Christina and Tamara traveled to Edmonton last weekend to attend a course put on by BikeFit Physio. The course was taught by Murray Tough, a physiotherapist and entrepreneur in the cycling industry. This seminar was both practical and interesting. Immediately, I felt able to offer more effective treatment to cyclists/triathletes who have a complaint that is related to the time they spend cycling. One of the best take-home messages I learned is that aches and pains experienced with cycling are usually correctable with making some adjustments to the set up of one’s bicycle. I also learned that bike fitting is an ongoing process because as a rider’s fitness level, age, and goals evolve, so should their positioning on the bike. Finally, optimal positioning on the bike leads to improved performance. For those of you interested in the course, you can go to http://www.bikefitphysio.com.
The wrist (carpus) is composed of 8 bones (carpals). All of these bones are vulnerable to injury following direct trauma. The scaphoid however, is the most commonly injured bone of the carpals, accounting for 60-70% of all carpal fractures. It is most commonly injured with a fall on an outstretched arm. In many sports such as rollerblading, skating, snowboarding, mountain biking and skiing this is a common mechanism of injury. In addition, the scaphoid may face complications during healing due to its unique anatomy.
The scaphoid is located on the thumb (lateral) side of the wrist and functions to link the radius of the forearm with the thumb, index and ring fingers of the hand. The scaphoid is bound to the radius and 4 other wrist bones by a complex ligament system. It functions in all movements of the wrist and is most vulnerable in a position of wrist extension (as in pushing up from a chair). The scaphoid is particularly involved with movements of the thumb and index fingers, which are essential for gripping activities and fine motor control. The scaphoid receives its blood supply from the radial artery. Unlike most bones, the scaphoid receives its oxygenated blood from its distal (furthest) end. The blood then must travel backwards to supply the proximal (nearest) end of the bone. It is this unique blood supply that often makes healing of scaphoid fractures difficult.
When wrist extension is combined with a fall onto the hand, or direct trauma to the wrist/scaphoid, ligament sprains or wrist fractures can occur. If the scaphoid is fractured, early detection and monitoring is essential to proper healing. These fractures can be diagnosed by wrist x-ray. Conventional wrist x-rays may not show a fracture, and therefore it may be necessary for specific x-rays of the scaphoid at various angles. Occasionally these fractures may still be missed, and follow-up x-rays are sometimes required if healing doesn’t proceed as expected. Alternatively, further examinations such as bone scan, CT scan or MRI may be used. If the fracture fails to unite, the blood supply to the proximal end of the bone may be compromised. This can result in decay of the bone from lack of oxygenation and mineralization, a condition known as avascular necrosis. Factors that may indicate a poor prognosis include late diagnosis, location and displacement of the fracture.
Treatment depends on the extent of the injury. If the scaphoid is fractured, the management will be more conservative than if the wrist is sprained. For fractures, the treatment is dependent on the type and extent of fracture.
Undisplaced, Stable Scaphoid Fractures
This means the broken parts of the bone are in close proximity to each other, and there is no movement of the bony ends. Prognosis is excellent in these cases. The thumb and wrist will be immobilized for a period of 4-6 weeks, typically with a wrist and thumb splint. X-rays are taken at 6 weeks, and if union is delayed, continued immobilization will be necessary.
Displaced, Unstable Fractures
This means the broken ends of the bone are not in even contact with each other and may be free to move around. The bones may need to be “repositioned” by an orthopaedic specialist and then immobilized through splinting and/or casting. In these cases, surgical intervention may be warranted.
In any case, if healing is delayed and the fractured ends do not unite, surgical intervention may still be necessary.
Non-Union of Scaphoid Fractures
Influenced by delayed diagnosis, severe displacement/dislocation, more proximal fractures (impaired blood supply), and associated carpus injuries. Many non-unions display minimal symptoms and can be tolerated well in the low demand wrist (older age, sedentary lifestyle.) Degenerative arthritic changes are probably inevitable, but may not occur for years.
Salvage procedures are generally reserved for painful non-unions. These include excision of small fragments, styloidectomy (more commonly used as a source for bone graft and to improve exposure), interposition of a dorsal soft tissue flap to create a painless pseudoarthrosis (Bentzon’s Procedure), vascularized radial graft, proximal row carpectomy, silicone implant arthroplasty, and partial or total arthrodesis of the wrist
2009 marked the first year that Trailside Physio was involved with Suburban Rush, a 30km off-road adventure race held in Port Moody, BC. The race requires participants to complete sections of trail running and mountain biking, along with mystery challenges.
In their inaugural year of participation, Team Trailside had four participants and three therapists working on racers following the event. The team members that participated in the race had a blast pushing themselves to the limits of their ability, and the therapists treating the racers following the event enjoyed helping them through the cramps and injuries accumulated along the way.
Suburban Rush has now completed its 10th and final year. Congratulations to race organizers for 10 successful years or putting on a great race!
The term golfer’s elbow refers to pain occurring over the inner (medial) aspect of the elbow. The injury is not exclusive to golfers, and is actually referred to clinically as medial epicondylitis. It is associated with inflammation in the tendons of the muscles involved in flexing the wrist and fingers. Pain is generally felt at, or near the bony prominence on the inner aspect of the elbow (medial epicondyle). Symptoms are often aggravated by gripping activities and by wrist flexion. The problem is caused in golfers by repeated or sudden club-face contact with the ground prior to striking the ball. The result is microtears and ensuing inflammation in the muscles and/or tendons involved in flexing the wrist and fingers.
Golfer’s elbow may be caused through repetitive use/trauma, or by a single episode of overloading the muscles and tendons affected. Examples of repetitive activities that could lead to problems include gripping, hammering, driving screws, playing certain musical instruments, canoeing, weight lifting, digging, and of course golf or other sports activities.
An acute strain of the muscles may be caused by lifting or pulling heavy weight, sudden forceful gripping, or large eccentric1 loads place on the muscles involved.
Someone may be predisposed to Golfer’s elbow if they have a job or regular activity that involves repeated use of the flexor muscles. Furthermore, neck and shoulder problems can often be associated with pain at the elbow. These areas often refer pain to the elbow, or cause elevated tone in the flexor muscles which may predispose someone to this injury.
As with Tennis Elbow, ergonomics play a role in preventing and minimizing the effects of Golfer’s Elbow. A poor work station set-up at a computer, poorly designed tools, or awkward lifting positions can be a recipe for injury.
Like Tennis Elbow, the best way to deal with Golfer’s Elbow is to not get it in the first place. At the first signs of pain or tightness on the medial side of the elbow, take steps to eliminate the causative factors. Here are some tips for preventing Golfer’s Elbow:
- Minimize repetitious activities. If this is not possible, get advice from a physiotherapist on ergonomic adjustments that can be made.
- If the problem is from golfing, consult your local golf pro to make the necessary changes which will prevent a reoccurrence in the future.
- Make adjustments to equipment to suit the size of your hands. Grips that are too large or too small can cause increased load on the tendons of the flexor muscles.
- As with Tennis Elbow, grip less tightly. A lighter grip often improves your “touch” and can ease strain on forearm muscles.
- An armband (as prescribed by your doctor or physiotherapist) can prevent recurrences of Golfer’s Elbow.
- Immediate treatment of pain or injury is the most effective way of preventing a problem from escalating into a long-term injury.
Initially, as per the R.I.C.E. guidelines, apply ice (not directly to the skin; use a towel for seperation) to the affected area for 10-15 minutes. Rest and compression may also help to relieve the pain from the injury. Examination by a physiotherapist may help to determine the specific cause and biomechanics of the injury. This information is important so the appropriate structures and movement patterns can be targeted for therapy.
Gentle stretching may begin almost immediately, but care must be taken not to aggravate the injury by stretching to aggressively. Often, the best stretch for Golfer’s Elbow involves straightening the elbow (elbow extension) and bending the wrist backwards (wrist extension).
Depending on the extent of the injury, your physiotherapist may decide to implement various treatment options, including both manual techniques and the appropriate physical modalities. Manual therapy may involve passive exercise, soft tissue manipulation or massage. In most cases, the modality used to deal with inflammation in the tendon is ultrasound, however other electrotherapy choices may be appropriate.
Once the initial healing phase has completed, muscle strengthening should begin to prevent recurrence of this injury. If this takes place too soon it will actually further the injury.
Lastly, your physiotherapist may discuss other options such as bracing or taping during the course of the injury, and should most definitely answer any questions you may have.
All of the previously mentioned tips for prevention of Golfer’s Elbow are equally as important when treating the injury. The only question is the degree to which one must change their activities, which depends on the nature and severity of the injury. Your physiotherapist should look at all aspects of the injury, beyond simply treating the symptoms.
Your physician may prescribe some anti-inflammatory medication, as well as provide some other options for treatment.
What should I drink and when?
Before answering this question lets take a look at the functions of each of these thirst quenchers. Water is the most essential ingredient to a healthy life. Important functions of water include: Transportation of nutrients and elimination of waste products, lubricating joints and tissues, temperature regulation through sweating, and facilitating digestion. Sports drinks contain salts and sugar, thus, they have the added benefit of replacing sodium, potassium, and other electrolytes lost through perspiration. For most people who work out at a moderate intensity for less than 60 minutes, water is adequate to replace lost fluids as it moves quickly from the stomach to the bloodstream. For athletes who work out for 60 minutes at high intensity or greater than 90 minutes at moderate intensity, sports drinks are a better choice to help replenish those lost solutes. Drinking water before working out is recommended. However before you go and drink large quantities of water prior to exercise it is important to note that firstly, fit humans can tolerate significant fluid loss before their performance suffers. Secondly, most cases of muscle cramps are not caused by dehydration or salt loss, they are caused by muscle damage and should be treated by stopping the exercise and stretching the cramped muscle. Thirdly, although rare, overhydration can occur, causing fluid to move from your bloodstream into your brain. This condition, termed hyponatremia, increases the pressure in your brain and can result in seizures and unconsciousness. It is recommended that the moderate athlete drink no more than 3.5 cups of water or sports drink prior to exercise.
Should I stretch during exercise?
A common question I hear is whether or not to stretch with exercise. With respect to athletics, research studies have found little evidence to support the idea that stretching actually prevents athletic injuries. Also, muscle tears result when the force imposed on them is greater than their strength, therefore, strengthening the muscle is a much better way of preventing muscle tear injuries. But before you decide to cut stretching from your regular exercise activities consider this. A survey of high school coaches in Michigan showed that almost all of them stretch their athletes for an average of 13 minutes before a practice or competition. Close to 95 percent of these coaches believed that stretching helps to prevent injuries, and nearly 73 percent felt that there were no drawbacks to stretching. Additionally, stretching has been shown to increase range of motion by elongating muscles and tendons. This results in a greater torque at the joint allowing the athlete to throw further, jump higher, and lift heavier. It is important to note that muscles should not be stretched cold, so if you choose to stretch make sure to perform a brief warm-up of at least 5 minutes duration beforehand. Studies support the use of thirty second stretches, after warming up, to help increase range of motion.