sportEX Medicine Journal Issue 61 - July 2014 by Co-Kinetic

ISSUE 61 July 2014 ISSN 1471-8138

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■ HIP JOINT AND PELVIC GIRDLE ANATOMY REFRESHER

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■ COUNTDOWN TO 2012 ■ SPORTS INJURIES REFRESHER: THE SHOULDER ■ AN OVERVIEW OF THORACIC OUTLET SYNDROME ■ THE APPLICATIONS OF IMAGEGUIDED THERAPY

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■ INJURY PREVENTION IN FOOTBALLERS ■ OVERUSE INJURIES IN YOUNG ATHLETES

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■ INJURIE FOOTBALLERS FEMALE SHOULDER ■ CASE STUDY: INSTABILITY IN SPORT FRACTURES ■ STRESS IS: ■ CASE ANALYS N OF A MEDIAL REHABILITATIOLIGAMENT TEAR COLLATERAL

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■ CHRON OME SYNDR -ACETABULAR ■ FEMEROEMENT SYNDROME IMPING KNEE YOUR OWN ■ GROW AGE CARTIL ESSION AL COMPR ■ ARTERI OMES AT THE STIC SYNDR - DIAGNO SHOULDER UVRES ARM MANOE

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■ COUNTDOWN TO 2012 ■ SPORTS INJURIES REFRESHER: THE SHOULDER ■ AN OVERVIEW OF THORACIC OUTLET SYNDROME ■ THE APPLICATIONS GUIDED THERAPY OF IMAGE-

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■ SPORTS INJURIES REFRESHER: THE ELBOW AND WRIST JOINT ■ WHAT’S THE BEST WAY TO ACTIVATE THE DEEP ABDOMINALS?

■ AN OVERVIEW OF TENDON INJURIES

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■ THE ROLE OF EXERCISE IN PREVENTION OF HAMSTRIN THE INJURIES G

■ CASE STUDY: SLAP II REPAIR ■ CHRONIC PAIN DISCUSSION

■ KNEE ARTICLUL AR CARTILAG REPAIR AND E ATHLETES ■ ARTERIAL COMPRESSION SYNDROMES AT THE SHOULDE R

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■ SPORT AND EXERCISE BALANCE REPORTS ■ GET THE BALANCE RIGHT – THE STAR EXCURSION BALANCE TEST AND SINGLELEG DYNAMIC BALACE TRAINING ■ COMMON SPORTING WRIST INJURIES

■ OSTEOPATHY IN SPORT ■ MEDICAL ASPECTS OF PARALYMPIC SPORT ■ PODIATRY IN SPORT PART 1: WEIGHTBEARING AND NON WEIGHTBEARING ASSESSMENTS ■ PODIATRY IN SPORT PART 2: GAIT ANALYSIS

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■ INJURIES SUSTAINED FEMALE FOOTBALLERSBY ■ CASE STUDY: SHOULDER INSTABILITY

■ STRESS FRACTURES IN SPORT ■ CASE ANALYSIS: REHABILITATION OF A MEDIAL COLLATERAL LIGAMENT TEAR

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■ IDENTIFYIN G SHOULDE R PAIN ■ ASSESSM ENT SACROILIAC OF THE JOINT ■ CASE STUDY: SI JOINT PAIN ■ MANAGIN G CONCUSS ION IN SPORT

HIGHLIGHTS ■ PLATELET-RICH PLASMA – ACTIONS AND APPLICATIONS

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■ GROIN AND HIP QUANDARIES

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■ MINDFULNESS & TEAMWORK ■ RESEARCH ANALYSIS

■ INJURIES SUSTAINED BY FEMALE FOOTBALLERS

■ CASE STUDY: SHOULDER INSTABILITY ■ CASE ANALYSIS: REHABILITATION OF A MEDIAL COLLATERAL LIGAMENT TEAR

■ STRESS FRACTURES IN SPORT

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■ IMAGING AND IMAGE-GUIDED THERAPY ■ VITAMIN D: AN UPDATE FOR THE SPORTS MEDICINE PRACTITIONER ■ SPORTS INJURIES: DIAGNOSIS AND TREATMENT ■ STRESS FRACTURES IN ACADEMY FOOTBALL

■ STRESS FRACTURES IN SPORT

■ CASE ANALYSIS: REHABILITATION OF A MEDIAL COLLATERAL LIGAMENT TEAR

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■ CHRONIC PAIN IN SPORT

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■ CHRONIC COMPARTMENT SYNDROME ■ FEMERO-ACETABULAR IMPINGEMENT SYNDROME ■ GROW YOUR OWN KNEE CARTILAGE ■ ARTERIAL COMPRESSION SYNDROMES AT THE SHOULDER - DIAGNOSTIC ARM MANOEUVRES

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■ LATEST RESEARCH ■ RESEARCH ANALYSIS

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■ SPORTS TRIAGE MEDICAL SCREENING CONTINUUM ■ THE TENDINOPATHY ■ SHOULDER IMPINGEMENT

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■ LATEST RESEARCH NEWS ■ RESEARCH ANALYSIS ■ PSYCHOLOGY OF SPORTS INJURIES ■ HAMSTRING INJURIES IN FOOTBALL

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■ LATEST RESEARCH ■ RESEARCH ANALYSIS

■ THE BRAIN: MOVEMENT & PAIN PART 2 ■ ACUTE SOFT TISSUE INJURY AND P.R.I.C.E

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■ SPRINT-RELATED HAMSTRING INJURIES

■ SLEEP WAKE TECHNIQUES FOR ELITE ATHLETES ■ RESEARCH ANALYSIS

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PLASM CATIONS LET-RICH ■ PLATE NS AND APPLI S ACTIO QUANDARIE AND HIP WORK ■ GROIN & TEAM ULNESS ■ MINDF SIS RCH ANALY ■ RESEA ■ SPORT AND EXERCISE BALANCE REPORTS ■ GET THE BALANCE RIGHT – THE STAR EXCURSION BALANCE TEST AND SINGLELEG DYNAMIC BALACE TRAINING

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■ COMMON SPORTING WRIST INJURIES

■ MEDIA L STRESS TIBIAL SYNDROME ■ CLINIC AL REASO FOR STUDE NING NTS ■ MUSC LE INJUR YOUR TREAT Y: ENSUR ING MENT IS BASED EVIDENCE■ THE SPINE : A REFRE ASSESSMEN T AND SHER TO DIAGNOSIS

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■ THE BRAIN: MOVEMENT & PAIN ■ PREDICTORS IN PFPS ■ PHYSIOTHERAPY AND PILATES FOR DRESSAGE RIDERS

■ SPORT AND EXERCISE BALANCE REPORTS ■ GET THE BALANCE RIGHT – THE STAR EXCURSION BALANCE TEST AND SINGLELEG DYNAMIC BALACE TRAINING ■ COMMON SPORTING WRIST INJURIES

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■ IMAGING AND IMAGE-GUIDED THERAPY ■ IMAGING ■ VITAMIN D: AN UPDATE FOR THE SPORTS MEDICINE THERAPY AND IMAGE-GUIDED PRACTITIONER ■ VITAMIN ■ SPORTS INJURIES: DIAGNOSIS FOR THE D: AN UPDATE SPORTS PRACTITIONER AND TREATMENT MEDICINE ■ SPORTS ■ STRESS FRACTURES IN INJURIES: AND TREATM ACADEMY FOOTBALL DIAGNOSIS ENT ■ STRESS ACADEM FRACTURES IN Y FOOTBA LL

■ ACC - A ESSORY CAS E REP NAVICU ■ ASS ORT LAR A KINESSING EMA PFPS ■ REH TIC PAR FUNCTIO ADIGM N: ATH ABILITA LETIC TION ■ THE SHO OF THE ULD ER BAR (RE-) EVO LUT INJU EFOOT RY RIS RUN ION OF K NING AND

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promoting excellence in sports medicine

contents july 2014 Issue 61 Publisher/editor Tor Davies 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 Dr Joseph Brence, DPT, coMT, FaaoMPT, Dac Technical aDvisors

steve aspinall Bob Bramah Paula clayton stuart hinds rob granter Michael nichol Joan Watt Prof greg Whyte

Bsc (BasraT), Msc McsP, MsMa Msc, Fa Dip, Mast sTT Dip ssT Dip ssT Bsc (BasraT) McsP, MsMa PhD, Msc, Bsc

is published by Centor Publishing ltd 88 Nelson Road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 www.sportex.net

Welcome

jul 2014

so, we’ve just completed our 15th year of publishing and on pages 32-34 i have taken time to reflect on what that’s meant for us at sporteX. in this editorial i’d like to look at what it’s meant for our readers. in December 1998 i vividly remember sitting at the top of the stairs in my house talking on the phone to one of my then-medical advisors about my concerns on the politics of sports medicine and the possible consequences on my soon-to-be fledgling journal. True to his role, my advisor very wisely advised me to stay out of the politics and in his words “just concentrate on producing a bloody good practical journal on sports medicine”, and that’s exactly what i’ve done. But i can’t help but look back and feel that politics and territory wars between professional groups have held us back as a broader physical therapy profession, and that makes me sad, particularly as i can’t see a light at the end of the tunnel. Physical therapy is disunited, it doesn’t matter if it’s sports therapists, sports rehabilitators, physiotherapists, chiropractors, or osteopaths, ultimately though we’re all physical therapists each with different strengths both professionally and personally and i can’t help feeling that all of us, including our professional associations, would be better served figuring out how we can work together to share expertise and knowledge in unity, rather being determined to plough our own furrows. My hope for the next 15 years is that we find a much better way of coexisting than we have for the last 15 because ultimately it will only be us as a profession that suffers. Tor davies, physio-turned publisher and sporteX founder tor@sportex.net

oTHeR TITles IN ge THe sPoRTeX RANge sporteX dynamics prom ing best ot prac - issn 1744-9383 sports tice Written specifically for care professionals working with a wide variety of athletes and sports people to help them get the most out of their athletic performance - personal annual subscription from £54, practice subscription from £94 in

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4 journal watch 8 Helping hands 13 ACl reconstruction 21 Adolescent PFPs

The latest key research from this quarter good social support improves rehab a case study of acl rehabilitation

considerations for treating adolescents

CoNTeNTs 26 Tendinopathy 32 sporteX milestones

UTc: a window into tendon health a look back over the last 15 years of sporteX

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.

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

AN EMERGING ADOLESCENT HEALTH RISK: CAffEINATED ENERGy DRINK CONSuMpTION pATTERNS AMONG HIGH SCHOOL STuDENTS. Azagba S, Langillec D, Asbridge M. preventive Medicine 2014;62:54–59

DOING AT LEAST TwO AND A HALf HOuRS Of vIGOROuS ExERCISE EACH wEEK CuTS THE CHANCE Of DEvELOpING fLu. Results of an online survey run by the London School of Hygiene and Tropical Medicine. For 5 years the National Flu Survey have produced an annual report about influenza. They track as much detail as possible about who does and does not get flu and this survey is especially relevant as the data comes direct from the public rather than via GPs or hospitals – given that many people with flu don’t visit a doctor so don’t feature in traditional flu surveillance. Around 4,800 people took part in this year’s UK online survey. Overall flu rates have been relatively low this winter; however, the headline grabber was the correlation between vigorous exercise and a reduction of around 10% in the chances of becoming ill. Moderate exercise made no difference.

This was a survey of 8,210 students in grades 7, 9, 10 and 12 attending public schools in Atlantic Canada. Correlates of energy drink use patterns, including substance use, sensation seeking, risk of depression and socioeconomic status were collected. Sixty-two percent reported consuming energy drinks at least once in the previous year, with about 20% reporting use once or more per month. Sensation seeking, depression, and substance use were all higher among energy drink users relative to non-users, and in higher frequency users relative to lower frequency users. Consumption was higher for males relative to females.

sportEX comment

This report comes from a web site, which is increasingly the place you read scientific reports first, especially if the daily press pick it up and it trends on social media. Anyone can take part in the survey. Log on at www.flusurvey.org.uk/

Ah! But what comes first, the energy drink leading to the negative health markers or those with the negatives seeking solace in an energy boost.

pREvALENT v vALENT MORpHOMETRIC vERTEBRAL fRACTuRES IN pROfESSIONAL MALE RuGBy pLA pLAyERS. Hind K, Birrell f, Beck B. pLoS ONE 2014;9(5):e97427 Ninety-five professional rugby league (n = 52) and union (n = 43) players average age 25.9 (SD ± 4.3) years; BMI: 29.5 (SD ± 2.9) kg.m2) received a vertebral fracture assessment (VFA), and a total body and lumbar spine dual energy X-ray absorptiometry scan (DXA). One hundred and twenty vertebral fractures were identified in over half of the sample by VFA. Seventy-four were graded mild (grade 1), 40 moderate (grade 2) and 6 severe (grade 3). Multiple vertebral fractures (≥2) were found in 37 players (39%). There were no differences in prevalence between codes, or between forwards and backs. The most common sites of fracture were T8 (n = 23), T9 n = 18) and T10 (n = 21). The mean lumbar 4

spine bone mineral density Z-score was 2.7 (SD ± 1.3) indicating high player bone mass in comparison with age- and sex-matched norms.

sportEX comment The modern professional rugby player spends most of his time doing power training. The result of this is that when two of them come together in a tackle the forces are similar to those generated in a car crash. Another study we report here stresses the dangers of scrums. Put that one together with this and you have to ask the question, “Is rugby of either code just too dangerous in its present form?” sportEX medicine 2014;61(July):4-7

JOURNAL WATCH

Journal watch IMAGING AND CLINICAL TESTS fOR THE DIAGNOSIS Of LONG-STANDING GROIN pAIN IN ATHLETES. A SySTEMATIC REvIEw. Drew MK, Osmotherly pG, Chiarelli pE. physical Therapy in Sport 2014;15(2):124–129 An initial literature search came up with 577 journal articles that were about diagnostic studies relating to athletic groin pain, professional or semi-professional athletes, symptoms lasting for more than 6 weeks, and not limited by age or gender. Five studies met all requirements. A variety of tests were identified. Sensitivity and specificity of clinical tests ranged between 30 and 100% and 88 and 95% respectively, with negative likelihood ratio of 0.15–0.78 and positive likelihood ratios of 1.0–11.0. Sensitivity and specificity of investigations (MRI, herniography, and dynamic ultrasound) ranged between 68% and 100% as well as 33% and 100% respectively with negative likelihood ratios between 0 and 0.32 and positive likelihood ratios between 1.5 and 8.1.

sportEX comment There are lots of tests, none of which stands out from the others.

COMpARATIvE CERvICAL pROfILES Of ADuLT AND uNDER-18 fRONT-ROw RuGBy pLAyERS: IMpLICATIONS fOR pLA pLAyING LA LAy pOLICy. Hamilton Df, Gatherer D, et al. BMJ Open 2014;4:e004975 Thirty high-performance under-18 players and 22 adult front-row rugby players were tested to compare isometric neck strength, height, weight and grip strength. The youth players demonstrated the same height and grip strength as the adult players; however, the adults were significantly heavier and demonstrated substantially greater isometric strength. Only two of the ‘elite’ younger players could match the adult mean cervical isometric strength value. In contrast to school-age players in general, grip strength was poorly associated with neck strength in front-row players; instead, player weight and the number of years’ experience of playing in the front row were the only relevant factors in multivariate modelling of cervical strength.

sportEX comment If older youths and adults are to play together, such findings have to be noted in the development of age-group policies with particular reference to the scrum. OK, that’s the official line but how about this. Follow Rugby League and scrap scrums. It won’t kill the game but it might stop killing a few people’s lives. www.sportEX.net

INfLuENCE Of ANKLE INJuRy ON MuSCLE ACTIvATION AND pOSTuRAL CONTROL DuRING BALLET GRAND pLIé. Lin C-w, Su f-C, et al. Journal of Applied Biomechanics 2014;30(1):37–49 Thirteen injured dancers and 20 uninjured dancers performed a 15s grand plié consisting of lowering, squatting and rising phases. The lower extremity motion patterns and muscle activities, pelvic orientation and centre of pressure (COP) excursion were measured. In addition, a principal component analysis was applied to analyse waveforms of muscle activity in bilateral medial gastrocnemius, peroneus longus and tibialis anterior. The findings showed that the injured dancers had smaller pelvic motions and COP excursions, greater maximum angles of knee flexion and ankle dorsiflexion as well as different temporal activation patterns of the medial gastrocnemius and tibialis anterior.

sportEX comment This is another obvious one but nevertheless it’s good to have a piece of research to prove that injuries affect other parts of the kinetic chain.

IS ONE BETTER THAN ANOTHER? A RANDOMIzED CLINICAL TRIAL Of MANuAL THERApy fOR pATIENTS wITH CHRONIC NECK pAIN. pérez HI, perez JLA, et al. Manual Therapy 2014;19(3):215–221 A total of 51 subjects with mechanically reproducible chronic neck pain (CNP) received either high velocity, low amplitude (HVLA), mobilisation (Mob) or sustained natural apophyseal glide (SNAG). Outcome measures were the Visual Analogue Scale, Neck Disability Index, Global Rating of Change and Cervical Range of Motion. Data from outcomes at baseline, at the end of treatment and 1, 2 and 3 months after treatment were compared. No significant differences were found between HVLA, Mob and SNAG at the end of treatment and during the follow-up in any of the analysed outcomes. There were no differences in satisfaction for all techniques.

sportEX comment Our Guru-led profession and each of these techniques has its spiritual leader and many disciples however it seems in reality that they are all the same. 5

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

THE EffECT Of DRy NEEDLING ON pAIN, pRESSuRE pAIN THRESHOLD AND DISABILITy IN pATIENTS wITH A MyOfASCIAL TRIGGER pOINT IN THE uppER TRApEzIuS MuSCLE. ziaeifar M, Arab AM, et al. Journal of Bodywork and Movement Therapies 2014;18(2):298–305 Thirty-three patients with trigger points (TrP) in the upper trapezius (UT) muscle participated in this study. The treatment group (n = 17) received a trigger point compression technique (TCT) onto the TrP. The experimental group received dry needling (DN). Pain intensity and pressure pain thresholds (PPT) were assessed for both groups before and after the treatment sessions. In addition, the Disability of Arm, Hand, and Shoulder (DASH) was administered.

Statistical analysis revealed a significant improvement in pain, PPT and DASH scores after treatment in the experimental (DN) and standard (TCT) group compared with before treatment. There were significant differences between the DN and TCT groups on the post-measurement VAS score. There was no significant difference between the two groups on the postmeasurement score of the PPT and DASH.

sportEX comment The simple conclusion is that dry needling seems to work for pain and function.

R RELATIONSHIpS BETwEEN LOwER LIMB BIOMECHANICS DuRING SINGLE LEG SquAT wITH RuNNING AND CuTTING TASKS. Alenezi f, Herrington L, et al. British Journal of Sports Medicine 2014;48:560-561 Fifteen recreational athletes, seven male and eight female (age 25.2 ± 5.1 years; height 1.6 ± 7.38 m; and mass 67.6 ± 10.93 kg), were recorded doing single leg squats (SLS) with running (RUN) and cutting (CUT) tasks using a 10-camera motion analysis system and a force platform. Visual 3D was used to process all data. The SLS was strongly correlated to run in knee valgus and hip internal rotation, and showed moderate correlation with knee external rotation SLS and CUT were moderate to strongly correlate to each other in knee valgus, knee flexion, and hip internal rotation and moderately in hip flexion.

sportEX comment This means that the biomechanics of single leg squats relate to the performance of other tasks. In those individuals displaying poor joint motion during SLS this is likely to be predictive of poor motion during running and cutting. What this means in practice is that assessing a person’s joint angles during the squat suggests you don’t need to do it during other tasks that are harder to capture. It might also be a screening tool for potential injury. DO MRI AND uLTRASOuND Of THE ANTERIOR pELvIS CORRELATE wITH, OR pREDICT, yOuNG fOOTBALL D pLAyERS’ CLINICAL fINDINGS? A 4-yEAR pROSpECTIvE STuDy Of ELITE ACADEMy SOCCER pLAyERS. Robinson pA, Grainger AJ, et al. British Journal of Sports Medicine 2014;doi:10.1136/bjsports-2013-092932 Thirty four male athletes (mean age 16.5 years) underwent clinical examination, a history/symptom questionnaire, ultrasound and MRI of the anterior pelvis. They completed an annual questionnaire. Ultrasound with MRI was performed every 18 months looking for abnormalities, which included pubic bone, capsule and tendon oedema and if scores correlated with symptoms and presence or absence of previous injuries. Over the 4 years the participant numbers fell from 34 to 22. None of the withdrawals were due to groin injury. At the start no athletes had undergone previous hip or pelvic surgery. On MRI, pubic bone oedema, secondary cleft,

capsule/tendon oedema and enhancement did not differ substantively between players with and without history of previous injury. κ Analysis for MRI scoring showed excellent agreement for pubic bone marrow oedema, secondary cleft, capsule/tendon oedema and enhancement. On ultrasound, inguinal wall motion and adductor tendinopathy did not differ substantively between players with and without history of previous injury. Stability of imaging assessments over time showed no consistent difference.

sportEX comments Great idea but, no, the scans don’t correlate with or predict injury. Pubic bone marrow and parasymphyseal findings (cleft, capsule/tendon oedema) on MRI or inguinal canal ballooning on ultrasound were frequently found in asymptomatic athletes but it still didn’t predict an injury.

sportEX medicine 2014;61(July):4-7

JOURNAL WATCH

A ANTERIOR CRuCIATE LIGAMENT INJuRy ALTERS pRE-INJuRy LOwER ExTREMITy BIOMECHANICS IN THE INJuRED AND uNINJuRED LEG: THE JuMp-ACL STuDy. Goerger BM, Marshall fw, et al. British Journal of Sports Medicine 2014;doi:10.1136/bjsports-2013-092982 Baseline unilateral lower extremity biomechanics were collected on the dominant leg of participants without anterior cruciate ligament (ACL) injury when they entered the Joint Undertaking to Monitor and Prevent ACL (JUMP-ACL) study. Thirty-one participants with subsequent ACL injury, reconstructive surgery (ACLR) and full return to physical activity completed repeat, follow-up biomechanical testing, as did 39 uninjured, matched controls. Not all injured participants suffered injury to the dominant leg, requiring separation of those with ACL injury into two groups: ACLR-injured leg group (n = 12) and ACLR-uninjured leg group

(n = 19). The landing biomechanics of these three groups were compared (ACLR-injured leg, ACLR-uninjured leg, control) before ACL injury (baseline) with biomechanics after ACL injury, surgery and return to physical activity (follow-up). ACL injury and ACLR altered lower extremity biomechanics, as both ACLR groups demonstrated increases in frontal plane movement (increased hip adduction and knee valgus). The ACLR-injured leg group also exhibited decreased sagittal plane loading (decreased anterior tibial shear force, knee extension moment and hip flexion moment). No high-risk biomechanical

RANDOMIzED TRIAL Of TRIGGER pOINT ACupuNCTuRE TREATMENT fOR CHRONIC SHOuLDER pAIN: A pRELIMINARy STuDy. Itoh K, Saito S, et al. Journal of Acupuncture and Meridian Studies 2014;7(2):59–64 Fifteen women and three men; aged 42–65 years with non-radiating shoulder pain for at least 6 months and normal neurological findings were randomised into two groups, each receiving five treatment sessions. The trigger point (TrP) group received treatment at trigger points for the relevant muscle. The other group received sham (SH) acupuncture treatment on the same muscles. Outcome measures were pain intensity measured by VAS and shoulder function via a Constant–Murley Score (CMS). Significant changes were noted in with pain intensity decreased and shoulder function increased between pre-treatment and 5 weeks after TrP. A comparison using the area under the outcome curves demonstrated a significant difference between groups. Compared with SH acupuncture therapy, TrP therapy appears more effective for chronic shoulder pain.

sportEX comment Normally we get on a soapbox about poor sham treatment in acupuncture studies. This one, however, was quite clever. They literally blinded the participants by giving them masks. They used short needles that didn’t penetrate the skin. They put the guide tube against the skin and tapped it so the patient felt the initial sharpness and 10min later pretended to remove the non-existent needles even dropping needles into a sharps box so that the patient heard the sound of the discarded needle. Oh and the ‘real’ treatment worked.

www.sportEX.net

changes were observed in control group participants.

sportEX comment This is one of those ‘of course it does’ studies. Mess about with the knee, or any joint for that matter, and there will be alterations in the kinetic chain somewhere. Nice to have proof though and if you want to prevent further injury you need to do something about it.

Eff EffECTS Of KINESIOTApING ON fOOT pOSTuRE IN pARTICIpANTS wITH pRONATED fOOT: A quASI-RANDOMISED, DOuBLE-BLIND STuDy. Luque-Suarez A, Gijon-Nogueron G. physiotherapy 2014;100(1):36–40 Sixty-eight participants with pronated feet were enrolled into a study where they were allocated into either an experimental kinesiotaping group or a sham taping group. Measures were collected by a blinded assessor at baseline, and 1min, 10min, 60min and 24h after taping. The primary outcome was a total Foot Posture Index (FPI) score and a rear-foot FPI score. The ‘real’ tape was applied in a single strip, 20cm in length, from the fibula at the lateral malleolus, around the calcaneus, with 100% stretch, to the middle third of the medial tibia. The ‘sham’ was to apply tape to the same place but without the stretch. There were no significant differences in total FPI score between kinesiotaping and sham taping at any time point. Similarly, there were no significant differences in rearfoot FPI score, apart from at 60min follow-up when the difference between groups was significant but the effect size was very small.

sportEX comment The only useful thing in this study is the use of the Foot Posture Index. It’s a great tool to quickly get an idea about foot pronation and supination. You can download it free here. The best thing to do is to cut out and laminate the example pictures used for scoring so you can actually hold them against your patient’s foot and make a comparison. You can download it free here.

BY Dale ForsDYke Msc, MsMa, MssT anD aDaM GleDhill Msc

BackGrounD Sustaining an injury and the subsequent rehabilitation journey is an arduous and stressful challenge for any athlete, regardless of level, age or gender. Previously it has been reported that injured athletes typically suffer with high levels of re-injury anxiety, low self-efficacy, feelings of isolation, self-presentational concerns, and pressure for a timely return to play (1). Whereas before injury an athlete may feel able to cope with stressors related to their sport, after sustaining an injury and progressing to full return-to-sport it is common for athletes to require extra support to cope effectively at a time of psychosocial upheaval (2). There is a growing body of research suggesting that athletes with an effective quantity and quality of social support will successfully respond to the challenges of rehabilitation and as such enhance their recovery (2,3). Conversely it can be assumed that a lack of social support has the opposite relationship. Feelings of alienation and isolation from coaches, teammates, and training partners may occur (4), as recovering athletes become almost ‘removed’ from their usual training and competition venues and alternatively spend more time in clinical rehabilitation settings as shown in Figure 1 (5). The consequences related to this may partly explain the frequently cited poor return to sport rates; especially in those that have sustained a severe and/or slow healing injury (eg. 6,7). Most definitions of social support relate to key terms should as feeling loved, belonging, assured, understood, connected and having something to rely upon in times of adversity. Within a sports injury context social support can be defined as ‘a form of interpersonal connectedness which encourages the constructive expression of feelings, provides reassurance in times of doubt, and leads to improved communication and understanding’ (8). Throughout the rehabilitation process it is common for the athlete to report concerns over social support and that, whereas effective social support is a coping 8

Reaching out foR a helping hand

The role of social supporT in sporTs injury rehabiliTaTion Psychosocial factors have an influencing role in sports injury risk and the rehabilitation process, and the ability of an athlete to cope with elevated stress can determine injury rate and affect rehabilitation outcomes. Sports injury practitioners are ideally placed to provide quality social support to injured athletes and this article will review the role of social support within the rehabilitation process to raise awareness and stimulate reflection on our current practice with injured athletes. resource, ineffective social support can be an additional stressor. At best, social support is a form of resource provision arising from the valued interpersonal connections (such as between patient and practitioner) and its availability is consistently associated with positive health outcomes (9). A note of caution is that there may well be a difference between the provider’s intentions behind and the athlete’s perceptions of social support, so including questions during athlete screening may prove

worthwhile. This is because perceived social support is considered to enhance psychological well-being (10). If ever in doubt, an athlete’s perception of social support can be measured using the Social Support Inventory for Injured Athletes (SSIIA) (11).

how Does social supporT work? Of particular interest to sports injury practitioners would be whether and how social support has a role in sportEX medicine 2014;61(July):8-12

evidence infoRmed pRactice

SOCIAL SUPPORT nEEDS ARE DynAMIC: ChAnGInG In InTEnSITy, DIRECTIOn AnD TyPE ThROUGhOUT PhASES OF InjURy REhABILITATIOn

Technical coaches

performance coaches

injured athlete

athlete/team

(b)

Technical coaches

performance coaches

www.sportEX.net

Buffering

adaptive emotional, cognitive and behavioural reponse to the rehabilitation process

Medical team

Figure 1: (a) Pre-injury team dynamic and (b) post-injury team dynamic showing the injured athlete isolated from the usual team and support staff. (D. Forsdyke & A. Gledhill, 2014)

reducing the distress experienced by injured athletes, increasing athlete motivation throughout rehabilitation, and improving treatment adherence (12). There are two principle concepts underpinning how social support may influence sports injury recovery: (1) the buffering effect approach; and (2) the main effect approach (13). According to the widely supported Integrated Model of Response to Sports Injury by Wiese-Bjornstal et al. (14), availability of social support is a situational factor influencing cognitive appraisals of injury rehabilitation. The buffering effect approach (Fig. 2) implies that the athlete’s perception of social support throughout rehabilitation has the potential to act as a ‘buffer’ against the stressors of rehabilitation through influencing cognitive appraisals throughout the injury process. Accordingly this will then lead to more adaptive cognitive, emotional and behavioural responses to injury, rehabilitation and return to sport, while preventing against maladaptive responses. Social support may intervene at specific points along the pathway of rehabilitation from encountering stressors, through experiencing high levels of stress, to

perceived effective social support

eventual physical and psychological rehabilitation outcomes (15). For example, social support is a coping resource and has the ability to redefine/reduce stressful situations, increase athlete perceptions of perspective and control, and act as a distraction from stressors. As practitioners it is important to recognise common sports injury stressors at the various stages of rehabilitation in order to act as a buffer

stressors relating to the injured athlete appraisals

athlete/team

(a)

Figure 2: Stress-buffering approach of social support. (D. Forsdyke & A. Gledhill, 2014)

from the stressors associated with sports injury rather than adding to them (Table 1). The less-supported ‘main effect approach’ differs by suggesting that social support has a more direct effect on rehabilitation outcomes and that this effect is independent of heightened stressors. The fact that the athlete perceives an effective amount and quality of social support built on positive relationships can lead

TaBle 1: injurY process sTressors iDenTiFieD BY coMpeTiTive aThleTes [D. Forsdyke & A. Gledhill, 2014: sourced Bianco (12) and Evans et al. 16)] injury onset stressors

injury rehabilitation stressors

return to sport stressors

Medical/ physical demands

Incapacitation Diagnosis Permanent limitations

Loss of fitness Lack of progress

Fear of re-injury Fitness levels Skill level

sport-related demands

Missed opportunities Losing place on team

Internal/external performance and return pressures

Coping with internal/ external pressures

social demands

Isolation Loss of independence

Social comparisons Isolation Unwanted attention

Financial demands

Inability to work Medication/ surgery costs

Rehabilitation costs Loss of salary

who Makes up a social supporT neTwork?

sources of social support before and after injury

to positive outcomes. For example, irrespective of high levels of stress, having a supportive network offers the potential for increasing positive affect/ emotion, more realistic expectations of recovery timescale, and better rehabilitation compliance (9). As therapists we should also be mindful that the opposite also applies, where the lower amounts of social support received, the less well off – both psychologically and physically – the athlete will be.

100% 80% 60% 40% 20% 0%

n Before n after

Family

Friend

coacha

97% 97%

92% 93%

71% 81%

physiciana

counselor

other

29% 40%

26% 29%

12% 13%

Figure 3: Sources of social support pre and post sports injury. a relates to significance (P <0.01) in pre/ post measures. [From Yang J, Peek-Asa C, Lowe JB, Heiden E and Foster DT. Social support patterns of collegiate athletes before and after injury. Journal of Athletic Training 2010;45:372–379 (2)]

The important role(s) of the sports injury practitioners in providing social support had been demonstrated by a number of studies (eg. 10,12,17) and has been attributed to the success of

Box 1: The perceiveD BeneFiTs oF sporT injurY pracTiTioner’s role(s) in proviDinG supporT [D. Forsdyke & A. Gledhill, 2014: sourced Carson & Polman (17) and Bianco (12)] n “[Physiotherapist] was really reassuring. he actually noticed I was a bit nervous and pulled me aside to say how well I’d rehabbed and that the testing we’d gone through was more intense than what I would experience”. n “Knowing a real specialist was helping me, really motivated me. The atmosphere was different. [I was] focused to get stuck into it.” n “We had the best relationship. he knew what I was thinking. he knew what I was going through. he was a moral supporter, a helper, and a psychologist he was pretty much everything for me.”

Box 2: characTerisTics oF an eFFecTive proviDer oF social supporT [D. Forsdyke & A. Gledhill, 2014: sourced Arvinen-Barrow & Pack (9)] n Demonstrate good active listening skills n Ability to differentiate the social support needs of athletes n Acknowledge effort and mastery and reinforce these where appropriate n Be able to match social support sources with the athletes social support needs n Possess awareness that social support is a necessity in effective rehabilitation (especially in slow healing or severe injury) n Recognises that they may not be able to provide all types of social support and may need to refer the athlete to other professionals.

athletica trainer 49% 83%

AS ThERAPISTS, DO WE ACT AS A BUFFER FROM ThE STRESSORS ASSOCIATED WITh SPORTS InjURy OR DO WE ADD TO ThEM? rehabilitation outcomes. The quotes in Box 1 illustrate the perceived benefits of sport injury practitioner’s role(s) in providing support (12,17). Outside of the sports injury practitioner, the social support available to an athlete will vary vastly based on their unique personal and situational circumstances. Before injury it is expected an athlete will have some form of social support network that is relied upon for a range of sport-related (eg. technical input), and non-sport related issues (eg. day-to-day chores). The dynamics of this network change when an athlete sustains a sports injury, such as involving additional professionals or relying on their current support network in a different way. For example, a study of 92 athletes found that following injury the profile of athlete sources of social support shifted to a reliance on medical staff (Fig. 3) (2). An injured athlete’s social support network may extend to a wide range of sources, such as: family, non-athlete friends, sports medicine team, sport team members, athlete friends, technical coaches, performance coaches, sport psychologist, sports fans, and engaging in social media, with each serving potentially different purposes. For example, family and friends are often best suited to provide emotional/listening support, sports

team members provide more sportspecific support, whereas the sports injury practitioner may fulfil a number of different roles to some extent (9). Clearly all sources of social support need to understand their roles and be careful not to add to the athlete’s distress by being critical of others, giving inappropriate advice or miseducation, and making rehabilitation become ambiguous in any way (Box 2). This list of social support providers is not exhaustive, yet it does raise the importance of clear communication with a strong and consistent rehabilitation message so as not to cause additional stress on the athlete, while also highlighting the need for remaining cognisant of respecting athlete confidentiality.

The BeneFiTs oF TechnoloGY-enhanceD social supporT? Although social media presents sports injury practitioners with a multitude of risks and concerns it potentially has a powerful role to play as an available source of social support for an injured athlete (4). An example of this comes from Twitter (see @ACL Diaries) where accounts have been created for athletes going through similar injury experiences, such as in rehabilitation following ACL reconstruction, to share sportEX medicine 2014;61(July):8-12

evidence infoRmed pRactice

their positive or negative experiences, and once rehabilitated assume a social model role. The level of engagement in this form of social support is optional, is always available to view and isn’t limited to a particular locality. Before suggesting to an injured athlete to engage with this source of support it is recommended to check the social media policy of your team or organisation.

whaT are The DiFFerenT TYpes oF social supporT? Types of social support fall into five broad categories: emotional support, informational support, tangible support, technical support and motivational support (9,12). For a description of these see Table 2. It may well be that the sports injury practitioner provides all types of support due to their close working relationship with injured athletes throughout the rehabilitation period (18). Intuitively, one may assume that effective working practice with athletes requires all types of support to be available. For example, a study with injured elite skiers (12) found that skiers who had experienced high levels of psychological distress during the injury onset phase indicated a strong need for listening support and emotional comfort to address the impact of the injury and help them come to terms with the event. Conversely, skiers who encountered motivational difficulties in rehabilitation showed a greater requirement for informational support aimed at helping them initiate and sustain active coping strategies, in order to fully adhere to rehabilitation activities.

suMMarY The appropriate provision of social support seems to be beneficial throughout the whole of the rehabilitation process in allowing the injured athlete to effectively combat the numerous challenges they face. Social support should be provided by a unified network (we like the term rehabilitation alliance) to be most effective, with the sports injury practitioner ideally situated to facilitate this. The sports injury practitioner is a key provider of social support; therefore, understanding www.sportEX.net

TaBle 2: TYpes oF social supporT ThaT MaY have BeneFiT To The injureD aThleTe wiTh DescripTion [Adapted from Arvinen & Pack (9)] Type of support

Description

esteem

Enacting behaviours that bolster an athlete’s self-confidence or sense of competence (eg. positive feedback on athlete’s ability to cope with injury)

listening

Active listening while remaining non-judgemental

emotional during setbacks

Providing impartial assistance via empathy, acceptance or encouragement during setbacks

emotional challenge

Challenging the athlete to do their utmost to overcome obstacles

shared social reality

Verifying an athlete’s current situation providing a sense of ‘normalisation’

Technical appreciation

Acknowledging the athlete’s efforts and intensity during rehabilitation session

Technical challenge

Encouraging athletes to achieve more, seeking new ways in which the athlete might rehabilitate

personal assistance

Providing advice, guidance and assistance with problems during rehabilitation

Material assistance

Providing tangible assistance (eg. transport)

Motivational

Encouraging athletes to overcome, or give in to, barriers during the rehabilitation process.

the mechanisms, different sources and types of support, and how it should be provided seems important in facilitating biopsychosocial rehabilitation (Box 3). It should be a concern if any injured athlete has a limited social support network or chooses to suffer alone. This is commonly viewed as a sign of poor adjustment to the sports injury process (19) and should be addressed as a potential psychosocial barrier to recovery. A key take home message that may improve practice would be to spend a little more time actively listening rather than just treating. References 1. Podlog L, Dimmock j, Miller j. A review of return to sport concerns following injury rehabilitation: practitioner strategies for enhancing recovery outcomes. physical therapy in Sport 2011;12:36–42 2. yang j, Peek-Asa C, et al. Social support patterns of collegiate athletes before and after injury. Journal of athletic training 2010; 45:372–379 3. Podlog L, Eklund RC. The psychosocial aspects of a return to sport following serious injury: a review of the literature from a self-determination perspective. psychology of Sport and exercise 2007;8:535–566 4. Gledhill A, Forsdyke D. Injury experiences in adolescent female soccer. Abstract accepted by the 19th Annual Conference of the European College of Sport Science 2014,

Amsterdam, The netherlands 5. Gould D, Udry E, et al. Stress sources encountered when rehabilitating from season-ending ski injuries. the Sport psychologist 1997;11:361–378 6. Ardern CL, Webster KE, et al. Return to the pre-injury level of competitive sport following anterior cruciate ligament reconstruction surgery: two thirds of patients have not returned by 12 months following surgery. american Journal of Sports medicine 2011;39:538–543 7. Evans L, hardy L, Fleming S. Intervention strategies with injured athletes: an action research study. the Sport psychologist 2000;14:188–206

Box 3: pracTiTioner Tips For proviDinG qualiTY social supporT To injureD aThleTes (D. Forsdyke & A. Gledhill, 2014) n Ask the athlete who supports them and how this support is offered n Clarify the athlete’s expectations of social support n Monitor any differences between perceptions of, and intentions behind, social support n help the athlete to develop an awareness of a range of other useful sources of social support n Spend time being an active listener, nOT just treating n Ask the athlete how ThEy feel, nOT just how the injury feels n Facilitate the athlete’s involvement with sport in some way (eg. by encouraging attendance or having a job role on match days) to prevent feelings of isolation or cutting off important sources of support.

8. heil j. Psychology of sport injury. human Kinetics 1993. iSBn 9780873224635 (£92.62). Buy from Amazon http://spxj.nl/1hylElv 9. Arvinen-Barrow M, Pack S. Social Support in sport injury rehabilitation. In Arvinen-Barrow M, Walker n (eds.) The Psychology of Sport Injury and Rehabilitation, pp.117–132. routledge 2013. isBn 9780415695893 (£22.99). Buy from Amazon http://spxj.nl/1oZlxV6 10. Clement D, Shannon VR. Injured athletes’ perceptions about social support. Journal of Sport Rehabilitation 2011;20:457–470 11. Mitchell I, Rees T, et al. The development of the Social Support Inventory for Injured Athletes. proceedings of the association for the advancement of applied Sport

psychology 2005;102 p 12. Bianco T. Social support and recovery from sport injury: elite skiers share their experiences. Research Quarterly for eexercise and Sport 2001;72:376–388 13. hardy Cj, Richman jM, Rosenfeld LB. The role of social support in the life stress/ injury relationship relationship. Sport psychologist 1991;5:128–139 14. Wiese-Bjornstal DM, Smith AM, et al. An integrated model of response to sport injury: psychological and sociological dynamics. Journal of applied Sport psychology 1998;10:46–69 15. Rees T, Mitchell I, et al. Stressors, social support and psychological responses to sport injury in high- and low-performance standard participants. psychology of sport and exercise 2010;11:505–512

FurTher resources

keY poinTs n The athlete is central in social support. n social support needs are dynamic: changing in intensity, direction and type throughout the phases of injury rehabilitation. n as therapists, do we act as a buffer from the stressors associated with sports injury or do we add to them? n our success as sports injury practitioners is not wholly determined by what we do with our patients, but also by how much we care. n The athlete’s perception of social support will make it either a coping mechanism or an additional stressor. n an athlete’s social support needs are best fulfilled by a rehabilitation alliance.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link http://spxj.nl/cpdquizzes

thiS Quiz iS acceSSiBle

fRee

with a SuBScRiption that includeS online acceSS to thiS JouRnal.

n Reflecting on the article, how comfortable are you as a sports injury practitioner in providing effective social support? n For a currently injured athlete you are working with DISCUSSIONS reflect on what their rehabilitation stressors are and how these may affect the individual. n how do you think social support needs of different types of athlete vary? Eg. young, female, elite and professional? n What are the advantages and disadvantages of using social media as a source of social support?

16. Evans L, Wadey R, et al. Stressors experienced by injured athletes. Journal of Sports Sciences 2012;30(9):917–927 17. Carson F, Polman R. Experiences of professional rugby union players returning to competition following anterior cruciate ligament reconstruction. physical therapy in Sport 2012;13:35–40 18. Taylor j, Taylor S. Psychological approaches to sports injury rehabilitation. aspen 1997. iSBn 978-0834209732 (£149.42). Buy from Amazon http://spxj.nl/noThxc 19. Petitpas A, Danish Sj. Caring for the injured athlete. In Murphy SM (ed.) Sport Psychology Interventions (pp.255–281). human Kinetics 1995. iSBn 9780873226592. (£82.95). Buy from Amazon http://spxj.nl/1k0V9e5

1. Fans unite in support of Theo Walcott, Arsenal Football Club. This shows how teammates can provide effective social support through the social media. http://spxj.nl/SMQvV0 2. Multidimensional Scale of Perceived Social Support questionnaire (Zimet GD, Dahlem nW, Zimet SG, et al. The multidimensional scale of perceived social support. journal of Personality Assessment 1988;52:30-41). http://spxj.nl/1ovtiFI

ThE AuThoRs Th Dale Forsdyke M Msc, MssT MsMA Dale is a lecturer in sport Injury Management at York st John university and a practising sports therapist within elite female football. he has dual professional body status with the society of sports Therapists (ssT) and sports Massage Association (sMA), and has completed Msc qualifications in both sport science, and sports therapy. he is currently undertaking a PhD examining the psychosocial factors influencing sport injury rehabiltation outcomes. For correspondence please email d.forsdyke@yorksj.ac.uk, and follow his Twitter account: @forsdyke_dale Msc Adam Gledhill M Adam is a senior lecturer in sport and Exercise Therapy at Leeds Metropolitan university where he teaches on u undergraduate and postgraduate sport and exercise therapy programmes, with his main teaching foci being based around the psychology of sports injury and rehabilitation, professional practice and research. Adam completed his Msc in sport and Exercise science in 2003, has vocational qualifications in sports massage and is currently working towards a PhD examining psychosocial factors associated with talent development in female soccer. Adam has extensive experience of sports therapy, sport and exercise science, and sports coaching qualification development. he has experience of providing sport science support to a range of athletes in different sports. For correspondence please email Adam.Gledhill@leedsmet. ac.uk, and follow his Twitter account: @gleds13.

sportEX medicine 2014;61(July):8-12

case study

ReconstRuction of a pilot’s anteRioR cRuciate ligament This article explores an RAF pilot’s anterior cruciate ligament (ACL) reconstruction. The case study discusses the mechanism of injury and the benefits of the different types of ACL graft as well as the patient’s problem list with respect to his role as a pilot. It looks at the examination process as well as detailing a rehabilitation management plan with time frames for the patient to return to flying. The rehabilitation programme, devised after a review of the literature, was a success. By DaviD LemoN BSc

Nature of the iNjury The anterior cruciate ligament (ACL) injury occurred when the athlete was performing a kicking action in football. There was no contact of any sort but the individual felt a popping in his right knee. Immediately afterwards, the player was unable to bear weight, with knee effusion causing restriction of movement. The mechanism of injury was unclear as the individual did not notice a twisting/rotating force applied to the leg and there were no direct forces from outside agencies. The patient was unsure if the injury was due to the kicking action and production of forces

The SpeCIFIC needS OF The pATIenT ARe A key FACTOR when pLAnnIng end-STAge RehAbILITATIOn www.sportEX.net

through acceleration of quadriceps and hip flexors or stress/strain of the quadriceps to the hamstrings/ gastrocnemius, taking the knee into forced hyperextension. There could have been a weakness in the ACL previous to the kicking action, which could have contributed to the extent of the injury. Other factors that could have added to the injury were type of playing surface and the type of footwear worn by the individual. The surface was a flat artificial turf pitch with the player wearing AstroTurf trainers, not moulded boots. Moulded boots are known to have caused knee problems when used on artificial turf due to rotational forces being applied through the knee. The pitch had an even playing surface, but this could have been influential in the injury if the player had slipped or overstretched. For various reasons, the individual’s initial assessment was conducted after surgery. Subjectively the patient complained of a large amount of swelling around the knee and an inability to

taBLe 1: rehaBiLitatioN maNagemeNt pLaN (D. LemoN, 2013) problem

action

timed goal

measurement

Swelling around knee

1. Cryotherapy 2. Compression bandage

1. Short term – decrease inflammatory response in 2/52 2. Long term – no activityrelated swelling 6–8/52

1. patient subjective reporting 2. Joint circumference measurement 3. Measure ROM and subjectively feel if restricted by swelling

inability to bear weight/ deficient gait

1. Crutch education 2. gait re-education 3. decrease swelling and pain through cryotherapy 4. early strength and ROM work

1. Short term – start to load muscles and partial weight bear in 3/7 2. Medium term – fully weightbearing without crutches in 10/7 3. Long term – good reciprocal gait pattern in 6/52

1. patient self feedback 2. Video/visual analysis to monitor progress and identify deficiencies

Decreased stability

1. progressive stability (balance and proprioception exercises)

1. Symmetric beSS score 6/52

1. beSS score unilateral test

Decreased rom

1. Flexion/extension ROM exercises 2. Cryotherapy (decrease swelling) 3. Manual therapy

1. 100–120° of flexion by 3/52 2. Full ROM by 8/52 (Fig. 1, 2)

1. goniometer 2. Joint circumference measurement

Decreased strength

1. CkC strengthening exercises for first 6/52 2. OkC exercises introduced after 6/52 3. neuromuscular electrical stimulation

1. Left leg = right leg in 4/12 for 1 rep max 2. Left leg = right leg in 6/12 for 1 rep max

1. dApRe 2. 10 Rep max 3. 1 Rep max

inability to run

1. Follow on from gait reeducation 2. perform walking drills once weight-bearing 3. Trampette jogging after 6/52 4. Running 3/12

1. perform hopping on injured limb pain free in 4/12 2. Running for more than 30 minutes symptom free in 5/12 3. pass RAFFT in 6/12 (Fig. 3)

1. Visual/video feedback for running and hopping 2. MSFT

Decreased cv fitness

1. early ROM and CV on stationary bikes 2. Use of other CV equipment, eg. rower, cross-trainer and treadmill (dependent on stage and time of recovery period)

1. perform 30 minutes on stationary bike with no symptoms in 3/52 2. Running for more than 30 minutes symptom free in 5/12 3. pass RAFFT in 6/12

1. Timing to fatigue or timed specific distance on CV equipment 2. MSFT

Landing/sea drills and plyometrics

1. early plyometric exercises after 3/12 (Fig. 4, 5, 6) 2. Cutting drills after 3/12 3. Swimming 4. parachute drills

1. pass pool drills and attempt sea drills in 4/12 2. Introduce landing on two legs from a height of 20cm without kit after 4/12. 3. parachute landing test 6/12

1. Triple hop for distance 2. knee valgus on drop test 3. hop crossover test 4. Swim test 5. parachute landing test

beSS, balance error scoring system; CkC, closed kinetic chain; CV, cardiovascular; dApRe, daily adjustable progressive rehabilitation exercises; MSFT, Multi-Stage Fitness Test; OkC, open kinetic chain; RAFFT, Royal Air Force Fitness Test; ROM, range-of-motion; 10 rep max, maximum amount of weight that can be lifted for 10 repetitions; 1 rep max, maximum amount of weight that can be lifted for 1 repetition.

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case study

Figure 1: Assessment of flexion rangeof-motion (D. Lemon, 2013)

Figure 2: Patient performing a straight leg raise (D. Lemon, 2013)

Figure 4: Trampette hopping (D. Lemon, 2013)

bear weight through the injured limb. Straight after injury the patient went to the Accident & emergency department and was given crutches so the joint was non-weight-bearing. he saw the military physiotherapist later that week, who referred him to the Regional Rehabilitation Unit (RRU). The patient visited the RRU a month after injury and still had considerable swelling, was using crutches for non-weight-bearing gait and was given a splint to protect the injury. They referred him for fast-track surgery which took 1 further month before operation, 2 months after initial injury. he had no exercise regime to follow, only pain and inflammation management. post-operation, the patient had 70Â° knee flexion, decreased extension, reduced strength, decreased gait (still using crutches) and a large amount of swelling. This is the starting point for the rehabilitation programme.

proBLem LiSt At the initial assessment, this patient was facing many problems. The individual is a fast jet pilot and was unable to fly because of the nature of the injury. hence there was a need for the patient to be fit for return to active service at the earliest stage possible.

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Figure 3: Patient attempting the RAF Fitness Test (D. Lemon, 2013)

Figure 5: Patient performing a step down (D. Lemon, 2013)

Figure 6: Patient performing a hip raise (a) and with leg extension (b) (D. Lemon, 2013)

This is the key factor when looking at end-stage rehabilitation. before the patient could get back to flying, there were certain assessments to pass. These included: completing parachute drills (for emergency landing), jumping off a box 50cm in height with survival equipment and performing a landing roll. Swimming and dingy drills are also a requirement of the job; these consist of a 100m swim, tread water for 2 minutes and climb out of the pool unaided followed by climbing into the back of a life raft in the sea after treading water for a short period of time wearing full kit. The flying role includes sitting for long periods with knee flexed to approximately 45Â° with occasional plantar and dorsiflexion of the ankle. There are also some rotational forces,

though minimal, applied to the lower limbs as the pilot looks over left and right shoulders as the legs are in the constant flexed position. In terms of fitness and sport, the individual has to complete the biannual Royal Air Force Fitness Test (RAFFT) which consists of the Multi-Stage Fitness Test (MSFT), press-ups and sit-ups. The individual also plays amateur football for the station football team and competes in the unit five-a-side competition. during all of these activities, there will be different loads placed upon the injury. The loads will include rotational forces through the knee during flying, turning in the MSFT, football and potentially when performing sea drills. There will also be impact forces through running which could equate to up to

five times body weight as the speed in the MSFT increases. These forces will be at least double when the patient is performing the parachute drills as they will be dropping from a height of 50cm with an additional 10–15kg of equipment. This would be a direct impact to the knee followed by a controlled eccentric loading of the quadriceps in order to complete the parachute roll. There is also load placed through the knee when playing football through kicking, running (including cutting drills) and tackling. when looking into the rehabilitation process, the athlete must be able to complete straight-line running before moving onto any rotational work. The protocol used for this patient illustrated that trampette jogging could not start before 6–12 weeks, progressing onto jogging/running from 3 months, noncontact sport training from 5 months and an earliest return to contact sports from 6 months. From these guidelines, the patient can progress onto cutting drills after the 3-month point, when he can perform control of the knee when turning. Therefore, when looking at returning to sport and military training, the earliest the patient will be looking to complete the MSFT would be after the 3-month point. The earliest for returning to playing sport would be after the 6-month point. even though parachute landings are a non-contact activity, they are high impact and create high loads, so would be realistically completed closer to the 6-month point. Flying and the sea drills could reasonably be starting from the 3-month point. All of the above goals are dependent on how the patient responds to the rehabilitation process.

maNagemeNt pLaN The management plan is detailed in Table 1.

juStificatioN aND criticaL appraiSaL of the maNagemeNt pLaN when looking at the management plan, there are certain goals and time frames that need to be followed. There has been much discussion into ACL reconstructions (ACLR) in the literature regarding the type of graft used,

open and closed kinetic chain exercises (OkC and CkC), types of training and time frames for return to sport (if at all). According to Risberg et al. (1), longer rehabilitation should be considered before ACL-injured individuals return to jumping activities, due to lower extremity biomechanics being significantly impaired during both walking and hopping. Therefore, rehabilitation of the reconstructed knee is critical for the successful return to risky cutting and jumping activities. before discussing the time frames and modality of management, knowing the type of graft and differences between grafts is important. There are three main types of ACL graft: patellar tendon (pT) autograft, hamstring (hT) autograft (where the ACL is reconstructed using parts of the patient’s own patellar tendon or hamstring) and allograft (where the ACL is reconstructed using a cadaver’s ACL). From the research into the different types of graft, herrington et al. (2) compared the results of 13 studies and found that there is no significant evidence to indicate that one graft is superior between pT and hT grafts. Recently, hT grafts have been used more frequently; however, the previous ‘gold standard’ was the pT graft. This change can be attributed to the risk of developing post-surgery complications such as anterior knee pain, patella fracture, kneeling pain and ligament rupture associated with pT grafts (2,3). One of the main differences noted between the types of graft is the location of the initial post-operative pain. The pT graft patients had worse pain anteriorly (87% v. 51%), whereas hT graft patients had worse pain posteriorly (49% v. 13%) (2). Zuckerman (4) compared the advantages and disadvantages of the different types of graft. From these findings, they found the pT graft had a strong fixation with the pT and the ACL, which was as strong as the contralateral limb. however, patients can get mild discomfort on the front of the anterior aspect of the knee, especially when kneeling. with hT grafts, the incision is away from the patella allowing patients to kneel comfortably. however, healing

occurs at a slower rate than bone-tobone healing and there is a slight loss of hamstring strength (4). The advantages of allograft include no pain or scarring at a donor site and a quicker operative time. The disadvantages are a national shortage of donor tendons due to the high demand. The patient in this case study had an hT graft, which according to Zuckerman (4), may include decreased hamstring strength (10% loss compared with pT graft). when looking into the rehabilitation of an athlete, most surgeons or hospitals have their own set of protocols to follow. They usually follow a similar pattern but the changes can occur when looking at OkC and CkC exercises, progressing the patient onto running, cutting drills and return to sport. Most of the protocols concur that before surgery, the main goals are to control swelling, restore range-ofmotion (ROM), strengthen musculature around the site of injury (quadriceps and hamstrings) using CkC exercises and prepare the patient mentally for surgery (5,6). paris et al. (6) claim that the timing of ACL surgery has a significant influence on the development of postoperative knee stiffness. If the surgical repair is performed when the knee is swollen, painful and with a limited ROM the patient is more likely to develop knee stiffness. In this case the patient had his ACLR 2 months after the initial injury, when the knee was still swollen and no pre-operative programme had been performed. This could, quite reasonably, have implications on the patient developing knee stiffness. The initial post-operative phase (first 48–72 hours) focuses on controlling the swelling and early ROM exercises. This can be done by medication, ice treatment and compression bandage as well as early flexion and extension ROM exercises. Up to day 7, the goals of rehabilitation are to control swelling, early ROM exercises, trying to restore full extension, early strength training and gait re-education. This is important as gait changes may contribute to prolonged quadriceps weakness (7). The starting point of treatment (initial assessment) was completed after day 7. by this stage, the patient

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case study

should be partially weight-bearing and may even be looking at full weightbearing without crutches. The patient was able to fully weight bear but there was a reduction in gait pattern with a noticeable limp on the injured side. The inflammatory response had decreased, as indicated by objective measurements taken of knee circumference on and after the initial assessment. A cryocuff was used to help with reducing swelling and aid compression. This was used for a period of 20 minutes every 90 minutes, where possible. Straight after cryotherapy, the patient performed basic ROM exercises to aid increasing ROM. Treatments completed at this stage were ROM exercises, CkC exercises, quadriceps strengthening and gait re-education. A study by Shaw et al. (8) consisted of a treatment group (quadriceps strength) who performed straight let raises and isometric quadriceps exercises throughout the first 2 post-operative weeks, and a second group who did not. performance of quadriceps exercises significantly improved a number of knee flexion and extensor ROM measurements. Isometric quadriceps exercises and straight leg raises can be safely prescribed during the first 2 post-operative weeks and have advantages for faster recovery of knee ROM and stability. There are other types of training modalities used to aid recovery. According to the review by wright et al. (7), early weight-bearing appears beneficial and may decrease patellofemoral pain. early motion is safe and may help avoid problems with later arthrofibrosis and postoperative rehabilitative bracing, either in extension or with the hinges opened for ROM, does not offer significant advantages over no bracing. Tovin et al. (9) considered rehabilitation exercises in water compared with traditional landbased exercises, with the water group demonstrating less knee effusion at 8 weeks. The patient did water-based exercises once a week, concentrating on ROM and gait re-education. Initial goals were to maintain full extension and achieve 100–120° of flexion by week 3, with full ROM being achieved by 8 weeks, as well as to reduce swelling so there were

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no bilateral differences in quadriceps circumference by week 8. This included any activity-induced swelling. by week 8, the patient was still not able to achieve full extension but was able to achieve almost full flexion. There was still swelling after exercise but resting quadriceps circumference had decreased dramatically and was similar to the non-injured side. At this point, more hands-on manual therapy was implemented to try to gain full extension. One of the biggest discussion points of ACLR is when to include OkC exercises and whether CkC exercises are better in the rehabilitation process. After a review of the literature, Ross (10) claimed there was little agreement in the literature but both OkC and CkC exercises can be modified and implemented for quadriceps strengthening without causing excessive ACL strain or patellofemoral joint stress. In agreement with this, Risberg et al. (11) found CkC exercise at knee joint motions of less than 60°, and OkC exercises with knee flexion angles greater than 40° for quadriceps muscle strength training were appropriate, without increasing the strain on the ACL and without increased stresses on the patellofemoral joint. however, bynum et al. (12) found that their CkC group had less patellofemoral pain, were more satisfied with the end result and more often thought they returned to normal daily activities and sports sooner, concluding that CkC exercises are safer and offer some important advantages over OkC exercises. kvist and gillquist (13) agree with bynum et al. (12) that CkC exercises are better than OkC. They found that with CkC exercises, patients were able to control static laxity, which was not achieved with OkC exercise. They also found that CkC exercises minimise sagittal translation in nonoperative management. wright et al. (7) compiled reviews from other researchers and found that few have used an evidence-based approach to create an overall protocol for ACL rehabilitation. They claim that despite the many discussions of OkC and CkC exercises, only five

TheRe ARe ThRee MAIn TypeS OF ACL gRAFT: pATeLLAR TendOn AUTOgRAFT, hAMSTRIng AUTOgRAFT And ALLOgRAFT

prospectively randomised studies have been conducted to investigate these issues. All of the following studies in this paragraph have been cited in wright et al. (7). bynum et al. (12) concluded CkC exercises were safe and effective and might offer the advantages of less stress on the healing graft and less patellofemoral pain. Mikkelsen et al. (14) concluded OkC exercises can be safely added at 6 weeks post-op without risk of increased knee laxity as well as improving quadriceps strength. Morrissey et al. (15) could not conclude OkC exercise increased knee laxity and that there was no difference in pain between OkC and CkC exercises. The other two studies cited in wright et al. (7) assessed final outcome at 6 weeks following 4 weeks of OkC versus CkC exercises, and this follow-up period may be too short to make reasonable conclusions. Also, these two studies may suffer from lack of power to detect the difference. Judging by the research and debate about OkC and CkC exercises, there is a need for additional research in this area. There is a lot of contradictory evidence about when to start to add in the exercises to decrease the amount of joint laxity or decrease patellofemoral pain. when completing the rehabilitation process, the protocols used by the hospital restricted OkC exercises to after the 6-week point, which falls in line with Mikkelsen et al. (14), cited in wright et al. (7). The CkC exercises used prior to the 6-week point included hip raise, step-ups, step-downs, stepovers, squats, calf raises and leg press. The bike was used as aerobic training as well as for ROM purposes. with the body-weight exercises, the programme started with lower reps and sets but as strength was gained, more reps were included. with the weight exercises, the daily adjustable progressive resistance exercise (dApRe) programme was used. This programme developed strength quickly for the patient and seemed to have benefits. The 10 rep max (ie. maximum amount of weight that can be lifted for 10 repetitions) was used initially to assess patient strength with a goal of 8 weeks for left-leg strength (uninjured knee) to equal right-leg strength

(injured knee) (left = right). This was then modified to 1 rep max (maximum amount of weight that can be lifted for 1 repetition) for left = right at week 12. This exercise regime worked for the initial period and strength was increased quickly and within time frames. Other forms of rehabilitation that could have been used include lateral slide-board exercises (16), a stair climber is a variable and safe alternative to cycling 17) and neuromuscular electrical stimulation. Fitzegerald et al. (18) found that neuromuscular electrical stimulation may help achieve quadriceps strength but does not appear to be a requirement for successful ACLR rehabilitation. however, they found that it did improve daily living scores. Risberg et al. (11), Snyder-Mackler (19) and Ross (10) all found that electrical stimulation decreased muscle atrophy when compared with the isometric training. Lieber et al. (20) found that it did not matter what the dosage of electrical stimulation was; there was no significant difference between groups at different time frames. This was backed up by Rebai et al. (21) with the only difference being the 20hz group, where there was less fat accumulation. wright et al. (7) concluded neuromuscular electrical stimulation should be of high intensity to achieve meaningful results. Risberg and holm (1) found there were no significant differences between neuromuscular exercise (ne) and strength exercise (Se) programmes at 1 and 2 years post-ACL reconstruction, for the primary outcome measurement. The rate of development was reviewed continuously but as the patient was developing at a steady rate, electrical stimulation was not used. As the patientâ&#x20AC;&#x2122;s development was gradual and within the time frames set, trampette jogging was introduced at the 6-week point and early plyometric exercises were introduced just before the 12-week point. he was able to pass his swim test in the time frame permitted and was back flying by 13 weeks (without completing the sea drills and the landing drills). The patient was able to run with decreased gait on week 12. Running drills were given once trampette jogging felt comfortable (week 9). The patient did struggle with cutting

drills due to control when turning. These were gradually introduced from week 14. At this point, the patient was able to control landing when hopping. however, triple hop test results were significantly decreased. There appeared to be fear-avoidance when moving onto the cutting drills and triple hop for distance. Ross (22) suggests that fearavoidance following ACLR can influence functional levels in activities of daily living and sports. physical impairments include single leg hop ability, quadriceps strength and anterior tibiofemoral joint laxity. Fear-avoidance is a psychological impairment that may influence disability, where fear causes patients to avoid behaviours that may potentially elicit pain or re-injury. Only 53% of their patients returned to their pre-injury level of activity 4 years after ACLR (22). when looking into the rehabilitation of the athlete, this is one area to consider. Confidence in training is important and through proprioception exercises we can try to eradicate fear-avoidance. exercises for proprioception and balance may improve dynamic knee stability and thus the functional ability of the patients. Further, there is some evidence suggesting that psychometric exercises will enhance muscular strength and athletic performance, and that rehabilitation programmes, including specific perturbation training may lead to beneficial neuromuscular adaptations. This has also been noted by Cupal and brewer (23) who concluded a relaxation-based and imagery-based psychological intervention programme may facilitate recovery from ACL reconstruction. Another form of rehab the patient looked into was nutrition. Tyler et al. (24) found creatine supplements did not demonstrate a beneficial effect during the first 12 weeks following ACL reconstruction. Creatine supplements are usually used for building strength and power, but have no effect on postoperative ACLR. This was mentioned to the patient.

Summary Overall, the rehabilitation programme for this pilot was a success. From here, more plyometric and proprioception

sportEX medicine 2014;61(July):13-20

case study

exercises need to be included so the patient can further develop stability and control. Running will be increased with practised turning for the MSFT component. Confidence would also be a big part in developing the control of landing during the parachute drills/ landing. This can be used when looking at knee valgus during a drop test. This would start off with a drop jump from standing followed by increasing onto a higher platform in stages, leading up to the full height of the test. References 1. Risberg MA, holm I. The long term effect of 2 postoperative rehabilitation programmes after anterior cruciate ligament reconstruction: a randomised controlled clinical trial with 2 years of follow up. american Journal of sports medicine 2009;37(10):1958–1966 2. herrington L, wrapson C, et al. Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery. the Knee 2005;12:41–50 3. goldblatt Jp, fitzsimmons se, et al. Reconstruction of the anterior cruciate

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ligament: meta-analysis of the patella tendon versus hamstring autograft. Journal of arthroscopic and Related surgery 2005;21(7):791–803 4. Slovik g. Surgery for ACL tears. 2013; http://spxj.nl/1oyrsMR. Retrieved May 2014 5. wilk ke, Reinold MM, hooks TR. Recent advances in the rehabilitation of isolated and combined anterior cruciate ligament injuries. the orthopaedic clinics of north america 2003;34(1):107–137 6. paris MJ, wilcox Rb, Millett pJ. ACL reconstruction: surgical management and postoperative rehabilitation considerations. orthopaedic practice 2005;17(4):14–24 7. wright Rw, preston e, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation. Journal of Knee surgery 2008;21:225–234 8. Shaw T, williams MT. and Chipchase LS. do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. australian Journal of physiotherapy 2005;51:9–17 9. Tovin bJ, wolf SL, et al. Comparison of the effects of exercise in water and on-land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstruction. physical therapy 1994;74:710–719 10. Ross Md. The effect of neuromuscular electrical stimulation during closed

The pATIenT deVeLOped STRengTh qUICkLy USIng The dApRe pROgRAMMe kinetic chain exercise on lower extremity performance following anterior cruciate ligament reconstruction. sports medicine, training and Rehabilitation 2000;9:239– 251 11. Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: how much and what type? physical therapy in sport 2004;5(3):125–145 12. bynum eb, barrack RL, Alexander Ah. Open versus closed kinetic exercises after anterior cruciate ligament reconstruction; a prospective randomized study. american Journal of sports medicine 1995;23(4):401–406 13. kvist J, gillquist J. Sagittal plane knee translation and electromyographic activity during closed and open kinetic chain exercises in anterior cruciate ligamentdeficient patients and control subjects. american Journal of sports medicine 2001;29(1):72–82

14. Mikkelsen C, werner S, eriksson e. Closed kinetic chain alone compared to combined open and closed kinetic chain exercise for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee surgery, sports traumatology, arthroscopy 2000;8:337–342 15. Morrissey MC, hudson ZL, et al. effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction. Knee surgery, sports traumatology, arthroscopy 2000;8:343–348 16. blanpied p, Carroll R, et al. effectiveness of lateral slide exercise in an anterior cruciate ligament reconstruction rehabilitation home exercise program. Journal of orthopaedic & sports physical therapy 2000;30:602–608 17. Meyers MC, Sterling JC, Marley RR. efficiency of stair-climber versus cycle ergometry in postoperative anterior cruciate ligament rehabilitation. clinical Journal of sports medicine 2002;12:85–94 18. Fitzgerald gk, piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior

DISCUSSIONS

cruciate ligament reconstruction. Journal of orthopaedic & sports physical therapy 2003;33:492–501 19. Snyder-Mackler L, delitto A, et al. Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. physical therapy 1994;74:901–907 20. Lieber RL, Silva pd, daniel dM. equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery. Journal of orthopedic Research 1996;14:131–138 21. Rebai h, barra V, et al. effects of two electrical stimulation frequencies in thigh muscleafter knee surgery. International Journal of sports medicine 2002;23:604–609 22. Ross Md. The relationship between functional levels and fear-avoidance beliefs following anterior cruciate ligament reconstruction. Journal of orthopaedics and traumatology 2010;11(4):237–243 23. Cupal dd, brewer bw. effects of relaxation and guided imagery on knee strength, reinjury anxiety and pain following anterior cruciate ligament reconstruction. Rehabilitation psychology 2001;46:28–43 24. Tyler TF, nicholas SJ, et al. The effect of creatine supplementation on strength recovery after anterior cruciate ligament

n what is the best type of graft in terms of rehabilitation and long-term sustainability? n what is the best time to introduce running following ACL reconstruction surgery? Most protocols state 6 weeks, is this too long/short and does this differ depending on the type of graft? n when looking at the management plan, what key factors would influence the programme? would final functional outcome be considered a key output from an early stage or would the basic key principles of rehabilitation be more important?

this quiz is accessible

fRee

with a subscRiption that includes online access to this JouRnal.

(ACL) reconstruction: a randomized, placebocontrolled, double blind trail. american Journal of sports medicine 2004;32:383 –388.

further reSourceS 1. Chester knee Clinic & Cartilage Repair Centre’s guide to rehabilitation of anterior cruciate ligament (ACL) reconstruction (http://spxj.nl/1kbm2V5)

Th AuThoR ThE dAvE lEmon bsc d dave is currently studying for an msc d in sports Injury Rehabilitation at salford university after completing a bsc (hons) in sports science in 2000. since 2001, dave has been a member of the RAF as a physical training instructor. he has been in the rehabilitation industry since 2005 after completing the Exercise Rehabilitation Instructor course. since gaining this qualification, the author has been practising at RAF units, including basic Regiment Trainees and Phase 2 military Training. other qualifications gained include a sports massage diploma, FA sports Injury diploma amongst other continued professional development and exercise related courses.

Key poiNtS n there are different factors that could cause an acL injury, including external factors such as the playing surface and footwear used. n a progressive management plan started with basic rehabilitation principles before moving the patient on to develop full fitness. n there were timed goals for the different stages of rehabilitation. n there were measurable elements on the problem list so that rehabilitation progress could be checked. n three main types of graft are used in acL reconstruction: patellar tendon graft, hamstring graft and allograft. n Different types of rehabilitation methods are available to achieve the same aim, ie. use of hydrotherapy, oKc and cKc exercises. n Basic protocols for regaining rom and quadriceps strength should be followed when performing acLr rehabilitation exercise regimes. n attention needs to be given to any particular requirements for end-stage fitness with respect to the patient’s individual needs and duties, rather than just performing rehabilitation for a general lifestyle.

sportEX medicine 2014;61(July):13-20

Literature review

treating adoLescent pateLLofemoraL pain Knee pain and especially patellofemoral pain (PFP) is common among adolescents, but most of the previous scientific research has focused on adults even though adolescents with PFP are frequently seen in the clinic. During the last five years a research group from Denmark has systematically investigated PFP among adolescents. The research group has explored how common this knee condition is, what characterises the adolescents with PFP and how adolescents with PFP should be treated. Adolescent PFP is hard to treat and this article highlights key aspects that need to be considered when treating adolescents with PFP.

BY Michael Skovdal Rathleff MhSc Phd

intRoduction knee pain among adolescents

females Males

report knee pain with approximately two thirds of these reporting an insidious onset of knee pain with no apparent trauma preceding their knee pain (4,5). Fifty percent of the adolescents with knee pain will at some point seek medical treatment, often through their general practitioner. This means that at some point, we are likely to meet them (and their parents) in the clinic.

25 n

Proportion of adolescents with knee pain (%)

Pain is not an uncommon experience among adolescents (1). At any given time more than 25% of adolescents will report some musculoskeletal complaint (2). For most pain conditions, females have a 2â&#x20AC;&#x201C;3-fold higher prevalence compared to males. One of the most common musculoskeletal complaints among adolescents is knee pain (Fig. 1) (3). Thirty percent of adolescents

Patellofemoral pain among adolescents

15 10 5 12

17 16 age (years)

Figure 1: Occurrence of knee pain among adolescents from 12 to 19 years of age. (M.S. Rathleff, 2014)

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One of the most common knee conditions among adolescents is patellofemoral pain (PFP). The most frequently self-reported symptoms in PFP are diffuse peri-patellar and retro-patellar localised pain (6). Pain is

typically provoked by activities of daily living that require loading on a flexed knee such as stair walking, squatting and jumping (6). The pathology behind PFP is unknown but PFP is likely to be an umbrella diagnosis composed of different pathologies which ultimately lead to similar symptoms (7). Proposed structures involved include the subchondral bone, lateral retinaculum, synovial lining and/or the highly innervated infrapatellar fat pad (8). Adolescents with PFP are common in the clinic but just how common is it in the adolescent population? To answer this question we conducted a population-based study among 2200 adolescents between 15â&#x20AC;&#x201C;19 years of age. To our surprise we found a prevalence of 7% with females 21

having a 2.3-fold higher prevalence compared to males (9). Previous studies show a similar high prevalence among adolescents, but these studies have been done in select sports populations. This is surprising and shows that PFP does not only exist among adolescents involved in sports.

knee injury and osteoarthritis outcome score

TO Our SurPrISe We FOuND A PrevAleNCe OF 7%, WITH FeMAleS HAvINg A 2.3-FOlD HIgHer PrevAleNCe COMPAreD TO MAleS 100 no knee pain

90 l

80 70

l l

60 l

PfP

40 30 20 10 0

Pain

Symptoms

adl

Sport/rec

Qol

Figure 2: Knee injury and Osteoarthritis Outcome Score for adolescents with patellofemoral pain (PFP) compared to adolescents with no knee pain. (M.S. Rathleff, 2014)

Maximal quadriceps torque (nm/kg)

2.5

1.5

0.5

PfP

no knee pain

Figure 3: Isometric knee extension strength among adolescents with PFP compared to adolescents with no knee pain. (M.S. Rathleff, 2014)

One third of adolescents with PFP in our large population-based study did not participate in leisure time sports outside of school. However, those involved in leisure time sports participated a median of 5 times per week. Interestingly, frequent sports participation is a risk factor for persistent knee pain among young adolescents (10,11). This suggests that activity level may be a very important factor as PFP is probably the result of excessive loading of the patellofemoral joint caused by physical activity or structural mal-alignment of the patellofemoral joint (8, 12). In our population-based cohort, adolescents between 15 and 19 years old with PFP had a median symptom duration of more than 3 years (38 months). They reported severe pain and had a low quality of life [see example of Knee Injury and Osteoarthritis Outcome Score (KOOS) in Fig. 2]. For comparison, the KOOS subscores resemble those of elderly patients (mean age 71.3 years) 6 months after total knee replacement (13), whereas the KOOS pain and KOOS symptoms scores resemble those of young female patients (mean age 25 years) waiting for primary anterior cruciate ligament reconÂŹstruction (14). This highlights that PFP is a significant problem for the adolescents. Among a subgroup of 57 adolescents with PFP, we compared the neuromuscular control during stair descent and isometric knee extension strength to a group of 22 adolescents with no knee pain. The results showed that adolescents with PFP had significantly lower isometric knee extension strength (Fig. 3) (15). The primary implication for this is that we should not only try to target control or strength in our exercise therapy. We need to target both control deficits and strength deficits as both are being reduced. Furthermore, we compared pressure pain threshold around the knee and lower leg among a subgroup of 57 female adolescents and compared them to 22 adolescents with no knee pain. Most interestingly, they had reduced pressure pain thresholds around the knee and lower leg, indicating local and spreading sensitisation of the central nervous

pain system (9). This is important, as it indicates altered processing of nociceptive information in female adolescents with PFP, and the likelihood that both peripheral and central mechanisms may facilitate their pain. The primary implication for this finding is that sometimes we may need to think outside the box and not only focus on biomechanics and strength factors. If the adolescent show signs of central sensitisation it might be important during the initial phase of rehabilitation to consider general exercises not involving the knee and to focus on self-management and education. Collectively, this highlights that PFP is a problem from both a self-reported point-of-view as well as shown by more objective measures of strength, neuromuscular control and pain.

tReatMent of adoleScent PatellofeMoRal Pain There is no question that adolescent PFP is a significant problem, but how should we treat it? Among adults with PFP, exercise therapy is the cornerstone and offers superior effects compared to patient education or wait-and-see (16,17). However, both patient education and waitand-see approaches are used in general practice and so far only a single study has compared patient education to exercise therapy (17). It showed better outcomes at 3 and 12 months among mostly adult patients randomised to exercise therapy (17). No studies have been conducted among adolescents with PFP which hampers evidence-based treatment of troubled adolescents with PFP. Therefore we started a project in 2010 to investigate the effect of exercise therapy as an add-on therapy to patient education compared to patient education alone on self-reported recovery. We conducted a cluster-randomised study and recruited adolescents from a closed population-based cohort (four upper secondary schools) consisting of 2,200 adolescents between 15 and 19 years. We randomised 121 adolescent with PFP to either: (1) patient education alone, or (2) patient education combined with exercise therapy. sportEX medicine 2014;61(July):21-25

Literature review

The patient education lasted for about 30 minutes and was standardised and covered the following topics: n Why does it hurt? n Pain management n Information on how to modify physical activity n How to return slowly to sport n How to cope with knee pain n Information on how to increase knee alignment during sit-to-stand, standing, walking, stair walking and bicycling n Questions from the student or the parents. After the patient education session, the adolescents received the information in an 8-page leaflet. exercise therapy consisted of both supervised and home-based exercises. The supervised group training sessions consisted of neuromuscular training of the muscles around the foot, knee and hip, strength training for the knee and hip, patellofemoral soft tissue mobilisation, and stretching of the muscles around the hip and knee. To progressively match the exercise level to the performance level of each participant, all exercises were available in multiple levels of difficulty (18). All adolescents started with exercises at level one and progressed from there. This was chosen to see how the adolescent responded to exercises and to avoid aggravating symptoms. The progression followed previously described rules (18,19): 1. good quality of movement, as determined by the physiotherapist, was defined as being able to keep hip, knee and foot aligned during exercises with both extra-slow and slightly faster than normal movement speed. 2. Ability to perform the number of repetitions specified in the training protocol. 3. No increase in self-reported pain directly after the training session or in usual morning pain the next morning. The unsupervised home-based exercises consisted of approximately 15 minutes of quadriceps and hip muscle retraining and stretching. Instructions were given immediately after patient education together with www.sportEX.net

a 5-page leaflet with pictures and descriptions of the exercises. The exercises were to be performed each day except on the days of supervised group training (20). The adolescents were instructed to incorporate the exercises into their normal daily routines. In addition patellar taping was offered to the adolescents who benefitted from it (18). The patellar taping was based on the McConnell approach (21). We used non-rigid, hypoallergenic tape to reduce skin irritation while rigid zinc-oxide tape was used for the corrections of the patella. Taping corrections was applied in a predetermined order of anterior tilt, medial tilt, glide, and fat pad unloading until the participantâ&#x20AC;&#x2122;s pain was reduced by at least 50%. However, tape was only used if patients achieved a minimum of 50% reduction in pain measured by the visual analogue scale (vAS) during a two-leg squat immediately after application of the tape. Adolescents were taught to independently apply the taping corrections and were instructed to reapply the tape daily and wear the tape during all waking hours. We found that at all time points from 3 to 12 months, adolescents randomised to patient education combined with exercise therapy were more likely to have recovered compared to the adolescents randomised to patient education alone. Twenty-nine percent had recovered in the group who received patient education while 38% had recovered in the randomised patient education and exercise therapy. This is indeed a lower proportion of recovery than van linschoten (62%) and Collins et al. (81%), which suggests that patient education and exercise therapy may be slightly less effective in adolescents with PFP compared to adults.

iS exeRciSe theRaPY indicated foR all adoleScentS with PfP? We previously showed that adolescents between 15 and 19 years of age with PFP were characterised by reduced strength of the quadriceps as well as altered neuromuscular control. This provides a strong rationale for using

a combination of strength training and neuromuscular control exercises. However, not all adolescents responded favourable to the exercise therapy and the effect was lower than what is seen among adults. This suggests that exercise therapy is effective for some, but not all. Interestingly, frequent sports participation is a risk factor for persistent knee pain among young adolescents (10,11). The activity level

AT All TIMe POINTS FrOM 3 TO 12 MONTHS, ADOleSCeNTS rANDOMISeD TO PATIeNT eDuCATION COMbINeD WITH exerCISe THerAPy Were MOre lIKely TO HAve reCOvereD COMPAreD TO THe ADOleSCeNTS rANDOMISeD TO PATIeNT eDuCATION AlONe (a)

100% 75% 50% 25%

(b)

100% 75% 50% 25%

Figure 4: Modifying the physical activity level from (a) strenuous to (b) moderate may be key to successful treatment and to avoid recurrence of knee pain. (M.S. Rathleff, 2014) 23

SOMeTIMeS We MAy NeeD TO THINK OuTSIDe THe bOx AND NOT ONly FOCuS ON bIOMeCHANICS AND STreNgTH FACTOrS may be a very important factor as PFP is probably the result of excessive loading of the patellofemoral joint caused by physical activity or structural mal-alignment of the patellofemoral joint (8,12). The clinical implication of this is that more emphasis should be placed on helping the adolescents to modify their physical activity level (Fig. 4). If we simply add exercise therapy on top of a high physical activity level we will not remove the factor that is the likely cause of their knee pain.

when Should we inteRvene? On average the adolescents reported knee pain for more than 3 years. This was quite surprising. Previous studies show that a long symptom duration is associated with worse outcome and only 5% of the adolescents reported a symptom duration below 6 months (22,23). This is a much longer symptom duration compared to previous trials on adults (17,24). The primary implication of this is that we need to treat adolescents sooner, rather than later, and to educate health personnel involved in the treatment of PFP of this. One of our previous studies showed that 50% of adolescents with knee pain seek treatment (5). Among those who choose to contact their gP only few are referred to physiotherapy. This means that 50% of adolescents don’t seek medical care even though they have significant knee pain. This highlights that we need to educate both adolescents and their parents to seek medical care and not wait too long to see if their knee pain will disappear by itself.

adheRence and Place of tReatMent Adherence may be one of the biggest challenges towards using exercise therapy as a treatment of adolescent 24

PFP. From clinical experience we know that only few of the adolescents will regularly show up at the clinic and only few will do their home-exercises. So the question is where the optimal place of exercise therapy should be? The high prevalence of PFP in upper secondary schools (6–7%) show that in a normal sized school of 500–800 adolescents there would be 30–50 adolescents with PFP. because of the high prevalence it might be worth considering if treatment of adolescent PFP using exercise therapy should be done at school premises. This would have the advantage of easier access to treatment as the adolescents are already at school five days per week. The exercise therapy can be done with minimal additional equipment besides rubber mats and therefore could be performed in any classroom.

concluSion and clinical MeSSage Most physiotherapists treating adolescents are likely to have used some sort of exercise therapy in the treatment of adolescent PFP. Our research highlights that we should continue to do so and now we can comfortably state that we have evidence for the effect of exercise therapy among adolescents. The exercise therapy should aim at increasing strength as well as improving neuromuscular knee control, as both seem to be affected. This is a heterogeneous patient group and in some adolescents it may be more relevant to target strength deficits whereas others are in need of exercises to help increase control of their knee. We need to talk to the adolescents and ask how much sport they are doing and help them to modify their activity to an appropriate level that does not overload or provoke their knee pain. From a health perspective it is important that we don’t encourage them to stop participating in sport – only to modify the level and intensity as needed. Additionally there may be some adolescents with both peripheral and central sensitisation where exercise therapy may not be the first step of their treatment but rather consider general exercises not involving the knee and focus on self-

management and education. Adherence may be the biggest obstacle towards the use of exercise therapy. exercises are unlikely to work if they are not performed. Therefore, discuss with the adolescents and the parents how exercises may be implemented in their everyday life and how it fits best with their schedule. References 1. Perquin CW, Hazebroek-Kampschreur AA, et al. Pain in children and adolescents: a common experience. pain 2000;87:51–58 2. King S, Chambers CT, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. pain 2011;152:2729–2738 3. rathleff MS, roos eM, et al. High prevalence of daily and multi-site pain--a cross-sectional population-based study among 3000 Danish adolescents. Bmc pediatrics 2013;13:191 4. Molgaard C, rathleff MS, Simonsen O. Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case-control study. Journal of the american podiatric medical association 2011;101:215–222 5. rathleff MS, Skuldbol SK, et al. Careseeking behaviour of adolescents with knee pain: a population-based study among 504 adolescents. Bmc musculoskeletal disorders 2013;14:225 6. Haim A, yaniv M, et al. Patellofemoral pain syndrome: validity of clinical and radiological features. clinical orthopaedics and related research 2006;451:223–228 7. Witvrouw e, Werner S, et al. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee surgery, sports traumatology, arthroscopy 2005;13:122– 130 8. Powers CM, bolgla lA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International research retreat. Journal of orthopaedic & sports physical therapy 2012;42:a1–54 9. rathleff MS, roos eM, et al. lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. Journal of orthopaedic & sports physical therapy 2013;43:414–421 10. rathleff Cr, Olesen Jl, et al. Half of 12-15-year-olds with knee pain still have pain after one year. danish medical Journal 2013;60:a4725 11. el-Metwally A, Salminen JJ, et al. lower limb pain in a preadolescent population: prognosis and risk factors for chronicity--a prospective 1- and 4-year follow-up study. pediatrics 2005;116:673–681 12. Powers CM, bolgla lA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International research retreat. Journal of orthopaedic & sports physical therapy 2012;42:a1–54 sportEX medicine 2014;61(July):21-25

Literature review

13. roos eM, Toksvig-larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS) – validation and comparison to the WOMAC in total knee replacement. Health and Quality Life outcomes 2003;1:17 Ageberg e, Forssblad M, et al. Sex differences in patient-reported outcomes after anterior cruciate ligament reconstruction: data from the Swedish knee ligament register. american Journal of sports medicine 2010;38:1334–1342 15. rathleff MS, Samani A, et al. Neuromuscular activity and knee kinematics in adolescents with patellofemoral pain. medicine & science in sports & exercise 2013;45:1730–1739 16. Collins NJ, bisset lM, et al. efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. sports medicine 2012;42:31–49 17. van linschoten r, van Middelkoop M, et al. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial. BmJ 2009;339:b4074 18. rathleff MS, roos eM, et al. early intervention for adolescents with

patellofemoral pain syndrome – a pragmatic cluster randomised controlled trial. Bmc musculoskeletal disorders 2012;13:9 19. Ageberg e, link A, roos eM. Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NeMex-TJr training program. Bmc musculoskeletal disorders 2010;11:126 20. Crossley K, bennell K, et al. Physical therapy for patellofemoral pain – a randomized, double-blinded, placebocontrolled trial. american Journal of sports medicine 2002;30:857–865 21. barton C, balachandar v, et al. Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms. British Journal of sports medicine 2014;48:417–424 22. Collins NJ, Crossley KM, et al. Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study. Bmc musculoskeletal disorders 2010;11:11 23. blond l, Hansen l. Patellofemoral pain syndrome in athletes: a 5.7-year retrospective follow-up study of 250

keY PointS n PfP affects 6–7% of school-attending adolescents between 15 and 19 years of age. n PfP can be treated using a multimodal approach with the basis being exercise therapy. n tailor the load and difficulty of the exercises to the individual. n Be aware of a high physical activity level and help the adolescent to modify it if needed. n exercise therapy is effective for some, but not all. n exercises are unlikely to work if they are not performed.

athletes. acta orthopaedica Belgica 1998;64:393–400 24. Collins N, Crossley K, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BmJ 2008;337:a1735.

fuRtheR ReSouRceS 1. Measurement of isometric muscle strength in adolescents: rathleff Cr, baird WN, et al. Hip and knee strength is not affected in 12-16 year old adolescents with patellofemoral pain--a cross-sectional population-based study. pLos one 2013;13(8): e79153. (http://spxj.nl/1n1Ndqp) 2. Training load and progression/ regression exercises: rathleff MS, roos eM, et al. early intervention for adolescents with patellofemoral pain syndrome--a pragmatic cluster randomised controlled trial. Bmc musculoskeletal disorders 2012;13:9 (http://spxj.nl/1l014l0).

ThE AuThor Th MichAEl SkovdAl rAThlEff MhSc phd Mich Michael is a physiotherapist and has a Masters degree in health science. recently he completed his phd studies on adolescent patellofemoral pain. his research aims to (1) understand why some adolescents develop long-lasting severe knee pain, (2) identify risk factors for long-lasting severe knee pain among adolescents, and (3) how we best treat adolescent knee pain. A special interest is patellofemoral pain, which is the most common knee complaint among adolescents with an insidious onset of knee pain. in addition, Michael uses his time on translation of his research through teaching at schools as well as to general practitioners and physiotherapists.

online n Would a couch-potato who is not involved in any type sport develop patellofemoral pain while lying on the couch? n What is the rationale for using exercise therapy in the treatment of adolescent patellofemoral pain? n What considerations do you take into account when treating an adolescent compared to an adult with patellofemoral pain? n you see an adolescent football player in the clinic. It is obvious that he has poor hip and knee control during high-load football-specific tasks. He plays football five times per week and he has a football tournament coming up in 6 weeks. How would you balance and prioritise advice on modification of physical activity level and exercises for his poor DISCUSSIONS hip and knee control?

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animation: Patellofemoral joint motion and patellar tracking

ManageMent of tendinopathies with ultrasound tissue characterisation Achilles and patella tendon pain is very common, but the precise nature of the complaint is difficult to diagnose and treat. The new imaging modality of ultrasound tissue characterisation (UTC) produces high resolution scans of the tendon, providing an indepth analysis of the health of the tendon tissue. In the future this technology will become indispensable for preventing tendon overload, diagnosing tendon conditions and monitoring rehabilitation. By Jarrod anTflick Bapp Bhsc pgcerT and chris myers Bsc msc pgcerT

Tendons and TendinopaThy Tendons connect muscle to bone and are able to withstand very high tensile loads. Tendon complaints are very common in recreational and elite sportsmen and women, particularly the Achilles tendon. Epidemiology data on recreational runners indicates 5â&#x20AC;&#x201C;34% will develop Achilles tendon pain, and in elite runners and elite sportsmen and women, tendon pain is responsible for significant time off training and competition. Achilles tendon pain provides a challenge to any health professional. Tendinopathy is characterised by matrix disintegration as a consequence of overstraining, ageing, degeneration and/or partial ruptures. The differential

UlTRAsoUnD TIssUE CHARACTERIsATIon (UTCâ&#x201E;˘) pRovIDEs A MoRE DETAIlED IMAgIng pRoFIlE oF THE TEnDon 26

diagnosis of Achilles tendon complaints is paramount to implementing the most effective treatment plan (Table 1).

imaging modaliTies Currently, ultrasound is the imaging modality of choice for the assessment of tendons as it has far superior spatial resolution to MRI and can assess for neovessels in and around the tendon. However, clinical improvement is not correlated with changes in imaging status or the amount of neovascularity (1). Also, ultrasound is dependent on the skills of the operator and produces a 2D image of a 3D structure, which introduces further limitations in assessing the structural integrity of the tendon.

UlTrasoUnd TissUe characTerisaTion A new novel imaging modality ultrasound tissue characterisation (UTCâ&#x201E;˘) provides a more detailed imaging profile of the tendon (Fig. 1). UTC imaging produces a multi-planar and 3D coronal view to assess in detail the structural integrity of the tendon (2).

sportEX medicine 2014;61(July):26-30

EvidEncE inforMed informEd practice practicE evidence

TaBle 1: possiBle differenTial diagnoses for differenT regions of The Tendon (J. anTflick, 2014) mid portion

distal tendon

medial tendon

lateral tendon

Achilles degeneration/ tendinosis

Insertional Achilles tendinopathy

plantaris rupture

sural neuropathy

Achilles dysrepair

Enthesitis

plantaris partial tear

Achilles intrasubstance partial tear

Insertional tendinopathic degenerative change

plantaris tendinopathy

Central/spinal sensitisation

Insertional calcification

plantaris friction syndrome

Achilles tendinopathy Achilles rupture

Retrocalcaneal bursitis

Achilles paratenonitis

(a)

+ excursion of transducer 0 r duce trans

beam axis -

(b)

Figure 2: The image created from the UTC scan indicates healthy or progressively more damaged tissue by a colour classification system: I. Green: intact and aligned bundles and fasciculi, diameter: ≥0.38mm II. Blue: discontinuous wavy bundles and fascicule, diameter: ≥0.38mm III. Red: mainly smaller fibres (‘fibrillar’), diameter: <<0.38mm IV. Black: mainly amorphous tissue containing cells and/or fluid, diameter <<<0.38mm. (H. van Schie, utcimaging) Figure 1: The Ultrasound Tissue Characterisation (UTC™) Tracker device provides a more detailed image of the tendon. The UTC Tracker (supplied by utcimaging) (a) is specifically designed to image tendons (b). [(a) Courtesy of utcimaging.com; (b) credit: J. Antflick, Tendon Performance, 2013]

The UTC probe travels automatically over the tendon’s long axis, collecting transverse images at even distances of 0.2mm over a length of 12–20cm. UTC produces a transverse, coronal and longitudinal image and a 3D coronal view. The tendon structure is classified into four discrete echo types: n Echo-type I (green), generated by reflections at intact and aligned tendon bundles (coloured green in

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processed images) n Echo-type II (blue), generated by reflections at discontinuous or waving tendon bundles (coloured blue in processed images) n Echo-type III (red), generated by interfering echoes from mainly fibrillar components (coloured red in processed images) n Echo-type Iv (black), generated by mainly cellular components and fluid in amorphous tissue. These different echo types provide objective information on the integrity of the tendon matrix from the distal insertion to musculotendinous junction. The scans are analysed to assess for focal areas of echo change and to

establish the overall health of the tendon (Fig. 2).

examples of UTc images The UTC Tracker produces images that give a clear indication to the health of the tendon. Figure 3 shows an image of a relatively normal healthy tendon. The scan data can also be presented in different types of graphical images. Figure 4 is a graph of the relative amounts of echo-types (and therefore tissue types) along the length of the tendon. Figure 5 is a bar chart, which gives a clear picture of the relative amounts of the healthy and damaged types of tissue as indicated by the different echo-types. The values for a normal healthy Achilles or patella tendon would typically be: green, 80% or greater; blue, 15%; and red and black together, 5%. Figures 6 and 7 show the recovery of a surgically repaired tendon following complete rupture and the healing that takes place over time. UTC plays an important role in monitoring athletes’ tendon health during each phase of the rehabilitation process and for managing in-season tendon pain. Managing tendinopathy in season is particularly challenging as training and competition loads are high and often there is not sufficient time for a full recovery. Tendon pain is provoked by excessive loading; the greater the load, the more pain is experienced (3). UTC is currently being used in British Athletics and Australian Rules Football in symptomatic and asymptomatic tendons to study the effect of load on the tendon matrix. The UTC data combined with clinical markers assess the tendons tolerance to load, such as 24-hour pain response, morning stiffness,

UTC IMAgEs ARE ColoURED ACCoRDIng To ECHo TypE, wHICH InDICATEs THE HEAlTH oF THE TIssUE 27

(a)

(b)

Figure 3: Scans of a normal Achilles tendon in the transverse plane (a) and the sagittal plane (b). (J. Antflick, Tendon Performance, 2013)

Right

60 50 40

(a)

Left Right

100

Percentage

100

Distance along tendon (cm) I

MTJ

(b)

Distance along tendon (cm) I

MTJ

Figure 4: Graphical presentation of the ultrasound echo-types (indicating tissue health) along the length of typical healthy Achilles tendons from the insertion (I) to the musculotendinous junction (MTJ) of the right (a) and left (b) Achilles tendons.

rehaBiliTaTion Complete removal of tendon load is catabolic for a tendon and only very short periods would be advocated in reactive tendons (6). It has been widely accepted that appropriately progressed loads to the tendon will maintain and/or remodel the tendon matrix (7). over the last ten years there has been significant attention to eccentric exercises with some promising results in tendinopathy. However, the appropriateness for managing in-season tendon pain is questioned when combined with a high training and/or competition load (8,9). Isometric exercise is a useful

100% 90% 80%

Percentage of echo-types %

pain on single-leg heel-raise and single leg hops. This information is used to adjust and modify tendon load to ensure the tensile loading capabilities of the tendon is not exceeded and the tendon remains pain free. This enables athletes, their clinicians and coaches to make informed and effective decisions about the capacity for training and performance. Research has demonstrated that UTC is valid, reliable and is sensitive at detecting a tissue response to load (4,5).

70% 60% 50% 40% 30% 20% 10% 0% Black % Red % Blue % Green %

Left 1.50 2.23 29.35 66.93

Right 0.90 1.73 23.48 73.89

Figure 5: The different echo-types present in the ultrasound image can be quantified and displayed as a bar graph to give a clear representation of the percentages of the healthy and damaged tissues present in the tendon. (J. Antflick, Tendon Performance, 2013).

adjunct for reactive tendon complaints and can be used for pain modulation in-season while still maintaining some load stimulus. Cook & purdham (10) suggest sustained holds for 40â&#x20AC;&#x201C;60 seconds, repeating 4â&#x20AC;&#x201C;5 times several times a day. such exercise is thought to recruit descending inhibitory mechanisms, resulting in mechanical hypoalgesia and increased pressure pain threshold (11,12). UTC is also

being used to monitor the response of the tendon matrix to medications, shockwave therapy and injectables. watch this space! There is limited evidence to suggest that isolated eccentric programmes offer superior clinical outcomes in comparison to combined loading programmes. The exact mechanisms underpinning clinical improvements seen with rehabilitation

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evidence inforMed practice

Initial scan – May

Follow-up scan – June

Follow-up scan – July

1cm proximinal

2cm proximinal

4cm proximinal

Figure 6: Scans showing injury and follow-up. Healing can be seen as the damaged (red) tissue becomes healthier (green). (J. Antflick, Tendon Performance, 2013)

programmes in pathological tendons are currently unknown. It would appear the key goal of an exercise programme is to increase the load tolerance and energy absorption of the tendon. Tendons are very slow to adapt and this process is likely to take several months (10).

one-sTop mUlTidisciplinary Tendon clinic Using UTc imaging Tendon performance and Fortius Clinic have teamed up in london to provide a multidisciplinary one-stop shop (a)

(b)

for tendon-related issues designed for elite athletes and recreational sportsmen and sportswomen. The clinic utilises UTC imaging to provide detailed analysis of the tendon to ensure it results in the most effective management plan. The multidisciplinary team consists of leading foot and ankle consultants, specialist physiotherapists, sports doctors and interventional radiologists (Box 1, 2).

Take-home poinTs The following list provides key points for you to bear in mind when diagnosing and treating tendon injuries: n Diagnosis is key: be specific and consider all differentials (Table 1) n Carry out a detailed examination with a thorough history. For example, does the patient remember a specific incident when they felt the pain? This will help to rule in/out a tear. n How long do they experience morning stiffness in the tendon? n palpate the tendon carefully and be specific – where is the pain? Is the pain on the mid portion, the enthesis or the medial or lateral side of the tendon? n Before commencing a loading programme, consider the irritability of the tendon: eg. how long does it take for the pain to go away once they have aggravated it? n Eccentric loading may be effective but consider other types of loading as well: eg. moderate and heavy isometric exercises. n soleus rehabilitation. Approximately 2/3 of the calf complex is soleus and it plays a very important role in the overall strength endurance of the calf – don’t forget it! n Beware loading into end-of-range

Box 1: Tendon performance Tendon performance is a clinical consultancy, led by physiotherapists Jarrod Antflick and Chris Myers, specialising in musculoskeletal services for recreational sportsmen and women, and elite level human and equine athletes.

Box 2: forTiUs clinic

(c)

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Figure 7: Serial scanning of the repair of a complete Achilles rupture at: (a) 4 weeks, (b) 12 weeks and (c) 7 months postsurgery. Tissue repair can be seen as the damaged (red) tissue is replaced by healthy (green) tissue. (J. Antflick, Tendon Performance, 2013)

Fortius Clinic provides leading orthopaedic and sports injury treatment, specialising in integrated musculoskeletal care. our Consultant Foot and Ankle specialists are recognised as leaders in the field of foot and ankle disorders, with particular expertise in arthroscopic treatment. we also offer many non-surgical therapies including the latest evidence-based techniques optimising treatment for Achilles tendon disorders (extra-corporeal shockwave therapy) and Achilles tendon rupture. Mr James Calder, Consultant orthopaedic Foot and Ankle surgeon and Dr Jeremiah Healy, Consultant Radiologist are closely involved with the tendinopathy clinic. Both have particular expertise in sports injury.

positions initially, especially if the tendon is irritable or you suspect the plantaris to be involved, ie. medial Achilles pain. n Monitor overall load on the tendon. stopping all tendon load, ie. complete rest, is unlikely to solve the problem but load modification is important. References 1. De Jonge s, warnaars JlF et al. Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements. scandinavian Journal of Medicine & science in sports 2013;doi:10.1111/sms.12072 2. van schie HTM, de vos RJ, et al. Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel noninvasive approach. British Journal of sports Medicine 2010;44(16):1153–1159 3. Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best practice & research clinical rheumatology 2007;21:295–316 4. Rosengarten s, Docking s I, et al. Tendon response in Achilles tendon of Australian football players using ultrasound tissue characterisation. British Journal of sports Medicine 2014;doi:10.1136/ bjsports-2013-092459.30 5. Docking s, Daffy J, et al. Tendon structure changes after maximal exercise in the thoroughbred horse: use of ultrasound tissue characterisation to detect in vivo tendon response. the veterinary Journal 2012;194:338–342 6. Kubo K, Akima H, et al. Effects of 20 days of bed rest on the viscoelastic properties of tendon structures in lower limb muscles. British Journal of sports Medicine 2004;38:324–330 7. ohberg l, lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of sports Medicine 2004;38:8–11 8. Fredberg U, Bolvig l, Andersen nT. prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in l and patellar tendons— the Danish super league study. american Journal of sports Medicine 2008;36:451–460 9. visnes H, Hoksrud A, et al. no effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. clinical Journals of sport Medicine 2005;15:227–234 10. Cook Jl, purdham CR. The challenge of managing tendinopathy in competing athletes. British Journal of sports

Medicine 2014;48(7):506–509 11. Rio E, Kidgell D, et al. Exercise to reduce tendon pain: a comparison of isometric and isotonic muscle contractions and effects on pain, cortical inhibition and muscle strength Journal of science and Medicine in sport 2013;16(suppl 1):e28 12. Kosek E, lundberg l. segmental and plurisegmental modulation of pressure pain thresholds during static muscle contractions in healthy individuals. european Journal of pain 2003;7:251–258.

fUrTher resoUrces 1. UTCimaging website. www.utcimaging.com 2. Follow Jarrod Antflick on twitter: tendonexperts@jarrodantflick 3. van schie HTM, de vos RJ, et al. Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach. British Journal of sports Medicine 2010;44(16):1153–1159 4. Cook Jl, purdham CR. The challenge of managing tendinopathy in competing athletes. British Journal of sports Medicine 2014;48(7):506–509.

DISCUSSIONS n what are the different diagnoses that can be made for the different regions of the Achilles tendon? n what kind of imaging technology does UTC use and what do the different colours on a UTC scan indicate? n what are the key points to think about in an Achilles tendinopathy rehabilitation programme? would you do things differently for inseason/off-season athletes?

key poinTs n achilles tendon complaints are very common in recreational and elite sportsmen and women. n Tendinopathy is characterised by matrix disintegration as a consequence of overstraining, ageing, degeneration and/or partial ruptures. n The differential diagnosis of achilles tendon complaints is paramount to implementing the most effective treatment plan. n Ultrasound tissue characterisation (UTc™) provides a detailed image of the tendon, producing transverse, coronal and sagittal images as well as a 3d coronal view. n UTc scans are coloured according to echo type, which reflects the current health of the tendon tissue. n successive UTc scans are useful for monitoring tendon health/rehabilitation. n eccentric exercises have been the focus of rehabilitation for the last 10 years, but is one loading strategy, there are many more depending on the diagnosis. n isometric exercises are useful for treating preseason and in-season reactive tendinopathy.

ThE AuThoRs Th JARRoD AnTFLIck BAPP Bhsc PGcERT J Jarrod is consultant physiotherapist with British Athletics sharing his time between clinical work (at Tendon Performance, complete Physio and The Fortius clinic in London, uk) and attending major championships. he is currently undertaking field research into the effect of tendinopathy on performance utilising uTc. Jarrod was a consulting physiotherapist for members of the us Track and Field Team in preparation for the London 2012 olympics. chRIs MyERs Bsc Msc PGcERT c chris is a physiotherapist, osteopath and Msk c sonographer. he runs a group of private clinics in London called complete Physio. he has a special interest in tendons and is especially interested in how imaging findings relate to pain and prognosis. he uses uTc as part of his daily practice in the clinic and treats many elite and recreational athletes from a variety of sports. For further information please contact: 1. Tendon Performance (www.tendonperformance.com); Email: info@tendonperformance.com; Twitter: tendon experts. 2. The Fortius clinic (www.fortiusclinic.com); Email: info@fortiusclinic.com; Tel: +44 203 1952442. 3. complete Physio (www.complete-physio.co.uk); Email: chris@complete-physio.co.uk; Tel: +44 207 482387.

sportEX medicine 2014;61(July):26-30

Best of

manual therapy Includes the “best of the best” of published articles for the manual therapist both in practice and in training. Easy to read and informative articles that bring topics to life and provide you with hands on tips and techniques to use in your application of massage and manual therapy. n 29 articles, many with multimedia animations, technique video clips and related quizzes to reinforce learning and retention of key points n Authors include world class practitioners such as Whitney Lowe (USA), Tom Myers (USA), Paula Clayton (UK), Bob McAtee (USA), Brad Hiskins (Aus) and Chris Norris (UK), amongst others n Access on all major mobile platforms (iPad, Android, Kindle Fire) as well as online mobile device

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milestones A few of our highlights and key milestones in the sportEX journey to date.

Jan 2001 Division of sportEX medicine into two titles – sportEX medicine which continued to focus on MSK diagnosis, treatment and rehabilitation and the launch of a new title, sportEX health, focusing exercise prescription, GP referral and some manual therapy. Due to the fact that many non-prescribing individuals were subscribing, at this point we also made the transition away from pharmaceutical sponsorship, towards a subscriptionbased funding model.

Journal

Blood pressure Nordic walking

Sept 2007 Saw our biggest, July 2004 although sadly our With the membership last, joint sportEX/ of the SMA growing SMA conference at the healthily we launched University of Bedfordshire, our sportEX dynamics featuring 6 international journal with the aim of speakers (3 from Canada, focusing on the dynamics 2 from the US and 1 from of sports performance Australia). At this time our and particularly sports spectacular conference massage/manual therapy. organizer who many of you will remember, Katie James, retired 2007 to motherhood, conference bringing to a close september 14-16 2007 our conference legacy (at least for the time being)! 5th

1st

us Bedford camp Bedfordshire University of s age and sport sports mass ilitation Injury rehab

lineup International including soft 2 x Australian sts tissue therapi physical 4 x American letic trainers therapists/ath therapist athletic n 1 x Canadia

Body image

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Produced in with association

June 2009 – We successfully tendered to become the publisher for the Register of Exercise Professionals (REPs) (30,000 members). This included a quarterly printed journal and a monthly email newsletter (circulation now 55,000). The first journal was published in Sept 2009 and we have just gone to press with the Summer 2014 issue.

July 1999 MYOFASCIAL THE

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22nd-23rd September 2006 CONFERENCE PROGRAMME FRIDAY SPEAKERS

SATURDAY SPEAKERS

DELEGATE FEES

July 1999 Launch issue of sportEX medicine – originally a controlled circulation magazine sent to general practitioners and sports medicine doctors, supported by pharmaceutical advertising and focusing on MSK and exercise medicine.

Feb 2003 sportEX took over the management of the Sports Massage Association, which had been launched one year previously by the National Sports Medicine Institute, and was facing budget cuts. At the time the SMA had just 130 members. When the SMA board was ready to take on the administration themselves in 2006, we had built the membership base to over 900. Sept 2003 We ran the first ever sports massage conference as a joint initiative between sportEX and the SMA. This came about thanks to the kindness and generosity of the organisers of the well-established Bodylife Conference, Kris Tynan and Tim Webster, who donated free space at Leisure Industry Week 2003.

TO BOOK

Sept 2006 In 2006 we managed to convince none other than Tom Myers, founder of Anatomy Trains and someone who will go down as a fascia revolutionary, as well as the prolific author and highly regarded soft tissue specialist, Leon Chaitow, to speak at the by-then annual sportEX/SMA conference, which we aptly named The Myofascial Matrix.

Sept 2008-2009 We got nerdy and coordinated the development of the elearning platform and strategy, as well as developed much of the content for Central YMCA to deliver fitness and health blended learning through both their training provider, YMCAFit, and their awarding body, Central YMCA Qualifications. Wow, that was a project and a half!

sportEX medicine 2014;61(July):32-34

MileStoneS

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PUBLISHED

Sept 2010 More nerding with the transition to a new ecommerce and content delivery platform, which has freed us from a lot of the day-to-day administration of earlier days.

Jan 2012 We launched our iPad app, followed a few months later by the Android app and the Kindle Fire Android variation.

apr 2014 With the popularity of our elearning quizzes, we decided to bite the bullet and converted all our elearning quizzes so that they would work on whatever technology platform you accessed them from regardless of whether it was a desktop/laptop or any kind of mobile device.

July 2014

april 2011 When we couldn’t find an elearning delivery platform that didn’t force us to buy annual licenses for users to access the platform, we decided to build our own SCORM-compliant mini elearning platform through which to deliver ad hoc continuing education quizzes linked to our articles. www.sportEX.net

Sept 2013 –Jun 2014 I confess has been a period of even more nerding (I don’t get out much as you can probably tell!) while we integrated the data from all our previous web shops into one central CRM (customer-relationship management) system. For the first time in about 8 years we have a record of every purchase, every subscription, every quiz result, every conference attendance and every support case request each of you has made, along with many of the email discussions we’ve had with you over the course of the last 15 years. Phew!

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today n We produce 11 journals a year (4 sportEX medicine, 4 sportEX dynamics and 3 REPs Journals). n We send out between 80,000-160,000 emails every month to 82,000 individuals. n We have just over 5,000 subscribers to our journals n We physically mail our journals to 23 different countries n We cover one of, if not the broadest spectrum of allied health professions, of any specialist publisher in the UK and possibly the world, ranging from every type of exercise professional through to all physical and manual therapists and finally elite sports medics and physicians.

what’S next? n We still hide our light too much under a bushel, so it’s time to get out there and be seen! n Greater exposure overseas, particularly Australia, New Zealand and North America. n A new way of running sportEX as well a new way of delivering content both collaboratively and cooperatively, the two go hand in hand. It’s all planned out, now it’s just a case of the implementation!

Watch this space... 33

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by Tor Davies, physio-TurneD publisher anD sporTeX founDer

often say that if I knew at age 27, when I set up sportEX, what I know now, I’d never have started! Getting this business off the ground has demanded EVERYTHING of me and there has been more than one occasion where it was nothing but luck that kept me in business. It’s without doubt the hardest thing I’ve ever done to date but 15 years on thanks to everyone who’s been involved, and particularly my right hand woman, Debbie Asher, who’s been with me from the start, we have managed to build both an incredibly robust brand and product as well as a solid and stable business base. I think back to the stress of those early years and I can’t believe how much things have changed. It seemed so simple then! We got some articles in, had them reviewed, designed some pages, sent them to the printer and then off to the mailing house and that was it, job done. In between we’d print some leaflets up to send out in other magazines and go to some conferences and somehow the subscriptions came rolling in. These days we do all that but we also put it online, create two additional new versions for our apps, produce elearning quizzes, and engage in preand post-publication social media campaigns – not to mention manage the increasingly sophisticated back-end technology and commerce platforms catering for multiple payment types and purchase scenarios. There’s so much that has to happen both behind the scenes as well as on the sportEX stage. I used to say I was a phyio-turned publisher, now I feel more like I work in IT, fortunately for sportEX I love doing both. The best thing is having been around in this industry now for 15 years, so many of you have become my friends. As a professional group, you are amazing to work with. I’ve never met so many incredibly kind, giving, caring people and every time I attend a conference, I’m reminded of how lucky I am to run my own business, in a subject matter that fascinates me, with a group of customers that literally couldn’t be nicer. Yes it’s hard work, I have to be a jack-of-all-trades and a master of none, I feel sometimes like I can do everything and sometimes nothing, and it’s impossible to take a holiday without keeping an eye on issues that can’t wait, but I wouldn’t swop it for the world and I can’t thank you enough for giving me the privilege of being able to do it for these last 15 years. I can’t wait to see what the next 15 years bring! sportEX medicine 2014;61(July):32-34

studEnt rEsourcEs sportEX publish journals and e-learning resources for people studying manual therapy and injury rehabilitation. If you run a training course and would be interested in providing access to these resources see the bottom of the page for more details. All resources are available online and via our mobile app. BEST of MANUAL THErAPy oNLINE BEST OF

MANUAL THERAPY

www.sportex.net

TRANSLATING MANUAL THERAPY RESEARCH INTO HANDS ON PRACTICE

Includes the “best of the best” of published sportEX articles on the topic of manual therapy. n 29 articles, many with multimedia animations, technique video clips and related quizzes to reinforce learning and retention of key points n Authors include world class practitioners such as Whitney Lowe (USA), Tom Myers (USA), Paula Clayton (UK), Bob McAtee (USA), Brad Hiskins (Aus) and Chris Norris (UK), amongst others

WorKINg IN SPorT: froM STUdENT To PrACTITIoNEr oNLINE From Student to Practitioner

working in sport www.sportex.net

n 40 articles with 7 eLearning quizzes and multimedia enhancements n designed to help students training to work in manual therapy and sport rehabilitation, make the transition to a paid job n It covers 5 sections: fundamentals; Working in Manual Therapy; Professional Practice; Working in Sport and Communication Skills

NEW

Practical advice on Making the transition to the Pitchside

ANAToMy & SofT TISSUE INjUry rEvIEW oNLINE anatomy & soft tissue injury review by Dr Simon Kay

Written by sports physician, dr Simon Kaye, this is a perfect resource for anyone studying anatomy and sports injuries. n Includes 53 animations and video clips to bring the anatomy to life n A randomised quiz lets you check your learning as you study n Continuously updated with new animations added as they are developed

www.sportex.net Produced by

THE MASSAgE THErAPIST’S SUrvIvAL gUIdE oNLINE n Written by Australian soft tissue therapist robert granter, this guide offers a wealthy of information on surviving life as a massage practitioner n It covers 8 areas: How to seek appropriate mentors; getting inspired about your profession; optimising your technique; optimising your treatment positions; Looking after yourself and avoiding injury; Using treatment therapy tools to relieve pressure on your body; Staying inspired and Protecting your business with adequate insurance

significant discounts available to both small and large training courses and colleges. Student subscriptions to sportEX medicine and sportEX dynamics also available. For more details about the content of the resources please visit the Manuals & Guides section at www.sportex.net and for pricing enquiries send me an email with approximate student numbers to tor@sportex.net

# therapyexpo

exhibitions, seminars, workshops for therapists

TherapyExpo 2014 is the UKâ&#x20AC;&#x2122;s dedicated Therapist event for hands on clinical therapists to experience the best choice of CPD Seminars and Workshops looking at Assessment, Intervention and Rehabilitation.

Join over 2,500 Physiotherapists, Osteopaths, Sports Therapists and Rehabilitation Therapists for 2 days this September to enhance your CPD and meet with like minded therapy professionals.

Over 85 CPD Sessions to choose from including: Current thinking on Assessing Trunk Movement Dysfunction Dr Lee Herrington Platelet Rich Plasma (PRP) for Tendon healing: Panacea or Placebo Adam Watts

The Biomechanics of Running & identifying running related injuries Mike Antoniades Achilles Tendinopathy Where do we go after eccentric exercise?

Advances in Knee Ligament Reconstruction Sanjay Anand Functional Rehabilitation of Shoulder Injuries Nicola Phillips

The Myth of Overpronation Ian Griffiths Biomechanical screening for Lumbo-Pelvic Dysfunction Mike Grice The Tendinopathy Continuum Daniel Lawrence

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