Resolving Groin Injuries – Part 3

Treating Groin Injuries

Acute stage

The 72-hour phase after an injury is characterized by swelling and pain. During this phase, use ice to reduce inflammation (ice massage), and if required, take an over-the-counter anti-inflammatory medication. Avoid using these medications after the first 72 hours since they can have a negative effect on tissue regeneration. Even during this initial stage, it is important to get some motion into the affected area in order to speed the healing process.

During this stage, I recommend that you get as much rest as possible. I also recommend you use a compression strap which will help to prevent further injury. Elevating the injured leg while doing the ice massage every 2 to 3 hours is also essential (ice only 7 to 9 minutes each time).

Manual Therapy

Manual therapy should be implemented as soon as possible. The longer that the injured person waits for therapy to begin, the longer the resolution time may be. The period of time that you will be unable to perform your usual activities will depend on the cause of injury and the degree of injury.

The first thing practitioners must do in treating a groin injury is perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns. This will give them an initial hypothesis as to which structures are involved. Refer to the previous section of this blog to see which muscles are involved.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area needing treatment has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions; they include: Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation.

The success rate in resolving a groin injury is very high in the hands of an experienced soft tissue practitioner. As the practitioner work through the soft tissue restrictions they will be looking for changes in tissue consistency, movement and function. Some of these changes are often noted even during the first treatment.

When you are being treated for a soft tissue injury, it is very important to communicate to the practitioner how the treatments are going, and how the condition is improving, if at all. In most cases, improvements in symptoms (decrease in pain) and functionality (ability to perform tasks better) will be noted if the right structures are being treated.

Exercise

Exercise is essential in the treatment of a groin injury for a complete recovery and to prevent any reoccurrences. In many of my blogs I stress the importance of stretching, strengthening, and balance training for a complete recovery. Without these three essential elements, your injured tissues will not remodel correctly and you will only be setting yourself up for a series of groin injuries.

Stretching Exercises

During the first 48 hours to six weeks after an injury, collagen is formed and laid down to repair the injured area. If the injured person is performing the correct stretching exercises, the majority of the collagen will be laid down in the same direction as the tissue being repaired, making the repaired tissue stronger and more capable of performing its function. If the individual is not stretching, the tissue will be laid down in more random patterns, leading to the development of weaker tissue that is easily re-injured.

1. Groin Stretch (Core Performance)
2. Lateral Lunge Moving - Dynamic Stretch (Core Performance)

Strengthening Exercises

Tissue remodeling can last up to 12 months after an injury. During this phase, the collagen fibers increase in size, diameter, and strength. The collagen remodels to withstand the stresses that are placed up on it. In other words, tissue remodeling is dependant on the forces that are applied the tissue. If the injured person is performing appropriate strengthening exercises, the collagen will remodel to withstand the stresses placed upon it. With exercise, this remodeling will lead to a complete recovery of the injured tissue, along with a decreased chance of re- injury. Without appropriate strength training, the possibility of re-injury is very high, no matter what therapy the patient has received.

1. Lateral Squat - Low (First learned this in martial art - to make harder go lower)

Balance Exercises – Proprioceptive Training

Whenever a groin injury occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to problems.

Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:

1. One-legged Stand

· This is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercises within a pain-free range-of-motion.

2. Wobble board training

· Slowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.

Returning to Activities

In order to return your normal sports and activities (hockey, scoccer etc.), you should be able to perform all movements required by that sport or activity without significant pain.

The time needed to return to a sport will vary depending on the movements required. Distance runners are only required to move in relatively straight lines compared to hockey player who requires constant force changes in direction during normal play. Returning too soon to a particular activity could set an athlete up for a series of injuries.

1. Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc. Sep 2001;33(9):1423-33.
2. Johnson R. Ice hockey. In: Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. 2^nd ed. Philadelphia, Pa: Hanley & Belfus; 1997:851.
3. Morelli V, Espinoza L. Groin injuries and groin pain in athletes: part 2. Prim Care. Mar 2005;32(1):185-200.
4. Verrall GM, Slavotinek JP, Barnes PG, et al. Hip joint range of motion restriction precedes athletic chronic groin injury. J Sci Med Sport. Dec 2007;10(6):463-6.

If you would like to more information or to purchase our books please go to www.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Ankle Sprain (Inversion Sprain) – Part 6

Restoring Flexibility to the Ankle

It is extremely important to stretch after experiencing an ankle injury of any kind. During the recovery phase, your body forms and lays down collagen to repair the injured area from two days, and up to 6 weeks after, the injury occurs.

If you suffer from an inversion sprain, and perform the correct stretching exercises, then you can ensure that the majority of the collagen that is being laid down, is being laid in the same direction as the tissue which is being repaired. This makes the repaired tissue stronger and more capable of performing its function in the future. However, if you do not stretch the injured area, the new collagen will be laid down in more random patterns, leading to the development of weaker tissue (scar tissue) that is easily re-injured

Here are some of the areas for which we recommend stretching exercises when our patients are recovering from an ankle injury:

• Calf muscle (gastrocnnemius and soleus) - Stretch the calf muscle as it often becomes very tight after an ankle sprain, as these structures try to protect the injured joint.

• Peroneal muscles – Stretch the peroneals (along the sides of your calf) as these muscles are often injured along with the ligaments in the ankles.

• Iliotibial Band – Yes, these tissues are in your upper leg, but there are direct fascial connections from the peroneal muscles into the IT band. A injury to the peroneal muscle may cause compensation injuries up into the IT Band. So be sure to perform stretches to release the IT Band.

• Gluteal muscles – Since the IT band is formed from the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae, problems in the IT band will affect hip function. So it is important to release the muscles of the gluteals with stretches and foam rollers.

Proprioceptive Training

Whenever an inversion sprain occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to chronic ankle problems.

Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:

• One-legged Stand

This is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercise within a pain free range-of-motion.

• Wobble board training

Slowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.

· Upside Down Bosu Ball

The Bosu Ball is a great device for dynamically stretching and strengthening the ankle. Try this Side-to-Side Peroneal Stretch.

§ Turn the Bosu Ball upside down, balance on the flat surface, with your feet about shoulder-width apart.

§ Shift your weight to the right side so that the right edge of the Bosu Ball almost touches the ground. Then immediately shift your weight to the left side so the left edge of the Bosu ball almost touches the ground. Continue to shift from side-to-side. As you do this exercise, you should feel a stretch in the muscles along the lower outside of your leg (peroneals).

§ After a few minutes of performing this action your lower extremity muscles should start to feel fatigued.

§ Once you become comfortable with balancing the side-to-side actions, you can start integrating arm actions into this exercise. As you shift your lower extremity to the right side, swing both your arms to the left. When you shift your weight to the left side, swing your arms to the right. This simulates a downhill skiing (cross crawl) type of action that integrates all the muscles of your body.

Sport Specific

If you are involved in a particular sport, take the time to create a balance/proprioceptive exercise that matches your specific sport. For example:

· If you are a soccer player who is rehabilitating a sprained ankle, you may want to try one-legged stand on the injured ankle, while kicking a soccer ball with the other foot. To increase the level of difficulty, try standing on a balance pad with the injured leg, and then kick the ball with the other.

· If you are a dancer suffering from an inversion sprain, try moving through your basic dance positions while on a wobble board or balance pad.

· If you are a basketball player, try standing on a wobble board with the injured leg and practice throwing hoops.

Be creative with your individual sport. Use wobble boards, balance pads, half-foam rollers, or bosu balls to rehabilitate the damage to your nervous system that is caused by an inversion sprain.

Bottom line - inversion sprains are a common, yet complex, injury. This injury can involve multiple structures across numerous joints, and may even extend a considerable distance up the body. To correctly rehabilitate the injury, you must use an approach that takes into consideration musculoskeletal connections, the nervous system, and appropriate tissue remodelling.

If you would like more information or to purchase our books please go towww.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Ankle Sprain (Inversion Sprain) – Part 5

Exercise Rehabilitation For Ankle Sprains

When prescribing ankle exercises, we must take into consideration the multiple structures that are involved in performing and coordinating ankle motion. To attain a full resolution from an inversion sprain, we must be sure to consider multiple muscles and complex fascial layers, all of which work together across numerous joints.

To do this, we must be sure to address three essential components: strength, flexibility, and proprioception.

Strengthening the Ankle

Strengthening exercises are essential! Manual therapy, by itself, will not fully prevent an injury from returning without the addition of strengthening exercises. This is because the type and quality of tissue remodeling that occurs after an injury is dependant on the type of forces that are applied to that tissue. When appropriate strengthening exercises are applied, the collagen remodels to withstand the stresses that are placed upon it. The possibility of re-injury is very high without appropriate strength training.

Strengthening exercises for an inversion sprain can be subdivided into several categories depending on the stage of the injury. The following subcategories describe stages from non-weight-bearing to full-weight-bearing. Note: These are examples of possible recommendations, but actual exercise recommendations will vary from case to case.

1. Active Range Of Motion (AROM) – Non-weight bearing exercises

a. Four basic foot motions – Perform the following four basic motions: plantar flexion, dorsi flexion, inversion, and eversion. Perform these foot motions slowly, holding the end range of each position for 5-10 seconds. Repeat the action several times.

b. Alphabet exercise – Use your foot to draw the letters of the alphabet in the air, allowing your ankles to rotate with each motion

2. Isometric strengthening of the ankle – Isometric exercises are performed in static positions (unlike dynamic exercises which are performed through a range of motion).

a. The Isometric Four – In this exercise, you need to resist each basic motion (plantar flexion, dorsi flexion, inversion, and eversion) of the ankle. For example:

· Start with your ankle in neutral position, with your foot braced against a wall or table.

· Then, without allowing your foot or ankle to move, try to perform each of the four basic actions. This causes all the muscles involved in the action to contract.

· Hold this contraction for 5-10 seconds and relax for about 10 seconds.

· Repeat this process for 4-8 repetitions, slowly increasing the number of repetitions.

· Repeat this routine for each of the four basic actions.

3. Resisted Strengthening of the Ankle – using Theraband or Tubing

a. Four-Way Resisted Tubing – In this series of exercises, we recommend using a theraband or tubing as you perform each of the four basic ankle motions. For example, with the inversion action:

· Attach a theraband around your ankle and attach the other end to a table or door.

· Against resistance, roll your foot inward (invert your ankle) and hold for 3 to 5 seconds.

· Repeat for 10 to 15 repetitions, increasing the number of sets from 1 set/day to 4 sets/day as you increase your ankle strength.

· Repeat this routine for each of the four basic ankle actions.

4. Partial Weight Bearing Ankle Exercise

a. Shifting Your Weight – In this exercise, lean against a counter or table, and try shifting some of your weight onto the injured leg. Start with just a few seconds of weight, and then increase this time, as the ankle permits. Repeat this exercise about 10 times. Be careful not to do too much, too soon.

5. Full Weight Bearing Ankle Exercises

Once the injured ankle is able to bear the full weight of your body, there are many exercises that will help to further strengthen the ankle. One of my favorites is the Eccentric Calf Raise.

Eccentric Calf Raises - One Legged
(Actually…these are calf drops, not raises)

In this exercise, the rising up portion is not that important. The key lies in the slow lowering of the body, as this builds strength without causing further injury to the body.

· Stand on the edge of step or curb, heels hanging over the edge of the step, and rise up on both legs in a classic calf raise.

· Now, using only one leg, slowly drop down to the starting position for a count of three

· Do 5 to 15 repetitions in each set. Start with two sets and gradually increase to 4 sets as your ankle strength increases.

· Allow your ankle to build up its strength slowly. Do not increase your repetitions and sets until you can complete each repetition with perfect form, and without pain.

Once you are able to properly perform full weight bearing exercises, you should consider beginning a routine that exercises your full body. These exercises should activate the knee, hip, and core.

In Part Six of Ankle Sprains we will cover stretching and proprioceptive exercises for resolving ankle sprains.

If you would like more information or to purchase our books please go towww.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)

Ankle Sprains or Inversion Sprains – Part 4

Fascia and Inversion Sprains

Fascia was once thought to be nothing more than packaging material covering muscles and organs. Back in school, when we worked in the dissection lab, we went out of our way to remove this material in order to expose those structures that were considered to be more important (an experience that I have heard repeated by many individuals in the medical field). Unfortunately, this lead to the very misleading perspective that fascia was unimportant.

Now, 20 years later I, and many others, have come to a very different conclusion. Fascia is everywhere, weaving through, and interconnecting every component of our body. Robert Schleip from Ulm University in Germany (of the Fascia Research Project) describes fascia extremely well when he describes fascia as “the dense irregular connective tissue that surrounds and connects every muscle, even the tiniest myofibril, and every single organ of the body forming continuity throughout the body.” In other words, fascia is the physical manifestation of the kinetic web that we have discussed so many times in our blogs and books.

Schleip R. Fascial plasticity—a new neurobiological explanation: part 1. J Bodyw Mov Ther. 2003;7(1):11–19.

Fascial interconnections are not theoretical entities; they are actual physical structures that have been well mapped out. Researchers such as Thomas Meyers (Anatomy Trains) and Luigi, Carla, and Antonio Stecco (Fascial Manipulation) have spent decades researching these interconnections. During the last International Fascia Research Congress at the University of Amsterdam, I had the privilege of listening to medical experts from around the world confirm this and related fascial research. (Take a look at these excellent articles for more details.)

Fascia as an Anchor for Force Generation

When one considers the prevalence of fascia throughout the body, it is not surprising to discover that it actually plays a critical role in all bodily actions, and that it is much more than the “bubble wrap” that many considered it to be.

In conventional medical theories, muscles have both an origin and insertion at the bone(s). In this view, when a muscle contracts, it pulls the origin toward the point of insertion to create motion. In reality, muscle fibers actually originate from, and insert into, fascial fibers. These fascial fibers, in turn, insert into multiple regions of the bone, and even into adjacent muscles. These additional points of contact and control provide the muscle with the ability to generate force in multiple directions.

In reality, when a muscle contracts to perform an action, only certain sections of the muscle contract. Force is not generated from just the origin and insertion points, but also through the numerous fascial connections. Anatomists at the University Maastricht in the Netherlands have done some incredible research that confirms this understanding.

Van Mameren H. Reaction forces in a model of the human elbow joint. Anat Anz. 1983;152:327–328.

Fascia as a Neurological Feed Back Loop

Muscles work together as functional units that coordinate their actions across multiple joints. Depending on the degree of motion required, and amount of force that is needed, each muscle will contract only specific areas of the muscle, rather than the entire muscle. As incredible as it may sound, these very specific motions are largely coordinated by the neurological receptors embedded in the fascia, and not by the brain. This is a form of non-localized intelligence, a concept that has long been postulated, but is only now being acknowledged as occurring in all life forms.

Fascia is full of two types neurological receptors - mechanoreceptors and proprioceptors. A mechanoreceptor is a sensory receptor that responds to mechanical pressure or distortion. A proprioceptor is a sensor that provides the brain with information about joint angle, muscle length, and tension.

Motion is coordinated by the feedback of the neurological receptors in the fascia when tension is transfered from one area to the next. (Previously these receptors were only thought to be located within just the muscles).

Fascial Lines and an Inversion Sprain

When we evaluate an inversion sprain of the ankle, we must also take into consideration all the fascial connections to the structures that are involved in performing and coordinating ankle motion. It is important to look at the big picture, and take into consideration that multiple muscles, working across multiple joints (all of which are interconnected by fascia) are all required to coordinate these motions.

In the case of an inversion sprain, the fascial connections we should consider is in the Lateral Line (see Anatomy Trains by Thomas Meyers). The following is a short synopsis of the lateral line. I have also included a link to the Anatomy Trains dissection video about the Lateral Line – Thomas Meyers Lateral line Video.

Lateral Line

· Beginning at the foot with the peroneal muscles, fascial interconnections travel up the outer leg to just below the knee (fibular head). This fascia then connects directly into the lower IT band into the deltoid complex (gluteus maximus, gluteus medius, and tensor fascia latae).

· The fascia then connects to the pelvis (iliac crest), which connects into the abdominal muscles (internal and external obliques), and then into the quadratus lumborum which connects into the ribs and the spine.

· The fascia then travels up between the ribs (intercostals muscles) and continues up the body to connect into the fascia of the neck (SCM, splenicus cervicis, and scalenes).

Once you see these videos, you will find it very hard to dispute the importance of these fascial connections.

Bottom Line: You can try treating inversion sprains with all the right techniques (ART, Graston, Massage etc.) and find that you still have not resolved a chronic inversion sprain if you did not consider, and treat, the fascial interconnections

Manipulation

In addition to the soft-tissue treatment component, you must also address the osseous (bone/joint) component. Joint manipulation helps to restore active range of motion in the ankle and speed recovery. It is very common for several of the joints of the feet to become stiff and rigid, due to either the initial injury or due to soft-tissue compensations over a period of time.

The exact area that requires joint manipulation varies depending on the severity of the sprain, number of reoccurrences, and the length of time that has passed since the injury occurred. The longer you wait, the more compensations your body must make, and the longer it will take to treat and recover from the injury.

In part five of Ankle Sprains we will provide Rehabilitative Exercises For Ankle Sprains.

Ankle Sprains or Inversion Sprains Part 5

If you would like more information or to purchase our books please go towww.releaseyourbody.com . 

If you would like information about our clinic in Calgary Alberta please go to www.kinetichealth.ca.

(COPYRIGHT KINETIC HEALTH 2012 – ALL RIGHTS RESERVED)