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Hip and Groin Injuries and Prevention in Hockey Goalies

Hip and groin injuries are commonplace among hockey players of all ages[1]. The elite hockey level accounts for 20% of all injuries[2]. A young goalie focuses much of their attention in strengthening their stance when developing their skills. A lot of the stress is placed on the hip joints. Research tells us that during the growing years of a young hockey athlete, there is an association with increased risk for developing hip injuries [4]. I will summarize the details of a recent study and provide you with tips for how to prevent and heal hip and groin injuries.

A recent study looked at the prevalence of hip impingement (Femoroacetabular impingement – FAI) in young ice hockey players and found a significant correlation between age and elevated angles of the hips[3]. Some suggest that constant irritation and dysfunction of the hip joint in sport may leads to increased bony overgrowths around the hip bones that leads to hip pain. These hip impingement deformities can lead to tears of the hip ligaments, poor biomechanics and further developmental issues, thus reducing player performance! This is especially noticeable among young, developing athletes, where they are more susceptible to hip impingement injury [4].

Hockey goalies are more likely to develop hip impingements than forwards and defensemen, due to constant stress along the hips during stance and lateral movements. It is believed that poorly developed body mechanics during a goalie stance are secondary to fatiguing hip and back muscles. The fatigued muscles ultimately effect the amount of force on the hip, and in turn can lead to hip impingement. A more recent study showed that the prevalence of hip impingement is higher than reported among elite level hockey players[5]. It is important to understand the link to the athlete’s biomechanics and movement, when planning a strategy for their development.

How do we help prevent hip impingement?

It is important to screen young athletes for hip and back biomechanics. Scheduling screening at different levels of their advancement provides a benchmark and tracking point to identify the level of their affected muscles and ligaments. The screens will also test for strength and effectiveness of the muscles involved during various movements that the athlete will use as they mature through their development, programing and conditioning. This screening can help guide the athlete away from improper movements that can lead to hip injuries. After an athlete’s biomechanics are assessed using a screening method, the athlete can then be guided in their development to further correct any movement deficits and strengthen areas that are weak, thus preventing impingement, and improving performance. Thus, a movement screening program for hockey athletes can help identify biomechanical disadvantages that prevent hip injuries such as impingement.

A Hockey Functional Movement Assessment will assess the biomechanics of the knees, hips, back, mobility of the ankles, middle back, shoulders, and neck, as well as the activation of certain groups of muscles that help with activating muscles that are key for movements. This integrated assessment will also help the athlete understand where their flaws are, and how to monitor development. The health care provider that administers this assessment will often recommend exercises to help rehabilitate certain areas and use clinical interventions such as manual therapy, acupuncture, and chiropractic care to further assist in enhancing development and improving performance.

It is important to note that while most of the studies mentioned in this article are particular to goalie athletes, the non-goalie hockey player can benefit from the assessment and treatment management suggested above.

The Royal Chiropractic and Sports Injury Clinic offers this biomechanical hockey assessment for athletes of all ages to help guide them through their development during training.

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Dr. Nourus Yacoub, DC
Chiropractor & Medical Director
Royal Chiropractic and Sports Injury Clinic

References
[1] Brown RA, Mascia A, Kinnear DG, Lacroix V, Feldman L, Mulder DS. An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results. Clin J Sport Med. 2008;18(3):221-226.
[2] Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med. 1999;9(3):151-156.
[3] Philippon MJ, Ho CP, Briggs KK, Stull J, LaPrade RF. Prevalence of increased alpha angles as a measure of cam-type femoroacetabular
impingement in youth ice hockey players. Am J Sports Med. 2013;41(6):1357-1362.
[4] Murray RO, Duncan C. Athletic activity in adolescence as an etiological factor in degenerative hip disease. J Bone Joint Surg Br. 1971;53(3):406-419.
[5] Lerebours F, Robertson W, Neri B, Schulz B, Youm T and Limpisvasti O., Prevalence of Cam-Type Morphology in Elite Ice Hockey Players. The American Journal of Sports Medicine, 2016; 44 (4).
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Hamstring Injury: Exercise and Manual Therapy for the Fix

In professional sports, athletes rely on their on- and off-season training to develop and enhance current sports specific movements that further prepares their bodies for maximizing sports performance. Unfortunately, many athletes encounter injuries which impede their growth and performance, and ultimately reduces playing time.

Soccer is one of the most popular sports globally. Very few sports are played across very large fields, with long playing times, and infrequent rest periods, which makes soccer a challenge for sports performance training. It is not uncommon to see athletes succumb to injuries throughout the season. Coaches rely on athletic training to allow their players to mitigate injury and perform at the best of their ability. Unfortunately, no matter how hard you train, sometimes the demand of the sport can be too much on your body, or an unforeseen play can lead to an injury.

Running injuries remain a hot topic in sports medicine, especially among soccer athletes. The hamstring muscles is one of the most common sites to be injured among soccer athletes. This group of muscles is comprised of the biceps femoris (BF), semitendinosus (ST) and semimembranosus (SB), and are commonly injured following explosive movements or kicking activities which puts biomechanical stresses along muscle-tendon units while in the frontal plane[i]. Research has shown us that when these three muscle bellies (BF, SMT, SMB) are not capable of engaging synergistically to provide adequate contractions, this causes the muscles to fatigue prematurely, ultimately resulting in injury[ii]. Research has also shown us that the cause of initial injury can be due to metabolic changes after the eccentric phase (unloading, kick follow through) which is found more often in the BF as a result of reduced activation of the ST, with recurring injuries due to poor endurance training. Unfortunately, it is difficult to isolate the training of these muscles bellies to unify neuromuscular recruitment, but strength endurance training can help prevent any neuromuscular inhibition or fatigue of the group which can further help prevent injury. Keeping all this in mind, it is not at a surprise that injuries often occur towards the end of a season or end of a match when fatigability settles into the muscles and thus heightens the chance of injury or re-injury.

Looking forward, in attempting to protect the hamstring against structural or functional damage, the soccer athlete should seek out effective training that involves plyometrics and heavy eccentric loading in the distal ranges of motion. An exercise to consider which has been shown to help with these training goals is prone leg curls until exhaustion[iii]. A recent study recommended an 8 week in-season plyometric training program that included various drills for 20-25 minutes, twice per week. Plyometric drills included multiple jumps (ankle hop, vertical and lateral hurdle jump), horizontal and lateral bounding, skipping, and footwork (speed ladder). Each plyometric session was composed of 4 different exercises and 2 to 4 sets of 6 to 12 repetitions[iv].

Prone Leg Curl
Demonstration of the Prone Leg curl.

Keeping in mind with injury prevention and training, clinical rehabilitation is very important to consider such as the use of acupuncture which helps disrupt taut bands of muscle that often would otherwise contribute to biomechanical dysfunction, fatigue, and imbalanced muscle tone[v]. Acupuncture has also been shown to reduce referral pain, improve range of motion and decrease trigger point irritability. Moreover, the use of spinal manipulative therapy, muscle release therapy techniques are also helpful in improving range of motion deficits and other biomechanical areas subject to stress such as the hips and mid and lower back. Together, these conservative therapies in combination with an eccentric and endurance exercise program are helpful in mitigating hamstring injuries among soccer athletes, and can be implemented across many other athletic disciplines.

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Dr. Nourus Yacoub, DC
Chiropractor/ART
Medical Acupuncture Provider
Dr. Yacoub is the owner and Chiropractor at the Royal Chiropractic and Sports Injury Clinic. He currently works with The Sports Clinic at the University of Toronto Mississauga , and is the medical trainer for the University of Toronto Mississauga Varsity Eagles., Team Chiropractor for the Evolution Martial Arts Fight Team and the MAFA Fight Team.
References:
[i] Opar D, Williams MD, Shield AJ. Hamstring injuries: factors that lead to injury and re-injury. Sports Med. 2012;42:209-226
[ii] Schuermans J, Van Tiggelen D, Danneels L, et al. Biceps femoris and semitendinosus: team mates of competitors? New insights into hamstring injury mechanisms in male football players: a muscle functional MRI study. Br J Sports Med. 2014; 48:1599-1606.
[iii] Schuermans J, Van Tiggelen D, Danneels L and Witvrouw E. Resonance Imaging Susceptibility to Hamstring Injuries in Soccer: A Prospective Study Using Muscle Functional Magnetic. Am J Sports Med. 2016; 20-31.
[iv] Meyland C and Malatesta D. 2009. Effects of in-season plyometric training within soccer practice on explosive actions of young players. Journal of Strength and Conditioning Research. 23(9) 2605–2613
[v] DeWitt J and Vidale T. 2014. Recurrent hamstring injury: consideration following operative and non-operative management. The International Journal of Sports Physical Therapy. 9(6) 798-812.

Low Back Pain, How a Chiropractor can help?

Low back pain has been ranked as the leading cause of disability among 291 conditions examined by the Global Burden of Disease study in 2010. Low back pain can be caused by many sources from the body such as muscles, discs, ligaments, nerves and bones, and it’s important that all these potential sources are examined when obtaining the best pain relief techniques.

A Chiropractor is a type of doctor that specializes in the diagnosis and management of musculoskeletal injuries of the body. A lower back injury falls into this category, and classically, Chiropractors have been the go to doctors to help with these conditions. The first visit to a Chiropractor will include a focused clinical history where questions will be asked about past injuries, family and personal health history, current health problems, current and past health care measure taken, lifestyle and diet choices, and sleeping habits. Then a physical examination will be conducted that includes a comprehensive look at what is causing your back pain. This may include taking your blood pressure and/or X-rays, or requesting co-management with your family doctor to discuss other medical options.

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After examination, the Chiropractor will offer a diagnosis and treatment plan that may last only a few visits to multiple visits over several weeks, it all depends on the nature of the injury. It is not uncommon for manual therapists to ask patients to seek manual care to treat their injuries over several weeks, as the body takes time to respond to the manual therapy, exercises and rest in between.

There are a variety of treatments Chiropractors use to help find pain relief for their patients. Chiropractors often use manipulation and mobilizations of the spine (moving the joints of the spine) to help improve the ranges of motion and activity of the spine and muscles, while offering pain relief to the localized area, thus improving function overall. In addition, the use of manual muscle therapy techniques and acupuncture can also be used to help with pain relief. It is important that your Chiropractor also works in finding a way to increase the active component of your treatment plan by prescribing home based exercises. Studies do show that when home based exercises are paired with visits to the chiropractor, low back pain intensity is quickly reduced and there are higher chances of long term success in reducing onset of the pain and preventing re-injury.

It is true that you are more likely to re-injure your back after you have already injured it before! That is why it is also important to get your low back checked out a few times a year even if you are not experiencing any pain. Remember, pain is your body’s way of saying I need rest to recover in the immediate, similar to how your lips get dry when you’re very thirsty. Now you don’t drink water when your lips only get dry do you? So why seek manual therapy for low back pain after experiencing it before, only when you have pain? So be active and proactive when seeking care for your low back pain!

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Dr. Nourus Yacoub, DC
Chiropractor/ART
Medical Acupuncture Provider

Dr. Yacoub is the owner and Chiropractor at the Royal Chiropractic and Sports Injury Clinic. He currently works with The Sports Clinic at the University of Toronto Mississauga , and is the medical trainer for the University of Toronto Mississauga Varsity Eagles., Team Chiropractor for the Evolution Martial Arts Fight Team and the MAFA Fight Team.

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3 Shovelling Tips to keep your back healthy during the Storm!

If your thinking you don’t have to read this because “I have a snow blower”, you’re not in the clear just yet! So there’s a storm, and you have to shovel, let these three tips help you prevent any aches and pains that you may encounter during or after the task.

1) Warm-Up Before Going Out

Take about 10 minutes and lightly stretch out the upper and lower body: Hamstring, low back, abs, hips, shoulders and neck should all be stretched. After a set of light static stretching, try a dynamic set of stretches like jumping jacks, running in one spot, forward and rear shoulder shrugs, and body squats.

2) Keep it Close and Breathe

When shovelling, keep the shovel close to your body. Have a tight grip and bend and lift with your knees and hips, not your back! If you start feeling that your back is getting sore, or tired, stop, take a breath and think what part of the body your are using when tossing that snow! Try to feel your knees and hips doing most of the work. Mind the way you’re breathing…tighten that abdominal core by breathing deep, creating a braced-like feeling. This brace helps keep those muscles tight and will allow you to rotate with less pressure on the low back.

3) Have a Plan and Take your Time

Don’t just go in without a strategy. Shovel with some intention, understand the dimensions of the driveway you’re about to shovel. If its near a sidewalk, you may want to start from there. Or if there is layers of snow, try shovelling off a layer first, then the second layer a bit later. That brings me to my next point, take breaks, take shifts, and don’t do it all in one shot! You’re more than likely to get injured when you are tired and your muscles are fatigued.

Remember to listen to your body, if it wants to stop, just stop…you will thank yourself you did!

Good luck and Shovel Safe!

Got a Question? Ask Below

Dr. Nourus Yacoub

Bite Sized Artichokes, Spinach, and Brie Hors d’oeuvre

With the Year coming to an end, many people are taking to condo/house parties for their New Years Eve bashes. Here is one of my favorite bite sized snack recipes that packs on some great health benefits and would make a great addition to any party! it is easy to make and great for all the guests.

Ingredients:
1 9-ounce box frozen artichoke hearts
2/3 cup cooked chopped spinach
1 teaspoon lemon pepper
1/4 teaspoon salt
18 thin slices brie

Prep:
Preheat broiler to a medium heat, then prep the artichoke hearts according to package directions. Combine the spinach, lemon pepper and salt in a small bowl. Place each artichoke on a baking sheet, then top with the spinach mixture and place brie on top. Broil until cheese melts for about 2 minutes, then serve!

Health Kick: Artichokes are low in saturated fat and cholesterol. They are rich with a source of fiber, and pack a lot of vitamin A and C. And, they are full of minerals such as calcium, iron, zinc, sodium, potassium, manganese and phosphorus. Artichokes are rich with antioxidants, fight cancers, lower LDL (bad cholesterol) and blood pressure, cleans your liver, great for maintaining bone health and they are a vasodilator which helps bring more oxygen to the brain!  And in case you haven’t picked it up yet, for those of you who have one too many drinks at the NYE party, this veggie will help cure your hangover so you can start your New Years with a visit to the gym, like you planned…no excuses this year!

Enjoy this recipe and have a safe new year!

*Thanks to cooking.com for this one!

Dr. Nourus Yacoub

Pumpkin Soup!….I Love Pumpkin Soup!

In those cold winter months, sometimes having a nice bowl of soup can really help warm you right up! Why not make it a pumpkin soup and add some nutrients to the diet! Pumpkins are full of Vitamin A, C and E which are powerful antioxidants. Vitamin A is very good for maintaining the integrity of your skin and helps protect vision. Also, studies show it can help protect against some cancers too! Pumpkin also has a rich source of Vitamin B which is good for maintaining the health of your digestive system, immune system, heart, nerves and muscles! Wait! Don’t throw the pumpkin seeds away…did you know that half a cup (100grams) of pumpkin seeds has 110% of the recommended daily intake of iron and just about ZERO cholesterol, not to mention its a great source of dietary fibre! Try topping of the soup with some of those or keep them as a pick me up snack throughout the day.

Say no to those canned soups and get your hands dirty in the kitchen with this warm pumpkin soup recipe:

Pumpkin Soup
1 cup organic chicken or vegetable broth
¼ cup unsweetened coconut milk
1½ cups organic canned pumpkin
½ Spanish onion sautéed.
1 cloves garlic, roasted
1½ tablespoons brown sugar
½ teaspoon paprika (optional)
¼ teaspoon cayenne pepper (optional
½ teaspoon freshly ground nutmeg
Salt and freshly ground black pepper, to taste

Directions
1. In a large non-stick wok pan, on medium heat, slice a clove of garlic and toss it in with a teaspoon of you favorite cooking oil (coconut oil is mine).

2. Add some small finely chopped onions for a bit of flavour.Sauttee them for a bit, until they get a bit brown.

3. Dump all the ingredients into the wok, and simmer on low to medium heat for about 7 minutes.

4. Garnish with toasted pumpkin seeds. Enjoy!

Dr. Nourus Yacoub, DC

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The Road to ACL Knee Rehabilitation

Ouch! You just had your ACL surgery and probably feel like you will never play your sport again….I get a lot of questions from many different level athletes regarding “How I should rehabilitate my ACL injury” and “why does my knee still feel unstable after a year of rehabilitation”. First off, I never tell my athletes they will never play again. I tell them you will play again, just takes time to recover from this injury, and that time you use to recover needs to be well spent!
Less than a half of athletes return to their sport after their first year following an ACL repair, and about 1 in 5 athletes will require a second surgery. As a health care provider, one of the biggest things to consider in your athlete is their neuromuscular control during dynamic movements. Any deficits in this system will result in increasing the chances of re-injury if no attention is paid to during rehabilitation.

After an ACL repair it is common to have muscle weakness, impaired movement, abnormal neuromuscular control and difficulty returning to your sport. These can lead to asymmetrical imbalances between both knees and hips and abnormal pelvic control. Some things to watch out for that affect neuromuscular control are: muscle weakness (or inhibition as I rather call it), joint effusion, abnormal ROM and impaired function, which can last up to several months following ACL repair. It is important to communicate that this process is going to take a little longer than normal to heal the ACL and get it back to functional working capacity for their sport.

When assessing neuromuscular control with your ACL repair patients, health care providers should be sensitive at picking up any: increases in external knee abduction, excessive out-of-plane knee loads, any frontal displacement of the trunk, decreased core proprioception, lower extremity biomechanical differences and flexor activation, between sides. Some test I like to use with my ACL patients to help assess for any asymmetries would be the Non-Weighted Front Squat, Prone Isolated Gluteal extension, Single Limb Hop Test, Tuck Jump, Drop Vertical Jump test and assessment of Deep Breathing Techniques. It is important to look for asymmetrical movement patterns during these tests, and even be sure to look at the opposite side (knee and hip)! In fact, I would argue that many health care providers don’t spend time assessing the opposite side (probably because we are driving toward a pain focused program of care and because we only spend about 15-20 minutes with a patient). Research has suggested that compensatory strategies of the uninvolved hip (transverse plane) are a primary predictor of risk factor for developing a secondary ACL injury. Other researchers argue to look at frontal knee plane and sagittal knee plan motions and postural stability as other risk factors to secondary injury. So, lets be smart health care providers when taking on a patient with ACL injury and preparing them to return to sport. I forgot to mention, we should also be looking for strength ratio symmetry between the quads and hamstrings (tests like the single hop test will help with this).

Ultimately it is the discretion of the health care provider to progress the athletes into the proper stages of rehabilitation while assessing neuromuscular deficits. There should always be good communication with the athlete and proper clinical judgment used when creating a proper progressive plan of management. I mean you shouldn’t get your ACL repair patient to do single leg hop after 1 week of surgery, duh! The main thing is to focus on restoration of symmetrical function and use those aforementioned tests to help determine the progress of any neuromuscular deficits as this is a big factor (I argue for it) in re-injury.

Now go out there and rehab properly, soccer season is approaching, wait isn’t it always soccer season?

 

Dr. Nourus Yacoub, DC

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Work, Work, Work but don’t let your posture down

With back to school and the new fall work schedule quickly approaching, we are going to be finding ourselves siting at the desk a lot, and as a result we may find ourselves suffering from poor upper posture, shoulder pain and maybe even headaches. Let me introduce you to what is known as Upper Cross Syndrome (UCS): Basically, it is a poor balance between the upper back muscles, neck muscles and shoulders. The person would usually complain of tightness in the front of the shoulder and chest area, have a head that protrudes forward, and upper back muscles that feel like steel! If you find that you have some of these, listen up, I got these 3 tips for you:

Preventing Poor Posture While Working

  1. Get up and Get Something!
    Often when we are seated, we tend to sit for a long time, finish our project and start another. Take about a 1-2 minutes break every 15 minutes from sitting. Get up from your seat, stretch around, make your way to the copy room, have a snack or a glass of water, do whatever you need to do just don’t sit. When we are seated, even when we think we are sitting with a neutral posture and crunching our abs to maintain proper stability, over time, our body likes to relax and your posture goes into a slouch. Our lower and upper back rounds out, our heads tend to inch forward, and our shoulders begin to round inwards. So by getting up, it gives your body a break from that poor posture technique and give you an opportunity to reset your posture. What I like to do is have a 15 minutes timer on my watch to remind me to get up, try it!
  2. Exercise!
    Some of the exercises that I find help my patients deal with UCS is scapular retraction exercises. All I recommend is about 1 or 2 sets of 10 reps per day, and the good thing is you don’t need a monthly gym pass, just a Tensor Band. The scapular is essentially that bulky boney part that makes up the back of the shoulder. First you would grab the tensor band in both hands and place it in front of you with your arms out, then begin by stretching the band about 25% of the way out and drawing your shoulder blades (scapula) in, squeezing them ever so slightly, and then relaxing back to the starting position. This helps wakeup the rhomboid muscles and mid and lower trapezius muscles, the ones that our body likes to forget to use, especially with UCS. I carry a tensor band in my bag, or keep one in my office desk, you should too.
  3. Stretch!
    With this UCS type of posture, one of the main problems is rounding of the shoulder. We can get a lot of other problems such as shoulder impingement with this as well. Often the pectoralis minor is the main culprit here, and we should know how to effectively stretch this one out. All you would need to do is hold your arms out against a wall and turn your body away from the wall, feeling the stretch in the upper shoulder chest area. Perform this with a few seconds hold about 10 times on each side.

Now, this should give you some temporary relief from poor posture, help condition against having it and help you get through your day without having the woes of feeling stiff after work! Remember to stay fit, health and keeping moving throughout the day!

Dr. Nourus Yacoub

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