Are you part of the 80% of the population who has suffered from low back pain?

Do you want to know how to prevent it from becoming a recurrent chronic problem?

Let’s start with some basic anatomy. Your spine is made up of a sequence of vertebrae, separated by discs. At every level of your spine (there are 5 levels in your low back, 12 in your upper back and 7 in your neck) there are 3 joints. When our back is working correctly this large number of joints allows our spine to move in multiple directions, to bend forwards and backwards, to lean to the side and to twist. Our muscles have two jobs. One job is to move the spine into these varied positions, for example if you lie down and contract your abs your spine will flex forward. Their other job is to stabilise the spine by holding all those joints together and stoping them from getting jammed up like a rusty hinge.

In order to perform these two jobs are body has developed two different types of muscles. The first group, the movers, are our big superficial muscles like our biceps, our quads and our 6-pack muscle. These muscles need to be strong to move our body, carry loads and propel us forward when walking or running. The second group are our deeper stabilising muscles such as our deep tummy muscle that supports our back, our deep neck flexors that support our head and neck and the lower part of our trapezius muscle that keeps our shoulders back and down. These muscles hold us in correct posture and stabilise our joints as we move around. They need to have excellent endurance as they are working in the background all the time.

If we look at the muscles in our back in more detail it can help us to understand what goes wrong when we get low back pain and our how to fix it. We have 3 layers of superficial tummy muscles, the 6 pack muscle and 2 layers of obliques. These muscles are working when we curl our trunk like a sit up, side bend and twist or when we cough or laugh. Your core muscles that protect and stabilise your lower back lie deep in your tummy. Your deep core muscle, called the transversus abdominus, wraps around the abdomen like a corset. When it contracts it sucks everything in like a weight lifters belt to stabilise the lower back.

As well as having a muscle wrapping around the front we also have a deep muscle as the back, known as multifidus, which acts like the lacing on the corset. These two muscles are also helped by our pelvic floor muscles which sit at the bottom of the core like a sling, and our breathing muscle called our diaphrapgm which sits on top like a lid. When all these muscles are working well together our low back is both stable and mobile, allowing us to bend, lift and twist painfree.

We know from clinical trials researching low back pain that when low back pain occurs our brain switches off these deep stabilising muscles and tries to use our superficial mover muscles instead. Hands on treatment from your physiotherapist will help to get your joints moving again and get rid of your pain, but it does not automatically fix the way the muscles are working. To get your deep tummy muscles strong again you need to do specific core muscle exercises. Otherwise your back remains vulnerable to injury and you will find your pain returns. These exercises can be shown to you by your physiotherapist and may seem quite challenging at first, especially if you are not used to using these muscles. They focus on getting the pathway from the brain to these muscles firing again and can require a lot of concentration to start with. Once you have the basic idea of turning these muscles on it is important to progress the exercises to incorporate movements of the arms, legs and torso. This is to make sure the stabilising muscles are working well when we are moving around during the day. Practising these exercises will help to prevent your low back pain becoming a recurrent problem and is particularly important if you have had pain for more than 6-12 weeks.

Many people find it hard to stay motivated to practice these exercises once their pain has gone, or find it difficult to know if they are performing them correctly. However just like going to the gym or changing our diet, if we only do it for a week or two, it is not going to give us any long term benefit. If you are one of those people who struggle to find the time to do the exercises at home or would like regular feedback to ensure you’re exercising correctly Pilates can be the answer.

Why Pilates?

Pilates exercises have a strong focus on the core muscles and are designed to help ensure correct technique. They also increase your flexibility, making sure your back stays supple. Pilates works all areas of the body. This is very helpful for people who have had low back pain because of tightness in their leg or bottom muscles or poor alignment in the knees or ankles. You will also find your posture improves with Pilates, taking pressure off not only your low back but also your neck and shoulders.

What to look for in Pilates class?

Pilates classes with low class numbers will ensure you get adequate attention and individualised feedback. Make sure you are being supervised by a qualified instructor, or even better, someone who is also a physiotherapist, to ensure you get the most benefit out of the exercises and you don’t develop any bad habits. This is particularly important if you still have pain or you have had other injuries. It is also important that people who have experienced low back pain start in a beginner’s class so that you have time to learn the basic exercises first. This way you will have a solid foundation to move from as the difficulty increases.

“If your spine is inflexibly stiff at 30, you are old.  If it is completely flexible at 60 you are young.” Joseph Pilates

Pilates is a great way to prevent recurrent injuries and correct muscle imbalances that predispose to overuse injuries such as hip pain, knee pain, shin splints and foot problems.

While running is great cardiovascular exercise its repetitive nature means some muscles get a hard workout while others get left behind. Also, regular running without appropriate stretching can lead to tight muscles that go on to give us pain and injuries. Pilates helps to engage and strengthen our deep tummy muscles (our core) that support our back and hips, and will give the body a more stable base to work from. Pilates exercises also focus on mobility and flexibility which is particularly important for runners as they commonly develop tightness through the gluts, hips and legs.

If you are part of the 80% of the population who experience low back pain, it is vital that you have proper rehabilitation, including retraining your core stabilizing muscles, before you return to, or commence, a regular running routine. If you do not work on the strength and endurance of these muscles you will find your pain keeps returning, interrupting your training and slowing you down. Pilates makes strengthening your core and your back easy and fun, and with a qualified instructor you can be confident your technique is spot on.

Improved breathing pattern and control is another area where Pilates can improve your running. Focus on the breath and correct breathing forms part of all Pilates exercises and is vital to promote oxygen exchange and increase stamina when running. Efficient breathing will leave you with more energy to run and avoid tension creeping into your neck and shoulders.

So if you’re a regular runner and want to break out of the injury cycle and improve your performance Pilates is a fun and relaxing way to keep you pounding the pavement painfree!

For more information on Pilates call Precision Physio now on 9280 2322 or email laura.c@precisionphysio.com.au.

“Patience and persistence are vital qualities in the ultimate successful accomplishment of any worthwhile endeavor.”  Joseph Pilates

Pilates is a safe, fun and relaxing way of strengthening your back and core, increasing your flexibility and preventing recurrent pain and injuries. Other benefits of Pilates include muscle toning, improved posture, flexibility, balance, coordination, management of chronic pain and improved sporting performance. Pilates also promotes general health and well being and helps to decrease stress and tension.

Precision Pilates involves a series of mat based exercises lead by your physiotherapist Pilates instructor.

At Precision Pilates we offer:

• Smaller class numbers – so you get individual attention and your technique is monitored
• Individual assessments – so we know your history and body type and can tailor the exercises to your needs
• Dual qualified physiotherapist and pilates instructors – specialising in pilates for rehabilitation
• Integrated approach – incorporating the latest scientific research on low back pain, core muscles, injury management and prevention with the time tried and tested methods of Joseph Pilates
• Safety – graded programme that builds your core foundation (and your confidence) first before progressing to more challenging exercises – you won’t be thrown in the deep end
• Health fund rebates – unlike standard Pilates classes, Physiotherapist run Pilates class are usually eligible for a rebate

At Precision Pilates the focus is on your body and your technique.

Who is pilates suitable for?

You don’t have to be flexible to gain the benefits of Pilates – from athletes to officeworkers, the young and the old, Pilates caters for those from all walks of life and can be adapted to suit all levels of ability.

If you have a recent or current injury or pain, speak to your Physio about whether Pilates is suitable for you. In most cases Pilates can be safely started even before your pain has resolved.

Pilates is also suitable for those with no pain or injuries looking to balance their lifestyle with regular strengthening and stretching.

If you are unsure email our Physio and Pilates Instructor Laura at laura.c@precisionphysio.com.au to find out if Pilates will work for you.

All equipment provided – it’s so easy to fit a class in at lunch or after work!

Call Precision Physio now on 9280 2322 or email laura.c@precisionphysio.com.au for more information.

Ligaments are tough bands of tissue that help connect bones together. The most commonly injured ligaments when you ‘roll’ your ankle are the three ligaments on the outside of the ankle. These are called;

• anterior talofibular ligament (ATFL)
• calcaneofibular ligament (CFL)
• posterior talofibular ligament (PTFL)

Normally, the ATFL keeps the ankle from gliding forward & inward, & the CFL keeps the ankle from rolling inward on its side. When the ankle joint is forced into these positions these ligaments are overstretched & can tear.

Initially the ankle joint will become swollen & may bruise. The ankle will be painful to move & depending on the severity of the injury, you may or may not be able to put weight through it. Certain areas, most commonly the outside of your ankle, may be tender to touch.

The best results after an ankle sprain occur when treatment begins straight away. If the ankle ligaments do not heal adequately the ankle may become unstable, causing the ankle to give way & feel untrustworthy on uneven surfaces. This is because the ligaments become weaker after the injury (even when the pain goes away) & without proper rehabilitation re-straining the ankle is very likely. People who have had several mild ankle sprains or one severe sprain may develop irritation & thickening of the ligaments that were sprained causing them to get pinched near the edge of the ankle joint on certain movements.

Studies show that the recurrence of ankle sprains can be as high as 80% & the incidence of developing a chronic ankle sprain between 20-40%. This is important because each sprain creates more scarring & increases the risk of more significant problems such as fractures (broken bones) & cartilage damage, so preventing recurrent sprains is essential. The 2 main reasons for these ongoing problems are;

• persisting weakness in the peritoneal muscles which help stabilise the outer ankle
• a loss of balance feedback (called proprioception) from your ankle to your brain.

Research shows that retraining these 2 components can dramatically reduce the risk of recurrent sprains. Your Physio can help you achieve this, as well as greatly speeding up your recovery from the original pain & inflammation. This lets you get back to your normal sports & activities a lot faster, & also reduces the risk of more inconvenience & damage through repeated injury.

• reducing pain & improving your ability to do daily tasks such as walk, drive & use stairs
• promoting weight loss, which reduces the stress & strain you put on your knees
• improving your balance & strength which helps prevent falls
• helping fight osteoporosis by increasing bone density
• reducing the risk of secondary problems with your ligaments, cartilage & kneecap

If you already have knee problems then exercise can be very good for you however you should consult your trainer or physio to make sure the exercise is right for you. Research shows that in conditions such as knee osteoarthritis the benefits of exercise are further improved when the exercise is done together with physio treatment & appropriate weight loss. The general recommendations for knee exercises for most people are;

• start gently and progress gradually. Have supervision if you are unsure or have any underlying problem or injury. You should not feel any knee pain as you exercise.
• use a mix of cardio & weights exercises
• keep to low-impact exercises initially eg exercise bike, cross-trainer, shallow squats (avoid deep squats as they stress your knee & your kneecap)
• make sure you wear appropriate shoes (trainers) because they absorb shock & help keep your whole leg in the right alignment
• keep the amount of strengthening you do for the back of your knee (eg hamstring curls) in balance with your exercises for the front (eg knee extensions). This balance is important for knee stability & preventing pain.

Following these few simple rules will get you on the right track to enjoying all of the great benefits that regular exercise can bring for your knees.

Between 50-80% of pregnant women will report SIJ (pelvis) or lumbar spine pain throughout their pregnancy. This pain is associated with the biochemical and structural changes during pregnancy and throughout postpartum (ie after giving birth) while the mother is still breastfeeding.

When  you are pregnant the hormone relaxin is produced and it continues to rise during the 1st trimester and in the final weeks of pregnancy. This hormone as the name suggests ””””relaxes”””” or loosens the muscles, tendons and ligaments in the body in order to allow the body to accommodate the growing baby. This hormone also breaks down collagen and prevents it from being synthesized.

So what does all this mean?

Well firstly, the increased weight of the belly means your pelvis tilts forward and as a result, your back compensates by arching back further i.e. the curve in your back deepens in order for you to maintain your balance. This ””””hyperlordotic”””” position can then cause the joints in your back to jam up and be irritated as the normal lubrication and movement through them is reduced.

What about the pelvis?

The joint between your pelvis (the illium) & your spine (the sacrum) is called the sacroiliac joint(SIJ). Normally the rough, groove like connecting surfaces of the sacrum and ilium interlock and help stabilise the joint. However when you are pregnant the relaxin hormone loosens and widens the joints at the front and back of the pelvis (SIJ and pubic symphysis) which reduces their stability and changes the efficiency of the muscles which attach around that region. Essentially the joint itself is loose, the ligaments become lax, and the muscles which usually stabilise  the pelvis aren””t able to work as efficiently. When you put all this together with the increased load on the baby you have an unstable pelvis which often causes pain.

Trauma at birth can also tear or loosen some of the ligaments in the pelvis. The pain around the pelvis will typically be a dull ache but can become a sharper pain with activities like standing from a seated position, climbing stairs and getting out of the car. Usually its on one side but can be across both, and the pain can refer down to the buttock or back of the thigh.

What can l do?

• avoid excessive unilateral (ie on one leg weight bearing activities eg excessive twisting, lifting, single leg stance postures, stair climbing.
• Get out of a chair or car with even weight through both feet.
• Sleep on your side with a pillow between your legs and under your pelvis.
• Get a physio to teach you how to train your core muscles as research has shown that these muscles are very important in stabilising your lower back and pelvis (they act like a corset around your low back and pelvic region).
• Avoid lying on your back for long periods of time, particularly after 19 weeks of pregnancy. This is because the weight of the baby and uterus can compress blood vessels & reduce the blood flow to the placenta and baby.
• When standing, maintain a good posture to alleviate the stress in your back and pelvis.
• Stand upright as though someone is pulling on a string attached to the top of your head.
• Keep your abdomen and buttocks pulled in to reduce the curvature in your lower back. Do not hold your breath.
• Keep your knees slightly bent when standing as locking the knees can increase the amount of curvature on your lower back.
• When sitting, choose a good straight backed chair and avoid slouching.
• Bend with your hips and not your back.
• Avoid lifting or carrying heavy objects.
• Reduce your stride length.
• A maternity belt around the pelvis can provide some relief as it re-stabilises your pelvis. Speak to your physio for this.
• Start training you pelvic floor muscles to prevent incontinence happening:
  • try to not go to the toilet on the first urge, but wait till the second urge
  • think of your pelvic floor muscles (muscles that allow you to hold your urine in) as a hammock and gently draw them up towards your belly; perform 10x 10 sec holds daily
  • using those same muscles perform 10 strong contractions (no need to hold these)

Pregnancy can be a tricky time for low back & SIJ pain, and often new mums find problems in these areas once they are caring for their baby as well. There is a lot that can be done to help re-stabilise your low back and pelvis to reduce these problems, and also advice about common daily activities that can help you reduce the strain you put through your back. If you are not sure then please chat to us or your local physio about how we can help you enjoy this exciting time of your life!

Unfortunately though, as with many sports there are always associated injuries and in swimming it is often the shoulder. One of the most common conditions that can occur is shoulder impingement.

Lets have a quick chat about the muscles and their function in the shoulder. There are 4 major muscles which make up your rotator cuff. Theses 4 muscles work to stabilise the shoulder as it moves through range.

If one of these 4 muscles are weak or there is tightness in the muscles controlling the shoulder blade then the top of the arm bone (humerus) can jam up under the roof of the shoulder blade (acromion). This can cause the tendons or the bursa (pocket of fluid) to become inflamed and painful.

Shoulder impingement usually occurs when your arm is up close to your ear in backstroke, freestyle, butterfly. It can also be when you are in a streamline position where your arm is slightly rotated inwards (internally rotated).

So think of the shoulder like a canoe and paddle – the swimmers hand is like a paddle and the rotator cuff muscles work like a fulcrum to stabilize the shoulder as the arm comes in and out of the water.

So how does shoulder impingement happen?

Shoulder impingement usually occurs when your arm is up close to your ear in backstroke, freestyle, butterfly. It can also be when you are in a streamline position where your arm is slightly rotated inwards (internally rotated).

This position causes friction of the head (ball) of the arm against the ligaments and the tendons.

This occurs due to:
• Poor swimming technique
• A large amount of training which can cause the muscles to fatigue and therefore work inefficiently or be overworked and fail
• Your hand crossing your bodys midline when it enters the water in freestyle or butterfly
• Your thumb pointing down and the palm facing outwards as your hand enters the water
• Unilateral breathing (ie only breathing on 1 side), as it can cause the opposite shoulder to become overworked
• The use of a kick board and streamline positions with the palm facing out can place the shoulder in a position of impingement
• The use of hand paddles or paddles without holes can increase the pull-through load, again placing increased strain on the shoulder muscles

Here are a few common swimming stroke problems to take note of to help avoid having a painful shoulder this summer!

Things NOT to do!

Butterfly:
• entering the water with your arms too far outside the shoulders or too close together (too close to midline)

Backstroke:
• pulling through with elbows extended (fully straight) which results in a straight arm pull through instead of an S shaped pull through.
• inadequate body roll

Freestyle:
• pulling through beyond the midline
• reaching out too far or aiming for too much length ahead
• inadequate body roll

Breaststroke:
• Excessive elbow straightening in the streamline position.

So have a think about your technique, have a think about the few technical problems mentioned above, and have a safe and painfree swimming season!

WAD

The type of neck problems people experience after a whiplash injury vary greatly and are collectively referred to as Whiplash Associated Disorders (WAD). These problems can range from mild neck stiffness to fracture/dislocation of the neck. Whipllash associated disorders include:

• neck stiffness
• neck pain
• pain in shoulders/arms/upper backheadaches
• dizziness
• double vision
• altered sensations in neck and arms
• weakness in neck and arms

WHAT THE LATEST RESEARCH SAYS ABOUT WAD

• Assuming serious injury such as neck fracture/dislocation has been ruled out a person with WAD can be rest assured that:
• The symptoms are a normal reaction to being hurt but there has been no serious damage. The muscles and joints have been affected but they have a natural ability to restore themselves which is helped by activity.
• Even though symptoms can persist for a while the acute pain will ease off in a few days or weeks, at least to a point where you can get on with your daily activities to some extent.
• Use simple painkillers to control your pain to help increase your activity levels.
• Avoiding daily activities slows recovery. Don’t stay in one position too long, move round before you stiffen up and keep moving!
• Gentle neck exercises are helpful.
• Try not to worry or be frightened of movement or pain. IN this case hurt is not the same as harm.
• Neck collars and rest are unhelpful.

HOW CAN PHYSIO HELP WAD?

Physiotherapy can help people with WAD provided they do not have the most severe WAD ie: fracture/dislocation of the neck for which urgent medical attention is required. Current research shows that people who carry on with their normal activities improve faster than those who limit their activities. Your physiotherapist can assist you in encouraging and promoting mobility in your neck. Working on mobility decreases the chances of the problem persisting into the long-term.

Physiotherapy can help you achieve this by prescribing you with appropriate exercises and progressing these as you improve. Manual techniques may also be used in the early stages to help with mobility of your neck . Your physiotherapist will also advise you about posture as this also plays a role in the path to recovery.
WADs are best treated with gentle movement as soon as possible-physiotherapists being movement specialists are here to help you get better as quickly as possible!

As the warm weather comes through there is no greater way to soak up the sun and enjoy spring but on your bike.

Cycling is a great way to get active for the recreational or competitive cyclist whether it be around the bay, through the park with your kids, through the bush or up and down dirt tracks on rugged terrain.

But before you get started here are a couple of tips on how to pedal and set up your bike properly to minimise injury and maximise your effort!

Firstly lets talk about seat height.

What is the optimal seat height?

Having a straight knee when the heel is resting comfortably on the pedal when you are sitting down on the bike. This means the knee will still be slightly bent on the maximum down stroke of your pedal.
Studies have shown that a forward seat tilting of 10-15 degrees will reduce the incidence of low back pain.

What happens if the seat is too high?

• Your hamstring (muscles as the back of your thigh) efficiency is reduced increasing the risk of hamstring strains.
• Your pelvis will tilt to the side thus causing your back to bend sideways too, causing jarring forces through your back and pelvis on that side.

What happens if the seat is too low?

• Your knee will bend more through the cycle which will increase forces onto your knee cap causing anterior knee pain (“patellofemoral pain”).
• Your hip will also go through greater ranges of bending potentially causing hip pain. Also, your back will have a tendency bend forward more increasing the load through the joints.

What is the ideal Handle bar position?

• When sitting on your bike, your spine should always be flat to reduce strain on your back
• the optimal trunk flexion (bend in your back) should be 20 degrees from horizontal, however, for recreational cyclists, 40-60 degrees of flexion is more comfortable and it will also reduce the strain on your back and neck as you have to look up to see the road ahead!
• Make sure the bend forward comes from your hips as much as possible rather than from your back.

Have you got the right pedalling technique?

• A good pedalling technique involves your ankle being at 90 degrees on the down stroke.
• When you ride too much with your toes you put more forces through the knee which can result in knee pain.

A good cycling revolution is:

• Push down using your buttock muscles, thigh, and calves pull across as you hit the bottom of the revolution then just relax on the up-phase of the revolution as the other leg starts to pedal down- do not try to pull the leg up! Its unnecessary work and will slow you down!
• Try to cycle without jolting when transitioning between the right and left leg; try to smooth it out.
• Concentrate on keeping your pelvis stable.

What can cause knee pain in cycling?

• The seat is too low or too far forward which increases the amount knee bend.
• Your bottom muscles are too weak! If they are too weak your quads will have to work extra hard to compensate.

What can I do if I have knee pain?

• tape up your knee – your local physio can show you how
• knee pain also commonly results from some muscles being too tight (eg your ITB) and others being too weak (eg your VMO and gluts (butt) muscles) – once again, your local physiotherapist can assess you and show you how to correct these problems

Check your program! Have you :

• Iced it for 20 mins post ride and relative rest i.e. reduce the intensity of your ride e.g less hills etc.

Well, this has been a whirlwind tour of how to get out and start pedaling in our beautiful Sydney weather. If you would like more information about cycling then check out http://www.topbike.com.au/physio.htm for heaps of information.

Each year around this time we start getting a steady stream of injuries from skiing, with many of them being knee ligament problems. The information below gives you an easy-to-understand background of why the knee is a problem area for skiing, and a run-down of the common ligaments that are injured. We’ll just stick to ligaments for this post, as cartilage & bone injuries are another whole story that we may look at another time.

Knee injuries account for about 1/3 of all skiing injuries, and the majority of these are related to ligament damage. Ligaments are like pieces of rope that cross over joints to hold the bones together in the right place.

As you can see in the diagram there are 4 main ligaments in the knee, one on each side (the medial and lateral collateral ligaments) and 2 that form a cross through the middle of the knee (the anterior and posterior cruciate ligaments).

Different ways of falling and twisting the knee predispose you to injure different ligaments, and more than one ligament may be injured in a single fall. Also, because treatment will vary depending on the degree of ligament damage, we use a system for grading the degree of injury;

• Grade 1 – minor sprain with no laxity (excess movement). Less than approx 30% of ligament fibres torn. Usually mild swelling and pain that often resolves in under a week.
• Grade 2 – moderate sprain with some laxity (excess movement) but still a firm “end feel” (a nice solid block that limits the movement). Approx 30-80% of fibres torn. There will be significant swelling and pain, and treatment is definitely required to ensure strong and durable healing.
• Grade 3 – severe sprain or rupture. Excessive laxity with no real end feel – effectively the joint will just keep moving the more you push it. 80% – 100% of fibres torn, which effectively means that the ligament has completely ruptured and does not hold the joint in position any more. Usually marked swelling and pain, although complete ruptures may present more as pronounced instability rather than pain as the 2 torn ends of the ligament are not joined any more and therefore do not get stressed with tension in the ligament.

Most Grade 1 & 2 ligament injuries respond well to physio and a full recovery is made. Grade 3 injuries need full investigation (eg MRI, orthopaedic review) to determine not just the full extent of ligament damage but also the usual damage to other structures like cartilage that often accompany Grade 3 knee ligament injuries.

Signs that you have a significantly damaged a knee ligament can include;

• Swelling, especially if this occurs rapidly eg within a few hours. Aggressive swelling, i.e. a large amount within 1-2 hours, strongly suggests a haemarthrosis (bleeding into the joint) and this should be investigated & treated ASAP.
• The knee does not seem to be aligned in it’s normal position
• You hear a “popping” sound or similar during your fall
• You are unable to take at least a moderate amount of weight through your knee due to pain &/or instability (just feels like it will give way)
• You aren’t able to fully straighten your knee
• There is sharp localised tenderness over 1 or 2 areas of your knee

If you have these signs then you should start RICE treatment straight away & go to see a physio or doctor ASAP. Getting treatment as early as possible is enormously beneficial to prevent secondary problems such as excessive swelling, muscle tightness, further injury due to more pressure through the knee, and muscle wasting due to reduced knee function.

As mentioned before you may injure more than 1 ligament in a single injury, &/or may injure other structures such as knee cartilage and bone. Below is a summary of the 2 most common knee ligament injuries – the medial collateral ligament (MCL) & the anterior cruciate ligament (ACL). Please remember that this info is for general advice only – please see your physio for an individual assessment of your knee.

Medial Collateral Ligament (MCL) Sprains

This is the commonest ski injury & accounts for around 25% of all ski injuries. It is often associated with the snow-plough position (ie skis wider apart & pointed inwards) & so is common in beginner skiers. It can also be caused by “catching an edge” as you start to go faster, so is also seen in intermediate skiers.

The mechanism of injury is a “valgus” force which is where the lower leg is taken out to the side so your foot moves outwards compared to you knee. This can be associated with an outwards rotation of the ski as well, so the front of the ski moves outwards twisting the knee out with it.

A diagnosis can be made based on the description of the fall (as above), and physical examination. There is usually at least some swelling in the knee, the inside of the knee will be tender to touch, it is often hard to fully straighten or bend the knee or take weight on it, and a valgus stress test whereby the lower leg is moved outwards relative to the knee reproduces pain.

The degree of movement and the “end feel” (ie how the ligament feels at the end of it’s stretched position) helps indicate the degree of injury, although often a full test is impossible initially due to acute pain.

Treatment includes techniques to reduce inflammation as quickly as possible, joint mobilisations (movements) to restore full movement, graded exercises to maintain and restore muscle strength, and proprioception exercises to restore your full balance and reaction times to your knee. These will be tailored later in your program to be specific to skiing & any other type of exercise you wish to return to.

Combining this end-stage proprioception retraining with specific strengthening is vital to ensure a full recovery and reduce the risk of re-injury. Most MCL injuries do not need further investigation (x-ray, MRI) or orthopaedic referral, however if your physio is concerned about the extent of injury further investigation will be arranged.

Anterior Cruciate Ligament (ACL) Sprains

ACL sprains account for about 15% of skiing injuries. They are one of the more serious knee injuries, partly because a full ACL rupture produces a very unstable knee that requires surgical repair (a “knee reconstruction”), and also because a fall that is bad enough to produce an ACL injury will often also injure other ligaments, bone or cartilage.

ACL injuries mainly occur when the tibia (shin bone) is sheared forwards on the femur (thigh bone), or when the knee is hyperextended (instead of bending backwards the shin bone is rotated forwards).

Because of the angle of the ski boot and the fact that the ankle is in a fixed position, if the back of the ski catches or hits first then the back of the ski boot drives the upper calf forwards, shearing the tibia forwards on the end of the thigh bone and damaging the ACL. The ACL also plays a role in controlling rotation of the knee so if this forward shearing is also associated by a rotation force then the ACL is very prone to injury. Hyperextension may occur if you catch an edge and the ski slows and changes direction and you effectively go forwards over towards the front of the ski.

There are 2 classic things that people report with ACL injuries. The first is hearing a “pop” during the fall (this may sometimes also be loud enough to be heard by other people nearby), and the second is a large swelling that appears rapidly (within 1-2 hours). This aggressive swelling is called a haemarthrosis, which means bleeding directly into the joint.

Other common things that people report after an ACL injury are moderate to severe pain (interestingly, sometimes complete ACL ruptures are not very painful because the 2 torn ends have no tension through them), inability to put weight through the knee, instability and feeling like the knee may just give way underneath them, and loss of range of movement.

Assessment in the clinic includes a thorough history and then several specific tests to check for the integrity of the ACL. If an ACL injury is suspected then you will be referred for orthopaedic assessment and usually an MRI. The earlier this is done the better especially as associated cartilage injury is relatively common, however some current schools of thought advocate delaying surgical ACL repair until the acute inflammation has resolved. Either way, early physio to reduce swelling, restore range and maintain/improve quads muscle function are extremely beneficial.

Partial tears of the ACL are treated in similar ways to partial tears of other ligaments, however complete tears routinely require surgical repair, especially if you plan to continue skiing and most other sports. Following surgical ACL repair physio is vital for progressing back to full function and minimising the risk of future problems. Depending on the surgery performed, any associated injuries, and your individual recovery pattern, return to full sporting activity is usually from 9 to 12 months and you may require a brace to help support your knee when skiing.

So, now you have a little background on the common ligament injuries encountered when skiing. Basically if you have a knee injury that limits your weightbearing or movement, produces some swelling or any feelings of instability then you should be assessed by a physio as early as possible. This is important not just for a speedy recovery from this injury, but is also vital for preventing secondary problems and potentially more injuries in the future due to incomplete recovery. Enjoy your time on the slopes