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Overview

Back on Track Physio is the Physiotherapy service that provides Physiotherapy services to the British Superbike Championship (BSB). The service functions as part of the travelling BSB Medical team, which includes various Consultant’s (Anaesthetics, Emergency Medicine, Orthopaedics, Specialist Nurses and Radiographer’s. Richard has been an active part of this service since its inception in 2008. Typically there are 3 Physiotherapists present at each round of the Championship.

The BSB Medical team is supported by the CJ Riders fund, who continue to raise funds for various important medical equipment including a portable digital X-ray machine and air-fencing which is transported to each circuit. Thus the riders are spared Hospital visits, unless they have multiple serious injuries and need specialist care.

Back on Track is supported by K-Tape, who are the market leaders in the production of Kinesiology Tape and the provision of expert training in its application. We also continue to receive support from Donjoy.

The Physio team is well versed in the intricacies of motorcycle crashes and the resulting injuries. From low sides to high sides, from the dreaded arm pump, to a cricked neck, to blisters; we have dealt with it. Interestingly the majority of injuries are unsurprisingly trauma related, from bruising to sprains to fractures. Fortunately serious injury is rare. There are surprisingly few overuse injuries; arm pump (chronic exertional compartment syndrome) being the obvious one, however we have also seen intersection syndrome (also affecting the forearm), and shin pump due to the gear lever being in a slightly different position !

Armpump seems to affect many riders, and infuriatingly has a myriad of causes, from too much gym work, to holding on too tight, to bar position, the list goes on. Rest assured that the team are well aware of all these mechanisms, having treated many cases. In a minority of cases there is a physical restriction in the muscular compartments in the forearm. This typically requires surgical release. We have good links with our surgical colleagues and if necessary can put riders in touch with them. The gold standard is endoscopic fasciotomy as the healing times are less and there are no long unsightly scars.

The treatment philosophy of Back-on-Track is simple:

"To effectively and appropriately manage injury, thus allowing the rider every chance to continue through the race weekend, as long as the rider retains sufficient function to remain in control of his motorcycle and not be a danger to himself and others"

Arm Pump Article

Chronic Exertional Compartment Syndrome (CECS aka ‘Armpump’)Read More

Overview

‘Arm pump’ is a compartment syndrome ‘overuse’ type injury. In that respect it is quite unusual in motorcycle racing, as the majority of injuries are traumatic in nature. It seems to be more commonplace in motocross, yet the list of elite riders who have suffered from this complaint includes:

Toni Elias, Sylvain Guintoli, Nicky Hayden, Chris Vermuelen, John Hopkins, Makoto Tamada, Marco Melandri, Kenny Roberts Jnr, Jorge Lorenzo and even Casey Stoner.

It exists due to the complex coordination necessary at the hands, wrists, elbows, shoulders and spine required to control a high powered motorcycle.

It must be differentiated from Acute compartment syndrome (where symptoms do not go away with rest), which is a normally caused by injury and is a true emergency. There may be permanent muscle damage in acute compartment syndrome unless surgically treated in less than six hours. It has been discovered when testing canine muscle that fewer than 5% of muscle cells were damaged after 4 hours of ischemia, while nearly 100% of muscle cells were damaged after 8 hours of ischemia.

CECS is not unique to motorcycle racing, it has also been reported in rock climbers (Schoeffl et al 2004), windsurfers (Segura et al 2005) and manual workers (Soderberg 1996).

CECS is prevalent in all racing classes, though barely in the 125gp class where there are riders as young as 13 years old, and the machines lighter. We conduct an audit of our service each year (fig 1 below), and it would appear that the more powerful and heavier the machine the greater the incidence of CECS.

Fig 1 Armpump distribution by class by round 2010

Pathophysiology

Muscles are held in fascial sheaths. Fascia is a tough, but thin, white gristle that envelops the compartment like a casing wraps a sausage. Fascia helps to anchor muscles and give them form. Fascia is very strong, but it is not very elastic. The inelasticity of fascia surrounding muscle means that even small increases in the volume of a fascial compartment can cause large pressure increases within the compartment. When subjected to continuous exercise muscle becomes engorged with blood and can increase its cross sectional area by up to 20%.

The engorged muscle is encased inside the inelastic fascia and, as it grows, the pressure within the fascia compartment increases. Although gases and solids are compressible, fluids are not. The incompressible fluid within the inelastic fascia makes the forearm feel hard as rock.

If the "compartment pressure" rises high enough, blood vessels can collapse, which restricts or stops the flow through that vessel. Veins, with their low pressure and thin walls, collapse earlier than high-pressure, thick-walled arteries. When venous flow reduces, arterial blood continues to enter the fascial compartment but is restricted from leaving (venous congestion). This restricted outflow further increases the pressure within the fascia compartment. If the compartment pressure rises higher than the pressure in the capillaries, or even the arteries, then these vessels may collapse, resulting in "muscle ischemia"-a painful condition of oxygen deprivation.

When the activity is stopped, the pressures gradually dissipate and the symptoms resolve, unlike as previously stated Acute Compartment Syndrome which does not.

Objective criteria for the diagnosis of chronic compartment syndrome are:

  • resting compartment pressures of 15 mm Hg or higher
  • 1-minute post-exercise pressures of 30 mm Hg or higher
  • 5-minute post-exercise pressures of 20 mm Hg or higher

Symptoms

There is usually pain out of proportion to the injury, tenseness of the forearm, swelling, and pain with passive movement of the compartment musculature. The patient generally has good capillary refill* and a palpable radial pulse.

If the volar compartment is involved, there may be paresthesias and altered sensation over the palm and the volar aspect of the thumb and index, middle, and ring fingers. The small finger is usually less affected than the others, because the ulnar nerve is less dramatically affected than the median nerve. The thumb and fingers will often be held in the flexed position. Elbow flexion and extension are painful, but are better tolerated than finger or wrist movement.

When the dorsal compartment is involved, sensation to the hand and fingers is usually normal, because the posterior interosseous nerve has no sensory component. There often is weakness of thumb, finger, and wrist extension. The hand and wrist are generally held in extension. Flexing the fingers causes excruciating pain.

When compartment syndrome affects the mobile wad**, there can be altered sensation over the dorsum of the hand. There may also be weak wrist extension. Elbow and wrist motion flexion is very painful. Finger flexion is better tolerated than elbow or wrist movement.

*Capillary refill is the rate at which blood refills empty capillaries. It can be measured by pressing a fingernail until it turns white, and taking note of the time needed for color to return once the nail is released. Normal refill time is less than 2 seconds

**(Mobile WAD is a collective term for the lateral muscles brachioradialis, extensor carpi radialis brevis & extensor carpi radialis longus).

Proposed Mechanism of action

When you grip something in your hand there is co-contraction between the muscle groups on the back (dorsal) and front (volar) of the forearm. To necessitate a stronger grip the wrist is pulled into extension. This co-contraction results in an increase in compartment pressure.

Thus to simply grip a handlebar increases pressure. To grip the handlebar of a rapidly accelerating or decelerating motorcycle necessitates stronger grip levels. If you then add the throttle action, which uses the dorsal wrist extensors more than the volar wrist flexors, then the clutch and brake levers, which use the volar finger flexors, then the complex nature of this injury starts to appear

Thus the main issue is that the arms are placed under a continuous but diverse load. Certain circuits load these factors differently –such as Oulton Park with its crests and lack of straights. Interestingly we visit Oulton park twice a year, and there is a noticable reduction in the volume of CECS patients at the second visit – suggesting specific ‘on the bike fitness’ as a measurable factor.

Ergonomics are extremely important with this type of injury, hence handlebar and lever position are crucial. As are lever pressures (carbon discs = lower lever pressure for a given braking force), short travel throttles, quick-shifters and so on. These are not the total solution as arm-pump still affects motogp riders, in theory the cream of the crop.

There is an important divide between those people who have ‘pathological CECS’ which does not improve with rider fitness nor respond well to conservative management, and those riders who experience symptoms at the milder end of the spectrum which does improve with rider fitness, technique refinement and is responsive to conservative management. Those riders with true pathological CECS are the ones who benefit from surgical decompression, indeed after talking with a surgeon he observed that the tissue surrounding the compartments is tougher in those people with true pathological CECS.

We assisted in the production of a study investigating any correlation between grip strength and forearm compartmental pressures. The results were interesting in that it showed a decrease in post exercise grip strength, which suggests that as the riders suffer from CECS they have to try harder to maintain the same level of grip on their machine.

Physiotherapy Management

As a service we have continously refined how CECS is managed over the last 5 years. We have now arrived at an approach that utilizes :

  • Compartmental Myofascial release – to alter the compliance of the fascia (Annan 2010, Myers 2010)
  • Biomechanical assessment of whole body – especially after a recent crash.
  • Questioning on riding style and prefered technique –some riders do not use the foot operated rear brake, others cannot ride without one.
  • Advice on remedial training programmes – to minimise any training unwanted training adaptations – and facilitate appropriate physiology changes.
  • K-Tape to enhance drainage of the affected compartments, and facilitate biomechanical efficiency .
  • It is planned to undertake a study of CECS pressures and their response to the various conservative management strategies that we utilize.

Surgical Management of pathological CECS

Many of the riders have undergone decompression by fasciotomy. This can be done either open or endoscopically. There exists debate between various surgeons as to the most efficacious method as in other surgical fields. We have had experience of both, the endoscopically performed procedure is assocaited with shorter recovery times, with the riders typically able to race at 3 weeks postoperatively. The open procedures take far longer and sem to have an association with keloid type hypertrophic scarring – likely as with the compartment being opened there is more tension on the closure sutures in the skin.

We have developed close links with a Consultant upper limb surgeon, who prefers the endoscopic method of surgery. He was kind enough to supply the pictures below. Central to his decision to operate is accurate confirmation that CECS behaviour is observed during provocative testing. For this he uses a BTE work simulator (Fig 2), this is preceded and followed by compartment pressure measurement (fig 3)and finally decompressive surgery as dictated (fig 4).

Top tips

  1. 1. Stay balanced, try to position your body weight so that the bike pushes you, rather than pulls you. Practice shifting your weight forward during acceleration by pushing from your legs, and shifting your weight back during braking. The main idea is to minimize the demands on your hands and teach you to keep your weight balanced.
  2. 2. It's all in the legs. Squeeze and initiate turning the bike with your legs, your boots should show evidence of this in the wear pattern on their soles. Do you suffer with blisters when you ride, if repeatedly so you may be holding on too hard.
  3. 3. Relax your grip, your hands and your shoulders. Try to ensure your breathing is not laboured and remember to relax a little more on straights to allow the arms to recover a little. Really think about this as you ride. Only grip as hard as you need to, any extra effort is wasteful and will speed up the onset of armpump.
  4. 4. Keep your equipment in check. You don't want your equipment to make you work harder than you need to, so be sure your suspension is properly setup, if you have no confidence in the front, yuo will hold on harder. Bar position, lever position, grip diameter & compound should also be fine-tuned and individualized. You may find that you can stay more relaxed with your bars more forward, back, etc. We have certainly seen cases of armpump caused by excessively tight gloves, leathers and compression garments.
  5. 5. Warm up
    Warm up before you go out on track. A quick jog, the use of a turbo trainer or other exercise to get your blood flowing prior to riding can only help.
  6. 6. Stay hydrated
  7. 7. Breath!
    Forgetting to breath while riding—as silly as it may sound—is among the most common causes of arm pump in beginner-level riders. Paying attention to your breathing will also help you relax. Breath holding can also speed the onset of symptoms.
  8. 8. If using weight training, again ensure that your grip is only what’s needed to stop you dropping the dumbbell, any more develops the grip muscles which can predispose to armpump. Training using kettlebells is also very effective. Lighter weights and high repetitions, rather than heavier weights and low repetitions, are typically more useful. Many racers cycle as part of their fitness regimes, how hard do you grip the handlebars on your bike, not hard at all is the answer.

References

Annan J (2010) An introduction to Myofascial release – part 2. Course notes

McQueen M (1998) Acute compartment syndrome. Acta Chir Belg. 98(4):166-70.

Myers T.W. (2001) Anatomy Train: myofascial meridians for manual and movement therapists. Churchill Livingstone

Schoeffl V, Klee S, and Strecker W (2004) Evaluation of physiological standard pressures of the forearm flexor muscles during sport specific ergometry in sport climbers. Br J Sports Med 38:422-425

Segura J F, Doreste JL and Mir-Bulló X (2005) Chronic forearm compartment syndrome in professional athletes. Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue SUPP_II, 324.

Soderberg T A (1996) Bilateral chronic compartment syndrome in the forearm and hand. J Bone Joint Surg [Br] 1996;78-B:780-2.

Tomida Y, Hirata H, Fukuda A, Tsujii M, Kato K, Fujisawa K, Uchida A (2007) Injuries in elite motorcycle racing in Japan.

After years of pain and discomfort and seeing numerous Dr’s, Specialists and Physio’s I’d just about given in to the fact that I’d never be without this pain/discomfort. After just one session with Richard I came away feeling refreshed and hopeful I could be normal again. He recognised my issues almost instantly (which numerous others had missed)and explained everything clearly – a complete breathe of fresh air. I’d have no hesitation in recommending him to anyone.

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We have a reputation for excellence locally as each member of our team has many years experience working in the field of musculoskeletal disorders both in and out of the NHS.
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