News

Tennis season is in full swing! Working in a high performance tennis academy I see a lot of 12-18 year old aspiring players and as a physio a good deal of the ones I meet are injured. The first thing to think when presented with an adolescent in pain, is that they are not just little adults. Teenagers have immature skeletons that make them prone to certain injuries and the demands of sports, such as tennis, present particular physical challenges that can result in specific injuries.
In adolescent tennis I see a lot overuse type injuries. These can occur as a result of rapidly increasing hours of practice/competition or changes in training conditions such as the transition between court surfaces at different times of year. Regardless, tennis is a highly repetitive sport that involves a lot of rapid movements of the entire body, high levels of skill and hand-eye co-ordination plus lots of change of direction and stop/start type activities. With incorrect technique or poor movement control, as is often seen in younger people, the repetitious nature can result in overuse injuries. 

In the lower limb two of the typical injuries I see, are Osgood Schlatter’s Disease and Sever’s Disease. Firstly and probably most importantly they are not diseases. Both are grouped under a technical term called ‘traction apophysitis’. Due to differences between the adult and adolescent skeleton, pain and inflammation can occur, at the part of the tendon that attaches to the bone, the ‘apophysis’.

Osgood Schlatter’s Disease is when this occurs at the attachment of the patella tendon to the lower leg and Sever’s Disease occurs where the Achilles’ tendon meets the heel. There are other differential diagnoses so accurate assessment is essential. Often, but not always, imaging such as X-Ray, Ultrasound or MRI is used to fully understand the specific diagnosis and to aid in management of the injury.  If this is required I would arrange for the individual to see a Sports Medicine Consultant or Orthopaedic Consultant.

In the spine not to be missed, is the teenage tennis player complaining of pain in the lower back, at the extreme of twisting or after lots of serving. This can be the tell-tale sign of a stress fracture in the spine called a ‘Pars defect’. These should be confirmed with imaging and referral to a Consultant is often the first course of action by the physiotherapist. 

Managing these injuries is firstly down to understanding the problem. Then it is a case of stopping or greatly reducing the offending movement or activity, identifying the movement problems that caused the injury in the first place, then working on a combination of strength, control, co-ordination and stability, followed by a gradual phased return to play. Often I use the down time from tennis to work on the person’s athletic development in other areas, this also helps to deal with the boredom and frustration of not being able to play their favourite sport. 

The majority of these injuries recover very well and very few need anything more drastic than accurate assessment and diagnosis, imaging where appropriate, a good plan and plenty of hard work. Adolescence is a key development time both physically and emotionally and dealing with injuries properly and promptly can stop them becoming a problem later in life. 

Injury prevention screening can be used to identify possible future injuries and nip them in the bud. Fit players of any age can carry minor problems or have movement faults and these can be identified with physical examination and functional movement testing. Preventative programmes can then be given to reduce the risk of picking up injuries during the long tennis season. I typically screen fit players twice a year or more depending on the level and demands of the individual. 

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Rehabilitation Exercises for Athletes with Biceps Disorders and SLAP Lesions – A Continuum of Exercises with Increasing Loads on the Biceps; Cools et al (2014), AJSM, Vol 42, No. 6.

Overview

Biceps disorders and SLAP lesions are relatively common injuries amongst overhead athletes and can generally be split into three main groups; inflammatory/degenerative lesions of the long head of biceps/superior labrum, instability of the biceps tendon in the bicipitial groove and superior labral anterior-posterior (SLAP) lesions.

SLAP repairs are performed when the long head of biceps and labrum become detached from the surface of the glenoid within the shoulder. Following this type of surgery it is typical that the biceps be ‘rested’ and no resisted activity allowed for eight weeks and then controlled with a steady progression of strengthening from 12 weeks post-operatively.

The authors of this study have utilised a series of relatively well established rehabilitation exercises for the shoulder and asked the question, how much does this exercise activate the biceps muscle? The exercises are split into three main groups; scapular muscle training, rotator cuff muscle training and biceps targeted exercises. Using surface electrodes that measure muscular activity, these exercises have then been scored and ranked in terms of the amount of activity of biceps brachii, known as the percentage of maximal voluntary isometric contraction or %MVIC. Other values were also recorded for various muscles around the shoulder complex.

The results are relatively unsurprising in that, when used in its normal anatomical functional capacity – shoulder elevation, elbow flexion and wrist supination – biceps exhibits it’s maximal muscular activity. What is interesting from the article is that under controlled circumstances with moderate loads (10 repetition maximum) that biceps activity never reaches 50% of its available capacity and is therefore defined as moderate in terms of %MVIC. Also it is shown in the article that exercises targeting the serratus anterior muscle – an important scapula stabiliser – tend to activate biceps more than exercises targeting the trapezius muscles or rotator cuff muscles.

Rather frustratingly the authors do not really list the exercises in order of loading/activity performed by biceps in an easily digestible way and the reader has to continually flick backwards and forwards through the article, therefore I have provided that list below with comparison figures for serratus anterior and lower fibres of trapezius – two very important muscles in shoulder rehabilitation.

Critique

The main flaw, as with most of these types of study is sample size. There were 32 participants, all fit and healthy with no previous history of shoulder problems. So while this data is interesting it may not be particularly representative of the entire population or those with injury, post surgery of other shoulder problems.

Surface EMG has been noted as being a relatively inaccurate way of studying muscle activity and is subject to interference from various sources. However, fine needle EMG is much more invasive and difficult to pass through ethics committees therefore surface EMG this is the most commonly used method.

The study also looked only at early stage exercises with moderate to low loads and is therefore only valid for the very early stages of biceps and labral recovery. No information is available for higher loads or plyometric activity although the authors are keen to point this out themselves.

Finally and importantly activity of the biceps does not necessarily represent tensile loading across the long head of biceps/superior labrum so despite the relatively low activation levels of biceps during certain exercises it is not truly known what is occurring at the surgical repair site in the shoulder. Also exercises performed in overhead positions may increase compression/impingement forces on the biceps tendon so despite being ‘low biceps activity’ should be performed with caution.

Clinical Relevance

There are certainly positive factors to be taken from this article and it is interesting to see the differing levels of biceps activity when performing various exercises, this informs practice well and ensures safety for practitioners and patients following SLAP repairs.

Also with the majority of shoulder issues there exists a scapula component so it is interesting to see which scapula muscle exercises particularly load biceps even though none of them reach a ‘high’ level of muscle activity. This may help define when, in a patients rehabilitation plan, that the scapula element is addressed.

Finally, this article does not represent a recipe for rehabilitating a shoulder and all post-surgical rehabilitation should be performed under the supervision of a suitably qualified professional to ensure the best and safest outcome for the individual.

These are my thoughts and views.

Nick Wirth

Senior Physiotherapist

Table 1 – Exercises Performed with %MVIC for biceps, serratus anterior and lower fibres of trapezius (Ranked for biceps activity from lowest to highest)

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Latarjet-Bristow Procedures

I spent this morning in theatre, at London Bridge Hospital, with Mr Andy Richards, Consultant Orthopaedic Surgeon, observing what is commonly known as a Latarjet Procedure.  Below is a link to a description of the procedure from www.shoulderdoc.co.uk an excellent web resource for all things shoulder. Follow this link to visit the page about Latarjet operations:

http://www.shoulderdoc.co.uk/article.asp?section=914

These kinds of visits are vital in developing a true understanding of the procedures that we regularly rehabilitate.  The insight into the complexity of the procedure and the anatomy of the area are both really important, in not only having empathy for your clients, but also in being able to properly plan rehabilitation programmes with appropriate time frames and goals.

This not a simple procedure and represents significant surgery for the shoulder hence the rehab can be lengthy and sometimes difficult but the success rate is very high and the recurrence very low.  Thanks to the great link that I have with Mr Andy Richards and other shoulder surgeons I believe that I am in a great place to offer expert treatment following this and other types of shoulder surgery.

Here is a link to an article outlining the phases of shoulder rehab, the article highlights, very importantly, that the shoulder is not a stand alone structure and that links to the scapula, through the core and into the lower limbs are required for really good shoulder rehabilitation.

Hope you enjoy the read.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811734/

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Check out this link to the chartered society of physiotherapy website.

The conclusion is simple:

“Speedy access to physiotherapy for people with MSDs (musculoskeletal disorders)  is clinically and cost effective for the health service, for employers and society.

It prevents unnecessary GP and secondary care appointments as well as improving patients’ quality of life.”

http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/musculoskeletal-disorders

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Great to see the players at Sutton Tennis Academy doing so well and especially well done to Lily Miyazaki on her WTA ranking!

As part of his work at Sutton Sports Physio – Nick Wirth screens, assesses, treats and manages the injuries of many of the academy and scholarship players at Sutton Tennis Academy.

In conjunction with the strength and conditioning team, sports psychologist, massage therapists and the coaches, players are then appropriately managed back from injury and also given prehabilitation exercise routines to prevent injuries where possible.

Nick currently works at Sutton Sports Physio on Mondays, Tuesdays and Thursdays.  Contact the clinic directly on 02082542150 if you wisj to see Nick at this venue.

http://www.suttontennisacademy.com/wordpress-coaches/?p=253

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A very good friend of mine, Anna Faulkner, has recently launched the website of her decorating company – Spruce.

Check out Anna’s website (below) for further information about how to contact Anna and her team plus portfolio images and testimonials about Spruce decoratings work.

www.sprucedecorating.com

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