Squash Injuries

      By Sally John – Registered Physiotherapist

Registered physiotherapist

Clinic; 1 Buckingham Blvd,

Collingwood, Ont,  L9Y 3Y9

   

This is a brief description of some of the injuries which occur with squash and their advised treatment

When ice is mentioned; it should be applied through a damp terry towel. The ice should be in a plastic bag and should be applied for 10-15 minutes every hour.

Most injuries, if carefully cared for, should take 4-6 weeks to improve.  All except; plantar fasciitis as this is a very difficult and varied situation and varies from person to person depending on the level of damage and commitment to do the therapy. Should injuries be taking more than 4-6 weeks to improve, other anatomical structures should be evaluated.

 

 

 

Foot injuries;

Plantar Fasciitis (sometimes known as calcaneal fasciitis or can be mistaken for Heel spur)

Symptoms;

·        Pain at the base of the heel, causing string like pulls towards the ball of the foot.  Especially tender when palpated at the heel.

·        Pain is usually along the inside of the foot. ( can be outside as well) aggravated by running or walking.

·         Made worse by running on pavement.

·        Worse in the morning, when getting out of bed.

Treatment

Ice with orange juice can – rolling foot back & forth for 15 mins every hour

Massage from the base of the heel into the ball of the foot.( best done by a therapist)

Tape plantar fascia – (ask your friendly therapist)

Stretches – by lengthening the plantar fascia and calf muscle & use a night splint

Heel raises

Orthotics in day shoes – assess need for new running shoes

Tape foot for squash – Use “Sorboair” insoles ( Great!  - Helped me to continue to play)

 

                     

Achilles tendinitis

Symptoms;

·        Pain at the back of the heel – always on the inside edge of the heel – sore upon  palpation..  Usually occurs due to over-pronating

·        Worse in the morning getting out of bed

·        Heel raising causes pain at the heel and there is reduced strength

·        Can be caused by shoes pressing on the back of the heel

Treatment

Place a 1cm heel raise under heel/ heel cup

Ice heel. 10mins every hour

Double heel raising and then go to single as heel pain dissipates. Every hour do 10x and increase number of repetitions to 40X

Reduce intensity of training. No reaching for drops! Play long game only.

 

 

Gastrocnemius Tear

Symptoms;

Sudden sharp pain at the back of the calf,  below the knee (mid belly) – “ like being shot”. Uncomfortable or unable to walk and heel raise.  Have to stop playing.

Treatment

If major tear, where the player can not walk, may need to be in a cast to let the muscle heal for 4-6 weeks with the foot in plantar-grade.

If minor tear.  Ice to calf – 10 minutes on every hour for first 24- 48 hours.  Use night splint if minor tear.   If a minor tear – player is able to walk after the injury, but it is very sore, then the following protocol should be followed and guided my a physiotherapist or athletic therapist.

·        Massage to calf avoiding the area of tear until tenderness starts to reduce

·        Isometric exercises to calf

·        Gentle heeling raising with no pain.  Mimic raising with the affected leg with very little weight on it and most of the weight on the unaffected leg. Gradually transfer weight onto affected leg as pain allows. 

·        Wobble board activity after pain reduces with heel raising.

·        After this, work on ballistics in the squash court.

Torn Achilles tendon.

Symptoms

Also feels like a gun shot, but this time, 6-8cm above the ankle joint.  Pain may be felt, and there is a complete loss of strength and the player is unable to weight bear.  Partial tear can become full and should be examined by an orthopaedic surgeon or sports medicine specialist.

Initially, is the time to tell if the tendon is torn.  After 24 hours, there will be increase in fluid in the area and if only a partial tear, this can be a hazard.  At this point, it is worth massaging the fluid away, to see if there is a small tear.  If so, a sports medical specialist should assess the need for further intervention.

Treatment

Depending on the severity of the tear – repair by a surgeon and then 6-8 weeks of touch WB until removal of cast.  However, in some cases, some surgeons do back-slab casts which can be removed for massage by a physiotherapist, who knows the danger of early intervention.  Dangers can be infection to the tendon, formation of scar tissue, due to over zealous work.  However, if do carefully, can speed up the process of recovery.

Once the cast is off, then; 6-8 weeks of rehab (4 if you work hard)

·        Massage around the scar line and on until the scabs are removed. Use of Vit E oil to the scar line.  Ensure a therapist works with this. 

·        Heel raises – moving from bilateral heel lifts, with little weight on the affected leg, to increasing the weight onto this.

Torn Achilles tendon (cont)

·        Wobble board activity; as strength returns.  Then gradual strengthening, through biking and finally lunging to return to normal activity, which should be guided my a physio or athletic  therapist.

 

Tendinitis of tibialis posterior / partial rupture

Symptoms;

·        Pain at the mid arch of the foot, which can go up the inside of the lower leg from behind the ankle bone. This is made worse upon foot strike (may have felt a tear with training especially after or during speed work) – tender to palpate at the navicular.

·        Aggravated by heel raise and especially painful with heel lowering from the heel raise.

Treatment

Ice foot 10 mins every hour

Tape muscle to reduce strain on the muscle.

Strengthen with heel raises

Reduce training and run on trail. No speed work.

 

Metatarsalgia

Symptoms;

Pain at the ball of the foot usually at the base of the 2nd toe.  Pain increases with push off in running or walking.

Pain is worse in the morning.

Treatment

Cool foot baths if tolerated

Use metatarsal pad eg; Spenco and tape to foot, just behind the metatarsal heads.

Mobilisations to your toes and foot by your friendly therapist

Assessment of walking or running pattern

 

Fracture  metatarsal

Severe pain on impact of foot – usually there is  shooting pain into toes and mid foot. (can be mistaken for severe metatarsalgia.

Xray may be necessary.

Treatment

Reduce weight bearing – no running – casting may be necessary for pain relief 4-6 weeks.

Then physiotherapy to regain movement at the 4-6 week mark.

Use of a metatarsal arch pad to reduce stress on the joints involved.

Lower Leg Injuries

 

Shin splints/ stress fracture of the tibial bone

The former is the tearing away of the anterior tibialis muscle from the fascia onto the tibia. A stress fracture is usually only diagnosed by bone scan and it is the minute fracture of cortical bone

Symptoms;

·        Pain usually caused by increased training

·        Tenderness is at the front of the leg and about 1/3 up from the ankle between the tibia and fibula (a space between the muscles)

·        Pain is aggravated with impact

Treatment

Ice cube along front of tibia.  If pain increases with icing, it may be a stress  fracture.  (See your doctor)

Reduce training intensity. Cross train – bike & swim,

Do isometric contractions using a theraband. – progress to active as pain reduces.

At the 4 weeks, if pain free return to squash; play only long game. No lunges.

Knee

Patellofemoral syndrome( anterior knee pain)

Symptoms;

Pain at the front of the knee cap, which can radiate down the shin.  Aggravated, when the  knee is bent to 90 degrees when sitting for long periods of time. (“movie goers knee”)

Aggravated by climbing hills or stairs. Knee can give way and can be confused with Meniscus problems (see below)

Problem – Knee cap is not in its correct  track and may be positioned incorrectly at the start of the movement. 

Treatment

1)      Reduce pain with ice if particularly tender

2)      Correct tracking with mobilisations and taping  (see a therapist who knows Jenny McConnell’s techniques)

3)      Check walking & running patterns to see if there are problems above or below.  Hip/back or foot.

4)      Check shoe wear – Is there a need for orthotics?

5)      Vastus medialis rehab – Check with a therapist  who knows (J.Mc work)

 

Patellotendinitis

Symptoms;

Acute pain below the knee cap.  Usually caused by jumping.  Tender at this area.

Treatment

1)      Ultrasound , massage or acupuncture may help to reduce tenderness. Brief icing.

2)      Use of Cho-pat  (available at Pharmacies) or taping.

3)   Isometrics to Quads and then gradual strengthening exercises. (See your friendly physiotherapist

 

Popliteus syndrome

Symptoms;

Point tenderness at the outer part of the knee – above the knee – not to be mistaken for  iliotibial band tendinitis which is pain below the knee joint on the outer side.  Injured with lunging.

This is aggravated by running downhill, or downstairs as the muscle acts as a check rein.

Treatment

1)      Ice over area with ice cube or pack for about 5-10mins every hour

2)      Work with co-contractions to hamstrings and quads to get activation of popliteus with help of muscle stimulation ( contact your local therapy unit for this)

3)      Manual therapy

4)      Correct downhill running. ( shorten steps – quick cadence.)

Torn Medial or lateral meniscus of knee

Symptoms

Pseudo-locking of knee or locks and has to be unlocked. Knee gives way.

Aggravated by duck walking, or squatting.

Treatment

This depends on the depth of the tear.  Tears may go to arthroscopic surgery if constant locking.  However, if pseudo locking and this appears to be lateral meniscus, this meniscus has a great blood supply and can heal.

See a therapist of physician for confirmation.

1)      manual manipulation of the meniscus to relocate is possible but does not always stay in place and heal.

2)      Isometric strengthening to increase blood supply for healing with the assistance of an EMS. (electrical muscle stimulator.) at different positions of knee bend without pain

3)      When improved graduated weight bearing exercises which avoid twist, until later in the therapy.

4)      May play squash when patient can squat to 60 degrees on one leg.  Long game to begin with.

 

Torn medial collateral ligament of the knee

Symptoms

Here is an injury, where there has to be a direct cause.  Usually happens when tripping over something.  Not often caused with running.  Here, the inside of the knee hurts from the injury. 

There is swelling. 

The knee does not lock. 

There is limited movement of knee bend and straighten.

Treatment

1)      Reduce swelling with acupuncture, ice

2)      Isometric quads/quads muscle strengthening -  Progressed to squats

3)      Movement exercises, - bend & stretch. Use of the bike when able

4)      Correct heel strike and swing through stage of gait as soon as possible – same progress to squash as above.

 

HIP Injuries

 

Piriformis Syndrome

Symptoms;

Pain at the buttock, which can cause sciatic type pain as the muscle can compress the nerve.  Aggravated when the leg is turned when standing and turned out when the hip is above 90 degrees movement  as in squatting below 90 degrees.  Follows the line of piriformis.  A line which is tender from the mid sacral region to the hip joint line.

This pain can be mistaken for low back pain from a facet joint problem. There is no back pain with this syndrome.

Leg is usually turned out for comfort and leading with the leg upstairs or uphill increases the pain.

Treatment

·        It is best to see a therapist who will also check your back and treat this condition.

·        Pulling the leg with the leg turned in sometimes help

·        the use of myofascial release. 

·        Retraining gluteus medius to work as a stabiliser of the hip.

 

                                     

 

Hip Bursitis

Symptoms.

There is extreme tenderness over the hip joint either at the front of the thigh or else at the outside of the hip.  The pain is made worse with climbing stairs of running uphill.

Treatment

1.      Check walking/running pattern

2.      Stabilization of the hip by re-training the glutei muscles. (see your therapist)

3.      Check hip flexors for increased tone and reduce tone.

4.      Check need for orthotics different running shoes.

5.      Check training methods. (ie) running uphill with foot turned out increases hip flexor activity and  not glutei work.

6.      Break bad standing habits.  

 

Iliopsoas Tendinitis.

Symptoms;

Pain at the hip into the groin especially with weight bearing, running up hill.

(cause often because the glutei muscles are not been correctly used and the hip flexor- iliopsoas catches on the pectineal eminence of the pelvic ring due to the angle of the pull in their attempt to stabilize the hip.

Treatment

1.      Check walking/running pattern (over-rotation of the thoracic spine.)

2.      Reduce tone in iliopsoas by using the opposite muscle group; the hip extensors - glutei

3.      Strengthen glutei in side lying and standing to functional positions (see you therapist for help)

4.      Check running shoes, assess the daily need for orthotics

5.      Break bad standing habits.

6.      Check training methods (as above)

 

                                         

 

Quads or Hamstrings muscle tear.

Symptoms

Injury occurs either at the muscle over the front of the leg called the quadriceps muscle, often just above the inside part of the knee for the former injury or at the back of the leg, for the latter.  These injuries usually occur after quick lunges or poorly warmed muscles in the beginning of a game or at the end of the game when the player is tiring.

There is usually a sharp pain, which ends in some amount of disability and the inability to continue to lunge.

Treatment

Immediate

·        Ice the area immediately post injury with 10-15 minutes on  & off with ice in a dampened terry cloth.

·        While icing – co-contract muscles and move ankle up and down to promote circulation and fast healing.

·        Pressure bandage over the injury, which will develop into some degree of haematoma, which will keep the swelling down.

·        Gentle knee bending without increasing pain

·        Reduce weight bearing if necessary – use of a cane. Weight bear as tolerated. (no increase in pain)

Next day

·        Repeat as above

·        Gentle massage around the haematoma

·        Isometric co-contractions of hamstrings and quads with the assistance of muscle stimulation, not enough to increase pain.

·        See a therapist for further treatment advice who will put you on a graded exercise program.  Recovery should be 4-6 weeks.

 

Lateral ligament tear of ankle.

Symptoms;

Athlete has gone over on his ankle when tripping

Treatment

1.      Reduce swelling of the ankle using ice.

2.      Keep movement of the ankle moving

3.      Increase strength of ankle muscles with heel raises

4.      Work with balance exercise – throwing and catching to the wall

5.       Progress to wobble board balance work.

6.       Can play squash with ankle taped or a brace as pain allows

.

Shoulder injuries

The main ones are;

Rotator cuff syndrome ( which includes painful arc syndrome)

Acromioclavicular dysfunction, or arthritis.

 

Rotator cuff syndrome

This is a syndrome, where 4 muscles of the shoulder called the rotator cuff, which normally stabilize the shoulder joint, become imbalanced with each other.  Other shoulder girdle muscles come into play to help stabilize and hence stresses are placed on certain muscles of this group.

The common 2, which are overused are often subscapularis, with an overarm throw, as in a base ball overarm throw, or with supraspinatus as with an over head serve or smash.  In squash, it is often supraspinatus that is overused,(the elevator of the shoulder), whereas the depressor (lower fibres of trapezius, and latissimus dorsi)  of the humeral bone does not act to balance the reaction.

Hence, from here syndromes, such as painful arc syndrome and impingement syndrome develop.  The former, being where the supraspinatus tendon is inflamed, and is caught under the acromion, (a bony point at the shoulder joint,) as the movement from 75 degrees to 120 degrees of sideways arm movement takes place (abduction).  The latter is where the supraspinatus is getting caught under the acromion at approximately 90 degrees of movement.   There may be many reasons why the supraspinatus tendon is being irritated and a physiotherapist or athletic therapist should be able to tell you this.  However, the best advice is to reduce the irritation by removing the pressure.

Symptoms

·        Pain with shoulder movement ; hand behind back,  hand across chest,  taking the arm above the head.

·        Impingement syndrome is specific pain which occurs at 90 degrees of  arm sideways movement  (in the same plane as the front of the body to  movement to above head -abduction).

·        Painful arc occurs with arm abduction from 75 – 120 degrees of shoulder movement.

Treatment

·        Reduce pain, by reducing the tendon pressure.  Use exercises to retrain the depressors of the shoulder, to reduce the pressure over the tendon. (Best shown by a physiotherapist)

·        Increase blood flow to the muscle of supraspinatus  tendon, which has been compressed.  Here there is an area called the critical zone, which if compressed for long enough, may deteriorate and abraid and possibly tear.  (This often happens in your 50s.   The former, rotator cuff problems, may happen in your 30-40s.)

·        Movement to the shoulder joint & neck may also be restricted due to compensations made by the body. ( an experienced physiotherapist or athletic therapist should be able to examine and treat effectively)

 

 

 

Acromioclavicular Dysfunction,

Usually caused by a fall on out stretched hand from the past, or leaning on the elbow.

The joint may be arthritic or mobile. Thorough examination will differentiate between the two.

Symptoms

Pain upon moving the arm out to the side between 120 – 140 degrees arm movement from the body. Arm across chest is also painful.

Treatment

Stabilise or mobilise  the joint as necessary depending on what is found and then use muscle work to work in conjunction with this. Again a therapist should be able to help you with this.

 

Tennis Elbow

There are many causes of tennis elbow, which need to be evaluated by a good manual therapist.  If it is indeed the type, which is caused by overuse of the common extensors of the forearm, care should be taken when advancing the exercises.  Tennis elbow can be very easily flared in the initial phases of the problem.  Tennis elbow may also be due to joint problems at the joint of the elbow called the superior radio-ulnar joint, or could also be nerve root irritation of the radial nerve which can be compressed in a small tunnel, called the arch of Frosche within a muscles called supinator.   Hence it is important that you see a therapist who can correctly clinically diagnose these problems and hence put you back together again.

Symptoms

·        Pain at the thumb side of the elbow, aggravated by wrist cock but more so with follow through, often worse with backhand (usually muscular)

·        Pain all the time at the elbow, which shoots down the forearm and into the base of the first finger and the back of the hand with or without any activity. ( likely nerve irritation)

 

Treatment

·         Ice immediately, the elbow is irritated.  However, in some cases, ice can actually, aggravate nerve irritations.  The best way is to create painfree movements which should best shown by your friendly physiotherapist.

·         Use of a good tennis elbow brace – ‘Trainer’s Choice” or any brace with a pressure area to press on the tendon included within the brace are recommended.

·        Activate muscle, using a foam ball to squeeze, holding for 10 secs and then repeating, with increasing length of hold and then increasing weight.  This is best monitored by an experienced physiotherapist

·        Encouraging nerve tissue movement when necessary.   Again best shown by an experienced therapist.