Posterior Cruciate Ligament Injury

What can we learn from footballer Zlatan Ibrahimović’s knee injury in 2017? Focus on Posterior Cruciate Ligament (PCL) and Anterior Cruciate Ligament (ACL) implications

The PCL is broader and stronger than the ACL, and has a tensile strength of 2000 Newtons – meaning injuring it requires a lot of force. Injury most often occurs when a force is applied to the front of the shin at the top when the knee is bent due to this, PCL injuries are most commonly seen in high impact car collisions. However, due to the anatomy of the knee, hyperextension (over straightening) and rotational forces, or forces in or out against the knee also may be responsible for PCL tears.

Start with a sports person

If we start with a sports person who has suffered an isolated mild to moderate (Grade I-II) PCL injury, we find they can do well with quality physiotherapy rehabilitation because surgical reconstruction tends to improve the instability but it does not provide a normal knee. Most isolated Grade III tears can be treated non-operatively using a specially designed PCL brace that holds the shin bone in a forward-reduced position that gives the PCL an opportunity to heal.  Unlike the common ACL tear, acute isolated PCL injuries can heal.

Unfortunately, Zlatan appears to have both an ACL and a PCL tear.

The case at hand

This injury was NOT an isolated PCL injury. Media reports suggest Ibrahimović also had an ACL injury (with the possibility of further damage not being mentioned but still present). A multi-ligament injury has the potential of neuromuscular injury which, when present, has an ominous prognosis. Even without that complication, the prognosis must be very guarded for an elite level football player to return to the demands of high level play with an ACL/ PCL reconstruction.

The goal

When we see similar patients is to ensure they have a stable knee they can walk on and live with. There are anecdotal reports of athletes returning to play after multiple ligament knee reconstruction but when scrutinised, the players are usually the slower lumbering players like an American football lineman — not players whose success relies on them being quick and agile.

As Clinicians

It’s important for us, as clinicians, to spend lots of time explaining prognosis to people who suffer serious injury and the rehabilitation team which includes Doctors, coaches, and parents in the case of juveniles, must communicate well and work together.

Source: 26 Apr, 17 |  BJSM Blog by Prof. Karim Khan


Kim – Functional Medicine Practitioner

Kim has been working in clinic full time since August 2014, after having completing twelve years at Solgar UK Vitamin & Herb; Travelling the UK and Ireland, delivering lectures and training workshops, as well as seeing patients in many different clinics.

Therapy focus points

Kim’s main focus is on chronic health conditions, where the NHS has gone as far as it can, with no conclusive diagnosis. She is primarily using blood tests to analyse vitamin, mineral, hormone & enzyme activity to get a good overall picture, therefore being able to diagnose more effectively.

This new diagnostic tool

She is not only able to see how healthy your gut bacteria is in terms of abundance and diversity, but it enables her to look at inflammation, immunology digestion and absorption, which NHS gastroenterology investigations often do not pick up.

Moving forward

Kim wants to explore the practical application of these methods in finding solutions to chronic long term conditions such as irritable bowel syndrome, diverticulitis, ulcerative colitis and crohns disease, type two diabetes, anxiety disorders and even obesity.


Returning to running

RunningPerhaps the most frustrating thing about running is trying to re-establish old form, getting over setbacks such as injury or illness, or worse still chronic problems such as long term or repetitive fatigue or injury.

Start from where you are

When you start in sport your training and fitness develops gradually and you naturally build strength and resilience along with your training volume. However, when things go wrong it is common to retain the mindset of past training and racing, along with the feeling that if it worked before you can do it again. This may be true, but if you have had a long time off, it may take time to build up again. It is important to remember you can only start from where you are and not where you want to be.

You will have to accept your current fitness levels and also the probably increased stress of your current life

You are likely to have to make some sacrifices, these may be avoiding running with friends until you get back some fitness or backing off on social time so you get sufficient recovery

You will have to make some changes, if you aren’t getting to the fitness levels you want, you are not doing the right things. This is clearly the case or you would be as fit as you want.

Take stock of your situation

The first and maybe the most important part is understanding your situation – how fit are you, what can you handle, and what your goals are.

Once you have established this it will probably be easier to motivate yourself to work with your current fitness levels and not rush back into things that have caused your recent problems. This isn’t to say you don’t have targets and goals. You can be happy in your progress knowing there are many things you can enjoy about your running now and also accept this is the best way to meet your longer term goals.

The next step is to think about how to move forward towards your longer-term goals of increased fitness and probably taking part in races. Three important steps for this are:

  1. Realistic goals to work towards

You will have an ultimate goal, which is your dream and some interim goals that you can see yourself achieving in the shorter-term. Maybe in the next month or few months; it is best not to put fixed time limits on these at this stage since you need to work with your body and lifestyle without rushing.

  1. One or two training sessions that build fitness to your initial goals

Since you now have an idea of what you can achieve you can work out what needs to change and hence some sessions that will help you meet your targets.

For example, if you have been unable to train properly for a while you may not have the endurance to run for a target length of time, particularly as your race pace is likely to be slower. One session would therefore be a longer run with the aim of building up to a target time over the next few weeks. It can be associated with one of your short term goals as well.

  1. Finding a level of training you can sustain  

This could well be the most important; it is certainly the key to getting back in shape. It also means finding a level of training that allows you to recover, which may be complete rest initially. It is important to build training volume for many reasons but you can’t do this if your body never recovers.

Using time and tracking your workouts

If you have run a lot in the past, your easy running would have been something you understood intuitively and managed within your normal training. However, after a setback it may not be so intuitive. Your running will have to be a lot slower and shorter. It is a good idea to use time to measure your runs rather than miles or kilometres; in this way you will not be drawn into comparing what you used to do with what you are doing now.

Set out a weekly plan with the two harder sessions on convenient days and fill in the rest with recovery runs and rest days. Build volume gradually and be prepared to take a step back if you get too tired.

By monitoring your fatigue (how tired you feel) and your resting heart rate each morning you can gain an indication of how you are recovered from the previous day.

If you are over tired you can do a recovery run or rest, if you are rested and it is a planned harder day you can do the hard day and then take the recovery days to get back to your rested level for the next hard day.

Take it easy and build gradually, listening to your body and the objective measures are key. Be consistent and prepared to step back a bit if you need to. Most importantly enjoy all the things you love about running.


Headache and Migraine prevention

stockimagesWhen it comes to headache and migraine prevention, there are the usual triggers to try to avoid or minimize, including skimping on sleep, too much alcohol, exposure to bright light, or even being around strong fragrances can bring on the pain in people who are prone to headaches. And tweaking various aspects of your diet, lifestyle, and behaviours can also add up to a hefty dose of prevention.

Common headache and migraine triggers include aged cheeses, cured meats, smoked or pickled fish, draught beer, tea, coffee, berries and and nuts.

But Dr Carol Redillas, neurologist and headache specialist with Ochsner Baptist Medical Centre in the United States, is quick to note that she doesn’t prescribe a ‘headache diet’ to patients. “Everyone’s triggers and sensitivities are different, so I usually recommend that patients keep a detailed log of their food intake and symptoms to help identify the particular items that appear to be associated with an increase in their headaches.”

This way, says Redillas, people don’t feel so restricted when they eliminate (or at least minimize) these specific foods.

But there are a few headache-prevention guidelines that can apply to most people, regardless of their individual sensitivities:

Firstly limit foods high in added sugars to minimize fluctuations in blood sugar levels, which can increase the odds of developing a headache.

Timing matters, as well. Skipping meals and going long periods of time without eating can leave you particularly susceptible to headaches, so try to close any gaps longer than four hours between meals with a nutritious snack, ideally one that pairs lean proteins and healthy fats with whole grains or fresh fruit.

And drink up! Dehydration is directly correlated to an increase in headaches, so aim to drink at least half of your body weight in ounces of fluid. It doesn’t have to be just water, though – any type of liquid that doesn’t contain alcohol can ‘count’ toward your total for the day, even foods like fresh fruit, soup, and Greek yogurt.

A number of supplements can also be effective in reducing the frequency and severity of symptoms of headaches and migraines, in addition to the above-mentioned diet and lifestyle changes.

Butterbur can reduce the frequency, intensity, and duration of migraines, with doses of at least 75 mg twice daily necessary for significant benefit.

Vitamin B2 (riboflavin), taken in dosages of 400 mg daily can significantly reduce the frequency of migraine attacks, possibly as effectively as taking beta-blockers. Be patient, though, it may take up to three months to feel the maximum benefits.

CoQ10 in doses of 100 mg, three times daily, has been shown to help prevent migraines, decreasing the frequency by about 30%. Again, it may take up to three months to notice the difference.

Magnesium in high doses (600 mg daily) may reduce the frequency and severity of migraines.

Feverfew has been shown to reduce the frequency and symptoms of migraines, but not all research shows a significant benefit. But feverfew can be better tolerated than some conventional migraine drugs, and it doesn’t appear to affect blood pressure, heart rate, or blood chemistry, so it may be worth trying.

In addition to identifying and reducing headache triggers and considering the above supplements, Redillas also encourages her patients to incorporate regular exercise, along with various mind-body therapies.

Exercise, for example, may be just as good as the drug Topiramate (Topamax) at preventing migraines, when incorporated at least three times weekly for 40 minutes.

And incorporating yoga on a regular basis has been shown to significantly reduce the frequency, intensity, and pain of migraines.

Redillas also recommends alternative therapies like acupressure and acupuncture for headache prevention, pointing to studies that suggest that acupuncture is at least as effective as certain drugs used for migraine prevention – plus it has fewer adverse effects.

And finally, make sure your job isn’t contributing to your headache, literally.

Marc Cavallino, PT, OCS, partner and clinical director at ISR Physical Therapy in Harahan, says that our typical posture at our desks: hunched over our computers, chin forward, shoulders rounded and drawn up toward our ears, can cause muscle tightness and compress nerves, which in turn can lead to headaches.

Cavallino recommends setting a timer as a reminder to get up every 10 to 15 minutes and ‘undo’ the repetitive movements of your job. Desk jockeys, for example, should tilt the head up and back several times, then place hands on the hips and arch back, then walk around a bit. The goal, says Cavallino, is essentially to move your body in the opposite way that you’re positioned for your job. “It doesn’t take long, just 60 seconds can be enough time, but the key is to be consistent. Our bodies just weren’t designed to sit at a desk all day.”

The above diet and lifestyle modifications can help to reduce the pain and frequency, but keep in mind that headaches and migraines can signify underlying health concerns, so if headaches come on suddenly and are more severe than other headaches, and/or accompanied by a fever, stiff neck, or change in speech or vision, play it safe and schedule an appointment with your GP.


Image courtesy of stockimages at

Bike transition tips for triathlon

digitalartIf you’re contemplating taking part in a triathlon then you’ll want to know how to mount/dismount with the shoes attached to your bike? Is it a case of practice, practice, practice?

It definitely takes practice but knowing what to practice will make perfecting a seamless switch between running and riding easier.

The first thing to do is clip your shoes to the pedals and tie two thin elastic bands through the heel loops. Spin the pedals until the drive side shoe is at 3 o’clock and the other is at 9 o’clock, and then stretch the band on the drive side shoe around the front much and the non-drive side shoe’s band around the rear brake or quick-release.

Provided the bands are thin enough, they’ll snap as soon as you start pedaling. Now you can start running with your bike, which for most people feels more natural on the non-drive side, so let’s assume that’s what you’ll be doing.

Start slowly and use your right hand to hold the saddle and guide the bike as you run. When it comes to mounting, grab the handlebar with both hands then push off with your left foot as you swing your right leg over the back wheel and onto the saddle. You’re not really jumping onto your bike, it’s more like hurdling onto it; the only difference is that instead of being in front of you and stationary, this hurdle is beside you and moving.

The momentum from your right leg should carry you into place and, even though you’re not jumping, aim to ‘land’ so that your inner thigh is against the saddle. From there, slide into place and start pedaling. Once you’ve got some clear space, reach down to get one foot into its shoe and then the other – while keeping your eyes on the road, of course.

Now for the dismount: as you approach T2, get your feet out of the shoes when it’s safe to do so and slow down to a comfortable running speed. If you’re dismounting to the non-drive side, bring the drive side pedal up to 12 o’clock and shift your weight so you’re standing on the non-drive side pedal. When you’re within about 5m of the dismount line, swing your right leg around over the rear wheel, then you can bring it through between the bike and your left leg.

Once your right leg passes your left leg, step off the pedal so you land on your right foot and begin running immediately. Bringing your right leg through lets you hit the ground in a running position rather than with your right leg overlapping behind your left.

You should be on foot as you reach the dismount line and when you are, let go of the bars and continue running while holding the saddle. Remember: your shoes are no longer banded so you may need to hold it further away to avoid them clouting your shins.


Image courtesy of digitalart at