I started running two and a half years ago and took it upon myself to make the Queenstown marathon my first race. Needless to say, starting from scratch and building up to 42km over five months with very little regard for rest and recovery led to injury. My first marathon was hindered by ITB syndrome and, unfortunately, I fractured my knee skiing prior to my second attempt a year later. I managed to complete the second attempt with 10 weeks of training, but it left me nursing a bone stress injury in my tibia for a year afterwards. I have certainly learnt the hard way about injury prevention in running and now feel passionate about sharing my learnings with patients.

One of the most frequent causes of injury we see in the clinic is athletes training at a level that their body is not conditioned for. For example, tendinopathies, patellofemoral pain, muscle strains and muscle tightness can all come about from placing a demand on the body which exceeds the supply. In addition, we often see athletes focusing on certain areas and neglecting others, and we have done this historically as physiotherapists too. For example, you may have frequently heard about your glute weakness and the impact this has on your alignment but, when it comes to running, is this the most important area to focus on? 

Luckily, we have ever-emerging biomechanical research to improve the quality of our treatment. When it comes to running, studies have indicated that we may need to look further down the chain with running rehabilitation. In a study by Dorn et al. (2012) it was found that, at slower running speeds, the soleus muscle in the calf complex takes on the biggest role in running mechanics. This is followed by the hip flexors, quadriceps, and hamstrings. As running speed increases, so do the roles of the hamstrings and quadriceps, and these muscle groups take over the soleus at high speeds. This gives us important insight into the areas we should be assessing for athletes with running injuries and helps to guide prevention of further injuries in the future.

The other problem we often come across in the clinic is insufficient rehabilitation. Muscles and tendons are built for multiple functions, such as producing peak force, deceleration and energy storage, and reproducing force rapidly. It is important that rehabilitation covers all these roles, not just strength training in isolation, to restore the muscle to its full function. Body-weight squats to improve strength just won’t cut it when the muscles are required to store and rapidly reproduce force thousands of times during a 5km run. 

The final area of running rehabilitation I am passionate about is injury prevention. As a physiotherapist we often assess a problem when the damage has already been done. Telling an athlete that they won’t be running the marathon they have been training for over the past six months is not the ideal situation. Most runners are heavily invested in their training and performance and will do whatever it takes to keep running. I find that the problem is very rarely a lack of willingness to train, but rather a lack of insight into what to train and how. This is where we come in.

At Bureta Physio and Wellness we are incredibly lucky to have the AxIT system for objective testing for our athletes. This system provides us with valuable data on a variety of muscle functions, such as peak force, rate of force development and reactive strength index. The system uses force plates to gather the data, ensuring it is objective and reproducible. It also compares the results to the normative range for body weight and gender providing us with clear and realistic benchmarks. We can measure the key muscle groups involved in running, repeat this reliably over time, and ensure current function is at an appropriate baseline compared to the normal population. 

If you are a runner, whether you are doing a couch to 5km, compete in the 100m sprint distance or take part in ultra-marathons, the AxIT system provides a great opportunity to make sure your body is conditioned for the demands of your training. We can utilise the system for injury prevention, for rehabilitation, and for delving deeper into those runners who have had a litany of injuries over the years. We also combine AxIT testing with a running gait analysis to determine both isolated issues, how they play out functionally and whether gait retraining needs to form part the rehab program. 

The AxIT session involves a 60-minute appointment to talk through training and injury history and to complete testing. Time is then taken for the therapist to analyse the results and send a summary report. A follow up appointment is then made to discuss results and run through programme issues, and this is included in the price of the initial appointment. Further follow ups can be booked to progress through a physiotherapy program as required.

If I had the chance to go back and use AxIT back when I returned to running, I would have jumped at it. As with all runners, I would have loved to avoid those weeks of rest, knowing I was losing fitness, missing out on races and undoing all the hard work. Just as you would get a warrant of fitness for your car, the AxIT system can be used as a warrant of fitness for your health to ensure your body is fit for purpose and ready to cope with whatever you need it for, whether simply to get fit and healthy or to achieve your goal of completing your ideal race. 

To avoid making the mistakes of me and many other runners, call the clinic on 07 576 1860 to book in for an initial assessment today! 

Pre-season can be the most dreaded period for any profession or amateur athlete alike. With some sports seasons now getting longer and longer, people are keen to make the most of their off-season and sometimes “enjoy” themselves too much or really just do nothing in their off-season.

As a physio, pre-season is the time we see people picking up little niggles and injuries that could have been prevented. Worse still, sometimes, if not managed well these injuries last well into or through a season. Pre-season really can be a make or break time.

Common things I see are:

• Tendonosis
• Aching joints
• Muscle sprains

These all seem to happen due to one thing, poor preparation.

In professional sport I check athletes each season, to review where there may be weaknesses and what that individual needs to work on to prevent injury through the season, where possible. The reason this is important is that if one body area is much stronger or more mobile than the other, it can cause overuse of that area and possibly an injury down the line.

Another thing I do is look at training loads, because the body can only tolerate small increases in training over a short period of time, before it starts to get sore and break down.

Some things to consider doing in your off-season before returning to training:

• Have an off-season plan that helps maintain specific strength and fitness but still allows you time away to recover and relax
• Know your strengths and weaknesses and what you need to focus on in the season ahead

With this in mind, why not book in for a full strength review using our AxIT system or to have a plan in place before you pick up any niggles.

To book an AxIT session with Jamie click here 

Physical preparation:

Why is this important?

• Training for more than 80% of your scheduled training time increases the ability for you to reach your performance goals.
• Physical preparation provides an opportunity to bulletproof athletes through key work-on’s and the ability to identify areas that will help to reduce injury risk.

What is physical preparation?

• Physical preparation is preparing you through training prior to competition by incorporating generic and individualised programming into your routine such as warm up or pre gym activation that influences injury risk and the burden to the athlete due to injury.

Recovery:

Why is it important?

• Good recovery ensures athletes are physically, physiologically and psychologically prepared for all training sessions and competitions.

What is recovery?

Recovery incorporates many different components including;

SLEEP – Studies have shown athletes are likely to have reduced or poor quality sleep due to training schedules. Both sleep quality and quantity impact upon performance. For tips on sleep hygiene have a read of our sleep hygiene blog here.

NUTRITION – Eating the right food at the right time consistently.

Recovery is AWESOME!

Active recovery: After games and trainings, do a low intensity warm down e.g. low intensity swim for 15mins.

Water/fluids: Remember to hydrate.

Eat: The right food at the right time. Refer to a nutrition plan from a performance nutritionist.

Skins/compression: Post competition, you can wear for up to 15 hours following.

Overnight/sleep: Sleep as much as you can! Extending sleep has been shown to positively impact performance. See our blog on sleep hygiene for a better night sleep.

Massage + option of ice baths post competition: Ice baths should be 2 x 5mins with 2 min break in between.

Exercise: Training block within competition season including our physical preparation!

There are many ways simple exercises can be incorporated into your current training program to reduce the risk factors associated with each individuals chosen sport. 

If you are wanting to learn more about ways to enhance your performance please get in touch with us via email reception@buretaphysio.co.nz or call 07 576 1860.

I have seen a few Achilles Tendon (AT) ruptures over the last few months, so I decided to write a blog about this injury. I hope it guides patients that have experienced this type of injury and explains how to reduce the risk of recurrence or reinjury if you have already suffered from an Achilles rupture.

Those that have experienced a rupture can confirm it is a long recovery process that can range anywhere between 6-12 months post rupture. The most common mechanism of injury in both the sporting and non-sporting environments are eccentric contraction of the calf muscle group (calf is on stretch as the heel hits the ground) and when the trunk of a person's body is opposite to the direction in which the person's foot is planted, e.g. when they change direction suddenly.

The Achilles tendon anatomy and Risks for Achilles rupture

A: Muscle tendon Junction (MDT): where the calf attaches to the tendon

B: Mid portion (the middle part of the tendon)

C: Insertional (part of the tendon that inserts onto the heel bone)

Achilles Tendon (AT) ruptures commonly occur in the active individual with underlying Achilles tendinopathy that they were unaware of (2/3 of people had no experience of pain prior to the rupture). Patients will commonly report they heard or felt a pop at the ankle when ruptured but this symptom is not always reported. Many described this as "feeling as though they were shot from behind". This is most commonly pain free at the time of the incident.  Those that do experience pain during or after the rupture, will commonly report pain starting at the ankle acutely and then migrating towards the calf over the next few days. Patients will usually complain of weakness and an inability to stand, walk, or run on their foot as they could prior to the rupture.

Males are more prone to AT ruptures and unfortunately, we do not know why however, females with an absent menstrual cycle, on hormone replacement therapy (HRT) and over 40 are also at a greater risk.

Higher risk individuals to AT rupture also include people within the age group of 30- 40 and 60-75 years old. Other factors that predispose you to tendon injuries are those that are:

• Taking regular medication - steroids, quinolone, or HRT (hormone replacement therapy)
• Genetic factors
• History of a previous rupture (this is the largest risk factor)
• Previous cortisone injection into a tendon for pain relief! Please DON'™T DO THIS EVER! Cortisone has been shown to weaken a tendon!

Most tendon ruptures occur at the mid-portion of the Achilles and this is usually due to existing tendon degeneration however, this can occur in individuals with NO tendon pathology too.  As mentioned before, this is usually the group that does not have pain with their tendon prior to rupture as most people that suffer from tendinopathy pain seek treatment and therefore begin rehabilitation that builds strength and capacity in their calf and Achilles complex and therefore their risk of rupture is reduced. So remember if you are someone who is struggling with Achilles tendon pain that has been persisting for a short or long period of time ensure you seek an assessment of this from someone who is experienced in tendinopathy pain so that you can get this on the right track. It is important you do this rather than being afraid your tendon may rupture as that is extremely unlikely in your case.

It is less common that a healthy tendon will rupture unless it has been exposed to a significant external force in which case rupture at the MDT portion of the Achilles will occur.

Management of AT ruptures

These can be managed conservatively or surgically but in New Zealand, the majority of these injuries are treated conservatively. This, at times, differs in the elite athlete population but research shows us that after 18 months post rupture the outcomes of surgical vs conservative care are largely the same. The conservatively managed population has a slightly higher risk of re rupture and the surgically managed group has a higher incidence of infection, but overall results are relatively even, and good function regained. Other things that may be taken into account when considering surgical vs conservative management are whether the injury is acute (5 days) or chronic (3-6weeks); the size and location of the tear, and the Orthopaedic surgeon's availability and assessment of the individual.

Overall, there is little difference in recovery and return to play with the 2 approaches. The main difference is that with operative management, the person may regain functional use of the foot a few weeks earlier than conservative BUT with all approaches, there are risks and benefits for each. As a physiotherapist, I would always encourage my patients to consider a conservative approach.

The most important contributing factor determining the success to a full return to function is the quality of the REHABILITATION post rupture.

 Both surgical and conservative approaches protocols include;

A: Immobilisation in serial casting in a plantarflexed position (pointed foot position)  for (2-3 weeks) whilst using crutches to avoid putting weight through the tendon.

B: At 3 weeks they are put in a moon boot with wedges keeping the foot into a pointed position and 1 wedge is removed on a weekly basis until the patients' foot is in a neutral (flat foot) position. The Doctor will advise on when gradual weight bearing can occur.

C:  Ideally from around 6 weeks the patient will be able to gradually start weight bearing and commence light exercise (guided by Doctor and Physio).

D: At 10 weeks post rupture, the patient is usually allowed to remove the boot and walk, gradually increasing walking time and distance.

The important thing during this initial phase of recovery is that we allow the tendon to heal properly and develop sufficient stiffness!  A long Achilles repair leads to less function as the final outcome.

The immobilisation period is important as it bridges the gap of the Achilles and promotes the tendon healing in a shortened rather than lengthened position. A tendon that heals in a lengthened position is less likely to be able to develop appropriate strength and force which leads to a less than satisfactory outcome including a greater likelihood of re-rupture.

Rehabilitation post rupture

As a physiotherapist, we want to ensure that we regain ankle and forefoot mobility, regain and optimise your calf and foot endurance, strength and proprioception of BOTH legs.

We also aim to achieve proximal strength through your hips, core and the remainder of your lower limb as this will facilitate recovery and a greater overall outcome.

We will guide you through sport specific training and return to play programmes to reduce the risk of re-rupture and ensure not only a return to play but more importantly over time a return to performance.

I always advise my patients to start physiotherapy ASAP as there is a lot we can do to help facilitate recovery without affecting the injured area. When you are out of the serial casting and put in the moon boot, we will then start with hands on treatment to regain ankle and foot mobility whilst protecting the AT.

It is comforting to know that 80% f people return to full sporting activities following a rupture and that the Achilles tendon can tolerate the force being put on it! With each running step the AT has a load of 6 X bodyweight put on it!

With appropriate rehab, you can feel confident and enjoy a return to sport without being afraid to re-rupture, provided you have done your homework.

If you have any questions or concerns regarding any Achilles pain you are having or have had, please contact us to talk to a qualified Physiotherapist

Written by Dunia Mouneimne Senior Physiotherapist

Editors note: If you are an athlete who is post-partum there is a section further down below that is important for you to read.

Over recent years we have seen an emerging social phenomenon with successful return to sport of many elite athletes. Guidelines and important points for athletes and non-athletes returning to exercise post childbirth are included in this blog.

Ideally seek medical guidance prior to returning to exercise post-partum. If you have had an uncomplicated pregnancy and birth your physiotherapist is one of the best suited professionals to seek advice from at this point.

The general guideline is that healthy women gradually return to physical exercise aiming to accumulate 150 to 300 minutes per week. Low impact endurance training should start gradually but can start early as desired as there is minimal impact on the pelvic floor. Return to high impact exercises and strength training may need to be delayed several months. Some exercises need to be more gradual especially exercises increasing intra-abdominal pressure. The initial focus should be on strengthening pelvic floor muscles.

Important points to be aware of for athletes and non-athletes:

• The pelvic floor is weak and injured in most women postpartum and will require rehabilitation to return to its "normal" functions. Those who struggle to perform the above exercise guidelines and those that have not completed pelvic floor muscle training prior to the birth may need an individualised and supervised programme to regain appropriate strength and control.
• Any physiological changes that occur during pregnancy and persist for four to six weeks post birth, such as elevated hormone levels, may mean your joints are more mobile than normal so take care with activities that require large amounts of movement, flexibility and dynamic exercises.
• Certain birth types may lead to complications. For example, C sections are more likely to cause abdominal pain postpartum.  Pain management and wound healing are therefore important prior to any return to exercise.
• Low back pain is common so must be considered prior to return to exercise. An assessment of this with a specific treatment and rehabilitation programme may be required.
• Stretched, weakened or separated abdominal muscles (Diastasis recti abdominis) may also delay or impede exercise ability.
• Increase energy and fluid intake if breastfeeding when returning to exercise.  Ensure particularly when breastfeeding that nutrition demands of both lactation and training are met. The caloric cost of breastfeeding is estimated to be around 600 kilocalories per day.
• Adequate intake of calcium and vitamin D during breastfeeding is essential.
• Ensure adequate hydration throughout the day.

• Consider psychological readiness to return to exercise as this is important post childbirth. Fear of movement is common particularly post C section and has been associated with restricted postpartum physical activity.
• Exercising after breastfeeding will likely be more comfortable to avoid engorged breasts.
• Take care with those exercises that cause high gravitational load on the pelvic floor or high impact activities in early stages.
• Complicated births such as a forceps delivery or levator ani avulsions are likely to slow down return to exercise post-partum and potentially lead to elevated complication rates of pelvic floor dysfunction and pelvic organ prolapse if time is not given to heal appropriately and rehab is not completed.
• Ensure that return to exercise is gradually increased.
• Consider the importance of individualized breast support support rather than compression is important from a comfort perspective.
• If an obvious Diastasis Rectus Abdominis (gap in between abdominal muscles) see a physiotherapist for an assessment to have a programme prescribed at the correct level and to ensure safe return to exercise without complications
• Sexual dysfunction is common postpartum. Those suffering may benefit from pelvic floor rehabilitation to improve this.

Stress incontinence (involuntary emission of urine when pressure within the abdomen increases suddenly, as in coughing, running or jumping) is one common post-partum complication. Pelvic floor rehabilitation post childbirth can be used successfully in resolving this issue in a large percentage of the population. If you or anyone you know is suffering from any stress incontinence, please contact the clinic and book in for a pelvic health assessment as this is often an extremely limiting condition that can be resolved relatively easily.

• Factors that may predispose you to post-partum stress incontinence are:
  • Giving birth,
  • Increasing age,
  • Vaginal delivery,
  • Pregnancy stress incontinence,
  • Running related pre pregnancy incontinence,
  • Partaking in high impact activities,
  • Women with multiple children, and/or
  • Return to high impact activities before the body has healed i.e., running.

Exercise guidelines:

• Research highlights that all post-natal mothers, regardless of delivery mode, should be offered pelvic health assessment from six weeks post-natal to comprehensively assess the abdominal wall and pelvic floor. In NZ this is uncommon and requires the mother to generally access private health providers for this. There is currently a movement for this to change so all mothers in NZ can access private pelvic health physiotherapy assessment and rehabilitation in the future which we believe is essential to the long term health and wellness of mothers in NZ.
• High impact activities, such as running, are associated with a sudden rise in intra-abdominal pressure and load the pelvic floor as a result.  For this reason, it is advised that you return to low impact activities post-partum prior to a return to running.
• Low impact exercise can be implemented within the first three months post-natal followed by a return to run between three to six months.

Key signs or symptoms of pelvic floor and or abdominal wall dysfunction:

• Urinary and or faecal incompetence,
• Urinary or faecal urgency that is difficult to defer,
• Heaviness pressure bulge dragging in the pelvic area,
• Pain with intercourse,
• Obstructive defecation,
• Pendular abdomen, separated abdominal muscles and or decreased abdominal strength and function, and/or
• Musculoskeletal lumbar-pelvic (low back) or pelvic pain.

Risk factors for potential issues returning to running and sport:

• Less than three months post-natal,
• Pre-existing hypermobility conditions i.e., Ehlers-Danlos,
• Breastfeeding,
• Pre-existing pelvic floor dysfunction or lumbar-pelvic dysfunction,
• Psychological issues that may predispose a post-natal mother to an inappropriate intensity or duration of running as a coping strategy,
• Obesity,
• C-section or perineal scarring, and/or
• Relative energy deficiency in sport (RED S).

A referral to a pelvic health physiotherapist is further highlighted if any of the following signs and symptoms are experienced prior to or after attempting returning to run:

• Heaviness or dragging in the pelvic area,
• Leaking urine or inability to control bowel movements,
• Pendular abdomen and or noticeable gap along the line of your abdominal middle,
• Pelvic or lower back pain, and/or
• Ongoing or increased blood loss beyond eight weeks post Natal that is not linked to your monthly cycle.

An inability to exercise may affect both your mental and physical wellbeing. It can be socially isolating not being able to complete exercises as you previously had. Please ensure that you reach out to us for an assessment if this sounds like you.

To book a pelvic floor assessment please call 07 576 1860 or email reception@buretaphysio.co.nz.

Exercise in Athletes Post Partum

Across the board, athletes return to sport sooner than non-athletes with a greater percentage within six weeks post-partum. Research also highlights that a large percentage of those athletes returning to elite sports post childbirth return to the same if not a higher level of performance. If you are intending on returning to competitive sports post pregnancy, ensure you include a multidisciplinary team in your planning.

Be aware that just as if you were returning to running or sport post injury, when you had a significant reduction in your training load, this is a period that exercise must be gradually resumed. Ideally, this would start with pelvic floor rehabilitation, alongside low impact activities, prior to a gradual reduction in high impact activities and those that result in significant increases in intra-abdominal and pelvic pressure such as lifting weights.

Moderate to vigorous physical activity in sport will not negatively affect breastmilk volume, alter the composition of breastmilk or affect infant growth if there is appropriate food and fluid intake.

Note that post-natal women with a history of RED-S (relative energy deficiency in sport) are at increased risk of stress fractures, pelvic dysfunction and fertility issues so must have appropriate multidisciplinary involvement regarding their return to training.

Things to take note of:

• Regaining functional control of the abdominal wall to manage intra-abdominal pressure and load transfer should be achieved prior to return to run or sport, otherwise overload and compensatory strategies may occur.
• Return to running with a diastasis if it is functional i.e. it is present but there are strategies to control intrabdominal pressure and transfer load across the abdominal wall that are adequate.
• Shoe/boot size can alter permanently with pregnancy and footwear previously worn should not be presumed to be the correct fit.
• Sleep deprivation in athletes is associated with increased injury risk. Sleep is key for recovery from both physical and psychological stress and is frequently restricted in the postpartum period. Utilise naps as able to optimise sleep quantity.
• Utilise sleep hygiene guidelines to optimise sleep quality.
• Similar to post injury situations, build training volume prior to increasing training intensity.
• Minimise large and sudden increases in load.
• Take note of key individual signs that need to be monitored during your return to run/sport i.e. heaviness, dragging, incontinence or moderate to severe pain may suggest excessive training distance or intensity.
• Mild musculoskeletal pain 0-3/ 10 which settles quickly after a run with no pain lasting into the next day is often acceptable; as is used in the management of tendinopathy and other conditions.
• If running with a buggy it must be a buggy that is specifically designed for running. Two handed technique where it is possible should be utilised and ideally your baby is greater than six months old as per buggy manufacturers guidelines. Note also that pushing a buggy has an increased energy cost when compared to running independently.

In summary:

Post-natal women will benefit from individualised assessment and guided pelvic floor rehabilitation for the prevention and management of pelvic organ prolapse, the management of urinary incontinence and for improved sexual function post childbirth.

Return to running is not advised prior to three months post-natal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to or after attempting return to running.