PatientHandbook_IsokineticLondon

T H E PAT I E N T H A N D B O O K
T H E
P A T I E N T
H A N D B O O K
ISOKINETIC MEDICAL GROUP
T H E
P A T I E N T
H A N D B O O K
Founded on April 7th 1948, the World Health Organisation is the
authority tasked with the responsibility for and co-ordination of all
health related matters within the United Nations and aims to help
the worldÕs population achieve the best possible state of health.
Introduction
The World Health Organisation defines health as a Òstate of complete physical, mental and social well-being and not merely the absence of disease
or infirmityÓ. This provides a clear, conclusive and challenging definition in which the members of the Isokinetic family have always had a strong belief.
Over the course of our twenty-seven year history, we have continually developed and improved
our methods in an attempt to provide our patients with good health, in its broadest meaning. In
fact, each rehabilitation pathway is not just a means to overcome an injury or illness, but a unique
opportunity through which patients can recover their fitness and seek a general state of wellbeing.
When taking this point-of-view, rehabilitation can become a positive life experience, changing a
patientÕs perspective. We have written this Handbook, with the hope that a deeper awareness of
what you are undertaking will help you to understand its potential.
Welcome to Isokinetic.
Stefano Della Villa
President, Isokinetic Medical Group
Page
Index
7
10
12
15
16
18
Our Story of International Sports Medicine
and Orthopaedic Rehabilitation
Our Vision and Inspiration
Howard De Walden and Harley Street
London Sport
About this Centre
The Layout
Page
20
22
24
26
30
34
36
40
42
Our Environments
The Reception and Lounge
The Consulting Rooms
The Rehab Gyms
The Pool
The Green Room
The Field
The Locker Rooms
The Library
Page
45
47
49
50
53
54
59
61
The Treatment Team
The Patient
Your Rehabilitation Programme
The Clinical Administrator
The Case Manager
The Rehabilitation Specialist
Internal Consultants
Managing Insurance / The Other People
THE FIVE PHASES OF REHABILITATION
Page
65
67
69
71
73
75
77
The goal: (To reach) 100% recovery
Phase 1 - Resolution of pain, swelling and inflammation
Phase 2 - Recovery of range of motion and flexibility
Phase 3 - Recovery of strength and muscular endurance
Phase 4 - Re-training of co-ordination and normal motor skills
Phase 5 - Recovery of (sport) specific technical movements
and return to play
How do I move from one phase to another?
FREQUENTLY ASKED QUESTIONS
Page
83
85
87
89
91
93
95
What happens during the initial consultation?
How do we reach a diagnosis?
How is the Rehabilitation Programme planned?
How do we measure strength?
How do we measure physical fitness?
When will I get back to playing?
When is it time to say goodbye to Isokinetic?
THE ISOKINETIC MEDICAL GROUP
Page 101
103
105
107
109
A medical group at our core
The Education and Research Department
The website
Our international connections
Our Centres
THE MOST FREQUENT INJURIES
Page 113
113
114
The Neck
Cervicalgia
Whiplash
Page 117
117
119
120
The Spine
Backache
Slipped Discs
Spondylolysis Ð Spondylolisthesis
Page 123
124
125
126
127
127
The Shoulder
Shoulder Dislocation
Subacromial Impingement Syndrome and Cuff Lesions
Acromioclavicular Joint Sprains
Fractures of the Clavicle
Adhesive Capsulitis of the Shoulder
Page 129
129
The Elbow
Epicondylalgia (Tennis and GolfersÕ Elbow)
Page 131
131
132
The Hand and Wrist
Carpal Tunnel Syndrome
Scaphoid Bone Fractures
Page 137
137
138
139
The Hip
Osteoarthritis
Hip Prosthesis
Groin Pain
Page 143
143
144
147
152
152
153
154
158
158
159
159
160
161
The Knee
Traumatic Knee Injuries
Lesions of the Anterior Cruciate Ligament
The story of a famous Anterior Cruciate Ligament
Lesions of the Posterior Cruciate Ligament
Lesions of the Medial and Lateral Collateral Ligaments
Meniscal Lesions
Cartilage Lesions
Patellar Tendinopathy, or ÔJumperÕs KneeÕ
Osgood Schlatter Disease, or Anterior Tibial Apophysitis
Patello-Femoral Syndrome
Ilio-Tibial Band Syndrome
Osteoarthritis of the Knee
Knee Prosthesis
Page 163
163
164
166
166
167
The Foot and Ankle
Ankle Sprain
Achilles Tendon Rupture
Achilles Tendinopathy
Plantar Fasciitis and Heel Spurs
MortonÕs Neuroma
Page 171
Muscular Injuries
Page 175
Fractures
6
Our Story of International
Sports Medicine and
Orthopaedic Rehabilitation
It was spring of 1987 at the Rizzoli Orthopaedic Institute in Bologna. A young post-graduate physician asked the lady in
charge to look in the Ôbig bookÕ where all the titles in the library were kept for anything on isokinetic testing Ð a new
rehabilitative method recently developed in the United States. After looking carefully through the index, the woman shook
UNIVERSITY
OF BOLOGNA
her head and told the young physician no such entry existed, before asking if he had remembered the name correctly. It
was this somewhat negative answer that started the Isokinetic story. Realising nobody knew what isokinetic rehabilitation
was, the physician told himself he would be the first to discover it. A few months later, the young man was on his way to
California, to study under the supervision of Prof Michael Dillingham Ð the director of Stanford UniversityÕs Sports Medicine
STANFORD
UNIVERSITY
programme and his faithful co-worker Rick Eagleston. Eventually, after buying one of these new isokinetic machines and
returning to Italy the physician was able to open a small clinic of his own.
After helping players recover from their injuries in record time the adventures of Stefano Della Villa, Gianni Nanni
and the ÒIsokinetic GuysÓ as Eraldo Pecci, the Bologna FC captain at the time called them, truly began.
BOLOGNA F.C.
7
Our Story
of Sports Medicine
and Orthopaedic
Rehabilitation
Our Education & Research
Department is the cultural
core of the group, continually
updating our approach.
We also actively share our
research with the rest
of the global Sports Medicine
community
Isokinetic has
7 Sports Medicine and
Rehabilitation Centres
across Italy, in:
Bologna, Rimini, Rome,
Turin, Verona and two
in Milan
NETWORK
Bologna
SCIENCE
GOALS
(1156 km)
FIFA
ROOTS
FOUNDATION
Bologna is an Italian city
famous for the oldest
University in Europe
and the quality of its
local cuisine - and where
Isokinetic began
In 1987, our President
founded the first
Isokinetic Centre,
with a vision
to revolutionise
Sports Rehabilitation
We have taken care of champions of the sporting
world for more than 27 years
On 27th October 2009,
the Isokinetic Medical
Group became the
11th FIFA Medical Centre
of Excellence, for the
prevention, treatment
and rehabilitation
of injuries in Football
LONDON 2012 & 2013
Milan 2014 edition was the
largest Football Medicine
Conference in the world with
over 2,200 delegates
11 Harley
Street
MILAN 2014
POP UP CLINIC
Marking our company’s Silver Jubilee and the year of the historic
Olympic Games, we opened our first international centre,
in London, 11th November 2012
After 3 years of planning
and construction we have
planted our International
Flagship centre on the
most famous medical street
in the world
FUTURE...
INTERNATIONAL
GROWTH
Our 21st and 22nd
International
Conferences on knee,
muscle and tendon
injuries attracted over
2,600 delegates from 77
countries
Our Vision and Inspiration
Isokinetic was born, twenty seven years ago in Italy, from the belief that there was a better way to help individuals recover from an injury; a more
practical approach to returning someone to their full potential. A method that could offer complete care, from the moment of injury all the way
through to return to the playing field.
We looked to bring together doctors, physiotherapists and other specialists in a way that enabled them to all unite around a common goal; that
of finding the best possible solution for their patient in a way that worked best for that particular individual, from not only a clinical perspective
but also a psychological and logistical one. We donÕt just treat a knee, but the patient that is suffering from knee pain and that is where our point
of difference lies. From this a personalised rehabilitation programme is constructed, based not only on the affliction a patient is suffering from,
but how much time and energy that patient can dedicate. Patients know that we will take care of them from every angle.
Our name takes its inspiration from a form of muscular evaluation and rehabilitation that was popular in American in the 1980s. We identified
with the fact that the ÔisokineticsÕ movement was synonymous with a different way of doing things. Now this approach is part of what we do,
but not exclusively, and it is only one of the many important links in a long chain of activities that we use to aid recovery.
The fundamental element that runs through all of these activities however, is that of physical exercise, which explains why in all our centres you
can find our logo of the little running men.
10
The chasm that existed between the forward-thinking American approach to rehabilitation and that of the rest of the world back in the 80s has
now been completely bridged, and more so. Our Italian heritage has enabled us to develop a unique culture, which is realised in a way of working
and company ethos that is highly valued and much praised by patients.
Rehabilitative care is a rapidly growing sector, but our complex, comprehensive method (quality certified ISO 9001) marks us out from the crowd.
Clients come to us from all over the world.
We now enter an exciting new phase of our journey, that of international expansion. For seven
years we have worked hard to prepare for this new adventure, with a strengthening of the
international dimension of our team.
Therefore it is with great joy that we will add, in the wonderful World Cup year, a new International
Flagship centre to our existing network of seven Italian centres and our own Education &
Research Department. Based in Harley Street, an historic street rich in medical culture,
we will once again draw inspiration from the pioneers who resided there before us.
Mike Davison
Isokinetic London Managing Director
11
Howard De Walden
and Harley Street
The Estate
Right in the heart of London, just minutes from the hustle and bustle of Oxford Street,
Marylebone provides an oasis of relative calm a neighbourhood renowned for its rich
history, beautiful architecture and highly welcoming community. The Howard de
Walden Estate is the areaÕs main landlord, owning, managing and leasing the majority
of properties across a 92 acre area extending from Marylebone High Street in the
west to Portland Place in the east and from Wigmore Street in the south to Marylebone
Road in the north.
With its deep historical connection to the area, the Estate is committed to maintaining
the distinctive character and balance that make Marylebone so special. This means
preserving the diversity and heritage of the neighbourhood while ensuring that the
facilities on offer are kept completely up-to-date and relevant. The EstateÕs large and
broad-ranging property portfolio includes residential, office, medical and retail
accommodation, with each sector vitally important to MaryleboneÕs unique appeal.
12
Harley St
History of the Building
Harley Street is an historic street in the world of medicine, and for many
¥ 1759 First Building on the site
is synonymous with high quality and pioneering healthcare services.
¥ 1760-1835 Residential: Lady Catherine Noel, Mary Gulston,
Since the mid-19th Century many doctors had moved into Harley Street,
John Balchin West, Mrs Hartley (number changed: 41,42,76)
choosing the area because of the housing, the central location as well
as the accessibility to major train stations such as Kings Cross
¥ 1835 Became Medical Building. William Macintyre.
1st case report on multiple myeloma
St Pancras and Marylebone. As more and more doctors moved to
¥ 1857 Sir Alfred Baring Garrod - Rheumatoid Arthritis
the area they invited colleagues to work with them from their prestigious
¥ 1866 Renumbered to 11. Herbert Tibbets: A handbook
homes and Harley Street began to thrive as a medical centre, especially
of Medical & Surgical Electricity
after the Medical Society of London opened in Chandos Street in
¥ 1887 Rebuilt by Sir Frank Elgood (21 years old)
1873 then the Royal Society of Medicine in Wimpole Street in 1912.
¥ WWII Became offices under Lord Samuel
Today there are over 3,000 people employed in healthcare in the
¥ 2006 Brought back into HDWE
Harley Street area.
¥ 2014 IsokineticÕs new home
Sport and Exercise Medicine though has not had a significant presence,
in part due to the constraints of the classical architecture of a grand
house with a mews property at the rear.
History of this Address
With the strong backing of our Landlord, we have been able to
From 1807 to 1814 the 1st Duke of Wellington, Sir Arthur Wellesley
change this and bring forward a new era in the services offered on
(1769-1852) lived here whenever home from his long Napoleonic
Harley Street.
Campaigns.
13
14
London Sport
15
About this Centre
11 Harley Street is situated just a short walk from Oxford Circus Tube station. Behind the magnificent
faade, preserving the 19th century architecture of the neighbourhood, is an innovative and inspiring
Sports Medicine and Orthopaedic Rehabilitation centre. Something that respects the past and
embraces the future.
Positioned at the south end of Harley Street, our clinic really is in the centre of London, allowing
easy access via public transport. Equally there is underground parking available at Q-PARK in
Cavendish Square, only 50 metres away. Being in the heart of the Marylebone Village also means
we are surrounded by some of the finest restaurants and shopping destinations in the world.
We have plenty of space for patients to be dropped-off and have a ramp to accommodate any
patients in wheelchairs. A bike rack is available for patients who would like to cycle into their
appointments.
We endeavour to make all of our patients as comfortable and happy as possible, if there is anything
you feel we can do to make your visit easier or more enjoyable, please do not hesitate to contact
us before your arrival.
If you do have any trouble reaching us, our clinic is listed on Google Maps, simply search for
ÔIsokinetic LondonÕ.
16
17
Green Room
MEZZANINE
Upper Gym
The Layout
Lower Gym
We worked actively with the architect to create
a series of environments that can inspire
recovery. Overall, the centre accommodates
Stairs
nearly 10,000 square feet of functional Sports
Medicine and Rehabilitation space. Set over
three primary floors there are rehabilitation
gyms, an aquatherapy pool, a 3rd generation
surface indoor field and consulting rooms.
18
Male
Locker Room
Pool
Headquarters
Consulting Room 4
Library
3rd
Administration
Consulting
Room 3
2nd
Lounge
Consulting Room 2
Consulting
Room 1
1st
Lounge
Stairs
Lift
Reception
Main Gym
GROUND
HARLEY
STREET
Lift
Female
Locker Room
19
Our Environments
Take a look around, snap some mental images of these
spaces and try to get acquainted with the layout, you
may well be spending a great deal of time here in the
future and we want you to feel that these spaces are
as much yours as they are ours. This may seem trivial,
but whenever we design a new Isokinetic Centre, we
try to make sure the space is as comfortable for those
who work here as it is for you Ð the patients Ð who are
20
fundamentally here to get better. We believe that we
have achieved this here and hope that you enjoy your
time here as much as we do. As time goes on, we want
you to feel more and more comfortable here so you can
begin to enjoy your rehabilitation as so many of our
patients have in the past. The following pages will show
each area of our clinic in more detail and hopefully
explain what their purposes are a little more clearly.
21
OUR ENVIRONMENTS
The Reception
and Lounge
You are now in front of the ÕreceptionÕ, the starting point of your therapeutic path, and where you will say
farewell once you have fully recovered. The high desk and our international clinical administrators are at the
heart of our organisation and here to help you both from a logistical and practical perspective. Above all, they
are here to make you feel welcome and to take away some of the stress of being injured.
Our ÔLoungesÕ are not just there for you to pass the time in before your appointment, this is a space where
we want you to feel at home, and also to give you the opportunity to learn about our past, present, and future.
The space should feel like a hybrid between the front room of someoneÕs home and also an executive lounge
at the airport. The intention here is to make you feel Ôpart of the familyÕ from the moment you enter our clinic.
22
As you would expect, Wi-Fi is available to all patients, and we
can provide Òhot desksÓ for those with busy lives to manage.
23
OUR ENVIRONMENTS
The Consulting
Rooms
Isokinetic London has four consultation rooms dedicated to our Sports Physicians. After first visiting our
lounge, the consultation rooms will provide your first taste of the Isokinetic experience, as you undergo your
initial examination. Throughout your rehabilitation with us, you will regularly return to the consultation rooms
to have follow-ups to monitor your progress and evaluate the effectiveness of your rehabilitation programme.
Each consulting room is used exclusively by one of our doctors and comes fully equipped with a range of
medical instruments and diagnostic equipment.
24
25
OUR ENVIRONMENTS
The Rehab Gyms
There are three well equipped and interconnected gym environments. You will move between these spaces under
the supervision of our Rehabilitation Specialists, undertaking physiotherapy activities and performing therapeutic
exercises. Sessions in our gym will usually last around 120-150 minutes, but donÕt worry if this sounds like too
much for you. In addition to making sure you are performing exercises correctly our Rehabilitation Specialists are
there to supervise you and let you know when itÕs time to take a break, or to have a drink from our water cooler.
Gyms are an open environment, so you will mix with several other patients. We have found over the years that
this opportunity for patients to interact and share their experiences with each other helps patients avoid the feelings
of isolation that often follow an injury as well as providing a little competition to spur you along.
26
27
Recruit
the
to go
strength
forward
OUR ENVIRONMENTS
The Pool
Performing exercises in the water is extremely useful in the early stages of rehabilitation, helping patients
recover their full range of motion without putting any load of the injured joints. This in tur n will guarantee
the early recovery of functional activities. W ith a water temperature of 32 degrees Celsius and multiple
depths up to 2 meters, it is a comfortable and stimulating environment.
Patients may also retur n to the pool as part of the strengthening phase and for an early assessment of
biomechanics, as the pool facilitates movements that would otherwise be impossible to perform in other
environments. For us the pool is a crucial part of our treatment plan and something different to what you
may have experienced before.
30
31
Achieve
the
of
fluidity
movement
OUR ENVIRONMENTS
The Green Room
A special room, unique in Europe, paved with turf to make you
feel like you are on a real pitch. The green room is equipped
with advanced technological tools including a movement
lighting system, Wii, and 2 HD screens connected to cameras.
Underpinning this infrastructure is custom software able
to help us study your movement patterns, and to understand
more the causes and the potential risks of injury associated
with the biomechanics of your lower limbs.
34
In the green room you will be asked to perform certain exercises and tests.
We will objectively measure the way you move, analyse the forces and
pressures which you submit your limbs and joints, and review muscle activation
patterns and muscle performance. There are return to sport evaluations for
those who have completed rehabilitation following injury or surgery and are
striving to return to previous activity levels as quickly and safely as possible.
Additionally we undertake performance evaluations aimed at improving
physical performance and preventing injury.
35
OUR ENVIRONMENTS
The Field
Smile! If you have reached the field, your rehabilitation
is almost complete. The field should not be confused
with a football pitch, it is simply an open space where
anybody can recover the skills relevant to their life Ð
whether these are sport-specific technical movements
or simply the movements needed to walk up and down
stairs. Sessions on the field are appropriate for patients
of all types and ages, regardless of their level of fitness.
36
For our professional players we will organise sessions on elite
level fields, courts or the environments that they will return to
with their teams or in competition.
Isokinetic London currently has access to three different fields,
a five-a-side all weather pitch and a natural grass field, as well
as an indoor field at LordÕs Cricket Ground. As with rehabilitation
in the gym, exercises here are performed under the supervision
of one of our Rehabilitation Specialists.
37
Rediscover
the
in your
trust
body
OUR ENVIRONMENTS
The Locker Rooms
Finally time for a shower. At the end of ÔRehabilitation DayÕ,
you can relax. We are pretty sure this is the first room you will
learn to reach with eyes closed, after the first few days in
Isokinetic. The facilities will offer you an individual space to
change into your sports gear, hang your clothes and then
freshen up once you return from the rehabilitation. Each
changing room opens out directly into the swimming pool, so
there is no creeping up the corridor needed.
40
OUR ENVIRONMENTS
The Library
Inside Isokinetic you will also find a library. Of course you are unlikely to find any novels or fiction here, instead it is
stocked with medical and scientific volumes dealing with the injuries that we treat. In addition to books, you will also
see skeletons and models of anatomic models which are useful to help explain and describe to you which are the
bones, muscles and joints of the body. Whilst this room is normally only at the disposal of the medical and rehabilitation
team, if you are interested in going into some aspects of your injury, you can have a look at the specialist medical
texts by just asking to your physician to lend you the book talking about ÒyouÓ. Apart from killing time, reading gives
you knowledge that could help Òan earlier recoveryÓ. But if you donÕt feel like reading medical-scientific books, you are
b e t t e r n o t d o i n g i t : t h i s i s n o t a s c h o o l , s o t h e re a re n o t c o m m i t m e n t s , b u t o n l y o p p o r t u n i t i e s !
42
43
Case
Manager
Patient
Rehabilitation
Specialist
44
Clinical
Administrator
THE TREATMENT TEAM
The Treatment Team
Imagine a triangle, with yourself in the centre and at each of the three points: your Case Manager, your Rehabilitation Specialist
and a Clinical Administrator. By working as a team, these three people will do all they can to guide your rehabilitation and
ensure things run as smoothly as possible. You are always at the centre of this shape and you will always be the focus of
their attention Ð your requests, doubts and needs will be dealt with as best as possible. Remember that part of our philosophy
is that we do not treat sports injuries; we treat people with sports injuries. Our Case Managers are not simply specialised
doctors, but overseers of your entire rehabilitation process who will track your progress and make adjustments to your
programme during its course. The Rehabilitation Specialists and Clinical Administrators are no less important than the Case
Managers as they have an equally active role over the course of your rehabilitation.
45
THE TREATMENT TEAM
The Patient
What kind of patient are you?
Whether you are a professional athlete, a young sportsperson, an inactive adult, a child, an actress, a manager, a chef or a
dancerÉ we will prepare a customised rehabilitation plan to suite your unique needs, goals and lifestyle. This is why it is
important to explain your expectations to the Case Manager during your first visit, whether they are to return to top-level
sports or simply to be able to sit down comfortably, this information helps us to paint a picture of your lifestyle and plan your
rehabilitation accordingly.
47
The Therapeutic Ambition
physical
state
r2
r1
TRAUMA
t0
t1
t2
time
We always have in mind the Maximum Functional Recovery possible for all of our patients. At the heart of our organisation, and
why we feel ourselves to be a little different, is our Therapeutic Ambition for you. In simple terms this means we want to accelerate
your rehabilitation (safely of course) and end up in a situation where you have more time to focus on improving your physical
state and overall health. We want you to go past where you were before you were injured.
48
Each rehabilitation programme is unique to each patient, however each course of treatment will typically share some
common factors:
TRAUMA/PATHOLOGY/SURGICAL INTERVENTION
APPOINTMENT SCHEDULED
with information about the centre
THE TREATMENT TEAM
Your Rehabilitation Programme
INITIAL MEDICAL CONSULTATION
where a personalised Rehabilitation Programme is planned
REHABILITATION SESSIONS
in the gym, swimming pool, and on the field
FOLLOW-UP CONSULTATION
FURTHER REHABILITATION SESSIONS
in the gym, pool and field
FINAL CONSULTATION AT POINT OF RECOVERY
and discussion of your Maintenance Programme
49
THE TREATMENT TEAM
The Clinical Administrator
The Clinical Administrators should be your first point-of-call for any and all information. On your first arrival, a Clinical Administrator
will take you to your initial consultation with the Case Manager and bring you back to reception afterwards to organise future
appointments and book rehabilitation sessions. They are always there to help you, and deal with the logistical & financial
considerations.
50
51
52
THE TREATMENT TEAM
The Case Manager
After the Clinical Administrators, the Case Manager should be able to answer any medical queries you may have. The first step
in the process is the initial consultation, after which the doctor will create a personalised rehabilitation programme for you. Your
Case Manager will choose your Rehabilitation Specialist depending on the exercises you will need to do, although they will
be available throughout your rehabilitation and will monitor your improvements, keeping you informed of your progress along
the way. Most importantly, it is the Case ManagerÕs responsibility to inform patients when their recovery is complete.
53
THE TREATMENT TEAM
The
Rehabilitation
Specialist
The Rehabilitation Specialist is probably the person within
Isokinetic you will spend the most time with. In each session,
the Rehabilitation Specialist will provide a therapeutic
intervention and show you new exercises and how to perform
them. They are there as well to motivate you whenever you
need a push. For these reasons, we carefully select only the
most patient, friendly and well-trained Rehabilitation Specialists
to ensure you can get the most from your sessions whether
they take place in the gym, pool or field. In addition to their
role as your Ôpersonal guideÕ of sorts, each Rehabilitation
Specialist is also a fully qualified physiotherapist capable of
performing manual therapies where necessary.
54
55
58
In addition to the people at the points of the triangle within our method, Isokinetic also rely on various specialists to ensure
patients receive the best care across a number of disciplines. From osteopaths, to orthopaedic consultants, nutritionists,
podiatrists and psychologists, we have a network of experts at your disposal.
Osteopathic Sessions
THE TREATMENT TEAM
Internal Consultants
The main use for osteopathic sessions is in cases where the spine needs correcting, although the pelvis and other
peripheral joints (the foot, knee, shoulder and jaw for example) may also benefit from these treatments. These sessions
are very helpful for all.
Gait Analysis, Podiatry and Bracing
These examinations are used to evaluate all aspects of walking and moving, from a slow walk, to running and then coming to
a stop, the patientÕs position and posture adopted are carefully monitored. These results are given to the Case Manager who
will then analyse them and decide whether or not there is something here that could be causing the patient problems.
Additionally we can supply orthotics and braces to aid the rehabilitation process and avoid future injuries.
Psychology
Injuries and chronic illness can have a devastating effect on the psyche that is often overlooked. We provide patients with
psychological counselling in cases where patients need emotional support during their rehabilitation. Additionally, psychological
consultations may be required after the Rehabilitation Programme has been completed as many athletes develop an understandable
fear of re-injury which must be tackled before they can return to play.
59
if you want to run fast run alone
if you want to run far run together
60
Many of you will have private medical insurance cover which can be used to pay for some or
all of your treatment. We are recognised by all of the major insurers for our services and have
direct billing agreements with BUPA, AXA-PPP, Allianz and CIGNA.
There are, however, many variations around benefits such as levels of reimbursement, annual
excess and number of sessions allowed per calendar year, that mean it is often very specific
to you. The most important starting point is to make your insurance company aware you are
coming to see us, and ask for a pre-authorisation number (where appropriate). We understand
that it is not always easy to manage in, so we will provide all the additional support you may
THE TREATMENT TEAM
Managing Private
Medical Insurance
need to make this as simple as possible. Please just ask if you have any concerns or need help.
The Other People
(people and services)
In the Isokinetic there are not just Doctors, Rehabilitation Specialists and Clinical Administrators
but there are other figures as well. There is the housekeeper and cleaning team, who take
care of our indoor and green spaces, and the maintenance man, who solves any problems
we can have in the centre (except for your knees).
Isokinetic also has agreements with some type of accommodation for our patients, who come
from further afield (either in the UK or abroad). We are happy to help organise local travel
arrangements.
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THE FIVE PHASES OF
REHABILITATION
To reach the
Maximum Functional Recovery Possible
5
Recovery of specific technical
movements and return to play
4
Retraining of coordination
and motor skills
Recovery of strength
and muscular endurance
3
Recovery of range of
motion and flexibility
1
64
Resolution of pain,
swelling and inflammation
2
The Isokinetic Medical Group is determined to offer you the best treatment possible; helping you to recover 100% of your preinjury potential and help you beat your expectations.
Achieving this 100% recovery is not as simple as just using the appropriate exercises for the patientÕs injuries; instead we must
plan a path to rehabilitation piece-by-piece around the patient and their specific needs. Reaching the end of this path, and
therefore 100% recovery, will require time, effort, sacrifice and conviction, however the end result is always worth it.
To reach your maximum functional recovery possible, this rehabilitative path must lead you through our five phases of rehabilitation.
Phase 1
Resolution of pain, swelling and inflammation
Phase 2
Recovery of range of motion and flexibility
Phase 3
Recovery of strength and muscular endurance
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
The goal:
(To reach) 100% recovery
Phase 4
Re-training of co-ordination and normal motor skills
Phase 5
Recovery of (sport) specific technical movements and return to play
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Resolution of pain,
swelling and inflammation
During the first phase of rehabilitation, the focus is on reducing your
swelling and/or inflammation and helping to alleviate your pain. During
this phase your Rehabilitation Specialist will alternate the use of
physical therapies, which exploit existing biological mechanisms to
accelerate your bodyÕs natural healing processes, and manual therapies
1
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
PHASE
designed to directly influence the symptoms relevant to your injury.
The therapeutic techniques used here are especially effective when
combined with the use of traditional drug treatments, the use of ice
and ensuring you get enough rest.
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2
Recovery of range of motion
and flexibility
The second phase of rehabilitation aims to recover your complete range
of motion in the affected area and enable specific movements to be
performed without any pain.
Again, your Rehabilitation Specialist may use several different techniques
here including articular mobilisation and muscular stretching. The sooner
these treatments begin, the more likely it is your recovery will be successful.
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
PHASE
During this phase, the knowledge and skill of your Rehabilitation Specialist
really comes into play Ð acting too aggressively during sessions can
actually worsen your inflammation, whilst too gentle an approach can
re s u l t i n l i t t l e t o n o e ff e c t o n y o u r r i g i d i t y o f m o v e m e n t .
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Recovery of strength
and muscular endurance
The goal of the third phase of rehabilitation is to recover your former muscular
strength and endurance.
Your Rehabilitation Specialist will firstly focus on exercises to improve your
strength, being careful not to overload you. Together with your Specialist,
you will also spend a significant amount of time improving your endurance
(aerobic ability) which will have started in the first phase of your rehabilitation,
3
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
PHASE
although much less intensively.
Quantitative measurement is very important at this stage, so isokinetic and
functional evaluation tests are used to examine your progress so far, which
in turn helps us determine when you are ready to advance to the next phase.
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Re-training of co-ordination
and normal motor skills
This phase focuses on restoring your co-ordination. Every musculoskeletal
injury will somehow adversely affect your proprioceptive mechanisms Ð these
mechanisms are what give us spatial awareness of our limbs in relation to
objects around them. Restoring proprioception is important in preventing
4
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
PHASE
relapse or re-injury.
Completion of this phase does not rely on quantitative, qualitative or
time-based means of evaluation, but instead relies on your Rehabilitation
SpecialistÕs skill and their ability to adapt exercises to the individual.
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5
Recovery of (sport)
specific technical movements
and return to play
The final phase of rehabilitation carriers a different focus depending on the
patient in question. For an ÔaverageÕ patient, the focus is on returning them
to daily activity and normal movement, whereas professional athletes will
concentrate on recovering sport-specific movements which require extreme
precision.
This phase takes place on the field and is appropriate for patients of all kinds
whether they are professional sportsmen or an older sedentary person who
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
PHASE
just wants to walk normally again.
As with the previous phase, there is no pre-determined end point for this
phase. Instead, the programme is modified each day according to the specific
needs and reactions of each patient.
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Splitting the rehabilitation process into five phases does not mean you have to complete one phases before moving
to the next, in fact all of these phases are linked and overlap each other in several areas. We use these phases as
a kind of Ôtraffic lightÕ system, by respecting red lights we know when we are safe to move to the next phase.
Pain and swelling are the first red lights we encounter.
Once past these obstacles, we must tackle the next red light, which is returning full range of motion. For example, it is
impossible to walk correctly if the knee cannot achieve full extension, and
running is impossible without full flexion.
Strength is necessary for performing more complex exercises Ð muscles
act as cushions and dynamically stabilise any articulations made. Performing
jumping exercises, for example, is impossible without the necessary strength
T H E F I V E P H A S E S O F R E H A B I L I TAT I O N
How do I move
from one phase to another?
to cushion the shock of landings.
In reality, strength and proprioception exercises must be performed in
conjunction before work from all five phases is combined in complex
movements relevant to your daily life.
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FREQUENTLY ASKED QUESTIONS
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THE INITIAL CONSULTATION
This should be a pivotal point in your rehabilitation. After discussing your previous medical history, the reasons you came to Isokinetic,
and relevant factors in your personal life, your Case Manager will then talk you through the customised rehabilitation programme. This
programme will take all aspects of your life into account Ð how far you have to travel, the time you are able to devote Ð and, and perhaps
most importantly Ð your own expectations. In some cases, your Case Manager may feel it helpful for you to see another specialist such
as an osteopath or orthopaedic expert, or to undergo further tests. In these cases we will organise everything on your behalf and ensure
the person you see is well informed. The final part of your initial consultation is the scheduling of the check-up appointment, which will
help your Case Manager and your Rehabilitation Specialists stay up to date on your progress. During your initial consultation, your
Case Manager will begin to fill in your clinical chart with details based on what you have told them about your background, your personal
life and any tests that have been performed. This clinical chart will also contain a great deal of information on your personal case, your
personalised rehabilitation programme and detailed instructions written by your
F R E Q U E N T LY A S K E D Q U E S T I O N S
What happens during
the initial consultation?
Case Manager specifically for your Rehabilitation Specialist. These instructions
may include the approximate length of your rehabilitation process, the number
of sessions (in the gym, pool, and field) you should complete each week, and more
specific instructions unique to you to help your Rehabilitation Specialist provide
you with the best possible care. Any copies of test results will be attached to your
clinical chart, whilst originals will be given to you directly. Although it may seem
trivial, this clinical chart allows our entire team to keep up to date with your case
and therefore improve the quality of care you receive from all our staff.
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DIAGNOSTIC TESTS
Sometimes, additional tests such as X-Rays, MRIs or CT scans are required to reach a confirmed diagnosis. In all of our
centres, we provide patients access to diagnostic ultrasound scans; these scans are extremely useful for evaluating the
severity of muscular injuries which in turn helps your Case Manager build a rehabilitation programme. Ultrasound scans are
particularly effective at exposing muscle and tendon injuries and monitoring
F R E Q U E N T LY A S K E D Q U E S T I O N S
How do we reach
a diagnosis?
the effectiveness of exercises and treatments intended to alleviate the
symptoms of these injuries.
It is worth noting that following a muscle injury, you should wait at least 48
hours before undergoing any kind of scan as it is easy to overestimate the
internal damage shortly after the injury took place. During the course of
rehabilitation, check-up scans are used to assess the healing process of
muscle fibres deep under the skin, giving the team around you an accurate
picture of your progress.
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THE MEDICAL RECORDS
(Cartella Clinica)
Isokinetic use a unique clinical chart to track each patientÕs injuries, from the initial consultation the Case Manager will begin
adding key information to this chart, including: your previous medical history, results of various diagnostic tests and outcomes
of clinical examinations. There is a wealth of other information contained
F R E Q U E N T LY A S K E D Q U E S T I O N S
How is the Rehabilitation
Programme planned?
within these clinical charts as well, covering personal information relevant
to your case, the length and frequency per week of rehabilitation sessions
and whether they are in the gym, pool, or field, as well as specific information
and advice for your Rehabilitation Specialist. As your rehabilitation progresses,
all of your test results will be added to the chart while copies are also passed
on to you. Your clinical chart provides an excellent communication resource
for the team supporting you through your rehabilitation, ensuring all parties
are kept informed of the latest updates and key information.
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THE ISOKINETIC TEST
To truly achieve 100% recovery, good muscle strength and endurance at the end of your rehabilitation is essential. To measure
strength and muscular endurance, we test patients using isokinetic machines. These devices apply consistent load to the
muscle during flexion and extension movements performed at various angles and speeds which in turn gives your Case Manager
an accurate, quantifiable measurement of muscle strength. The results from the injured limb are then compared to the uninjured
limb to give a functional deficit figure, once there is no longer a deficit in the injured limb, rehabilitation is almost complete.
This test is most commonly performed on the knee, whereby we follow a specific procedure:
Before the test, your normal warm-up and stretching exercises must be
F R E Q U E N T LY A S K E D Q U E S T I O N S
How do we measure
strength?
performed, before each limb is independently tested. The test requires you
to perform several sets of repetitions of flexion and extension movements at
varying angles and speeds. The results for each limb are then compared to
give your Case Manager an accurate, quantifiable measure of your Ôfunctional
deficitÕ Ð the difference in strength and endurance between the injured and
un-injured limb. Although the knee is the most commonly tested joint, other
areas like the shoulder and ankle can also be tested in this way.
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THE THRESHOLD TEST
The threshold test allows us to measure your heart-rate, which is vital for planning
your rehabilitation around your objectives and expectations. The test is performed
on the treadmill or an exercise bike, putting you through a series of increasingly
intense exercises designed to continually increase your heart rate. Your heartrate is monitored throughout the test while a small sample of blood taken from
your earlobe allows us to determine the amount of lactic acid you are producing.
The combination of this data then gives us an idea of your metabolic characteristics
F R E Q U E N T LY A S K E D Q U E S T I O N S
How do we measure
physical fitness?
as well as your aerobic and anaerobic thresholds.
The aerobic threshold (S2) refers to less intensive level of exercise which can be
performed for extended periods of time, helping you to lose weight and improve
endurance. The anaerobic threshold (S4) on the other hand refers to more intense
exercise which produces more lactic acid than the body can recycle.
Periodic follow-up tests are useful here to measure changes in your level of fitness
and adapt your training regime accordingly. The chart to the right shows the
levels at which we expect different types of patient to reach their aerobic threshold:
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AFTER TESTS
IN THE CONSULTING ROOMS,
AND ON THE FIELD
So you are yet to start your gym or pool training sessions and you are already
F R E Q U E N T LY A S K E D Q U E S T I O N S
When will I get
back to playing?
asking when you can play sports again. We understand that this is your goal
and you want to achieve it in the shortest time possible. However, before
you can do this you must go through a series of tests designed to ensure
you do not suffer from re-injury, or make your current injury worse. Starting
in the consulting room, your Case Manager will conduct tests to evaluate
your strength and endurance before later performing similar tests on the field.
These tests aim to verify your rehabilitation has been successful Ð and that
most importantly, your running speed and heart rate are as predicted.
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THE FINAL CONSULTATION
Sadly, there will come a day when we say goodbye to each other, the day you are told ÒYour recovery is completeÓ. Everybody
celebrates this in their own way Ð some go for dinner, others throw parties while some prefer to play football again with their
friends, regardless of how you celebrate you will always be able to say ÒI
F R E Q U E N T LY A S K E D Q U E S T I O N S
When is it time
to say goodbye
to Isokinetic?
did itÓ. During your final consultation, your Case Manager will assess your
recovery, the progress you have made, listen to your thoughts and fears
and give you some final pieces of advice. After this, your Rehabilitation
Specialist will prepare a unique maintenance programme for you (comprised
of strength, aerobic and stretching exercises) to complete in any gym, or
at home. Continuing on a good path after leaving the centre is very important
in preventing re-injury, if you have any fears or doubts after you leave we
are always just a phone-call away.
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THE ISOKINETIC MEDICAL GROUP
100
A medical group at our core
After spending some time within our clinic, we hope that you realise we are something more than Ôanother physiotherapy groupÕ. Isokinetic is a
medical group in which more than one hundred and fifty individuals have chosen to share common values, work as a team and pursue excellence
on a daily basis with the ultimate goal of providing our patients with the best care possible. Our staff members periodically evaluate each otherÕs work
to ensure we are achieving the right results. Members of Isokinetic take part in many scientific meetings, as well as organising our own International
Conference on Sports Rehabilitation and
Traumatology since 1992, to which
more than 2,000 Sports Medicine
p ro f e s s i o n a l s f ro m
around the world attend.
www.FootballMedicineStrategies.com
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Bologna
London
Verona
Milan
City
Centre
Turin
Milan
Navigli
Rome
Rimini
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The Education and Research
Department
Formed in 2000, our Education & Research Department is the cultural heart of the Isokinetic Medical Group.
It offers young, bright people the opportunity to become a member of our Sports Rehabilitation network through
internships, courses and exams, ensuring they are fully versed in our methods.
The Education & Research Department is also responsible for managing relationships with the national and
international academic worlds, helping us keep up to date with the latest developments in research.
Additionally, we make an active contribution to global Sports Medicine by presenting our own findings at scientific
meetings around the world.
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Start your
recovery with
one click!
www.isokinetic.com
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The website
Switch on your computer, head to www.Isokientic.com and youÕll find a wealth of information about your
injury and your path to recovery as well as more information about our history, our expertise and even photos
of all our clinics around the world. With one click, you can make an appointment,
get in touch or simply ask us for more information. Within the website, you will also
find a ÔPatient GuideÕ area where you can find detailed information
on the most common sports injuries.
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FIFA Medical Centres of Excellence
Zurich
Auckland
Johannesburg
Kawasaki
Munich
Santa Monica
Cape Town
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Doha
Oslo
Regensburg
Bologna
SaarbrŸcken
Sao Paulo
Algiers
Durham
Guadalajara
Prague
Zeist
Brugge
Budapest
Rome
Stockholm
Cardiff
Bangkok
Melbourne
Lyon
Barcelona
Brasilia
Clairefontaine
Istanbul
Pachuca
Porto
Innsbruck
London
Murcia
New York
Tokyo
Our international
connections
The Isokinetic Medical Group is recognised as a FIFA Medical Centre of Excellence for the prevention and treatment
of sports injuries. FIFAÕs vision is to create a network of qualified establishments around the world to provide a
benchmark for the professional care of injured athletes.
Centres are located globally including; Brazil, Japan, Germany, Norway, New Zealand, Qatar, United States of
America, South Africa, Thailand and Switzerland.
Throughout the years we have also built and maintained numerous relationships with universities and foreign
colleagues that have allowed us to co-operate on scientific projects.
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Our Centres
Until now, this book has focused only on our London centre. Over the next few pages you can have a look at some of our other centres across
Italy. Starting with the oldest: our Bologna centre was opened in 1987, Milan opened in 2001, before Turin in 2003, then Verona in 2004,
Rome in 2005, Rimini in 2009 and most recently, London in 2012.
On average, our group cares for more than 11,000 patients a year offering us a wealth of case studies we can use to further improve our
knowledge and expertise.
Bologna
via Casteldebole, 8/10
40132 Bologna
phone: +39 051 573017
[email protected]
London
11 Harley Street
W1GÊ9PF London
phone: 0207 4865733
[email protected]
Milan City Centre
via Vivaio, 22
20122 Milano
phone: +39 02 76009310
[email protected]
Milan Navigli
via Morimondo, 26 (building 18)
20143 Milano
phone: +39 02 36569185
[email protected]
Rimini
via Nuova Circonvallazione, 57/D
47900 Rimini
phone: +39 0541 775650
[email protected]
Rome
via Flaminia, 867
00197 Roma
phone: +39 06 33221808
ro m a @ i s o k i n e t i c . c o m
Turin
via Rosmini, 5/a
10126 Torino
phone: +39 011 6692422
[email protected]
Verona
via Sparavieri, 28
37024 Arbizzano di Negrar
phone: +39 045 6020830
[email protected]
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THE MOST FREQUENT INJURIES
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PATHOLOGIES OF THE NECK
The Neck
Cervicalgia
Pain arising from the neck, or ÔcervicalgiaÕ, has many different underlying causes. These include problems connected to poor
posture, sedentary behaviour, the use of improper pillows, impact sports (especially rugby, wrestling and boxing), a Ôslipped
discÕ, arthritis and, not least, traumatic events such as whiplash injury.
Cervical pain can be localised to the neck or felt in other parts of
the body. Cervicobrachialgia is the term used to describe sharp,
shooting type pain that is perceived in the shoulder, arm and hand,
through to the fingers. This is often caused by nerve root compression
but the formulation of a clear diagnosis is fundamental to plan a
proper rehabilitation path. This will always require a thorough clinical
examination and often a series of investigations. These may include
Cervical
Vertebrae
a series of X-rays, which help evaluate the state of the vertebra and
their alignment, a CT scan or an MRI to detect possible compressions
of the spinal cord or the presence of the slipped discs causing
compression of the nerve roots.
Conservative (non operative) methods can treat the vast majority of
cases of cervicalgia, especially when the underlying cause and
contributing factors are appropriately addressed. During therapeutic
sessions manual based therapies are used to help relax the muscles of the cervical spine and shoulder girdle that are commonly
a source of tension. Specific exercises are utilised to help strengthen deeper, postural muscles of the neck and shoulder girdle
that often become weaker from poor posture, pain or disuse. Stretching of overactive muscles is also particularly effective.
An important matter is identifying at the first medical examination poor postural habits that can make the rehabilitation path
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PATHOLOGIES OF THE NECK
more complicated and neutralise positive results. The patient has to be conscious of the fact that, in part, the results patients
obtain depend on small details of their lives such as the way they sit on the sofa, or the time they spend in front of a computer.
This attention to detail may seem trivial, but these small factors often explain why symptoms persist for months or even years.
Surgical treatment: this choice is reserved for selected cases when conservative treatment has been ineffective or in emergency
situations, due to irreversibile neurological deficits.
Whiplash
THIS IS THE MOST COMMON INJURY AFFECTING THE CERVICAL SPINE
Whiplash injury occurs after a sudden, violent hyperflexion/hyperextension movement of the cervical and upper thoracic
spine. Causes of these injuries vary from: sports injuries, falls, accidents in the workplace, and most commonly car accidents.
The pain experienced here can be extremely intense and is usually felt most in the cervical muscles, whose tension and rigidity
can increase over time, limiting movements of the head. Vertigo and intense headaches often contribute to the pain experienced.
In rare cases pain can radiate along the arm through to the fingers of the hand which may be associated with altered sensation
and weakness. If these symptoms occur it may be the sign of a slipped cervical disc(s) and needs particular attention.
In these cases the first diagnostic exam you may undergo is a standard X-ray of the cervical spine in order to exclude
fractures.
A CT scan may be required if there is any suspicion of a fracture that the first X-Ray may have missed. MRI scans may also
be used where neuropathic pain is experienced.
Initially, treatment involves immobilisation of the neck with a cervical collar until further assessment can confirm that there
is no underlying instability. Specific pain relief drugs may also be employed, as well as muscle relaxants on occasion.
Finally, patients are instructed on correct posture. This is of extreme importance when optimising rehabilitation. A cycle of
treatment including specific physical and manual therapies is suggested to accelerate recovery times here.
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PATHOLOGIES OF THE SPINE
The Spine
AROUND 80% OF THE POPULATION ARE
Cervical
Vertebra
AFFECTED BY PROBLEMS WITH THE SPINE
AT SOME POINT
The vertebral column consists of 7 cervical vertebra, 12
Thoracic
Vertebra
thoracic, 5 lumbar, the sacrum and the coccyx. The spine
has four curves in the sagittal (side) plane: two with an
anterior convexity (cervical and lumbar lordosis) and two
with a posterior convexity (the thoracic kyphosis and at
the level of the sacrum and coccyx).
Lumbar
Vertebra
Vertebras are short bones constituted by a body in the front
and by an arch in the back. In between the vertebral bodies
are the inter-vertebral discs; structures made of a special
type of cartilage which assist in stability and movements of
Sacrum
Coccyx
the spine, as well as working as shock absorbers.
The main functions of the spine are related to support, protection and movement. The lumbar-sacral segment of the spine is the
most flexible but also exposed to the most amount of load. This aspect, as we will see in the subsequent pages, exposes this segment
to continuous overload that can damage vertebral joints, ligaments, discs and muscles which contribute to providing support and
stability to this region. The cause of spinal pain is ascertained after a thorough evaluation and careful clinical exam, which may also
involve further investigations, including X-Rays, a CT scan, MRI and on occasion, nerve conduction studies.
Backache
HOW MANY OF YOU HAVE SUFFERED BACKACHE AT LEAST ONCE?
Here ÔbackacheÕ, describes pain localised in the lumbar region and is due to many different causes. It is not our intention to
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PATHOLOGIES OF THE SPINE
bore you by listing all the potential causes and classifications of backache, rather to give you a general overview.
This is a very common condition affecting around 85% of the population. Backache is usually characterised by an aching pain
slowly or suddenly rising up the spine, which may or may not spread to the buttocks and thighs, as well as limitations on
movement as a result of this pain. 'Acute backache' may occur after a sudden torsion or flexion-extension movement of the
spine and can result in extreme sudden pain. Patients typically tell their doctors that they were trying to lift something heavy
from a semi-fixed position and that their back Ògot stuckÓ or that Òsomething wentÓ. In cases where normal activities continue
to exacerbate pain, a period of rest may need to be enforced.
'Sciatica' refers to a burning pain shooting down the posterior side of the thigh down to the foot, this is caused by compression
or irritation of the sciatic nerve.
Backache is defined as a chronic problem if it persists for more than 3 months. Patients describe pain and feelings of stiffness in
the morning that improve throughout the day, although they may experience difficulties maintaining the same position. This kind of
problem is particularly prevalent amongst those with sedentary occupations, including those which require long periods of driving.
During the clinical examination, it is important to identify the origin of backache and whether or not there is any evidence of
nerve root compression. Compressed nerve roots can cause sharp, burning pain and, depending on the site, a loss of or altered
sensation and weakness in the surrounding muscles.
Muscles governing movements of the spine are frequently contracted and sore in these cases (gluteus, quadrates lumborum,
paraspinal etc.) which can cause nocturnal disturbances which affect the quality of sleep - an often overlooked and important
factor in rehabilitation.
If spondyloysis is suspected, an oblique (angled beam) X-Ray is required. When the cause of the pain/problem could be due
to a discopathy (pain arising from intervertebral discs) an MRI scan, or CT scan, is requested to give a better understanding
of the underlying bone structures.
Conservative (non operative) treatment is warranted in the vast majority of cases but as with cervical pain, it is of paramount
importance to address contributing factors, such as poor posture.
Therapeutic sessions are generally based on the use of manual therapies to aid in relaxing the muscular groups responsible
for controlling movements of the spine and pelvis in addition to physical therapies designed to reduce pain.
When possible, exercises are used to selectively improve tone in certain muscles and to correct imbalances of strength which
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qualitative progression.
All of these exercises are used to create a 'follow-up programme', given to patients at the end of their recovery. Patients must
also become aware of how the 'small factors' mentioned earlier can affect the outcomes of therapy, and continue to pay
attention to things like how they sit on the sofa, how much time they spend behind the wheel and perhaps most importantly,
how much weight they have gained recently. It is important to focus on these seemingly trivial details in order to prevent the
recurrence of symptoms.
Slipped Discs
CAUSED BY THE POSTERIOR OR POSTERIOR-LATERAL
MIGRATION OF THE NUCLEUS POLPOSUS DUE TO A
Vertebral Body
WEAKENED FIBROUS RING
Spinous
Process
The intervertebral discs act as shock-absorbing cushions interposed
between two consecutive vertebra. They consist of a central 'nucleus
polposus', rich in water and held in place by an external fibrous cover.
Movements of the spine change the position of the nucleus polposus
Annulus Fibrosis
PATHOLOGIES OF THE SPINE
are almost universally present in cases of persistent backache. Later in the rehabilitation process, aerobic activity allows
inside the vertebral disc; an anterior flexion causes the nucleus polposus
to move backward, while an extension of the spine will result in it moving
forward. These physiological movements are prone to stress during
the repetition of incorrect posture and during sudden, large impacts.
Nucleus Polposus
In these cases, the nucleus polposus may protrude (bulge), pushing
it to the side without tearing the fibrous ring that retains the nucleus inside the intervertebral disc. These fibrous rings are
supplied with rich supplies of nerves; therefore the pressure exerted by displaced nuclei can result in pain. In more advanced
phases, where the fibrous ring has torn, the material contained inside the ring leaks out (slipped disc) pushing downwards
or sideways. Slipped discs and bulging of the nuclei vary according to their location and the direction in which they have
migrated. This is important to establish as it will dictate both the urgency, and type of treatment required. Clinical examinations
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PATHOLOGIES OF THE SPINE
are used to determine whether or not there are signs of a compressed
nerve. This may cause an aching, shooting type of pain as well as a
loss of strength in the muscle supplied (myotome) and/or an alteration
in cutaneous sensations in the area around the compressed nerve
root (dermatome). These alterations may include hyperalgesia (an
increase in sensation) or hypoalgesia (a decrease/loss of sensation).
Diagnostic tests required here include MRI or CT scans. It may also
Vertebral
Body L3
Vertebral
Body L4
be neccessary to undergo an electromyography (EMG) or nerve
conduction study (NCS), in order to evaluate any neurological deficits.
These examination can be quite invasive as they require the introduction
of needles into muscles or nerves to test their functioning.
Treatment here is usually conservative, especially when there is minimal
muscle weakness, since even the most severely affected discs tend to correct themselves in a few weeks or months.
Surgical treatment is reserved for more severe cases where: the disc has slipped into the intraforaminal area (the space in
which the spinal cord travels), where the nucleus is dehydrated, when muscle and sensory limitations do not improve, cases
where conservative treatment has been unsuccessful and in urgent cases where irreversible neurological deficits are possible.
Spondylolysis - Spondylolisthesis
THE MAIN CAUSE OF BACKACHE IN ADOLESCENTS
Spondylolysis (spondy = spine, lysis = breaking) refers to an alteration in the morphology of the lumbar spine, involving an
interruption in the continuity of the vertebral arch, more specifically the isthmus (parts interarticularis) between the superior
articular process and the inferior articular process of the facet joint. This absence of bone tissue then becomes filled with
thick fibrous tissue. Whilst the causes of this condition are not fully understood, it is thought that some people may simply
have a congenital weakness of the isthmus. Successive microtraumas, or a single sudden jolt may cause the bone to fracture
at this point, resulting in subsequent backache. If the isthmus is interrupted on both sides (as usually happens), the vertebral
body tends to slide forward on the vertebra below, producing a spondylolisthesis (listhesis = sliding). This pathology is the
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young athletes mention recurring backaches.
This most commonly affects the fifth lumbar vertebra (L5), which tends to
Isthmus
Fracture
slip on the body of the sacrum (S1) and also, although less commonly, the
fourth lumbar vertebra (L4) sliding along the fifth (L5). This condition is typically
benign, although it will progress over the years causing an instability in the
L-5
lumbar spine. As such, it is important to control this situation as early as
possible with proper clinical and diagnostic examinations. Medical history
S-1
and clinical examinations may lead to a suspicion of this condition, but further,
more specific investigation is required to reach a clear diagnosis. These tests
include X-rays of the lumbar sacral spine to investigate the presence of any
'sliding' or fractures. However, these fractures can be difficult to see on
X-rays, meaning more specialised CT scans are sometimes needed to rule out this possibility. MRI scans may provide evidence
PATHOLOGIES OF THE SPINE
main cause of backaches in adolescents and is frequently the culprit when
of a 'stress response' in the isthmus. In the most advanced of cases, this sliding may result in a stenosis (narrowing) of the
spinal canal with subsequent nerve compression and irritative symptoms. It is important to remember that not all cases of
spondylolisthesis are the result of a fractured isthmus, older adults may experience spondylolisthesis without any associated
spondylolysis occurring as the result of advanced degeneration of the joints between the lumbar vertebrae.
Treatment here is almost always conservative, consisting of reinforcement exercises to reduce the sliding forward of the vertebral
body, address the tilt of the pelvis, reduce lumbar lordosis and strengthen lumbar-pelvic control. in addition, physical and
manual therapies can be used, depending on the severity of symptoms. Surgery should only be considered in cases of marked
instability and a large 'slip', where fixation using metal rods, screws and bars is necessary. Following surgery, many of the same
issues will be present (poor lumbar-pelvic control for example) so a period of rehabilitation will still be required.
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THE SHOULDER IS A VERY COMPLEX JOINT
This is the most mobile joint of the body and enables a wide range
Acromion
Humero-Coraco
Ligament
Coraco-Acromio
Ligament
of movements that facilitate arm and hand movements. However it
is often only after a problem with the shoulder that one begins to
understand the important role it plays in everyday activities.
The aim of the next few sections is to provide the reader with a better
Coracoid
Process
understanding of the basic anatomy and mechanics of the shoulder,
and likely diagnostic and therapeutic interventions that may be
Scapula
required to help manage problems that develop in this region.
The shoulder joint comprises of three bones: the humerus (upper
arm bone), the clavicle (collar bone), and the scapula (shoulder
blade) which are interlinked by muscles, tendons and ligaments.
Humerus
Biceps
Tendon
Subscapularis
Muscle
The humeral head is ball shaped that partially fits into a cavity or socket called the glenoid (the joint component of the
scapula). The glenoid is quite shallow allowing for the wide range of movement at this joint. Stability is achieved by connecting
ligaments and the shoulder labrum, a special type of cartilage which provides a greater surface area for the bones to form
continuity with one another. The humerus remains close to the glenoid thanks to a tight fibrous cuff, comprised of the joint
PATHOLOGIES OF THE SHOULDER
The Shoulder
capsule, and the stabilising action of the powerful rotator cuff muscles surrounding it. Above the humeral head is a bony
prominence arising from the scapula, called the acromion, which in the space below (subacromial space) flow the tendons
of the rotators cuff muscles. In this space the shoulder tendons pass over each other during shoulder movements. The
efficiency of these movements is achieved due to the presence of bursae (naturally lubricated linings between adjacent
structures), with the subacromial bursa being the largest in this region. In addition to providing stability, they permit the lifting
and rotating of the arm itself. The two tendons of the biceps and of the pectoralis major muscles insert near the humeral
head. This whole complex is covered by the deltoid muscle.
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PA T H O L O G I E S O F T H E S H O U L D E R
DOES YOUR SHOULDER CAUSE YOU TROUBLE?
Diagnosis requires examination by a specialist who will be able to inform you of what is happening, based on the type of symptoms,
their duration, the way in which the shoulder moves and specific functional tests. However, confirming a diagnosis often requires
further investigation:
- X-rays: these help detect the presence of any fractures or structural changes to the shoulder joint. They may also reveal the
presence of calcifications forming on the rotator cuff tendons.
- Ultrasound: this dynamic scan is invaluable when diagnosing shoulder injuries as it enables your physician to visualise the integrity
of your tendons during shoulder movement. This may reveal the presence of tendon tears, inflammation, degeneration or bursitis.
- MRI: this provides the clinician with information of the whole shoulder region and is often required for more complex injuries,
especially where surgical intervention may be considered.
- MRI Arthrogram: this is the same as an MRI scan but requires a radiologist to inject a special contrast agent into the shoulder
joint prior to the scan. It provides more information about the shoulder joint, especially where tears of the shoulder labrum and
supporting ligaments are suspected.
- CT Scan: occasionally, this is required to provide 3D assessment of the bony anatomy of the shoulder, such as after certain fractures.
Shoulder Dislocation
The large range of motion at this joint can impact on its stability. Static stability is achieved by the ligamentous and cartilaginous
components of the rotator cuff which ensure tight continuity between the glenoid and humeral head. Functional stability (stability
during movement) is further supported by the rotator cuff muscles and the shoulder girdle. If one of these stabilising structures
is damaged during trauma, or is inherently weaker due to individual characteristics, certain movements of the upper limb can
result in excessive sliding of the humeral head into the glenoid, causing pain and a sense of instability. If there is a partial loss
of continuity between the two surfaces of the humeral head and glenoid then the term used is subluxation, if there is a complete
loss, then dislocation has occurred.
HAVE YOU EXPEREINCED A SHOULDER DISLOCATION?
Except in individuals with congenital, excessive ligamentous laxity, shoulder dislocation usually results from a high energy, traumatic
episode. There is an immediate sensation of powerlessness and often intense pain. The patient if standing, will tend to support the
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PATHOLOGIES OF THE SHOULDER
injured side with the opposite arm and there will be an obvious dip on the outside contour of the shoulder due to displacement of the
humeral head. Occasionally the reduction of the displacement, that is the repositioning of the humeral head inside the cavity may happen
spontaneously. More commonly, reduction requires a doctor to undertake a specific manoeuvre to relocate the humeral head, which is
not always easy to accomplish due to pain and muscle spasms. For this reason analgesic is often required. Additionally it is important
that an assessment is made of any fracture that may be present or signs of nerve damage that can occasionally occur if the humeral
head is forced against nerve(s) in close proximity to the shoulder joint. Treatment following an injury will initially require a short period of
immobilisation and further pain relief. In addition to pain, there may be a short period of joint stiffness and possible muscle wasting from
not using the arm. Rehabilitation is essential here as ensuring the arm can be freely and painlessly articulated is crucial in avoiding future
instability in the shoulder. If the shoulder's stability is not fully restored, the risk of future dislocations or subluxations (and therefore further
damage to the joint) is increased. The subsequent long-term management of a shoulder injury will be determined by several factors
including the patient's occupation, which sports they play, how many times they have suffered a dislocation in the past and the severity
of their current injury. Accurately evaluating the extent of a patient's current injury requires a great deal of investigation, from clinical
examinations to diagnostic scans such as X-rays and MRI's. Most patients can recover full stability in the joint through rehabilitation,
however those suffering from recurrent episodes, or professional athletes may require surgery.
SURGERY
The aim of surgical stabilisation is to repair where possible, or to augment the static stabilisers (ligaments, capsule and labrum) of
the shoulder joint, to preserve and restore its continuity. After surgery, the pain will probably be quite intense, but it responds well to
analgesic and the application of ice. You will be discharged with a brace but gentle movements of the arm are possible and are
important to stop the joint becoming too stiff. A period of rehabilitation afterwards is of
paramount importance to maximise the benefits of surgery.
Subacromial Impingement Syndrome
and Cuff Lesions
A QUICK DIAGNOSIS ENSURES EFFECTIVE REHABILITATION
Every time the upper arm is lifted overhead, a narrowing of the space between the
humeral head and acromion occurs. This space, (the subacromial space) is where
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PATHOLOGIES OF THE SHOULDER
tendons of the rotator cuff are located, protected by the bursa. Performing sports, or everyday activities which require repetitive
overhead movements, rotator cuff muscle imbalances, or irregularities in the acromion profile may all cause increased friction inside
this space, which can lead to the formation of calcium deposits within the subacromial space. The tendon most frequently involved
in these injuries is the supraspinatus tendon, due to its location. The end result of these kinds of injuries are feelings of weakness
and pain, often most felt at night time. The lack of movement that results from these feelings of pain can in turn perpetuate the
injury as the joint becomes more and more stiff through under-use. Pre-existing, but undiagnosed wear of the shoulder joint is
also a concern here as it can further contribute to the pain experienced. Quick and correct diagnosis followed by an early start
to rehabilitation is key here, as stopping the vicious cycle mentioned above ensures rehabilitation is faster and more effective.
Adopting this approach negates the need for prolonged courses of anti-inflammatory drugs, as well as preventing secondary
damage to the joint through the adoption of bad postures. In cases of large calcific deposits, or complete tears of the rotator cuff
tendon, surgery may be required. However, rehabilitation is always necessary here to correct and prevent the underlying issues
which may have led to the injury forming in the first place.
Acromioclavicular Joint Sprains
The clavicle articulates with the acromion part of the scapula to form the acromioclavicular joint. This joint is held congruence by the acromio-clavicular ligament and
the coracoclavicular ligament, which rises from the coracoid part of the scapula. Injuries
Second
Degree
Ligament
Tear
to this joint usually arise from a fall onto the shoulder, resulting in the clavicle separating
from the acromion. The levels of pain and functional limitation depend on where both
ligaments are involved and whether the ligaments themselves are torn, or just stretched.
The degree of separation can be measured with a simple X-ray of the shoulder joint,
which is often required anyway to check for associated fractures of the clavicle. Ultrasound scans can also be used here. In
cases of mild lesions, there is usually only minor swelling of the joint and only partial separation of the two joint surfaces. Treatment
of these mild injuries consists of tight strapping of the joint to ensure the ligament fibres remain in place to aid their healing. A
period of rehabilitation after this immobilisation is important to relieve any stiffness which may have formed in the joint as efficient
movement of the shoulder requires a fully functioning acromioclavicular joint. In more complex injuries where the ligaments have
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surgical intervention is required to restore the continuity of the joint.
Fractures of the Clavicle
The clavicle plays an important role in ensuring the efficiency of shoulder movements as well as postural control of the neck and
chest. Falls onto the shoulder, especially when the arms are outstretched, can easily cause a fracture to this bone. Fortunately,
even in cases of marked deformity, this bone tends to heal very well. Immobilisation is useful here, typically a figure-of-eight bandage
is tightly wrapped around the shoulder and under the arm, however, due to the high concentration of blood vessels and nerves in
the axilla (armpit), it is essential that any colour changes, or sensations of tingling in the hand are reported as quickly as possible.
Recovery from these kinds of injury typically takes around four weeks, particular focus is given to sessions in the gym and pool as
reducing the patient's pain and restoring their full range of motion are crucial here. Surgical interventions are rare and is usually
reserved for comminuted fractures (fractures with multiple fragments), fractures that do not heal well, and in cases of gross deformity.
Adhesive Capsulitis of the Shoulder
Commonly referred to as 'Frozen Shoulder', this condition arises when the glenoid and humeral head adhere to each other, causing a
progressive restriction, and loss of movement in the shoulder as the joint capsule thickens. Most commonly observed in the 40-60 age
range, females, following a period of immobility in the arm, and in those with diabetes, in fact this condition is often the first presentation
of late-onset diabetes. This tends to affect the left shoulder more frequently than the right and can often occur without any previous
history of trauma or injury. Capsulitis tends to advance in three stages: first, the 'cooling phase' where pain is spread throughout the
PATHOLOGIES OF THE SHOULDER
completely torn, the clavicle completely separates from the acromion. In these cases, the pain can be particularly intense and
shoulder, worsening during movement and resulting in a reduced capacity to use the arm. During this phase, many patients try to protect
their arm and avoid using it which only worsens the condition as it encourages further thickening of the joint capsule. The second phase
is the 'freezing phase' in which the pain becomes more localised around the humeral head, worsening throughout the night and therefore
impeding sleep. Finally the third phase can be referred to as the 'thawing phase' as there is some degree of recovery and an increase
range of movement. Diagnosis is usually clinical, but support from ultrasound or MRI scans is sometimes useful. Typically speaking,
treatment is conservative, combining anti-inflammatories, physical modalities, joint mobilisation and muscular stretching. Surgical treatment
is saved for cases where rehabilitation has had little or no effect, here the joint is mobilised through the removal of adhesions.
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Epicondylalgia (Tennis and GolfersÕ Elbow)
Humerus
This painful syndrome is localised around the lateral (outside) epicondyle
(the bony protrusion of the humerus) and can be called 'tennis elbow',
lateral epicondylitis, or epicondylalgia. In the majority of cases, this
Lateral
Epicondyle
presents itself due to a series of microtraumas to the tendons in the
wrist and the hand's extensor muscles near to where the tendon
attaches to the epicondyle. Conversely, 'golfers' elbow' (or medial
Common
extensor
origin
epicondylitis/epicondylalgia) is characterised by pain on the medial
(inside) epicondyle, caused by microtraumas to the flexor tendons of
the hand and wrist. Repetitive movements in the presence of muscular
imbalances result in changes occuring in the tendon of either (or both)
Radius
Ulna
the medial or lateral medial epicondyle.
Problems are more prevalent in certain sports such as fencing or rowing, or certain occupations like painters, hairdressers
PATHOLOGIES OF THE ELBOW
The Elbow
or carpenters. Generally speaking, this affects those in the 30-50 range the most. Tennis elbow usually features pain
localised to the lateral region of the elbow at the epicondyle level which may spread down the forearm and is exacerbated
by extension and supination movements - including shaking hands or turning a key - as well as feelings of weakness in
the arm. Diagnosis is clinical with support from ultrasound scans to assess the integrity of the tendon. Treatment plans
focus on a period of rest followed by rehabilitation including: muscle building exercises, stretching, massage, analgesic
physical therapies (laser, ultrasound, and shockwaves) and also analgesic injections into the tendons. In the (very) rare
cases where rehabilitation is unsuccessful, the tendon can be operated on arthroscopically (keyhole surgery).
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PATHOLOGIES OF THE HAND AND WRIST
The Hand and Wrist
Carpal Tunnel Syndrome
This syndrome forms as the result of compression of the median nerve as it passes through the carpal tunnel (wrist tunnel),
formed by the carpal bones and the flexor tendons of the fingers
and wrist. The most common causes of this are the thickening and
swelling of the tendon sheaths or the irregularity or enlargement of
the carpal bones due to osteoarthritis. Alternatively, chronic conditions
such as amyloidosis, diabetes mellitus and rheumatoid arthritis as
well as hormonal changes due to pregnancy or menopause can
narrow the diameter of the carpal tunnel, therefore compressing
Transverse
Carpal
Ligament
the median nerve. Finally, fractures to the wrist can also cause
damage to the median nerve, bringing on the onset of this condition.
Initial symptoms include nocturnal disturbances as a result of
Median
Nerve
tingling/numb sensations in the hand and fingers. Patients frequently
discuss difficulties in performing delicate tasks like tying their shoelaces
or buttoning up their shirts. After some time, these feelings of tingling
evolve into feelings of pain, especially during movement, that persists
throughout the day. Given the fact that motor fibres are also often involved in this condition, the nerve supply to the thumb
muscles can be affected, leading to weakness and wasting. Diagnosis of this disorder is based on specific clinical tests backed
up by an electromyography (EMG) test to confirm the extent of the nerve degeneration. Depending on the patient's clinical
history, other tests such as blood tests, X-rays and CT scans may be useful in cases of secondary forms of the disorder.
Prognosis here generally leads to a total absence of any sensory disturbances after a few months. Rehabilitation using splints
and physical treatments to address the muscular imbalances, especially those in the wrist and forearm, is key for the restoration
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PATHOLOGIES OF THE HAND AND WRIST
of fine motor control. In more advanced cases where motor components are affected, a surgical procedure known as 'carpal
tunnel release' may be required to prevent irreversible damage to the nerve and the muscle it supplies.
Scaphoid Bone Fractures
Among the different types of fractures to affect the bones in the hand, those involving the scaphoid bone are the most
frequent. Generally occuring after a fall onto the hands, these injuries may also cause damage to the small ligaments
surrounding the scaphoid bone that link it to the other carpal bones, in particular the lunate bone. This kind of fracture
typically results in deep pain and swelling in proximity to the
anatomical snuff box (the small triangular area at the base of the
thumb and index finger). Pain may also be felt over the scaphoid
tubercle (the bony prominence) and when the thumb is moved
towards the wrist joint. Wrist movements, especially extension with
a closed fist, can be particularly painful and troublesome.
The localisation of fractures is extremely important when establishing
a therapeutic path and a long-term prognosis. There are three
different types of fracture to consider here: proximal and distal
fractures, and fractures to the waist. Proximal fractures (fractures
to the uppermost pole) are the most serious here as the blood
supply follows a distal to proximal path which often means that
blood flow is reduced in these injuries. Diagnosis is based on the patient's clinical history as well as examinations which
should be confirmed by X-rays of the wrist. Fractures here can often go unnoticed during an initial X-ray, especially if it took
place shortly after the injury itself happened, but if your doctor suspects that there may be a fracture, they will likely order
another X-ray to take place 15 days later, or a CT scan to confirm their diagnosis. Late diagnosis, or improper immobilisation
are the two most frequent causes of complications which can include, avascular necrosis ('dead' bones due to a lack of
blood supply) in the proximal pole and arthritis of the wrist. Unfortunately, scaphoid fractures commonly pass unnoticed or
are miss-diagnosed as simple wrist sprains later giving rise to advanced arthritis. Treatment is generally conservative for
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fractures with a benign prognosis (distal and waist fractures) and consists
of 6-10 weeks of immobilisation using a plaster cast. Proximal fractures
instead are usually treated with surgery consisting of a small cannulated
screw being inserted into the joint to lock it in place before a 2 week
period of immobilisation. After radiographic evidence of the fracture healing
has been found, the plaster or brace can be removed and rehabilitation
can begin. This will initially focus on the recovery of range of motion and
strength of the intrinsic and extrinsic hand muscles before later moving
on to specific, relevant exercises matched to each patient's sport or
occupation.
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PAT H O L O G I E S O F T H E H I P
The Hip
Osteoarthritis
ARE YOU EXPERIENCING PAIN IN YOUR HIP DESPITE NOT SUFFERING ANY TRAUMA?
For reasons still unclear, some people seem to be more prone to osteoarthritis of the hip joint than others, rather than this being
a simple case of 'wear and tear'. One view is that this is all due to how the body repairs itself, those who seem to repair themselves
better than others will typically experience less, or less intense symptoms. In some cases, the body's attempts to repair the joint
are actually detrimental and can lead to an alteration of bone structure, an extra bone or osteophytes, or further loss of cartilage
leading to a progressive loss of movement. It seems that some individuals are more prone to this than others, women and
overweight patients are usually affected more, as well as those undergoing repetitive weight-bearing movements and those
with a previous trauma such as a cartilage (labral) tear. Structural changes to the bone may occur in childhood and slowly cause
mechanical changes in the way the joint operates therefore accelerating the joint's deterioration. Symptoms here are generally
very clear and include groin pain (which tends to worsen when walking
or moving after a period of inactivity), pain that radiates to the knee
Iliac Crest
(this is why any patients who complain about knee pain will have their
hip joints examined, especially when there is no history of trauma to
the knee), and a weakness, wasting, and imbalance of the hip and
thigh muscles which can lead to lower back pain. Diagnosis is clinical
Hip Capsular
Ligament
and radiographic, with X-rays being used to reveal alterations to the
bone structure and CT and MRI scans used to detect the presence
Femur
of cartilage irregularities.
TREATMENT
Education and explanation of the diagnosis is a very important component
here. A proper Rehabilitation Plan aimed to reduce pain, increase range
of motion, return the patient to their active daily life and most importantly,
Sacro-Tuberous
Ligament
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PAT H O L O G I E S O F T H E H I P
slowing the progression of the disease is effective only when performed early and correctly. Patients may also benefit from a
reduction in their physical work or changing to more suitable physical and sporting activities. The body's natural response is
to protect damaged areas, especially those involved in movement, therefore rehabilitation exercises to restore efficient range
of motion, reduce the levels of muscle weakening and imbalances, eliminate bad postural behaviours and maintain good
coordination are of great importance here. These exercises can significantly help in pain control and improving quality of life
and should not be underestimated.
Hip Prosthesis
Surgery to install a hip prosthesis will only be suggested by your doctor in cases of
persistent pain, irreversible damage to the joint and/or a marked restriction in joint
movement. This kind of operation is usually reserved for patients over the age of 60 to
ensure the patient does not outlive the effective lifespan of the prosthesis, therefore
having to undergo further surgery.
There are four types of hip prosthesis:
- Total hip prosthesis or arthroplasty, where both the femur and acetabulum are replaced
- Hemiarthroplasty, where only the femur is replaced
- Resurfacing prosthesis, this is where the worn-out femoral head is covered, without
removing it. This type of surgery is usually used on younger patients in order to preserve their bone and allow for the possibility
of arthroplasty at a later date if it is required
- Revision prosthesis, where a previously implanted prosthesis is replaced.
Starting immediately after surgery, rehabilitation here begins with mobilisation of the leg with help from your Rehabilitation
Specialist and aims to focus on restoring range of motion, muscular strength, coordination and correct gait patterns. This
is a crucial time requiring significant effort and dedication of both the patient and their therapist.
Sessions will take place in the gym, the aquatherapy pool and then the field, where targeted work to restore technical skills
f o r d a i l y l i v i n g i s p e r f o r m e d a s t h e s e m o v e m e n t s w e re l i k e l y i m p o s s i b l e b e f o re t h e o p e r a t i o n .
Generally speaking, recovery of normal living takes around 4-6 weeks, varying on the patient's condition, frequency of
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Groin Pain
A VERY COMMON PROBLEM, ESPECIALLY IN FOOTBALL PLAYERS
The patient may complain of a mild ache in the sacroiliac joint, which may worsen when performing particular movements,
therefore limiting sporting activity. Sometimes the patient may also complain of 'click' or 'clunk' noise coming from the hip.
Usually there is evidence of an acute trauma, or repeated microtraumas over time. The pain that follows, if it is not managed
appropriately from the outset, may lead to a number of biomechanical changes around the lower back, hip and groin. Due to
the ambiguity of these symptoms, it is common for the patient to undergo a number of different examinations, before their
underlying cause is determined.
In sportsmen, especially footballers, the iliopsoas muscle and tendon are commonly responsible for many cases of groin pain.
The iliopsoas is an internal muscle of the hip that flexes, abducts and externally rotates the head of femur. It originates from
the lateral facets of the first four lumbar vertebrae and from the iliac joint, and inserts on the lesser trochanter of the femur. This
is a bilateral postural muscle which is typically under greater tension amongst individuals with accentuated lumbar lordosis.
PAT H O L O G I E S O F T H E H I P
rehabilitation sessions and the type of prosthesis.
The diagnosis is usually clinical, and is based on muscular tests to determine resistance and palpation.
Sometimes, additional examinations are required, MRI scans are extremely useful in identifying muscular lesions or further
problems in the hip joint.
Treatment is universally conservative and it is based on specific myofascial massage, postural and stretching exercises which
selectively tone the psoas and synergistic muscles.
It is also very useful to integrate therapies in the gym with a vertebral manipulation course that can address possible failures
in the articulation of the pelvis, chiefly around the sacroiliac joint.
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THE KNEE IS ONE OF THE MOST COMPLEX JOINTS
IN THE BODY
The knee is one of the most complex joints in the entire human
body. It relies on sophisticated laws of anatomy and biomechanics,
making it exceptionally strong whilst equally delicate. Even small,
subtle changes to the anatomy can affect the efficiency of the joint,
Posterior
Cruciate
Ligament
Medial
Meniscus
Anterior
Cruciate
Ligament
to the extent that pain may be felt during every step that is taken.
The knee joint connects the femur (thigh bone) with the tibia
(shin bone), and is protected anteriorly by the patella (knee
Lateral
Collateral
Ligament
cap) which helps facilitate and strengthen the muscular
movements needed for flexion (bending) and extension
(straightening) of the limb. These bones are lined by a layer
of cartilage which works to reduce friction between them,
Lateral
Meniscus
Patella
(superficial articulation)
Medial
Collateral
Ligament
Patella
Tendon
(cut and
folded down)
PAT H O L O G I E S O F T H E K N E E
The Knee
facilitating the sliding motions required during movement.
The menisci (lateral and medial) are specialised cartilaginous structures lying between the femur and tibia, their ring-shaped
structure allows them to increase the jointÕs stability as well as working as shock-absorbers, reducing the effects of impacts
and loading on the joint.
The knee joint is stabilised by four very strong ligaments: the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial
collateral ligament (MCL) and lateral collateral ligament (LCL). Further stability and support to these ligaments is provided by the joint capsule.
Traumatic Knee Injuries
Traumatic rotational or twisting type movements are responsible for most knee injuries in sport, especially prevalent in football,
rugby, and skiing. It is also commonly found in motorists who have been involved in collisions (head-on collisions in particular)
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PAT H O L O G I E S O F T H E K N E E
or among motorcyclists (who twist the knee as they fall).
If you have experienced any kind of knee rotational trauma, you are likely to suffer some degree of swelling and/or discomfort.
While waiting to see a doctor, we would recommend you apply ice to the knee, elevate the leg and avoid putting any load on
it, use crutches if you have access to them. Getting a doctor to assess your injury is essential, the examination may be painful
due to the acute pain and swelling you are likely to experience, however without knowing exactly what type of injury you have,
planning your rehabilitation appropriately would be next to impossible. In addition to the initial consultation and examination, a
MRI may be required to investigate the integrity of the knee joint.
Lesions of the Anterior Cruciate Ligament
WHAT IS THE ANTERIOR CRUCIATE LIGAMENT?
The anterior cruciate ligament is fundamental for the passive stability of the knee. It is a sturdy, fibrous bundle connecting the
femur to the tibia, rising up the centre of the knee joint. The name of the ligament comes from the unique position of its bundles
that create a cruciform (cross shape) with those of the posterior cruciate ligament. The cruciate ligaments play a very important
role, preventing excessive forward or backward movement of the femur on the tibia.
WERE YOU DIAGNOSED WITH A LESION OF THE ANTERIOR CRUCIATE LIGAMENT?
Those suffering ACL injuries often find themselves feeling very scared about their future as
they assume their only course of action is surgery. At Isokinetic, we see ACL injuries as
less of a serious problem for patients, rather as a situation that requires care and attention.
Surgery is not always necessary, or even the best course of action, when dealing with
ACL injuries and typically, waiting a few months before making a decision on surgery does
not result in any disadvantages for the patient.
ACL lesions are very common in those who play high-impact sports such as football, skiing,
volleyball and basketball. Symptoms of an ACL injury vary from patient to patient, however
generally speaking they include severe pain, the rapid onset of swelling and extremely limited
functional movement. Diagnosis is based on the patientÕs unique history, combined with
appropriate clinical examination used to determine the kneeÕs stability. MRI scans are
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SURGICAL OR CONSERVATIVE TREATMENT?
The decision as to which type of treatment to take (conservative, or surgical) is a complex one, and doctors must take many
different factors into account such as: the age of the patient, the severity of the injury, whether or not there are associated lesions
around the area and the level of sporting activity the patient engages in. With any injury, it is crucial to follow an appropriate
rehabilitation plan which details all the steps the patient must complete.
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
There are three surgical techniques commonly used here:
¥ Reconstruction using tendons from semitendinosus (ST) and gracilis (GR) tissues
¥ Reconstruction using the patellar tendon
¥ Reconstruction using an allograft (donor tendon)
Reconstruction with semitendinous or gracilis tissues are now the most commonly used options. These interventions involve
the use of two medial flexor muscles from the thigh, which are then passed through a bone tunnel into the joint. The surgery
is performed arthroscopically.
During rehabilitation, it is very important to take the flexor musclesÕ (from where the tissue was taken) healing time into account.
Reconstruction using the patellar tendon involves the removal of the central third of the patellar tendon through an incision, approximately
PAT H O L O G I E S O F T H E K N E E
frequently used here to evaluate any damage to the meniscus, collateral ligaments and cartilage, without aggravating the tender area.
5 cm in length. This tendon is then inserted into the joint through a bone tunnel using arthroscopic guidance. This type of intervention
tends to weaken the extensor apparatus of the knee which can lead to painful tendinopathy of the quadriceps and patellar tendon
if excessive load is used during rehabilitation - therefore increasing the recovery time and making it a less popular option.
Reconstruction with an allograft is a graft obtained from a donor Achilles, or patellar tendon. This intervention has the advantage
that tendons are not taken from the patient, avoiding the weakening of the thigh or quadriceps flexor muscles as in the two
previous interventions.
Use of a brace to immobilise the knee after surgery is at the discretion of the orthopaedic team. In most cases, the use of
crutches is suggested for around 3 weeks. Rehabilitation should begin two days after the surgery, either in hospital or at home,
before starting at one of our centres around ten days later. Rehabilitation from these kinds of surgery can take up to five months,
with activity alternating between the pool, gym and eventually, the field.
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All of us are potential patients like the great Roberto Baggio,
greater emphasis to the optimism in determination, rather
although not all of us can boast the same footballing skills!
than the pessimism found in reason. Willpower, training,
Baggio has done more than enthrall us with great goals, he
dreams and faith... this is a special mix that should be used
has been an amazing 'life player', always dealing with his
by everybody. Naturally, having an accurate diagnosis and
injuries in the best way. Roberto's final exploit was in 2002,
innovative surgical techniques have been really important,
just before the World Cup in Japan at the end of a challenging
but having a positive mental attitude has been equally so".
championship season, in which he had to battle for survival
For this reason, Isokinetic gives a great deal of focus to the
in Serie A (the Italian equivalent to our Premier League). In
mind and thoughts, the personal, precise and meticulous
the spring, Baggio ruptured his anterior cruciate ligament
care given by our Case Managers and Rehabilitation
- a serious injury for a footballer, and even more so for a 35
Specialists takes over later on. Roberto Baggio knows this,
year old footballer with a history of bad injuries. Was this
and provides a great example for others to follow. You can
the end to Baggio's season and thus his career? Far from
be like Baggio, you just have to believe in yourself.
CASE STUDY
We'd like to tell you a story about
a famous anterior cruciate ligament
it! Baggio was not willing to give up and chose to undergo
surgery to reconstruct his ligament before subsequently
starting his rehabilitation with Isokinetic. 77 days later, he
returned to play, saying: "I carried on thanks to my willpower
and faith, which have always been with me. What has
determined my success has been my desire to plan the
future and make my dreams come true, I have been giving
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FROM THE SPORTWEEK SUPPLEMENT OF THE ÒGAZZETTA DELLO SPORTÓ 26/10/2002, WRITTEN BY CLAUDIO GHISALBERTI
Time to get the weight off my chest. The truth on BaggioÕs injury
Last season, we heard of Roberto Baggio's miraculous return to play only 77 days after receiving a serious injury to his anterior
cruciate ligament. This rapid recovery was the result of dedication and medical advances, as the champion of Caldogno tells
Sportweek for the first time...
You have had two serious anterior cruciate ligament ruptures during
your career, what do you remember from the first time it happened,
and what was different the second time around?
On both occasions, I remember the pain, but the second time around
the new rehabilitation techniques helped me recover quicker.
What went through your head when you realised you had been injured
a second time?
The pain is so intense during the first few seconds that you cannot
think, you just want the pain to be over. Many sleepless nights followed
where I began to think about the future and what people would think
when they read about it in my new book, which comes out in a few
weeks.
Where did you find the motivation to get back to playing so quickly?
Being unable to help my team was making me suffer more than the
pain, I knew how important the last few days of the season would be
and how much my team needed my help. And of course, I was thinking
about the World Cup in Japan approaching.
Were there any difficulties during your rehabilitation?
Yes, but I overcame these by thinking about my future and my desire
to accomplish my dreams.
How important was your faith and outlook on life during your recovery?
Even in seemingly negative situations, it is important to remain
determined and optimistic. Logical reasoning would make some people
think to themselves: ÒRoby, you are 35 years old, you have already
had more than one knee operation in the past Ð your rehabilitation will
be slow and painful, nobody has ever recovered their previous form
in less than three monthsÉ it is impossibleÓ. Thanks to my faith and
determination, I was able to focus on the optimism of determination,
rather than the pessimism that can be found in reason. I think I have
showed that anything is possible, it all depends on your willpower and
desire to achieve. In my case, faith is behind my success.
How much time did you spend in rehabilitation?
Too much! I was spending 9-10 hours a day working, only resting on
Sundays. Overall it was an incredible success though, and I must
thank all my doctors, physiotherapists and everybody else who played
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a part in my recovery. Their warmth and friendliness really helped
me through the darker, more difficult moments.
When did you realise you were going to make it back in time for the
end of the season?
About one month after I was able to run again, thatÕs when I realised
I was on my race to the finish line. People thought I was crazy, but
all the tests I had taken suggested I was ready.
As soon as you were back, you scored two goals against Fiorentina,
how did you feel at the end of the game?
Excited and very happy. I can remember exactly how I felt because
that feeling has stayed with me for a long time now. When you have
a dream, you have to suffer and fight to achieve it, but when you do
reach your goal you feel amazing Ð there is always a lot of emotion
after a tough fight!
How did you feel after you finished the last 3 championship games?
Great! My test results were better than when I left for the USA, you
would have thought IÕd had an extra month of training.
How do you feel now?
The knee that was operated on feels the same as the other and I
am really happy with my post-operative recovery. Obviously both of
my knees have their battle-scars, I am 35 and still fighting, but I am
performing a training regime to help me better cope with the pressures
of the season.
What is your next big challenge?
Well I have never played in the EuroÕsÉ (laughs)
FROM THE SPORTWEEK SUPPLEMENT OF THE ÒGAZZETTA DELLO SPORTÓ 26/10/2002, WRITTEN BY CLAUDIO GHISALBERTI
For Science he is a pioneer.
The head of Bologna speaksÉ
An interview with Dr. Stefano Della Villa, president of the Isokinetic Medical Group, and the man in charge of the team who
brought the striker back to the pitch.
From a medical point-of-view, what made BaggioÕs recovery so fast.
His recovery was a real exception, made possible thanks to a mixture
of four factors: his determination, innovative and effective surgical
techniques, a method of rehabilitation perfected over many years and
a little bit of luck in that he did not suffer any complications.
LetÕs talk about that first factor Ð Roberto himself
He wanted this. He had a specific target in his head and was determined
to spend 3 months of his life to achieve it. His determination was so
strong that he has inspired others as well Ð his brother Giorgio, his
friend Vittorio Petrone and all of his medical team. When I was working
closely with him and the team around him, it was amazing to see this
one man create such a sense of energy and positivity that inspired an
entire group of people.
Well, his energy must have been very important, but in reality we are
talking about ligaments and tissues hereÉ
I agree completely, whilst I am sure that RobertoÕs passion and spirit
have helped him reach this stage, as a man of science I cannot ignore
the physical changes to his knee. The surgery he underwent involves
reconstructing the torn anterior cruciate ligament using tendons taken
from the semitendinous and gracilis muscles of the same knee. This
technique is now widely used as it has been perfected by outstanding
surgeons over the past twenty years.
77 days after his surgery was extremely impressive, but what is more
amazing is that he was able to play a full 90 minute game just two
weeks later in which he acted as a real leader, and inspired his team
to give a great performance.
There are a lot of expectations now, it seems that everybody who
has this kind of surgery will expect similar results
This is normal, but one case in medicine does not mean a lotÉ
whilst this represents a successful method to follow, we need to
adopt a protocol based on this, apply it to a group of patients, verify
the results and then present them to the appropriate scientific
organisations. What happened to Baggio could become the norm
in five to seven yearsÕ time.
Has a new path been created?
We are speaking about the knee of a footballer, not a manÕs life, I
am confident in saying this has been a great success for Italian
So, instead of the torn ligament there are now two tendons, but how
are these attached to the bone?
In this case, Dr. Marcacci, RobertoÕs surgeon passed these two
tendons through tunnels in the tibia and femur before fixating them
in place with two screws. This technique facilitates the tendons to
attach themselves to the bone over a period of several months negating
the need for these screws. This kind of technique makes much faster
rehabilitation possible which made it perfect for Baggio as he wanted
to get back on the field as soon as possible.
So all of these factors have come together to make a rehabilitation
record?
I donÕt like to refer to this as a record, as what is more important is
that RobertoÕs recovery was quick but most importantly, successful.
I think that returning to the pitch for 20 minutes and scoring twice just
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medicine. We base all our activity on protocols that result from many
years of study, I would say that this case has been a big win for us
and for Sports Rehabilitation as a whole, helping the field to grow
culturally.
Tell me about these protocols
They are equivalent to a prescription for a drug. Whilst some doctors
will tell you what kind of pills and how many you should take each
day, we say how many and which kind of exercises to do each day,
measuring progress along the way. These exercises are performed in
the gym, pool and field, always under the supervision of our rehabilitation
coaches, with increasing difficulty and intensity based on the patientÕs
condition.
Did you give Roberto Baggio any special attention during his
rehabilitation?
No, Baggio received the same treatment as any of our other patient
would. His Case Manager, Dr. Gianni Nanni planned a programme for
him, and kept a close eye on his endurance, heart and lungs and of
course his muscles and tendons. Roberto would undergo periodic
tests to measure his lactic acid levels during and after exercise to help
determine his workload for following sessions. These simple and
efficient programmes were perfected by Dr. Sergio Roi, the director
of our Research Department, who spent many years with the sky
runners Ð a group of people who compete in marathons at the base
of Mount Everest.
You mentioned luck earlier as wellÉ
Yes of course, this was a very important factor in RobertoÕs recovery.
There are so many things that could have gone wrong for him: if his
knee had swollen, we would have had to slow the pace of rehabilitation;
if his tissues became inflamed we would have had to stop completely
for a few days; scarring of the muscles after the surgical graft would
have been equally disruptive. Roberto was fortunate enough not to
suffer any of these complications, in his case his tissuesÕ response to
our stimuli was perfect.
Is that everything?
In my opinion, these were the main reasons for his amazing recovery.
But Carlo MazzoneÕs decision to bring Roberto back onto the pitch,
despite a relatively low number of training sessions with the team, was
the right decision based on his many years of experience, and one I
completely agree with.
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This experience of accelerated recovery
following anterior cruciate ligament
reconstruction has been published in
several pieces of international literature
including detailed descriptions of the
protocols used and the way in which
progress was monitored.
Figure 1: Case 1 - Celebration after scoring the first goal in an official game, 77 days after surgery.
A poster on accelerated rehabilitation
Madrid 2002
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PAT H O L O G I E S O F T H E K N E E
Lesions of the Posterior Cruciate Ligament (PCL)
THE POSTERIOR CRUCIATE LIGAMENT: A ROBUST FIBROUS BUNDLE BETWEEN THE FEMUR AND TIBIA
Lesions to the PCL are much rarer than those to the ACL as they typically occur when the leg is pushed backwards with enough
force to overcome the ligamentÕs mechanical strength. These kinds of traumas are most common amongst those involved in headon collisions, and those who play contact sports.
Immediate symptoms of these kinds of injury can be very subtle, making early diagnoses very hard to make.
In general, patients will experience feelings of instability and pain that persist after the initial injury occurs. MRI scans and other
diagnostic tests are typically required to reach a reliable diagnosis, as well as helping to identify any meniscal lesions or other
damage around the area.
SURGICAL OR CONSERVATIVE TREATMENT?
A conservative approach is usually the best solution for these kinds of injuries, although dependent on any associated meniscus
or collateral ligament injury. The early stages of treatment for PCL traumas follow similar procedures to those used for other knee
injuries, before becoming more specific during later stages. Surgical solutions are reserved for more severe cases where conservative
treatments have failed to reduce instabilities.
Lesions of the Medial and Lateral Collateral Ligaments (MCL, LCL)
WHAT ARE THE COLLATERAL LIGAMENTS?
These are two ligaments joining the femur and tibia, stabilising the knee during side to side movements. This injury typically occurs when
the leg is overextended inwards or outwards. As abnormal movements such as these are common in many sports, these kinds of injuries
are very frequent.
The gravity of collateral ligament injuries is closely linked with how intense the mechanism of injury was: a minor trauma causes a lesion
of 1st degree, in which only a portion of the fibre is damaged, causing the knee to ache without any effect on stability; a moderate trauma
leads to a more severe 2nd degree lesion, characterised by mild instability and a lot of pain. An intense trauma causes a 3rd degree
lesion, tearing the ligament completely causing swelling, pain and most importantly significant instability.
Initial examinations may be sufficient to correctly diagnose these injuries, although an ultrasound is sometimes suggested to evaluate
the state of the ligament or even an MRI to assess any associated lesions.
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WHAT TO DO?
The decision as to a course of treatment depends on the degree of damage to the lesion but the use of a knee brace and/or
crutches is initially suggested. In contrast to cruciate ligaments, collateral ligaments will respond well to immobilisation, beginning
to heal on their own accord.
Stiffness needs to be prevented by removing the brace as soon as possible and starting exercises in a pool with deep water.
Specific exercises will be added to the rehabilitation program to avoid unnecessary stress on the affected ligament and promote
its correct orientation to assist the healing process and the eventual full recovery of knee function. In rare cases an orthopaedic
specialist may suggest surgically repairing the damaged ligament.
Meniscal Lesions
A lesion of the meniscus may occur during the combined movements of flexion and
rotation typical in traumatic distortions. A lesion may also occur, however, after a banal
movement or through cartilage degeneration and loss of elasticity in elderly people.
Symptoms vary from an acute sting localised along the articular line to a dull and
undefined pain that flares up during certain movements. Important meniscal lesions
may generate a real articular block which most of the time can be resolved with
appropriate tilting manoeuvres in flexion-extension.
During the medical examination different parameters will be evaluated such as finding the exact area of pain, swelling, defining
the range of motion and the presence of any looseness. The tests used to confirm the diagnosis include magnetic resonance
imaging (MRI) or computer tomography scans (CT) due to their ability to show both skeletal components and muscular structures.
An accurate diagnosis is crucial in order to plan a suitable rehabilitation program. This will be differentiated, based on the type of
lesion and the patientÕs unique needs.
IMMEDIATE AND CONSERVATIVE TREATMENT
It is important to rest and apply ice to the knee for around 20 minutes, three times a day immediately after the injury, the use
of crutches if you have access to them is also recommended. Rehabilitation can begin almost immediately after the injury,
helping you to recover some level of normal living. Clinical and investigative findings will help define what kind of treatment and
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rehabilitation path to follow here.
SURGERY
Patients are offered this type of surgery after particularly serious injuries, or following the failure of conservative treatment. Typically
these procedures are conducted arthroscopically, there are four main categories here: meniscal suture; selective meniscectomy;
implantation of meniscal scaffolding; implantation of meniscus from a donor (allograft).
¥ Meniscal suture: If the size and location of the lesion will allow it, the surgeon will make a meniscal repair using a suture.
Rehabilitation programmes here last much longer than in simple medial meniscectomies.
¥ Selective meniscectomy: Where meniscal suturing is not an option, a surgeon will have to remove the detached meniscal fragments
in order to restore the meniscal profile to normal. This type of surgery typically involves a very short period of time in hospital.
¥ Meniscal scaffolding implants: This surgical technique was preceded by a long evaluation period. Currently it is a very popular
technique as it results in extremely positive outcomes. A synthetic meniscal prosthesis is introduced arthroscopically, encouraging
growth of new meniscal tissue, thus delaying the onset of osteoarthritis.
¥ Implantation of meniscus from a donor, or allograft: This surgical technique involves the implantation of meniscal tissue obtained
from a donor which is then sutured into the knee of the recipient. As in the case with meniscal scaffolding, the time for the biological
integration of new tissue requires some cautious monitoring, and recovery times will be much longer than for simple meniscectomies.
Every surgery will be followed by an intense and often lengthy rehabilitation process.
Cartilage Lesions
CARTILAGE ALLOWS FOR FRICTION-FREE ARTICULATION MOVEMENTS
Cartilage is a very sophisticated pearly tissue surrounding the bony joint surfaces that when damaged, is difficult for the body
to regenerate. Its smoothness ensures efficiency of movement. The occurrence of cartilaginous problems is common due to
wear caused by the repetition of certain movements, or following a trauma to the area. The erosion of the cartilage, however
severe, is called a chondral defect and causes an altered sliding of the heads of the bones. This results in pain, swelling and
difficulty of movement. If you have been diagnosed with serious cartilage damage in a joint like the knee, you should be aware
that recovery can be a very long process. After an in-depth clinical examination, the doctor will prescribe a magnetic resonance imaging
scan (MRI) that can highlight and quantify the area and severity of the lesion. 4 chondral defect stages have been identified with increasing
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degrees of severity, that also differ in their therapeutic approach: conservative treatments can be used for the most minor injuries, whilst
surgery is usually more appropriate for more severe ones. The aim is always to stop the vicious circle created by friction, which leads
to joint degeneration. The rehabilitation program will be customised according to the location and severity of the lesion. The intention is
to reduce pain and restore the tone and endurance of specific muscle groups that
play important protective roles.
TREATMENT
The rehabilitation of knee chondral defects requires a dedicated period of time
from the patient but the guidance of the physician and physiotherapist will ensure
that this time is put to good use. The principal objective of therapy is to interrupt
the vicious circle that has developed, with the increase in friction leading to an
increase in joint degeneration. There are essentially 4 recognised stages of pathology
increasing in severity, dependent on the grade of chondral defect from 1 to 4.
These 4 stages are described below to help explain the nature of rehabilitation
required. It is important to remember that weight loss, in case of an overweight
patient, is compulsory: the reduction of the load transferred to the joint is a key
part of treatment.
¥ Stage 1: A Grade 1 chondral defect, when the cartilage mantle is soft and swollen. The lesion can be seen on a MRI, but
can also be detected clinically. We would suggest a careful rehabilitation programme, which includes strengthening exercises
for certain muscular groups, to balance the loads on the articulation and absorb your weight.
¥ Stage 2: Represents grade 2 and 3 chondral lesions, where craters of varying sizes are present in the articular cartilage linked
to the grade of the lesion. This kind of pathology is only identifiable through MRI scans or arthroscopic surgery. Rehabilitation
Programmes follow similar paths regardless of whether or not a surgical intervention was made and aims to reduce experienced
pain, and re-build the tone and shape of muscle groups that play a critical protective role. This programme has to be tailored according
to the severity of the injury, and the anatomical and functional features unique to the patient.
¥ Stage 3: Grade 4 defects, where the cartilage is completely worn away, exposing the bone beneath. The seriousness of these
kinds of lesions impair articular movement, resulting in a constantly swollen knee which turns red and feels rigid and stuck in a
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state of flexion, and therefore hinder daily life. If the patient is suitably healthy and the orthopaedic surgeon supports it, surgery is
usually the best way forward here.
SURGERY
The surgical techniques adopted here are numerous: some of them aim to stimulate the capacity of the residual cartilage tissue
to repair itself through the production of fibrocartilage, while others are aimed at the ex-novo regeneration of damaged cartilage,
and replacement with new hyaline cartilage. Obviously, this option is reserved for the most serious injuries that may require a
more radical intervention.
¥ Chondral abrasion, or cartilage shaving: This is an intervention that simply regulates the surface of the damaged cartilage. In
Grade 1 leasions, cartilage starts to fray and form fibrils which are removed with a specific tool in an attempt to remove the flaps
and loose edges that mechanically conflict with joint articulation. The long-term results of this strategy are poor. This technique
by itself is not a final solution, because it has no reparative or regenerative capacity, it is merely used to alleviate symptoms.
¥ Microfractures: this technique uses tiny needles to create numerous perforations at the sub-chondral level at a distance of
3-4 mm apart. This draws blood from the layer of bone beneath the cartilage, forming a new layer of qualitatively inferior cartilage
(fibrous cartilage) when compared to the original (hyaline) cartilage, although this new layer is still biomechanically acceptable.
This intervention is a reparative surgery. The load is generally prescribed one month after surgery, but high-impact sports are
allowed until around 6 months later.
¥ Osteochondral autologous graft (OAT) or Ôplastic mosaic techniqueÕ: Core cartilage tissue is extracted together with a
portion of sub-chondral bone from non-loading joints which is then inserted over the properly prepared, damaged cartilage.
In this way the cartilage defect is filled with hyaline cartilage, giving good results even in the long term. This intervention includes
a non-loading period for 30-45 days after surgery and allows return to high-impact sports from 8 months onwards.
¥ Transplantation of autologous chondrocytes (ACI): This method involves two separate surgeries: First, chondrocytes are
taken from the joint and are cultured for one month; after 30 days the chondrocytes are grafted on a three-dimensional matrix
(hyaluronic acid, collagen and alginate) and are then reinserted into the joint to fill the cartilage defect. The long-term results
are excellent, but rehabilitation times are very long. This intervention involves non-loading period of 30-45 days after the surgery
and allows return to high-impact sports after around 10 months.
¥ Biomimetic Scaffolding (MaioRegen): One of the latest developments in surgery, this technique involves the implantation
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of synthetic support structures consisting of hydroxyapatite and collagen fibers. The technique involves a single surgery during
which the scaffold is shaped over the cartilage defect. This part is then inserted after allowing the lesioned surface to bleed,
so that totipotent cells contained in the blood can colonize the scaffold and produce chondrocytes. This intervention includes
a non-loading period of 45-60 days after surgery and allows return to high-impact sports from 10 months onwards.
¥ Transplantation of autologous mesenchymal cells: Stem cells are taken from the patient's bone marrow, extracted from
the iliac crest. These cells are inserted on a support structure loaded with additional growth enzymes extracted from the patient's
blood. Finally, this compound is implanted at the site of the lesion, filling the chondral defect. The results from these surgeries
are comparable to those obtained from Biomimetic Scaffolding procedures, although the initial non-loading period is shorter
at 30-45 days, high-impact sports must be avoided for at least 12 months.
In all these cases, rehabilitation after surgery will obviously vary widely, depending on the surgical technique used. Times can
vary significantly, but in all cases we proceed through our five phases of rehabilitation: starting with the reduction of postoperative pain and swelling, then recovering the range motion, before muscle strength and endurance, followed by the restoration
of neuromotor coordination and finally the return to sport. It is essential to carry out an adequate rehabilitation protocol that
allows the maximum functional recovery possible in accordance with the biological healing time of the cartilage tissue.
Each transition from one phase of rehabilitation to another is decided by the physician who evaluates specific clinical parameters.
The first phase of rehabilitation will be carried out by alternating time between the pool and gym. This moment is particularly
delicate because the replaced cartilage is vulnerable to mechanical stimuli. If load is built up appropriately, it can stimulate the
integration of new cartilage and its maturation; on the contrary, excessive loading can cause catastrophic failure of the implant.
Manual and physical therapies will be alternated in the gym, strengthening and proprioception exercises will be used according
to the specific programme set out by the Case Manager. In the pool, the patient works to recover correct gait and movements
in the operated joint. If the patient is an athlete of some kind, specific exercises in deep water can also be introduced to begin
restoring correct movements without loading the joint.
Even in the pool, as in the gym, strength and coordination exercises are tested using fins, life jackets and floats of various sizes.
In the following months, the patient will begin to run on the treadmill and perform preparatory exercises for rehabilitation on
the field. During the rehabilitation isokinetic training sessions are included which culminate in an isokinetic test to evaluate the
differences in strength between the operated limb and the healthy one. When the operated limb is no longer significantly weaker
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than the un-operated one, introduction to the field begins, assuming the appropriate amount of time has passed to allow the
biological recovery of the cartilage. In this phase the patient is given a threshold test to evaluate the state of the limb and give
accurate information on their progress to rehabilitators on the field, so that they can carry out more personalised and effective
work. This stage-by-stage progression will bring the patient back to their pre-injury fitness on the field and the restore their
dexterity in the use of the specific sport movements.
Patellar Tendinopathy, or ÔJumperÕs KneeÕ
This is a very common disease affecting athletes who use explosive strength (in volleyball, basketball and athletics for example).
This can be the result of an acute event due to a functional overload, or the result of repetitive microtraumas.
Clinically, pain is noted at the inferior pole of the patella accompanied by painful swelling. The pain builds gradually, decreases
after warming up but then gradually intensifies, limiting performance.
There are 4 clear clinical stages to this condition:
¥ Stage I: pain appears after training, activity is not limited
¥ Stage II: pain is initially present, disappears after warming, then reappears again after that
¥ Stage III: the pain persists for the whole duration of the play/movement
¥ Stage IV: tendon rupture
The diagnosis is usually clinical, supported by ultrasound scans of the muscle-tendon to get an idea of the degree of tendinosis,
or an MRI for the most severe cases. For all but the most severe cases (complete tendon rupture), conservative treatments are
more commonly used. The course of treatment here is quite a delicate process, where success is based upon the severity of injury
and the time taken to start after the onset of symptoms
Osgood Schlatter Disease, or Anterior Tibial Apophysitis
This is most common in male adolescent athletes (10-13 years old) who have grown rapidly.
This causes an abnormal overload on the growing cartilage that causes microfractures of the apophyseal bone core.
The clinical picture is characterized by pain localised in the anterior tuberosity of the tibia, which is exacerbated by physical
activity and reduced during rest; locally there is a painful swelling.
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The diagnosis is clinical and is supported by X-rays in order to evaluate any calcifications or insertional problems.
During periods of exasperated pain the athletes have to stop exercising. The disease tends to be resolved itself as suffered
finish growing.
Patello-Femoral Syndrome
THIS CONSISTS OF A GROUP OF MORPHO-FUNCTIONAL ALTERATIONS THAT RESULT IN THE ONSET
OF ANTERIOR KNEE PAIN.
The patella moves inside a cavity, dug into the distal part of the femur; bone surfaces slide over one another, facilitated by cartilage
covering them and are guided by the tension of certain muscle groups like the patellar tendon and alar ligaments. A small alteration of
form or function in one of these components is enough to increase the pressure on one part of the patellofemoral joint with consequent
onset of pain or, even worse, instability which can lead to the patella leaving its seat in painful episodes of dislocation.
Diagnosis relies on support from X-rays and CT or MRI scans. The majority of cases benefit from a personalized rehabilitation program,
while surgical solutions are reserved for the most serious of cases. Rehabilitation begins in the gym, but continues through everyday life
when patients will need to put small changes into place to maintain full functionality. The only real cause for surgical treatments is the
presence of major patellar instability, characterised by habitual dislocation of the patella or its on-going malposition.
Surgical interventions include the realignment of the extensor apparatus, which can be performed arthroscopically or with open surgery.
There are many ways to deal with this as the origin of instability is often due to many different factors. However, this decision is always
taken by an orthopaedic surgeon specialised in knee surgery, who will always account for all the different factors affecting the patient.
After surgery, rehabilitation aims to restore full function in the knee, first resolving the inflammation, then recovering the range of motion,
followed by muscle strength, and finally the more sophisticated movements used in everyday life or the patientÕs chosen sport.
Ilio-Tibial Band Syndrome
This term indicates a framework of chronic inflammation that affects the last section of the fascia lata (iliotibial section) where there may
be mechanical friction that generates a painful inflammatory condition, felt most during movements of flexion and extension of the knee.
This syndrome is particularly prevalent among footballers, runners and cyclists and it may arise from overloading of the joints, or
from training on hard or irregular surfaces. Some anatomical factors may increase the incidence of the disease, such as varus
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knee and hypo-extensibility of the posterior muscular chain. The main symptom is pain at the lateral part of the knee. Sometimes
there is also swelling at the insertion points of the tendons. Sport is often made impossible due to pain and the feelings of stiffness
that accompany it.
The diagnosis is essentially clinical. Ultrasound can help in confirming the diagnosis and showing the degree of inflammation.
Magnetic resonance imaging (MRI) may be useful in the differential diagnosis between this and an external meniscal condition.
The treatment is almost always conservative and consists of a mix of physical and manual therapy. In the acute phase it is necessary
to reduce, change, or suspend sporting activity depending on the severity of the situation.
Surgical solutions can be considered in selected cases where resistance to the conservative treatment is found.
Osteoarthritis of the Knee
Osteoarthritis is a very common condition, which is mainly degenerative and characterised by wear and aging. In rare cases, it
may occur at an early age, originating from a traumatic injury if not properly treated.
This degenerative phenomenon often resits attempts to reduce pain, instead formations of periarticular ossifications (osteophytes)
can cause disabling restrictions to movement. This condition can occur in otherwise healthy joints affected by altered joint mechanics,
or due to malformations caused by previous injuries. It is particularly prevalent in women and overweight patients.
In those suffering from this condition, repetition of certain movements or flawed posture can cause irreversible damage to joints
in the long run.
Symptoms are well defined in these cases; pain, swelling, limp walking, feelings of resistance in the joints and cracking noises
from joints during activities all point towards this diagnosis.
To reach a definitive diagnosis, clinical and radiological methods are typically used. X-rays provide a good picture of any abnormalities
in the skeletal profile, whilst CT and MRI scans can detect abnormalities in the cartilaginous tissues.
CONSERVATIVE TREATMENT
Well-designed rehabilitation programmes can improve quality of life for those suffering, by reducing pain and restoring range
of motion to the joint therefore slowing any advancement of the condition. As always, we believe that improving movement
through therapy is fundamental to success.
There are some basic guidelines patients should follow to reduce the effects of osteoarthritis. These include weight loss, or
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Knee Prosthesis
Prosthesis surgery is recommended in severe cases of osteoarthritis where the pain is
persistent and there are serious limitations in joint function and where radiographic diagnosis
has confirmed the situation.
In general, we mainly recommend these treatments to the over 60Õs, both with a view to
the duration of the prosthesis, and because as age increases, demand for physical
performance falls. The prosthetic surgery should be delayed as long as possible in patients
who continue to maintain sufficient functionality and have tolerable pain. If osteoarthritis
affects the articulation of a young person, operations such as osteotomies are preferred as they correct the axes of load, reducing
the stress on load-bearing joints.
Rehabilitation after prosthesis surgery aims at first to recover range of motion, then muscle strength, coordination, and finally gait
pattern. Difficulty here depends on the status of the limb before surgery. The orthopaedist will organise the start of rehabilitation
a few days after surgery, with assisted mobilisation of the limbs.
Around the fifth day patients will move from their bed to a chair, they should begin to walk again between the 10th and the 15th
PAT H O L O G I E S O F T H E K N E E
conversely, avoiding excessive physical exercise, as well as maintaining correct posture during both day and night.
day, helped by a therapist as well as crutches. These times may vary depending on whether the joints had already been subject
to surgery. The period that follows discharge is used to restore the strength, motility and functionality typically found in that district,
which requires a considerable effort both from the patient and their rehabilitator. Patients will be assisted in the gym or at home
and, if possible, in the pool where recovery is particularly fast.
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THE ANKLE JOINT IS SUBJECT TO CONTINUOUS STRESS
If your ankle is becoming painful, the problem may be due to the pressure transmitted from the ankle to the foot. The foot
has a very limited area of support compared to the body weight and the position of the center of gravity. Therefore the ankles
Fibula
can be prone to distortion or sprain, resulting in very limited movement.
The foot is a strong and complicated structure:
it is made
up of 26 bones, connected in 33
Anterior
Talo-Fibula
Ligament
Posterior
Talo-Fibula
Ligament
joints, and strengthened by more than 100
ligaments. Body weight is transmitted to the foot
by the ankle or by tibiotarsal joint. The tibiotarsal
joint is a bone-ligament complex with the shape
of a mortar: the tibia and fibula with their two
malleoli surmount and wrap around the upper part
Calcaneo
Fibula Ligament
of the astragalus, which transfers the pressure
to the other bones of the foot.
If the ligaments are strained, the tough fibrous cords can break, and as a result this can lead to more severe distortive injuries.
An increase of the movement within the joint will improve resultant instability.
Ankle Sprain
Most people will experience an ankle sprain at some point in their life, ankle sprains are the most frequently seen sporting
injury and are particularly prevalent amongst professional sportsmen.
PAT H O L O G I E S O F T H E F O O T A N D A N K L E
The Foot and Ankle
The most common cause is the internal rotation of the foot. Sprained ankles can also be caused by eversion (an external
rotation of the foot) and sometimes both injuries can coincide. The ligament most prone to an inversion injury is the anterior
talofibular (ATFL) followed by the calcaneal fibular (CFL) and the posterior talofibular (PTFL). While eversion injuries more
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PAT H O L O G I E S O F T H E F O O T A N D A N K L E
often result from an injury to the deltoid ligament.
The swelling is usually immediate and the pain can be very intense. Movement is severely limited due to the swelling, whilst
the ankleÕs stability can also be affected in more severe cases.
If the area around the ankle is remarkably swollen, an X-ray is usually performed to rule-out the presence of any fractures.
An ultrasound performed a few days after the injury can help to highlight distortion and ligament damage. In rare cases, the
examination can be completed with an MRI or CT scan.
Rehabilitation following acute traumatic injuries is crucial for the restoration of joint stability and for it to function dynamically.
It is also important that the patient continues a maintenance program once their rehabilitation is complete in order to avoid
the problem recurring.
Achilles Tendon Rupture
THE ACHILLES TENDON IS THE LARGEST AND MOST
ROBUST TENDON IN THE HUMAN BODY.
Repetitive stress in athletes or simple aging in inactive people can lead
to variations in this tendonÕs structure. This can lead to partial or even
Tibia
Achilles
Tendon
complete tears of the tendon itself.
This injury often results from unrecognised or misunderstood chronic
tendonitis. It mostly affects jumpers, runners, footballers and tennis
players. It is believed to be the result of an abrupt contraction.
Typically, the athlete reports a sharp and sudden pain in the posterior
region of the leg, often associated with a loud "crack" sound.
Patients often report the sensation of having received a whip or kick from an opponent. The rupture generates an immediate
functional impairment, preventing any kind of ambulation.
Diagnosis is mainly based on the clinical presentation: sometimes there is a gap evident at the break. The suspected diagnosis
is often confirmed by an ultrasound that clearly shows the disruption of tendon fibres and allows us to distinguish between
total and partial ruptures. Surgical intervention is always required in these cases.
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PAT H O L O G I E S O F T H E F O O T A N D A N K L E
Achilles Tendinopathy
Several inflammatory and degenerative conditions fall under this heading and they can be classified by the location and
duration of the pathology. They may be the result of an acute injury triggered by functional over-loading, or repetitive
microtraumas typically caused by unsuitable footwear, hard terrain or exercising in the cold.
Initially, symptoms tend to worsen during rest before easing after movement (the first few steps taken on a morning can be
particularly uncomfortable). After some time, the pain may no longer ease after movement, severely hindering the patientÕs
movement. Over time, stress on the distal portion of the tendon can lead to inflammation of the pre-achilles bursa, further
complicating the clinical situation.
Diagnosis is based on the localisation of pain (usually found around where the tendon inserts into the calcaneus) as well as
swelling and flushing of the skin. These indicators are usually supported by an ultrasound scan, used to more accurately
determine the location and extent of the lesion.
Tendinopathy requires delicate treatment and the chances of success vary depending on the severity of the injury and time
since the onset of symptoms. Regardless, planning an effective rehabilitation program is still important as the later, less
severe stages of the condition must not be ignored.olgono inizialmente alternando piscina e palestra.
Plantar Fasciitis and Heel Spurs
Plantar fasciitis is a disorder relating to the fibrous connective tissue structures originating from the calcaneal tuberosity (tip
of the heel bone) and inserting into the metatarsal heads (balls of the feet).
During the stance phase of step and run movements, the plantar fascia is stretched significantly, causing a great deal of
stress around the insertion on the medial tubercle of the calcaneus. Over time, calcification can occur along the length of
this band that produces a typical radiological heel spur. The presence of these kinds of spurs is not necessarily linked with
the presence of pain - heel spurs are often found by chance during X-rays for other injuries that have not caused the patient
any pain, whilst some patients experience very painful plantar fasciitis in the absence of a heel spur.
This condition is common amongst athletes involved in running, dancing, tennis and basketball, especially if they have
increased their load too quickly during training.
It may also present itself in older individuals who have started wearing flat shoes, those who are overweight, people required
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a tendency to hyper-pronate). Generally speaking, this condition tends to be chronic as it is often overlooked or neglected
by sufferers for several months whilst it worsens.
Symptoms usually consist of severe pain during the first steps of the day which gradually improve after some movement,
before flaring up again later on. Swelling may also be present around the affected area. It is not uncommon for patients to
experience deficits in strength and extensibility of the calf muscles.
X-rays, ultrasound and possibly electromyography scans are useful in establishing a diagnosis. Electromyography is especially
useful if there is any numbness or paralysis due to associated nerve compression.
In the short term, the patient must stop all sporting activity (with the exception of swimming and cycling) and attempt to
reduce the effect of predisposing factors (avoid wearing inappropriate footwear, or losing weight for example). Using insoles
may help correct any abnormalities in the plantar arch. Shockwave therapy can be very effective at reducing inflammation
in these conditions.
Morton's Neuroma
MortonÕs Neuroma is often attributed to swelling in the plantar nerve
branches that run between the second and third, and third and fourth
metatarsals. Compression of these nerves between metatarsal heads
can be caused by microtraumas resulting from the use of inappropriate
footwear (narrow shoes in particular).
Patients usually present with a sudden onset of pain, often likened
to an electric shock. Numbness is also frequently present in the
two affected toes.
The diagnosis is essentially clinical, but can be confirmed through
PAT H O L O G I E S O F T H E F O O T A N D A N K L E
to wear unsuitable shoes for work reasons and those with irregularities in their arches (flat feet, hard soles and those with
an ultrasound, or an MRI scan.
Initial treatment is conservative, but in severe cases where surgical
intervention is necessary the neuroma is removed.
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MUSCULAR LESIONS ARE AMONG THE MOST COMMON INJURIES IN SPORTS MEDICINE (AROUND
10-30% OF ALL SPORTS INJURIES)
It is important to consider the underlying reasons how and why muscle injuries can occur. Essentially though they usually result in
one of two ways, either from a direct blow (contusion) with resultant haematoma (bruise formation), or indirectly with subsequent
strain (stretch) of the muscle fibres following a sudden, unexpected or improper movement. Bruises are easy to identify, since the
athlete can tell exactly when and where he felt pain, generally after a contact with the opponent or object. More complex, instead,
is the identification and classification of indirect injuries. If pain is accompanied by a spread and increase in the muscle tone and
generally occurs at the end of the sports activity, where it is not possible to relate it to a particular trigger or to localise it is usually a
MUSCULAR INJURIES
Muscular Injuries
muscle contracture or shortening. On the contrary, if pain is easy to localise, increases during sporting activity and makes playing
difficult even if still possible, this is likely to be a strain, characterised by demonstrable macroscopic evidence of muscle fibre disruption.
The strains can be further classified and graded dependent on the amount and size of muscle fibre disruption. The severity is related
to the quantity of tissue involved, amount of bleeding and the muscle involved. Detecting the level of disruption to muscular fibres is
easier here, given that the athlete felt a sudden pain triggered by a particular movement, in fact the athlete may even be able to put
their finger directly on the point of the lesion. Levels of functional limitation here are closely linked to the severity of the lesion.
DIAGNOSIS
This is essentially clinical, but is confirmed and graded by an ultrasound or MRI 24/48 hours after the trauma. Ultrasound scans
can be repeated throughout rehabilitation, to keep the outcome under control.
TREATMENT MUST TAKE INTO ACCOUNT THE DEGREE AND LOCATION OF THE LESION, AS WELL AS
THE PATIENT'S LIFESTYLE
We know that muscular lesions are often improperly treated. This is why we are committed to using unique protocols that
are tailored around the lesion's type and location, and also the patient's interest. Clinical and ultrasound follow-ups are
important throughout the process to assess progress and recovery, whilst being mindful of potential complications and with
focus on avoiding recurrence.
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A FRACTURE IS DEFINED AS AN INTERRUPTION OF THE BONE'S CONTINUITY
Fractures occur when a force is applied to the bone capable of overcoming its capacity for resistance. Fractures are classified
in a variety of different ways:
- According to the origins of the fracture: traumatic, pathological (typical in elderly subjects), or due to stress
FRACTURES
Fractures
- According to the mechanism of the fracture (direct or indirect)
- According to the type of fracture (traverse, oblique, spiral or longitudinal)
- According to the pattern of fractured segments (comminuted or compound)
- According to the extent of damage to the overlying skin (closed or open)
- According to the thickness of the bone exposed to fracture (complete or incomplete)
- According to the fracture's stability (stable or unstable)
Typical symptoms in fractures are characterised by pain, rigidity, haematoma and functional limitations in the affected limb.
Diagnosis is usually confirmed with a standard X-ray. The urgency of treatment is based on whether or not associated nerve
or blood supply damage. Reduction, or realignment of the bones may be required to restore normal anatomy, whilst immobilisation
is needed universally. If the fractured segments are in good continuity, the fracture will usually heal itself during the period of
immobilisation, negating the need for surgery. However, fractures that are unstable, have a wide degree of separation, and
those deemed unlikely to heal themselves will often require surgery to lock the joint in place with metal wires, rods and screws.
Stress Fractures
STRESS FRACTURES ARE COMMON IN SPORTS MEDICINE
These form are the result of repeated and cyclical loading of the bone. Diagnosis requires an accurate clinical analysis, during which
your physician should be informed of typical physical activity performed and any recent changes to loading that may have occurred.
There are several predisposing factors that can increase the risk of suffering stress fractures, including playing sport on hard ground,
and qualitative and quantitative variations in load and age. Those most commonly affected by this kind of injury are long-distance
runners, soldiers and the elderly. Around 2-3 weeks after the initial fracture, pain becomes unbearable and the patient has no choice
but to cease all, or almost all, physical activity. Care must be taken when diagnosing these injuries as sometimes a fracture can take
14-15 days after occurring to become visible on X-rays, for this reason, CT and MRI scans may be required both in confirming
diagnosis and assessing severity. Treatment will differ according to the location and intensity of the fracture, ranging from a short
immobilisation period and integrated rehabilitation, to a more prolonged period of immobilisation with a cast, and even surgical fixation.
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Thanks to:
- For the photos, Stefano Martelli Blow Up Studio, Paolo Simonazzi & Giuseppe Leurini
- For the text, Dr. Matthew Stride, Giulia Indelicato & Sara Mattioli
- For the graphics, Massimiliano Baccanti
GRUPPO MEDICO ISOKINETIC
T H E PAT I E N T H A N D B O O K