Return to exercise post-COVID-19 infection

Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022

Reference: D.C. Hughes, J.W. Orchard, E.M. Partridge, et al., Return to exercise post-COVID-19 infection: A pragmatic approach in mid-2022, Journal of Science and Medicine in Sport, https://doi.org/10.1016/j.jsams.2022.06.001

We posted in February (Returning to exercise after Covid-19) about returning to sport after COVID. With increasing experience in managing patients back to activity, we recommend the following approach

The following flow chart provides a safe pathway guide for individuals to return to exercise following Covid-19 infection.  The article identifies that the initial concerns of myocarditis in young healthy individuals has revealed very low rates and most individuals can return to exercise in 7-14 days post infection.

Our head of Physiotherapy at Ballarat Sports Medicine, Luke Blunden, recommends individuals consider the following flowchart along with medical advice for a return to exercise post Covid-19.

How a mother’s love and a miracle gave Xavier new life

When a car hit Xavier Mahabelo so hard it ripped the skin and muscle clean off his leg, his only shot at survival was on the other side of the world in a Melbourne hospital.

This wonderful article describes how our own BallaratOSM orthopaedic surgeon, Mr Shaun English, assessed Xavier’s injury on the ground in Madagascar in 2019, when he volunteered with Australian Doctors in Africa.  Shaun subsequently liaised with his colleague Professor Leo Donnan back in Australia, who offered to undertake the life changing surgery.  Read more about Xavier and the incredible gift dedicated orthopaedic surgeons provided HERE.

World Athletics Championships Oregon 22

Ballarat Sports Medicine’s Dr Greg Harris, Sport & Exercise Medicine Physician is soon to travel to Oregon, USA to be part of the World Athletics Championships. Greg will be the team doctor for the Australian contingent.

Initially the team will be based in Seattle for a pre-event training camp for 10 days before transferring to Eugene, Oregon for the main event, July 15th-24th 2022.  Greg will be reporting back to Ballarat Sports Medicine on his experiences upon when we aim to update our followers on social media about Greg’s experiences.  Outside the Olympics, the World Championships is the premier world event for track and field athletics.  It is not only a great honour and privilege being appointed to team doctor but a testament to the skills and experience that Greg brings.     

Greg will be unavailable for appointments from July 1st – July 29th but our Sport & Exercise Medicine registrar, Dr Bryn Savill will still be seeing patients. 

NOVAR Musculoskeletal Research Institute (NMRI)

Tax-Deductible donations of support welcome

Ballarat OSM and NOVAR Specialist Healthcare work closely with NMRI, a non-for-profit clinical research, training, and education institute based in Ballarat. 

Through collaboration with the community, we seek to improve the lives of patients with musculoskeletal conditions and diseases. Our aim is to enhance the understanding and healthcare of musculoskeletal disease through published clinical and non-clinical research, by collecting and collating data utilised for information dissemination through publishing high quality articles in reputable journals and enhancing cooperation.

You can help by participating in our patient outcomes research program, and by making a tax-deductible donation to support the research institute.

No bones about it, we can’t do it without your support.

Our Vision

Masters of responsible research and innovation, driving collegiality and improvement in musculoskeletal disease healthcare.

Our Mission

Innovative patient focused research institute that engages and enriches the community, through improved musculoskeletal healthcare outcomes via strong commitment to excellence in the field of traumatic and degenerative musculoskeletal disease.

Perioperative Carbohydrate Loading

In our quest to improve Rapid Recovery Surgery, we’ve been carbohydrate loading our patients. Now there’s a Randomized Controlled Trial on the subject.

“Don’t upset the applecart” has been a key component to rapid recovery surgery. Simplifying peri-operative care has been a consequence. An old anaesthetic idea of “fasting for 6 hours” has been replaced with “no solid food for six hours, but free fluids until 2 hours prior to surgery”. By reducing the risk of vomiting, endotracheal tubes have been mainly replaced with laryngeal masks, which is more comfortable for the patients. By adding carbohydrate to the clear fluid (eg Powerade) the patients don’t feel as “starved” and have better energy mobilising after surgery. At BallaratOSM, we’ve done this since 2015, giving the patients a bottle of Powerade to have an hour before they’re due at the hospital.

In the Journal of America Academy of Orthopaedic Surgeons, there’s been a published randomised controlled trial, between 800ml “Nutricia Preop”, 400ml lemon flavoured water, and no water. No differences were found on the long list of things they tested…. Except readmission rate. The Odds Ratio of readmission was 0.08 between their carbohydrate loaded patients, and the entirely fasted group. p-0.024 Postoperative boluses of narcotics are more likely in the fasted group as well. Length of stay for their knee replacements, like ours, averaged a bit over a day.

We’ll stick to our plan of not upsetting the applecart.

Reference:

Kadado, Allen MD; Shaw, Jonathan H. MD; Ayoola, Ayooluwa S. MD; Akioyamen, Noel O. MD; North, W. Trevor MD; Charters, Michael A. MD. Effects of Preoperative Carbohydrate-rich Drinks on Immediate Postoperative Outcomes in Total Knee Arthroplasty: A Randomized Controlled Trial.

Journal of the American Academy of Orthopaedic Surgeons: June 1, 2022 – Volume 30 – Issue 11 – p e833-e841 doi: 10.5435/JAAOS-D-21-00960

Masters Swimming Ballarat

Do you know the most common injuries in swimming?

The Masters Swimming Australia National Championships were held April 20-24th at the Sydney Olympic Park Aquatic Centre this year. There are many Masters Swimming clubs around Australia, including a club in Ballarat. The Ballarat Masters Swimming club includes several members from the medical fraternity who swim regularly on Tuesday, Thursday, and Saturday each week. The President of the club is Dr Greg Hughes, Anaesthetist, and part of the Anaesthetic Group of Ballarat, with which BallaratOSM has a close working relationship. In addition, Dr Andrew Lowe, General Surgeon, specializing in upper gastrointestinal surgery and biliary and pancreatic surgery, Alicia Concannon, Medical Radiation Scientist, and our own Practice Manager, and Medical Scientist, Adrian Warmington. Programs in Ballarat are designed by a club member from Daylesford and former Canadian Olympic swimmer Tim Bach.
But as the name suggests, Masters swimmers are prone to injury. Swimming involves both explosive short distance sprinting and longer distance repetitive motion swimming. Different strokes involve a range of dynamic movements and use of a range of muscle groups.


Common injuries include

  • Labrum tear (SLAP-lesion)
  • Rotator cuff injury
  • Patellofemoral pain syndrome
The Ballarat Sports Medicine and BallaratOSM teams are always available to assess, diagnose and treat your injuries. Contact us to see our Physiotherapist, Sport & Exercise Medicine physicians, Rehabilitation Physician and Orthopaedic Surgeons.

Labrum tear (SLAP-lesion)

The glenoid labrum is a cartilaginous rim that stabilizes and protects the shoulder joint. Labrum injuries often occur in throwing sports and sports where the arm is frequently raised above shoulder height such as swimming and in particular butterfly.

The labrum is located where the upper arm attaches to the shoulder blade. It surrounds the head of the upper arm and thereby increases the stability of this joint during shoulder movements. The most common labrum injury is called a SLAP lesion. It occurs in the upper part of the cartilaginous rim, where the biceps tendon attaches.
The labrum can be damaged as a result of an acute injury and also as a result of an overuse injury from repeatedly performing a throwing movement with high forces. As such, SLAP lesions are common in throwing sports like water polo, where the arm is frequently used above shoulder height.

A common symptom of a SLAP lesion is pain in the upper or back part of the shoulder. The shoulder can also feel unstable, and there might be a sensation of “catching” or “clicking” in the joint.

Treatment

The first step in treatment will always be a rehabilitation period of at least 3 to 6 months with guidance from a physiotherapist or Sport & Exercise Medicine physician. If there is no improvement during this time, surgery may be considered. The surgeon will often determine how much the injured person should be allowed to move their shoulder once the surgery is completed. It is important to follow these restrictions as it allows healing to take place.
Between 80 to 100% of athletes return to sport following surgery, but only 50 to 60% of these can perform at the same level as before.

Rehabilitation

In the first phase following surgery and until the injured area has fully healed, it should be kept immobile. This usually takes up to 6 weeks.


During rehabilitation, it is important to train:

  • Mobility
  • Interaction between the muscles
  • Movement control
  • Strength


It takes on average 11 to 13 months before an athlete can return to sport. All measures to restore normal strength and control should be taken before the athlete’s return to sport.

Impingement of the rotator cuff

The rotator cuff is a term for the muscles around the shoulder blade. Shoulder impingement is a very common cause of shoulder pain in athletes it is considered an overuse injury.

Shoulder overuse injuries in athletes often occur when they perform many repeated movements. The tendons of the muscles can also be injured if they become impinged between bones in the shoulder joint during certain movements, such as throwing.

Injury to rotator cuff tendons usually happens gradually. In the early stages, pain can actually be felt without the occurrence of any structural damage. In later stages the tendon tissue can become weaker. This is known as tendinosis, and it can ultimately result in the partial or complete rupture (tearing) of the tendon.
Tendinosis of the rotator cuff is very common among athletes in sports that involve a lot of movement with the arms raised above shoulder height such as swimming. This activity places extreme demands on the shoulder.

Impingement

Impingement is one of the most common causes of shoulder pain in the rotator cuff. It results from a tendon becoming pinched between the upper arm and the shoulder blade (scapula) in certain positions when the arm is raised.

There are two main types of impingement: subacromial impingement. This is when the arm is raised straight up above the head, and posterior impingement, which occurs when the arm is held all the way back in a throwing position.

Subacromial impingement

Subacromial impingement occurs in the so-called subacromial space between the head of the upper arm and the top of the shoulder blade where they make up the shoulder joint. The supraspinatus tendon (one of the rotator cuff muscles) is most often affected. In addition, other structures such as a fat pad (subacromial bursa) can also be affected. Given that several structures can be involved, we often refer to this as impingement syndrome.
Subacromial impingement syndrome can be caused by variations in shoulder anatomy, muscle tightness, a stretched joint capsule or due to a lack of stability from the muscles around the shoulder blade. A common and effective way to treat this is to use an individualized training program. If conservative treatment fails, surgery can be performed to increase the subacromial space. Subacromial impingement is most common among people aged above 45, but it can also occur in younger athletes.


Posterior impingement

Posterior impingement is common amongst athletes in sports where the main activity is above shoulder height. The condition concerns the tendons of the infraspinatus and supraspinatus
muscles and occurs when the shoulder is held all the way back in a throwing position. Typically, athletes with posterior impingement experience pain in the back of the shoulder when in this position.

Posterior impingement can be caused by a lack of control and stability of the shoulder blade. Poor swimming technique during strokes such as butterfly and backstroke increase the risk of posterior impringement.

Treatment and rehabilitation

The first step in treatment for almost all injuries of the rotator cuff is an individualized rehabilitation program. During rehabilitation, the athlete should be removed from the activity or sport that caused the injury. A physiotherapist or Sport & Exercise Medicine physician should supervise the program and focus should be on specific factors such as:

  • Mobility of the shoulder
  • Strength and coordination of the rotator cuff
  • Control of the shoulder blade
  • Sport specific training (for example, in throwing sports strength and mobility of the hip, upper back, and shoulder are very crucial)


It is imperative that the load and demands on the shoulder are increased gradually so that the athlete can fully participate in the sport without experiencing pain. This approach is successful in the majority of cases, even when there is considerable structural damage to the tendon, such as with a full thickness tear. It often takes up to 6 months of rehabilitation before any significant improvements are noticeable.

Sometimes a cortisone injection can be of help in relieving the pain and allowing rehabilitation to proceed. A cortisone injection usually will not fix impingement by itself, and is best done with ultrasound or some other form of imaging guidance.

If conservative treatment is unsuccessful, surgery should be considered. However, surgery should not be viewed as a quick-fix solution. Recent research shows that around 25% of athletes in throwing sports don’t return to sport following surgery to the rotator cuff, and only a small percentage of those who do return manage to do so at their pre-injury level of performance. Also, rehabilitation following surgery takes a long time. The average duration for a return to sport is 12 months.

Patellofemoral pain syndrome

This condition is characterized by diffuse pain in and around the kneecap without a specific cause.

Studies have shown that around 50% of non-specific knee pain (pain of unknown cause) may be due to patellofemoral pain syndrome (PFPS). PFPS is not uncommon particularly in breaststroke swimmers. The amount of pain directly correlates with the number of years of training, amount of training, skill level and age.
PFPS may be caused by several factors, and with athletes it can be related to excessive overload.

Symptoms

The most common symptom is a diffuse pain in and around the kneecap without having an injury. The pain is aggravated by using stairs (especially going down), squatting, cycling, and with prolonged sitting. It is uncommon for the knee to lock-up or give-way, as is common with other knee injuries and conditions. The knee may feel stiff, even though it still has normal flexibility. Noises from your knee are common and not a sign of damage.

Diagnosis

A doctor, Sport & Exercise Medicine physician or a physiotherapist will take your medical history and conduct a physical examination to confirm the diagnosis. X-ray and MRI images are often normal and are therefore of limited use.

Risk factors

We do not know exactly what causes PFPS. Some anatomical and biomechanical factors have been suggested as risk factors for developing the condition. Examples include overpronation (when the foot lands on outside of the heel and rolls inward), reduced strength and hip control. It is also likely that the training volume and intensity may play an important role. When anatomical factors are combined with overuse, there may be a risk of developing PFPS.

Gender is also considered a risk factor; female athletes have 1.5 – 3 times higher occurrence of PFPS than their male counterparts.

Treatment and rehabilitation

The treatment of PFPS requires a holistic approach that considers all the potential factors that might have caused the condition. For some it might be appropriate to focus on strength, mobility or muscle control. This is usually done with a structured training program. It is advised to consult a physiotherapist or Sport & Exercise physician who has expertise in dealing with this condition.

Load management

Load management is one of the most important aspects of effective treatment and the athlete’s total training load should be summarized and evaluated. It is often necessary to reduce the amount of pain provoking activities for a short period. Using orthotics (knee braces) and tape may reduce symptoms, but often temporarily. They can, therefore, be used as part of the overall treatment strategy. The return to sport should be gradual and well structured. Good communication and collaboration with the coach are recommended throughout the rehabilitation.

For more information about water polo injuries visit https://fittoplay.org/sports/swimming/the-most-common-injuries-in-swimming/

Practice Nurses here to assist

BallaratOSM employs three highly skilled nurses. Not only do our nurses frequently assist our surgeons in theatre, but they are always present in our rooms during normal business hours to provide care for patients. Our practice has two dedicated treatment rooms, specifically designed and set-up to provide clinical care. Patients have both pre and post operative appointments with nurses, but if things are not going entirely to plan, the nurses are always available to take a call from a patient to discuss wound management and pain management; or any other question to ensure excellence in the patient health care experience.

The nurses have a dedicated mobile phone that is a particularly valuable tool particularly for remote patients. Rather than travel into the rooms, the nurses can frequently assist patients using video calls or MMS images of wounds. These can also be shown to the surgeon for review for specialist advice if required.

Our post graduate trained nurse practitioner adds the ability to refer patients to allied health and specialist clinicians such as physiotherapy, Sport & Exercise Medicine physicians and Rehabilitation physicians for specific health care options. Our nurse practitioner will also assist patient pain management by providing scripts for pharmaceutical needs. And post-surgery, when the patient is due for orthopaedic review, our nurse practitioner can refer the patient for radiological examination.

Our nurses are a key healthcare professional in the expansive team that is Ballarat Orthopaedics and Sports Medicine.

National Junior Basketball Champions!

‘It was a fun week learning from, teaching and working with amazing sports people in Ballarat’

The National Junior Basketball championships were held in Ballarat from 10th to 17th April at Selkirk stadium. You may have noticed that Luke Blunden was not in the clinic at Ballarat Sports Medicine as he had been asked to provide his Sports Physiotherapy expertise to the under 18 Victorian Metropolitan women’s basketball team. Luke supported the elite team coached by Michael Brookens assisting with team and player preparation, monitoring, recovery, rehabilitation and performance needs. The team benefited from the diversity of Lukes Sports Physiotherapy experience describing the input as a critical factor to their success.

The Vic Metro team was able to blast an undefeated path through the competition into the finals where it then overcame strong competition from the Victorian Country, North and South Queensland teams to claim the gold medal and national junior title!

For Luke it was a fun week stepping out of the clinic to support sporting teams for the first time in a few years. It was a great opportunity to support young talented athletes, providing them with an elite Physiotherapy experience to assist in their campaign and development as athletes. It was also a great learning opportunity meeting other sports physiotherapists, coaching and support staff from over Australia.

You can find out more about this event on the Basketball Australia website or Basketball Victoria Facebook page and games can be watched on Kayo sports or via you tube.

Rehabilitated Cyclist & the Peaks Challenge

Mr David Mitchell, Orthopaedic Surgeon and Dr Josh Collingwood, Rehabilitation Physician have completed the Peaks Challenge – one of the more gruelling bike rides in Australia.

235km. 4500m vertical climbing. From Falls Creek, one descends to Mt Beauty, across the Tawonga Gap to Harrietville, up Mt Hotham, down to Omeo, and up the back of Falls and across the high plains. Ironically, it was training for this ride that David had a spinal injury a year ago, but was allowed back on the exercise bike a week after surgery. Josh Collingwood, retired professional cyclist, now rehabilitation physician, saw this an opportunity for a special training program.

Individualised patient care!

Mr David Mitchell

Dr Bronwyn Sudholz is returning

Dr Bronwyn Sudholz is returning from Maternity leave after Easter and looking forward to once again receiving referrals and looking after patients. Bronwyn is a registered Clinical Health Psychologist who works with teenagers and adults presenting with anxiety, depression, trauma, and personality disorders, and has a particular interest and expertise in the areas of:

Bronwyn will be increasing her private practice hours to two full days (Tuesdays and Thursdays). She runs 50 minute sessions; clients can pay privately or gain rebates from Medicare, private health, or a third party (eg: Workcover, TAC).

Bronwyn has over 10 years’ experience in health psychology, gained from private and community settings, as well as at Deakin University in research and teaching. She has expertise in various evidence-based therapies: Cognitive Behavioural Therapy, Acceptance and Commitment Therapy (inc. Mindfulness), Dialectical Behaviour Therapy and Schema Therapy. For more information on her experience and approach see https://ballaratosm.com.au/psychology/.