Concussions Part I

Starting the New Year off with a happy topic…

A concussion is considered to be a minor traumatic brain injury. For the 48 hours following a concussion/blow to the head, careful monitoring should be carried out because there is an overlap between symptoms of concussions and haematomas/haemorrhages (bleeds on the brain). However, if a brain scan is carried out and there’s no bleeding or swelling only then can concussion be diagnosed. Generally a concussion isn’t a huge source of worry, but evidence has suggested repeated concussions can cause long term problems with mental abilities and trigger a form of dementia called chronic traumatic encephalopathy. This is a particular issue in athletes who suffer repeated severe concussions.

Delving a little further into the causes of concussionreticular-activating-system.jpg, it occurs when a sudden impact causes a disruption to the reticular activating system (RAS) in the center of the brain. This area helps to regulate awareness and consciousness; for example sleep cycles, attending to important information such as your name being called in a busy doctor’s surgery. If a head injury is severe enough to cause a concussion, the disruption in the brain cells triggers symptoms such as loss of memory and mental confusion.


Certain sports have a higher-than-average risk, including rugby, boxing, cycling, and martial arts. It’s argued that the benefits of regularly engaging in these sports outweigh potential concussion risks, particularly if correct equipment is worn. However, boxing is highlighted by doctors as dangerous because  the risks of serious brain injury are unacceptably high – the aim of the game is to beat the crap out of each other after all. (We’ll get to concussions in hockey in a later post and why it’s a hot topic currently!).

Mild concussions can be treated with self-care techniques such as a cold compress to reduce swelling, paracetamol for pain relief, rest, avoiding alcohol and drugs, and no contact sports. There is no definitive agreement on when one can safely return to sports following a concussion. The general steps are to wait until symptoms have passed for at least 24 hours then light exercise can be brought in, sport specific exercises (that exclude any impact to the head), non-contact training then full training with a return to play. However if symptoms re-emerge then take a step back. A concussion takes – on average – 7 to 10 days to recover fully.

It is worrying though that despite the awareness and research that has gone into concussions, we still do not have anything particularly concrete on them. Are certain individuals susceptible? Could we develop a biomarker to definitively diagnose a concussion? What about a treatment that actually does something rather than rest and gradual return?

Post-concussion syndrome (PCS) is used to describe symptoms that last for several weeks or months but the exact cause is poorly understood: There are thoughts that it could be a result of damage to nerve cells in the brain or a chemical imbalance triggered by the initial injury. The majority of PCS cases resolve within three to six months, and treatments for specific symptoms can be used to alleviate it, for example migraine medication for headaches or anti-depressants for depression. [X]



Imagery is a way of cognitively reproducing or visualising an object, scene, or sensation, as though it were occurring in overt, physical reality. One of the easiest ways to do this for yourself is to close your eyes and imagine yourself peeling an orange. Think of your nail scraping through the peel, the smell of the fruit, the stickiness of the fruit. And that’s imagery in the simplest of terms. It can be used in sport to visualise movements, e.g. complex  sequences in gymnastics, or slow motion imaging of taking a penalty kick.


Imagery can be internal or external therefore it’s essential that you assess whether athlete’s have a preference. This can be done using the Vividness of Movement Imagery Questionnaire which assesses whether athletes visualise the movement as watching themselves, through their own eyes, or by feeling it.

An imagery script can be written with an athlete to maximise the effects of imagery. The more vivid the actions and emotions are, the more valuable the script will be. It’s good to do this with the athlete, with only a small amount of input to help them, as it ought to be written in terms they will use as they are the one using the script. Scripts should include salient details to generate a good image.

Step 1: Tell the basic story Step 2: Add the details Step 3: Refining the script
Descriptors Action/Emotional Words

e.g. Usain Bolt is writing an imagery script to prepare himself for the 100m sprint.

Step 1: Getting ready

Step 2:Excited but energized, nervous, confident, aware of crowd buzzing

Step 3: I am getting ready for the start of the final in the 100 metre sprint. I am excited but energized, nervous but confident in my ability.

The script can help an athlete to focus and prepare themselves prior to a performance. As they say, if you fail to plan, you plan to fail!

Imagine standing on a putting surface seven feet from the hole. The hole lies at the top of a slight incline. You are aligned to the ball with an effortless stance. Your arms, wrists and putter are a single, relaxed but firm unit. You begin your backswing which is performed with a smooth pendulum like movement. As you make contact with the ball, your forward swing glides above the surface as you maintain a solid flowing form. – Holistic Imagery Script for a golfer

Injury Related Imagery

Imagery can also be used during injury rehabilitation as it can accelerate the process in some cases. If an athlete has injured their knee and has never come across imagery before then a good method is to show them the x-ray and highlight the damage then have the athlete visualise it. Then imagery can be introduced for the physiotherapy exercises used for rehab. Injured athletes have reported using it prior to performing exercises, to maintain their sport-specific abilities, and to motivationally image themselves as healthy. To assess motivational, cognitive, and healing functions of imagery, the Athletic Injury Imagery Questionnaire (Sordoni, Hall, & Forwell, 2002) is used.

Shoulder Injuries


  • AC injuryshoulder.png
  • Shoulder dislocation
  • Labral tears – SLAP lesion, unstable joint; if the joint is unstable then bicep will still function but will be less efficient
  • Bankhart’s lesions
  • Cuff tears – overloading young sports players or degenerate joints in old people are most common causes
  • Impingement

Cuff Tears:

  • Partial
  • Complete
  • Acute
  • Chronic


  • Pathology
  • Most common in overhead athletes such as swimming or racquet sports
  • Causation
  • Intrinsic e.g. acromium made the wrong shape
  • Extrinsic e.g. what you’re doing such as excessive serving for tennis


  • Core stability; fix core, scapula, move well
  • Scapula control; often anterior structures are damaged
  • Range of movement
  • Cuff strength
  • Strength through range

Achilles Tendon Injuries

Structure and Function:ankle


  • Two muscles in calf joint (gastrocnemius and soleus; gastro goes across two joints – knee and ankle)
  • Ankle-plantar function
  • Elastic structure
  • Key function: absorbs force and recoils


  • Rupture
    • Acute injury
    • Possible pre-existing pathology
    • History – feels like somebody kicked them
    • Examination
    • Investigation – if examined immediately then can feel the tear, but then blood clot will fill it.
    • Treatment
      • Surgical – mixed results for stitching
      • Conservative
    • Rehab
      • Pathology/procedure
      • Degree of atrophy
      • Commitment to rehab
      • Very hard to get back to the same standard after achilles tendon damage
    • Tendonopathy
      • Also known as tendonitis but this is false as it suggests inflammation, but anti-inflammatory tablets will do nothing.
      • Pathology
        • Pathology is a continuum
        • Reactive tendinopathy
        • Tendon disrepair
        • Tendon degeneration
      • Symptoms
      • Investigation
      • Underlying causes
      • Role of Pain
        • Occurs at any point – normal looking ones can hurt
        • 2/3rds of ruptures have no pain


  • With so many treatments available, none can be gold standard
Unloading Eccentric loading Strengthening NSAIDs
Massage Surgery Orthotics GTN patches
Acupuncture ESWT Dry needling Various injections

Hamstring Injuries

Structure and Function:

  • Three muscles
  • Crosses two joints; they start above the hip and below the knee.hamstring.png
  • Complex balance of concentric and eccentric actions.
  • Greatest function is eccentric and very demanding; control.
  • Acute hamstring injuries come from sprinting most often. People feel something rip – like carpet tearing.
  • Check the spinal movements e.g. sciatica as hamstring pain can often be neurological rather than something genuinely wrong with the muscle.


  • Tears
    • Grade 1 – microscopic damage; mild muscle pull or strain
    • Grade 2 – majority of tears; partial muscle tears
    • Grade 3 – one bit torn away from the other; complete muscle tear
  • Tendonopathy
    • Proximal
    • Distal
    • How much of the muscle is involved?


  • Clinical
    • Strength; will hurt them, assess strength and pain
    • Stretch; also going to hurt, assess flexibility and pain
  • Investigation
    • Ultrasound
    • MRI; looking for the size of the injury, not the size of the edema


  • Interventional
  • Rehabilitation – a lot more options available
    • Pathology
    • RICE – limit secondary muscle damage
    • Mobilise
    • Strengthen – weights, open and closed chain; look what strength they have within a comfortable range.
    • Return to function
  • Strength
    • Low level of activity: knee flex and extend hip so leg raise. Hamstring and gluteals extend hip so need to strengthen glutes to prevent future hamstring injury.
    • Build up to low resistance flexion with the rubber bands around ankles or hips and a post.
    • Resisted weight machines as these are closed chain activities; it strengthens the muscle but it is not functional.
    • Put the closed chains together, making it open chained, so squats, lunges, and dead lifts.
    • Must be able to walk before they can run.
    • Cycling – mainly concentric, low risk, protects cardiovascular fitness and gets muscle working.
    • Cross trainer is a good progression from walking with reduced loading compared to running, but is a similar action.
    • Walking then uphill or backwards then jogging.
  • Speed
  • Acceleration
    • Acceleration/deceleration are very important in sports but likely to damage hamstring, so this must be put into rehab
    • Can use GPS tracking to get a look at speeds etc
    • The quicker you push an injured athlete and harder, more likely they will break
    • Have to introduce sport specific skills e.g. spring to this cone then kick a ball
  • Endurance
  • If fibres heal shorter than others then they will take all the stress so need to make sure they’re flexing and lengthened

Anterior Cruciate Ligament Injuries Part Two

The first post on the anterior cruciate ligament (ACL) focused mostly on the anatomy of the knee joint and how injury occurs there. This second part will look at treating one, from a sports physiotherapist point of view.

Conservative or Surgical:

  • Often both methods are required
  • Depends upon:
    • Age of athlete
    • Degree of instability
    • Associated injuries
    • Pivoting in sport
    • Compliance with rehab programme
  • Basically, is it worth the surgery? It’s a long lay off for ACL injuries in terms of rehab, and if you’re just playing football on a Sunday morning with your mates, you may have to consider whether a lengthy rehab plan is worth it.

Surgical Treatment:

  • People will often say that it gives way – the knee is trying to slip out of place due to no ACL and that puts the meniscus at risk and can lead to joint degeneration.
  • Aim is to replace the torn ACL with a graft that reproduces the normal function of the ligament. You cannot repair the ACL, it would be like trying to repair a piece of string.
  • Surgery options:
    • Bone-patella tendon-bone; this gives a chronically sore knee so bad if you need to kneel a lot
    • Hamstring graft; doesn’t anchor as well and is quite thin so you can double it up to make it less stretchy


  • Patella tendon reconstruction is associated with pain on kneeling, a higher rate of morbidity and a big scar.
  • Hamstring reconstruction is associated with decreased end range knee flexion power.
  • If a hamstring graft is done then you almost must ensure this muscle goes through rehabilitation too.
  • Often methods depend on surgeons and countries. Some countries they will use the hamstring from the injured leg, whereas others prefer to take it from the non-injured knee. There’s no right or wrong option here either.

The next half of this post will go over a general rehab plan for ACL injuries.

Accelerated Rehabilitation: ACL.jpg

  • Prehabilitation
    • Reduce swelling/pain, restore FROM and educate the athlete. This can be walking, cycling or easy front crawl in a pool. Surgeon will not operate until injury site is ready with ROM and effusion has stopped. Talk to player, reason with them and explain why the operation cannot be performed immediately. PRICE and movement are key. More you move, the quicker the swelling goes down.
  • Phase 1 (0-2 weeks) Post-Op
    • Partial/full weight bearing, or functional brace could be worn. Aim to reduce swelling and get 0-100 degree movement range. 5/5 hamstring and quads strength. Start with simple exercises and build up; quads, VMO, bilateral calf raise, hip adduction and extension, hamstring pulleys, gait drills.
  • Phase 2 (2-12 weeks) Post-Op
    • No swelling, full flexion 130 degrees and full hyperextension. Full squat ability and good balance with unrestricted walking. ROM/quads, mini-squats and lunges, leg press, step-ups and exercise bike.
  • Phase 3 (3-6 months) Post-Op
    • Full ROM/strength. Return to jogging/agility. Restricted sport specific drills. Straight line jogging, road bike, jump and land drills, agility drills.
  • Phase 4 (6-12 months) Post-Op
    • Progressive return to sport, restricted then unrestricted training. Partial match play then competitive match.
    • Must do skill work too – practice kicking balls if they’re a footballer.

Outcome Measures:

  • Return to sport
  • Re-injury rate
  • Prevalence of osteoarthritis

Anterior Cruciate Ligament Injuries

Anatomy: knee.png

  • The knee is the largest joint in the body and it’s made of a double condyloid joint that includes the distal femur, proximal tibia, and patella bones.
  • There are two types of ligaments- collateral and cruciate. The collateral ones are medial and lateral, and the cruciate are posterior and anterior.


  • It resists excessive anterior movement of tibia on femur.
  • It prevents hyperextension.
  • It aids resistance of excessive valgus stress.

ACL Injuries:knee2.png

  • Very common sports injury-in the UK, majority from football, but this is due to the sheer number of people who play football. You’re more likely to tear your ACL in a sport like taekwando that involves a lot of pivoting.
  • It can occur in isolation or in combination with a meniscus or MCL
    (medial collateral ligament) tear.
  • If left untreated then it can lead to instability, degeneration, or meniscal injuries.
  • Symptoms include an audible pop or sensation, extreme pain and swelling within an hour.

ACL Injuries and Women:

  • Women are 3-6 times more likely to injure their ACL than men, but statistically more men injure their ACL because more play sport.
  • Anatomically; women have a wider pelvis and the intracondylar notch is narrower (where the ACL starts)
  • Hormonal; progesterone has an effect on the tensile strength of ligaments and tendons
  • Neuromuscular; women can’t control their knees as well as men?