The Two Options You Have When You Are Injured…

Person: “Doctor, my back started to hurt this earlier this week, and hasn’t gotten better. It hurts every time I bend forward.”

Doctor: “Ok, stop bending forward then. I want you to take the next few days off and just relax at home.”

Hmm… that IS one way to go about it. But what if there is a better way? What do you think the downside is of stopping your activities?

When you are injured, the activities you were doing before can be painful, whether it is deadlifting or washing the dishes doesn’t really matter.

To manage your injury, you essentially have two options….

Option 1: Decrease your activity level

The idea here is that you decrease your activities to a level that doesn’t cause pain.

This is a viable option for some injuries, but it is never a permanent solution. If you decrease your activity too much for too long, you will end up deconditioned, and then you live in a feedback loop where you keep getting worse… Just like this picture:

I recommend that MOST of my patients decrease their stressors for a period of time (but this is only for a few days). Then we get into Option 2…

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Option 2: increase your capacity

With this strategy, you work to increase your strength, endurance, and recovery to improve your overall capacity to a level that can handle the stresses of your activity.

Personally, Option 2 sounds like a better solution to me.

The more we can increase your capacity, the larger buffer you have between your demands and your threshold.

In order to use Option 2 though, you need to have a plan. We need a structured, progressive and intentional exercise plan in order to build up this buffer. It can’t be done in a day, and it doesn’t work to just use random exercises with no intention.

Option 2 is a 3 step process.

Step 1: Calm Stuff Down

This often still consists of a period of decreased activity, but it is NOT a permanent strategy. It is only long enough to give us a window to build upon. We also use things like stretching, foam rolling, mobilization, and hands-on therapy during this phase to decrease your pain.

Step 2: Build Back Up

During this phase, the focus is on building strength and endurance around the body parts and systems involved in your activity. This means strength and mobility exercises, with less emphasis on mobility or hands-on treatment.

Step 3: Bridge the Gap

This is the fun part. After your symptoms are under control, we start to work on speed, strength and re-integrating your favourite activities. You like to run? Your rehab plan involved running. You like to ski? Yup, that’s part of the plan. Mountain Biking? You bet we include that.

Here are a couple of the components of Bridging the Gap:

Movement Quality and Capacity: how well do you move in relation to your sport/activity, and do you have enough range of motion for your task

Sport/Activity Specific Cardiovascular and Muscular Endurance: even though you are out of pain doing a simple single-leg squat in the clinic, doesn’t mean you maintain that same quality when you are out of breath

Rate of Force Development: can you generate force quickly enough, as you need it, during your activity?

Recovery: making sure you have the strategies and skills in place you need to recover from the demands of your activity.

This is also one of the most IMPORTANT parts. If all you do is get out of pain, but you don’t continue to improve your movement quality, recovery strategies, and overall capacity, it is extremely common to start sliding backwards, right back to where you started.

The reason I use this framework is that it is not only the most effective method that I have found, it also helps YOU develop the tools you need to keep your pain from coming back.

If you are ready to take control of your pain and get back to doing the things you love, I can help you.

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Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Chiropractic and Sports Rehab in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Dealing with a new knee injury

The first thing I recommend doing if you think you have injured your knee is to get a proper assessment. I can help you if you are looking for a sports medicine oriented chiropractor or physiotherapist in Vernon, BC.

Sometimes, though, getting in to see someone you trust can be a challenge. Your chiro doesn’t have an opening, your physio is off, or your athletic trainer is busy. It is helpful to have some strategies to manage your knee injury in the meantime.

IMPORTANT NOTE:

If you have severe swelling, heard a pop/snap followed immediately by pain, or you have any reason to suspect it is fractured, you need to get an x-ray as soon as possible. Visit your local emergency room or urgent clinic.

ACUTE knee pain just means that you had a recent injury that might be responsible for your pain. A slip and twist, or a fall and catching yourself. Even just a long day of skiing or hiking hard can lead to an incident of acute knee pain.

When a patient comes to me with acute knee pain, we have 3 goals:

1. Limit or reduce swelling

2. Maintain active range of motion

3. Preserve muscle mass and strength, especially in the quads (front of the thigh)

Managing Swelling

Swelling leads to pain and stiffness, which usually leads to inactivity, which always leads to loss of muscle mass and strength. So in essence, managing swelling is already starting to accomplish the other two goals.

Here is how we manage swelling with acute knee pain:

• Keep the joint in motion as often as possible within pain-free (or manageable pain) range of motion. Keeping the ankle and hip moving is also helpful in pumping out swelling.

• Elevation to take advantage of gravity to clear swelling

• Compression to increase clearing of fluid and limit swelling

VIDEOS: 

Maintaining Range of Motion

Motion is the lotion. You don’t use it, you lose it. Same same. We want to keep moving as much as possible, within reason, immediately following injury. That might mean you are literally moving your knee joint 5 degrees, or your knee doesn’t even move but you are pumping your ankle through range of motion. Do as much as you can within PAIN-FREE RANGE (or at least tolerable pain). 

Here are the exercises I recommend to my patients to maintain range of motion:

1. Quad Sets

2. Passive Range of Motion

Maintaining Strength and Muscle Mass

The key to maintaining muscle mass after an injury is: movement and nutrition. If left immobilized, the leg muscles can atrophy (i.e. shrink) by ~5% in a single week. Atrophy tends to slow over time (since there is less muscle to waste away), but it is not uncommon to have upwards of 15% muscle loss in a month of mobilization. That is a big deal.

Here are the first things we do to prevent as much muscle mass and strength loss as possible:

1. Nutrition:

   1. Immediately increase protein consumption. Your body NEEDS protein to heal your injuries, and even though your activity level may decrease, your protein needs often INCREASE

   2. Avoid highly inflammatory foods whenever possible (even though I know how tempting it is to finish that pint of ice cream to cope with the frustration)

2. Isometrics or low-load movements - keep the injured joint moving as often as possible with as much stress as you can handle.

   1. Isometrics: activates the muscle without moving the joint through range of motion, and is often tolerable even when in a lot of pain

   2. End range limited range of motion exercises like Quad sets

   3. Contralateral leg training: i.e. exercising with the OPPOSITE limb can actually maintain both muscle mass and strength (pretty cool, eh?)

Exercise for Acute Knee Pain:

Not sure where to start?

That is where a qualified Chiropractor or Physiotherapist in Vernon, BC can help. A good Chiro or Physio will put you through a thorough assessment and help identify the extent of your injury and your pain triggers. Then, they will help you put together a rehab plan to get you back in action.

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Book an Appointment with Dr Murdoch: book here

Instagram: Base.Camp.Doc

Skiing and ACL Injuries - part 1

ACL Injuries are the most common injury that put alpine skiers in the hospital. They can be life-changing, they’re brutal to rehab and can truly be a depressing and career-ending injury.

In this article, we are going to cover:

• What is an ACL injury?

• How do ACL injuries happen?

  • How do I know if I have an ACL injury?

• Why are they so common in downhill skiing?

In Part 2, we will cover:

• What to do if you think you have an ACL injury

  • How do I know I have an ACL injury?

  • Do I need surgery to fix my ACL?

  • Will I have knee pain forever after hurting my ACL?

  • Can I still ski after I tear my ACL?

In part 3, we will cover:

• How to prevent alpine skiing ACL injuries

• Training in preparation for the ski season

• Training during the ski season

What is an ACL, anyways?

The ACL is shorthand for the Anterior Cruciate Ligament. Ligaments attach bones to each other and limit unwanted movement. The ACL is one of the most important ligaments that stabilize your knee, attaching your shin bone (tibia) to your thigh bone (femur). The primary job of the ACL is to prevent anterior translation of the tibia on the femur. (Huh?) In other words, it keeps your shin bone from moving forward underneath your thigh bone. (Fun fact: ligaments also help us with our ‘joint position sense’, also known as proprioception).

The ligaments are what are known as ‘passive stabilizers’ of your joints. They don’t actively contract or control movement like your muscles do. Instead, they pretty much work just by being there and waiting until they’re needed (at least when it comes to joint stability).

Most of the time, our ligaments are some of the most reliable structures in the body. They save us from ourselves all the time and keep us moving!

When they are injured though, they like to let us know about it.

What does it mean if the ACL is injured?

Ligament injuries are known as SPRAINS and come in levels, known as ‘GRADES’, each more severe than the one before.

GRADE 1 SPRAIN: some mild stress on the ligament causing irritation.

• This level of injury is almost never diagnosed in the ACL. This is because the ACL is so strong that most of the time it can handle the twists and stresses we through at it.

• The most common ligament to be sprained is the ATFL (anterior talofibular ligament) aka an Ankle Sprain

• Not usually associated with swelling or bruising

• Despite the lack of ligament damage, this injury can be extremely painful and still requires proper rehab

GRADE 2 SprAIN: some stretching and possible tearing of the ligament

• ACL injuries usually fall somewhere between Grade 2 and 3. This is because Grade 2 is very broad, and covers everything from mild tearing up to just shy of complete tearing

• Often extremely painful

• Associated with joint swelling, bruising and range of motion limitations

GRADE 3 SPRAIN: complete tearing/rupturing of the ligament.

• ACL ruptures are the most common reason a skier will end up in the hospital

• Grade 3 Sprains are often accompanied by severe swelling and bruising

• Surprisingly, a full ACL tear is not always associated with extreme pain, at least not immediately. This is because the nerves that sense pain are also ruptured, so the knee can no longer send the pain messages back to the brain. The pain usually takes anywhere from minutes to hours to develop, and in some cases, never truly comes.

Complications: it is important to note that a severe ACL injury is often accompanied by damage to other structures in the knee. The most common grouping is known as the ‘terrible triad’ and includes the ACL, MCL (medial collateral ligament), and the medial meniscus.

How do ACL injuries happen?

Injuries happen when the forces applied exceed the body’s ability to resist them. In the case of a ligament, those injuries typically have specific patterns. We typically see ACL injuries with either a straight leg landing (for example landing a jump with stiff knees while in the backseat on your skis) or with a paired twisting and forward force (like trying to get up on your skis, but catching the tail end and torquing your knee).

Here is an example of pro skier Landon Gardner (Team USA) tearing his ACL landing a freestyle jump in 2009: https://www.youtube.com/watch?v=XguonAtk3C8&ab_channel=LandonGardner (while this is not a graphic video, it might not be the most pleasant to watch).

For skiing specifically, there are two primary injury mechanisms:

1. The Phantom Foot mechanism

2. The Boot-induced mechanism

1) The Phanton Foot mechanism happens when a skier is either trying to get up from a seated position, or they are off-balanced and fall backwards. Often the skier will place all of their weight on a single leg with weight on the inside edge of their downhill leg. The other ski basically either floats in the air or (worse) catches the ground, but the downhill leg keeps going. The ACL is unable to manage the force and snaps under the tension.

2) The Boot-induced mechanism happens when a skier is again off balance when landing with their legs straight. The landing forces the shinbone up and forward relative to the thigh bone and again overloads the ACL.

Ski-Knee.com has some great graphics on these mechanisms:

http://www.ski-knee.com/causes 

Why are ACL injuries so common with skiing?

There are many reasons why injuries happen.

In the case of skiing, the forces, the gear, and the terrain are have a large impact on the nature of the injury.

THE GEAR:

Most gear advancements have decreased skiing injuries. Improvements in ski, boot, and helmet technology have all decreased injury rates since skiing inception. However, better gear also means fast skiers and faster skiers means higher forces… which we already know is a risk for more serious injury.

Skis themselves also change the way our legs function. They limit our rotational movement through the hips (because your can’t exactly twist your skis in any direction without consequences) and essentially eliminate motion in the ankle. When we cannot perform rotation in the hips, and can’t use our ankles in rull range of motion, the only joint left to take responsibility is the knee. The knee is what is known as a hinge joint. It is great at bending forward and back. It is not so great at rotation or side bending (the two primary forces involved in ACL tears).

THE FORCES:

Any time we add in a tool, we increase the amount of force we dealing with. Try throwing a hockey puck as hard as you can slap shot it. Not going to happen. Any time we add in a form of transportation that lets us move faster than we can run (skis, bikes, skates, cars) we start exposing ourselves to forces and speeds that are much more dangerous than we can typically produce with our own power.

This is one of the reasons why skiing injuries can be so devastating. When you are moving at higher speeds, even a small mistake can lead to some pretty frustrating consequences.

THE TERRAIN:

Skiers encounter all sorts of terrain and snow conditions. The nature of the sport takes advantage of gravity while sliding along on a slippery surface. Gravity tends not to care if you are ready for it or not, so often ACL injuries involve unprepared landing or falls.

Snow conditions can also be a fracture, when one ski hits a patch of wet and heavy snow, causing it to trail behind, and putting some crazy forces through the knee.

At the end of the day, the last thing I want you to be thinking about is your ACL. Instead, I want you to be recounting the best stories from the day with your buddy over a beer or a good whiskey. The last thing I want is for you to be scrambling to make an appointment with me on Monday morning. If you DO think you have an ACL injury… well that is what Part 2 is for. (Stay tuned).

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Disclaimer: This blog is intended for general informational purposes only and is not intended for the delivery of medical advice. No doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog and website is not intended to be a substitute for medical advice.