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Cold therapy Sheddon Physio Sports Clinic Oakville Mississauga

Cold Schmold

As the temperatures drop and the snow accumulates, many individuals will slowly start to hibernate indoors and become less and less active. Outdoor exercise in the winter can become a challenge due to ice, snow and freezing temperatures. While the cold winter months aren’t for everyone, outdoor exercise and physical activity can still be enjoyed with some extra planning, winter-specific gear and layers. Common winter-related injuries include hypothermia, frostbite and cold- induced asthma, as well as injuries sustained while slipping and falling on ice.


            Hypothermia develops when heat loss exceeds heat production. Mild hypothermia is characterized by shivering, dizziness, nausea, quick breathing, confusion, increased heart rate, lack of coordination and fatigue. Coaches and athletes need to be aware of these signs and symptoms in order to prevent further injury. As moderate to severe hypothermia sets in, you will notice lack of coordination, slurred speech, slow-shallow breathing, weak pulse, drowsiness and confusion. Moderate-severe hypothermia can be life-threatening and requires immediate medical attention.

Risk Factors:

  • Energy depletion/fasting: Shivering is a protective response to produce heat through muscle activity. Food restriction and energy depletion have been shown to impair the shivering response, thus increasing the risk for hypothermia;
  • Lack of sleep/fatigue;
  • Wet clothing from sweat, wind, immersion in water and exercise in rain;
  • Low body fat – Athletes with a higher percentage of body fat can maintain core temperatures better than leaner athletes;
  • Age – People over the age of 60 and young children are both at increased risk for hypothermia.


Clothing: Clothing plays a major factor in the prevention of hypothermia. Layers are the best option in order to avoid overheating and prevent excessive sweating, while staying warm and dry. Your base layer should be lightweight polyester/polypropylene, which should not readily absorb moisture (cotton would be a bad choice for a base layer), but should wick moisture to the outer layers where it can evaporate. The middle layer should be polyester fleece or wool, which provides the insulation and warmth. The outer layer should be a shell, which will repel wind and rain and have venting to allow for moisture to escape.

Food and Fluid Intake: Surprisingly, all those extra layers, heavy gear and shivering can make you expend more energy compared to the same exercise done in warmer weather. Furthermore, dehydration in cold weather is common, since thirst is normally less noticeable in colder weather. Ensure adequate fluid and food intake prior to, during and after exercise.


Frostbite is most common in exposed skin, such as the nose, ears and cheeks, as well as the fingers and toes. The first sign of frostbite is numbness in the body part. While warming up of the area, people will experience pain, burning, tingling and aching. The skin will appear red, then turn white, with possible blisters, depending on the severity.

Risk Factors:

  • Inadequate clothing;
  • Wetness;
  • Tight boots or constrictive clothing;
  • Wind chill and cold temperatures.

Prevention: Windchill plays a major factor in temperatures below -27, whereby frostbite can occur in less than 30 min. Clothing is your best option for prevention with dry, warm clothing and layers being the most important. Mittens provide more protection than gloves. Also remember to keep your gloves, socks, scarves and hats dry. If exercise has made these garments sweaty and damp, you will be at an increased risk for frostbite. Have extra gear if you get wet or sweaty, or take off some layers as you start to overheat.

Cold-Induced Asthma

Cold-induced asthma is caused by a narrowing of the airways while exercising in cold weather. It can occur to individuals with asthma, as well as those who don’t have it, but are sensitive to changes in temperature and humidity. Symptoms include shortness of breath, tightness in the chest and coughing/wheezing.

Risk Factors:

  • Athletes working out at high intensities;
  • Athletes in indoor ice rinks.

Prevention: Although there are not many preventive measures, one way to help combat this issue is to wear a scarf that covers your mouth and nose in order to help warm the air before being breathed in.

Slips and Falls

Slips and falls on ice can hurt your ego and lead to a number of injuries, including broken wrists, pulled muscles and bruised tailbones. The icy/slippery sidewalks and roads can make outdoor exercise tricky. Make sure your footwear has good traction and grip. Be extra cautious, slow your pace and focus on the ground ahead. Adding some balance and proprioception exercises into your daily regime can also help keep you on your feet when you hit slippery terrain.


Young et al., 2006. American College of Sports Medicine position stand: Prevention of cold injuries during exercise. Medicine and Science in Sports and Exercise.

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Hitting the Slopes

Following the first snowfall to hit the GTA and a forecast that’s predicting a very snowy winter, many are groaning and complaining…minus the avid skiers and snowboarders who are eagerly awaiting to hit the slopes. If you’re one of the many who have waited well over six months to dust off your equipment, surely you don’t want to cut your season short with an injury.

Who is at risk?

Research has shown that the risk of injury is higher for the following individuals:

  1. Snowboarders vs. skiers;
  2. Beginners;
  3. Younger participants;
  4. Participants who rent their equipment or use improper equipment;
  5. Athletes with insufficient core strength/muscle imbalances;
  6. Athletes with an underlying injury.

Mechanism of Injuries

  • More experienced skiers sustain an injury related to jumps, while beginners sustain injuries related to falls;
  • Snowboarders are 3x more likely to experience injuries related to jumps, while only 10% of injuries are related to collisions (with objects or other people);
  • Skiers will likely injure their knees due to sudden changes in direction of the legs in regards to the torso;
  • Skiers tend to injure their knees following these distinct mechanisms:
    • The slip-catch: where the outer ski catches the inside edge, forcing the knee into internal rotation and valgus;
    • Landing from a jump with most of their weight back, the skier will land with their knee extended and the boot heel will catch the snow;
    • During forward falling positions when the inside edge of the ski engages the snow.

Common Injuries

While skiers and snowboarders share the slopes, they have very different injury patterns across all skill levels. Skiers will typically injure their lower body, specifically their knees, while snowboarders are more likely to injure their upper body, especially their wrists.


Skiers are more likely to injure their knees than snowboarders do, with a prevalence rate of between 30-50%. Injuries generally occur following a traumatic event (i.e., falls, collisions, sudden changes in direction and twisting accidents). Injuries include meniscus and ligament tears (especially to the ACL and MCL), osteochondral lesions and occasional muscle strains and fractures. Overuse injuries are also common in skiers, with patellar tendinopathy being the most common.


Ankle injuries, such as sprains and fractures, are more common in snowboarders due to boots that do not fit properly. Skiers are less likely to have injuries to the ankle due to the higher and stiffer boot.

Skiers Thumb:

Injury to the ligaments on the inside of the thumb is common in skiers following an incident where the thumb gets caught in the strap of a ski pole or the snow.

Wrist Injuries:

20-40% of snowboarding injuries occur at the wrist, with the majority being fractures following a fall on an outstretched hand. Wearing wrist guards can significantly decrease the risk of injuries to the wrist.


HIgh speeds, acrobatic movements, falls and risk of collision make both skiing and snowboarding high risk sports for concussions. Studies have shown that concussions account for 20% of all ski and snowboarding injuries. While helmets prevent skull fractures and facial injuries, the research is inconclusive as to whether or not it helps in the prevention of concussions.

Prevention Strategies

  1. Lessons:

Lessons with a skilled instructor will dramatically reduce the risk of injury to beginners and novices.

  1. Education:

Research has shown that a large number of injuries are a result of poor decision making and risky behaviours, especially in younger, inexperienced athletes. Be sure to ski and snowboard within your limits, with regards to terrain, speed and experience. Cusimano et al (2012) examined whether an instructional safety video and handout could minimize the risk of injury in young, novice skiers and snowboarders. Their education video included basic information about helmet use, equipment, trail and terrain sign interpretation, and emergency procedures. The study had promising results by demonstrating that a little bit of knowledge and education goes a long way in preventing injuries.

  1. Conditioning:

These sports require a combination of strength, balance and endurance. Embarking on a week-long ski trip, following a year of being sedentary, will increase your chances of suffering an injury. Proper conditioning prior to the start of the ski season/trip will help prepare the appropriate muscles. Furthermore, overuse injuries can generally be prevented with proper conditioning.

  1. Equipment:

Ensure your equipment is safe, fits well and is appropriate for your skill level.

  1. Snow conditions/weather/course conditions

While these factors are out of your control, be aware of the conditions prior to skiing/snowboarding (i.e., poor visibility, technical/challenging runs, fatigue, etc.) and make smart choices as to when you should get off the slopes.

Don’t get stuck sitting in the chalet sipping hot cocoa while you heal an injury. Follow some of these tips and enjoy the slopes this winter

Cusimano et al., (2012). Evaluation of ski and snowboard injury prevention program. International Journal of Injury control and Safety Promotion.

Mayr et al., (2016). Prevention of Injuries and Overuse in Sports Directory for Physicians, Physiotherapists, Sports Scientists and Coaches.

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off balance post concussion physiotherapy sports clinic oakville mississauga

Feeling “Off Balance” Post Concussion

Assessment and treatment of concussions involves a multi-faceted approach in which many systems are examined and treated. An important area to address post concussion is  the vestibular system, which plays an essential role in balance, coordinating movement and spatial orientation. However, it doesn’t work entirely alone. It interacts with the visual system and proprioceptive receptors in muscles and joints, which together send messages to the brain to help achieve and maintain balance and stability as we move through daily activities. Following a concussion there can be direct/indirect damage to any of the systems, which may result in the person feeling off balance, dizzy, nausea, spinning, lightheaded or disorientated. Research has suggested that anywhere from 23-81% of patients will experience one or more of the above symptoms post concussion. Furthermore, these symptoms may be a risk factor for prolonged recovery and can persist in 10-30% of patients. The most common complaint related to dizziness following a concussion is feeling “off balance.” These symptoms are perfectly normal post concussion and can be treated with vestibular rehabilitation.

Vestibular rehabilitation is a key management technique for getting concussed patients back to feeling normal. At Sheddon Physiotherapy and Sports Clinic (SPSC), concussed patients suffering from dizziness and imbalance are thoroughly assessed in order to determine which aspect of the vestibular system is affected. Due to the complexity of the balance system, assessment also includes the visual system (read our past blog here regarding visual rehabilitation), proprioceptive receptors, as well as the integration of all three systems.

From the assessment, patients will be given a treatment approach and exercise program tailored to their individual needs. Exercises may include simple eye-head coordination exercises, visual rehab, static and dynamic balance, ambulation tasks and symptom habituation exercises. A key feature with these exercises is that patients may often feel worse before they feel better, which is counter-intuitive to why they are seeking your help. In most cases, the brain has to learn to compensate in order for your symptoms to improve. Therefore, if you avoid the activities that make you dizzy, you generally will not get better. Having said that, more isn’t better either. Your assessment findings will help your therapist determine how much and how often you should be doing your exercises. Everyone is different and your program will progress as your symptoms improve. 

If you have suffered a concussion and can’t shake the feeling of dizziness and feeling off balance, contact one of the therapists at SPSC in order to assess and treat these symptoms. If you haven’t suffered a concussion, but have any of the above symptoms, vestibular rehabiliation can also work for you (it’s not just for concussed patients). Read our past blog here on living with dizziness.

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ACL rehab monster walk Sheddon Physio Sports Clinic Oakville Mississauga

ACL Rehabilitation: What you Knee’d to know.

ACL injuries continue to be one of the most common and devastating sports injuries. Despite the long and extensive rehabilitation process, rates of re-injury range from 3-22% for an operated ACL and 3-24% for the contralateral ACL in the first 5 years after surgery. Due to these numbers, many athletes never return to their sport. A recent systematic review was published by a group of ACL experts in order to help develop evidence-based guidelines for rehabilitation following ACL reconstruction. Topics they examined included:

  1. Preoperative factors that can effect recovery;
  2. Effectiveness of physical therapy;
  3. Benefits of specific exercises;
  4. Return to play guidelines;
  5. Risk for re-injury.

Preoperative factors

Many athletes will start doing physiotherapy prior to surgery in order to strengthen the knee. The above researchers found that quadriceps weakness, as well as extension deficit (not being able to reach 0 degrees of extension or more) prior to surgery, will have a negative consequence on the rehabilitation process post-surgery. Don’t tell yourself these issues will get “fixed” with surgery, prehab is essential to guarantee a successful post-surgery outcome.

Strength and Neuromuscular training

There are many exercise programs designed for ACL injuries. What exactly should you be focusing on? Strengthening, proprioception and neuromuscular training are vital, especially for return to sport. For some ideas on where you should be focusing, please read our earlier blog, here.


Most physiotherapy clinics use a variety of different modalities with their patients, but which ones are most useful post ACL?

Muscle stimulation has been shown to be effective when combined with exercise. The muscle stimulation will help activate the muscles, which are either too weak to engage, or are inhibited due to pain and/or swelling. The machine helps turn on the muscle during exercise, and the patient is encouraged to work with it to help regain strength. In addition, cryotherapy has been shown to help with acute pain and swelling.

Return to Play

Return to sport rehabilitation should focus on plyometrics and agility, as well as take off and landing mechanics. A series of different tests need to be performed in order to determine readiness to return to sport. These tests should assess strength, balance, and proprioception, as well as functional sport patterns. It is essential that both the injured and uninjured knees be tested, due to the high rate of injury to the opposite knee with return to sport.

Risk of Re-injury

Rates of re-injury range from 3-24% for either the surgical or non-surgical knee, with some researchers claiming that the opposite knee is twice as likely to get injured upon return to sport.  Other studies have shown that age is a major predictor of recurrent ACL injuries, with young athletes (under 20) having a rate of 20-40% re-injury. Other risk factors include:

  • Poor neuromuscular function and biomechanics;
  • Higher activity level;
  • Allographs vs. autographs.

Whether you have just been diagnosed with an ACL tear and you’re waiting for surgery, or you’ve undergone the surgery and are working on rehabilitation, the staff at SPSC can help guide you along the way to ensure a full and successful return to sport.

Van Melick et al., (2016). Evidence-based clinical practice update: Practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. BJOSM.

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vision test concussion management physiotherapy sports clinic oakville mississauga

Focus on the Eyes

No two people will experience a concussion in the same way. There are a number of different symptoms that patients will experience, such as physical symptoms (headaches, fatigue, dizziness), cognitive issues (attention, concentration) and emotional disturbances (irritable, sadness). One area of recent interest is concussion related visual dysfunction. The visual system is largely interconnected with most areas of the brain (roughly 60%), as such, following a concussion, specific visual areas of the brain, as well as integrative pathways, can be affected, resulting in visual dysfunction.

The prevalence of visual dysfunctions post concussion is roughly 40% in adults. Concussion related visual dysfunctions can involve impairments to eye movements, eye reflexes, visual tracking, focusing and pupil function. Unless an individual is assessed properly post concussion, these dysfunctions generally get missed, since most individuals are not aware that their symptoms may be coming from their eyes and visual integration system. Occasionally symptoms are specific to the eyes (blurred vision, sensitivity to light, eye fatigue, lack of visual clarity, etc.). However, often the symptoms are vague, with the most common visual dysfunction symptom being having difficulty reading, as it requires eye coordination, clarity and focus in order to be done with ease. Post concussion, many adults and adolescents have trouble returning to school or their job due to issues with reading, using computers, light sensitivity and focusing. As such, it is important when choosing a health care provider following a concussion that they assess all aspects of the brain, including the visual system. Recognition of these dysfunctions is essential for recovery, as well as return to work, school and sport.

At Sheddon Physiotherapy and Sports Medicine all concussion patients are thoroughly assessed for visual impairments with a series of clinical tests. From these findings treatment is specific to the visual deficit present. If you or someone you know is struggling with concussion symptoms, book an assessment with one of the therapists at Sheddon Physiotherapy and Sports Medicine in order to help pinpoint the origin of these symptoms.

Master et al., (2015). Vision Diagnoses are common after concussion in adolescents. Clinical Pediatrics. 1-8.

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