Injury is an all too often event in sport at all levels of participation. This may be the consequence of trauma such as falling off a bike or attrition associated with the repetitive nature of training for improved sports performance. These injuries will invariable result in time away from training and racing, and reduced performance. Injury is normally associated with a negative impact on the triathlete and a time of frustration. However, it should be viewed as a window of opportunity to review, refine, recondition and to improved athleticism and mental toughness.
What does a physiotherapst do?
Physiotherapists are traditionally associated with the rehabilitation of the injured and disabled. However before rehabilitation can begin it must start with the correct clinical diagnosis. Physiotherapists are skilled in the diagnosis of musculoskeletal conditions and undergo specialist training at undergraduate and postgraduate level. At a philosophical level physiotherapists first screen patients for signs and symptoms of serious medical conditions that need referral to a hospital for urgent care such as a fracture, tumour or neurological disorder. Once they are satisfied that the athletes condition is not mimicking a serious illness the search for the cause of the symptoms can begin.
Physiotherapists use an analytical process to establish the cause of the athlete’s symptoms in addition to prescribing treatment to reduce the severity of the symptoms. However, the cornerstone of good quality physiotherapy is to establish the cause of the athlete’s symptoms which is especially true in a sport such as triathlon because of its repetitive nature. The physiotherapist will take a full history of all the factors that led up to the injury and also examine other areas of the athlete’s lifestyle that may be delaying recovery. A physical examination is conducted:
* To make a clinical diagnosis
* To identify the consequences of the injury
* To identify the biomechanical or movement errors that may have contributed to the injury or continued delay in its recovery
Why see a physiotherapist?
Physiotherapists are human movement specialists and use their education of the human movement system to diagnose and treat pain which is related to movement. To understand the development of musculoskeletal pain one must accept that movement which is excessive, imprecise or insufficient can contribute and be the cause of injury and pathology.
The identification of these factors in an athlete’s injury history is the real difference between a skilled physiotherapists and other healthcare practitioners. While many healthcare professionals will focus on identifying and treating the injured soft tissues, the often ignored and more important question is “What caused them to become painful in the first place”. This can only occur through an analytical process using a structured interview with the athlete and conducting a detailed physical examination
What happens during the physiotherapist's physical examination?
The examination is a most important step in the physiotherapist’s management of persistent injuries and must never be rushed or curtailed in the sprint to begin treatment.
This is often the case for many healthcare professionals that have not undergone specialized training and for patients that don’t understand the importance of establishing a diagnosis for the injury and its biomechanical and movement consequences. This is a problem in the National Health System where time is rationed because of limited resources. However, it is also a problem in the private sector where patients often expect treatment on their first visit because they are paying for it!
So to be CLEAR!
* The physical examination is to clarify the extent and nature of your injury.
* To identify the biomechanical or movement errors that may contributed to the injury or continue to delay its recovery.
* It is to record numerical data about the athletes problems in order to establish a basis to judge their progress against.
Then and only then can a diagnosis be established to successfully treat the “Entire” problem.
Once the diagnosis has been made physiotherapists can offer the following:
* Manipulation
* Mobilisation
* Sports Massage
* Taping
* Dry needling (AKA Acupuncture)
* Exercise therapy and rehabilitation
* Two dimensional video analysis
* Strength and conditioning
* Lifestyle advice
* Behavioural modification
However, treatment without an in-depth understanding of the patient and their condition is like a house built of straw, its foundations are always flimsy and likely to collapse in unpredictable conditions.
Click here for an example case study
Uzo Ehiogu is Clinical Director of Inside Edge Physiotherapy a specialist clinic in the UK specialising in extreme outdoor sports, climbing and triathlon. He is a specialist musculoskeletal physiotherapist and strength and conditioning coach.
Uzo is a former Commando and British Army Officer and is himself a passionate climber and outdoor fitness athlete. For more information visit www.insideedgephysio.com or email at him info@insideedgephysio.com, or connect on Instagram and Facebook.
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Consider the case of a patient referring themselves with shoulder pain. This is a case which on face value should be relatively easy to manage by most competent healthcare professionals. However, now add in the fact that the patient is a triathlete and also has occasional pain traveling from the shoulder into the neck and down into the elbow. This is not an uncommon situation.
An isolated shoulder condition has been transformed into a complicated condition. It could in the worst case require a surgical procedure because of the patient’s hobby and potentially sinister neck and elbow symptoms. Add to this the fact that the patient has had neck pain while riding tri bars for over six months, has trained through the pain and is training for a half Ironman in four months.
Firstly, the physiotherapist must establish the correct diagnosis in order to design the right treatment plan. They must first determine which structures in the shoulder are injured if indeed the symptoms are located in the shoulder at all! The injured part could be one of four joints comprising the shoulder complex, over four tendons of the rotator cuff and many other muscles geographically close to the shoulder that can refer pain to the elbow and beyond. It could be any one of four peripheral nerves passing close to the shoulder complex.
Then the physiotherapist must assure themselves that your symptoms are not referred pain from the neck joints which can refer symptoms to your shoulder and elbow. So this needs to ruled out as a potential source of your symptoms by examining those areas or at least enquiring about them during the initial interview.
And there is more!
The expert also needs to medically screen the triathlete because they will always have an index of suspicion about serious illnesses that can mimic neck, shoulder and elbow symptoms.
Many patients are blissfully unaware that the lungs, gall bladder, diaphragm, heart, spleen and cancerous tumours in the lungs can refer pain to the shoulder and elbow when they are inflamed.
Now assuming this is a straight forward case of shoulder and neck pain which can only be established after a comprehensive interview and physical examination. We must explore the behaviour of the problem to determine the treatment procedures and their application. We know the neck and shoulder are persistent and longstanding, so there will invariably be secondary problems associated with this disorder.
For example, persistent shoulder pain can be the cause of reduced shoulder elevation at the forward reach phase during swimming because of reduced thoracic spine mobility. This can cause excessive movement at the shoulder region leading to overload of the local tendon tissues. In another example excessive abdominal muscle tightness caused by prolonged riding on tri bars can cause neck pain during swimming.
Abdominal tightness from riding in a flexed position can reduced thoracic spine expansion during swimming. This reduces head and neck rotation during the hand exit phase of the swimming stroke. This can cause neck pain and tension headaches. Sustained and repetitive postures can cause biomechanical or movement errors that may contribute to the injury or continue to delay its recovery.
Therefore, as you can see a comprehensive diagnostic examination is without question one of the most important steps in the physiotherapist’s management of sports injuries.