Lumbar Bone Stress Injuries: The Dark Horse of Low Back Pain in Active Teens

Low back pain in young athletes is more common than you’d think, but one type of injury that should not be missed and diagnosed correctly is lumbar bone stress injuries.

These injuries are sneaky. They can look like everyday back pain but may actually involve stress to the bones in your lower spine, and if missed, they can delay return to sport or even cause long-term problems.

Let’s break it down so you know what to look out for and what to do about it.

What Are Lumbar Bone Stress Injuries?

These injuries affect the posterior elements of the lumbar spine, mainly a region called the pars interarticularis, a small bridge of bone connecting the vertebrae.

You may hear terms like:

• Spondylolysis – a stress reaction or fracture in the pars

• Spondylolisthesis – when the vertebra slips forward, often due to a pars injury

• Bone stress reaction/fracture – part of a continuum of overuse injury

• Non-uniting stress fracture – a stress fracture that hasn't fully healed within the expected timeframe but shows fibrous healing, indicating biological repair and often remaining stable with appropriate load management.

These injuries are a lot like shin splints; they happen when the bone is overloaded by repeated movements like jumping, twisting, or bending backwards. At first, it’s just tiny stress on the bone, but if the load keeps building without enough rest, it can develop into a stress fracture. They often show up early in the season, during pre-season, or when there’s a sudden increase in training after a break. 

t is critical to identify bone stress injuries early because continuing to load an already stressed bone can cause the injury to worsen, potentially progressing from a stress reaction to a full fracture. This not only increases the severity of the injury but also significantly prolongs recovery time, often requiring weeks to months of complete rest from sport. Early detection allows for timely offloading, targeted rehab, and a quicker, safer return to activity.

Who Gets These Injuries?

Lumbar bone stress injuries are most common in:

• Teen athletes aged 11-18 

• Athletes who partake in sports with back extension, rotation or side-bending (e.g. cricket fast bowling, gymnastics, AFL, soccer, tennis)

• Athletes who’ve had a sudden spike in training or competition

How Does It Happen?

• Repetitive lumbar extension + rotation (e.g., kicking, jumping, arching, throwing)

• Sudden increase in training volume or intensity

• Poor technique or poor core control

• Inadequate recovery between sessions

• Over time, the bone fatigues faster than it can repair – that’s when injury happens.

• Adolescents are more suceptible during growth sports: 

• Peak Height Velocity (PHV) is the period during adolescence when growth in height is at its fastest, typically between ages 11–13 in females and 13–15 in males. 

• During this time, bone mineral density temporarily drops and coordination declines due to rapid skeletal growth outpacing muscular and neuromuscular adaptation. This makes the spine, particularly the lumbar region, more vulnerable to overload and bone stress injuries.

Common Symptoms

What makes lumbar bone stress injuries tricky is that they can feel just like regular low back pain. A physio will look closely at your history, symptoms, and how your back responds to certain movements to decide if a bone stress injury might be the cause.

Symptoms can include:

• Localised low back pain (one or both sides)

• Worse with arching, bending back, twisting

• Tight hamstrings or glutes

• Pain with prolonged standing or running

• Often, no pain at rest

• May feel better after warm-up, worse after activity

Red flags to seek physio/doctor immediately:

• Tingling, numbness, or weakness in legs

• Night pain or constant, non-resolving pain

• Sudden loss of function

What Can It Be Mistaken for?

As we’ve mentioned before, lumbar bone stress can masquerade as other conditions of the low back, including: 

• Non-specific low back pain

• Muscle spasm or strain

• Facet joint pain

• Sacroiliac joint irritation

That’s why accurate diagnosis matters. If we suspect a lumbar bone stress injury, we’ll refer for an MRI, as X-rays often miss early stress reactions. These early-stage injuries don’t show up well on X-ray because there is no visible fracture line or cortical disruption. X-rays detect changes in bone density and structure, which typically occur later in the injury process. Additionally, lumbar spine X-rays often require oblique views, which expose the athlete to relatively higher doses of radiation. MRI, on the other hand, is more sensitive to early bone marrow changes and doesn’t involve radiation, making it the preferred imaging choice in young athletes.

What Can Physio Do?

If caught early, these injuries heal really well with the right approach. At High-Performance Rehab, we guide you through a structured plan:

• Phase 1 – Acute (0–8 weeks)

• Rest from aggravating activity (no running, jumping, twisting)

• Swelling management & pain relief

• Light core control and hip strengthening

• Biking for alternative cardio to prevent loss of cardiovascular fitness

• Phase 2 – Load Introduction (8–16 weeks)

• Guided return to sport-specific drills - Gradually reintroduces mechanical loading to the healing bone in a controlled, progressive way.

• Core, glute & lumbar strengthening - Weakness can lead to compensatory loading through the lower limbs, especially at the site of previous BSI.

• Movement control retraining - Poor control can result in altered biomechanics (e.g. excessive hip adduction or internal rotation), increasing stress on specific bone sites.

• Gradual build-up to training loads

• Phase 3 - Strength Accumulation (17+ weeks)

• Continue a gym full-body (upper, lower, core) based program 

• Monitor and maintain training loads

Most athletes return to full sport within 3–4 months, depending on the severity and timing of diagnosis. The earlier a suspected bone stress injury is diagnosed, the earlier we can start the offload process.

Can It Be Prevented?

Yes, and that’s the best part.

Our prevention strategies include:

• Gradual increases in training volume (no big spikes)

• Regular technique check-ups (especially for bowlers and kickers)

• Core and hip stability work

• Load monitoring for game + training, and school sports

• I.e. As per Play Cricket - Australian Cricket Junior Bowling Guidelines recommends a maximum of 3 bowling days per week (match & training) A maximum of 5 overs in each bowling spell for U13-U17 age groups

Struggling With Back Pain?

Don’t turn the stress reaction into a fracture and be proactive with diagnosis and management.

Book an assessment with one of our physios today. We’ll help uncover the cause and map out a plan to get you back doing what you love,  safely and confidently.

Article Written by: Martin Law

AC Joint Sprain

Written By Martin Law

You tripped, landed hard on your shoulder, and now lifting your arm feels impossible. What’s going on up there?

What is it

The AC joint (short for acromioclavicular joint) is located at the top of your shoulder, where your collarbone (clavicle) meets a part of your shoulder blade called the acromion.

A sprain occurs when the ligaments that stabilise this joint are stretched or torn, typically when force exceeds what the ligament can tolerate. This often happens from a fall directly onto the shoulder or onto an outstretched hand. 

AC joint sprains lie on a classification called the Rockwood classification (a scale from 1-6), which classifies the severity of the AC joint sprain with reference to an X-ray. The higher the classification, the more damage there is to certain structures.

Type I – Mild (Sprain)

• What it is: Minor stretching of the AC ligaments, no tearing

• What you see: No visible deformity, normal X-ray

• Function: Shoulder is stable, but tender to touch

• Recovery: 1–2 weeks with conservative care

Type II – Partial Dislocation

• What it is: Tear of the AC ligament, but coracoclavicular (CC) ligaments are still intact

• What you see: Mild bump or prominence at the joint

• Function: Slight loss of motion or discomfort with overhead use

• Recovery: 2–4+ weeks with rehab

Type III – Complete Dislocation

• What it is: Full tear of both AC and CC ligaments

• What you see: Visible step deformity ("bump") on top of the shoulder

• Function: More noticeable weakness or instability

• Recovery: Often managed without surgery, but surgical consideration for active individuals or cosmetic concerns (6-8 weeks with rehab)

Type IV – Posterior Displacement

• What it is: The distal clavicle is pushed backward into or behind the trapezius muscle

• What you see: Obvious deformity, often confirmed with imaging

• Management: Usually surgical

Types IV–VI are more severe and less common, often needing surgical input. We’ll refer you to the right specialists if needed.

How Does It Happen?

Common mechanisms include:

• Falling directly onto the tip of the shoulder

• Landing on an outstretched arm

• Contact injuries in sports like rugby, AFL, or cycling

These forces place sudden strain on the AC ligaments, potentially causing pain, swelling, and joint instability.

How Is It Diagnosed?

• A physiotherapist or doctor will examine your shoulder movement, pain location, and strength

• An X-ray may be used to confirm the grade of injury

• In some cases, an ultrasound or MRI may help rule out other injuries

What Are the Symptoms?

• Dull throbbing pain

• Pain with overhead movements 

• Pain with reaching across the body 

• Pain with externally rotating your shoulder

• Possible bump, swelling, or bruising over the joint

What can it be mistaken for?

• Clavicle Fracture 

• Rotator Cuff Strain

• Shoulder Impingement

• Shoulder Dislocation/Subluxation

• If you have intense pain, visible deformity, or can’t lift your arm at all, seek a physiotherapist or doctor promptly to rule out fractures or more serious injury.

What Can We Do? 

• Manual therapy to reduce pain and restore movement

• Individualised rehab exercises to strengthen shoulder stabilisers, increase shoulder movement, and maintain shoulder strength while the ligament is healing

• Education and activity guidance to avoid flare-ups and re-injury

• Taping to help with AC joint support and posture

Can It Be Prevented? 

While it can be difficult to reduce trauma to the AC joint or shoulder during contact sports, the risk of a sprain can be reduced by:

• Ensure a proper warm-up of your shoulder before games

• Strengthening the shoulder muscles to attenuate impact 

• Learning how to fall safely 

Shoulder pain bothering you?

Let’s take a look — the earlier you get on top of it, the better the outcome.

We regularly work with athletes and active individuals recovering from AC joint sprains — whether it’s post-rugby match or an awkward fall.

Shin Splints

Written by Martin Law

Sharp pain in your shins after a run? You might be dealing with more than just muscle soreness.

What is it

Shin splints happen when the bones and muscles in your lower leg get overloaded, usually from doing too much, too soon. 

Every time you run or jump, tiny stresses go through your shinbone (the tibia), which is completely normal. Normally, your body can repair these micro-stresses. But if the load is too high and the rest is too little, the bone can’t keep up with the damage, leading to pain.

Medial tibial stress syndrome is part of the bone stress injury family. It lies on a continuum, on one end being bone stress reaction, on the other end being a bone stress fracture.

How Does It Happen? 

There are many compounding factors with shin splints; ultimately, they can be broken down into:

External Factors (Things outside the body)

• Acute increases in training load - Sudden spikes in distance, speed, or intensity without proper adaptation.

• Switching to new shoes — especially those with less support or a different heel drop — can alter mechanics and load.

• Changing training surfaces (e.g. soft surface vs hard surface) - Moving between grass, turf, concrete, or asphalt can change shock absorption and stress on the shins.

Internal Factors (Things within the body)

• Improper running mechanics, such as overstriding, poor alignment, or inefficient gait patterns, increase the load on the tibia.

• Flat feet (overpronation) - Alter force distribution, often leading to increased shin stress.

• Bone health - Low vitamin D or calcium levels or inadequate nutrition can reduce bone density and impair healing

• Genetics & Endocrine status - Some people are predisposed to bone stress injuries due to genetic or hormonal factors (e.g., low estrogen in females).

• Chronic training load - Consistently high volume or intensity without proper recovery reduces bone remodelling capacity.

• Underlying bone pathology - Conditions like low bone mineral density or stress reactions.

• Medication - Some medications (e.g., corticosteroids or certain contraceptives) may affect bone strength or recovery.

All these factors can affect the process of bone building and breaking downIn a healthy person, whenever we exercise and load the bones, e.g. jogging, there are micro-stresses/fractures in the bone. Our osteoblasts will then break down these areas, and then our osteoclasts will lay down new and stronger bone on top of this to adapt to the stimulus. This is a normal part of the healthy process. However, the catch is that this can take time (approx 24-48 hours). When we do not allow for adequate rest to allow this process to occur, this can lead to shin splints. 

What Are the Symptoms?

Common symptoms can include

• Dull, aching pain along the front or inside of the shin (usually the lower two-thirds)

• Pain that starts during or after exercise, especially running, jumping, or fast walking

• Tenderness when pressing along the shinbone

• Mild swelling in the lower leg

• Tightness or soreness in the calf muscles

• Pain that improves with rest but returns when activity resumes

When to See a Physio or Doctor

• Pain that doesn’t improve with rest

• Sharp or localised pain (may signal a stress fracture)

• Pain that starts earlier and earlier in your workout

• Visible swelling or bruising

What can it be mistaken for?

• Stress Fracture - Sharp, localised pain on the shinbone; worsens with impact; may hurt even at rest or night.

• Chronic Exertional Compartment Syndrome (CECS) - Tight, cramping pain during exercise that eases with rest; may include numbness or weakness.

• Tibialis Posterior Tendinopathy - Pain along the inside of the shin/ankle, often worse with walking or running; may cause arch collapse.

• Peripheral Nerve Entrapment (e.g., saphenous nerve) - Burning or tingling along the inner shin; not usually linked to impact.

• Bone Tumour or Infection (Osteomyelitis) - Very rare. Constant, worsening pain, often with swelling, warmth, or fever.

What Can We Do?

• Load management plan for competitions or to return to your activities of daily life

• Monitor weekly training load and plan adjustments if flare-ups occur 

• Be mindful of training surfaces and adjust training volume as needed 

• Prescribe a well-rounded strength program of lower limbs to reduce impact on shin bones (calf, tibialis anterior, glutes, quads, hamstrings)

• Recommendation to help with pain, e.g. orthotics, type of running, supportive footwear

• Optimal running mechanics (Overstriding, excessive heel strike, or poor cadence can overload the shins)

• Use cross-training modalities (swimming, cycling, cross-trainer) to maintain cardiovascular fitness while allowing shins to rest 

Can It Be Prevented?

• Gradual load progression - gradually increase load no more than 10% per week in terms of mileage

• Avoid sudden spikes in volume, speed, or terrain difficulty (e.g., hills, hard surfaces).

• Use well-cushioned, supportive shoes appropriate for your foot type and gait.

• A well-rounded gym program which involves foot intrinsics, calves, hips and thigh muscles

• Being mindful of changes in surfaces when running

• Ensuring adequate rest in between exercise bouts

• Maintain adequate energy availability to support bone remodelling 

If you have shin splints and it is affecting you in reaching your goals or living day-to-day life, contact us - we can help  

Return to Sport testing. Why is it Important?

Returning to sport without sport specific testing is like driving a car without checking if it has any petrol tank, it’s a risky game to play!

Returning to sport following injury is the most important decision you and your physiotherapist need to make. This decision needs to respect injury pathology healing time frames, strength levels, a return to training and most importantly a sport specific battery of tests.

Each injury is different and will require different tests, as well as tailoring the testing battery to what activity you aim to return to. Here are a few common tests we use at HPRS to assist the decision making process when returning an athlete back to sport.

Returning to sport testing needs to include three elements. Strength, power, and reactive strength/power. Mechanics and movement biomechanics need to analyzed and tests can assist to use metrics to compare to baseline measures and assess limb symmetry (difference between left and right).

Countermovement Jump (CMJ)

• Can be performed and tested using force plates or jump mat. The movement starts with hands on hips then jumping as high as you can.

• Metrics measured here are jump height, contact time and Reactive Strength Index (RSI).

• This can be a good sport specific movement to test as force production through jumping can also correlate with athletic ability and strength.

Single Leg Vertical Hop

• Can be done and tested on our jump mat. The movement starts with the athlete standing on one leg hands on hip then jumping as high as they can and landing on the same leg.

• The same metrics as the CMJ are measured here as well as side to side differences.

  Different to CMJ as it can be used as a single leg strength/power measure as well it can assess your landing ability on one leg.

• Lee et el, 2018 showed that this test is a functional measure of strength, power and ability to absorb force through a single limb.

Single Leg Vertical Drop Hop (Jump)

• This occurs where an athlete steps off a box, lands on the jump mat with one foot and hops vertically in the air. We use this test to measure reactive power.

• Hop height, Contact Time and RSI are measured here. Each metric can assist the therapist to target their rehabilitation according to what needs to improve. Eg increasing strength and power can assist jump height, while contact time can be improved through plyometric and jump mechanics training. Particularly working on fast reactive plyometrics focusing on fast ground contact time.

• Kotsifaki et el, 2022 showed that single leg vertical tests and performance metrics showed larger limb discrepancy and asymmetry than horizontal jump testing.

• The ability to jump and land on a single leg is crucial in sport and especially important in sports that require you to take off on one leg.

Broad Jump

• The movement starts with hands on hips then jumping as far forward as possible.

• The distance from the jump is the measure.

• This tests your ability to produce horizontal force through your jumping ability.

• A very simple test to administer.

• Your ability to take off and produce force through a double leg jump is sport specific as all sports require you to produce force through your legs in some form eg jumping for as header, jumping for a mark or even diving off a platform.

What other tests do we do?

Tailored testing will be prescribed specific to the injury. Strength testing is also important but again tailored to what the injury was. For example Quadriceps and hamstring strength testing is crucial for ACL injuries where Calf muscle strength testing may be more important for ankle and foot injuries. In the clinic these type of tests are done using 1RM testing or using our hand held dynamometer.

Restoration of pre injury test measures are ideal, if this information is unknown then limb symmetry can be used and researched benchmarks can also assist to make the return to play decision.

Example Testing Scores:

Here is an example of two sets of testing for an athlete completing their ACL Rehab. The top Table was tested at 6 months and the bottom table is tested at 10months.

What does this testing show us?

The orange boxes show the difference between Right and Left leg scores.

Things to note:

• Difference in contact time- At 6months this athlete was spending a longer time in contact with the floor before hopping up - meaning they are less reactive and slow.

• The difference in jump height- At 6 months this athlete could only achieve a hop of 12cm high off the ground, improving this height at 10months.

• RSI- The difference shows at 10months this athlete is spending less time on the ground and a higher hop - meaning they are faster with their hop.

This is just a snapshot of the type of testing done at HPRS. Again, this will be tailored to the specific athlete and specific injury. Testing as seen here helps aids decision making when returning to sport, assists goal setting and can show outcome progress.

Article Written by Antonietta Del Pinto

Acromioclavicular (AC) Joint Instability

AC joint instability can be defined as a disruption to the ligamentous integrity of the joint, creating instability between the acromion and clavicle. This is most often associated with trauma or direct contact and can usually be successfully treated with a graded conservative rehabilitation program.

Anatomy

The AC joint is comprised of two bones: the acromion of the scapula (shoulder blade) and the clavicle (collar bone).

The primary ligaments of the AC joint are:

1.      Acromioclavicular ligament

2.      Coracoclavicular ligament

3.      Coracoacromial ligament

Grades of AC Joint Injuries

 The Rockwood Classification is most commonly used to diagnose grading of AC joint injuries. This classification accounts for the mechanism of injury, clinical presentation and plain radiographic (X-Ray) presentation.

 The table below outlines the anatomy of AC joint injury grades and their clinical presentation:

 When Should I get an X-Ray?

 Imaging for your injury should always been guided following assessment from a medical professional. It is not always necessary to image a suspected AC joint injury, especially if there is no obvious step or other bony deformity.

Some indications for imaging would include:

·       Suspected high grade (≥ Grade III) AC joint injury

·       Tenderness on the clavicle, separate to AC joint tenderness

·       Persisting night time pain (aching/throbbing without provocation)

Surgery for AC Joint Injuries

 Conservative management (non-operative) is often successful, and patients are able to return to their previous sports and daily function without issue. Because of the strong outcomes of conservative management for Grade I-III AC joint injuries, surgery is often considered an unnecessary expense. However, not all AC joint injuries are able to be successfully managed without surgery. A confirmed Grade IV, V or VI injury must be treated with surgery and a consult with a specialist surgeon should be immediately arranged if this is the case.

In the physiotherapy world, Grade III injuries often carry a debate of surgery versus conservative management. Some indications for considering Grade III surgery would include:

·       Excessive and unsettling pain, causing day-to-day dysfunction

·       Cosmetics and patient expectations

·       Work demands (e.g. overhead/press movement requirements)

·       Contact/overhead athletes

·       Unstable/dislocating joint

AC Joint Rehabilitation

 An individualised and graded rehabilitation program is fundamental to the successful outcome of your injury, regardless of surgery or not. Due to the anatomy of the injury, targeting upper trapezius and deltoid strength throughout the rehab program is key to reducing deconditioning and long-term joint dysfunction.

 Like any injury, a rehab plan should be discussed in the early stages of your recovery, systemised into specific phases, with goals set for each phase, in order to achieve an overall goal of returning to your chosen sport or activity.

 A few key muscle groups that are not to be missed in the rehab of any AC joint injury include the upper trapezius, deltoids and serratus anterior.

·       Upper trapezius – this muscle has a partial insertion on the acromion and will play a part in improving joint stability of the AC

·       Deltoids – a group of three muscles which are primary movers of the glenohumeral joint (shoulder) in flexion, abduction and extension

·       Serratus anterior – often a deficit in this muscle is a contributing factor to not restoring full upward rotation of the scapula, leading to limitations in end range shoulder flexion (overhead)

 Like any other injury, it is important you liaise with your treating health care provider when rehabilitating your AC joint injury.

 If you have sustained an injury to your AC joint, please feel free to contact one of our Sports Physiotherapists for assessment and management of your injury.

Written by Edward Gellert – HPRSP Physiotherapist

Contributors to Hamstring Injuries and Reinjuries

1 in 3 Hamstring strains will reoccur, usually in the first 1-2 weeks after returning to sport. It has been speculated that there are potentially a few reasons for this. Are athletes returning too early to sport, are we missing a piece of the puzzle in rehab, or are there some risk factors that are stacked against us anyway?

To date, we don’t have an exact answer to this question, as most injuries are multi-factorial, it can go back to the correlation vs causation argument e.g. If you smoke, it doesn’t mean you definitely WILL get lung cancer, but you are more likely to get lung cancer. The figure below shows the consideration required to prevent injuries in a professional sports team – with a little bit of luck coming into the equation!

So how should we go about reducing these injuries if there are all these potential causes?

1.      Starting well – is it actually a hamstring injury?

Pain at the back of the thigh can vary in cause and that is an important factor to note. We can’t manage an injury to its potential if we don’t know where the origin of the pain is coming from.

Some of the causes of pain at the back of the thigh include:

-          Hamstring Strains – muscle tears and ruptures

-          Neural Hamstring pain

-          Referred Pain from the lower back or glutes (deep gluteal syndrome)

-          Quadratus Femoris pain

-          Tendon pain (tendinopathy)

-          Delayed onset muscle soreness (DOMS)

-          Adductor Magnus Muscle strain

 A correct diagnosis is a great place to start. In most cases, this can be done in the clinic by a physiotherapist or sports doctor without imaging, however, there are some circumstances where medical imaging may be warranted. Imaging is justified if treatment will differ depending on the diagnosis or if required to rule out another diagnosis.

 A sharp pain on a specific point at the back of the thigh whilst performing an activity such as running (usually sprinting), kicking or a rapid change of direction movement should create some suspicion of a hamstring strain/tear.

 2.      Age

Over the age of 23, hamstring injuries are more common. We call this a non-modifiable risk factor as it is something we can’t change, because we can’t turn back time! This means we just have to be more diligent with preventing and managing hamstring injuries after this age, particularly if there is a past history of hamstring injuries.

 3.      Previous history of hamstring injury

Unfortunately, once you have had a hamstring injury, you are more likely to suffer another one. This is likely to do with scar tissue (what replaces the injured muscle tissue) being weaker than the original muscle tissue. Like age, this is another non-modifiable risk factor.

 4.      Tendon involvement  

The tendons in the hamstrings are very long, and in some places they overlap the muscle (see image below of the back of the thigh). The significance of tendon involvement is that it receives less blood flow than muscle, leading to a slower healing process. Tendon involvement can significantly slow the athletes return to play or cause a re-tear of the hamstring if certain activities are commenced too soon. Hence it is important to return to sport confident that all the boxes have been ticked by your physio.

 5.     Exposure to High Speed Running

As with strengthening your muscles in the gym via resistance exercise, if you perform high speed running, this will improve the ability of the muscle to withstand the forces required for running. As sprinting is one of the most common ways to injure your hamstring, it should be approached in a calculated manner (not too many) but not avoided completely.

The exposure to high speed running on a regular basis (>90% efforts) was successful for Tom Trbojevic’s return in the 2021 NRL season after a series of hamstring injuries.

 6.     Eccentric Exercises

Eccentric exercises are where the muscle is working as it lengthens, compared to a concentric contraction, where the muscle is working as it shortens e.g. lifting the weight up to your shoulder during a bicep curl). When you are lowering the weight back down to your waist/side (starting position), that is the eccentric phase.

 The “leap” phase of running in the photo above, where the foot is advancing forward before impact is where the hamstring works most with sprinting. It works to decelerate the foot so that it doesn’t shoot out too far in front of you. This is where the hamstring is at its weakest and where we need to work on getting it stronger, it is an eccentric contraction as the hamstring is working but stretching at the same time.

 Much like exposing your hamstrings to high-speed running to make the muscles more adaptable and resilient, we need to strengthen it in a certain way to get the best results.

Exercises like the Nordic are popular in hamstring injury prevention, reducing injury rate by around 50%. https://www.youtube.com/watch?v=NfBGKhjedD8 It is quite a challenging exercise, and can lead to DOMs (delayed onset muscle soreness for a few days afterwards. It is advised that you perform this exercise with good supervision at least initially and a proper warm-up or build up beforehand. Modifications are often required due to its difficulty.

 It works the hamstrings eccentrically in the range of motion required to reduce the chance of muscle failure i.e. a muscle tear.

7.      Returning to sport when the hamstring stops being painful (too early!)

The absence of pain when walking or jogging is not enough when it comes to returning to sport. In fact, pain free jogging and walking is generally something achieved quite early in the rehab process for a hamstring injury, it is high-speed running and kicking which needs to be built back in.

It is heavily encouraged to have a tickbox approach to return to play with set criteria, this should involve at minimum the following steps:

-          Successful completion of high-speed running sessions

-          Successful completion of a training week at full intensity

 A physiotherapist will also use some of the following criteria to gauge readiness to return to training and sport:

-          Full pain free strength, comparable to the other side

-          No pain with stretching the muscle

-          Completion of agility, hopping and running tests

-          Other hamstring specific tests

-          No pain when pushing (palpation) over the area of the tear

 In Summary

Whilst hamstring muscle injuries are common and there are some risk factors that may be out of our hands (such as age and previous injury), it is important to have appropriate guidance with these injuries to rehabilitate them thoroughly and leave no stone unturned. Returning too early without completing adequate rehabilitation is something that is in our control.

 If you need assistance or guidance with a hamstring injury, or any other muscle tear, feel free to contact one of our Sports Physiotherapists.

Written by Matthew Anthis – Titled Sports and Exercise Physiotherapist and Hamstring Researcher

Imaging for Sports Injuries

Imaging is a commonly used tool in professional sport for Sports Injuries. It is also accessible to the general public for Sports and Musculoskeletal injuries.       

Imaging is used to get more information on an injury after an initial clinical assessment has been done by your Sports Physio or Doctor.

Common imaging options include X-Ray, MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) scans.

MRI Machine

What Is Imaging?

Medical imaging is most commonly done in private radiology clinics or within hospitals.

There are many different types of imaging that allow us to see our musculoskeletal anatomy that assist in an injury diagnosis.

This can be useful in many types of injuries, especially if injury diagnosis is unclear after standard clinical assessment.

Why Is Imaging Used?

Imaging can be used to give further information about an injury, or to confirm or exclude a diagnosis.

Imaging for sports injuries can give important information that directs the type of management and treatment of an injury. In all cases imaging results need to be interpreted by an experienced Sports Doctor or Sports Physiotherapist and used in conjunction with your clinical presentation and symptoms.

Types of Imaging

The most common types of imaging used for sports are;

X-Ray – This is the easiest, most affordable and most commonly used. X-rays give good information on bone injuries such as fractures, and also some information about joints and swelling eg. Knee Osteoarthritis.

Ankle fracture on X-Ray

MRI – Gives great information about soft tissue injuries such as muscle strains and ligament sprains. These scans can be very useful in assisting diagnosis and prognosis of injuries.

They also provide further insight into hard tissue such as cartilage and bone.

Knee MRI - Green arrows pointing to Meniscus cartilage tear

CT – Used for more detailed information on bone. Commonly used when an X-Ray provides a negative result but a fracture or bony injury is still suspected.

What Injuries Are Scans Useful For?

Scans can provide crucial information for both acute and longer-term chronic injuries. Some examples of these include hamstring and calf muscle strains, knee and ankle ligament sprains, eg. ACL/MCL, and for acute fractures.

Scans give information about grading of these injuries, which is important to decide how each injury is managed, including whether a rehab period is appropriate or referral to a specialist or surgery is needed.

MRI - Green line and surrounding white fluid indicating Hamstring Strain

Once you have had a scan it is important to consult with your Sports Physio or Sports Doctor to get an accurate assessment and diagnosis of your injury.

Written By Sports and Exercise Physio Chris Bailey

Gluteal Tendinopathy and Bursitis

A common cause of pain on the lateral (outer side) part of the hip is from tendinopathy of either the gluteus minimus and/or gluteus medius tendon.

What is the Cause?

Gluteal tendinopathy is often caused by a change in load of these tendons with a spike or change in activity levels, or from a new form of exercise. A baseline weakness of the attached glute muscles also contributes. This creates a higher demand than the tendon can tolerate, which can elicit a painful response and tendinopathy. This pain typically begins the day following exercise, and gradually worsens as you continue to move and exercise.

The large bursa (a fluid-filled sac – in the picture below) in the lateral hip is the greater trochanteric bursa. When the gluteal tendon becomes overloaded and painful, this often causes the bursa to also become inflamed and painful – called bursitis.

ANATOMY

The hip is a ball and socket joint. The ball arises at the top of the thigh bone, called the femur. The socket, called the acetabulum, is made of the three bones of the pelvis – the ilium, ischium and pubis.

The gluteus medius and gluteus minimus originate from the ilium of the pelvis and insert onto the greater tuberosity of the femur. As such, they are important abductors of the femur relative to the pelvis – meaning they take the leg away from the body. They also help to control the rotation of the hip joint and stabilise the hip when walking or running.

The greater trochanteric bursa is located between the femur and the gluteal tendons and functions to de-load the tendon friction over the bone. If this occurs excessively it can cause high levels of pain

How Does This Injury Present?

A patient will typically report their symptoms are felt at the start of exercise (e.g. the first 1km of a walk, or the first few steps after getting up from a chair), which then eases as you “warm-up”. Painful symptoms may then return toward the end of an exercise session as the body is fatiguing.

Patients may also report walking up and downstairs is painful, lying down directly on the affected side or crossing their legs also replicates pain.

This injury is far more common in women due to the differences in hip anatomy between men and women.

What is the treatment?

Like other tendinopathies, diagnosis and determining the type of tendon injury is crucial as early as you have symptoms. Offloading the tendon somewhat while maintaining physical activity is important if this can be done in a fashion that does not aggravate your lateral hip symptoms; either during, after or the following morning. 

Based on your examination, you will be provided with a small series of exercises to begin improving the strength tolerance of your affected tendons. Once symptoms are beginning to settle, your prescribed exercises will likely become progressively more difficult to facilitate the healing and strength of your tendon and musculotendon unit.

Tendon-based injuries may take an extended period to fully recover, this is in part due to the lower blood supply compared to other soft-tissues, but it is possible to return to your full levels of activity prior to full resolution of symptoms. Rehab timeframes are often months rather than weeks for full resolution of symptoms.

Imaging may be used to assist in the diagnosis and management of this injury if symptoms remain persistent.

If you are having any lateral hip pain, please feel free to contact one of our Sports Physiotherapists for assessment and establishing a management plan for your injury.

Written by Ed Gellert

The Sporting Shoulder - Atraumatic Injuries

Injuries to the shoulder can occur with or without an incident or trauma. For shoulder injuries that occur without a mechanism, pain is often felt locally around the shoulder or can refer pain down the outer aspect of the upper arm. Commonly the pain starts as a minor annoyance but gradually worsens. A physiotherapy appointment at the initial onset of the pain can help with an accurate diagnosis, leading to a quicker return to performance.

Shoulder Pain

The most common cause of shoulder pain without incident or trauma is an “overload” in your chosen sport (e.g. swimming). Often after a break from your sport, even for just a short period, a return to your previous training loads can be enough to cause an injury. Some common signs and symptoms to look out for regarding your shoulder pain include:

·       Pain reaching away from the body at shoulder height

·       Pain at the start and/or toward the end of your exercise session

·       Pain reaching across your body (e.g. when showering or pulling on your seatbelt)

·       Pain at night, often worse when lying on your affected shoulder

·       Feeling “tight” in the muscles above your shoulder

ANATOMY OF THE SHOULDER

The shoulder is a ball and socket joint, with a large ball called the humeral head (on the long arm bone) and a shallow socket called the glenoid (on the shoulder blade), which allows for the large freedom of movement of the shoulder.

The rotator cuff is a group of four muscles which originate from the shoulder blade and insert on the humeral head. These muscles are:

·       Supraspinatus - helps to take the arm out to the side of the body

·       Infraspinatus - helps to turn the arm outwards

·       Teres minor - aids infraspinatus

·       Subscapularis - helps to turn the arm inwards

Rotator Cuff Muscles

Each cuff muscle has an individual action, though as a group of muscles their primary role is to help stabilise the humeral head within the glenoid as we move to use our arm and shoulder.

Sitting in the subacromial space between the “roof” of the shoulder (the acromion of the shoulder blade) and top of the humeral head lives two fluid-filled sacs, called bursae. A bursa helps to cushion these bones, lubricate the joint and partially protect some of the rotator cuff tendons. The term “bursitis”, meaning inflammation of the bursa, is often associated with shoulder injuries and can be a source of significant shoulder pain.

COMMON DIAGNOSES

·       Rotator cuff tendinopathy and bursitis – refers to an overload of one or more of the rotator cuff tendons. This often leads to pain and the bursa becoming inflamed as a result of the altered function of the shoulder. 

·       Rotator cuff tear – more commonly associated with a trauma in younger athletes, however, an older athlete may have normal age-related changes of the rotator cuff tendons, including a small tear, which can be made symptomatic by an acute overload of the shoulder.

·       Sub-Acromial Impingement – this occurs when your shoulder muscles are not strong enough to support your ball (humeral head) in your socket (glenoid) which causes increased movement in the shoulder space and compression and pain of those soft tissue structures that live there. This is particularly common in sports such as swimming and tennis with repetitive overhead use, or jobs with repetitive activities.

·       Frozen shoulder – presents in its early stages similar to a rotator cuff tendinopathy and bursitis, though is unresponsive to therapy. Please speak to your GP or physiotherapist if you feel you may have a frozen shoulder.

TREATMENT OF THE SPORTING SHOULDER

Treatment is determined by your presentation at initial physiotherapy examination. Often when a shoulder is overloaded, the load needs to be managed appropriately to allow symptoms and structures to settle. This then allows for a faster and more successful return to performance.

The four common stages for shoulder specific treatment are:

1. Control (Acute) phase – regaining neuromuscular control of the scapular and rotator cuff muscles with pain and inflammation symptom management as required.

2. Load introduction phase – strength-based exercises targeting muscles and actions specific to your sport.

3. Reconditioning phase – progressing your individualised gym strength program and building to reintroduction into your sport at reduced loads.

4. Return to performance phase – getting back to your chosen sport or activity to a pre injury level, while maintaining your strength rehab work to prevent an injury recurrence.

Shoulder Rehab

If you are experiencing any shoulder pain, please feel free to contact one of our Sports Physiotherapists for assessment and management of your injury.

Written by Edward Gellert – HPRS Physiotherapist

Calf Muscle Injuries and What To Do?

Pain felt in the calf is often the result of a strained or “pulled” calf muscle. With a specific incident, these can be occasionally confused with an Achilles Tendon rupture as you may feel a “pop” or as if you’ve been hit in the back of the leg. Typically, the incident causes sharp pain in the calf which progressively increases over time.

Typical symptoms are:

·      Unable to walk

·      Bruising in the back of the calf

·      Inability to rise onto tiptoe

What Causes a Calf Muscle Tear?

Generally, these injuries happen at steady state running or when accelerating. The most commonly torn calf muscles are your medial gastrocnemius as it crosses over both the knee and ankle joint, and your deeper soleus muscle as it plays a large role in running.

Calf Anatomy

The calf is composed of 3 muscles:

·      Gastrocnemius – comprised of medial head which has more faster twitch muscle fibres and the lateral head.

·      Soleus – lies deep to the gastrocnemius and the largest of the 3 muscles. This muscle takes up to 8 x body weight load when running (compared to x 2 times in other muscels) which significantly increases it’s risk of injury in running activities .

·      Plantaris – located in posterosuperficial compartment of the calf and isn’t a prime mover but acts with gastrocnemius as a knee flexor and ankle plantarflexor

All 3 of these muscles form together to attach into the Achilles Tendon and attach on the calcaneal bone (heel).

Calf Injury Classification

Grade 1

·      This is a mild strain involving partial tearing of a small amount of muscle fibres. Symptoms can vary from being able to continue playing to acute sharp pain at the moment of injury and pain on walking. They do however recover quickly and often returning to sport within 3 weeks.

Grade 2

·      Occurs with a greater degree of partial tearing of calf muscle fibres or a partial calf tendon tear. Players are usually unable to continue playing, although some describe a strong cramping sensation in a particular location of their calf. Return to running loads and sport specific training should be guided by your Sports Physio to prevent a further tear which unfortunately can be common in moderate calf tears.

Grade 3

·      This is the most severe calf strain causing a complete tear or rupture of your muscle fibres or tendon. These injuries require an extended rehab period prior to return to sport and this time frame will be affected by which muscle or tendon unit is involved. In a grade 3 tear it’s important to clear if there has been an Achilles Tendon rupture. If this is the case recovering can be upwards of 6 months.

Management of Calf Injuries

Whilst management depends upon the severity of injury the first step is to get an accurate diagnosis of degree of injury from your Sports Physio or Sports Doctor and work on a management plan. Appropriate rehabilitation is required for these to ensure they recover and are safe to return to sport, and avoid a risk of re-injury.

Early Protection Phase – Like most muscle injuries the initial management is to follow RICER principles to reduce the load and protect the local area. Along with this it is important to regain range of motion of the ankle and reintroduce correct walking patterns.

Introductory Loading Phase – Begin to strengthen the calf complex and lower body strength. If necessary these may begin non-weightbearing and then progressively increase to resistance exercises. Low level running can be introduced here.

Transition Phase – Progress to power and plyometric exercises such as sled push (or prowler - see picture below) along with sport specific skills and training as appropriate.

Return to Perform – As mentioned above it’s important to ensure that the calf is able to withstand high loads relevant to the sport and thus the final step is to work on the higher level plyometrics such as repeated jumping and sprinting.

If you have a calf injury or are having recurrent issues then please get in contact with one of our Sports Physiotherapists to assess and design a program suited to your needs.

Written by Simon Wybenga - HPRSP Physiotherapist