handful of players having surgery for femoral acetabular impingement (FAI), “hernia” repairs and/or abdominal “tears.”
Whenever there is a huge increase in certain procedures, I’m always a little suspect whether it’s just the latest trendy thing to be done or truly necessary. In June of 2018, the Journal of Orthopedic Sports Physical Therapy even dedicated their whole issue to FAI occurrence and treatment.
It was an interesting issue that didn’t just address FAI, but a large number of complex groin pain. I realized much is the same as it was 20 years ago, but the understanding of the concurrent injury has improved.
What’s In A Name?
Complex and difficult to treat groin pain has gone by a lot of names over the years. Gilmore’s Groin, Sports Hernia, Core Muscle Injury, Athletic Pubalgia. All these different terms complicate literature searches and lead to poorly defined anatomy definitions.
It is now agreed upon to leave the term “hernia” behind because the injury usually involves the various structures that compromise the pubic and abdominal aponeurosis, but rarely a deficiency of the posterior wall.
The literature also doesn’t agree whether surgical intervention or conservative treatment is best. These patients may seek you out for pain management or while waiting for a diagnosis.
Who’s At Risk?
Males are at higher risk than females due to the narrow pubic arch angle. As well as athletes that involve high frequency of deceleration and acceleration particularly with cutting/pivoting such as ice hockey, soccer, rugby, and our military personnel.
71% can relate the pain to a reproducible, specific activity that usually involves hyperextension of the trunk and hip hyperabduction. And there is a high incident with a co-existing FAI. Athletes with limited ROM due to FAI will rely more on trunk extension and the pivot point of the pubic symphysis perhaps making them more at risk to develop tears of the aponeurosis. Repetitive pelvic motion against a fixed extremity with decreased range due to CAM or Pincer lesions may result in rectus abdominus sheath and oblique muscle fiber injuries (Strosberg et al 2016). Studies have shown if the athlete has their abdominal/groin tear repaired, but not FAI, only 25% return to sport.
However, if both are repaired 89% return to sport (Larson et al 2014).
What Do I Need To Look For?
We are not going to diagnosis an athlete with FAI or athletic pubalgia.
But what if our athlete comes to us with groin pain and we aren’t sure if it’s something muscular to treat?
What makes this diagnosis difficult is there is no great test or exam that is specific for these injuries. And studies have shown that there are potentially 17 different structure that can be involved! Common Hallmark Signs include:
- Deep going or lower abdominal pain
- Pain exacerbated by very specific sports activity that is relieved by rest
- Palpable tenderness over a conjoined tendon or rectus abdominus insertion near pubic tubercle
- Pain with resisted abdominal curl up
- Pain with resisted hip abduction at 0, 45 and 90 degrees of hip flexion
And of course, if your patient isn’t responding to treatment, it’s always time to investigate further.
To Treat Or Not To Treat?
Most guidelines agree to always treat conservatively.
However, only 27% of athletes return long term to sport with conservative treatment.
Also, the length of a conservative treatment trial is somewhat controversial and inconsistent. Nature of injury, level of performance of the athlete and length of time before return to pre-injury play all need to be considered when deciding how long to have a trial of conservative treatment.
I think back to my college athletic training days and I realize there were quite a few “sports hernia” surgeries being done. So maybe this isn’t a new trend after all! However, it’s always good to remind myself of signs and symptoms and anatomy so we all make sure we are treating our patients effectively. It will, of course, be crucial for you to do your own assessment and use your critical thinking on how to progress with treatment, along with how to manage it as a conservative treatment as recommended. But at least after this hockey season is done, I’ll have my own answers as to how necessary the treatments on my favourtie players are.
Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athletic Pubalgia: A Review. Rhode Island Medical Journal (2013)[serial online]. October 4, 2016;99(10):31-35.
Copperthite K. Athletic Pubalgia, Part 1: Anatomy and Diagnosis. Athletic Therapy Today[serial online]. September 2010;15(5):4-
Harris-Hayes M, Steger-May K, van Dillen LR, Schootman M, Salsich GB, Czuppon S, Clohisy JC, Commean PK, Hillen TJ, Sahrmann SA, Mueller MJ. Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain. J Orthop Sports Phys Ther. 2018 Apr;48(4):316-324. doi: 10.2519/jospt.2018.7810. Epub 2018 Mar 16.
Heerey J, Risberg MA, Magnus J, Moksnes H, Ødegaard T, Crossley K, Kemp JL. Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial. J Orthop Sports Phys Ther. 2018 Apr;48(4):336-342. doi:10.2519/jospt.2018.8002.
Hopkins J, Brown W, Lee C. Sports Hernia: Definition, Evaluation, and Treatment. JBJS Reviews[serial online]. September 2017;5(9):e6
Larson CM. Sports Hernia/Athletic Pubalgia: Evaluation and Management. Sports Health. 2014;6(2):139-144. doi: 10.1177/1941738114523557
Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesana G, Zatti G. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World Journal Of Clinical Cases[serial online]. September 16, 2015;3(9):823-8
Strosberg D, Ellis T, Renton D. The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management. Frontiers In Surgery[serial online]. February 12, 2016;3:6.
Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, HÖlmich P. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. J Orthop Sports Phys Ther. 2018 Apr;48(4):239-249. doi: 10.2519/jospt.2018.7850. Epub 2018 Ma
This is one of those topics that inevitably comes up on a regular basis.
The last time I taught our course on pain science and therapeutic exercise, there was some resistance to the idea that massage therapy does not increase circulation and last week there were some big discussions on the topic on one of the massage groups on facebook.
This was a harsh reality for me when I realized we don’t have any effect on circulation and I remember the day in college when I started to question it (I’d love to say it was because I was some sort of forward-thinking genius, but I digress). I was working with a hockey team and one of the players had an episode in the summer which required him to be on blood thinners. I was super worried that if I did any massage I’d have an adverse effect on him, so I approached one of my teachers to ask if massage was contraindicated and what I should do as I was worried about the increase of circulation with his condition.
My teacher simply looked at me and said: “you’re not going to increase his circulation any more than him playing hockey!”
It was like a light bulb of astonishment went off, I wish I had a picture of my face.
Now, surely that story can be taken anecdotally if you choose to, so the question will remain: “what does the research say?”
Heart Rate And The SNS
I remember in college while working in the student clinic, part of each treatment we had to develop three goals prior to treatment to be reviewed by one of the clinic supervisors.
Most of the time my goals would look something like this (they got more specific as school progressed):
- Increase circulation.
- Decrease SNS firing.
- Patient education.
I think the reasoning behind “decreasing the sympathetic nervous system firing” was more to just a way of saying we calmed the patient’s stressors down and essentially helped them relax. As we know the SNS is responsible for our “fight or flight” response, which is essentially used when we are scared because we’re being chased by a bear or something. In order to have a “fight or flight” response, it would require our heart to start pumping hard and feed blood to the necessary parts of our body to get us moving and run from the said bear.
One of the assessment tools we would use to prove whether we actually had an effect on the patients SNS was to check their pulse before and after treatment to see if there was a change. Inevitably their pulse rate would be slower post-treatment than it was prior to treatment, thus justifying how we “relaxed” our patient.
So how in the world did I think I could simultaneously increase circulation, while both decreasing sympathetic nervous system activity? My assessment was literally proving me wrong. The sad part is I only thought of this example last week, at no point during my education did I ever question this, I just habitually put them as goals.
One thing we know for sure (and we’ve written about it before, you can read it here), is that massage therapy can help with hypertension and actually decreasing blood pressure. Some articles argue this entirely depends on the type and depth of massage technique used. One study showed using trigger point therapy and sports massage actually increased BP, however, the article wisely ackn0wledged this was due to the pain caused during a trigger point treatment. In this case, the treatment would be causing a sympathetic nervous system reaction to withdraw from pain, thus temporarily increasing blood pressure.
With everything we know about modern pain science and the knowledge around old theory of trigger point therapy, I hope we aren’t going in and causing pain with our patients anymore, as we know it’s not effective. In turn, it’s also not a technique we should use to fight the argument about an increase in circulation. As far as sports massage causing an increase, we’ll get to that in a bit.
In the sport massage world, there has been a long time practice of using tapotement techniques to help with warm-up and increase blood flow before a competition.
While this can be an effective way of helping an athlete warm-up, there is probably more of a psychological aspect to it than anything about bringing circulation to a specific body part or tissue (this may be part of the reason that a typical warm-up involving exercise is always recommended before seeing a therapist to assist with warmup).
There is also the argument about doing a “leg flush” post-competition to help clear out lactic acid as part of recovery.
While there are several studies showing that blood flow is increased with massage (to help prove the above theories), most of the methods used to try and prove this theory wasn’t very reliable. However, more recent studies have shown that massage has little effect on arterial blood flow.
There were theories that reported a 50% increase in circulation after a vigorous massage, but later studies (which used somewhat unreliable measurement tools) showed not only smaller increases, but some showed no increase at all.
The above-cited study actually did tests post-exercise to see if massage would still have any effect when it comes to circulation. They used one group who would take regular rest post-exercise and one group who would receive massage. There was no significant difference between the two groups on femoral artery blood flow and massage performed on the quadriceps.
So what does this tell us? The only real way to increase blood flow is through movement and exercise. As our friend Alice Sanvito stated in a forum not too long ago: “If we mean there is more blood to an area, we run into another problem. The circulatory system is a closed-loop. There is a relatively fixed amount of blood. If more blood is shunted to one area, then there must be less blood somewhere else.”
The body would not let this happen, so we cannot actually alter circulation to bring more or less to any area of the body, without significant injury, which would result in shock, or blood loss.
Changes In Skin Colour
The question came up, “if we don’t increase circulation why does the skin go red!?”
Great question!, so I had to do some research on that as well.
We have all seen it in our clinic, we work on a specific area of the body and the skin changes color and gets a little bit pink, or maybe even red. Well, there are two possible mechanisms at work here, either the friction created doing, say, an effleurage stroke is irritating the skin, or a change in temperature from touch is the culprit. What about the clients you treat where the skin doesn’t change colour? Does this mean the massage is having less of an effect on them?
Well, studies show that skin friction can increase heating which causes hyperemia in the local massaged area. But the same thing happens when I put a cold pack on my arm and isn’t cold actually supposed to cause vasodilation and a decrease in circulation?
While there is a minor increase in blood flow to the capillaries of the skin, the increase in blood flow has been measured and shows that the amount is so arbitrary, there is no way it is being diverted away from local musculature. So, while this is p0ssibly a minor increase to the skin, we can’t assume we are increasing circulation to the muscle because the skin is changing colour.
As we mentioned before, what about those clients whose skin colour doesn’t change? Does this mean there is something wrong with their circulatory system, and we aren’t influencing circulation to that area? I’d venture to say no, it probably has more to do with skin sensitivity, or it’s a true measure of how minimal the circulation increase actually is.
Our friend Alice Sanvito also made a stellar point about this:
“What were we taught about the sympathetic and parasympathetic nervous systems? The sympathetic “fight or flight” nervous system diverts blood away from the skin and internal organs and towards the muscles. The parasympathetic “rest and digest” nervous system diverts blood away from the muscles and towards the internal organs and the skin. Since massage tends to relax people, it is probably safe to assume it is downregulating the sympathetic nervous system.”
Like it has been with so many other things in our career, we really have to take a step back sometimes and critically look at the things we were taught. This has been a huge learning curve for me during my career, but there is also a refreshing side to being able to give honest and logical answers to patients. While we may encounter arguments from others on these points, it’s important to keep educating ourselves and others to stay on top of current research and evidence-based practice. We’ve said it before on this blog in regards to circulation, there’s more of an increase happening by your patient walking into your clinic and getting on your table than from anything that happens during the treatment. And you know what? That’s okay because what you are doing for them on the table is FAR more important than worrying about increasing their circulation.
Is yoga effective for managing chronic pain? Maybe, but then again maybe we just need to look at safe, non-threatening movement as a way to cure or manage chronic pain.
“Yoga, Mice, Pain and Your Brain” – Sarah Haag
There are some great points in this article about doing aggressive psoas work on patients, but there’s some things I don’t like about the article. To say that only those trained in visceral work should be doing this kind of work (because there’s not much evidence to say visceral manipulation is effective), is a bit of a stretch. However, I like the overall gist, that only trained professionals should be doing the work, and to be careful, there’s no need to do “aggressive” work.
Load management in athletes is an important factor in making athletes available for, and being in the best shape possible for competition. This post reviews three factors related to load management to help your athletes.
“Load Management Is Not About Decreasing Minutes” – Tim Gabbett
I love sleep, so I hate this part of the year where I lose an hour of it putting the clocks forward (why are we still doing this!?). A lack of sleep can lead to a host of health conditions and can affect brain health. Fortunately, massage therapy helps with sleep, so this could be a good article to share with your patients as another reason to get a massage!
“Why Are We So Sleep Deprived And Why Does It Matter?” – The Conversation
I’ve been asked many times if I would ever open up a practice at home and while it’s not for me, I know plenty of therapists who do. This post lays out several things to consider if you are wanting to open a home-based practice.
“Opening A Home Based Massage Business” – Allissa Haines
Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.
I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).
For many years, I did just that.
I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.” During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.
It opened my eyes to how athletics can affect females differently than males.
Since then, how we view the triad and how we treat it has changed.
Can you recognize and screen for the signs of the triad? Do you know who is at risk?
What Is The Triad, And How Do We Recognize It?
Adolescent girls should participate in sports. I want that to be clear.
Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.
But they are at risk for injury, 48% of female athletes will have injury severe enough for them to miss playing time.
Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females. Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption. The most common places are the foot, lower leg and pars in the spine. Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.
90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes. So any non-traumatic bone injury is cause for concern.
It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.
Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.
The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis. The triad has now been expanded to include a spectrum of each pathology. Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A -2.0 standard deviation or greater is concerning.
The crux of the triad seems to be low energy availability due to disordered eating.
The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight. Many are just unaware of the amount of food it takes to fuel their daily activity. Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers! This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.
Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation. When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.
Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right? Studies now show that using oral birth control does not change the bone density, even with prolonged use. The first treatment should be nutritional counselling and improving caloric intake. There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.
Also, find a nutritional counsellor in your area used to working with athletes.
What Can We Do?
So what do you do as a healthcare professional?
Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components. The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.
Have information available. Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food. Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources. Certain medications can also impact bone health and may predispose your athlete to bone injuries.
Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.
Female Athlete Triad is primarily hormonal and dietary driven. It’s important to have a multidisciplinary approach to diagnosis and treatment. It’s also important to be a nonjudgmental place for your athlete. Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.
- Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
- Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
- De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
- Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
- Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
- O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554