sportEX Medicine Journal Issue 62 - October 2014 by Co-Kinetic

ISSUE 62 Oct 2014 ISSN 1471-8138

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n latest research news n research analysis n Knee menisci injuries

medicine n hamstring injury prevention - part 2

n assessment techniques for water based athletes

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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. ■ 29 articles, many with multimedia animations, technique video clips and related quizzes to reinforce learning and retention of key points ■ 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 ■ Access on all major mobile platforms (iPad, Android, Kindle Fire) as well as online mobile device

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TRANSLATING MANUAL THERAPY RESEARCH INTO HANDS ON PRACTICE

contents oCTober 2014 issue 62 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

oct 2014

One of the challenges of content development and production these days is that firstly there is so much free information out there and secondly delivery/ presentation opportunities are growing all the time. I often say that these days I work more in technology than I do in content production (luckily I love both!). Did you know that we actually produce five versions of every issue of sportEX medcine? There’s the print version, the online (website) version and then the three variations on the apps (Apple, Google, Kindle Fire). Each one requires individual set up and formatting. However these challenges are also opportunities because we can use our community of expertise to identify these free resources and filter out the wheat from the chaff so that you don’t have to. One of the missions of sportEX has always been to save you time, and that gets more and more important as the volume of web content grows. This is what we aim to achieve through both our Journal watch pages and our Social watch (Twitter in the case of this issue) at the back of the journal. In September I gave the green light to phase one of the development of our new web platform (more nerding for me!). Without giving too much away, the ambition is that this will be a game changer for both our sports medicine industry but also for provision of content in a business to business context. It’s a bold goal but I believe an achievable one. Unfortunately I won’t have anything to show you until the first quarter of next year but the community it will help to facilitate will be great for our members. In the meantime enjoy Autumn and enjoy this issue. Tor davies, physio-turned publisher and sportEX founder tor@sportex.net

oTHer TiTLes in X range THe sporTeX 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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sportEX is printed in the UK by cambrian Printers ltd, award-winning colour printing specialists, independently audited to ISO 14001 and EMAS environmental standards. sportEX is printed on paper from FSc certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

4 Journal watch 8 research reviews 12 Knee menisci 19 Hamstring injury - part 2

The latest key research from this quarter Screening for DVT; T4 syndrome

Structure, function and common injuries Prevent hamstring injuries in footballers

ConTenTs 28 assessment techniques

Is the single leg squat an appropriate assesment technique in waterbased activities?

33 Twitter resources

Some of this quarter’s best resources

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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 initial 42 patient encounters and 17 first follow-up visits to physiotherapists were recorded. The patients were adults with back pain referred by a GP. From this, a list of 11 key clinical opening questions were identified for the initial visit and 7 for the start of a follow-up visit. The wording of these questions was then used as the base for a national survey via the interactive Chartered Society of Physiotherapy (iCSP) website to determine clinicians’ preferences. Among the 43 physiotherapists who responded, the

OpENING CLINICAL ENCOuNTERS IN AN AduLT muSCuLOSKELETAL SETTING. Chester EC, Robinson NC, et al. manual Therapy 2014;19(4):306–310 preferred ‘key clinical question’ for an initial encounter was, “Do you want to just tell me a little bit about [problem presentation] ﬁrst of all?”, and for follow-up encounters, “How have you been since I last saw you?” Number 8 in the initial list was, “Do you want to tell me your story?” Number 7 on the follow-up list was, “What was the take home message that you got from me last time”.

sportEX comment According to the authors, “These results provide an important and novel contribution to the profession”. There are 52,000 members of the CSP yet only 43 completed the survey. Guess the vast majority don’t think it’s important at all.

EvIdENCE BASEd mEdICINE: A mOvEmENT IN CRISIS? Greenhalgh T, Howick J, maskrey N. BmJ 2014;348:g3725 This is an essay by Tricia Greenhalgh, Professor of Primary Health Care at Queen Mary, University of London and a group of equally eminent colleagues. Its main points are that it is 20 years since ‘evidence based medicine’ with its reliance on randomised controlled trials became the driving force in health care. Unfortunately it is now in a state of crisis because: n The evidence based ‘quality mark’ has been misappropriated by vested interests n The volume of evidence, especially clinical guidelines, has become unmanageable n Statistically significant benefits may be marginal in clinical practice n Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred n Evidence based guidelines often map poorly to complex multi-morbidity. Each of these points is discussed as are the following which are what evidence based medicine should be: n Make the ethical care of the patient

the top priority n Demands individualised evidence in a format that clinicians and patients can understand n Is characterised by expert judgment rather than mechanical rule following n Shares decisions with patients through meaningful conversations n Builds on a strong clinician-patient relationship and the human aspects of care n Applies these principles at community level for evidence based public health. The following actions are required to deliver real evidence based medicine: n Patients must demand better evidence, better presented, better explained, and applied in a more personalised way n Clinical training must go beyond searching and critical appraisal to hone expert judgment and shared decision making skills n Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what

purposes, and under what constraints n Publishers must demand that studies meet usability standards as well as methodological ones n Policy makers must resist the instrumental generation and use of ‘evidence’ by vested interests n Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence n The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from over-diagnosis.

sportEX comment We make no apology for devoting so much Journal Watch space to one piece. In the field of manual therapy study after study tells us that there is little evidence for the efficacy of hands on treatment in its

sportEX medicine 2014;62(October):4-7

JOURNAL WATCH

Journal Watch A ACCuRACy Of CLINICAL TESTS IN THE dIAGNOSIS Of ANTERIOR CRuCIATE LIGAmENT INJuRy: A SySTEmATIC REvIEW. Swain mS, Henschke N, et al. Chiropractic & manual Therapies 2014;22:25 This review searched the main medical databases up to June 2013 and found 285 full-text articles comparing the accuracy of clinical tests for anterior cruciate ligament (ACL) injury to an acceptable reference standard of arthroscopy, arthrotomy or MRI scan. Risk of bias was appraised using the QUADAS-2 checklist. From the original list, 14 studies were included. Nine clinical tests from the history (popping sound at time of injury,

giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman’s test, prone Lachman’s test and pivot shift test) were investigated for diagnostic accuracy. Positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy.

sportEX comment various forms and, as is pointed out here, that becomes a management strategy. Why hire a therapist when the evidence suggests it is more cost efficient to do nothing or prescribe a pill? Yet every manual therapist reading a study stating that massage, mobilisation and manipulation don’t work thinks, “Hang on I’ve just done that to hundreds of patients and achieved a positive outcome so why am I being told otherwise?” The answer is that the evidence gathering process is flawed. It is not asking the right questions of the right people. At last a few forward thinkers are questioning the whole process. Everybody should be doing it. Evidence based medicine (EBM) sounds great on paper but the reality is that it is turning musculoskeletal medicine into ‘rest and take a pain killer’. If you want to know more about why the research behind EBM is flawed, read Loannidis JPA, ‘Why most published research findings are false’, PLOS Medicine 2005, available free at http://spxj.nl/1pA5mB2

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Oh dear. The answer to this is easy. If there is the slightest suspicion, scan the knee.

T EffECT Of BuRN REHABILITATION THE mASSAGE THERApy ON HypERTROpHIC SCAR AfTER BuRN: A RANdOmIZEd CONTROLLEd TRIAL. Choa yS, Jeona JH, et. al. Burns 2014;doi:10.1016/j.burns.2014.02.005 One hundred and forty-six burn patients with hypertrophic scar(s) were randomly divided into an experimental group and a control group. All received standard rehabilitation therapy for hypertrophic scars and 76 patients additionally received burn scar rehabilitation massage therapy. The scores of both VAS pain and itching scale decreased significantly in both groups. The massage group showed significantly better scar characteristics (scar thickness, melanin, erythema, transepidermal water loss, scar elasticity, immediate distension and gross skin elasticity).

sportEX comment We included this piece of research to prove that the apparently lost art of soft tissue therapy is alive and well and has a meaningful clinical application.

Imp ImpACT LOCATIONS ANd CONCuSSION OuTCOmES IN HIGH SCHOOL fOOTBALL pLAyER-TO-pLAyER COLLISIONS. Kerr Zy, Collins CL, et al. pediatrics 2014;doi:10.1542/ peds.2014-0770 Data from a National High School (USA) Sports-Related Injury Surveillance Study (2008/2009– 2012/2013) was analysed to calculate rates and describe circumstances of American football concussion (eg. symptomology, symptom resolution time, return to play) resulting from player-toplayer collisions by impact location (ie. front-, back-, side-, and top-of-the-head). It was found that most concussions resulting from player-to-player collisions occurred from front-of-the-head (44.7%) and side-of-the-head (22.3%) impacts. Number of symptoms reported, prevalence of reported symptoms, symptom resolution time, and length of time to return to play were not associated with impact location. A larger proportion of concussions from top-of-the-head impacts experienced loss of consciousness (8.0%) than those sustaining concussions from impacts to other areas of the head (3.5%) Players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the-head impacts (86.4%) than concussions from impacts to other areas of the head (24.0%).

sportEX comment Concussion is a hot topic. In the USA the NFL is facing a major lawsuit from retired players. In California a group of ‘soccer moms’ have started a class action against the football (Association not American) world governing body FIFA alleging, “there is an epidemic of concussion injuries in soccer at all levels around the world” and, “FIFA presides over this epidemic and is one of its primary causes” due to its role in making the rules. Both Rugby codes in the UK have recently issued new guidelines. Check out the RFU website for more information. Their campaign is called ‘Headcase’ (http://spxj.nl/1B9yO3A).

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

A RANdOmIZEd CONTROLLEd TRIAL Of ECCENTRIC vS. CONCENTRIC GRAdEd ExERCISE IN CHRONIC TENNIS ELBOW (LATERAL ELBOW TENdINOpATHy). peterson m, Butler S, et al. Clinical Rehabilitation 2014;28(9):862–872 One hundred and twenty sufferers of tennis elbow lasting more than 3 months were given either an eccentric or concentric exercise regime which involved lowering or lifting a weight, at home daily, for 3 months with gradually increasing load. Results: the eccentric exercise group had faster regression of pain, with an average of 10% higher responder rate at all levels of pain reduction, both during muscle contraction and elongation. The eccentric group also had a greater increase of muscle strength than the concentric and the differences persisted throughout the follow-up period 6 and 12 months. There were no significant differences between the groups regarding function or quality of life measures.

sportEX comment This is similar to studies on tendons. They seem to respond better to eccentric loading. f fuNCTIONAL OuTCOmES AfTER SuRGICAL mANAGEmENT Of ARTICuLAR CARTILAGE LESIONS IN THE KNEE: A SySTEmATIC ARTIC LITERATuRE REvIEW TO GuIdE pOST-OpERATIvE REHABILITATION. Schmitt LC, Quatman CE, et al. Journal of Orthopaedic & Sports physical Therapy 2014;44(8):565 uRINATION dIffICuLTIES duRING dOpING CONTROLS: AN ACT Of REBELLION? Elbe A-m, Brand R. Journal of Clinical Sport psychology 2014;8(2)204–214 Apparently approximately 1/2 of all athletes suffer at least once from urination difficulties during dope tests. This study involved 187 German-speaking athletes participating in elite sports at the national team level. In addition to demographic data and information about doping controls, the Psychogenic Urine Retention during Doping Controls Scale (PURDS) and Therapeutic Reactance Scale (TRS) were used. The results indicate that reactance correlates negatively rather than positively to urination difficulties during doping controls.

sportEX comment If you have ever had to hang around for hours waiting for an athlete to produce a sample you will relate to this. We confess that we had to look up what ‘reactance’ meant. To quote Wikipedia, “It is a motivational reaction to offers, persons, rules, or regulations that threaten or eliminate specific behavioural freedoms”. It occurs when a person feels that someone or something is taking away his or her choices or limiting the range of alternatives. The surprising result here was that the athletes most likely to display reactance were not the ones most strongly affected. It was the ones most likely to want to comply with the regulations that couldn’t pee. The paper suggests cognitive-behavioural therapy, relaxation or education that many other athletes can’t fill the bottle either. 6

A search of the usual data bases from inception to September 2013 for studies pertaining to muscle performance, knee joint biomechanics, and performancebased measures of function following articular cartilage procedure in the knee resulted in the discovery of 16 articles. Seven evaluated muscle performance, all showing persistent deficits in quadriceps femoris muscle strength for up to 7 years postoperative procedure. Quadriceps femoris strength deficits of greater than 20% were noted in 33% and 26% of individuals at 1 and 2 years following microfracture and autologous chondrocyte implantation (ACI), respectively. Two studies evaluated knee mechanics post-ACI, showing persistent deficits in knee kinematics and kinetics for up to 12 months postoperative procedure compared to uninjured individuals. Seven studies showed improved functional capacity (6min walk test) over time, and three studies showed persistent performance

deficits during higher-level activities (single-leg hop test) for up to 6 years post-procedure. Five studies comparing weightbearing protocols (accelerated versus traditional/current practice) following ACI found few differences between the groups in function and gait mechanics; however, persistent gait alterations were observed in both groups compared to uninjured individuals.

sportEX comment Significant lack of strength, gait deviations, and functional deficits 5 to 7 years following ACI and microfracture surgical procedures suggest that either the procedures weren’t done well or the rehab wasn’t or both. Or maybe it’s time to skip the cartilage repair and go straight to a full or partial knee replacement. However, a report by Riddle DL, et al. in Arthritis & Rheumatology 2014;66(8):2134– 2143, suggests that 1/3 of the knee replacements in the USA are inappropriate, so you can’t win. sportEX medicine 2014;62(October):4-7

JOURNAL WATCH

pREvALENCE ANd INCIdENCE Of CARTILAGE INJuRIES ANd mENISCuS TEARS IN pATIENTS WHO uNdERWENT BOTH pRImARy ANd REvISION ANTERIOR CRuCIATE LIGAmENT RECONSTRuCTIONS. Wyatt RWB, Inacio mCS, et al. American Journal of Sports medicine 2014;42(8):1841–1846

Am mANdATEd CHANGE IN GOALIE pAd WIdTH HAS NO EffECT ON ICE HOCKEy GOALTENdER HIp KINEmATICS. Wijdicks CA, philippon mJ, et al. Clinical Journal of Sport medicine 2014;24(5):403–408 This study examined whether or not equipment changes imposed by a sports rule makers has an effective on the kinematics of the actual players. In this case it was the width of an ice hockey goalies pads being reduced from 30.5 to 27.9cm and the effect (if any) this would have on hip kinematics. Ten male ice hockey goaltenders at the Midget AA level or higher (15–18 years) performed butterfly motions wearing three different widths of leg pads in a randomised order: their own 27.9cm, standard 27.9cm, and standard 30.5 cm. The butterfly manoeuvre involves the keeper falling to the knees whilst internally rotating the hips which allows the pads on both legs to lie flat on the ice. The knee ground reaction force upon landing was 1.45 ± 0.43 times the body weight. Hip internal rotation was reduced when goaltenders wore their own, previously ‘broken-in’ set of pads as compared with the set of standard new 27.9cm pads (17.5 ± 4.8 v. 20.1 ± 4.8°, respectively).

sportEX comment This study had an admirable intention but does it go far enough? It is a pity that they didn’t include data on the knee because the butterfly save gaps the medial knee joint. The Journal Watch editor’s experience in a similar rule change in adult ice hockey was that over time the keepers complained of medical knee pain. At least this study eliminates the hip as a root cause of that pain.

Two hundred and sixty-one patients who underwent primary and then revision anterior cruciate ligament reconstructions (ACLR) from February 2005 to September 2011 were identified using a community-based registry. Revision ACLR was performed for instability in 256 patients (98%) and for infection in 5 patients (2%). The prevalence of cartilage injuries increased from 14.9% at primary ACLR to 31.8% at revision ACLR. The prevalence of meniscus tears decreased from 54.8% at primary ACLR to 43.7% at revision ACLR. The prevalence of lateral meniscus tears was 32.2% at primary ACLR but only 18.4% at revision ACLR, while the prevalence of medial meniscus tears was the same at primary and revision ACLRs (32.6%). Patients who underwent meniscus tear treatment at primary ACLR had a 70.8% prevalence of meniscus tears at revision ACLR.

sportEX comment Between primary ACLR and revision ACLR, the prevalence of articular cartilage injuries increased, while the prevalence of meniscus injuries decreased. Why is speculative. It may be because the articular cartilage injuries are new injuries. The change in menisci injury could be because during primary surgery the areas susceptible to injury were dealt with. Both could be as a result of changes in knee kinematics or injury exposure patterns. The worrying statistic is that 98% of the revisions were due to instability, which suggests that all was not right either at the operation stage or during rehabilitation.

pREvALENCE ANd pREdICTORS Of AdOLESCENT IdIOpATHIC SCOLIOSIS IN AdOLESCENT BALLET dANCERS. Longworth B, fary R, Hopper, d. Archives of physical medicine and Rehabilitation 2014;doi: http://dx.doi.org/10.1016/j.apmr.2014.02.027. Thirty dancers between the ages of 9 and 16 years were recruited from a certified dance school in Western Australia; each dancer provided a consenting age-matched non-dancer (n=30). Measurements were taken for angle of trunk rotation using a scoliometer to assess the presence of scoliosis, and height and weight to produce generalised joint hypermobility using Beighton criteria and an age-adjusted BMI. A subjective questionnaire regarding age of menarche and participation in dance and other sports was completed. Thirty percent of dancers tested positive for scoliosis compared with 3% of non-dancers. Odds ratio calculations suggest that dancers were 12.4 times more likely to have scoliosis than non-dancers of the same age. There was a higher rate of hypermobility in the dancer group (70%) compared with the non-dancers (3%); however, there were no statistically significant relations between scoliosis and hypermobility, age of menarche, BMI, or hours of dance per week.

sportEX comment Adolescent dancers are at a high risk of developing scoliosis. Parents, teachers and therapists need to be vigilant so that the problem can be spotted early and surgical intervention avoided.

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BY Joseph Brence DpT, coMT, DAc While recently completing my post-doctoral fellowship (AAoMPt) training at Sports Medicine of Atlanta, I came across two patient scenarios that warranted immediate medical attention. Both situations were caught during my medical screening and both were related to potential deep venous pathology. In this article I wanted to share the clinical scenarios and the screening protocol for this serious condition.

clinicAl scenArio 1 A 32-year-old male presented with primary complaints of bilateral, distal-medial thigh pain following a car accident. he reported that the injury was a direct impact of the distalmedial thighs against the steering wheel. Since the accident he has been sedentary while waiting for his injuries to heal. he had sustained a C2 fracture, which was being treated by a local neurologist. he also reported a past medical history of congestive heart failure and chronic obesity (1.78m/172kg), which was currently being managed by a cardiologist. he saw both physicians before coming to us. During visual inspection of his thighs, I noted a significant amount of ecchymosis distally, accompanied by ‘softball-sized’ pockets of fluid on the inside of either thigh (just proximal to the knee). these felt ‘hard’ and ‘warm’, and were painful to light touch. he also had entire leg swelling (bilaterally) and a significant degree of calf swelling (the more ‘symptomatic’ leg measured 5cm larger than the less ‘symptomatic’ leg). on palpation, he demonstrated pitting oedema which took 20s to rebound. the rest of the objective examination was completed with no major signs noted (all special testing of the knee and hip was negative). After this part of the exam he said, “By the way, I had a blood clot travel up to my lung three years ago.” A Wells clinical prediction rule (CPr) was administered next.

our regular research reviewer, physical therapist Joseph Brence, reviews two clinical scenarios that resulted in referral of the patient to A&E for Doppler ultrasound scans for deep vein thrombosis.

The imporT imporT Tance ance of medical screening for deep venous pa paT Thology Wells clinical prediction rule for deep vein thrombosis (DVT): 1. Active cancer (treatment ongoing or within previous 6 months): No = 0 2. Paralysis, paresis or recent plaster immobilisation of the lower extremities: No = 0 3. recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring anaesthesia: yes = 1 4. Localised tenderness along the distribution of the deep venous system: yes = 1 5. Entire leg swelling: yes = 1 6. Calf swelling at least 3cm larger than asymptomatic leg (measured 10cm below tibial tub): yes = 1 7. Pitting oedema confined in symptomatic leg: yes = 1 8. Collateral superficial veins (nonvaricose): No = 0 9. Previous DVt: yes = 1 10. Subtract 2 if there is an alternative diagnosis at least as likely as a DVt. Total score: 6 the score of this test demonstrated that this patient had a high likelihood for deep venous pathology. As a physical therapist, I was obliged to refer him to A&E because literature has indicated that any score >3 on this CPr indicates a high probability (75%) for DVt (1) (table 1). After a lengthy waitin A&E, a Doppler ultrasound scan revealed that this patient did not have deep venous pathology. Despite this negative result, I feel that I provided a proper referral based upon his subjective and objective signs and symptoms.

TABle 1: proBABiliTY of Deep Vein ThroMBosis AccorDing To The score froM The Wells clinicAl preDicTion rule. probability of DVT

Wells score

high

Moderate

1–2

Low

clinicAl scenArio 2 A 39-year-old body builder presented to our clinical following a recent meniscectomy to his right knee. he reported that he has been less active since the surgery, but is anxious to return to the gym. he reported that he had noted a significant amount of pressure in his right calf since the procedure and is concerned that he may have a clot. upon visual inspect of the calf, he had protruding collateral superficial veins on the symptomatic side and a significant side-to-side girth difference in calf size. upon palpation, his calf felt ‘hard’ and was painful to touch. his entire right lower extremity appeared to be swollen. his knee range of motion was limited to 105° of flexion with pain at end-range (in his calf). Again, I administered a Wells CPr:

Wells clinical prediction rule for DVT: 1. Active cancer (treatment ongoing or within previous 6 months): No = 0 2. Paralysis, paresis or recent plaster immobilization of the lower extremities: No = 0 3. recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring

sportEX medicine 2014;62(October):8-11

research review

anaesthesia: yes = 1 4. Localised tenderness along the distribution of the deep venous system: yes = 1 5. Entire leg swelling: yes = 1 6. Calf swelling at least 3cm larger than asymptomatic leg (measured 10cm below tibial tub): yes = 1 7. Pitting oedema confined in symptomatic leg: No = 0 8. Collateral superficial veins (nonvaricose): No = 0 9. Previous DVt: No = 0 10. Subtract 2 if there is an alternative diagnosis at least as likely as a DVt Total score: 4 Because he also scored >3, I was obliged to refer him to A&E. A few hours after leaving my clinic, this patient called and stated that a Doppler ultrasound

scan revealed that he indeed had a deep venous thrombosis. he was treated within the hospital and a few days later, released back to our care. When assessing the results of these two cases, we can see that the ‘number’ of predictors present weren’t accurate in predicting the patient who had the DVt. Simply the >3 criterion was helpful in determining who should be referred to emergency medical care. this tool has been validated and there appears to be a potential ‘economic impact’ when administered (there are three steps to validating a CPr and this is the third step). A 2012 study found that when presented with patients who have a suspected DVt, both physician judgement and the Wells CPr were able to safely

discriminate patients with and without DVt (2). the researchers further found that fewer patients were referred for ultrasonography when the CPr was used to guide decision making, thus resulting in a positive economic impact.

suMMArY overall, I hope these two clinical scenarios will highlight the value of medical screening and how the use of a simple tool, such as the Wells CPr, can screen for potential serious pathology. References 1. Wells PS, Anderson Dr, et al. Value of assessment of pretrest probability of deep-vein thrombosis in clinical management. Lancet 1997;350:1795–1798 2. geersing gJ, Weert h, et al. Diagnostic classification in patients with suspected deep venous thrombosis: physicians judgement or decision rule? British Journal of General Practice 2012;60:742–748.

T4 syndrome: a clinical example of The regional inT inTerdependence Theory – A clinicA clinicAl comment commentA Ary BY sTeVe KArAs Dsc, pT cMpT ocs, AnD AlBerT pAnnone Bsc, ATc

MusculosKeleTAl spine pAin Attempting to locate the exact cause of musculoskeletal pain in the spine has been shown to be a difficult, if not unattainable proposition. Numerous publications and treatment paradigms (all beyond the scope of this article) have detailed this in the literature, leaving us with more questions than when we started (1–4). Still, we know that spinal manual therapy works due to a list of research too large to include, but in the end as a profession, we cannot agree upon exactly why it works. the neurophysiological and mechanical ‘camps’ each have their rationale. thankfully, our patients are not concerned as to how it works, they are just grateful that it does work when included with appropriate education, exercise and adjunctive therapies.

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In this issue, the team at the Nxt gen Institute of Physical therapy guide you through improving your management of a range of symptoms that improve with therapy aimed at the thoracic spine. Whether the mechanisms involved are mechanical or neurophysiological, we see clinically and in the research, that treating an adjacent, related area can help in the management of spinal pain. Perhaps nowhere has this relationship been more extensively studied than in the recent articles detailing the use of thoracic spine thrust and non-thrust manipulation for the treatment of neck pain (5–7). the construct validity of the biomechanical perspective can be appreciated via thoracic spine movement as you actively move the neck. yet, a neurophysiologic explanation may be required to explain why thrust manipulation to the thoracic spine results in a change to lower trapezius strength (8,9). thrust manipulations to the thoracic spine improve neck pain

outcomes, and also have an effect on the lower trapezius strength; a muscle whose unilateral weakness has been correlated with neck pain (10).

regionAl inTerDepenDence regional interdependence may be the best model to explain the intricate results gained from thrust manipulation to the thoracic spine. the regional interdependence model has suggested four areas to evaluate and address when treating a patient’s pain: (1) musculoskeletal, (2) biopsychosocial, (3) neurophysiological and (4) somatovisceral (11–13). While this model appears to be a new concept, it has been seen in the past in the clinically relevant, yet evidentually weak, concept of t4 syndrome.

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T4 sYnDroMe t4 syndrome appears to have its genesis in the writings of Maitland, Bogduk, and grieve, has been mentioned in a paucity of articles since, and has found its way into modern texts (14,15). Explanation of the syndrome has been as inconsistent as the signs and symptoms attributed to it (table 1). Musculoskeletal symptoms such as bilateral and unilateral upper extremity pain referral and paresthesia, mid-thoracic hypomobility and aching, limited cervical range-of-motion, and temporomandibular joint (tMJ) pain have all been reported. Biopsychosocial issues such as loss of sleep and anxiety have been present in case research. Neurophysiologically, authors have cited swelling, conductance issues and temperature changes in patientsâ&#x20AC;&#x2122; hands and general neurovascular compression. Although from an observational standpoint only, patients with t4 syndrome have had somatovisceral issues such as

cardiac and oesophageal pain referral, head and neck pain, headache and autonomic nervous system dysfunction (15â&#x20AC;&#x201C;19). In all of the aforementioned cases, thrust or non-thrust manipulation directed to the fourth thoracic vertebrae has been suggested as a component of the treatment. While none of the authors could describe the exact mechanisms involved with this treatment, competent manual physical therapists would likely, in their examination of a patient with t4 syndrome complaints, assess the thoracic spine, discover areas of hypomobility, and treat it with manipulation and exercise. In one study, further implicating t4, patients were treated with epidural blocks at the t4 level, yielding alleviation of complaints (19). Clinically, we have all seen patients who have complaints that do not fit what we are expecting to find. Pattern recognition, while a sign of expert clinical reasoning, does not always

fit the patients we see. Because the reported signs of t4 syndrome are varied, and no high-level evidencebased research has been completed, it seems reasonable to suggest that most physical therapists have treated the syndrome (whether we have realised it or not) by treating positive findings from their screening examinations and using the regional interdependence model.

suMMArY While t4 syndrome represents a group of encountered complaints, it lacks the data generated by clinical research to warrant an independent diagnosis. research suggests that signs and symptoms consistent with spinal pathology can often not be labelled after a clinical exam or further special testing. We do a disservice to our patients by trying to name specific spinal pathologies, rather than using the best available evidence and our clinical experience to effectively alleviate their

TABle 1: signs AnD sYMpToMs of T4 sYnDroMe (KArAs & pAnnone, 2014) Author

Musculoskeletal

DeFranca (16)

n Mid-thoracic hypomobility n upper extremity paresthesia: unilateral or bilateral

Two case studies Evans (17) Focus piece

Conroy (18)

neurophysiological

somatovisceral n headache

n Forward head posture, kyphosis n Flat thoracic spine n upper extremity referred pain n Paresthesia in digits

n temperature changes in hands n Swelling in hands

n Cardiac pain or pain pattern n referred pain from heart or oesophagus

n Bilateral shoulder and hand pain n Bilateral hand paresthesia

n Loss of sleep n Anxiety

n Neurovascular compression

n head and neck pain

n Loss of sleep

n uE weakness and coldness n Allodynia n hypoalgesia

n headache

Two case studies (treated with t4 epidural block injection)

n thoracic spine aching pain and stiffness n Limited cervical spine roM n temporomandibular joint pain n upper extremity paresthesia bilateral

olson (15) Text

n upper thoracic spine hypomobility

n Bilateral upper extremity referred pain

n Autonomic nervous system affected

Case report Mellick (19)

Biopsychocosocial

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1. Wadell g. A new clinical model for the treatment of low-back pain. spine 1987;12:632–44 2. Delitto A, Erhard r, Bowling r. A treatmentbased classification approach to low back syndrome: identifying and staging patients for conservative treatment. Physical therapy 1995;75:470–485 3. Bialosky J, Bishop M, et al. the mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy 2009;14:531–538 4. Flynn t, teyhen D, Elliot D. A failed voyage: in search of the anatomical source of pain. Presented at the american Physical therapy association’s combined sections Meeting 2011, new Orleans, La, Usa 5. Cleland J, Childs J, et al. Immediate effects of thoracic spine manipulation in patients with neck pain: a randomized clinical trial. Manual therapy 2005;10:127–135

6. Cleland J, glynn P, et al. Short-term effects of thrust versus nonthrust mobilization/ manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical therapy 2007;87:431–440 7. Cross K, Kuenze C, et al. thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review. the Journal of Orthopaedic and sports Physical therapy 2011;41:633–643 8. Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. the Journal of Orthopaedic and sports Physical therapy 2004;34:713–22; discussion 22–4 9. Liebler E, turfano-coor L, et al. the effect of thoracic spine mobilization on lower trapezius strength testing. the Journal of Manual and Manipulative therapy 2001;9:207–212 10. Peterson S, Wyatt S. Lower trapezius muscle strength in individuals with unilateral neck pain. Journal of Orthopaedic and sports Physical therapy 2011;41:260–265 11. Suecki D, Cleland J, Wainer r. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of Manual and Manipulative therapy 2013;21:90–102

12. Wainner rS, Whitman JM, et al. regional interdependence: a musculoskeletal examination model whose time has come. the Journal of Orthopaedic and sports Physical therapy 2007;37:658–660 13. Cleland J, Mintken P, Boyles r. Integrated manual therapy and exercise for the cervicothoracic spine and shoulder: a regional interdependence approach. Presented at the american academy of Orthopaedic Manual Physical therapist’s conference 2012, san antonio, tX, Usa 14. grieve g. Common vertebral joint problems, 2nd edn. churchill Livingstone 1988. isBn 978-0443033650 15. olson K. Manual physical therapy of the spine. Saunders 2008. isBn 9781416047490 16. DeFranca g, Levine L. the t4 syndrome. Journal of Manipulative and Physiological therapeutics 1995;18:34–37 17. Evans E. the t4 syndrome: some basic science aspects. Physiotherapy 1997;83:186-189 18. Conroy J, Schneiders A. the t4 syndrome. Manual therapy 2005;10:292–296 19. Mellick g, Mellick L. Clinical presentation, quantatative sensory testing, and therapy of 2 patients with fourth thoracic syndrome. Journal of Manipulative and Physiological therapeutics 2006;29:403–408.

Th auThORs ThE JOsEph BREncE DpT, J cOMT, Dac c Joe is a physical therapist and clinical researcher from pittsburgh, pa, usa. he is also a fellowship candidate with sports Medicine of atlanta, Ga, usa. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and determining how it applies to physical therapy practice. he is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising of pain, the effects of mobilising v. manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain

syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the blog www.forwardthinkingpt.com. sTEvE KaRas Dsc, pT cMpT Ocs p steve is a faculty member s at chatham university where he teaches basic sciences, orthopaedics and the spine, while maintaining regular clinical practice. he obtained his physical Therapy Doctorate from andrews university along with a certification in manual physical therapy from The north american Institute of Orthopedic Manual Therapy (naIOMT). his current research includes the evaluation of techniques and outcomes related to thoracic spine manual therapy. he also has studied and presented on methods of knowledge translation specific to manual

therapy techniques. he has presented nationally and internationally on these topics. Dr Karas is a member of the american academy of Orthopaedic Manual physical Therapist (aaOMpT) research committee, a reviewer for the Journal of Manual and Manipulative Therapy and Manual Therapy, and has contributed to the content of the american physical Therapy association (apTa) Orthopedic certification specialist (Ocs) examination. alBERT pannOnE Bsc, aTc albert is currently studying a for his Doctor of physical Therapy degree at chatham university after graduating u from Frostburgh state university with a bachelors of science in athletic Training. he enjoys working with acrobats and martial artists and is currently applying to residency programmes in Orthopedic physical Therapy.

complaints. Just because symptoms we encounter in our patients may have at one point been given a label, does not mean the label will assist us in resolving their complaints and improving their function.

references

The nxtgen institute of physical Therapy is a post-professional physical therapy continuing education residency and fellowship program based in the usA. nxtgen institute in association with foward Thinking pT have partnered with sporteX to produce regular editorial contributions. for more information visit www.nxtgeninstitute.com and www.forwardthinkingpt.com

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Knee menisci

BY Brendon skinner Bsc, Gsr, Paul ashworth Bsc and steve Bateman Bsc

Basic anatomical structure The word meniscus derives from the Greek word mēniskos meaning ‘crescent’, diminutive of mēnē, meaning ‘moon’ (1). The menisci are two fibrocartilaginous wedge shapes which are found between the femoral and tibial condyles of the knee (2). They are meniscal, or half-moon in appearance and they are attached to the tibial plateau on the medial and lateral aspect of tibia (Fig. 1; Animation 1), with the medial meniscus covering approximately 60% and the lateral meniscus covering approximately 80% of the tibial plateau (1–3).

This article provides an overview of knee meniscal injuries. The article reviews elements relating the structure and function of the medial and lateral menisci, the common mechanisms of injury, and the presentation of signs and symptoms following injury. The article also provides descriptions of the current assessment tests and procedures commonly used by practitioners in confirming diagnosis of this injury. Finally the article reviews the research literature that evaluates the accuracy, specificity, sensitivity and predictive values of each test.

The function of the menisci have been identified as: increasing joint congruity between the femur and tibia; increasing the proprioceptive reflexive feedback (4); absorption and transfer of load place upon the joint (2); and assisting the locking mechanism of the knee (3).

a smaller surface area on the tibial plateau (60%) it is the largest measuring meniscus anterior to posterior, with the posterior part being broader, this is due to its semicircular presentation (3). The anterior horn of the medial meniscus is attached to the anterior aspect of the intercondylar fossa, anterior to the anterior cruciate ligament. The posterior horn is attached to the posterior intercondylar fossa, attaching between the posterior cruciate ligament and the posterior horn of the lateral meniscus (1,3). The entire periphery of the medial meniscus is attached to the joint capsule which limits the available range of movement achieved (3). Some of the posterior fibres of the medial meniscus also have an insertion with the transverse ligament of the knee (3).

medial meniscus

lateral meniscus

Although the medial meniscus occupies

The lateral meniscus occupies a

role/purpose of the meniscus

greater surface area (80%) than the medial meniscus (60%), however, it measures shorter anteriorly to posteriorly, this is due to its 4/5 of a circle presentation (3). Makris et al. (5) documented the vascularity differences

Figure 1: Outline of meniscal appearance

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slideshow 1: menisci of the knee (sporteX, 2014)

ThE COMMOn MEChAnISM FOr A MEnISCAL Injury IS A pLAnTED FOOT wITh rOTATIOn OF ThE FEMur On ThE TIbIA wITh A FLExED knEE females it is 11–20 years (6,8). Meniscal tears have been reported to account for 10–20% of all orthopaedic injuries (9) and 50% of knee surgeries (10).

Presentation

within the menisci at particular ages. The authors identified the vascularity of the menisci from prenatal to shortly after birth and confirmed the menisci are fully vascularised, with the blood being supplied by the middle, medial and lateral inferior genicular arteries (3). At approximately 10 years of age, the vascularity is showing signs of abatement with only 10–30% of the menisci being vascularised (1). Once maturity has been achieved the menisci shows signs of vascularity in around 10–25% of the periphery (5). Due to the vascularity identification of the menisci there are two regions relating to the degree of blood they receive, the thick concave peripheral region is referred to as the red zone and the inner region which tapers to a free edge is referred to as the white zone, which is avascular (1,5). Subsequently, the location of the meniscal injury plays a huge part in whether the lesion will heal or not.

injurY of the meniscus mechanics of meniscal injury The common mechanism for a meniscal injury is a planted foot with rotation of the femur on the tibia with a flexed knee (3,6). Acute tears during sport generally involve non-contact events with an associated cutting movement with the knee in some degree of flexion, or even hyperflexion (7), or a tear during landing activities www.sportEX.net

that compromises the knee joint exposing it to the susceptible position of knee flexion and internal femoral rotation (7). The pathomechanics of injury expose the medial meniscus to be the most common meniscus to be torn (6,7). This is due to the movement of the meniscus during 0–120° knee flexion whereby the menisci move posteriorly. Goldblatt et al. (7) documented that the lateral meniscus moves 11.2mm, but that the medial meniscus only moves 5.1mm, with the deep fibres of the medial collateral ligament (MCL) and semimembranosus guiding the movement. The entire periphery of the medial meniscus is attached to the joint capsule (3), and also forms an attachment to the deep fibres of the MCL which also limits the overall movement possible (7). It is this decreased movement of the medial meniscus that exposes it to be torn more frequently than the lateral meniscus, with the middle and posterior portions being the most commonly torn area (3,6,7).

Prevalence It has been reported that incidence rate for meniscal tears was 60–70 per 100,000 people per year, with the ratio of male to female tears being between 2.5–4:1 (7,8). The peak injury incidence age for males has been identified as 21–30 years of age, whereas for

Meniscal injuries can be difficult to identify due to a proposed the lack of nociceptors located in the menisci (6); however, earlier studies by Day et al. (11) and Gray (12) confirmed there is nociceptive innervation to the menisci with the anterior and posterior horns being richly innervated and the outer third of the body of the menisci having a greater neural innervation than the middle third. The authors hypothesised this is due to the required biomechanical correction within the knee joint when it is loading the menisci too much laterally. To be accurate in assessing an athlete, a thorough history should be taken, including mechanism of injury as well as a using the appropriate special tests (8). Athletes presenting with a meniscus tear most commonly present with joint-line tenderness with a specific area of pain (6); audible confirmation at the time of injury is possible, with athletes reporting popping or clicking noise at the moment of femoral rotation on a fixed tibia (6). If ambulation is possible for the athlete with a meniscal tear, they may complain of a giving way sensation, or even a locked knee (6). Effusion is commonly delayed in appearance (24–48h post-injury).

meniscal injurY assessment tests There are five common assessment tools used alongside a thorough subjective assessment that are frequently used by therapist when forming a diagnosis. The methods of 13

application of these tests are described below.

mcmurray test lateral meniscus: with the patient in a supine position support the knee with one hand (fingers along the joint line) and hold the sole of the foot with the

online

Video 1: The McMurray test (Skinner, Ashworth & Bateman, 2014)

other. passively move the patient into full knee flexion. Medially rotate the tibia and extend the knee while applying a valgus force at the knee (the aim here is to ‘trap’ the meniscus between the tibial plateau and femur) (Video 1). medial meniscus: repeat with external rotation of tibia and applied varus force.

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Positive result: Snap or click at the joint line that is often accompanied by pain.

apley test The Apley test (Video 2) consists of two elements, the Apley’s Compression and Apley’s Distraction. During both phases the patient lies prone with the knee flexed to 90°. compression: now apply a compression force along the tibial axis from the heel while again rotating the tibia medially and laterally (this has been likened to grinding a pepper pot). This can be repeated at varying angles of knee flexion. As with the McMurray test, the aim is to trap the meniscus between the tibia and femur. distraction: using the therapist’s knee, anchor the patient’s femur to the couch. Grasp the tibia firmly and apply a distraction force along the lower leg. rotate the tibia medially and laterally while applying the distraction force. Positive result: rotation plus compression is more painful than rotation plus distraction. bilateral comparisons must also be considered.

thessaly test Video 2: The Apley test (Skinner, Ashworth & Bateman, 2014)

Video 3: The Thessaly test (Skinner, Ashworth & Bateman, 2014)

The patient stands in upright position with feet flat on the floor. The therapist supports the patient by holding their outstretched hands. The patient then stands on the effected leg and bends their knee to 5°. while supported, the patient then rotates their femur and body internally or externally three times (Video 3). repeat this procedure with the knee flexed at 20°. Positive result: Medial or lateral jointline discomfort possibly with a sense of locking or catching. n.B. Always perform this test on the non-symptomatic knee first to familiarise the patient with good form and technique and to facilitate a baseline non-symptomatic result.

ege’s test This is a weight-bearing test where the patient stands with feet 30–40cm apart and performs a variation of a squatting action (Video 4). medial meniscus: Instruct the patient to turn the feet into maximum external rotation and then perform a squat sportEX medicine 2014;62(October):12-18

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keeping feet flat on the floor. The distance between the knees will increase as the squat is performed. Instruct the patient to squat as deep as possible before slowly return to start position. lateral meniscus: repeat the above procedure with feet in maximal internal rotation. This time the distance between the knees will decrease. Positive result: pain and/or a clicking felt by the patient at the related site of the joint line. n.B. prevent further squatting as soon as pain or clicking is felt.

Video 4: Ege’s test (Skinner, Ashworth & Bateman, 2014)

joint-line tenderness (jlt) Instruct the patient to sit on the edge of the couch with knees hanging at 90°. The therapist then palpates along the lateral and medial tibiofemoral joint line (Video 5). Positive result: Focal pain is reported on palpation.

Video 5: Jointline tenderness test (Skinner, Ashworth & Bateman, 2014)

analYsis of research findinGs A wide range of clinical tests are used to diagnose meniscal pathology, with the five tests described above regularly forming part of a physical therapists practice. As practitioners’ knowledge and skills grow we continue to seek to establish which of our clinical tools are the most effective. Each of the tests described have been evaluated for their diagnostic accuracy, validity, sensitivity and specificity. Definitions of the clinical measures used in research to establish the effectiveness of each test can be seen in Table 1 in accordance with powel and huijbregts (13). by attempting to document each test along with its strengths and weaknesses we aim to provide practitioners with a broader understanding of the range of tools they use to assess meniscal tears. Akeski et al. (14) made comparisons between the McMurray test, joint-line tenderness (jLT) and a proposed new weight-bearing test, Ege’s Test, for their diagnostic value in an attempt to establish a more functional (mechanics replicating) test. Their findings report that 127 meniscal tears from the 150 tears diagnosed on arthroscopy were determined. In this investigation there were no statistically www.sportEX.net

ThE LOCATIOn OF ThE MEnISCAL Injury pLAyS A huGE pArT In whEThEr ThE LESIOn wILL hEAL Or nOT taBle 1: oPerational definitions of diaGnostic accuracY terms used in estaBlishinG the validitY of clinical tests for meniscal PatholoGY (Skinner, Ashworth & bateman, 2014) statistical measure

definition

calculation

sensitivity

The proportion of people who have the dysfunction/ condition who test positive

Tp / (Tp+Fn)

specificity

The proportion of people who do not have the dysfunction/condition who test negative

Tn / (Fp+Tn)

Positive predictive value

The proportion of people who test positive and who have the dysfunction/condition

Tp / (Tp+Fp)

negative predictive value

The proportion of people who test negative and who do not have the dysfunction/condition

Tn / (Tn+Fn)

accuracy

The proportion of true results (both true positive and true negatives) in the population. An accuracy of 100% indicates the test identifies all injured and non-injured people correctly.

= (no. of Tp + no. of Tn) / (no. of Tp + Fp + Fn)

tP, True positive; fP, False positive; fn, False negative; tn, True negative

taBle 2: summarY of the diaGnostic values rePorted BY akeski et al. (14) (Skinner, Ashworth & bateman, 2014) Diagnostic measure

joint-line tenderness Medial / Lateral

McMurray Medial / Lateral

Accuracy (%)

71 / 77

66 / 82

71 / 84

Sensitivity (%)

88 / 67

67 / 53

67 / 64

Specificity (%)

44 / 80

69 / 88

81 / 90

positive predictive value (%)

74 / 47

80 / 59

86 / 58

negative predictive value (%)

67 / 90

53 / 88

57 / 90

Ege’s Medial / Lateral

ThE ThESSALy TEST AT 20° hAD A 94% DIAGnOSTIC ACCurACy rATE In DETECTInG MEDIAL MEnISCuS TEArS AnD 96% FOr LATErAL MEnISCuS TEArS, AS wELL AS A prODuCInG LOw FALSE pOSITIVE rATES AnD LOw FALSE nEGATIVE rATES

significant differences between the three tests in detecting tears; however, better accuracy, specificity and sensitivity were found using the Ege’s test (findings summarised in Table 2). Findings indicated that the jLT gave higher accuracy rates but the specificity of the Ege’s tests was noticeably higher (81% compared to 44%). Lateral meniscal tears were more accurately reported than medial tears with the Ege’s test again providing better results when compared to the others. Developing further from Akeski et al.’s (14) notion of the need for more functional weight bearing tests, karachalios et al. (15) developed and investigated the Thessaly test. utilising 213 symptomatic and 197 asymptomatic patients, who were all assessed by magnetic resonance scanning (and arthroscopic surgery in the symptomatic group), were clinically examined using the jLT, McMurray, Apley’s Compression and Distraction tests and the new proposed Thessaly tests at 5° and 20° knee flexion, again using the same measures of validity as outlined in Table 1. The Ege’s test was not used for comparison within the study. Findings from this investigation highlighted the Thessaly test at 20° had a 94% diagnostic accuracy rate in detecting medial meniscus tears and 96% for lateral meniscus tears, as well as a producing low false positive rates and low false negative rates, leading the authors to state that this test has changed their clinical practice, using MrI scanning as a second-line screening test for patients whereby the mechanics, history, and examination indicate the presence of a disorder other than a meniscal injury. The authors state that this change in practice has allowed a reduction in the

taBle 3: values for diaGnostic Parameters of the clinical eXamination tests rePorted BY karachalios et al. (15) (Skinner, Ashworth & bateman, 2014) Diagnostic measure

joint-line tenderness Medial / Lateral

McMurray Medial / Lateral

Apley Medial / Lateral

Thessaly: 5° Medial / Lateral

Thessaly: 20° Medial / Lateral

Accuracy (%)

81 / 89

78 / 84

75 / 82

86 / 90

94 / 96

Sensitivity (%)

71 / 78

48 / 65

41 / 41

66 / 81

89 / 92

Specificity (%)

87 / 90

94 / 86

93 / 86

96 / 91

97 / 96

False positive (%)

8.8 / 9.3

4.2 / 12.4

4.6 / 13

2.9 / 8

2.2 / 3.7

False negative (%)

10 / 2

17.6 / 3.2

20 / 5.4

11.4 / 1.7

3.6 / 0.73

sportEX medicine 2014;62(October):12-18

EvidEncE informEd practicE

cost of diagnostic imaging and reduced the level of unnecessary MrI scanning. Table 3 summarises the key findings from the study. having identified previous inconsistencies in the diagnostic values reported in literature Chivers and howitt (16) provided a narrative review of orthopaedic literature into physical examination tests used for knee meniscal injuries. having provided a comprehensive review of the existing findings their review concludes by stating further investigation is needed to establish more advanced diagnostic methods. practitioners are encouraged to use a battery of test to support their diagnosis is needed, and greater evidence is needed in relation to which combination of tests provides the greatest level of accuracy, along with the need to combine physical assessments with history taking. The accuracy of any one single diagnostic test is stated to be dependent upon the skill of the examiner, and the range of meniscal tests available highlights

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taBle 4: summarY of ranGes for sensitivitY and sPecificitY of the different tests [Skinner, Ashworth & bateman, 2014: derived from Chivers & howitt (16)] test

sensitivity range (%)

specificity range (%)

McMurray

16–70

59–98

joint-line tenderness

55–95

15–97

13–41

80–93

Thessaly

65–92

80–97

Ege’s

64–67

81–90

Apley

the reliability of each individual test is questionable. Table 4 summarises the ranges of sensitivity and specificity reported across the studies included within this review.

conclusion Meniscal injuries have long been, and continue to be a frequently occurring injury to both professional and recreational athletes. Many attempts have been made to establish accurate and reliable diagnostic tools to support physical therapists diagnosis skills and

assist early detection. There are clear movements towards trying to develop more functionally relevant assessment procedures with the introduction of the Ege’s and Thessaly tests; however, a lack of agreement and clarity remains over which diagnostic tool is the most reliable. with therapists’ skills levels also reported to influence the accuracy of findings, therapists are encouraged to use a battery of tests and not rely on any given single procedure to ensure effective diagnoses are made.

references 1. Fox AjS, bedi A, rodeo, SA. The basic science of human knee menisci: structure, composition and function. orthopaedic Surgery 2012;4(4):340–351 2. Masouros SD, McDermott ID, et al. biomechanics of the meniscus-meniscal ligament construct of the knee. Knee Surgery, Sports traumatology arthroscopy 2008;16:1121–1132 3. palastanga n, Soames r. Anatomy and human movement: structure and function, 6th edn. churchill Livingston 2012. ISbn 978-0702053085. (paperback ( £37.99 £18.02 kindle) buy from Amazon spxj.nl/1uw4DME 4. Gabrion A, Aimedieu p, et al. relationship between ultrastructure and biomechanical properties of the knee meniscus. Surgical and radiologic anatomy 2005;27:507–510 5. Makris EA, hadidi p, Athanasiou kA. The knee meniscus: structure-function, pathophysiology, current repair techniques and prospects for regeneration. national institute of Health 2011;32(30):7411–7431 6. Anderson Mk, hall Sj, parr Gp. Foundations of athletic training: prevention, assessment and management, 4th edn. Lippincott Williams & Wilkins 2008. ISbn 978-0781784450 (£66.00) buy from Amazon http://spxj.nl/1lhu0Fz 7. Goldblatt jp, Lafrance rM, Smith jS. Managing meniscal injuries: the diagnosis. rheumatology network 2009;1–8 http://spxj.nl/VzZs5t 8. Maffulli n, Longo uG, et al. Meniscal tears. open access Journal of Sports medicine 2010;1:45–54 9. Logerstedt DS, Snyder-Mackler L, et al. knee pain and mobility impairments: meniscal and articular cartilage lesions. Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical Therapy Association. Journal of orthopaedic and Sports physical therapy 2010;40(6):1-69 10. harrison bk, Abell bE, Gibson Tw. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. clinical Journal of Sport medicine 2009;19(1):9–12 11. Day b, Mackenzie wG, et al. The vascular and nerve supply of the human meniscus. arthroscopy: the Journal of arthroscopic and related Surgery 1985;1(1):58–62 12. Gray jC. neural and vascular anatomy of the menisci of the human knee. Journal of orthopaedic and Sports physical therapy 1999;29(1):23–30 13. powell jw, hijbregts pA. Concurrent criterion-related validity of acromioclavicular joint physical examination tests: a systematic review. Journal of manual and manipulative therapy 2006;14:E19–E29 14. Akeski D, Ozcan O, et al. A new weight 18

bearing meniscal test and a comparison with McMurray’s Test and joint Line Tenderness. arthroscopy: the Journal of arthroscopy and related Surgery 2004;20(9):951–958 15. karachalios T, hantes M, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection on meniscal tears. Journal of bone & Joint Surgery (am) 2005;87:955–962 16. Chivers MD, howitt SD. Anatomy and physical examination of the knee menisci: a narrative review of the orthopaedic literature. Journal of canadian chiropractic association 2009;53(4):319–333.

further resources 1. Meniscal Injuries: Management and Surgical Techniques by jD kelly. ISbn 978-1461484868. (harcover £99.51 £94.53 kindle) buy from Amazon http://spxj. nl/1rm3w8l 2. Sports-Related Injuries of the Meniscus (Clinics in Sports Medicine) by pr kurveil. saunders 2012. ISbn 9781455739356. (hardcover £73.92 kindle edition £52.47) buy from Amazon http://spxj.nl/1vguI1b

n If a battery of tests all provide positive results should patients still be required to undergo an MrI scan? n Should therapists choose practical ability over the reliability of tests when choosing which assessment tool/test to choose? n Should more research be conducted to develop further or alternative DISCUSSIONS meniscal tests?

Th AuThOrS ThE BrEndOn SkinnEr BSc, GSr B Brendon is a lecturer on the Sports Therapy BSc degree course and award leader for the BSc Strength and conditioning (Fasttrack) course at Staffordshire university and has been lecturing on the Sports Therapy programme for over 8 years. Brendon can be contacted at Brendon.skinner@staffs.ac.uk. PAul AShwOrTh BSc P Paul is a lecturer on the Sports Therapy BSc degree course at Staffordshire university and has been lecturing on sports therapy for 3 years. Paul can be contacted at P.ashworth@staffs.ac.uk. STEVE BATEMAn BSc S Steve is the head of Sports Therapy at Staffordshire university. he has 20 years experience as a practising sports therapist and ran a number of successful sports therapy companies across Staffordshire. he has been lecturing in sport therapy since 2009. Steve can be contacted at s.j.bateman@staffs.ac.uk.

keY Points n The menisci are half-moon shaped in appearance and attached to the tibial plateau on the medial and lateral aspect of tibia. n The common mechanism for a meniscal injury is a planted foot with rotation of the femur on the tibia with a flexed knee. n Common symptoms of meniscal injury include swelling, instability, clicking, locking and joint-line tenderness. n The five common tests used for assessment of meniscal injuries include the McMurray, Apley, Thessaly, Ege’s and the joint-line tenderness tests. n Meniscal tears are reported to account for 10–20% of all orthopaedic injuries. n The accuracy of any one single diagnostic test is stated to be dependent upon the skill of the examiner. n Analysis of each assessment test indicates practitioners should use a battery of tests when assessing meniscal injuries.

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Literature review

Hamstring injury prevention in footbaLL Part 2 BY WAYNE GILL BSc, McSP

amstring injuries are the most prevalent injury in football, and serious concerns arise from the fact that hamstring injury and reinjury rates have not improved over the last three decades (1â&#x20AC;&#x201C;4). this may be the result of the game becoming more physically demanding, with higher speed and more intensive play than seen previously. additionally, the lack of decline in hamstring injury rates may also suggest that current practices aimed at preventing them have been ineffective (5). another supporting factor for focusing on the prevention of hamstring injuries is the recurrence rate. Hamstring injuries have been shown to have almost double the rate of recurrence in comparison with other sporting injuries, with 12% of hamstring injuries recurring in comparison with a 7% recurrence rate for all other injuries in football (3). therefore, the high injury rate and potential for recurrence enforces the need to produce a holistic prevention programme that has a specific aim of reducing this injury (6).

RISk fActoRS Preventing injury implies the identification and understanding of the factors leading to that injury. Such an approach could allow the development

this article provides the reader with an evidencebased update on the risk factors commonly associated with hamstring injuries in football. these risk factors have been classified into two groups: non-modifiable and modifiable. additionally, the reader is provided with a detailed insight of the prevention strategies and interventions used to nullify the modifiable risk factors and ultimately reduce hamstring injury rates. this article follows on from the article published in the Jan 2014 issue of sportEX medicine (issue 59). of the most appropriate strategy for reducing the risk (7). Understanding the individual risk factors for injury is important on the basis for developing preventive measures. risk factors are traditionally divided into two main categories: internal (intrinsic) and external (extrinsic). However, It would be more relevant to make a distinction between modifiable and non-modifiable (8). Despite this, hamstring injuries invariably result from the interaction of several modifiable and non-modifiable risk factors.

NoN-ModIfIABLE RISk fActoRS Previous injury Following a hamstring injury soccer players have more than twice as high a risk of sustaining a new hamstring

injury (9,10). a number of suggested maladaptations that can occur after hamstring-strain injury are thought to contribute to the increased risk of future injury. these maladaptations include the formation of immature scar tissue, which has been associated with reduced flexibility, muscle weakness and alterations in motor control (11,12). the connective (immature) scar tissue is the weakest point of the injured muscle, with full strength taking time to return depending on the size and localisation of the injury (13). However, mature scar tissue is stiffer or even stronger than healthy muscle (13). therefore, it appears plausible that athletes may be returning to sport before a sufficient amount of muscle healing is complete (13). additionally, it is suggested that the proliferation of

HamStrIng InJUrIES HavE bEEn SHown to HavE almoSt DoUblE tHE ratE oF rEcUrrEncE In comParISon wItH otHEr SPortIng InJUrIES www.sportEX.net

a study on English soccer players reported players older than 22 years of age had a significantly higher risk for hamstring injuries than players younger than 22 years of age (3). additionally, it has been estimated that the odds for sustaining a hamstring injury increased 1.8 times for each 1 year increase in age for English soccer players (17). Different theories have been proposed linking hamstring injuries to age. the most common theory relates to hamstring muscle denervation due to l5 and S1 nerve impingement caused by agerelated lumbar spine degeneration. Furthermore, it hass been suggested that entrapment of the l5-S1 nerve root could also be caused by hypertropthy of the lumbosacral ligament (5).

Anatomy and architecture the biceps femoris (bF) is the most

(a) Short head of biceps femoris

Different hamstring injury rates in athletes of different races have been repeatedly reported in the literature. australian football players who were of aboriginal descent had a significantly

Power (W)

Long head of biceps femoris

Ethnicity

Activation

Age

commonly injured hamstring muscle, accounting for 84% of all hamstring strains (2). the anatomy of the bF may help explain its higher rate of injury. Firstly, it has a long and a short head, both with separate nerve supplies (18). this dual innervation may result in mistimed uncoordinated contractions, leading to reduced force production and greater instability of the muscle when faced with rapid eccentric contractions (6). variations in muscle architecture may also explain the high rates of muscle specific hamstring strain injuries. For example, the bF short head possesses much longer fascicles but a much smaller physiological crosssectional area compared with the bF long head (19). longer fascicles allow for greater muscle extensibility and reduce the risk of over lengthening during eccentric contraction (5). However, the bF long head, which undergoes the greatest lengthening of all the muscles during sprinting, has shorter fascicles compared with the bF short head (Fig. 1) (5,7,20). thus, the bF long head is predisposed to repetitive micro-trauma and injury (5,20).

ΔL (mm)

scar tissue can cause adjacent muscle fibres to experience greater strain during eccentric contractions and resulting in a greater risk for re-injury (14). also, a past history of injuries to the knee, calf, and osteitis pubis has been linked to hamstring strain injuries (15). remaining deficits in physical conditioning or neuromuscular control, or altered movement patterns after a previous injury may provide a link to anatomically unrelated injuries (16).

higher risk of hamstring muscle injuries in comparison to players of other races (21). additionally, it has been reported that English professional soccer players of african descent have a significantly higher risk of hamstring strain injury in comparison to players of other races (3). both high proportions of type II fibres and excessive anterior pelvic tilt have been suggested as factors in the incidence of hamstring strain injuries in these populations (3,16).

ModIfIABLE RISk fActoRS fatigue Studies in professional soccer have reported that hamstring injuries tend to occur at the end of each half, suggesting that fatigue may be a risk factor for these injuries (1,3). Hamstring fatigue has been associated with decreased eccentric strength, reduced motor proprioception and motor control, and alterations in running mechanics (22–24). Small et al. (23) reported hamstring fatigue in soccer players resulted in changes to running mechanics including an increase in anterior pelvic tilt, while hip flexion and knee extension were reduced. collectively these changes cause a shorter stride length and a reduction in hamstring length. therefore, any sudden increase in hamstring length in a fatigued state

Biceps femoris long head

(b)

0 50

Time of peak stretch

-50

Energy absorption

400

-400

Gait cycle (%)

100

Figure 1: The anatomy (a) of the long head of biceps femoris and its positioning during the gait cycle (b). [From Heiderscheit BC, et al. JOSPT 2010;40(2):67–81 (7)]

sportEX medicine 2014;62(October):19-27

Literature review

may result in the lower leg being uncontrollably ‘whipped’ through, potentially creating additional strain on an already tight musculotendinous unit and increasing injury risk (5,24). thus, deficits in proprioception when fatigued may elevate the risk of hamstring strain injuries. additionally, it has been reported that fatigue causes a decrease in eccentric hamstring strength (23). this could potentially impair the ability of the hamstrings to decelerate the limb effectively to avoid risk of injury, especially within a reduced range-of-motion (rom) and with proprioception deficits.

Shortened optimum angle of peak tension many believe that athletes who produce peak tension at shorter lengths are more likely to be injured (25). this is because a shorter optimum length would mean that the hamstrings would be expected to work on the descending portion of the length–tension relationship across a greater rom, leaving them prone to injury. a retrospective study identified the optimum length as a risk factor for hamstring injury with previously injured hamstrings producing peak tension at 12.7° less than the uninjured hamstring (ie. shorter optimum length) (26). However, it is not known if this was the cause of, or the result of the injury given the retrospective nature of the study. It is therefore possible that previously injured hamstring muscles may display a decrease in the optimum angle as a result of post injury morphological changes caused by scar tissue remodelling (14).

Strength Imbalances Bilateral hamstring asymmetry It has been frequently proposed that a significantly weaker hamstring on one leg compared with the contralateral leg, termed hamstring bilateral asymmetry, may predispose the weaker hamstring to an elevated risk of injury (27). Studies have reported that a greater than 10% bilateral deficit in isometric strength was a predictor of hamstring injury (28,29). Elite australian footballers with a bilateral concentric

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asymmetry of 8% or more were found to have an increased risk of hamstring strain injuries (30). However, a study on soccer players reported while eccentric hamstring strength asymmetries were predictive of hamstring strain injuries, concentric strength asymmetries were not (31). assessment of eccentric strength may be a more meaningful marker of muscle weakness especially as the injury mechanism associated with hamstring strains is eccentric overload (32). Hamstring to quadriceps ratio Studies have reported an increased risk of hamstring strains with a decrease in conventional hamstring to quadriceps (H : Q) ratio (concentric hamstrings to concentric quadriceps) (30,33). a study on athletes reported a conventional H : Q ratio of less than 0.6 significantly increased the risk of hamstring injury by 17 times (33). additionally, orchard et al. (1997) also found a conventional H : Q ratio of less than 0.61 substantially increased the risk of injury. therefore, it has been suggested that a conventional H : Q ratio of less than 0.6 (<60% concentric strength) would indicate a strength imbalance between the hamstrings and quadriceps which could predispose one to injury. more recently, the functional H : Q ratio (eccentric hamstrings to concentric quadriceps) has been popularised and reflects the force length and velocity properties of the agonist–antagonist knee muscle (31,34). In principle, this ratio is more useful in determining an injury risk because the relationship describes the ability of the eccentrically acting hamstrings to break the action of the concentrically contracting quadriceps during the swing phase of the gait cycle. croisier et al. (33) found that soccer players with uncorrected muscle imbalances, which included a conventional H : Q ratio below 0.45 and a functional ratio below 0.80 were 4.6 times more likely to sustain a hamstring strain compared with the players without strength imbalances. these findings provide the strongest evidence available that sufficient functional H : Q ratios protect players from hamstring injuries.

HamStrIng InJUrIES InvarIably rESUlt From tHE IntEractIon oF SEvEral moDIFIablE anD non-moDIFIablE rISk FactorS 21

additionally, the onset of hamstring injury in elite sprinters was related to hamstring weakness during eccentric contraction across the knee (knee flexion) and concentrically across the hip (hip extension) (35). thus, it may be important to also assess the concentric strength of the hip extensors (gluteals and hamstrings).

Neuromuscular control Protection against muscle strain is provided not only by strong muscles but also by the appropriate timing and magnitude of neural control (36). In other words, an athlete can be very strong but have poor motor patterns and neuromuscular control. throughout the running cycle there are many neuromuscular events. For example, the hamstrings control hip and knee motion in late swing and provide hip extensor torque in early stance. additionally, the main functions of the gluteus maximus muscle are to control trunk flexion of the stance leg, decelerate the swing leg and provide powerful hip extension (37,38). During sprinting, these muscles actions occur over a short period of time, and if the control and coordination are inadequate, then muscle strain injury may occur (39). Indeed, reduced hip extension strength has been shown to be a risk factor for hamstring strains in elite sprinters (35). therefore any alteration in gluteus maximus activation, strength or endurance places greater demand on the hamstrings to control hip extension of the stance leg and decelerate the leg during the swing phase (40).

flexibility Hamstring flexibility It is proposed that greater flexibility may reduce the risk of strain injury due to a greater ability of the passive components of the musculotendinous unit to absorb energy as a result of greater compliance (41). However, the literature contains controversial findings regarding the association between hamstring flexibility and the risk of injury. Several studies have reported an association between poor hamstring flexibility and hamstring injuries in professional soccer players

(41–43). witvrouw et al. (41) found that hamstring flexibility of less than 90° in a passive straight leg raise (Slr) correlated significantly with future hamstring injuries. Henderson et al. (42) also reported poor flexibility as measured using the Slr test was significantly associated with increased susceptibility for hamstring injury. Furthermore, it was demonstrated that for every 1° decrease in Slr, propensity for injury is increased by 1.29. In support of these findings, bradley & Portas (43) reported that players who sustained a hamstring strain during the season had a preseason hamstring rom approximately 3° less than that of the uninjured players. on the other hand, studies have also failed to demonstrate a significant correlation between poor hamstring flexibility and hamstring injuries in soccer players (31,44). the differences in the results may be attributed to the different measurement techniques employed. a number of hamstring length tests including the Slr, active knee extension (akE), passive knee extension (PkE), and the sit and reach (Sar) test have been used to measure hamstring flexibility. However, no ‘gold standard’ measurement for flexibility has been established (45). Furthermore, it has been suggested that even if measurements were reproducible, there is no means of determining whether a subject has been stretched to their maximal rom (46). Hip flexor flexibility the flexibility of other muscles, particularly the quadriceps may be of more significance than that of the hamstring group. It has been suggested that during running an increase in pelvic tilt, due to tight hip flexors could increase the length of the activated hamstring muscles and thus increase the risk of injury (47,48). Excessive contraction of the hip flexors can cause anterior pelvic rotation, compensated with a lumbar hyperlordosis, resulting in a lack of hip extension (49). Studies have reported reduced hip extension rom to be associated with subsequent hamstring injury risk (43,50). gabbe

et al. (50) identified that for each 1° increase on the modified thomas test (decreased hip flexibility) the risk of hamstring muscle strain increased by 15% in australian football players of less than 25 years of age. However, it’s been argued that results from static measures like the thomas test should not be generalised to dynamic actions such as sprinting (49).

Lumbo-pelvic hip complex Core stability recently core stability has been linked with hamstring injuries (47,51,52). core stability is one of the most misused terms in the literature and has been incorrectly used synonymously and interchangeably with balance, core strength, hip strength and spine stability. It has often been referred to as the musculature that surrounds and inserts into the lumbo-pelvic region (ie. a total of 29 muscles) (53). these muscles act synergistically to stabilise the trunk, pelvis, hip and knee joints. core stability depends on the relationship between the passive structures, the ligaments, vertebral facets and active neuromuscular controllers. optimal recruitment, strength and endurance of the 29 muscles (attached to the pelvis) are necessary to maintain and restore joint (core) homeostatic stability in response to internal or external forces from expected or unexpected perturbations. this occurs through all planes of motion and despite changes in the centre of gravity (40). kibler et al. (54) summarised lumbo-pelvic stability in a sporting environment as the “ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities”. Quantitative analysis suggests that 10% of maximum voluntary contraction (mvc) of abdominal co-contraction may be sufficient to achieve spine stability during normal movements (55). recently it has been reported that stability is achieved in the first 25% of mvc (56). However, fatigue of the stabilising muscles in the lumbo-pelvic area can create inefficiencies in running

sportEX medicine 2014;62(October):19-27

Literature review

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Neural tension Several studies have confirmed that 13–19% of all hamstring strains reported are without any mrI confirmed structural muscle damage (2,21). these injuries have been linked with the neuromeningeal structures and been defined as abnormal neural tension. abnormal neural tension is defined as abnormal physiological and mechanical responses in the neuromuscular system (68). Its postulated abnormal neural tension may be due to resistance to elongation of the neural tissues (intraneural) or restrictions between the neural tissues and the surrounding tissues preventing them from gliding freely (extraneural) (69). Several causes have been postulated including alterations in lumbo-pelvic posture, lumbar spine pathology, and muscle tightness involving the gluteal and piriformis muscles (61,70). additionally, due to the plasticity of the nervous system recurrent hamstring injuries have been hypothesised to possibly lead to sensitisation of the dorsal horn of the spinal cord, which may predispose to injury by altering hamstring and gluteus maximus firing patterns (69).

cto

EccEntrIc StrEngtH traInIng IS tHE bESt DocUmEntED PrEvEntatIvE IntErvEntIon For HamStrIng InJUrIES

Iliopsoas

Lumbar spine posture and disorders In relation to soccer, a muscular imbalance known as the lower crossed syndrome, which produces tightness of the hip flexors and lumbar erector spinae and weak, inhibited gluteal and abdominal muscles can result in an anterior pelvic tilt, increased hip flexion and a hyperlordosis of the lumbar spine, known as lower crossed syndrome (Fig. 2) (57). Excessive anterior pelvic tilt is associated with a decrease in the activation of the gluteal muscles and an increase in the muscle length and tension within the hamstring muscles (58,59). therefore, excessive anterior pelvic tilt has been suggested as a risk factor for hamstring injury because it places the gluteal and hamstring muscles in a mechanically disadvantage position (6). additionally, it’s been suggested an increase in lumbar lordosis will reduce the joint space at the lumbosacral junction, resulting in l5-S1 nerve root impingement which has been associated with hamstring injuries (60,61). Hennessey and watson (58) found a significant increase of lumbar lordosis among hamstring injured athletes in comparison to their uninjured counterparts, which indicates a possible association between hamstring strain injury and lumbar posture. additionally, it has been speculated that low back pain could be a risk factor for acute hamstring injuries (21). weakness or activation deficiencies of the stability muscles (multifidus and transversus abdominus) and earlier activation of the hamstrings have been associated with low back pain (62–64). therefore, spinal pain and dysfunction may put extra stress and tension on the hamstrings, which could increase the likelihood of injury (19).

Pelvis and sacroiliac joint dysfunction the sacroiliac joint (SIJ) links the two lower extremities with the spine, which effectively transfers loads from the spine to the legs. It has been proposed that any SIJ dysfunction could lead to leg asymmetries during functional movements, altered gait patterns, early hamstring activation and loss of pelvic stability (64–66). Specifically the contribution of bF, via its insertion through the sacrotuberous ligament and attachment to thoracolumbar fascia (tlF), has shown to increase SIJ stiffness (67). therefore any pelvis position change or neuromuscular dysfunction can disrupt load transference through the pelvis and possibly overload the hamstring muscles. a past history of groin injury and osteitis pubis, being significant risk factors for hamstring injury, is evidence that altered pelvic mechanics may play a role in injury (21).

Ere

style, thereby increasing the workload of multiarticular muscles, such as the hamstrings. this may predispose to early muscle fatigue and subsequent injury. therefore, it is possible that feedback control, muscle endurance and stability may be more important than strength for reducing the risk of injury.

tight (facilitated) lumbar erector spinae

Weak (inhibited) abdominal muscles

Weak (inhibited) gluteals (gluteus maximus, medius and minimus)

Figure 2: Lower crossed syndrome

(a) Closed kinetic chain exercises

i. Step-ups

ii. Lunges

iii. Arabesque

i. Cable knee extensions

ii. Hamstring curls

iii. Nordic drops

(b) Open kinetic chain exercises

Figure 3: Hamstring exercises. (Photo credit: C. Hanson, 2014)

INtERvENtIoNS

Strength training

a successful hamstring injury prevention strategy would attempt to nullify the previously modifiable risk factors. For example, fatigue can be overcome by training in a way that ensures that the athlete’s fitness level exceeds the demands of the competition. the next section will outline a method of overcoming the remaining modifiable risk factors (lack of flexibility, insufficient strength, poor pelvic stability, and optimising pelvic biomechanics).

Eccentric strength training is the best documented preventative intervention for hamstring injuries. the benefits of eccentric training include increasing peak torque values (strength) and increasing the optimum angle of peak tension (length–tension relationship) (26,71). Furthermore, eccentric training can both lower the risk of hamstring strain and improve performance through increasing maximal running speed (72,73). the nordic hamstring

exercise is the best documented preventative exercise for hamstring injuries in football players (72–74). the fact that the nordic exercise is easy to perform and requires no additional equipment allows this popular exercise to be easily implemented into most training programmes. However, the nordic exercise does have a few inherent limitations. First, it is a bilateral exercise and it may cause a further increase in the magnitude of imbalance between the limbs (71).

(a) Slider (start position)

(b) Slider (finish position)

Figure 4: Neural mobilisation exercises (sliders and tensioners). (Photo credit: C. Hanson, 2014)

sportEX medicine 2014;62(October):19-27

Literature review

iv. Romanian deadlifts

hamstring muscle should include not only knee flexor training but also hip extensor exercises (75). additionally, it would be more specific to perform multi-joint eccentric exercises (76). It’s been recommended that exercise interventions for the prevention of hamstring strains should include as many of the following characteristics as possible: high forces, maximal elongation, high velocities, multiple joint movements, closed and open chain exercises, and unilateral exercises (76). Exercises including nordic hamstring, glute-ham raise, hamstring curls, romanian deadlifts, lunges, step-ups, cable extensions, and Swiss ball knee extensions are commonly used in prevention programmes (Fig. 3) (76, 77).

online If you have a current subscription, login at www. sportex.net to view these videos or download the mobile apps which are free to subscribers with online access. video 1: Slider exercise.

(video credit: c. Hanson, 2014)

flexibility

iv. Swiss ball leg curls

Second, the nordic hamstring is a single-joint exercise (knee flexion). Finally, very few individuals are able to complete the exercise throughout the whole available range, only managing to resist the eccentric lowering to around 45° (mid-range) of knee flexion. However, hamstring strains commonly occur during the terminal knee extension phase of running. therefore, the specificity of this exercise is questionable. Furthermore, it has been suggested that strengthening of the

Several studies have proposed various stretching programme to improve hamstring flexibility (78). Emphasis may also be placed on increasing the flexibility of the hip flexors (iliopsoas and quadriceps) in order to optimise the pelvic biomechanics and reduce hamstring tension. Interventions used to improve flexibility have included static stretching, proprioceptive neuromuscular facilitation (PnF), muscle energy techniques (mEt), and dynamic soft tissue mobilisation (78–80). It’s suggested that increases in tissue flexibility come not necessarily from affecting the mechanical properties of the muscle (expressed as changes in stiffness) but from changes in the perception of stretch (increased tolerance to stretch). this is known as the sensory theory and it proposes that increases in muscle extensibility after stretching are due to modified sensation (81). therefore, it’s been proposed that neurodynamic mobilisation techniques (sliders and tensioners) may be used to reduce neural tension, modify sensation, and ultimately, improve flexibility (Fig. 4, videos 1 & 2) (82,83).

Pelvic stability (d) Tensioner (finish position)

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Sherry & best (51) found that athletes who performed a core stability rehabilitation programme suffered

video 2: tensioner exercise.

(video credit: c. Hanson, 2014)

significantly fewer hamstring strains in comparison with a group of athletes who performed isolated strength and stretching. additionally, kuszewski et al. (52) demonstrated how pelvic stability exercises reduced the amount of hamstring stiffness. the increased stability of the lumbo-pelvic muscles with associated liberation of the hamstrings in maintaining lumbo-pelvic stability may explain this phenomenon.

(a) Double-leg bridge

(b) Knee extension bridge

(e) Kneeling side plank

(f) Kneeling plank with hip abduction

(g) Long side plank

Figure 5: Pelvic stability exercises. (Photo credit: C. Hanson, 2014)

tHE bEnEFItS oF EccEntrIc traInIng InclUDE IncrEaSIng PEak torQUE valUES (StrEngtH) anD IncrEaSIng tHE oPtImUm anglE oF PEak tEnSIon (lEngtH–tEnSIon rElatIonSHIP) therefore, programmes consisting of Pilates, yoga or other forms of core strengthening and neuromuscular control can help to improve pelvic stability and reduce hamstring injury risk (Fig. 5) (6,11,51).

Manual therapy as the cause of hamstring injury can often be associated with nonlocal factors including lumbo-pelvic conditions (19), manual therapy techniques may be used to reestablish the lumbo-pelvic function. mobilisation techniques of the lumbopelvic hip complex and manipulation of the SIJ has been proposed and used successfully in the literature as

a tool to re-establish the lumbo-pelvic function (84,85). the mechanisms underlying the benefits of spinal manipulation therapy (Smt) are not well understood. It is suggested that a high velocity, short duration load delivered during the impulse of Smt can stimulate muscle spindles, Pacinian corpuscles and golgi tendon organs more than preload or that achieved by mobilisations (86). Furthermore, it is hypothesised that a physiological effect of Smt may relate to the discharge of reflex proprioception stimulus producing multifidus and erector spinae activation, resulting in spinal stabilisation (87).

coNcLuSIoN Hamstring injuries remain the predominant injury in football and have shown a high rate of recurrence which have the capacity to impact negatively on individual and team performance and the financial viability of football clubs. this article provides the reader with an update on the risk factors associated with hamstring injuries and the efficacy of preventative interventions. although there are a large number of potential risk factors it is widely acknowledged that the causes of injuries are multifactorial. However, by creating and implementing a strategic approach to injury prevention through focusing on individual screening, more of the players’ time can be spent competing and training instead of rehabilitating.

fuRtHER RESouRcES 1. opar D, williams m, Shield a. Hamstring strain injuries. Factors that lead to injury and re-injury. sports medicine 2012;43(3):209–226. 2. liu H, garrett w, et al. Injury rate,

sportEX medicine 2014;62(October):19-27

Literature review

d) Single-leg bridge

THE AUTHOR WAYNE GILL BSc, MCSP Wayne spent 10 years as a professional footballer playing for Blackburn Rovers, Blackpool, Tranmere Rovers and Oldham Athletic before retiring in 2004 due to injury. In 1999 he completed a HNC in Sports Science and in 2008 he graduated from the University of Salford with a first class honours degree in Physiotherapy. Following his graduation he worked at Portsmouth FC for 4 years which included being involved in the FA Cup final in 2010. In 2012 he joined Fulham FC and is currently studying for an MSc in Sports Physiotherapy at Bath University.

n Describe how risk factors have been commonly categorised. n what are the nonmodifiable and modifiable risk factors? n Describe the functional H : Q strength ratio. n Describe the benefits of eccentric strength training.

DISCUSSIONS

kEY PoINtS (h) Star side plank

mechanism, and risk factors of hamstring strain injuries in sports. a review of the literature. journal of sport and Health science 2012;1:92–101. 3. Hoskins w, Pollard H. the management of hamstring injury – part 1: issues in diagnosis. manual therapy 2005;10:96–107.

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n Hamstring Injuries remain the most prevalent injury in football. n High recurrence rates have been documented and remain a concern for clinicians. n Preventing injury implies the identification and understanding of the factors leading to that injury. n understanding the individual risk factors for injury is important on the basis for developing preventive measures. n It would be more relevant to make a distinction between modifiable and non-modifiable risk factors. n Hamstring injuries invariably result from the interaction of several modifiable and non-modifiable risk factors. n Modifiable risk factors include fatigue, shortened angle of peak tension, strength weaknesses and imbalances, poor lumbo-pelvic hip stability and neuromuscular control, neural tension and flexibility. n Eccentric strength is the best documented preventative intervention for reducing hamstring injuries. n Eccentric strength training should focus on high forces, maximal elongation, high velocities, multiple joints movements, closed and open chain, bilateral and unilateral exercises. n Pelvic stability and neuromuscular control training should be included in hamstring prevention programmes.

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

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witH a subscription tHat incLudes onLine access to tHis journaL.

BY KaY atKin Bsc, McsP and Lee Herrington Msc, MscP cscs

introduction Medial collateral ligament (MCL) problems at the knee are a major cause of lost training time in water polo (1,2). Within the knee joint the MCL acts as a primary stabiliser, against valgus movements as shown by both in vivo and in vitro studies (2â&#x20AC;&#x201C;4). Hence when the knee is placed under extreme valgus stress, such as during the eggbeater kick, the MCL can become injured (3â&#x20AC;&#x201C;5). In the British national water polo squad water-based jumps are the primary activity reported to contribute to knee pain, which is mainly of an overuse origin (2) rather than a traumatic onset as is often the case during land-based sport. Abnormal or altered biomechanics in the lower limb joints and/or movement patterns are major factors in overuse injuries of the knee (6), and screening is routinely carried out to identify athletes at increased risk in order to reduce injury and the associated time out of training (7). Knee-valgus-angle screening has been shown in a number of studies to be a predictor of risk for an anterior cruciate ligament injury and strain of the MCL (4,8). However, musculoskeletal screening is commonly carried out on land, in a clinic-based setting, even for aquatic sports (9). As there is no research to support land-based screening for water-based athletes, investigation is needed to determine if current screening practices are appropriate. The purpose of this study was to determine if a correlation exists between knee valgus angle during a land-based screening activity (the single-leg squat) and a sportspecific aquatic activity (the waterbased vertical jump).

MetHods subjects Twenty subjects were recruited, and, after exclusions for current leg or back injuries or recent knee surgery, 16 actively participated in the study. All subjects were participating in water polo at least three times a week at a national or international level. The mean age of the subjects was 22.3 28

Is there a correlatIon between knee valgus angle durIng a land-based sIngleleg squat and a water-based vertIcal jump In water polo athletes?

The single-leg squat is commonly observed as a screening method for knee valgus. This has also been the case when assessing a water polo playerâ&#x20AC;&#x2122;s knee when they have reported knee pain in the pool. The aim of this project was to evaluate if any correlation was present between the knee valgus angle during a land-based singleleg squat and in a pool-based vertical jump. The results of the study help to provide further information around current screening methods. years. Data collection for the study was carried out at Varley Street Pool and Manchester Aquatics Centre.

experimental approach To examine if a correlation is present between knee valgus measurement on land and in the pool, each subject was filmed performing single-leg squats on land and water-based vertical jumps. Measurement of knee valgus from each video was compared allowing statistical analysis for correlation. The single-leg squat was chosen as the land-based knee valgus screening tool as it is commonly used by physiotherapists to assess knee control (6), and a number of reliability studies for 2D analysis of

knee valgus on single knee dip have also been completed (6). A vertical jump in the pool was chosen as a sport-specific activity during which medial knee pain is often reported in water polo. Performing a vertical jump allowed the subject to be positioned facing the underwater camera allowing for 2D analysis following a similar method to the already proven landbased method (8).

Procedure Each subject had joint markers drawn onto their dominant lower limb with waterproof pen: knee midpoint marker, at the midpoint between femoral condyles; midpoint ankle marker, sportEX medicine 2014;62(October):28-32

research

Quintic Software to calculate the knee valgus angle using the marker lines (10) at the midpoint frame (Fig. 1). The midpoint frame demonstrated the midpoint of the subject’s knee rangeof-movement and was defined as the middle frame between the frames where greatest flexion and greatest extension occurred. The knee valgus angle was calculated three times for each video clip by the same assessor to allow intra-tester reliability to be established. Statistical analysis was performed using SPSS software for windows (SPSS Inc., Chicago, IL, USA). A P value of <0.05 was used to indicate statistical significance. Correlation (r) between the land and water measurements was analysed using a Pearson’s correlation. An independent samples analysis of variance (ANOVA) was performed to assess intra-tester reliability for joint angle measure on land and underwater.

Figure 1: Midpoint underwater image with measurement markers applied. (Atkin, 2013)

online if you have a current subscription, login at www.sportex.net to view these videos or download the mobile apps which are free to subscribers with online access. Video 1: a subject performing single-leg squats on land. (atkin, 2013)

resuLts Mean measurements were recorded for each subject’s land and water knee valgus angles (Table 1). There is a wide variation of valgus midpoint between malleoli; and thigh marker, from anterior superior iliac spine (ASIS) down proximal thigh to knee midpoint (6,10). The subject’s participant number was also drawn onto the thigh to allow matching of the land- and water-based video footage for analysis. The subjects were allowed familiarisation time for each task (6), and then filmed while performing three single-leg squats at the poolside (Video 1) and then three vertical jumps in the water (Video 2). A single-leg squat was defined as standing on the floor marker with the dominant leg. The subject was then asked to squat to a knee bend of greater than 45° without placing the non-dominant limb to the floor. In the pool, the subject commenced the eggbeater kick to maintain position and was asked to perform a vertical jump as if shooting, allowing the dominant arm to perform a shooting action, the subject returned to the eggbeater kick between jumps and the jumps were performed in their own time.

statistical analyses Video footage was analysed using www.sportEX.net

taBLe 1: caLcuLated Mean angLe (°) of Knee VaLgus for suBjects’ Land-Based singLe-Leg squat and water-Based VerticaL juMP (Atkins, 2013) subject

Land

water

7.05

25.44

7.92

4.08

14.64

7.71

16.31

5.67

9.07

18.96

9.07

18.53

13.55

22.7

13.77

34.12

20.26

32.25

9.52

4.01

7.79

21.07

21.78

7.79

18.19

26.68

16.9

7.47

20.13

13.22

Video 2: a subject performing vertical jumps in the pool. (atkin, 2013)

7.39

5.68

Land valgus angle

THErE IS A WIDE VArIATION OF VALgUS ANgLE IN BOTH LAND- (7.05–26.68°) AND WATEr-BASED (4.01–34.12°) TESTINg 40 35 30 25 20 15 10 5 0

10 15 20 Water valgus angle

Figure 2: Correlation chart of land-based single-leg squat and water-based vertical jump knee valgus angle. (Atkin, 2013)

taBLe 2: Pearson’s correLation of intrasuBject Land-Based singLe-Leg squat and water-Based VerticaL juMP Knee VaLgus angLe (Atkins, 2013) Land

Water

Pearson correlation (r) Significance (2-tailed) n Pearson correlation (r) Significance (2-tailed) n

Land

Water

–0.015 0.956 16 1

16 –0.015 0.956 16

taBLe 3: Pearson’s correLation of intrasuBject Land-Based singLe-Leg squat of Less tHan 10° and water-Based VerticaL juMP Knee VaLgus angLe (Atkins, 2013) Land Land

Water

Pearson correlation (r) Significance (2-tailed) n Pearson correlation (r) Significance (2-tailed) n

Water

–0.500 0.207 8 8 –0.500 1 0.207 8 8

taBLe 4: Pearson’s correLation of intrasuBject Land-Based singLe-Leg squat of greater tHan 10° and water-Based VerticaL juMP Knee VaLgus angLe (Atkins, 2013) Land Land

Water

Pearson correlation (r) Significance (2-tailed) n Pearson correlation (r) Significance (2-tailed) n

Water

0.006 0.990 8 8 0.006 1 0.990 8 8

angle in both land- (7.05–26.68°) and water-based (4.01–34.12°) testing. The knee valgus angle calculated from the water-based jump had a group mean of 16.43° and a standard deviation of 9.76. The land-based knee valgus measurements had a group mean of 12.87° and a standard deviation of 5.89. However, because of the large range of values collected both on land and in the water, it cannot be said that the knee valgus angle is greater during water-based measurement: for 7 of the 16 subjects their land-based measurement was greater. Correlational analysis of intra-subject land-based single-leg squat and waterbased vertical jump knee valgus showed a very weak negative correlation (r =–0.15) which is not statistically significant (P>0.05) (Table 2). Plotting the water- and land-based valgus measurements on a correlation chart further demonstrates the lack of correlation (Fig. 2). However, the graphical data in Figure 3 showed a potential correlation for the land to water knee valgus in those subjects with a land knee valgus of under 10°, so a further correlational analysis was performed on the subgroups of (a) land knee valgus under 10° (Table 3) and (b) over 10° (Table 4). The correlation of land to water knee valgus in those subjects with a land knee valgus of under 10° shows a moderate negative correlation (r=–0.500) which is not statistically significant (P>0.05). The correlation of land to water knee valgus in those subjects with a land knee valgus of greater than 10° shows a poor correlation (r=–0.500) which is not statistically significant (P>0.05). An investigation of intra-rater reliability showed that P>0.05 for both land- and water-based measurements indicating that no significant differences within a set of measurements were present.

discussion Screening in sport continues to be a much discussed topic. In aquatic sports there is still a tendency to screen on land despite the athletes main environment being aquatic (9). In order to assess if land-based screening is appropriate for water-based athletes, this study was designed to test whether knee valgus angles measured on land correlated with those measured in the water. This study found no significant correlation in land- and watermeasured knee valgus angles, in the complete subject group and also the two subgroups that were analysed. It is unlikely that measurement error affected the results as the analysis of intra-tester reliability showed very low standard error (<0.216) and mean difference (<0.159). A number of factors may influence the findings of this study, including the accuracy of underwater video. Moderate negative correlation was shown in the <10° land valgus subgroup but was not statistically significant; greater subject numbers might have provided a statistically significant result. Underwater frontal 2D video analysis of knee valgus angle has not been evaluated. This study did assess intra-rater reliability, however, further comparison of 3D and 2D results would be beneficial if 2D underwater screening alone is to be utilised as a screening tool within water polo or other aquatic sports. 2D analysis was used in this study as it is less time consuming and less costly than the ‘gold standard’ 3D analysis (6,8). Valgus stress has been demonstrated to correlate to MCL and anterior cruciate ligament injury risk (10,11), and working on neuromuscular control, especially during sport-specific tasks can help reduce dynamic valgus strain (11), so reducing the possibility of injury and missed training. Currently, knee valgus screening for water sports is performed on land. However, this study has shown that land-based and water-based valgus angle measurements do not correlate, indicating that knee-valgusangle screening needs to be carried out during an activity required by the sport in a relevant environment, in sportEX medicine 2014;62(October):28-32

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this example within the pool. Then, if a large knee valgus angle is found when performing that water-based dynamic activity, the kick biomechanics can be corrected with input from the coaching staff to reduce the valgus stress (7,12).

PracticaL aPPLications One of the main reasons land-based screening has been adopted is the limitation of pool time. The purpose of screening is for injury prevention to reduce time missed from training by identifying potential issues and addressing them (7,13), which will only happen if appropriate screening is carried out. Discussions around the positives and negatives of screening should be discussed with the coaching team to allow them to gain understanding as to why valuable pool time may be beneficially used for this purpose. A portion of land-based screening is likely to still be beneficial given that strength and conditioning training occurs in the gym environment. Further evaluation of what is trying to be achieved from the screening is required to allow selection of the most appropriate test and environment (7). For the knee it would appear a 2D underwater approach analysing a sportspecific dynamic movement would be most specific to the sport.

MUSCULOSKELETAL SCrEENINg IS COMMONLy CArrIED OUT ON LAND IN A CLINIC-BASED SETTINg EVEN FOr AQUATIC SPOrTS

References 1. Franic M, Ivkovic A, and rudic r. Injuries in water polo. croatia medical journal 2007;48:281–288 2. Shahpar FM. Knee problems in aquatics. In: 17th FINA World Sports Medicine Congress. FIna 2007 3. Berns gS, Hull ML, et al. Strain in the medial collateral ligament of the human knee under single and combined loads. journal of biomechanics 1996;29:199–206 4. gardiner JC, rosenberg TD, Weiss JA. Strain in the human medial collateral ligament during valgus loading of the knee. clinical orthopaedics and related research 2001;391:266–274 5. Wijdicks CA, Ewart DT, et al. Structural properties of the primary medial knee ligaments. the american journal of sports medicine 2010;38:1638–1646 6. Carolan M, Herrington L, Munro A. reliability of 2-dimensional video assessment of frontal-plane dynamic knee valgus during common athletic screening tasks. journal of sports rehabilitation 2012;21:7–11 7. Mallac C. Musculoskeletal screening: why musculoskeletal screening for athletes matters and how to go about it. the sports

www.sportEX.net

MANy CUrrENT SCrEENINg PrOTOCOLS ArE BASED ON ANECDOTAL EVIDENCE rATHEr THAN rESEArCH Injury bulletin (http://spxj.nl/1brpsrp) 8. Ford Kr, Hewett TE, et al. Evaluation of a two dimensional analysis method as a screening and evaluation tool for anterior cruciate ligament injury. british journal of sports medicine 2005;39:355–362 9. graham K, Naughton g, romiti M. The relationship between musculoskeletal screening and injuries in athletes at the New South Wales Institute of Sport. new south wales Institute of sport 2010 (http://spxj.nl/1jFc3vX) 10. Akai M, Fukubayashi T, et al. Statistical modelling of knee valgus during a continuous jump test. sports biomechanics 2008;7:342–350 11. Hewett TE, Myer gD, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. the american journal of sports medicine 2005;33:492–501 12. Victor J, Wong P, et al. How isometric are the medial patellofemoral, superficial medial collateral, and lateral collateral ligaments of the knee? the american journal of sports medicine 2009;37:2028–2036 13. Abrahamson E, Comfort P. Sports rehabilitation and Injury Prevention. r wiley-blackwell 2010. ISBN 0470985631 w (£33.96). Buy from Amazon http://spxj.nl/1fvK0tA

furtHer resources For a demonstration of how to assess knee valgus angles watch this Valgus Test video (http://spxj.nl/1kynAuw)

ThE auThORs Th KaY aTKIN Bsc, McsP K Kay qualified as a chartered physiotherapist in 2007 from the university of Nottingham. she first worked at Kings Mill hospital in Mansfield covering rotations in orthopaedics, rheumatology, women’s health, medical, surgical, respiratory, and critical care. she moved to Rotherham as a senior physiotherapist in the neuromusculoskeletal field in early 2009. In February 2010 she left the Nhs to take a full-time role at the English Institute of sport, sheffield, working with the GB women’s volleyball team. In august 2010 she then moved to a part-time position at the English Institute of sport, Manchester, working with the GB men’s water polo team. Kay currently works within the private sector focusing on sports and musculoskeletal rehabilitation. she is in her final year of an Msc in sports Injury Rehabilitation at the university of salford. LEE hERRINGTON Msc, MscP cscs M Lee qualified as a chartered physiotherapist in 1990 from Manchester university,

having previously completed a degree in human Biology from Loughborough university. In 1996 Lee was awarded an Msc in sports Injury and Therapy from Manchester Metropolitan university. he has also been certified by the National strength and conditioning association (usa) as a strength and conditioning specialist and by the cincinnati sports Medicine Research and Education foundation as a sportsmetrics™ trainer (www. sportsmetrics.net). currently, Lee is a lecturer in sports Rehabilitation at the university of salford and has links with the Manchester Metropolitan university, Prince Faisal sports Medicine hospital in saudi arabia as well as being a member of the international advisory board to the Journal of Physical Therapy in sport. he has worked with elite sportspersons for the last 15 years including time with Great Britain Rugby League and Wigan Warriors Rugby League club, amongst others. Lee’s specialist areas of clinical interest are the treatment and rehabilitation of sports injuries, specifically patellofemoral joint pain and rehabilitation following knee surgery (principally acL and complex ligament reconstruction).

KeY Points

n Should athletes been screened within their training/ competitive environment? n Is screening important? n Is there a place for underwater joint analysis as part of physiotherapy assessment? n Are current screening methods the best methods to use? DISCUSSIONS

n Medial collateral ligament (McL) problems at the knee are a major problem in water polo. n the McL acts as a primary stabiliser of the knee against valgus movements. n the eggbeater kick used in water polo places the knee under extreme valgus stress and can injure the McL. n screening of knee valgus angle indicates risk of McL strain. n screening of water polo athletes is usually carried out on land, although their sport is water based. n Knee valgus angle was measured in a land-based single-leg squat and in a water-based vertical jump. n this study found no significant correlation between land- and watermeasured knee valgus angles. n the best screening is achieved by analysing an underwater sportspecific movement.

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join anx the ity. s arti ana ). The injured plus l phal ro-iliac . With Dista s the as previou rmation erely tive instabil pulsion, toe) acutely to the sac cle review (5th at nly sev rela re info anx ng and y, pro le phal e form for mo commo due to its of the bod in squatti and injuries s. This arti Midd toe) most the samthe article stly (5th port und as walking t as change follows e is the ulder mo w sup the gro y, as in imal end of and the foo Prox The kne the sho e is to allo o near joint n of at the the bod phalanxGP mediate like tors box toe) Inter ving acceleratio limb, n of the kne of the Kay, iform in (see n(5th be mo cune id joint ing Simo um Sacr functio g position can either wing rap By Dr injured ment ral erview : allo Fifth joints lloliga y ov monly tarsal n of femo is Pate allowin Propulsion the foot ral joint meta of two ral proportio abulum, st com talo-fibular ly simple n ial anatomconsists the tibio-femo the tibia ilium ving high ing. femo mo Med acet r thick the of tive sitt mo knee s the iform joint or by the labrum of The joint ral ruent due to cune anterio is a rela of inversio e of le is er main Late of the facettwo cong abulum covered by a running 1. the ists iform to furth acet and head lised (behind The anker limb, the d ankle) severity the mortic as cons cune with the ing. stabi femur acting ioned 1-2). lla) , which GP further tissue, pate tures in kick m (figs. hip is id r, cush articulate the low sic spraine but as the joint and ch can be le, ective n Kay, of the Cubo the femu cular struc which acetabulu of the conn Simo entS ved in neck n r ces on two avas -talar r en the ral position r projected the injury vem ed whi By Dr the ank (the clas surfa Navicula femu deep by lity is femu e mo ps are invol ntous es, the sub be disrupt consider from Talus - a joint on The neut of the uctionto its stabi ly. stabilisedsici s laterally l joint ligame muSclmuscle grou . s les ie. facet the neck ly and knee introDmostly due at least acute ent increas joint can ry. We will aneumora the men musc with s Calc of the patella-fe V-shaped h articulate lla Differ tring posterior injury nosu ow ment The hip, injured joint, of femoro- injuries ankle article. 2. the e inju whic pate slightly m. tibio n move flexion - hams i-membra y from of een shallthe patella ral h. The help g sem a rarel recognitio ent and the true as any kne foot in this betw r is acetabulu femo of undin some 1. Knee dinosus, the ral troug for the two main gem which surro menisci with um the femu With the back the femo a fulcrum r impin joint and ists of ischi joint severe ar joint and semi-ten s femoris le, popliteus, front entS head of cons by three with ges. as n. ice acetabula -iliac lling in chan only acts tibia, LiGamstanding, the acetabulum allow mort ists and bicepssory musc to flexio muscles The ankle ntially the sacro situation hip is to sub-tal to a cle, trave into the t s prior the to lar Femur acce esse cons mus s , Whils ting ricep s into : )knee (simi the les, the ion of the vastu efficient. in ricep and inser work joints joint tightly musc the limbs ver ks the nsion - quad lateralis, (fig.3): quad held ankle unloc s in wood the talus ent ally more no part ents knee The funct trunk on otion. Howetibia GP exte 1. the joint vastu of the pays of the it mechanic key ligam oral ligam the two medialis. also aid N Kay, 2. Knee s femoris, tenon including facet ort of is to fibula g locom -fem ent withh ts inter ing and s SIMo . s ular the supp foot durin les men and mak by artic ulate 1. Ischio moral ligam ent. that and ing and ie. rectu and vastu musc the ularly e of move By Dr the knee femur . Man strike Note of the which artic on the tibia mius partic n of the Tibia ing, jump ter fibula heel the ankle is fixed 2. Ilio-fe femoral ligam tighten with n) medialis gastrocne ulatio e rang d to ces – the stand ion of of force at (teno ing, runn hip, to grea level the foot his legs surfa the mortice) a whol The the artic tibia is linke ligaments ) and r rigid 3. Pubo e ligaments ing us to r. e joint ruent the ing, walk on the or The funct pation n when upright on and femu powe ide a the sing The cong h form sub-talar (ACL Thes e phas flexio stand all involve le nding dissi ht s of ty, allow muscle , s all tibia g cros (whic to prov propulsiv knee depe Talus ligament ent (PCL). allow ted g facet straig (see of musc ndly fibula t of gravi t use of the extension s of the kickin r degrees the hip bear ple and two stroncruciate mass inferior complica effec running s on of this can stand the facet joint in full of grea and seco a stable iater ligam they have three Fibula 2. the e ut a t facet cruccula or lesse of time that ht. For exammit ing and is a large e purpose use the anterior eriorNavi As part the ents Pleas witho een the congruen lity. beca s. lise there be ity. g walk mation). to allow weig are unt ract joint prim trans ligam stabi stabi betw ugh durin amo will cont id bone talar le activ s are not oiliac the post nly for of body hips infor ht, ss and Altho the hip, the otion, not ly. They covered and the exce lock to of gait musc Sacr xes to avoid -weig the mmo supp more joints injurie the sub- ground. talus and cubo and ising refle multiples l ing se refer body Unco vascular 1 for tring or on around is for locom of the SI ent joint neum the to minim stand mus cle s Box e (plea sportEX the foot, uneven ments of lingreas the joint s twist lity calca le thet spinaately main whils that hamsthis articl may on ligam in te half ising, and ioning a good thehurd within ACL stop musc hiphas Calcaneu move note opria gThis shed by relies the posit the stabi rol oxim the nt anterior rough joint appr ENTS entric ssed appr t. runn throu es publi pain from the if aghpatie injury s for containedvium. The s and The PCL to cont durin of the Similarly symphysis joint addre allow ht rs vermen bone ht. r. and concare used occu sition g than ous articl lly the MovEM aNKLE Femero- ar move ankle weig howe weigafter ent femu by syno the two ntric and durin icant theitis the pubic and oppo abul to previ topic). Usua weights, ligam Ecce ing,arthr signif acet of body on the een posterior muscles of the foot oF ThE t of the truetion, plantar o 1). why gth tion and leg ACL ss jump tibia betw of huge with stren ient % men for this injury is moren. . Exce ionticula joint the shin ments the knee defic-500themiss of the along femur (see disar Move in one direc plane) (vide alar ation s. r ntothe joint bea 400 le the glide S twist flexio the trans facet t withi toultim ttal leg, ately rs musc the move and supin strain on rciSe of powe rior, Theuse the subt and on the stops the knee ents occu beca end of fermen on knee a ion (sagi a and s of trunk tibia also move is ante the joint ently G eXe at th ility of sion effect nG l at the pronation can put traum of ligam r and the thesstrans lesr from of the nin ’t inher ie. tibial dorsi-flex dimension for inver exce rni to Look and and The stabthe array mino s pane glide would ear s model musc al Lea ation hip wasn joint pronation of the foot gh to ntrically, can to and femu g the omic esthetic): omical see e extra s). The three ver allow leads the ntricrs slow if the throu of ecce Onlin tors and pronbox and ng ecce ation. This n (kina that ritis. the anat same with howe is a due g the tibia surroundin onse to an anat ton, to s inver for video ptionlder, nsoarth o 2) cal joint oste s on pron disrushou .prime move mea contracti ectin muscles tions (vide itions article neutral and are the ght line. r. the in the in resp facet then an skele under verti conn sion Defin when the rate of to occu n of g the e,As often ated knee hum The of ever strai (see s riptio . stabl stron a ts lock the the more the in of of desc ation men very are activ ligaments control r far er point only nded ions supin 3-5 for a move the faces sure. N.B. the rim occu which the posit e trigg h not and it’s how s pres joint with jointS ular joint fully exte Knee caus within ents whic but also figure ward eversion sion ion is ately anD ro-acetab up the hip the leg down ther, ments). ment of rCISE tensions the ligam eS of thers in two al posit approxim r of inver nd , firing toge femo S t move EXE s ining is omic Bon i.e. the It ched occu tilted ent NG Try exam bone anat th thee femu that make of: The move movemenrough grou stret s pelvis ) ss The hip six joints consists ting can the two they are cal and allow movemt of the knee LEarNI of the of terac hold to take esthetic): which ttal plane. which joints ng exce men the verti riorly. when coun : foot is one (sagi hip girdle ular (FA) Move n (kina ulated foot tly, to fully the tions ut putti 30 to tilted ante twist s the tighten ch receptors . The direc of etab allow extension ion or girdle unt witho main an artic d apart sligh aspects ro-ac (SIJ) slightly off stret of rotat knee to on and into acco 2 x femo -iliac joints the n Flexi ll amount be prise e the 3-D r. sma to allow 2 x sacro symphysis ion nA appreciat joint. can occu ion is stable junct rotat re flexion 1 x pubic ar-sacral This subtalar ugh very befo altho 1 x lumb FA joint, ‘unlock’ The

this sly in Previou (issue cles. t st er arti , hip join and wri e w refresh ue 44) injury the elbo of the spin t (iss ies of ulder join 46) and title ue the ser sho cle the last in ered the le joint (issn this arti girdles. cov is the ank e give muscle re This we have 45), hav mo ue e we ociated to series e joint (issAlthough becom . and ass kne I have but difficult ds47), that han ue 49) the spine al, atic nd (iss e fou pragm a practic apy, joints re about her ch I hav ies in a it is it is mo rap this, physiot l theory, approa y, the for n rap ow ious apology the ofascia ne. People, ing my ing var no sports cture, my dici ient Review politan, mix ch. I make involves x me pun stic pat ch. It ns, acu orthodo y holi cosmo ce’ approa approa mobilisatio good old that a trul t ‘eviden ary care ssage, iatry and differen on, primlation, ma pod are so ues, h sports, essential. manipu ns techniq of whic : their each eve, roles ons, Mulliga es and different five secti is, I beli spin d into to perform their approach divide d specialise based

and

Pubis

is ical GP n Cerv acic n Kay, n Thor bar n Lum al two-fold: tion Duc the spine is with n Sacr ygeal. to l cord ion of n Cocc spina e roots The functction of the ned to l nerv g spina is desig positionin ical and limbs 1) Prote n of the cerv ents ical spine and allow r limbs distributio ive segm of good rmost , uppe r limbs, The cerv the skull relat oses is joint the trunk . lowe ort uppe their of phys arms and supp for purp The two sym Support pelvis use of the skull ed ing. 2) Pubic evolv on the of the ribed and of have and hear and skull locomotion lems desc the body me vision vertebrae ion. ing prob ently, funct the r allow of has becoring cervical ally differ latte Most (Atlas) bral to the anatomic vertebra relate first vertend vertebra below an the first from the seco From the rate y to lex. lop sepa fused are comp e, they deveeen anatom brae and has ectiv betw fuse are The verte gical persp which vertebrae embryolo centres The three of age. from 15 years 8 and Simo By Dr

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