Return to Play- the Physio’s Perspective

Image Credit: Niall McNelis

Christine Coffey chats all things return to play and physiotherapy during lockdown with Niall McNelis, physiotherapist with UCD RFC and Old Belvedere’s rugby teams, as well as the Dublin Back Clinic (DBC), located on the UCD campus.

University Observer: How has your work as a physiotherapist changed since the beginning of the first lockdown?

Niall McNelis: From a sports physio point of view, normally at this time of year we’d be coming into a post-Christmas block, kind of business end of the season. Any knocks that are more than 8 weeks would end a player’s season. It would be high pressure, short timelines, with a focus on getting lads and ladies back on the pitch and available for selection as soon as possible. Now we’re seeing less injuries, but different types of injuries, so I suppose the role of the physio has changed. One of the main principles of injuries, particularly in over-use or soft-tissue injuries like hamstring strains… it would be someone trying to do something that they’re not able to do after too long of doing nothing - too much after too little. Or, alternatively, too much after too much. The role of the physio at present is making sure that lads and ladies have access to a plan that they can follow, and that’s where it’s really important to be linking up with the S&Cs (strength and conditioning coaches). When it comes to return to play, particularly for a sport like rugby, given its attritional nature…players are going to need to be really, strong, really robust. At the moment, its keeping lads and ladies at a sort of an ‘even keel’ which allows them to maintain fitness and which should lead into a 5-week training block (when it does happen) to allow players to get back to normal.

Since there’s no rugby to play, the focus of the physio has moved away from performance and return-to performance, and towards return to activity and quality of life. For a physio like me, it’s taken some time to get used to that, that lack of pressure. You can treat each injury as it should be rather than, say, turning an ankle around in two weeks or strapping him/her up and getting them back on the pitch. An ankle sprain could take 4-6 weeks…you have the luxury of not only rehabbing the ankle but also then bringing the player through a prevention plan and a maintenance plan and thereby reducing the risk of injuries both up the kinetic chain as well as down the kinetic chain.

UO: What sort of injuries are you seeing at the moment?

NMcN: From my point of view we’re seeing a lot of tendinopathies from training too hard - hamstring tendinopathies, Achilles tendinopathies and patella tendinopathies. Given the sort of change in working habits, we’re seeing a lot of people with neck and back stuff because lots of people aren’t used to working from home. The real benefit that comes with the lack of contact is you’re seeing [fewer] concussions [and] car crashes, which is always nice.

UO: In relation to these types of injuries, is there any advice you’d give to athletes returning to sport?

NMcN: In Ireland, the sports that are most common would be your rugby, GAA, hurling, your soccer. What those sports all have in common is [that] they’re high-intensity intermittent sports. They’re going to require a lot of short blasts of high-speed running, a good bit of change of direction and things like that. Regardless of whether it’s a concussion or an Achilles tendinopathy one of the big, big risk factors is fatigue, so if you are physically less conditioned you are more likely to get injured. Ensuring that you have a decent base of cardiovascular fitness is important. It’s not just a question of going for a 20–25-minute run or a 5k, (though all movement is good, all exercise is good) - that particular set of runs, that particular exercise, is good for your aerobic fitness, but may not transfer as nicely to games. Having a mix of aerobic, anaerobic - higher intensity shorter sessions combined with longer lower intensity sessions, so that you’re hitting all your benchmarks with regards cardiovascular fitness [is important]. 

In addition, regardless of the sport, be it hurling or cricket or anything, you need to make sure that you’ve got a really good strength base-really focussing on the lower limb. If you look at any injury, be it ACL, be it concussion, be it hamstring; lower limb strength, particularly glute and hamstring strength, if that’s reduced, you’re going to be in trouble. Hamstrings are most active - they’re most strained - during high velocity running when they have to slow the forward movement of the shin and work eccentrically in a lengthening capacity to slow us down. 

It doesn’t just mean squatting or deadlifting or Bulgarian split-squatting; it’s making sure that if you’re working the muscle in the front you’re also working the muscle in the back. If you’re doing a Bulgarian split squat, you could super-set that with a glute bridge, you could superset that with an RDL, you could superset that with sliders or the Nordic exercise. [The] hamstring is the most common soft-tissue injury in any sport really -probably the most common injury that’s going to happen now. We’ve seen in the German Bundesliga and all the competitions where epidemiological studies have been carried out, that injury incidence is through the roof, particularly soft tissue injuries, particularly soccer after lockdown…players trying to do too much after too little. Making sure your hamstrings are worked, that your glutes are worked, will reduce your risk of injury. Nordics are often theorised to be a fantastic exercise for injury prevention, which they are, but there’s no one exercise that is a silver bullet for preventing injury. How you prevent injury is making sure that cardiovascularly, as well as strength-wise, you’re as strong as you can be. 

In addition to that, you’re also making sure that your training week is not every day. You see these motivational videos “I hit the gym an hour every day” - that shouldn’t happen. For the people I’m working with, it’s 3 days on, 1 day off, 2 on, 1 off. Also, ensuring that during the days off that it is a day off. Very minimal exercise, you might go for a walk or a short cycle; so you don’t have a consistent stimulus (muscle activation/muscle strain) -that’s when tendinopathies occur, that’s when you put yourself at more risk of injury. You may find that, when it comes to getting back to performance, that 'I’m not hitting my PBs on the squat', 'I’m not able to sprint as fast as I can', [that is] because you’re fatigued and you’re risking things like overtraining syndrome.

UO: This discrepancy between one side and another, or one muscle group and another, is that something you’d be concerned about with players getting back on the field?

NMcN: Oh, 100%. There are many studies into the ‘anterior pelvic tilt’ - where the muscles at the front, like your quads, will be more developed. The body moves as it wants to, in the easiest way possible, so, by logic, that would be using big muscle groups that are already well developed. When we’re kids and we’re growing up and running, we’re predominantly using our quads and our lower back. You go to kindergarten and you go to primary school and you sit down for 6-8 hours a day. You go to secondary school you sit down for 6-8 hours a day. On our days off we watch TV, which is sitting. You might go to college and you’re asked to sit down for however many hours a day. That seated position will shorten your hip flexor and pull you into that anterior pelvic tilt - basically, your pelvis is going to be tilted forward ever so slightly and this has been found in 85-90% of the general population. It’s not necessarily a bad thing, but what it does do is it places more of a load on, or it stretches, the hamstrings. If a muscle is stretched it has to work much harder to produce the same force. If it has to work much harder, it will fatigue more quickly, it puts itself in a danger zone, where it’s easy for a strain to occur. That’s why hamstring strains are so, so common: because of just how the hamstrings function and living in that anterior pelvic tilt.

If you look on Instagram, the most common things you’d see are, say, squats, Bulgarian split squats or deadlifts, because they’re easy to do and you can shift a serious amount of weight very, very easily with them. Whether the technique is correct or not you can still do a fairly heavy weight. If you’re building up the quads; the hamstrings and the glutes can be left behind. A lot of the studies done on lower limb injuries in general, hamstring, ACL, MCL, any other common injury, a discrepancy between quad and hamstring strength is to the fore, and if you’re reinforcing that imbalance with squats, with deadlifts, with even Bulgarian split squats, the body is going to move as it wants to in the easiest way possible, it’s going to use those big muscle groups that have already developed. You have to make sure you’re working the glutes and the hamstrings. They’re exercises that you don’t see as often, they’re less valued.

I suppose that is me talking with a sports physio hat on. As a general physio and a medical professional, movement is medicine and if you’re doing something, that’s great. If you’re playing sport, you need to make sure that your gym plan isn’t something you’ve drawn up yourself or something you’ve just seen on Instagram. You need to make sure it’s equally balanced, both front and back. 

UO: You mentioned this distance or disconnect between physio and player and there are some obvious challenges associated with these lockdowns. Are there any positives or benefits to be taken from this time as a physio?

NMcN: I would say it really challenges your clinical reasoning. For example, in the last lockdown, I had a really complex shoulder injury that I was dealing with, an auxiliary nerve injury, that you’d have loved to have gotten your hands on. I’ve had some really bad backs, just disk injuries from lack of activity more so than anything else and you’d love to be able to get there, get your hands on and improve their symptoms, but, given that you’re talking to someone through a computer screen or over a phone, you don’t have that luxury. It’s also more challenging in terms of building a relationship with people, more challenging in terms of trying to get your message across.

I don’t like being negative with regards Covid and injuries, but I see quite few ‘benefits’ apart from the normalisation of online sessions, whereby athletes can just hop on a Zoom and we’re all much more au fait with that. Rather than needing to be near the Dublin Back Clinic (DBC) to get physiotherapy treatment, you can now get access to physiotherapy anywhere in the world, as long as you have an internet connection, and if you don’t, you can use the phone. 

People are becoming more and more aware of what physio is. If you come to DBC, you get exercises, you get stretches, you get mobility stuff, you are given the tools for recovery. I think that’s another benefit, seeing how you can help more, so rather than saying I can just give you a massage, we can give people the tools for their own recovery, to give people the tools to deal with pain. And from a psychological point of view, that’s really, really valuable. 

If you have neck or back pain in normal times. You could go to the cinema; you could go out for a few drinks and forget about it. However, what we’re now seeing with this social isolation and with this working from home, pain comes on and there’s no distraction to get away from it. Pain is getting to people because people can’t escape pain. The big thing with regards lockdown, it’s tough on everyone… that sense of isolation. 

If you twist your ankle, you understand why your ankle is sore. With your back it’s a lot more insidious…literally anything can feed into back pain. It can go from a bit of tension to a bit of stiffness, a bit of stiffness to a bit of reduced motion, reduced motion to discomfort, discomfort to pain, pain to disability, disability to just not being able to get out of bed and then feeling (not good) because you can’t run, you can’t walk, you can’t do anything, and then you might start to gain weight, and then that feeds into everything. I suppose that ability to still be able to give someone the tools for their own recovery is really essential.

 I think the first thing you should look at is rather than focusing on sport, [is] focus on the physical activity. The cardiovascular, the metabolic, the mental health benefits of physical activity are sensational. The big thing is to enjoy it. If you’re not enjoying your physical activity then try change things up, if you hate going for a 5k then grand, try a bike. If you don’t have access to a bike, try interval training or Pilates or yoga. Physical activity is no longer something that is just for gym rats and marathon runners and that’s it. It’s literally for everyone.