Over protection

By 13th December 2008 August 27th, 2013 Uncategorized

THERE are so many things that can spoil your skiing experience and that is why when everything is perfect it makes it that much more special. Right up there with frozen digits, fogged goggles and lack of new snow is pain. A sore knee or dodgy lower back will often cause you to ski below your full potential, hit the onsen early or even in chronic cases, give up the sport completely. However having some pain in a joint does not have to permanent and the solution might be easier than you think. As a winter sports physiotherapist you become quite familiar with diagnosing the typical acute injuries and pain suffered on the hill. However for those people that are carrying injuries for long periods (chronic injuries) the diagnosis and treatment often involves more of a psychological component as our minds have become hard wired to protect the body part.

Most people assume the classic interaction between a physiotherapist and a patient entails the patient desperately appealing to be allowed to return to their sport, while the therapist struggles against their will for them to rest. Occasionally this is accurate, especially at the elite level. However a more frequent scenario sees the physio trying to get the patient to trust their injured body more than they do and actually put it through more stress, so the body part becomes stronger and hence more biomechanically efficient. This is most common when dealing with long term knee problems and most types of lower back pain. Once a body part is injured our minds become aware that the appendage is less than perfect and we often modify our behaviour to take all the stress away from the body part. Without realising it many people will take most of their weight through their ‘good’ leg through the thousands of movements they do throughout the day – standing, getting out of a chair, walking up or down stairs; and this becomes self-fulfilling – the ‘bad’ leg gets even weaker and more biomechanically inefficient decreased function and inevitably, more pain.

One knee surgeon who we work with regularly has been known to encourage some of his patients to ‘thrash’ their knee – with the goal being to re-wire the mind to trust the knee again and strengthen the knee. However there are not many general doctors who would be prepared to give this type of advice as often their understanding of the true cause of the condition is not adequate. Patients can tend to lead health professionals into telling them what they want to hear with statements like “I just don’t stretch enough before I play, that’s the problem isn’t it” or “I just need to rest it more and stop playing for a while don’t I”. It takes a confident and knowledgeable health professional to disagree with these types of statements.

Of course it is not appropriate to advise all people suffering from knee conditions to work them harder and some cases do indeed require the patient to decrease their activities or have complete rest. An arthritic knee where the cartilage and or meniscus is worn out or long distance runners clocking 200kms a week are different cases. Some body parts – such as rotator cuff injuries in the shoulder, many neck problems and others don’t respond well to this type of management. So of course you should see the correct health professional to get your condition diagnosed before setting out on a ‘thrashing’ program. Often the level of stress that the body part is put through needs to be carefully graded so the condition that is causing the pain is not exacerbated by the program, so it is better to go through the rehabilitation program with occasional visits to a physiotherapist to check on your progress.

In the past two years of working at Niseko Physio I have termed a new condition I call ‘Powder Snowboarder’s Knee’. As most readers would know when in deep powder, riders need to lean back and put about 75% of their weight on their back leg to keep the nose from sinking down in the powder. This is even more important for snowboarders who are riding non-powder specific boards regularly in powder. When this is done for days, weeks and sometimes months on end it results in the front leg becoming much weaker than the back and often dysfunctional, injured and finally, painful. Patella tendinopathy and patella mal-tracking are the most common ailments that are the end result of ‘Powder Snowboarder’s Knee’. Once pain is present, the overprotection cycle begins and the problem becomes difficult to shake. It then becomes the therapist’s job to get the person to put the knee through more stress and make it as strong as the other leg again.

The lower back is another area that is often overprotected. Traditional management for bad backs was bed rest, and many general doctors still recommend this quite readily. The latest research suggests that backs respond faster when people are encouraged to continue on with their normal activity as much as possible. As in the knee, there tends to be a ‘fear factor’ that needs to be overcome for normal movement and function to return. Treat it normal and it will become normal, can often be a good motto.

How to know if you are an over-protector?

Try standing on one leg and doing one leg mini-squats until you are exhausted. Repeat on the other side. If there is a large difference in the maximum number that you can do, you need to strengthen the weak leg.

While doing your one leg squats, if you find your balance is particularly poor or your hip is ‘kinking’ out to the side as you lower your weight down on one side it is also a sign that the leg is somewhat dysfunctional.

Use a tape measure and check the circumference of your thigh 20cm above your knee on both sides – anything greater than a 1.5cm difference is significant.

While in long sitting flex your thigh muscles while looking at them and you may be able to see a difference – tapping on the muscle while it is flexed may reveal a difference in the density of the muscle.

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