Squash Ontario

Sport Injuries

Disclaimer: The information, advice, and injury prevention and fitness tips in this section are intended as a general guide to physical activity, health, fitness and squash information. It should not be relied on as medical advice and/or opinion and all physical activity recommended should be done with caution; Squash Ontario is not responsible for any injury incurred from following these tips and advice.

Hamstrung by a Hamstring???

Tennis Elbow in Squash Players??

Did you SQUASH your Disc??

Ball Therapy… a fad that has stuck! WHY??

How to Prevent Lower Leg Injuries

Hamstrung by a Hamstring???

By: Lorie Forwell, MScPT

The hamstring muscle is one muscle in the body that is the cause of much evil. If it is tight, it can alter the function of the lower leg, knee, hip, pelvis, and back. If it is weak it will not protect the joints. If it is too strong, it can create muscle imbalances. So how do I know? And what do I do?

A lot of athletes will know if they have tight hamstrings because they will feel tightness at the back of their thigh when they try to touch their toes. Most people will not realize if they are too strong or too weak. To be sure, a thorough assessment by a registered physiotherapist is the best way to start.

The hamstring muscle starts at the pelvis, crosses the hip joint, runs down the back of your thigh, crosses the knee joint and inserts into each of the two bones in your lower leg, figure 1. Because of the extent of its excursion, the hamstring can play havoc with a number of muscles and joints along the way.

The feeling of tightness at the back of the thigh when touching toes is often indicative of hamstring tightness. However it is very common to stretch the hamstrings ineffectively. One common stretch is seen in figure 2. Although you will feel a stretch in the back of your thigh, you will also give a significant stretch to your back, which may or may not be good. If you keep your back straight, it will more likely isolate your hamstring muscle. A better stretch to isolate your hamstring muscle is shown in figure 3. Be sure to keep your back straight with your shoulders slightly in front of your hips as you slowly straighten your knee. If you cannot straighten your knee all the way without slouching, then your hamstrings are tight. That is your starting point. With repetitive stretches you will eventually be able to straighten your knee all the way. If you slouch you are cheating!! Try it with a slouch and see the difference.

The strength of the muscle is another story. If weak or slow to contract, the hamstring muscle will not work to stabilize or protect the joints that it moves. This is more likely if you have previously injured the muscle or your back. More commonly we will see a hamstring muscle that gets carried away and does more work than it should. One example, common in runners is hip extension. Hip extension occurs when your leg goes out behind you as in full stride. Your gluteal muscles in your buttock and your hamstrings should share this job. If the hamstrings dominate, the gluteals will slack off and gradually weaken. This will affect the way the gluteal muscles stabilize the pelvis and therefore the base of support for our back. This domino effect can also run down the leg to affect the control of the lower leg.

In squash players it is the lunge. In the situation where the player takes the long step or lunge to the front court, he/she will need their gluteal muscles and hamstrings to control the hip and pelvis to effectively get back to the ‘T’. If the hamstrings are inefficient, the pelvis will tilt backwards and place excessive stress on the back. Repetition of this poor recruitment will eventually result in back pain.

The beauty of the hamstring is that it is ultimately trainable. If functioning inefficiently this muscle can be easily trained to function properly as long as the problem is thoroughly assessed and the athlete understands the objective and mechanics of the correct exercise. If in doubt, check it out!!!

Lorie Forwell is the Director of Physiotherapy at the Fowler Kennedy Sport Medicine Clinic in London, Ontario. Lorie is an Adjunct Instructor at the Faculty of Health Sciences at the University of Western Ontario. She obtained her BScPT from McGill University in 1984 and her MScPT in 1994 from Western University.

Tennis Elbow in Squash Players??

By: Lorie Forwell, MScPT

Elbow problems plague a lot of squash players. Many will see a physician and receive a diagnosis of ‘tennis’ elbow. How can that be if I am a squash player??

Tennis elbow is the common name for lateral epicondylitis. The epicondyle is the location at which the common extensor muscle attaches to the humerus (upper arm bone). Lateral refers to the outside of the elbow. On the medial, or inside, of the elbow, the common flexor muscle attaches. This pathology is commonly known as golfers elbow. And yes, squash players are also susceptible to that. Epicondyl-itis is the inflammation of that area.

There are three potential causes of lateral epicondylitis:

Overuse: This is a result of playing too many hard games, too close together with too much of one particular stroke (for example, right wall players in doubles playing a lot of forehand strokes). The muscle has to contract fast, hard and repetitively. If there is inadequate recovery time, the effect of the repetitive strain can accumulate into inflammation and pain. Rest, ice, stretching and occasionally an elbow brace can often effectively treat this problem.
Sport Specific: There are a number of sport specific causes for elbow pain. In the case of squash it is either your racquet or your technique. With respect to your racquet, you need a racquet that is properly weighted and strung to your ability and style of play. A squash pro or racquet rep would be the best persons to provide advice on this element. The grip of the racquet can also be a factor. If it is too big or too small that may produce a problem. Some players grip their racquet too tightly. This will add additional stress to the common extensor muscle and therefore to its attachment to the bone. Then there is your stroke. Over-hitting the ball, inappropriate point of contact, and incorrect stroke mechanics are examples of technical causes of elbow pain. The advice of a squash professional is essential.
Dysfunction at the base of support: This is a mouthful to say that the source of the problem is not the elbow at all. Neck pain can refer to the elbow. An imbalance of strength at the shoulder can lead to more power coming from the elbow. Muscles controlling the shoulder blade provide an essential base of support for the entire upper extremity. Weakness or dysfunction in any of these areas can lead to elbow pain. This kind of elbow pain will return when you resume squash after a rest period that takes away the pain. In essence you have treated the inflammation with rest, but not effectively treated the cause of the inflammation. In this case it is important to seek advice from a trained health care professional, like a physiotherapist or physician. To extend the rest period or simply play less to control the pain, will not treat the problem. In addition, pain may present itself in other activities of daily living within weeks, months or years, because of the same source. The problem will be easiest to treat when relatively young. And most of these problems are treated with exercise, mobilization and modalities.

If an elbow problem gets out of hand, other options for treatment are cortisone shots and even surgery (although not common!).

One last word about elbow braces: Elbow braces may help with allowing you to stay on court and manage the pain. However they do not deal with the cause of the problem in most cases. The best course of treatment would be to seek out the cause and treat it. Use the brace to keep you playing in the interim. In very rare cases should an elbow brace be used forever!

Did you SQUASH your Disc??

By: Lorie Forwell, MScPT

Low back pain is a common complaint among squash players. The problems could be related to muscle, joint, ligament….. or often disc.

The disc in your low back (lumbar spine) is like a jelly donut sandwiched between two bones (vertebrae). On either side of the spine at the level of the disc, a nerve exits from the spinal canal through a channel (foramen). If there is any encroachment on that foramen, you could put pressure on the nerve. This may result in pain, numbness or loss of reflexes in the leg on that side. One thing that can cause that encroachment is a bulging disc.

We have all heard about ‘slipped’ discs. The truth is that discs do not ‘slip’, they bulge. Like the jelly donut the disc has an outer portion, the dough, which is called the annulus. The nucleus of the disc is the ‘jelly‘. If there is a tear in the annulus, the nucleus can bulge in that direction. If that bulge is straight backwards, it can put pressure on the spinal cord. If it bulges backwards to one side, it may put pressure on one of the nerves (Figure 1). It is unusual for a disc to bulge forward, but if it did, there is little trouble it can cause.

How does the annulus tear?? The most common cause of damage to the annulus is postural. The normal curve of the lumbar spine should be slightly forward (Figure 2). When bending over, as if to touch your toes, this will first flatten the curve, then reverse it. This position allows the front of the vertebrae to approximate and the backs of the vertebrae to separate. If this flexion curve is sustained, the fibres at the back of the annulus can be stretched and weakened, allowing the disc to bulge into the weakened fibres. As the fibres continue to weaken and the disc continues to bulge, it is the beginning of a vicious cycle. It is just a matter of time until there is enough bulge to pressure the nerve.

Squash players spend a lot of time in flexion: running forward, pursuing the drop shot in the front corner, digging a deep shot out of a back corner, etc. In addition, this flexion is coupled with twisting (rotation) and a forceful muscle contraction (which happens with a power swing and contact) that will also add stress to the weakened fibres of the annulus. The cumulative stress of squash may be enough to create a symptomatic bulge. Poor sitting posture can also allow the lumbar spine to sit in a sustained flexed position (Figure 3). Add this stress to the stresses of squash and the picture is even more likely.

Symptoms of a bulging disc include: back pain (central or to one side), pain down the leg (to buttock, knee, ankle or foot), loss/change of reflexes in that leg, or weakness of that leg. If the bulge is moderate, sitting may be uncomfortable, but standing and walking less uncomfortable. If severe, standing and walking may also be uncomfortable.
The symptoms occur because of pressure on the nerve. Since there are other structures that can also put pressure on the nerve, a thorough assessment by a health professional is important.

Treatment of disc pathology will depend upon how far the disc is bulging. If the bulge is mild, rest alone may improve the pain; but will not likely reduce the disc to its best position. If the disc is not reduced, the next incident need not be great to cause similar symptoms. Exercises prescribed by a physiotherapist can be very beneficial. These exercises must follow a complete assessment. The exercises that will improve pain caused by a disc bulge are exactly opposite to those that may best if the pain is cause by an irritated joint. Close supervision in the early stages of treatment is important. Positioning and posture during the healing phase of the disc is supremely important. Sitting, especially in poor posture should be avoided. One must learn to bend from the hips instead of their back in the short term. Many people with a disc bulge will also say that the only time they have relief is when they curl up in the fetal position. This is the worst possible position for this problem. This position will open up the area to allow the disc to bulge more. It feels good because it creates more room for the nerve and disc. However once the back is straightened to get up, the pain is often worse because the disc has now bulged more! Again, if this is the case, close supervision and instruction regarding exercise and positioning is important.

The good news: less than 5% of patients with disc pathology require surgery. Only those people whose discs have bulged so far that they cannot be reduced, or so far that a piece has actually broken off (sequestered). In these cases, the success of physiotherapy is limited, and surgery may be an option.

The moral of this story is to treat back pain early before the bulge is so large that pain is severe, activities of daily living are limited, and worst of all, a squash game needs to be cancelled!!!

Pictures of: anatomy, posture (good and bad sitting), normal spinal alignment, disc bulge

Figure 1 Figure 2 Figure 3

Ball Therapy… a fad that has stuck! WHY??

By: Lorie Forwell, MScPT

Gym balls or physio balls seem to now be a staple in many workout facilities. There are ‘ball classes’ and more and more personal trainers, fitness consultants and kinesiologists use balls as part of the plethora of exercises in their armamentarium. But why is this technique to popular? And why has is outlasted other fads that have gone the way of Tai Bo, jazzercise and pole dancing?

Core stability is probably the number one application of ball exercises. Core stability refers to the strength, control and function of the muscles of the core. Those muscles are your abdominal muscles and back muscles. You have 4 abdominal muscles: rectus abdominus, internal obliques, external oblique and transversus abdominus. Similarly you have a number of muscles in your back: erector spinae, multifidus and quadratus lumborum; just to name a few. Different exercises can isolate different sets of muscles and it is important to address those muscles that are weak. As all these muscles work together, if there is a stronger muscle it can be more easily recruited and dominate a given movement. In that instance, that muscle will continue to get stronger and the other muscles will strengthen in a lesser manner, if at all.

So how does the ball help? Exercise can incorporate balls with sitting or lying on them. In this way, instead of a nice stable base of support, you have a mobile base of support. This requires that you contract a series of muscles to create a balanced force couple that will prevent you from falling from the ball. If one muscle dominates, that force couple will not be balanced and the exercise will be much more difficult. As the body will always take the path of least resistance, you will reflexively correct that balance. With concentration and repetition, you can teach your muscles to do exactly what is required.

Once you start the exercise, it can be progressed by decreasing the support i.e. sitting on the ball with two feet on the floor, to one foot on the floor (see figure 1).

Figure 1

Then you can add resistance with weights, in particular with movements that displace your center of gravity (see figure 2).

Figure 2

Lying on your stomach, you can have more support for an arm exercise if your shins are on the floor (figure 3). If you straighten your legs such that only your toes touch the floor, the exercise requires significantly more core stability.

Figure 3

Lying on your back (figure 4), you can stretch and strengthen your abdominals in the same exercise.

Figure 4

Some people may use a ball to sit on at work. This simple application of a gym ball makes sitting an active rather than passive activity. It is much more difficult (but not impossible) to slouch on a ball and therefore avoid the posture pitfalls of a desk job.

The ultimate challenge for the high level and finely trained athlete is to progress your exercises to include kneeling or even standing on the ball. These exercises are very difficult and should not be tried without adequate supervision and instruction.

There are other ways to introduce a mobile base of support. Balls are easy, relatively inexpensive and highly versatile. Exercises are limited only by your imagination and ability. And the best part….. it is FUN!!

Lorie Forwell is the Director of Physiotherapy at the Fowler Kennedy Sport Medicine Clinic in London, Ontario. Lorie is an Adjunct Instructor at the Faculty of Health Sciences at the University of Western Ontario. She obtained her BScPT from McGill University in 1984 and her MScPT in 1994 from Western University.