sportEX Dynamics Journal Issue 38 - October 2013

ISSUE 3 8 Oct 2013 ISSn 1744-9383

promoting

best practice in

highlights

manual therapy

n latest research news n youth strength and conditioning training

n self-myofascial release n achilles tendinopathy management

To purchase tickets visit http://spxj.nl/APPI13

contents ocTober 2013 issue 38

Editorial

publisher TOr DAvIES BSc (Hons) tor@sportex.net art editor DEBBIE ASHEr debbie@sportex.net sub editor AlISON SlEIGH Journal watch BOB BrAMAH subscriptions & advertising support@sportex.net +44 (0)845 652 1906 COMMISSIONING EDITOrS Brad Hiskins - Australia & NZ Whitney lowe - USA & Canada Humphrey Bacchus - UK & Europe Glenn Withers - Worldwide Dr Marco Cardinale - Worldwide Dr Thien Dang Tan - USA & Canada TECHNICAl ADvISOrS

Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds rob Granter Michael Nichol Joan Watt Dr Greg Whyte

It’s been a busy but good year. and it’s been fantastic to reconnect with so many of you at the events we’ve attended that have made it so busy!

At the time of writing this editorial, we’re about to head up to Manchester, to the inaugural Therapy Expo and then in October we’re off to the ACPSEM conference in Glasgow. Talking to so many of you this year, has reinforced my passion for what I always set out to do with sportEX: to take the ever-growing evidence base and turn it into good solid hands on practice.

Sometimes we run out of space, sometimes the nature of the writing doesn’t quite fit with the journal. and sometimes we just want to have a bit of fun Where this is the case, we publish the content in our blog (www.sportex.net/blog).

BSc (BASraT), MSc MCSP, MSMA MSc, FA Dip, Mast STT Dip SST Dip SST BSc (BASraT) MCSP, MSMA PhD, BSc (Hons)

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This month on the blog we’ve published some research extracts on manual therapy and nerves, brought to us by softtissuetherapy.com.au, a couple of opinion pieces on the state of the manual therapy industry and we’ve launched our first ghost-written fictional character, Will Wilting. Will is a demoralized and professionally under-rated lecturer who teaches sports therapy to generally bored students somewhere in the North of England. Will is a man of unfulfilled ambition. He was briefly the bucket and sponge man for Patricroft Athletic, a Saturday afternoon pub team that got to the semi final of the Manchester Amateur Cup in 1993.... To read more about Will’s exploits come and join us on the blog - just search for Will Wilting! Enjoy!

Tor Davies, physio-turned publisher and sportEX founder

sporteX medicine - ISSN medicin e 1471-8138. Written specifically for professionals working in the field of soft-tissue injury diagnosis, treatment and rehabilitation - personal subscription £54, practice subscription £94, library subscription £175

finD us

oct 2013

sportEX is printed in the UK by Cambrian Printers ltd, awardwinning colour printing specialists, independently audited to ISO 14001 and EMAS environmental standards. sportEX is printed on paper from FSC certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

conTenTs

4 8

Journal watch

This quarter’s latest research

Youth training

The role of strength and conditioning training programmes for young athletes

12 self-myofascial release tendinopathy management 18 achilles

A study of female footballers and self-myofascial release of the hamstrings

A treatment case study

To finD ouT more abouT sporTeX visiT

DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form.

The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

www.sportEX.net

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online

clicK on research titles to go to abstract

e effect of core strength anD enDurance training on performance in college stu stuDents: ranDomizeD pilot stuDy. schilling Jf, murphy Jc. Journal of bodywork and movement therapies 2013;17(3);278–290 Ten untrained students were randomly assigned to core isometric endurance (n=5) and core isotonic strength training (n=5). Each performed three exercises, two times per week for six weeks. Improvement in trunk flexor and extensor endurance along with squat and bench press strength occurred with the strength group. Improvement in trunk flexor and right lateral endurance along with strength in the squat were found with the endurance group. Neither training protocol claimed superiority and both were ineffective in improving performance.

sportEX comment We wonder sometimes how stuff like this gets published. It is a very small sample and it effectively tells us nothing. Can we make a plea to researchers, please? If your work doesn’t significantly add to a body of knowledge, bin it and start again.

Durability of effect of massage therapy on blooD bloo pressure. givi m. iinternational Journal of preventative medicine 2013;4(5):511–516 Fifty pre-hypertensive women were divided into control and test groups. The test group (25 patients) received Swedish massage 10–15 min, 3 times a week for 10 sessions and the control groups (25 patients) also were relaxed at the same environment without receiving massage. Their blood pressure (BP) was measured before and after each session and 72 hours later. The results were that mean systolic and diastolic BP in the massage group was significantly lower in comparison with the control group. There was still a significant difference between the groups 72 hours later.

sportEX comment The fact that massage lowers BP is not news but it is nice to have yet more evidence to prove it.

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a pilot stuDy to investigate the short-term effects of specific soft tissue massage on upper cervical movement impairment in patients with cervicogenic heaDache. hopper D, bajaj y, et al. Journal of manual & manipulative therapy 2013;21(1):18–23(6) Eight subjects (mean age 28.1 years) with a cervicogenic headache (CGH) mean history of 7.1 years were measured for range of rotation of the upper cervical spine at preintervention, intervention, and post-intervention. The specific soft tissue (SSTM) intervention consisted of an 8-minute soft tissue massage to the cervical muscles bilaterally. There was a significant improvement in range of rotation after the first, second, but not third intervention, from an average range of 27.5° at baseline to 45.9° at the third treatment session. After the 2-week post-intervention phase, range of motion remained stable without decline, and was considered full range.

sportEX comment Another tick in the plus box for soft tissue therapy.

the motion of an arbitrarily rotating spherical proJectile anD its application to ball games. robinson g, robinson i. physica sciripta 2013;88(1):018101 This is about spinning balls. In particular it looks at cricket balls and the behaviour of a ball delivered by an off- or leg-spin slow bowler. Its laudable scientific aims are to produce equations of inherent scientific value and to cultivate student interest by giving them the science behind their killer deliveries. Here is a typical equation: EFD = 12 ACDV2 · (−Vˆ ) = 12 _ ACDV · (−VVˆ ) Hope that means something? In practical terms the findings were that in cricket the lift force generated by a slow bowler’s spinning the ball around a horizontal axis, directed along the line of the pitch can cause the ball to drift sideways in both directions while in flight. For an off-spinning delivery the drift is first to the leg and then to the off side, while for a leg-spinning delivery the reverse is true. The amount of sideways drift is increased

by the presence of a head-wind and a cross wind may cause the ball to lift or dip when compared to a ball bowled without spin thereby altering the point of pitching.

sportEX comment One for the sports scientists. The authors state that the equations should be well within the grasp of first year university students in physics and engineering and, with the guidance of teachers, good final year secondary school students.

Err…get us a teacher quick because it could have been in Swahili as far as we were concerned. We do, however, know that the England team won the Ashes so our bowlers understand the practical aspect of bowling with the wind. sportEX dynamics 2013;38(October):4-7

JOURNAL WATCH

Journal watch roller-massager application to the hamstrings increases sit-anD-reach range of motion within five to ten seconDs without performance. sullivan Km, silvey DbJ, et al. the international Journal of sports physical therapy 2013;8(3):228 The roller-massager used here is basically a dense foam rolling pin that according to the paper was designed to serve a similar purpose to foam rollers but be a more portable device that uses the upper body rather than body mass to provide the rolling force.

Seventeen volunteers took part. Seven males (70.2 ± 10.4kg, 173.4 ± 8.8cm, 22 ± 1 years) and 10 women (63.7 ± 9.8kg, 167.2 ± 5.5cm, 23 ± 5 years).

Nine participants (3m, 6f) were used as controls who were not rolled but sat quietly between tests for 5 minutes.

All took part in recreational activity on an average of 3 times per week and had no previous experience of using a roller-massager. The intervention group had 4 trials of hamstrings rollermassager rolling (1 set – 5 seconds, 1 set – 10 seconds, 2 sets – 5 seconds, and 2 sets – 10 seconds) at a constant pressure of 13kg. They set up a mechanical apparatus to ensure a constant rolling rate and pressure.

Measurements taken before and after each rolling session were a sit-andreach test for range of movement (ROM), along with a maximal voluntary contraction (MVC) force and muscle activation of the hamstrings via

electromyography (EMG).

All of the roller group increased their ROM on average by 4.3%, with the 10 seconds roll being the optimum.

There were no significant changes in MVC force or MVC EMG activity after the rolling.

sportEX comment The abstract of this study starts with the words, ‘Foam rollers are used to mimic myofascial release techniques’. We like the idea that trained therapists should do the myofascial release but if you really want one, the gadgets are made by Theraband. They cost around £25 so they may be something you could flog to your clients to use as an adjunct to professional treatment.

comparison of massage baseD on the tensegrity principle anD classic massage in treating chronic shoulDer pain. Kassolik K, andrzejewski w, et al.

Journal of manipulative physiological therapeutics 2013;36(7):418–427 Thirty people with chronic shoulder pain symptoms were divided into 2 groups, 15 received classic (Swedish) massage to tissues surrounding the glenohumeral joint and 15 subjects received the massage using techniques based on the ‘tensegrity’ principle. The authors describe this as a treatment to muscles, fascia, and ligaments that structurally support the painful area so that not only is the painful area addressed but also tissues which have a direct and indirect influence on the motion segment. Both treatment groups received 10 x 20min sessions over 2 weeks. The McGill Pain Questionnaire and glenohumeral ranges of motion were measured immediately before the first massage session, on the day the therapy ended 2 weeks after therapy started, and 1 month after the last massage. The tensegrity massage group demonstrated statistically significant improvement in the passive and active ranges of flexion and abduction of the glenohumeral joint. Pain decreased in both massage groups.

sportEX comment Tensegrity is an architectural term coined by Buckminster Fuller which basically means that 3 dimensional structures are under multiple tensions.

For more information on how this applies to the human body see Tom Myers’ excellent book Anatomy Trains or his articles in earlier editions of sportEX. As to this study it all seems obvious but nevertheless it is great to be able to quote positive research in this evidence based age. Note to the NHS: This is ‘hands on’ manual therapy that can be given in a very short appointment.

www.sportEX.net

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online

clicK on research titles to go to abstract

m massage therapy anD exercise therapy in patients with multiple sclerosis: a ranDomizeD controlleD pilot stuDy. negahban h, rezaie s, goharpey s. clinical rehabilitation 2013;doi:10.1177/0269215513491586 Forty-eight patients with multiple sclerosis were randomly assigned to four equal subgroups labelled as massage therapy, exercise therapy, combined massage–exercise therapy and control group. The treatment groups received 15 sessions of supervised intervention for five weeks. The massage therapy group received a standard Swedish massage. The exercise therapy group was given a combined set of strength, stretch, endurance and balance exercises.

Patients in the massage and exercise therapy received a combined set of massage and exercise treatments. Patients in the control group were asked to continue their standard medical care. Pain, fatigue, spasticity, balance, gait and quality of life were assessed before and after intervention. The massage therapy resulted in significantly larger improvement in pain reduction, dynamic balance and walking speed than exercise therapy. Those in the combined massage–exercise therapy showed significantly larger improvement in pain reduction than those in the exercise therapy.

sportEX comment You still hear the lament that there is no evidence for the use of massage. Please direct such naysayers to sportEX. We keep finding loads of the stuff.

manual treatment for cervicogenic heaDache anD active trigger point in the sternocleiDomastoiD muscle: a pilot ranDomizeD clinical trial. bodes-pardo g, pecos-martin D, et al.

Journal of manipulative and physiological therapy 2013;36(7):403–411 This is a study to examine the feasibility of a larger clinical trial. Twenty patients, 7 males and 13 females with a clinical diagnosis of cervicogenic headache (CeH) and active trigger points (TrPs) in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received a TrP therapy described as manual pressure applied to taut bands and passive stretching. The other group received simulated TrP therapy which is described as putting on no pressure after the TrP was identified other than longitudinal stroking and no additional stretching.

Outcomes were headache intensity using a numeric pain scale based on the headaches experienced in the preceding week, neck pain intensity, cervical range of motion (CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor performance.

Measurements were taken at baseline and 1 week after the treatment.

The results were that the TrP group showed greater reduction in headache and neck pain intensity plus greater improvements in motor performance of the deep cervical flexors, active CROM, and PPT.

sportEX comment Of course they did. Bring on the larger clinical trial with a longer follow-up and maybe a group that gets a post-treatment exercise routine and one that doesn’t.

the prevalence of latent myofascial trigger points anD Diagnostic criteria of the triceps surae anD upper trapezius: a cross sectional stuDy. grieve r, barnett s, et al. physiotherapy 2013;2:doi:10.1016/j.physio.2013.04.002 Two hundred and twenty healthy volunteers (132 females and 88 males) were examined to ascertain the extent of latent myofascial trigger points (MTrPs) in certain muscles. The inclusion criteria were: 1. A palpable taut band or nodule within the skeletal muscle 2. A hypersensitive tender spot within the taut band 3. Recognition of current pain complaint by pressure on the tender nodule/taut band (identifies an active MTrP) 4. Painful limit to full stretch range of motion.

MTrPs were found in all triceps surae, left upper trapezius and right upper trapezius). None were found in the middle fibres of deltoid. Taut bands were most prevalent in the right gastrocnemius medial head; a tender spot in left gastrocnemius medial head and nodules in the right upper trapezius. A local twitch response, the least frequent diagnostic criterion was only found in the left gastocnemius medial head. There was a significant increase in latent MTrP prevalence for females compared to males in five of the six triceps surae MTrP sites, with no significant association for gender and latent MTrP prevalence in the left or right upper trapezius.

sportEX comment Trigger point city. What do you need to treat them? A trained soft tissue therapist. Enough said!

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sportEX dynamics 2013;38(October):4-7

JOURNAL WATCH

challenging beliefs in sports nutrition: are two ‘core principles’ proving to be myths ripe for busting? peter brukner. bmJ open 2013;47(11):663–664 This is an editorial from the journal written by arguably the best known sports medicine guru. It questions a couple of long held beliefs. (1) Thirst is not a good indicator of hydration. You must drink lots of fluids before, during and after exercise. (2) The optimum diet for weight control, general health and athletic performance consists of low fat, high carbohydrate.

On the thirst front the answer is ‘not always’. In fact, excessive fluid overload is the major danger in endurance exercise, not dehydration and heat stroke.

Exercise-associated hyponatraemic encephalopathy (EAHE) is the medical term for it. On the second point the multi-million dollar question is, how come we live in a world of low fat foods yet society is getting fatter and diet-related illness such as type 2 diabetes is rocketing? The latest science seems to suggest that low carbohydrate and high fat diets are not the villains they were thought to be.

There is a thought that saturated fats are important nutrients and do not cause increased levels of small particle cholesterol and triglycerides. Even the notion of high carb diets for sports people is being challenged.

sportEX comment Wow! This is Peter Bruckner former head of Sports Medicine at Liverpool FC. The article is available free online and references its sources for further exploration. Its most scary quote comes from nutrition researcher Professor Tim Noakes, “50% of what we tell you is wrong, we just don’t know which 50%”.

www.sportEX.net

7

The role of sTrengTh and condiTioning in Training programmes for young aThleTes

by AdAm Kerr mSc, bSc, AScc

IntroductIon Paediatric strength and conditioning is an area of sport performance training that is often misunderstood and surrounded by many myths. There is a compelling body of evidence that suggests that strength and resistance training as well as conditioning is not only safe, but can elicit significant performance improvements (1–4) and help reduce the risk of injury (3,5–7). Three of the biggest strength and conditioning associations around the world, the National Strength and Conditioning Association (NSCA), the Australian Strength and Conditioning Association (ASCA) and the United Kingdom Strength and Conditioning Association (UKSCA) provide position statements highlighting that proper supervised and progressed resistance training can improve the health, fitness and sporting performance of young athletes (3,5,7).

Although it has been recommended that strength and conditioning for young athletes has many benefits, implementing a strength and conditioning programme should be considered alongside the growth and maturation status of the anatomical, neurological, hormonal and musculoskeletal structure and function (8). It has been suggested that basing training around chronological age is considerably flawed (8), and that programme prescription should be based on the status of each individual athlete, looking at biological maturity,

This article discusses all areas of strength and conditioning for both performance improvements and injury reduction across the different growth and maturity stages of young athletes. As this area of performance training is often misunderstood, guidelines and training recommendations are presented on how to successfully implement a strength and conditioning programme for young athletes of different ages.

From PerFormINg A STreNgTH-bASeD TrAININg ProgrAmme, yoUTH ATHleTeS CAN INCreASe THeIr STreNgTH levelS beyoND THAT oF NormAl growTH AND DeveloPmeNT 8

training age, motor-skill development, technical proficiency and current strength levels rather than using age-determined protocols (7).

Strength trAInIng effects of strength training during childhood The development of strength in youth athletes is influenced by muscular, neural and biomechanical factors and can be greatly influenced by the physiological and biological elements of growth and maturation (7), as healthy children can be expected to achieve noticeable gains in muscular strength without using any form of strength development training (9). However, performing a strength-based training programme, which has sufficient training load, intensity and volume over a continued period of time, can allow youth athletes to increase their strength levels beyond that of normal growth and development (10,11).

During the early stages of childhood, before puberty, the training-induced strength increases for both boys and girls are seen to be mostly due to improvements of the central nervous system, through motor unit recruitment and synchronisation (12). As the athletes proceed to go through puberty, which is generally around the age of 11 for girls and 13 for boys, the increased changes in strength, after a period of training, are seen to relate to structural and hormonal changes (13), in addition to the continued development of the sportEX dynamics 2013;38(October):8-11

evidence informed pracTice

central nervous system (14). If strength work is implemented in the early stages of childhood very little hypertrophy will be evident, however, an increase in motor coordination, strength, power production, change-of-direction speed and running velocity can all be seen during this time (2,3).

Throughout childhood, very little difference is seen in strength levels between girls and boys (15). However as puberty is reached, we start to see that males demonstrate greater changes in training-induced muscular strength and hypertrophy, mostly due to the increase in testosterone levels (11), whereas training-induced changes in females is thought to be limited by the reduced amount of testosterone at this stage of their development (9).

Despite all the research that suggests the safe nature of strength training for athletes as young as 6 years old (16), coaches should be aware of the maturation status of the athlete, as any training programme should ensure each athlete is trained according to the biological status rather than their chronological age (7). emotional maturity should also be a key factor for deciding when to initiate a strength programme (5). The athlete must not only be physically ready, but also mentally ready so that they can understand and follow the coach’s instructions, as well as being able to cope with the stresses of such training (3).

training recommendations Any training programme design and implementation for young athletes should be fully supervised by qualified strength and conditioning coaches (3,5,7). The programme should be carried out using appropriate equipment, with logical progressions based on technical proficiency, biological status, motor-skill competency and existing strength levels (3,5,7). The training programme should be developed based on the individual athlete in order to reflect variance in training age and technical ability. Children who demonstrate greater training age and strength levels would be able to use advanced progressions in comparison to a child displaying a low training age. exercise selection can vary greatly, though it is important for each strand of the exercises selected to have a continuum of progressions and regressions so that each athlete can be provided with appropriate levels of intensity based on their individual needs. All equipment used for any selected exercise should be the appropriate size and weight for the athlete (17). weights should be selected based on technical competency and existing strength levels (7), as all performed repetitions should be completed with perfect technique. In addition, athletes should not be held back due to age if technical competency and strength is demonstrated, with an increase in resistance or more complex progressions added when needed. It is also suggested that free-weight resistance training is more beneficial than machine-based resistance training for muscle activation levels, and for increasing more functional movements related to sporting performance (18,19). Athletes with a very low training age should be performing exercises that improve overall fundamental movement patterns and competency, before moving on to more advanced progressions of strength training (7). In contrast, athletes who have a higher training www.sportEX.net

A ComPellINg boDy oF SCIeNTIFIC reSeArCH SUggeSTS THAT CHIlDreN oF All AgeS AND mATUrATIoN levelS CAN mAKe TrAININg-INDUCeD ImProvemeNTS IN STreNgTH, Power, SPeeD AND AerobIC FITNeSS THAT SUrPASS THe ImProvemeNTS From NATUrAl growTH AND DeveloPmeNT age can progress to greater intensities using percentages of the athlete’s one repetition-maximum (1rm) to determine training weights. It has been suggested that the relative strength levels in the parallel squat for young elite athletes with long-term training experience could be seen to be a minimum of 2.0×bw (body weight) for 16 to 19 yearolds, 1.5×bw for 13 to 15 year-olds, and 0.7×bw for 11 to 12-year-olds (20). The UKSCA Position Statement suggests beginners may be prescribed 1–2 sets of 8–10 repetitions with around 50–70% 1rm. Then, once training has been maintained and the athletes technical competency and strength levels improve, it can be increased to 2–4 sets of 3–6 repetitions of 60–80% 1rm, with further progress allowing more advanced training modalities of 2–5 sets of 2–8 repetitions with 70–100% 1rm for more experienced and advanced lifters (7). Ideally, strength training should be completed 2–3 times a week on non-consecutive days to develop muscular strength (7), as it has been found that an increase in training frequency is correlated to an increase in training effect (2,7). The UKSCA also highlights that the recommendations for training prescription should be seen only as a guideline, making sure to take into account each athlete as an individual, with an understanding of maturation status, training age, movement competency, technical understanding and existing strength levels (7).

AerobIc condItIonIng effects of aerobic conditioning during childhood The development of aerobic fitness during growth occurs due to changes of the peripheral and central cardiovascular system, muscle function and cellular capacity (8), all of which can be influenced by training. However, there is much conflicting evidence around the trainability of the endurance system during childhood (8), and, although it is felt that all children can make training-induced gains during growth and maturation, the mechanism for these adaptations may vary depending on biological status (8).

Performing a period of endurance training with sufficient overload of intensity can cause an increase in vo2 peak beyond that of normal growth and development in young athletes (1,21). It has also been found that young athletes recover quicker between high-intensity exercise bouts compared to adults, and are therefore able to repeat the efforts more consistently, suggesting a shift of focus from steady state training to high-intensity interval training (1).

9

FollowINg THeSe gUIDelINeS wIll HelP yoUNg ATHleTeS To ImProve PerFormANCe levelS oN THe PITCH, CoUrT, TrACK or FIelD AND HelP To reDUCe THe rISK oF INjUry, AND NoT PromoTe INjUry or reTArD growTH AS IS CommoNly THoUgHT IN THe geNerAl PUblIC

come from plyometric activity before speed training, during peak height velocity it shifts towards plyometric and then strength training, and then after peak height velocity a combination of strength and plyometric training together in a training phase, followed by strength training (22). The types of training at the different stages of maturation seem to align with the natural development phases throughout childhood. In the early stages of growth it is the central nervous system that becomes fully developed, so more neural-type training is needed. Then, as children go through peak height velocity, changes in the muscular system occur, so training to improve muscle structure and function is needed (8).

training recommendations

training recommendations

Specific protocols for the improvement of aerobic capacity during childhood will vary greatly depending on both sport and the individual athlete due to maturity status and existing levels of fitness. Therefore, any training programme should be overseen by suitably qualified coaches who understand the physiological and psychological variations between children of different chronological and biological ages (1).

The number of various training parameters should be based on a high-intensity intermittent nature, working above 85% max Hr (1), as supplementing with this type of training has shown to be a time-efficient strategy to supplement the technical and tactical elements of training to elicit sufficient improvements of aerobic fitness (1).

Specific protocols for the improvement of strength and power during childhood will vary greatly depending on both the sport and the individual athlete, due to maturity status and existing levels of fitness. Therefore, any training programme should be overseen by suitably qualified coaches who understand the physiological and psychological variations between children of different chronological and biological ages (1). many studies have highlighted that adding additional speed and plyometric training to technical and tactical work can help improve markers of functional performance, such as sprint speed, vertical jump height and change-of-direction speed (23–26), however these look at various volumes and intensities, so it is difficult to give specific recommendations.

It has also been suggested that reducing training time dedicated to aerobic fitness work by approximately 20%, and then supplementing it with explosive strength, jumping and sprint work, can improve sprinting speed over 30m without sacrificing aerobic fitness levels (4). overall, the findings for improving speed and power during growth and maturation, suggest using some of the training time dedicated to aerobic fitness for more explosive speed and power work, performing this type of work 2–3 times a week, making sure to appreciate the type of work needed to improving these fitness characteristics depending on stages of development, and to follow proper progressions and regressions of plyometric training, ensuring intensity and volume are never prioritised over technical competency (1,8,22).

Speed And power trAInIng effects of speed and power training during childhood The development of speed and power during growth is seen to occur due to the development of the central nervous system, muscle-tendon size, structure and function (8); again these fitness characteristics have been seen to be influenced by training throughout maturation (22). Although limited in the number of studies, a review paper highlighted the most effective types of training at different stages of biological growth for developing speed and power. The different stages of biological growth roughly fall into the categories of before, during and after peak height velocity, which is defined as the age at which the speed of growth is greatest. Prior to the athlete going through peak height velocity most benefits

concluSIon

yoUNg ATHleTeS SHoUlD NoT be HelD bACK DUe To Age IF TeCHNICAl ComPeTeNCy AND STreNgTH IS DemoNSTrATeD 10

A compelling body of scientific research suggests that children of all ages and maturation levels can make traininginduced improvements in strength, power, speed and aerobic fitness that surpass the improvements from natural growth and development. All types of training covered are considered safe and effective if the strength and conditioning coach understands and appreciates the complex nature of the growing athlete, and ensures that any training is properly progressed and monitored. Any training prescription should be based on biological status, training age, technical competency, existing fitness levels and emotional maturity.

Following these guidelines will help young athletes to improve performance levels on the pitch, court, track or field and help to reduce the risk of injury, and not promote injury or retard growth as is commonly thought in the general public. sportEX dynamics 2013;38(October):8-11

evidence informed pracTice

references 1. williams C, bond b. High intensity training in young athletes. professional strength and conditioning Journal 2012;26:3–8 2. behringer m, vom Heede A, et al. effects of resistance training in children and adolescents: a meta-analysis. pediatrics 2010;126:1199–1210 3. Faigenbaum AD, Kraemer wj, et al. youth resistance training: updated position statement paper from the National Strength and Conditioning Association. Journal of strength and conditioning research 2009;23:s60–s79 4. mikkola j, rusko H, et al. Concurrent endurance and explosive type strength training improves nueromuscular and anaerobic characteristics in young distance runners. international Journal of sports medicine 2007;28:602–611 5. baker D, mitchell j, et al. resistance training for children and youth: a position stand from the australian strength and conditioning association (asca). 2007; http://spxj.nl/1bw601I (accessed 2 December 2012) 6. behringer m, vom Heede A, et al. effects of strength training on motor performance skills in children and adolescents: a meta-analysis. pediatric exercise science 2011;23:186–206 7. lloyd rS, Faigenbaum AD, et al. UKSCA position statement: youth resistance training. professional strength and conditioning Journal 2012;26:26–39 8. oliver jl, lloyd rS. long-term athlete development and trainability during childhood: a brief review. professional strength and conditioning Journal 2012;26:19–24 9. rowland T. muscle Strength, pp. 181–195. In: Children’s exercise physiology, 2nd edn. Human Kinetics 2005. ISbN 978-0736051446 10. Faigenbaum AD. strength training for children and adolescents. clinical sports medicine 2000;19:593–619 11. Kraemer w, Fry A, et al. resistance training and youth. pediatric exercise science 1989;1:336–350 12. ramsay jA, blimkie Cjr, et al. Strength training effects in prepubescent boys. medicine & science in sports & exercise 1990;22:605–614 13. Tonson A, ratel S, et al. effect of maturation on the relationship between muscle size and force production. medicine and science in sports and exercise 2008;40:918–925 14. malina rm, bouchard C, bar-or o. Introductory concepts, pp. 3–20.

In: growth, maturation, and physical activity. human Kinetics 2004. isBn 978-0880118828 15. Faigenbaum AD, milliken l, westcott w. maximal strength testing in children. Journal of strength and conditioning research 2003;17:162–166 16. Faigenbaum AD, westcott w, et al. The effects of different resistance training protocols on muscular strength and endurance development in children. Pediatrics 1999;104:e5 17. Stratton g, williams CA. Children and fitness testing. In: Sport and exercise physiology testing guidelines: volume 1 – sport testing. The british Association of Sport and exercise Sciences guide. routledge 2006. ISbN 978-0415361415 18. Schwanbeck S, Chilibeck PD, binsted g. A comparison of free weight squat to smith machine squat using electromyography. Journal of strength and conditioning research 2009;23:2588–2591 19. granacher U, goeseles A, et al. effects and mechanisms of strength training in children. international Journal of sports medicine 2011;32:357–364 20. Keiner m, Sander A, et al. Strength performance in youth: trainability of adolescents and children in the back and front squats. Journal of strength and conditioning research 2013;27(2):357–362 21. lemura lm, von Dullivard SP, Carlonas r. Can exercise training improve maximal aerobic power (vo2 max) in children: A meta-analytic review. Journal of exercise physiology 1999;2(3):1–14 22. rumpf mC, Cronin jb, et al. effect of different training methods on running sprint times in male youth. pediatric exercise science 2012;24:170–186 23. buchheit m, mendez-villanueva A, et al. Improving repeated sprint ability in young elite soccer players: repeated shuttle sprints vs. explosive strength training. Journal of strength and conditioning research 2010;24(10):2715–2722 24. Chelly mS, ghenem mA, et al. effects of in-season shortwww.sportEX.net

term plyometric training program on leg power, jump- and sprint performance of soccer players. Journal of strength and conditioning research 2010;24(10):2670–2676 25. mujika I, Santisteban j, Castagna C. In-season effect of short-term sprint and power training programs on elite junior soccer players.

Journal of strength and conditioning research 2009;23(9):2581– 2587 26. Faigenbaum AD, mcFarland je, et al. effects of a short-term plyometric and resistance training program on fitness performance in boys age 12 to 15 years. Journal of sports science and medicine 2010;6:519–525.

Further reSourceS For further information on this topic, and a database of accredited coaches around the country, visit The UK Strength & Conditioning Association website; www.UKSCA.org.uk.

ThE AuThOr Th Adam Kerr is an accredited strength and conditioning coach (ASCC) with the uKSCA and the current head of fitness for Middlesbrough Football Club. he graduated in Sport Science from Liverpool John Moores university in 2006, and completed his MSc Sport and Exercise Science (Strength and Conditioning) from Sheffield hallam university in 2008. Adam has previously worked at Arsenal Football Club as the lead academy sport scientist and fitness coach, and was also lead strength and conditioning coach at Middlesbrough Football Club. he has worked with youth athletes in many different sports including golf, football and rugby league. he also lectures for the Professional Golfers Association on the Sport Science modules for trainee professional golfers.

DISCUSSIONS

n Is strength training safe for young athletes? n what is the most time-effective way to train young athletes? n Is it safe to use free-weight resistance over machinebased resistance? n Can youth athletes improve strength, speed and power?

continuing education Multiple choice questions This article also has an elearning test which can be found under the elearning section of our website.

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11

The immediaTe effecTs of self-myofascial release on female fooTballers Is It benefIcIal for hamstrIng flexIbIlIty? This article presents a report on a testing protocol which was performed on 15 amateur female footballers. Hamstring injuries are reported to be the most common injury in professional football. A successful regime to aid the prevention of this injury and increase hamstring flexibility is proving hard to find. The fascia is often ignored when discussing muscle flexibility, but is commonly believed to play an important part. This study found that a self-myofascial release technique can increase active knee extension test scores immediately after application and discusses further research suggestions, with a view to enhancing effective flexibility protocols.

BY KatY SheffIeld BSc and nIall cooper BSc

12

IntroductIon Hamstring injuries account for 12% of all injuries in professional football, of which, 53% involve the biceps femoris (1,2). It is reported that running, eccentric contractions, poor flexibility (3), rapid acceleration and sprinting (4) can be a predisposition for hamstring strain. Strains are generally common in a multi-joint muscle, due to the greater functional demand and higher levels of fast-twitch fibres. The hamstring is reported to be the most common multi-joint muscle group to be strained (5). When a footballer strains a hamstring they are reported to miss approximately 3 football matches or weeks of play (4). Hamstring strains are a highly documented injury, yet their incidence has not reduced in recent decades (3).

The biceps femoris has a strong fascial connection with the peroneus longus at its insertion and is continuous with the sacrotuberous ligament

attaching to the thoracolumbar fascia at its origin (4). Fascia is connective tissue that enables movement of one structure relative to another. It contains small blood vessels and tissue receptors, therefore it has specific dynamic properties and can be relatively elastic (6). With the high rate of injuries (53%) to the biceps femoris and due to the myofascial attachments, the biceps femoris in particular could be more prone to injury (4).

It has been reported that limited flexibility may predispose a person to musculoskeletal injuries and affect a person’s functional ability. However, poor flexibility has not been conclusively linked to the cause of a hamstring strain (2–5).

Few tests have been developed to measure hamstring flexibility. Perhaps the most common test would be the sit and reach test (7,8). The sit and reach test has been recommended as a measurement for flexibility of the hamstrings as it is highly valid and reliable

(7,8). Another method of measuring hamstring flexibility is via the slump test, which further measures the neural tension for patients with lower back or hamstring injuries (9). More recently the active knee extension (AKE) test has become a commonly used clinical test for measuring hamstring flexibility. Although the AKE test has been identified as a reliable measure of hamstring flexibility, there is, however, an element of the test that may stretch the sciatic nerve (10), which therefore questions its validity. The passive knee extension test (PKE) is another modality which can be used to measure the flexibility of hamstrings and has been shown to give greater range of movement than the AKE test (10).

Myofascial release (MFR) is a common technique used to release soft tissue from an abnormal hold of tight fascia. The Golgi tendon organs are an important part in this technique of flexibility release (11,12), by sensing a change of tension and responding by inducing relaxation. A sustained pressure is applied onto the restricted tissue barrier until release of the tightened fascia occurs (12). Self-myofascial release (SMR) follows the same principles but allows the athletes themselves to apply the pressure, using a foam roller or similar product. Myofascial release can increase the range of movement/flexibility of a joint (13). However, no significant changes in hamstring flexibility were reported from using a foam roller over an 8-week period (11). Other methods for increasing hamstring flexibility have also been explored. It has been suggested sportEX dynamics 2013;38(October):12-17

research

There were 15 participants in this study.

All subjects were female footballers who trained four times a week and during the season, played 90 minute competitive football matches twice a week. All participants were aged between 16 and 20 years old (mean age±SD = 17±1.3 years; SD = standard deviation).

Any subjects who were deemed to have had a lower limb injury within the last 6 months (16) were excluded from the study, and injury was defined as not being able to participate in training or competition for at least 7 days (2).

The protocol was performed at pitch side during a training session, using a foam roller of 89cm in length and 15cm in diameter. The AKE test was conducted before and after the foam roller protocol. One group of 8 participants was tested in week one and one group of 7 participants was tested the week after; the groups were randomly assigned. All participants were required to be wearing football kit appropriate for training.

Following the guidelines of previous research discussed for the AKE test (10), subjects were marked on their greater trochanter of the femur and the lateral condyle of the femur for the points of axis of measurement. All subjects being tested lay supine and were instructed to flex their hip and knee to 90°, and these angles were checked using a goniometer. Subjects were then asked to manually hold their hip in position throughout the testing procedure (Fig. 1).

Subjects actively moved their knee in to maximal extension until they felt slight discomfort (17) while keeping their hip still and foot relaxed. The participants held the position for 5 seconds (10), after which time the degree of extension was measured using a goniometer (Fig. 2). To allow for familiarisation and to obtain an average score, the AKE was measured bilaterally three times. The

average score was taken as the final figure for statistical analysis.

Following the AKE test, subjects carried out a foam roller routine bilaterally for myofascial release of the hamstring group. The subjects were to roll from the origin of the hamstrings to the posterior aspect of the knee (Fig. 3). They rolled distally 3 times and proximally 3 times. If discomfort was felt at any point along the hamstring, they were instructed to hold over the area for 30 seconds (18,19). After the subjects performed the foam roller protocol the AKE test was immediately repeated in exactly the same form as before.

To analyse the results, standard descriptive measurements were used such as averages, standard deviation of variance and percentages. A paired (dependant) t-test was used via

Figure 1: Measuring 90° hip flexion with a goniometer

Figure 2: Measuring degrees of knee extension using a goniometer

Figure 3: Hamstring SMR using a foam roller

that backward walking over a 4-week period can increase hamstring flexibility in females (14). In addition, many studies have suggested that regular passive static stretches and muscle energy techniques can aid in the development of hamstring flexibility (15).

reSearch purpoSe and hYpotheSIS Given the debate from previous research regarding a suitable solution for enhancing flexibility of the hamstrings, it would be sensible to approach all anatomical regions that may affect this element of fitness. General muscle flexibility and range of movement can be enhanced by a simple static stretching programme (15); however, the fascia must also be considered when exploring injury prevention. This study sets out to investigate the immediate effects of an SMR technique on amateur female footballers to encourage the research around flexibility and fascia tightness as an injury predisposition and performance detractor. Considering other findings (11–13), it may be postulated that there will be an immediate increase in flexibility after performing a SMR technique.

MethodologY

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Du DuRInG REHAbIlITATIOn IT IS SuGGESTED THAT MyOFASCIAl COMPOnEnTS MuST bE ADDRESSED TO EnAblE Full FunCTIOn OF MuSClES AnD jOInTS

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Microsoft Excel 2010 which identified any levels of significant difference (P <0.05) between the pre-SMR and postSMR test scores of the right and the left leg (20).

Table 1 shows the bilateral results of the pre- and post-SMR scores of the AKE test for each individual participant. The mean scores and standard deviations are also shown in this table.

Figures 4 and 5 show the graphs of the pre- and post-SMR AKE test scores for the left and the right leg.

The results from this testing protocol show a poor standard deviation (SD). For those tested on their right leg the SD of the difference scores is measured at 8.13, and those tested on their left leg are measured at 6.25.

These results suggest quite a wide variability; however, there are a few abnormal results which may affect this figure.

After performing the SMR technique, an overall mean score of 4.6° of improvement on AKE is reported on the left leg and an overall mean score of 3° improvement is reported on the right leg.

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From the testing procedures, the immediate effects of SMR on the hamstring show a considerable improvement. Out of the 15 subjects tested, 60% showed an overall increase in flexibility on the AKE test for both right and left legs. On the right leg, 27% showed no change in AKE results, and 13% decreased their AKE score. On the left leg, 33% out of 15 showed no change and only 7% decreased their AKE scores.

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Figure 4: Graph of the AKE test scores before and after SMR for the right leg

taBle 1: BIlateral aKe teSt ScoreS pre- and poSt-SMr participant dominant foot

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subjects improved immediately in the AKE after performing the SMR technique in what was considered their dominant kicking leg. Out of those 10 subjects, 8 of the subjects improved more on their dominant leg than their non-dominant leg. The other 2 subjects improved more on their non-dominant leg on the AKE test immediately after SMR, compared to their dominant leg.

A significance value (P-value) was calculated for the difference between the AKE scores before and after SMR for both the left leg and for the right leg measurements. This value shows us whether the difference between the AKE scores before and after SMR is a significant (ie. real) difference or not. For a result to be significant, the P-value has to be 0.05 or lower; a P-value greater than 0.05 means that the difference in the results is not significant.

Interestingly, the results for the right leg indicated that there was not a significant improvement in hamstring flexibility after SMR (P=0.08), although this is approaching significance (P=0.05).

However the results for the left leg indicated that hamstring flexibility did improve significantly after SMR (P=0.04).

dIScuSSIon Overall, the results from this study show that there is generally an immediate improvement on hamstring flexibility from completing a specific SMR technique on a foam roller.

Flexibility of the hamstring muscle group can be measured in many ways (7,10). However, it is not always certain as to what anatomy may be sportEX dynamics 2013;38(October):12-17

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Figure 5: Graph of the AKE test scores before and after SMR for the left leg

restricted during these tests. Muscles can be perceived as tight, yet, due to the anatomy involved, the fascia may be a predisposing factor for this illusion and may have an abnormal hold over a muscle (11), demonstrating tightness in various testing protocols and perhaps a misunderstanding of muscular flexibility.

During rehabilitation it is suggested that myofascial components must be addressed to enable full function of muscles and joints (21). It has been suggested that the biceps femoris may

online

be more pre-disposed to injury due to its myofascial attachments (4). It would be sensible when aiming to improve flexibility that the fascia is also taken into consideration. by taking part in activity the soft tissues will experience trauma, and fascia is said to often be affected when physical trauma is involved (21).

Although the sample size in this study was relatively small, there was an obvious immediate improvement on the AKE test for most participants (60%) on the right and left leg after using an SMR technique.

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Slideshow 1: anatomy of the hamstrings

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It is important to note that in this study there were no real exclusions of patients from the testing, except for those with injuries. In a recent study of measuring hamstring flexibility using the AKE test, the testers excluded those who had better flexibility and suggested those reaching over 80° during knee extension were too flexible to be tested and only selected those who had an AKE test of below 80° (11).

In a study that used the PKE test for hamstring flexibility, participants who had poor flexibility were also excluded.

Poor flexibility was considered for those who could not reach at least 30° of knee extension (15). Therefore it would have been more appropriate to set a definitive figure for this research study to include only those who may be considered to have average flexibility between the range of 30° and 80° to ensure that flexibility changes are measured as significant.

In this study, three subjects had a score of at least 60° in AKE before the SMR technique, which could be considered as relatively high flexibility. by taking out the subjects who had an initial higher level of flexibility (above 60°), this gives a figure for the right leg

animation 1: anatomy of the hamstrings

15

of 75% of participants improving their AKE score and 25% staying the same.

There was no decrease in AKE test results at all in those with a flexibility score of less than 60° prior to the SMR technique. Excluding those subjects who had an original higher level of flexibility (above 60°) for their left leg, gives a figure of 67% of subjects increasing their flexibility and 33% of subjects with no change after SMR. Again there was no decrease in AKE test results in those with a flexibility score of less than 60° before the SMR technique.

It is important to discuss the individual results of those who did not improve or had a reduced AKE score and make suggestions as to why this may have happened. Subject 2 (right leg) had a decreased AKE score after using a foam roller; however, the initial score was very high (85°), potentially suggesting that hamstring flexibility and muscle fascia was not notably tight, and, in concordance with previous studies (11, 15), would gain no significant benefit from SMR. This was the same on their left

leg where the pre-test score of flexibility was relatively high (65°) and decreased after SMR. Subject 14 also demonstrates this (right and left leg) where their results of the AKE test initially was relatively high (65°), and did not improve in flexibility after using the SMR technique.

This could suggest that only those who have poor flexibility will improve, and those who already have good flexibility do not need to and will not improve their flexibility scores significantly. Thus, it can be suggested that in future, testing takes place on only those who are less flexible, whether this be left or right leg.

In the results from this study there is a clear difference of the average scores when comparing dominant verses nondominant legs in the pre-test scores of flexibility. This figure demonstrates as an average of 1.2° of more flexibility in the dominant leg than the non-dominant leg.

Out of the 15 subjects tested, 86% are right leg dominant and of these, there was an average of 1.1° difference between the right and left leg pre-SMR scores, suggesting that on average, the dominant

leg is more flexible. This may support the fact that the significance value is accepted (P=0.04) for the left leg, but not for the right leg (P=0.08). However, it is clear that the P-value for the right leg dominant group is approaching significance. Therefore with a larger subject population and a guideline on those who take part with regards to baseline flexibility scores, the data may become significant and consistent.

This protocol was testing only the immediate effect of SMR on the hamstring muscle group flexibility. Due to the immediate increase in flexibility it could be suggested to use SMR pre to competition or training only. The effects of SMR on the hamstrings over a longer period of time, however, seem to be insignificant (11) and a normal stretching programme over a long period of time has shown to improve general flexibility (15). Therefore, the idea of combining static passive stretching over time and SMR for immediate effect would provide a good testing procedure.

Although the effects of longer term SMR have been shown to be insignificant (11), the testers did not use full guidelines to find an area of tenderness and hold over the area for a set amount of time (18,19). This technique would have enhanced the release of the fascia. It may also be useful for a different measure of flexibility to be used: the PKE test may be a slightly more relevant test of flexibility (10). It may also be beneficial to test the effect of SMR on various elements such as sprinting, agility and power; which are considered more functional to football. It is just as important to increase function as it is to reduce the risk of injury.

concluSIon c In conclusion, it would be reasonable to say that from this particular testing, performing an SMR treatment on the hamstrings does have an immediate effect of increasing flexibility, as measured by the AKE test. However, the testing protocol needs to be explored and developed to support this conclusion.

It would be beneficial to include further exclusions and guidelines for the subjects who take part, such as only those within a certain range of baseline flexibility. In addition to this, more subjects 16

sportEX dynamics 2013;38(October):12-17

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should be tested to give a larger sample size to allow a more robust statistical analysis. Further testing of other elements related to football skills should be tested, as flexibility is not the only element that may predispose subjects to injury. references 1. Woods C, Hawkins R, Maltby S, et al.

The Football Association Medical Research Programme: an audit of injuries in professional football – analysis of hamstring injuries. british Journal of sports medicine edicine 2004;38(1):36–41 2. Mackey C, O’Sullivan K, O’Connor A, et al.

Altered hamstring strength profile in Gaelic footballers with a previous hamstring injury. isokinetics and exercise science 2011;19:47– 54 3. Opar DA, Williams MD, Shield Aj. hamstring strain injuries, factors that lead to injury and re-injury. sports medicine 2012;42:3209–226 4. Hoskins W, Pollard H. The management of hamstring injury – part 1: issues in diagnosis. manual Therapy 2005;10:96–107 5. Davis DS. Ashby PE, McCale Kl, et al. The effectiveness of 3 stretching techniques on hamstring flexibility using consistent stretching parameters. Journal of strength and conditioning research 2005;19(1)27–32 Rl, Vogl WA, Mitchell AWM. 6. Drake R Gray’s Anatomy for Students (2nd edn). elsevier 2010. ISbn 978-0443069529 e (Print £33.57, Kindle £25.18). buy from Amazon http://spxj.nl/1d4bGlf 7. baltaci G, un n, Tunay V, et al.

Comparison of three different sit and reach tests for measurement of hamstring flexibility on female university students. british Journal of sports medicine 2003;37:59–61 8. barlow A, Clarke R, johnson n, et al.

Effect of massage of the hamstring muscle group on performance of the sit and reach test. british Journal of sports medicine 2004;38(1):349–351 9. McHugh MP, johnson ohnson CD, Morrison RH. The role of neural tension in hamstring flexbility. scandinavian Journal of medicine science sports 2012;22:164–169 10. norris CM, Matthews M. Inter-tester reliability of a self-monitored active knee extension test. Journal of bodywork and movement Therapies 2005;9:256–259 11. Miller jK, Rockey AM. Foam rollers show no increase in the flexibility of the hamstring muscle group. Journal of Undergraduate research 2006;9:1–4 12. barnes M. The basic science of myofascial release. Journal of bodywork and movement Therapies 1997;1(4):231–238 13. Hanten W, Chandler S. Effects of myofascial release leg pull and sagittal plane isometric contract-relax techniques on passive straightleg raise angle. Journal of orthapaedic & sports Physical Therapy 1994;20(3)138–144 14. Whitley CR, Dufek jS. Effects of backward walking on hamstring flexibility and low back range of motion. International Journal of exercise science 2011;4(3):192–198 15. Shadmehr A, Hadian MR, naiemi SS, et al. www.sportEX.net

Hamstring flexibility in young women following passive stretch and muscle energy technique.

Journal of back and musculoskeletal rehabilitation 2009;22:143–148 16. Abián-Vicén j, Alegre lM, FernándezRodríguez jM, et al. Ankle taping does not impair performance in jump or balance tests.

Journal of sports science and medicine 2008;7:350–356 17. Warren P, Gabbe bj, Schneider-Kolsky M, et al. Clinical predictors of time to return to competition and of recurrence following hamstring strain in elite Australian footballers. british Journal of sports medicine 2008;44:415–419 18. Comfort P, Abrahamson E. Sports rehabilitation and injury prevention.

2010 Wiley-blackwell. ISbn 978-0470985632 (Print £33.96, Kindle £25.47). buy From Amazon http://spxj.nl/1d6PleS) 19. Colluci T. Roll, release, react: prepare class for movement. idea fitness Journal 2011 april 20. Ary D, jacobs lC, Sorensen C, et al.

Introduction to research in education (8th edn).

Wadsworth Cengage learning 2010. ISbn 0495601225.

21. Curran PF, Fiore RD, Crisco jj. A comparison of the pressure exerted on soft tissue by 2 myofascial rollers. Journal of sport rehabilitation 2008;7:432–442.

ThE AuThOrs Th Katy sheffield, Bsc (hons) sports Therapy, is a sports therapist and lecturer at solihull College. she also practises in a private clinic: suffolk Clinic, Coventry. Part of the role at solihull College is to provide sports therapy and football coaching to the ladies football academy in affiliation with Birmingham City Ladies Football Club. Before this Katy was a lecturer at Exeter College for the Foundation Degree in sports Therapy, working as research project tutor and module leader for the clinic-based topics.

Part of the role at the college was also the ladies football academy coach. Email: Katy-rose.sheffield@ solihull.ac.uk Niall Cooper, Bsc (hons), is a sports therapist who graduated from university Plymouth Marjons and completed an Fdsc sports Therapy degree at Exeter College prior to this. Niall carried out the testing for this article. he also worked closely with the ladies football academy as their sports therapist throughout one season, travelling with them to their Cup Final.

Niall also worked in the Exeter College and Marjons university sports injury clinic for two years. Niall is seeking to develop his sports therapy career within the sporting environment.

How important is the fascia when it n comes to flexibility testing and have you experienced this with any of your clients/ DISCUSSIONS subjects? n What other methods could be used to release the fascia? n How effective and accurate do you think the AKE test is and would it have been better to use the PKE test? n Would you expect to see the same results in males who have a higher risk of hamstring injuries according to research?

further reSourceS For more information on how to use a foam roller to improve flexibility and strength and to perform selfmassage see the Foam roller workbook: Illustrated step-by-step guide to stretching, strengthening & rehabilitation techniques by K. Knopf, ulysses Press 2011. ISbn 978-1569759257 (Print £6.47, Kindle £6.71). buy from Amazon http://spxj.nl/13HZSKv.

continuing education Multiple choice questions This article also has an elearning test which can be found under the elearning section of our website.

Tests from April 2013 onwards can be done on most digital devices.

1. login to our website, click the Online Access button in the main menu bar and the go to the elearning section (you must be logged in).

2. Click on the quiz you wish to do. Successful completion results in a stored certificate under the My Account area of our website. This can be downloaded or printed at any time as evidence of continuing education for many national and international membership associations.

This qUiz is accessible

free

WiTh a sUbscriPTion ThaT inclUdes online access To This JoUrnal.

17

The minefield of Achilles TendinopAThy mAnAgemenT – A cAse study this case study is based on both personal and professional experience of injury and rehabilitation, and it looks at the pitfalls and difficulties that patients will come across. this experience was one I wished to share with fellow clinicians as it allowed me to see things from the perspective of the patient, athlete, practitioner and coach. this journey is something that will shape my practice for years to come and I hope you, the reader, can get the same out of it!

Case study part 1: aCute management of aChilles tendinopathy

tHe stANdARd stReNgtH tRAININg tHAt Is eMPLoyed by MANy MeReLy AggRAvAted tHe PRobLeM 18

BY MIchael carolan MSc, BSc, GSr

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t has been shown that Achilles tendinopathy has an incidence rate of over 53% in running-based sports (1), and this case study, based on my own personal/professional experience of this pathology, has the same etiological link with my chosen sport of athletics.

From the age of 17 I have trained and competed in the 100m and 200m sprints, and until the age of 25 I played football on a regular basis. However, after injuries I returned to athletics and found that, like many runners, my progress was hampered by Achilles tendinopathy. the injury progression lasted over 12 months, during which time I was often concerned that I would never regain full fitness. Nonetheless, I am now back training in preparation for competition. the point of this case study is to take the science and research and apply it to a real-life clinical context examining what worked and what didn’t work. the first part of this article will outline the underlying factors that could have been associated

with the onset of this injury and the management interventions often used by practitioners in clinical and sportsbased practice and discuss their efficacy.

PatIent context the patient was a 30-year-old male sprinter, running distances of 100m, 200m, 4×100m relay (1998–present time).

Previous sports include: n Football (1991–2005) n Martial arts (1988–2003).

Previous injuries include: n Lateral ankle ligament injuries; right and left, 6 in total (2000–2005) n Anterior cruciate ligament hamstring graft; right leg (2010) n sciatic nerve irritation; left leg (2006) n Right sacroiliac joint up-slip and anterior (2012).

InjurY hIStorY September 2011: initial onset Initially, acute onset of the injury followed an aggressive, combined training session involving both plyometrics and sprint sportEX dynamics 2013;38(October):18-26

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running reps. As is often is the case, my problem presented with acute pain and stiffness in the mid-portion of the Achilles that increased during the session and into the next day. At first this was managed by short rest and resistance training, as advocated by much research (2,3). It is important that the rest period is not too long, as this can cause the tendon to atrophy through a reduction in collagen present within the tendon and therefore cause an associated loss of strength (2).

December 2011 the management described above allowed for some decrease in pain and increase in function, although full training was not yet possible without a return to the previous pain state.

After 3 months, the christmas break conveniently allowed the coaches to prescribe 10 days rest, with only small amounts of self-directed training.

Following the break, an indoor session showed that the pain state was good, with no aggravation. However, the selfdirected training involved no running.

At a subsequent training session, after warming up, some short runs were tried, but unfortunately the pain returned. Attempts to stretch and take more warming-up time did not help and the pain remained. Insertional pain and mid-portion pain were present in not just the left Achilles but also the right: both had been aggravated during this time.

Figure 1: Body-weight heel raises with straight knee on the flat

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january 2012: secondary onset

rest

From this point on I was unable to run without pain, and morning stiffness and pain were apparent on a daily basis, as were weakness and trigger points in the soleus and gastrocnemius.

Atrophy of the tendon was noticed as time went on, accompanied with a greater level of pain and sensitivity than previously. standard strength training employed by many, including weighted eccentric heel raises on a step merely aggravated the problem.

Psychologically, as with many runningbased patients, I felt frustrated and lost. the issue was compounded by my work as an exercise rehabilitator demonstrating rehabilitation protocols, and with pitch-side intervention during rugby matches involving running on to attend to injured players. this didn’t allow for any recuperation of the tendons, and prolonged the pain cycle for several months.

Interventions such as stretching, massage/frictions, electrotherapy, icing, non-steroidal anti inflammatory medication (NsAIds), rigid and kinesio taping, heel raises, and orthoses were all used during this initial time period to aid in pain management as advocated in current research (1,3–9).

taking away the aggravating factor was my first concern both for loading of the tendon in the acute phase and to combat the central irritation that occurs with peripheral nociceptic sensitisation. this helped initially, however, prolonged rest from any kind of running was difficult because of work. cook et al. and Kader et al. recommend that in the acute phase, or for acutely injured tendons, rest is pivotal to allow for collagen reformation prior to altered loading and rehabilitation (1,2).

nSaIDs

P.R.I.c.e was employed where appropriate, with compression replaced with a heel raise and elevation with taping.

there is contention in the current body of research regarding the use of antiinflammatory medication and tendon health. Paolino and orchard showed they are useful in the short term for pain relief, however, they are ineffective and can actually cause tissue damage with prolonged use (10).

In my case I had two courses of ibuprofen at 400mg, 4 times per day for 7 days. the first, at the initial onset, helped a great deal; the second, 3 months into ‘recovery’ helped manage the pain, but they were not in any way a solution for the problem.

Magra and Maffulli (11) showed that NsAIds can have a beneficial pain relieving effect, though, long-term use (as often prescribed by gPs) was shown to have either no effect or an adverse one and can actually add to the chronic nature of such conditions (10).

Figure 2: Body-weight heel raises with bent knee

Figure 3: Body-weight heel raises with heel off a step

InterventIonS

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loading and strength work I’ve worked with runners who have had similar issues and almost all have come across a routine of progressive eccentric body-weight heel raises utilising a step.

Repetition advice varies from 6–15 reps for 3–5 sets. eccentric loading has been said to be more beneficial than concentric loading (4,6,7,12,13).

From september 2011 to January 2012, I progressed through a regime of daily body-weight exercises involving heel raises with the knee straight on the flat (Fig. 1), the knee bent (Fig. 2) and with the heel off a step (Fig. 3). this had some benefit in decreasing some of the early morning stiffness associated with this pathology and decreased the pain experienced to the point I was able to train with little discomfort after a warm up.

In the gym, exercises included step-based weighted heel raises with a straight knee, using the smith machine, and dumb-bells on a step and/or a leg press machine. these were progressively loaded over time.

Interestingly, they helped initially and then improvement reached a point of plateau.

However, after the second incident in January 2012, these exercises actually aggravated the issue at the tendon insertion and distal tendon. this still remains the best form of intervention for renegotiating tendon health.

taping and strapping Working pitch side on rugby match days made rest and recovery of the tendon difficult. strapping, to offload the tendon and prevent excessive lengthening of the tendon causing subsequent eccentric loading, gave little or no benefit to the problem.

Kinesio taping is contentious with some cases showing it to have a significant effect on pain and function (9) and others no effect (see Further Resources 1). this intervention was the second most effective of all in the management of pain and loading, but this only worked to decrease pain and tension formation within the muscle tissue and had no effect on my ability to train.

orthortics and heel raises As advised by podiatrists and 20

examined in some research for acute management (3,13), a 4mm heel raise was employed for a period of 3 to 4 weeks, although a 12–15mm heel lift has been advocated previously (13). this helped initially, but again was only a short-term solution. orthoses were then suggested to offer an ‘offload’ during walking as they would have little effect when doing sprint training. unfortunately, they increased the associated stiffness within the tendon over a period of 6 weeks from october to december 2011. once discarded, the pain level decreased to that experienced before the orthotic prescription. one possible reason for this may be length of the triceps surae complex, previous ankle injury and relative dorsiflexion, which if prevented due to inflexibility may have then transferred loading further up the kinetic chain.

Stretching because of the noted lack of mobility through the gastrocnemius and soleus, static and dynamic stretches were both practised after periods of prolonged sitting and or immobility. stretching is contentious in the literature with regards to both injury prevention and management.

I found that it did help alleviate soft-tissue tension and discomfort that came from an increase in pain as a result of a heavy work day, but still didn’t seem to offer much in the way of long-term alleviation and progression towards resuming activity.

ultrasound ultrasound was used in the acute phases for pain management and did have some short-term alleviative effects lasting up to 4 hours. It has been shown to have an effect in managing pain; however, it has also been seen to have little effect on tendon injury. this line of treatment was used for a short period of time, but only as a way of managing pain.

Massage and deep transverse friction massage techniques Pioneered by cyriax in the treatment of such conditions (1,13) and used by many manual therapists, myself included, this was the third most effective

intervention. Friction techniques are done at the site of pain but transverse to the fibres. However, the Achilles tendon isn’t a long strand of fibres but is actually a spiral of fibres so this could be folly if the damage to the tendon follows this line (1). Friction massage may work well, though, in the case of a paratenon tear or damage. deep tissue massage of the muscles caused nervous sensitivity to the peroneal nerve, proximal to the fibular head (a known neural epicentre), and to the tibial nerve and its extension running proximal to the Achilles – the sural nerve. due to either pain or muscle weakness, or possibly both, trigger points formed regularly in the lateral head and through the soleus.

DIScuSSIon All the interventions discussed above are often employed in clinical practice for the management of acute pain associated with Achilles tendinopathy.

However, from my own experience and research, I found that the most effective were: 1. Initial rest from aggravating activity 2. strength work post acute phase 3. Kinesio taping between treatments 4. deep transverse frictions and massage.

It must be noted, however, that this is a case study based on personal experience and is not a recipe for all, as some interventions may have greater effect than others and only in my context did these have the greatest efficacy. this, then, begs the question… did they solve my problem? the answer was no. As with many patients this format did help for a time to alleviate the symptoms but didn’t allow me to return to full training or eventual competition. the pain and dysfunction continued to May 2012, the end of the rugby season and the beginning of summer.

Part 2 of this article discusses the decision-making process that was involved with changing the emphasis and management of the injury towards functional return, and proved to me how important looking at the patient’s context and planning their progression is when working towards recovery and return to sport. sportEX dynamics 2013;38(October):18-26

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cAse study PARt 2: Post-Acute MANAgeMeNt, AssessMeNt ANd ReHAbILItAtIoN oF AN AtHLete WItH LoNg-teRM AcHILLes teNdINoPAtHy In Part 1 we discussed the nature of pain management and confounding factors associated with my Achilles tendinopathy. this covered the timeframe from the initial onset in september 2011 until the second onset in december 2011/January 2012 and then through to May 2012.

MaY–julY 2012: reSt anD footwear chanGe It took until after the rubgy season finished, 5 months after initial onset, for any change to begin. I sat down with various individuals including my colleagues at salford university, sports Rehab uK and my coaches at Manchester Harriers to discuss ways to move forward. the first decision was a simple and predictable one, that prolonged rest would be best to take away any irritation (1). this fitted well with an end of the rugby fixtures and a long planned trip to Asia travelling for 3 weeks. this allowed complete rest other than walking.

footwear of interest and by pure accident, the change in footwear during this time seemingly had a positive effect. Having previously worn cushioned trainers (Adidas supernova glide), I wore nothing but Havaiana flip flops for nearly a month. upon return to the uK, donning the cushioned shoes once again brought about immediate stiffness and discomfort. Having realised that the flat footwear had had a major effect in changing my pain state, contrary to www.sportEX.net

many articles (1,13), I ordered some Nike Free Run+ 2 shoes (Further Resources 2). Luckily they arrived within days and immediately I felt a benefit. the reason I chose this footwear was that they were at the half-way point between a ‘barefoot’ shoe and a cushioned trainer, with similar sole thickness to the footwear I had worn when away.

My reasoning for this effect was that my 30 years of injuries and training has involved being in a plantarflexed position applying high eccentric/ explosive loads, which would cause a related limitation in available dorsiflexion necessary in gait. this would cause the foot to flatten and collapse and develop a wide flat forefoot shown to be characteristic of many sprinters (14).

As a result, the previous ‘blocking’ action through orthoses and cushioned trainers may have transferred a sheering force up and through the tendon. A podcast on Physioedge (available on itunes) also discussed the role of different footwear and the change in foot strike that may well affect the Achilles tendon (see Further Resources 3). the choice of footwear for patients is an important consideration for clinicians. In my case it had a particularly significant effect.

Goal setting this is something I do with all patients now asking them, “What do you want to get out of this process?” the change in pain state was a great boost, however, I was aware that what had been done was not enough. I now ask all my patients the following questions.

What do you want to achieve?

My long-term goal was to return to full fitness and training in athletics competing in the 200m, my preferred event, and to achieve or better my personal best in the next 2 years. this allowed goal setting to be broken down and to be measurable.

What would hinder this?

Physical fitness. Although the injury period allowed me to improve on physical strength, especially in learning the olympic lifts (purported to be a useful training aspect of sprinters), my

actual running capability was at an all-time low. Having researched into the role of fascia (15) I found that I would have to begin to retrain this network of vital tissues that includes the Achilles tendon, and with my previous difficulties relating to flexibility I saw this as another way to retrain my body.

What do you need to do to achieve this? start small and set intermediate goals along the way towards the long-term goal.

The initial goals Having asked myself the questions above, I decided on two initial shortterm goals: n goal 1: complete a running session on the track n goal 2: complete a week of training on the track (3 sessions). the first two goals were to be achieved within the first month with slow running on the grass pitch adjacent to the track, coupled with strength training to affect the durability of the tendon.

However, I also included knee flexion and extension during tendon loading (see Fig. 4).

julY–auGuSt 2012 Following my period of rest, my rehabilitation training began and included running as well as strength training (table 1).

Grass running sessions the early phase of the running training started with grass running sessions made up of drills, as well as slow straight-line runs and fartlek running (table 1: July/August 2012). this was guided by pain and fatigue, sessionby-session, with my coaches Lance salmon (speed coach) and Michael Fennell (assistant head coach).

Strength training the strength sessions, detailed in table 1 (July/August 2012), were in conjunction with other fitness training such as ‘core work’, cardiovascular exercise not to load the tendon excessively such as spinning. As discussed, heavy eccentric training, through mild discomfort was beneficial 21

taBle 1: rehaBIlItatIon time frame

running sessions

Strength training*

July/August 2012

1. Drills

1. calf machine: 60kg bilateral, 25 kg unilateral, 3×15 reps

2. Slow straight-line runs: progressing from 40 to 100m, 6–10 reps

2. olympic lifting: n squats 100kg, 3×12 reps n deadpulls 60kg, 3×8 reps

3. fartlek running: 50m/50m walk-jog, then jog-run, 4–6 reps.

August/ september 2012

Quadriceps: Knee extensions: 60kg bilateral, 3×8 reps High step-ups: 15kg dumb-bells, 30–45cm box, 3×10 reps bilateral drop downs: 30cm box, 3x8 reps single-leg squats: 3×8 reps.

1. Drills: 30 minutes

1. calf machine: 70kg bilateral, 35 kg unilateral, 3×15 reps

2. Slow straight-line runs: progressing for 100m, ×6

2. olympic lifting: n squats 110kg, 3×12 reps n deadpulls 70kg, 3×8 reps

3. fartlek running: on track 50m/50m jog-run, ×2 4. run on track: 3×250m 5. run on track: 3×300m

october 2012

3. n n n n

Pyramid session 1. Drills: as before 2. Stride runs: 5 x 100m warm up 3. Speed pyramid: 100m, 200m, 300m; 30 seconds rest between each 5 minutes rest 300m, 100m, 200m; 30 seconds rest between each 5 minutes rest 200m, 300m, 100m; 30 seconds rest between each Cool down Indoor session 1. drills and slow running (warm up)

3. Quadriceps: n Knee extensions: 70kg bilateral, 3×8 reps n High step-ups: 17.5kg dumb-bells, 30–45cm box, 3×10 reps n bilateral drop downs: 30cm box, 3x8 reps n box jumps: 30cm box, 3x8 reps n single-leg squats: 3×12 reps.

1. olympic lifting: strength phase 3×5 reps, 80–85% max for squat, dead lift, weighted step-up.

2. overhead squats: 20–30kg 3. Quadriceps: n Knee extensions 3×6 at 80–90% max.

2. 5×20m run with rolling starts; jog into quicker running 3. 5×40m run with rolling starts; jog into quicker running 4. block starts over 20m.

Nov/dec 2012

1. Speed pyramid as of week 20: 120m, 150m, 200m; 30 seconds rest between each 5 minute rest 200m, 120m, 150m; 30 seconds rest between each 5 minutes rest 150m, 200m, 120m; 30 seconds rest between each

1. calf machine: progressed to 85kg bilateral and 45kg unilateral 2. Squats: 120kg, 3×8 reps 3. Deadlifts: 100kg, 3×5 reps 4. unilateral pistol squats: with trx, 3×12 reps 5. unilateral high step-ups: 15kg dumb-bells, 3×8 reps

2. Speed endurance session: 3×400m, 3×200m, 2×150m, 1×100m 3. timed 200m session: in less than 27/26 sec; ×4. *Additionally, circuit training for fitness and core training was carried out.

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over both concentric training and stopping if pain was present. I followed this model, as with any exercise discomfort is expected. once I returned to the track my coaches and I agreed on the next progression of sessions.

(2002). Fitness was needed, though I appreciated that having not run for over 2 years and lacking sprint endurance was a major role in this. With this measure, my coaches (Lance and Mike) and I agreed on the following goals.

auGuSt/SePteMBer 2012: 12 MonthS after InItIal onSet

Goal 4 goal 4 was to run 200m equal to or under 26 seconds by the end of the year 2012. this was achieved.

running sessions After achieving goals 1 and 2, my training progressed to include some track running (table 1: August/ september 2012). Again, this was all guided by pain and fatigue, session-by– session, with my coaches as above.

Strength training over the coming months the strength sessions became progressively more specific (table 1: August/september 2012), guided by any pain and or stiffness, often allowing 24 hours for recovery between exercise type. over this time my week was divided into 3 track-based sessions and 3–4 gymbased sessions. the most noticeable difference was that discomfort in the morning had decreased significantly and my durability within sessions had increased.

Goal setting It is necessary to revisit goals in order to adjust them as they are achieved.

Having completed a months’ worth of track training we decided to break the sessions.

Goal 5 goal 5 was to run 200m equal to or under 25 seconds by February/March 2013.

Goal 6 goal 6 was to run 200m under 24/23 seconds by the end of the 2013 season/2014.

octoBer 2012: PYraMID traInInG running sessions by october I was able to do a speed endurance pyramid, a component vital for 200m running. out and out ballistic speed was not as important at this stage, more so was the ability to maintain form under fatigue. I found that my speed was actually good running 60m reps in under 8 seconds for 8 runs; however, the latter part of my longer runs was slower and this was what I needed to develop over the coming months prior to working on high quality reps through spring 2013.

Goal 3 goal 3 was to increase the range of training activities: n Monday: long running sessions of 200–400m reps n Wednesday: interval or pyramid session n Friday: speed session, high intensity/ quality session, block starts this break allowed for specific components to be developed and focused on throughout the week. Additionally we completed a timed 200m run and found that although training was going well, I was disappointed with a time of 26 seconds, having previously achieved a personal best of 23.6 seconds www.sportEX.net

(a)

(b)

Figure 4: Knee flexion (a) and extension (b) in calf exercises

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tHe FIRst decIsIoN WAs A sIMPLe oNe: PRoLoNged Rest WouLd be best to tAKe AWAy ANy IRRItAtIoN Pyramid session detailed in table 1 (october 2012), this was a huge achievement as there was no pain, even though this was a very testing set of sessions. but it indicated that of all the interventions the strength training was the most effective in eliciting a response. Mondays and Wednesdays were left for this kind of training. Friday sessions were devoted to speed and quality training. Initially this involved both plyometrics and 40m runs with some block practice.

Indoor session example Again described in table 1, this was a boost psychologically as previously I had trepidation towards any indoor training. this is often regarded as a yellow flag within clinical practice as it can hinder adherence to rehabilitation (16), and is something that needs to be monitored as confidence goes hand-inhand with competence.

As practitioners we see our patients sometimes at their most vulnerable, at their weakest point of physical and often emotional or psychological fracture. our judgement and support can be the difference between rehab success and failure and our reasoning needs to align with this, not excessively pushing the patient to bend to our will but instead allowing them to feel supported through this difficult period (16).

nov/Dec 2012: ProGreSS wIthout PaIn during this time my training progressed well, both in the strength work and the running sessions.

running sessions these included pyramid, speed endurance training and timed 200m session in less than 27/26 seconds (4 reps) (table 1: Nov/dec 2012).

Strength training this was done every other day until a 24

peak was reached, and then maintained with at least 2 sessions per week geared towards lower-limb strength (table 1: November/december 2012).

things to note At this point in time, as there was no pain throughout the day, especially in the morning, there was no real need for any other interventions discussed in Part 1. In many cases most patients would have stopped their involvement with practitioners at the point where the pain had decreased, however, I was still well aware that astute and diligent management was needed to ensure a return to full fitness. currently my training is going very well, my coaches are happy with the return of fitness, form and confidence, and I will continue to train hard and work towards my goal.

MovInG forwarDS: DecISIon MakInG for clInIcIanS In Parts 1 and 2 we have discussed the specifics of the case study, but now we will discuss how we can use some of this information based on research and personal experience with patients in the future.

aSSeSSMent Firstly, an assessment is needed to decide on the nature of the pathology, and questionnaires, such as those offered by cook et al. (2) and the victorian Institute of sports Assessment-Achilles (vIsA-A) questionnaire, have shown to be useful offering you a measurable score to which you can refer back to and track progress. the lower the score the greater the extent of the injury; however, further questions need to be asked, such as: 1. Where is the site of pain? Is it: n Insertional? n distal 1/3? n Proximal 1/3? n Paratenon?

2. Is there a neurological involvement?

For example, sciatic–tibial–sural nerve divisions (see Michael shacklock, clinical Neurodynamics, Further Resources 4).

3. What is the context of the patient?

consider and assess: n Age n Foot biomechanics n Footwear n Lower-limb strength and biomechanics n training constraints.

age Age plays a role as tendon tensile strength decreases over time (1).

foot biomechanics A lateral heel strike induces a whipping action of the Achilles if excessive pronation occurs (1,2). the other linked biomechanical issue is said to be forefoot varus.

footwear this is contentious within the world of running and the relevant literature: in my case I found that a flatter shoe allowed my foot ‘to do what it needed to do’. However, this does not deny the need for orthoses in patients with this issue. It is an interesting paradox that needs further discussion and consideration (2).

lower-limb strength and biomechanics Assessing the patient using activities such as the single-leg squat using the coaches eye app for ipad (Further Resources 5) can give you information regarding hip, knee and ankle alignment in addition to relevant strength of stabiliser muscles associated with these joints. If it were the case that any part of the system is incapable of distributing loads during running and jumping, then force exerted on the body would be transferred to another proximal site. this excessive force could cause increased micro-trauma to the tissues.

training constraints this could be another pivotal factor in relation to lower-limb strength and was discussed at length by specialists on a recent (2012) bbc Panorama programme regarding sports drinks, supplements and footwear types (Further Resources 6).

If the training demands exceed the tissues’ ability to recover and heal then the body would reach a breaking sportEX dynamics 2013;38(October):18-26

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point where injury would ensue. this needs to be closely monitored with either parents and/or coaches, so communication with the individuals involved regarding the level of training the athlete undertakes is vital.

next StePS once you have the relevant information from the questions above, you can decide what to do next. Management during the acute phase either at initial onset or during a reactive phase of an ongoing pathology is important.

acute phase and daily pain n Rest; minimum of 2 weeks from aggravating activity n Kinesio taping combined with heel raise to offload tendon n Ice; 10 minutes every 2 hours.

Post-acute phase n Rest n Kinesio taping and heel raise; minimum of 4mm n Massage and deep transverse frictions n exercise prescription.

exercISe PreScrIPtIon this is based on what they’re capable of doing initially but it may take 2–4 weeks to decrease the discomfort.

Remember from Part 1, I had done a great deal of walking without any other exercise for a period of over 3 weeks.

In other patients you could prescribe a shorter period of rest with targeted strength exercises.

Research discussed previously showed that strength training has a significant effect on tendon histology, health and pain, and, based on the scores and measures above but guided by pain, you can have them doing exercise early enough in the rehabilitation process. one thing I would note that isn’t often considered: include knee flexion–extension exercises as part of the exercises. this is because the gastrocnemius is bi-articular in nature and in closed kinetic chain movements it is involved in both knee flexion eccentrically and knee extension concentrically. so if we look to isolate this complex we need to not only do the strength training with a straight leg, as www.sportEX.net

many standard Achilles programmes suggest (ie. on a step dropping the heel below with a straight leg) but consider also the options of alternate exercises or modifications of standard exercises to use.

Additionally if you wish to include full kinetic chain exercises, squats and single-leg squats can be a starting point if you include a heel raise. bilateral squats would allow for higher loading through a more functional motion while attempting to train other muscles and tissues. targeting apparent weaknesses associated with any dysfunction found would also be recommended, ie. a weak gluteal complex could be combated by single-leg squats with support and/or video feedback if necessary (coaches eye app for ipad; Further Resources 5) to allow for learning, single-leg deadlifts and single-leg glute bridge exercises could be used in addition to training the quadriceps. If this primary knee extensor is weak in comparison to necessary force loading then it could overload gastrocnemius and therefore overload the Achilles tendon. exercises to consider include: n Knee flexion–extension in calf exercises n Heavy loaded exercises – reps of 5–8 for tendon loading n squats – bilateral for heavy loading n unilateral exercises n target weakened areas, ie. quadriceps. over time you would then use the assessment scales suggested above and, most importantly, pain as a gauge in respect to exercise capability in order to, day-by-day and week-byweek, gradually increase the exercise difficulty and intensity towards sportsspecific training activities.

In SuMMarY the lesson that I learned on my rehabilitation journey is that management of long-term tendon complaints is multifactorial and complex. the patient’s context (including movement/performance capabilities) shouldn’t be disregarded, and a clear examination is needed 25

of what is lacking and what is then necessary to overcome those short comings in order to return to function again. ultimately the change in training emphasis, footwear and heavy strength training for gastrocnemius and soleus were the most significant factors in my recovery. the points that will shape my thinking process in the future are: n Allow time for rest n Recovery isn’t quick: up to, or more than, 6 months n strength training is necessary n Identify and correct dysfunction n once pain decreases, start to train movement n goal setting for long-term progression n communication with coaches and or parents n Manage training load – periodisation. references 1. Kader d, saxena A, et al. Achilles tendinopathy: some aspects of basic science and clinical management.

British Journal of sports medicine 2002;36:239–249 2. cook JL, Khan MK, Purdam c.

Masterclass: Achilles tendinopathy. manual Therapy 2002;7(3):121–130 3. Magnussen RA, dunn WR, thomson Ab. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. clinical Journal of sports medicine 2009;19:54–64 4. Alfredson H, Pietila t, et al. Heavy-Load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.

American Journal of sports medicine 1998;26(3):360–366 5. Mundermann A, Nigg bM, et al. Foot orthotics affect lower extremity kinematics and kinetics during running. clinical Biomechanics 2003;18:254–262 6. shalabi A, Kristoffersen-Wilberg M, et al. eccentric training of the gastrocnemius complex in chronic Achilles tendinopathy results in decreased volume and intratendinous signal as evaluated by MRI. The American Journal of sports medicine 2004;32(5):1286–1296 7. Andres bM, Murrell gAc. treatment of tendinopathy. clinical orthopedic related research 2008;466:1539–1554 8. Zajt-Kwiatkowska J, Rajkowska-Labon e, et al. Application of kinesio taping for treatment of sports injuries. Research yearbook 2007;13(1):130–134 9. Lee JH, yoo Wg. treatment of Achilles tendon pain by kinesio taping in an amateur badminton player. physical Therapy in sport 2012;13(2):115–119 26

10. Paolini J A, orchard JW. the use of therapeutic medications for soft tissue injuries in sports medicine. the Medical Journal of Australia 2005;183(7):384–388 11. Magra M, Maffulli N. Nonsteroidal anti-inflammatory drugs in tendinopathy: friend or foe. clinical Journal of sports medicine, 2006;16:1–3 12. Norregaard J, Larsen cc, et al. eccentric exercise in treatment of Achilles tendinopathy. scandinavian Journal of medicine & science in sports 2007;17:133–138 13. Maffulli N, sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. Journal of the Royal society of medicine 2004;97:472– 476 14. Lee ssM, Piazza sJ. built for speed: musculoskeletal structure and sprinting ability. The Journal of experimental Biology 2009;212:3700–3707 15. schleip R, Muller dg. training principles for fascial connective tissues: scientific foundation and suggested practical applications. Journal of Bodywork and movement Therapies 2013;17(1):103–115 16. Nicholas MK, Linton sJ, et al. early identification and management of psychological risk factors (yellow flags) in patients with low back pain: a reappraisal. physical Therapy 2011;91:737–753.

DISCUSSIONS

further reSourceS 1. Kinesio taping Association uK (www.kinesiotaping.co.uk) 2. Nike Free Run+ 2 shoes (http://spxj.nl/15kvefe/) 3. Physioedge podcasts – Running and footwear (http://spxj.nl/19JskbM) 4. clinical neurodynamics: A new system of neuromusculoskeletal treatment by Michael shacklock. Butterworth-heinemann 2005.

IsbN 0750654562 (£42.11) buy from Amazon http://spxj.nl/13WqerZ. 5. coach’s eye ipad app, Apple itunes app store (http://spxj.nl/12Wb2ps) 6. bbc Panorama documentary ‘the truth about sports products’ (http://spxj.nl/1c5M0gL).

ThE auThOr Th Mike’s work is multifactorial, after completing an undergrad degree in sports rehabilitation at Salford university and later an MSc at Manchester Metropolitan university. he now works in elite rugby with Macclesfield ruFC, he is clinical director at Sports rehab uK based in Manchester, Wilmslow and Warrington, and teaches part time at Salford university. he is also set to compete for his athletics club this year in the 200m and 4×100m relay events.

n consider the nature of injury: how do we decide if the patient is in an acute reactive state or a ‘chronic’ degenerative state? n What interventions are most used in clinical practice with this form of pathology? n Is pronation good or bad? Is it necessary or part of the problem? n Which is more important: contact time, cadence or stride length? try to rank these in order.

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highlights

n functional screening of a semi-profe ssional footballer

n the brain: movement & pain n preDictors in pfps n physiotherapy anD pilates for Dressage riDers

n sleep wake techniques for elite athletes n research analysis