sportEX Medicine Journal Issue 63 - January 2015 by Co-Kinetic

ISSUE 63 Jan 2015 ISSN 1471-8138

promoting

excellence in

highlights

sports

n Vitamin D leVels in athletes n Youth psYchologY n tennis elbow rehabilitation

medicine n pFp rehabilitation

n case For neuroimaging in the assessment oF concussion?

BOLD HEAD LIGHT HEAD

ANATOMY & SOFT TISSUE INJURY REVIEW By Dr Simon Kaye, Sports Physician and General Practitioner

ONLINE & MOBILE £24.95 PRINT COPY AVAILABLE AT TIME OF PURCHASE AS A £6.99 UPGRADE WITH ONLINE PURCHASE

InjuryRefresher_proofed AS.indd 1

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CONTENTS ■ Overview of diagnosis and treatment of sports injuries ■ Shoulder Joint and girdle ■ Elbow and Wrist ■ Ankle ■ Knee ■ Spine ■ Hip joint and pelvic girdle

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■ Provides tips for examination, learning exercises and highlights key points ■ Gives links to further reading ■ Useful for practitioners and those in training

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rec cles anx ity. The plus The hip,. With the ro-iliac join the anatom vious arti tion). injured l phal ve Dista s erely tive instabil pulsion, pre rma toe) to achie acutely to the sac cle review (5th at as ment nly sev rela re info anx ng and y, pro move le phal e form for mo commo due to its of the bod in squatti and nubrial injuries s. This arti es Midd ees, o-ma Pictur toe) most the samthe article 180 degr stly at Primal (5th port und as and stern walking t as ©2010 change follows joint ter than cic rotation e is the ulder mo w sup the gro y, as in imal this end of and the AC of abduction and grea thora the foo Prox with rds The kne the sho e is to allo o near sly in joint of some ees at the onwa the bod ation of phalanxGP mediate some like tors box ved with 180 degr degrees toe) Inter Previou (issue ates limb, n of the kne of the moving acceler Kay, iform in 150 (see onstr is achie n(5th cles. t st cune joint ing nt dem Simo um es n From ction/flexion er be g rapid roctio er arti , hip join and wri Dr patie Pictur Sacr ition red iew eith fun hume joint By nt inju abdu d the Primal e w ral erv joints: can l g pos refresh ue 44) allowin behin ts well. Fifth ©2010 radia lloy ov monly ular ligame ple tarsal n of femo is T1-3. n from injury the elbo of the spin Pate allowin Propulsion the foot men ral joint t (iss meta of two rvatio move ral proportio abulum, -fib st com n Kay ies of ulder join 46) and anatomconsists the tibio-femo the tibia ilium Obse providing as title joint ly sim femo of the Simo Medial body the high the acet m of thick sitting. or moving ges in ue s of the mo erior taloa relative inversion of ment s iform the ser sho joint By Dr by The knee joint ral cle the of the r limb as well ing. ruent due to cune ant labru le is the chan joint er entS ed in move two gros main Late of the facettwo cong e is of abulum last in ered the le joint (issn this arti girdles. covered by a running 1. the ists iform to furth acet uction flexible of the uppe lifting and carrybility and articles head lised (behind The anker limb, the d ankle) severity the mortic as movem are involv divided into cov is the ank cons cune with the stabi femur acting ioned lla) , e give muscle esher Simon introDlder the mostof motion like throwing, nse of insta my kicking. re which Scle le groups roughly be This we have 45), be ulate id r, cush GP aine (figs.1-2). is the further low tissue, pate les tures in hav and refr m e mo mu ue artic spr t as anato the Kay, y hip shou femu e can h ted the musc musc struc expe ts range can ectiv n we of Dr Cubo sic the The ent le, whic tom ocia ws the cular ilising acetabulu of the conn ment Simo entS ved in neck to r r, and a wide r movemen ry but -talar join ed which series e joint (issAlthough s at the Differ becom /stab ces on two avas Move r mino more s ana en the ral position r projected the st and and hip, come e briefly revie By Dr the ank us with actor (the clas surfa powe Navicula . and ass femu us injuradio kne deep by movem are invol into a I have but difficult dslity is contr shoulder. femu mobility (IS), teres rating Talus thejointsub be disrupt consider articl previou e, ankle of the wri ions 47), - a joint on The neut of the that – the han ally from ue 49) the spine e going various soft mento eases, Scle le groups. : gene uctionto its stabiacutely. stabilisedsici dorsi, our joint pinatus tely this ntial. This ulnar al, atic nd s later l (RC) ts kne (iss liga mu befor ie. e e areas neck er. s roD imus the r, on will can infras les facet lder join the outlin 1) ly and e fou int mostly due at least s to ent musc the knee tor cuff incr aneumora Unfortuna injury pote ing pragm a practic apy, ulde the men We r, latiss triceps. Thes joints re about ical reg each oth musc with . We joint video s Calc of the shou of injurie 1. Rota spinatus (SS),(see Video patella-fe V-shaped h articulate lla Differ tring posterior cle. girdle injury ying nosu Follow g the sho issue, at the h anatom injury. ralis majo s and ch I hav ies in a to ow ment The hip, injured joint, of femoro- injuries )) Pictures ankle osis and high ments of , it is 2. the whic siother ory, to move is mo pate slightly m. tibio Primal n move flexion - hams i-membra y from shoulder accompan and diagn it ©2011 of supra laris (SSc – pecto of r, bicep fashion, true any knee t in this arti ) lla een shallthe bot erin approa pate ral h. The therap the related g this abulu for this rapy, phy d sem (PM) a rarel recognitio ent and mino with n view e help h ssed l is and movelook at the ng up the the betw capu cov r ly rs in ntric main us, acet femo troug Knee of undin the ow ralis rior som upe asse 1. foo ious an iques as subs logy rts the the ral ate ks two gem maki whic be /ecce dinos surro menisci like with gro (supe um ofascia ne. People, the femu Pubis ary move r, pecto femo fulcrum for With detailed the back tures nt techn ture can r impin joint and ists of ischi joint ing my ing var und it no apo severe ar joint and semi-ten s femoris le, popliteus, st spo Kay loo We have are so intim 2. Prim teres majo in a concentric entS head of struc the foot with the cons by three re, my in front ges. as a ) dici n. ient s of ice acetabula -iliac assessmeeach struc lling es roand surro head again ly tissue chan id, only view Review politan, mix ch. I make involves acts LiGamstanding, the acetabulum allow bone mort ists Pictur sacro and bicepssory musc to flexio muscles punctu odox me trave joint most hume The ankle rior delto simple the tibia, rus how ntially sub-tal to a stic pat dial joint, main elbow. er as they t Primal situation hip is to , s joint (ante prior to the to the Femur les act some showing esse muscle, s The ro-ra s ch. It . Whils ting into efficient. ricep s©2010 ns, acu ulna into the ): : orth y holi the hume g shoulder ) - cons (similar the acce the knee close is one cosmo ce’ approa musc les, the ion of the the hip vastu e 1a: hume osed ge, ricep and inser rus. joints work the joint - quad tightly joint, s of in musc the limbs ver ks Figur to hold approa mobilisatio good old that a trul durin (fig.3 foota les like quad togeth the radiuination) held rotating lateralis, lly diagn ankle bone red by unloc in wood the talus n/ ent ally more no part ents the humeRC musc job is g stability knee The funct trunk on otion. Howetibia eral (GH) joints are GP extension vastus t 1. the 2. the rotation of ‘eviden ary care of e 1: The the n joint differentia are cove h contractio pays of the it mechanic e. Their The key ligam oral ligam the two the elbow rview gleno-humgirdle. These ation/sup medialis. also aid N Kay, 2. Knee s femoris, ing ssage, iatry and differen Figur including sleev ort of is to fibula g locom maintainin les are -fem ent s of the and teno ular facet allow twitc GP s with SIMo . s inter supp plete durin les ments ing and thus y ove ifically the ally (pron and the making that the by on, primlation, ma pod musc lder artic ulate 1. Ischio moral ligam ent. Pictures and footstrike ie. rectu and vastu e 1: Joint n Kay, musc the incom ularly e of move By Dr facilitates are so the knee femur in a slow rus into Primal . Man spec ues, id fossa rotator cuff of Note of the which artic on the tibia longitudinthe ulna Figur Simo mius the shou ©2011 partic n of the which anatom Tibia ing, jump ter fibula heel the ankle is fixed les act hume head 2. Ilio-fe femoral ligam tighten with h lder or make up d n) medialis gastrocne ulatio e rang d to joint sports, essential. manipu ns techniq ces – the the gleno ts. The By Dr stand ion of of force at (teno aroun ing, runn level to grea of whic : the foot his legs surfa the mortice) -ulna RC musc head of the to move the n is pulled a whol that men The shou The their , the artic tibia is linke ligaments ) and r ion two joints3. Pubo e ligaments ing us to r. each joint ruent a rigid phase lliga move ing, walk ve the hip, on the or The funct pation eve joints the rs. The n when upright on and femu ted les the radio ment. and roles uct g ons, powe form ide the these tendo sing The talar cong 3. Mu five h allow (ACL le beli Thes e of flexio effec stand le move hand musc nding dissi es of the pullin ht invol s ty, move is , s all tibia g cros (whic to prov propulsiv different musc s: five secti knee is, I depe Talus ligament ent (PCL). prime allow ted sub- ior facet g all spin introD g how vitallopment, i.e. ion, it is straig (see of musc joint fashion ing the PM shorten as ndly fibula rotating t of gravi t use of the Rotation for d into to perform extension s of the kickin r degrees the hip bear ple joint and as follow-humeral iderin two stroncruciate their approach mass infer t: complica effec running s on pulat divide of this can stand the facet joint in full nt: of d grea (AC) isometricfossa, allow muscles the scapula. and seco a stable Cons n deve rate nsible iater ligam they have oin three for Fibula lesse 2. the ialised e ut a Poi t facet knee time that ht. For exam cruccula or the ing and huma is a large e purpose use respo ed and mani are injure 1. gleno ioclavicular id anterior eriorNavi As part nsible the ents mit witho of the is spec ical een the congruen The RC Key gh three sepa K lity. beca s. lise the ium of us being bas there 1). gleno ity. Pleas not be g walk mation). to allow are to rdination joint at weig s of they are unt ract joint prim trans ligam respo rus. c post stabi stabi betw bone ugh le acrom activ durin joint that acrom amo will cont Video icular id 2. talar le oilia the pinat of body hips infor ht, ss the arm note and nly for Altho the hip, the otion, not lthouugh are all ly. They covered GP s are and the n Cerv altho exce lock to oclav the hume under the of gait musc eye co-o in a way Sacr xes to avoid infras with e 1: The -weig laris musc on (see the mmo tus supp more c joint joints injurie acic , the sub- ground. talus and cubo and ising refle multiples l ing n Kay, se refer s they capsule Figur 3. corac body ising Unco vascular 1 for rotated, lder is tring are. is or on around is for locom of the SI elbow ent cuff with subscapu ntric fashi ezius, serra joint neum n Thor joint the to minim stand mus Simo cle s ulothoraci joint medially Box surpr asne e (plea sportEX the foot, uneven ments of lingreas they the joint s twist the bar lity calca le same thet spinaately the shou or internally main rotator n of the whils / ecce ula (trap shoulder that hamsthis articl may on ligam in tion te half ising, fine 4. scap oclavicular and ioning a good By Dr onli rotate, thehurd within ACL stop musc hiphas Calcaneu inatio move n Lum al ion of in the note opria gThis injec h the shed by the rotation and concentric by relies the posit the stabi as little rol oxim the nt s both rnally anterior rough r joint appr tion is two-fold: ENTS entric stabilise, ssed appr the scap a t. runn throu (in whic 5. stern neutral posit er exte es publi pain from the if aghpatie injury s for containedvium. The s and The PCL The combwrist allow plus powe to cont durin of the Similarly symphysis enclosed facilitate 2). ulae) Duc n Sacr ygeal. joint addre spine les of with external rotation, in allow ht rs vermen bone neith ht. r. e and concare used occu The sition position g than ous articl lly the MovEM aNKLE Femero- ar move ation h can ankle weig musc howe or scap weigafter ent al figur hands, function is femu by syno the two intro ion of the spinal cord roots to rm and ntric and chest, durin icant mical theitis the pubic and oppo abul whic n Cocc to previ topic). 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The three ver allow Move skull leads the ntricrs slow ed if the throu ShoulDt of the shou ing. of ecce Onlin tors 2) Supp on the pelviand use of ribed Pubic plane elbow pulation le, as mob and pronbox and re 3) direction ng ecce ation. This n (kina ) the anat same with that ritis. evolv este of the howe is a due g the tibia surroundin onse to rotation an anat ton, to of YouT inver the iple’ move ‘basic’ for videoview of ptionlder, nsoarth men o 2) (in cal skull anan . g. Mani have joint in one plane) (Figu oste and hear (sagittal external desc s on pron otion disrushou .prime move mea contracti ectin muscles (vide isn’t itions riorral and are the Move article(supeneut r. skele a need as gross line. in the sanjupositionin r verti is a ‘multn of all six in resp ) and facet nsion of the then the body me vision vertebrae conn and when the rate of to occu ding g /www m/ which the e,As view ing locomthe problemsr function. ated ment knee human lock unde et ofoften eversion (see Defin ription (sagittal straight ently, foot The s threa OQhair and elbow . joint http:/ be.co stabl stron shot. a ts inatio rior and exte internal the true the activ allow 11 rol a more the move as 15 tEX.n in the the dial of of has becoring of ents g desc gz18e ation men cervical ally differ the very latte are (ante nth of r far er point .spor s of only d ), and nded youtufine GOZj ing our ions MosttEX.net ule cont supin 3-5 for a ulna joint. humero-ra d part of move is a comb the faces sure. 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Rotation involve multi from the o when coun aroun up) and re 4a+b). : foot is one (sagi the move fuse are hip girdle ular (FA) The verte gical persp Move n (kina ulated foot tly, to fully the tions ut putti 30 to tilted ante faces twist s the tighten ch receptors lation of the consists joint (a hinge rity of which vertebrae . The (Figu of from: ments direc of etab allow (palm extension ion or girdle unt witho move ee of angu abduction embryolo centres main an artic d apart sligh aspects ro-ac (SIJ) the majo The slightly lar facet the the floor) off stret of rotat knee to on and The elbow ro-ulna g ees, three articu into acco faces of age. 2 x femo -iliac joints of GH with the degr ple durin hume the from n Flexi ll amount be prise e the 3-D 0 degr of the ratio r. lates 1. the 15 years 25-3 sma to allow is 2:1 2 x sacro symphysis ion consists For examneutral to h articu 8 and nA appreciat joint. can occu ion is ment stable play junct which rotat re flexion rus whic on the ulna s into 1 x pubic ar-sacral n from the GH joint, ees the move ment This subtalar ugh very befo the hume surface altho move le come is at 1 x lumb FA joint, 0 degr oracic ‘unlock’ ruent the clavic 30-9 cong ula-th The et n from t to scap of abduction et et tEX.n men .spor tEX.n tEX.n move 90 degrees www 20 .spor .spor www www n after 26

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s 2011

www.sportex.net Produced by

■ Back to basics revision of anatomy of each joint ■ Includes 53 anatomy animations and video clips to bring the facts to life ■ Covers diagnosis and treatment options with background theory and evidence based medicine

Picture

by Dr Simon Kay

and

ANATOMY & SOFT TISSUE INJURY REVIEW

This resource is packed with animations and is highly visual coviering all the major joints and surrounding soft tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals. It is also a perfect tool for showng patients and clients exactly which anatomical structures they have injured. The resources is regularly updated and expanded with new images and animations.

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.spor www

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contents January 2015 issue 63 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

Welcome

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2014 has been the year in which the fuse was lit on the time bomb that is concussion management in sport. Most sports medicine practitioners believe we ‘ain’t seen nothing yet’ and that things are going to get worse...much worse. In July this year a federal judge in the US removed a cap on damages paid out to thousands of NFL players experiencing neurological problems related to concussions suffered during their professional playing careers. However it might be worth mentioning here that the NFL has an annual revenue of $10 billion. Also this year the National Collegiate Athletic Association (NCAA), which according to Wikipedia is a non-profit association which regulates athletes of 1,281 institutions, conferences, organizations, and individuals, had a suit filed against them asserting that the organisation was negligent by failing to adopt any formal concussion policy until 2010 – and failing to establish any minimum standards when it finally did. This is serious stuff! American sport is infinitely better funded than most, if not all, of our sports in the UK. National governing bodies of impact sports where concussion is a signficant risk to their athletes, could be crippled by law suits along the lines of those that the NFL and NCAA have had to deal with. There is no doubt that this is one of the biggest sports medicine issues that NGBs are going to have to face, and it could well drag on for some time to come. Tor davies, physio-turned publisher and sportEX founder tor@sportex.net

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4 Journal Watch d in sport and 8 vitamin exercise medicine 12 The challenges of youth 18 Tennis elbow

ConTenTs

The latest key research from this quarter

Are low levels affecting performance? Psychosocial response to injury and rehabilitation in youth athletes Rehab guide for this difficult condition

22 patellofemoral pain 27 Concussion neuroimaging 32 research reviews 34 social Watch Proximal intervention for PFP management

Are we protecting our athletes? Rotator cuff pathology

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clicK on rEsEarch titlEs to go to aBstract

f finitE ElEmEnt analysis of plantar fascia during walKing. chen yn, chang cw, et al. foot & ankle international 2014;doi:10.1177/1071100714549189

Eff EffEct of thErapEutic insolEs on thE mEdial longitudinal arch in patiEnts m with flatfoot dEformity: a thrEEdimEnsional loading computEd tomography study. Kido m, ikoma K, et al. clinical Biomechanics 2014;29(10):1095–1098

Because mechanical overload has been identified as the primary causative factor of plantar fasciitis this study explores what happens to the plantar fascia under load. A 3D foot model comprising bones, cartilage, ligaments, and a complex-shaped plantar fascia was constructed. During the stance phase, the kinematics of the foot movement was reproduced and Achilles tendon force was applied to the insertion site on the calcaneus. All the calculations were made on a single healthy subject. The results were that the plantar fascia underwent peak tension at pre-swing (83.3% of the stance phase) at approximately 493N or 0.7 of body weight). Stress concentrated near the medial calcaneal tubercle. The peak von Mises stress of the fascia increased 2.3 times between

Computed tomography (CT) scans were performed on both feet of eight people with mild flatfoot deformity under non-loaded and full-body-loaded conditions, first with accessory insoles and then with therapeutic insoles (arch support and inner wedges) under the same conditions. Three-dimensional CT models were constructed for the tibia and the tarsal and metatarsal bones of the medial longitudinal arch (ie. first metatarsal bone, cuneiforms, navicular, talus, and calcaneus). The rotational angles between the tarsal bones were calculated under loading with accessory insoles or therapeutic insoles and compared. The accessory insoles, the therapeutic insoles significantly suppressed the eversion of the talocalcaneal joint.

the mid-stance and pre-swing. The fascia tension increased 66% because of the windlass mechanism.

sportEX comment The clinical relevance of this is a suggestion that an adjustment of gait pattern to reduce heel rise and Achilles tendon force may lower the fascia loading and therefore reduce pain in patients with plantar fasciitis. Please don’t forget that regular foot massage also helps to reduce tension. See Young CC et al. Treatment of plantar fasciitis. American Family Physician 2001;63(3):467–474.

rEport on a mEmBErship audit of thE association of chartErEd physiothErapists in rEflEx thErapy (acpirt). Berry g, svarovska B. complementary therapies in clinical practice 2014;20(3):172–177

sportEX comment One for the podiatrists. There is, however, a bit of a debate about what is better in the long term, orthotics or muscle strengthening to assist flatfeet. Perhaps someone could do a study where each foot received a different treatment.

Reflex Therapy (RT), akin to reflexology, is a non-invasive physiotherapy modality approved by the UK Chartered Society of Physiotherapists. One hundred members of the Association of Chartered Physiotherapists in Reflex Therapy (ACPIRT) participated in an audit to establish a baseline of practice. Findings indicate that experienced therapists use RT in conjunction with their professional skills to induce relaxation (95%) and reduce pain (86%) for patients with conditions including whiplash injury and chronic pain. According to 68% of respondents, RT is ‘very good,’ ‘good’ or ‘as good as’ orthodox physiotherapy practices. Requiring minimal equipment, RT may be as cost effective as orthodox physiotherapy with regards to duration

and frequency of treatment.

sportEX comment You may not have heard of the CSP Professional Network for Reflex Therapy but they are a thriving group and worth looking into. As this report states the evidence in the form of randomised controlled trials may be sparse but the case reports by practitioners tells a different story. Your Journal Watch editor is happy to say that he has used reflexology on professional footballers with great results although I should add that I didn’t tell them it was reflexology I just said it was a foot massage. It costs nothing, is non-invasive, highly unlikely to do any harm and may just do a great deal of good. sportEX medicine 2015;63(January):4-7

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journal watch Twenty-seven healthy male football players and 27 football players with a history of hamstring injuries (recovered and playing fully) underwent standardised muscle functional (mf) MRI. The mfMRI protocol consisted of a resting scan, a strenuous bilateral eccentric hamstring exercise and a post-exercise scan. The exerciserelated T2 increase or the signal intensity shift between both scans was used to detect differences in metabolic activation characteristics between the different hamstring muscle bellies and between the injury group and the control group. The result was that a more symmetrical muscle recruitment pattern corresponding to a less economic hamstring muscle activation was demonstrated in the formerly injured group. The injured group also

BicEps fEmoris and sEmitEndinosus—tEammatEs or compEtitors? nEw insights into hamstring injury mEchanisms in malE footBall playErs: a musclE functional mri study. schuermans j, Van tiggelen d, et al. British journal of sports medicine 2014;48:1599–1606 demonstrated a significantly lower strength endurance capacity during the eccentric hamstring exercise.

sportEX comment What this suggests is that the biceps femoris may have to compensate for the lack of endurance capacity of the semitendinosus which, in turn, may lead to increased hamstring injury risk. Does this mean we need to develop exercises to stress the individual injured hamstring rather than the whole muscle group during rehab?

aromatic-turmEronE inducEs nEural stEm cEll prolifEration in Vitro and in ViVo. hucklenbroich j, Klein r, et al. stem cell research & therapy 2014;5:100 Stick with us on this one. Both in vivo and in vitro primary fetal rat neural stem cells (NSCs) were exposed to various concentrations of aromatic (ar)-turmerone and cell proliferation and differentiation potential were assessed. In both the proliferation of the stem cells increased.

sportEX comment Ar-turmerone is the bioactive compound of Curcuma longa, which you will know better as turmeric, the stuff in the spice pot lurking at the back of your kitchen cupboard. It was known to have anti-inflammatory and neuroprotective properties but now it seems it helps in the production of endogenous neural stem cells (NSCs). These are multipotent cells that have the potential to generate neurons or glial cells and therefore are important targets for neural regeneration. It is thought that this study will lead to the ability to target pharmacological intervention following neurodegenerative disease and stroke. For those of you that worry about animal experiments the authors point out that all animal procedures were in accordance with the German Laws for Animal Protection and were approved by the local animal care committee. www.sportEX.net

t rolE of thE EndocrinE systEm in fEEding-inducEd tissuEthE spEcific circadian EntrainmEnt. sato m, murakami m, et al. cell reports 2014;8(2):393–401 Travel is a performance killer. If you are crossing time lines and the dreaded jet-lag kicks in this study may help. It has long been known that the light–dark cycle regulates the body’s internal clock through receptors in the retina, which activate a timekeeping centre in the brain called the suprachiasmatic nucleus. This study focuses on the circadian cycle in the liver cells of mice and in other tissues. They found that insulin-induced phase shift in peripheral clocks was dependent on tissue type, which was consistent with tissue-specific insulin sensitivity, and peripheral entrainment in insulinsensitive tissues involved PI3K- and MAPKmediated signalling pathways. Or in English that biological clocks in the cells could be reset by exposing them to insulin.

sportEX comment When travelling from Britain to the USA, the scientists prescribe a full English breakfast and a small evening meal. On the homeward journey, they suggest a lighter breakfast and a large bowl of pasta or potatoes for dinner. This is our sort of research. Pass the ketchup please.

online

clicK on rEsEarch titlEs to go to aBstract

n noninVasiVE and altErnatiVE managEmEnt of chronic low BacK pain (Efficacy and outcomEs). neuromodulation: technology at the neural interface 2014;17(s2):24–30

thE impact of psychological rEadinEss to rEturn to sport and rEcrEational actiVitiEs aftEr antErior cruciatE ligamEnt rEconstruction. ardern cl, Österberg a, et al. British journal of sports medicine 2014;48:1613–1619

This is a literature review of available non-invasive and alternative treatment options for chronic low back pain. It comes to the conclusion that the strongest evidence in the literature for good efficacy and outcomes include exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation and acupuncture. Therapies with fair evidence or moderately supported by literature include yoga, back schools, thermal modalities, acupressure and cognitive-behavioural therapy. Those therapies with poor evidence or little to no literature support include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis and aromatherapy.

One hundred and sixty-four participants completed a questionnaire battery at 1–7 years after primary anterior cruciate ligament (ACL) reconstruction. The battery included questionnaires evaluating knee self-efficacy, health locus of control, psychological readiness to return to sport and recreational activity, and fear of re-injury; self-reported knee function in sport-specific tasks, knee-related qualityof-life and satisfaction with knee function. The primary outcome was returning to the pre-injury sport or recreational activity. The results were that at follow-up, 40% (66/164) had returned to their pre-injury activity. Those who returned had more positive psychological responses, reported better knee function in sport and recreational activities, perceived a higher knee-related quality-of-life and were more satisfied with their current knee function. The main reasons for not returning were not trusting the knee (28%), fear of a new injury (24%) and poor knee function (22%). Psychological readiness to return to sport and recreational activity, measured with the ACL-Return to Sport after Injury scale (was most strongly associated with returning to the pre-injury activity). Age, sex and pre-injury activity level were not related.

sportEX comment On the day this landed on the desk Rodger Federer pulled out of the end of season tennis finals, so treatment for bad backs are as relevant to elite sports as they are to the general population. NHS staff please note that the best results come from supervised physical therapy including back schools so please can you stop sending people home with a sheet of exercises and leaving them on their own to follow the instructions.

sportEX comment This is shocking. Less than 50% returned to their pre-injury sport or recreational activity. Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the pre-injury activity. Is it perhaps time that a great deal more time was spent in the various physical therapy disciplines on sports psychology?

a narratiVE rEViEw of massagE and spinal manipulation in thE trEatmEnt of low BacK pain. sejari n, Kamaruddin K, et al. archives of pharmacy practice 2014;5:139–143 Data for this study came from a search of the usual medical databases and textbooks and web pages were used as an additional source. The literature reported that building a successful rapport is a single most important factor in a relationship between clinician and patient. Understanding the patient’s perspective in their illness such as belief about cause, treatment approaches and quality-of-life will help the clinician create plans that are more appropriate to the patient’s situation and preferences. The patient’s trust eases the way for the clinician to provide treatments. Based on current evidence, there are arrays of conservative treatments shown to be effective in treating low back opain (LBP). Massage and spinal 6

manipulation are the most popular among LBP patients because it contributes a good effect in reducing pain intensity. Massage was seen to provide a relaxation element, especially the oriental forms such as Thai massage and Tui Na. Spinal manipulation also showed a positive outcome on pain reduction and joint hypomobility.

sportEX comment We include this article not just because it is yet another that confirms that massage as a treatment for LBP is effective (we already knew that) but because it has cropped up in a journal we don’t normally review (The Archives of Pharmacy Practice). The word is spreading.

u undErstanding fiBroBlasts in ordEr to comprEhEnd thE ostEopathic trEatmEnt of thE fascia. Bordoni B, Zanier E. Evidence-Based complementary and a alternative medicine 2014;id:860934 This paper examines the current literature regarding the function and structure of the fascial system and of the fibroblasts that form its foundation. The fibroblasts play a key role in the transmission of the tension produced by muscles and in the management of the interstitial fluids. They are a source of nociceptive and proprioceptive information as well, which is useful for proper functioning of the body system. They have the ability to rapidly remodel their cytoskeletons.

sportEX comment If you are already tuned into the wonders of myofascial release or wondering what all the fuss is about then this paper is for you. It’s available free. If you want to see for yourself fascia’s ability to alter its structure, search ‘You Tube’ for, ‘Strolling under the skin’. It is film of ‘live’ connective tissue being explored with a ×30 magnification camera. sportEX medicine 2015;63(January):4-7

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t anatomical footprint of thE achillEs tEndon: a cadaVEric study. Ballal ms, walker cr, molloy thE ap. the Bone & joint journal 2014;96-B:1344–1348 ap This is another cadaver study. Twelve freshfrozen leg specimens were examined to identify the insertional footprint of each fascicle of the Achilles tendon on the calcaneum in relation to their corresponding muscles. A further ten embalmed specimens were examined to confirm an observation on the retrocalcaneal bursa. They found that the superficial part of the insertion of the Achilles tendon is represented by fascicles from the medial head of the gastrocnemius muscle, which is inserted over the entire width of the inferior facet of the calcaneal tuberosity. The deep part of the insertion of the Achilles tendon is made of fascicles from the soleus tendon, which insert on the medial aspect of the middle facet of the calcaneal tuberosity and the fascicles of the lateral head

of the gastrocnemius tendon insert on the lateral aspect of the middle facet of the calcaneal tuberosity. They also found that in three specimens this insertion of medial head of the gastrocnemius was in continuity with the plantar fascia in the form of periosteum and that a bicameral retrocalcaneal bursa was present in 15 of the 22 of the specimens.

sportEX comment The eventual clinical relevance of this study may be that a better understanding of which muscle has an effect on which part of the tendon may lead to a better understanding of Achilles tendinopathies. The lack of a bursa in some specimens and the link to the plantar fascia in others could be an explanation for why some people get injured and others don’t and why some respond to treatment more successfully than others.

a morphological study of third hEad of BicEps Brachii in human cadaVErs with its clinical implications. gupta c, d’souza s. saudi journal for health sciences 2014;3:129–132 The study was carried out on 24 cadaveric upper limbs. Dissection of the front of arm was done and the origin and insertion of the biceps brachii (BB) was examined. The extra head was found unilaterally in three male cadavers, one belonging to the left side and two to right side. In two of the cases the third head of BB originated near the insertion of coracobrachialis and at the origin of

the brachialis and merged with the other two heads to and insert into the posterior part of radial tuberosity. In the other example it originated along with the long head of BB and its tendon inserted into the deep fascia of the arm.

sportEX comment

3-headed biceps? Have the writers of traditional anatomy books ignored this or are we witnessing evolution in action? This is another free access journal and there are pictures of the dissections. Not sure that it makes much difference to physical therapists but it might do to orthopaedic surgeons doing repairs.

Has there always been a proportion of the population with

manual thErapiEs for primary chronic hEadachEs: a systEmatic rEViEw of randomiZEd controllEd trials. chaibi a, russell mB. the journal ournal of headache and pain 2014;15(1):67 A search of the usual medical databases came identified six randomised controlled trials (RCTs) all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group. Only two studies avoided cointervention, which may lead to possible bias and makes interpretation of the results more difficult. The RCTs suggest www.sportEX.net

that massage and physiotherapy are effective treatment options in the management of CTTH. One of the RCTs showed that physiotherapy reduced headache frequency and intensity statistical significant better than usual care by the general practitioner. The efficacy of physiotherapy at post-treatment and at 6-month follow-up equals the efficacy of tricyclic antidepressants.

sportEX comment At last, a study that says that physio is better than drugs. Well done to that group of researchers. 7

Vitamin D in sport anD exercise meDicine

A prAcTIcAl rEVIEw

BY Professor CathY sPeed BMedsCi, diP sPorts Med, Ma, Phd, frCP, ffseM (i) (UK)

What is vitaMin d? The fat soluble secosteroid prohormone ‘vitamin D’ exists in two main forms: Vitamin D3 (cholecalciferol; D3), and vitamin D2 (ergocalciferol; D2), the difference being in their side chains. D2 and D3 are also collectively known as calciferol. Vitamin D3 is synthesised in the skin in response to ultraviolet-B (UVB) light exposure, or it is obtained in small amounts from food, in particular oily fish, egg yolks, liver and some fortified foods (cereals, margarine, milk and infant formula milk). Both D2 and D3 are converted in the liver then the kidney into the active form, 1,25-dihydroxyvitamin D (hereafter referred to as ‘Active-D’. This process is stimulated by parathyroid hormone (pTH), as well as low calcium and/or phosphorous levels and inhibited by calcium and circulating fibroblast growth factor 23 (FGF23), which is released by osteocytes. There are receptors for Active-D all over the body, including in bone, skeletal muscle, gastrointestinal tract, kidney, skin, pancreas, immune cells, the thyroid, parathyroid, pituitary and adrenal glands, the central nervous system, the prostate and urinary tract (2–4). Active-D has advanced hormonal 8

Suboptimal levels of vitamin D are now recognised as a worldwide public health problem (1), having a range of effects through many mechanisms. A wide range of individuals – even the supremely fit – can have suboptimal vitamin D levels. This article provides an overview of the current understanding of vitamin D, its effects, mechanisms, measurement and approaches to supplementation. effects on the skeleton, regulating mineral and skeletal homeostasis. It acts on bone, intestine (particularly the duodenum) and kidney to activate calcium transport into the bloodstream. Active-D also helps the immune system in fighting against infections and can reduce local inflammation too. These anti-inflammatory effects are also proposed by some to help to protect against cancers. Vitamin D levels are influenced by a number of factors: living further north than 37° latitide, limited UV-B exposure, being female, deficient diet,

VITAMIN D INSUFFIcIENcy IS wIDEly rEporTED IN SporTING popUlATIoNS AcroSS THE worlD

darker skin pigmentation, diseases, BMI above or below the normal range, smoking, increased age, or premature birth all being linked with suboptimal levels (Box 1). Vitamin D is just a micronutrient in the diet, which provides only 100–200IU per day. This represents just 10–20% of the daily stated requirement (400–2000IU/ day). An additional problem in northern and western Europe and half of North America is that sunlight exposure for 6 months of the year is inadequate to stimulate enough endogenous vitamin D production. During the other 6 months, a maximum of 2000IU will be generated by sunlight exposure for 20–30 minutes (5). Serum levels of vitamin D are maximal in September and lowest in February in the UK (6) Elderly people produce 75% less cutaneous vitamin D3 in sunlight than sportEX medicine 2015;63(January):8-11

eViDence informeD practice

young adults (3,4), and those with pigmented skin will also generate much less. It is not possible to give a uniform message to the population about optimal safe sunlight exposure, given the individual variation in response, and effects of time of day, latitude, skin pigmentation and risks of over exposure, etc.

vitaMin d in sPort Vitamin D insufficiency is widely reported in sporting populations across the world. For example, 37% of German gymnasts are reported to have vitamin D levels lower than 25nmol/l. Sixty-seven percent of young Finnish females have vitamin D levels less than 37nmol/l in the winter, with no difference in incidence in gymnasts and runners versus age-matched controls. Even in countries where sunlight exposure is high, levels can be low. For example in Hawaiian skateboarders, 51% had low vitamin D status (7). Those athletes with low body fat, those who train indoors away from sunlight, those who have insufficient diets and/or pigmented skin are all at risk. whether athletes are more at risk of suboptimal vitamin D levels has not been demonstrated. However, those who have suppressed immune function or those with low bone mass related to intense training or other factors, will be particularly affected by lack of vitamin D. Extreme levels of performance may be affected by low vitamin D, due to potential neuromuscular effects, and possibly to adverse effects on the adaptive response to the training stimulus (8). However such consequences of vitamin D insufficiency as yet have not been thoroughly evaluated.

definitions There is considerable debate about the best definition of vitamin D deficiency and insufficiency. Definitions of deficiency are largely based on those levels known to be associated with bone disease, and insufficiency when there are potential non-skeletal disease associations. In general, a level <25nmol/l indicates deficiency and 26â&#x20AC;&#x201C;49nmol/l is regarded as insufficient. levels >200nmol/l indicate toxicity. www.sportEX.net

effeCts of vitaMin d Musculoskeletal effects The links between vitamin D deficiency and osteomalacia (soft bones) and rickets (9) and with elevated risk of lumbar vertebral and hip fracture (10) are well established. A significant increase in the risk of hip fracture is noted with a decline in serum vitamin D; the odds ratio for fracture is nearly doubled when vitamin D is <50nmol/l (11). Specific vitamin D receptor (VDr) polymorphisms have been associated with increased fracture risk (12) and in the future, screening for VDr polymorphisms may be useful in identifying those at increased risk. calcium and vitamin D supplementation have been shown to benefit bone health and also to reduce fracture risk in older people (13,14). However, the effects on stress fractures in sport are less clear. A single prospective interventional study of calcium (2g/day) and vitamin D3 (800IU/day) over an 8-week period reduced the incidence of stress fractures in female military recruits by 20% (15). More such studies are warranted. In normal muscle, vitamin D plays a role in contraction through its influence on intracellular calcium. In osteomalacia and rickets, proximal myopathy is a feature, with a non-specific type II fibre atrophy and fatty infiltration demonstrated on biopsy (16, 17). low vitamin D is associated with a reduction in muscle power, which may be the result of declines in contraction velocity rather than strength per se (18).

Performance There are many plausible mechanisms by which vitamin D supplementation may improve physical performance in the individual with low vitamin D levels. There is neither evidence nor a rationale to support supplementation of those with normal levels of vitamin D; the focus should be on the detection and treatment of those with subnormal levels, and ensuring that healthy levels are maintained in all. In ageing individuals, vitamin D receptors decline. A significant relationship between physical performance (walk test, chair stands, tandem stand) and serum vitamin D

Box 1: risK faCtors for loW levels of vitaMin d n lack of cutaneous conversion: not enough sunlight or pigmented skin n Decreased dietary intake n Diseases: gastrointestinal, liver, kidney, metabolic disorders. has been demonstrated (19). Vitamin D supplementation has also been linked to a reduction in falls in this group (20). This may be due to neurological effects rather than direct effects on muscle. Vitamin D receptors have been identified in a wide range of neural tissues, and there are suggestions that vitamin D has neurotrophic, neuroimmunomodulatory, anti-ischaemic and antioxidant effects (2). other apparent effects of vitamin D deficiency include age-related cognitive decline, postural sway, and reaction times â&#x20AC;&#x201C; all significant factors in falls. In younger adults, the full extent of the neuromuscular effects of vitamin D and its effects on performance and recovery have not yet been established. Some interventional studies of vitamin D have shown improvements in performance parameters in vitamin D deficient young adults (21), but overall research on the association between vitamin D and athletic performance is limited. As long ago as the 1930s, studies were performed in Germany and russia of the effects of UV-B irradiation on performance markers (22). claims of improved cardiovascular fitness and muscular endurance in irradiated groups were made in small, short studies. The role of vitamin D in these reported findings has not been established. Seasonality of physical fitness is commonly described, but there are too many confounding factors to understand the role of vitamin D in this.

VITAMIN D IS SyNTHESISED IN THE SKIN IN rESpoNSE To UV-B ExpoSUrE AND IS prESENT AS A MIcroNUTrIENT IN THE DIET 9

Pain There are some conflicting small reports of the effects of vitamin D on musculoskeletal pain and fatigue. In subjects who had low vitamin D levels, one small study of subjects with osteoarthritis showed no significant benefit from vitamin D supplementation (23); another showed an improvement in fibromyalgia pain scores (24).

other aspects There is a clear link between low vitamin D and cardiovascular diseases and obesity; also associations have been proposed between low vitamin D levels and reduced resistance to infection and exacerbations of asthma. Vitamin D also influences cognition, mood and sleep.

What is the Best WaY of sUPPleMenting vitaMin d? In those who are vitamin D deficient or insufficient, supplementation is indicated in order to replenish stores and maintain levels thereafter. conceivably, lifestyle changes and reduction of adiposity may reduce the individual’s supplementary vitamin D requirement. A serum vitamin D level above 50nmol/l and preferably between 75 and 100nmol/l should be the target. In those who have suboptimal levels, supplementation is possible: usually with cholecalciferol (D3), preferably taken with a meal containing some fat to ensure absorption. Substantial between-individual variability exists in response to the same administered vitamin D dose. D2 is preferred in vegetarian/vegans. In those with moderate to severe deficiency (<30nmol/l), the aim is to deliver a minimum total of 600,000

and up to 1,000,000IU of vitamin D orally over 8–12 weeks, although some recommend shorter loading time frames (1). The obese and the most deficient are likely to need higher doses than lean and/or less deficient subjects. Vitamin D and calcium levels are then rechecked 4 weeks after completing the supplement course. Intact pTH may take months to return to normal, but if it has risen from baseline at this stage, this could indicate primary hyperparathyroidism. once levels of vitamin D are in normal range, maintenance supplementation should deliver 800–2,000IU/day, rechecking after 4–6 weeks to assess response. If levels of vitamin D are still suboptimal, then either the oral loading is repeated, or parenteral supplementation (eg. 600,000IU by intramuscular injection) used. reasons for a poor response must be considered: in particular concordance and malabsorption. Monitoring of vitamin D levels is most useful at least in autumn and spring. calcium should not be supplemented unless the patient is hypocalcaemic.

toxiCitY Side effects of high doses of D2 or D3 are rare but include polyuria and irritability, and potential anaphylaxis must be considered with the parenteral form. True vitamin D toxicity is extremely rare with the regimes described, but the possibility of toxicity must still be considered, usually in those taking high amounts for several months. renal stones may also occur in those who have high calcium intakes.

sUMMarY Suboptimal vitamin D levels are common in broad spectrum of

A rUlE oF THUMB IS THAT IF yoUr SHADow IS loNGEr THAN yoU ArE TAll, yoU woN’T BE SyNTHESISING ANy VITAMIN D 10

individuals who attend sport and exercise medicine clinics, and pose potential significant adverse health effects. The clinician should be vigilant in the detection, treatment and monitoring of this problem in their patients. References 1. Hollick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. the american Journal of clinical nutrition 2004;79:362–371 2. Bouvard B, Annveiller c, et al. Extraskeletal effects of vitamin D: facts, uncertainties and controversies. Joint Bone spine 2011;78:10–16 3. lips p. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. endocrine reviews 2001;22:477–501 4. lips p. Vitamin D physiology. progress in Biophysics & molecular Biology. 2006;92:4–8 5. Adams JS, Hewison M. Update in vitamin D. Journal of clinical endocrinology & metabolism 2010;95(2):471–478 6. webb Ar, Kift r, et al. The role of sunlight exposure in determining the vitamin D status of the U.K. white adult population. British Journal of Dermatology 2010;163:1050–1055 7. Binkley N, Novotny r, et al. low vitamin D status despite abundant sun exposure. the Journal of clinical endocrinology and metabolism 2007;92:2130–2135 8. Stewart cE, rittweger J. Adaptive processes in skeletal muscle: molecular regulators and genetic influences. Journal of musculoskeletal & neuronal interactions 2006;6:73–86 9. Mozolowski w. Jedrez Sniadecki (1768-1838) on the cure of rickets. nature 1939;143:121 10. Bischoff-Ferrari HA, Kiel Dp, et al. Dietary calcium and serum 25-hydroxyvitamin D status in relation to BMD among US adults. Journal of Bone and mineral research 2009;24:935–942 11. cauley JA, lacroix AZ, et al. Serum 25-hydroxyvitamin D concentrations and risk for hip fractures. annals of internal medicine 2008;149:242–250 12. chatzipapas c, Boikos S, et al. polymorphisms of the vitamin D receptor gene and stress fractures. Hormone and metabolic research 2009;41:635–640 13. cranney, A, Horsley T, et al. Effectiveness and safety of vitamin D in relation to bone health. evidence report/technology assessment 2007;(158):1–235 14. Tang BM, Eslick GD, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007;370:657–666 sportEX medicine 2015;63(January):8-11

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15. lappe J, cullen D, et al. calcium and vitamin d supplementation decreases incidence of stress fractures in female navy recruits. Journal of Bone and mineral research 2008;23:741–749 16. Floyd F, Ayyar D, et al. Myopathy in chronic renal failure. the Quarterly Journal of medicine 1974;43:509–524 17. Sato y, Iwamoto J, et al. low dose vitamin D prevents muscular atrophy and reduces falls and hip fractures in women after stroke: a randomised controlled trial. cerebrovascular Diseases 2005;20:187– 192 18. Annweiler c, Beauchet o, et al. Is there an association between serum 25-hydroxyvitaminD concentration and muscle strength among older women? results from baseline assessment of the EpIDoS study. the Journal of nutrition, Health & aging 2009;13:90–95 19. wicherts IS, can Schoor NM, et al. VitaminD Deficiency nand neuromuscular performance in the longitudinal Aging Study Amsterdam (lASA). Journal of Bone and mineral research 2005;20(suppl 1):s35 20. Flicker l, MacInnis rJ, et al. Should

older people in residential care receive vitamin D to prevent falls? results of a randomized trial. Journal of the american Geriatrics society 2005;53(11):1881–1888 21. Gupta r, Sharma U, et al. Effect of cholecalciferol and calcium supplementation on muscle strength and energy metabolism in vitamin D deficient Asian Indians: A randomized controlled trial. clinical endocrinology 2010;73:445–451 22. cannell JJ, Hollis B, et al. Athletic performance and Vitamin D. medicine & science in sports & exercise 2009;41(5):1102–1110 23. warner AE, Arnspiger SA. Diffuse musculoskeletal pain is not associated with vitamin D levels or improved by treatment with vitamin D. Journal of clinical rheumatology 2008;14:12–16 24. Arvold DS, odean MJ, et al. correlation of symptoms with vitamin D deficiency and symptom response to cholecalciferol treatment: a randomised controlled trial. endocrine practice 2009;15:203–212.

fUrther resoUrCes 1. owens DJ, Fraser wD, close Gl. Vitamin D and the athlete: emerging insights. european Journal of sport science 2014;18:1–12. 2. world map showing the prevalence of multiple sclerosis, which has been linked to low vitamin D levels, at the All About Multiple Sclerosis website (http://spxj.nl/1rNvDZl).

DISCUSSIONS

n How does the body usually acquire vitamin D? n what vitamin D levels are considered to be (a) normal, (b) insufficient and (c) deficient? n what problems can be caused/ exacerbated by low levels of vitamin D? n what methods are there for vitamin D supplementation?

THE AUTHOR PROfEssOR CATHy sPEEd BMedsci, dip P sports Med, MA, Phd, fRCP, ffsEM s Cathy is a consultant in Rheumatology, sport & Exercise Medicine. she is based at The fortius Clinic, London, and at the Cambridge Centre for Health and Performance in Cambridge. she is also a senior physician for the English Institute of sport.

KeY Points n vitamin d is synthesised in the skin in response to Uv-B exposure. n small amounts of vitamin d are obtained from food such as oily fish, eggs and fortified foods. n vitamin d has effects on many areas of the body, most notably the bones, but also the immune and nervous systems. n risk factors for suboptimal vitamin d levels include: limited Uv-B exposure (living in northern latitudes, spend little time outside, higher skin pigmentation), deficient diets and smoking. n Many athletes have low levels of vitamin d – including skateboarders in hawaii. n Problems related to intense training can be exacerbated by low levels of vitamin d. n supplementation of vitamin d in individuals with low levels may improve physical performance. n lifestyle changes and/or oral vitamin d supplementation can be used to increase vitamin d levels to the normal range. n vitamin d toxicity is rare but the clinician should perform monitoring of treatment to avoid it.

www.sportEX.net

The challenges of youTh Psychosocial resPonse to injury and rehabilitation in youth athletes BY ADAM GLEDHILL MSC AND DALE FORSDYKE MSC, MSST MSMA

INTRODuCTION Many practitioners throughout their career will work with child and youth athletes, yet the guidance currently available to those working in this type of challenging – yet rewarding – setting is somewhat lacking. This is important for practitioners given that youth injury and recurrence rates in a variety of sports are as high as 49% (2) and can be as a result of physical, physiological, perceptual and psychosocial factors. As a result, injured youth and adolescent athletes present practitioners with a unique challenge (3); not only because the injured athlete will have clear physical and psychosocial responses (4), but also because adolescent athletes are already dealing with a number of developmental issues such as lessening dependence,

WHen IT coMeS To yoUTH ATHLeTeS, beIng InjURy FRee AnD In A STATe oF pSycHoLogIcAL WeLLbeIng IS MoRe IMpoRTAnT THAn pLAyIng eveRy gAMe 12

Understanding the psychosocial challenges faced by youth athletes can be key to a successful return to competition following sports injury. This article extends other recent articles that have examined the salient role of psychology within sports injury risk, rehabilitation and return to competition (1) by providing an overview of some of the challenges of working with youth athletes as well as presenting some strategies that can be used to enhance the quality of rehabilitation outcomes. It is hoped that this will stimulate reflective practice and increase practitioner confidence in working with some of the psychosocial challenges presented by youth athletes. increasing independence, refining a range of social skills (5) and identity development (6). From this, it is important for practitioners to consider that they may be playing a central role in rehabilitating not only the injury, but more importantly the person and the athlete behind the injury. Despite this, many practitioners feel underequipped to deal with the psychosocial responses to sports injury or how to apply their existing knowledge in a practical context in order to benefit their patients (7).

SO wHAT ARE THE CHALLENGES OF wORKING wITH YOuNG ATHLETES? For youth athletes, their sport is just

one part of a complex identity and typically difficult time of their lives. Sport will often be a central focus of their attention; where they will sacrifice a ‘normal’ development in pursuit of sporting dreams (8). As a result of this, sports injuries, particularly long-term injuries or recurring injuries, may have a significant psychosocial impact. Injured adolescents will often demonstrate lower health-related quality of life (HRQoL) than uninjured adolescents, with factors such as perceptions of pain or discomfort, increased catastrophising over the injury, decreased social functioning, or their ability to fulfil personal roles and responsibilities all negatively affected by sports injuries (3,9). In addition, sportEX medicine 2015;63(January):12-17

evidence informed pracTice

athletes tend to display increased depressive symptoms at the onset of injury, although these will likely decrease over time as long as the athlete is exposed to and engages with appropriate coping strategies, such as social support (5). For the sports injury practitioner, it is important to consider these markers of overall psychological wellbeing during rehabilitation and return to competition so that the young athlete does not become more susceptible to re-injury.

despite having physically recovered from their injuries (11). youth athletes thinking negatively about their injury and the injury status regardless of their stage of recovery may present problems for the practitioner; including an increased risk of re-injury as a result of injury-related distress and an increased fear of re-injury (12) therefore strategies to reduce injuryrelated stress in youth athletes should be common place in our work as practitioners (see Table 1 for examples and potential benefits).

BuT wON’T pSYCHOLOGICAL REHABILITATION juST HAppEN?

BuT THEY juST wON’T DO IT... HOw DO I MOTIvATE THEM?

A common misconception within sports injuries is that physical and psychological rehabilitation happen at the same time (10). Research with adolescents suggests that the negative psychological effects of injury may be long lasting, even after physical recovery has taken place. For example adolescents have been reported to experience injury-related distress

Quite often, a fear of re-injury or disrupted progress in injury rehabilitation can result in decreased motivation in youth athletes. equally so, accelerated progress can result in over-motivation which can result in an increased risk of re-injury or secondary injury, and ultimately increase rehabilitation time (13). A recent review of literature (10) suggested that athletes

BOx 1: SIMpLE MOTIvATIONAL STRATEGIES FOR uSE wITH INjuRED YOuTH ATHLETES (gledhill & Forsdyke, 2014) n goal setting (short-, medium-, long-term; combination of outcome, performance and process goals; use SMARTS acronym) n Decision balance sheets n Motivational interviewing n performance profiling SMARTS: specific, measurable, action-oriented, realistic, time-bound, self-determined.

THe ULTIMATe goAL oF ALL yoUTH ATHLeTeS IS To ReTURn To coMpeTITIve AcTIon, bUT THeRe WILL LIkeLy be bUMpS In THe RoAD

TABLE 1: STRATEGIES uSED DuRING INjuRY REHABILITATION AND THEIR pOTENTIAL BENEFITS (gledhill & Forsdyke, 2014) Common strategies used in injury rehabilitation

potential benefits for the youth athlete

Imagery

n n n n n n n

Increased confidence and sense of competence Decrease injury-related stress Aid skill maintenance or development Decrease rehabilitation time pain management Management of negative thoughts emotional control.

Self-talk

n n n n n n n

Increased confidence and sense of competence Decrease injury-related stress Direct behaviour Increase attention to particular aspect of a rehabilitation exercise persistence with rehabilitation activities Increased goal commitment Increased positive affect.

Social support

n n n n n

Increased sense of competence and confidence Decrease injury-related stress Increase pursuit of rehabilitation goals Increase athlete’s perceptions of self-worth encourage athlete’s to overcome rehabilitation barriers.

progressive muscular relaxation

n n n n n

Decrease tension Alleviate mood Decrease injury-related stress Increase athlete’s perceptions of control pain management.

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with high competence, autonomy and relatedness will tend to have more self-determined motivation, which can then impact on their desire to achieve rehabilitation goals. Moreover, athletes who are successful in returning to full competition have a tendency to recognise the positives and negatives of injury, so it is important that practitioners are confident to work with young athletes using simple motivational strategies to help maintain rehabilitation adherence (box 1). These motivational strategies are particularly useful as they can help patients develop a stronger sense of intrinsic motivation which, in turn, can lead to long-term favourable behaviour change. Further, these strategies are beneficial because they can be used to benefit the patient in instances where they are either under- or over-motivated. Should you have any concerns about the rehabilitation adherence of your patient, you may wish to use a questionnaire such as the Sports Injury Rehabilitation Adherence Scale (SIRAS) (14).

SuRELY IT IS juST ALL ABOuT MOTIvATION wITH YOuTH ATHLETES? Many practitioners often feel that rehabilitation adherence and compliance is simply a matter of athletes being motivated enough to 13

take part. Although motivation certainly plays a significant role in rehabilitation adherence and compliance, athletic identity is also important. In a study that examined age-related differences in predictors of adherence to rehabilitation after anterior

cruciate ligament reconstruction, it was reported that a strong athletic identity was positively associated with home exercise and cryotherapy completion for adolescent athletes (6). A successful return to competition will usually be more of a priority for athletes with a strong athletic identity, so it is likely that this will impact on their approach to the home-based elements of injury rehabilitation. Maintaining athletic identity is also important from a HRQoL perspective because athletes with a strong athletic identity can suffer greater depressive symptoms as a result of sports injury, due to the threat that the injury poses to the athletic identity, so it is a particularly useful for practitioners to know ways of helping athletes maintain their athletic identity (box 2).

SO BEING INjuRED IS BAD, RIGHT? As practitioners, we are always constantly seeking ways of trying to improve the injury experiences of our athletes. Although the common opinion is that injuries are a negative experience for adolescent athletes

eMpHASISIng THe poSITIveS oF A LengTHy InjURy peRIoD MAy be cenTRAL To ReDUcIng InjURy-ReLATeD AnxIeTy AnD ReInjURy AnxIeTy, AS WeLL AS FAcILITATIng peRceIveD pSycHoLogIcAL gRoWTH BOx 2: pRACTITIONER TIpS FOR ENHANCING REHABILITATION OuTCOMES (Gledhill & Forsdyke, 2014) n n n n n n n n n

Understand the athlete’s rehabilitation beliefs and adherence emphasise the positives of any lengthy injury periods Foster opportunities for learning and development (eg. providing injury education) Integrate life-skills (eg. goal setting, time-management) and psychological skills (eg. imagery, selftalk) into normal rehabilitation be aware of any signs of poor adjustment to injury (eg. over-emphasis on RTc, pre-occupation , with minor setbacks/achievements, excessive mood changes/disturbance) Aid the athlete in maintaining their athletic identity (e.g. encourage presence and having roles during training and match days) Don’t allow the injury identity to become too overpowering (eg. make sure that your first question is asking the athlete how THey are, not how THe InjURy is) openly educate the athlete about the injury and what they can expect, avoiding any ambiguous language (rehabilitation is often a bumpy road) Facilitate social support via social modelling as this can help the injured adolescent understand that they can recover and RTc ‘as good as new’.

RTC, return to competition

(9,15), the injury period can also provide an opportunity for positive youth development and psychosocial growth (15,16). This growth can be seen through increases in motivation, the ability to overcome challenges, learning to be patient during times of difficulty, and accessing learning opportunities (15). one example of this comes from an injured adolescent female football player (16) who talked about how much she had learnt about football during her injury period because it was a time where she was able to watch a number of football games. Her growth as a player came through being able to watch people who usually play in her position and the opposing positions to see how they played. As a result, she was able to learn more about the technical and tactical elements of her position and she felt that this benefitted her when she returned to competition. coaches, teammates and parents also played a role in fostering her learning about football as she was able to de-brief with these individuals. They cultivated formal performance-related reflections and inadvertently facilitated other psychological skills development (eg. the use of imagery to create ‘performance scenes’ prior to her return to sport). From this, we recommend that practitioners take opportunities to emphasise the opportunities for positive youth development and psychosocial growth, and integrate these into practice wherever possible.

wHAT ABOuT THE pEOpLE AROuND THE ATHLETE? There are a number of social issues faced by young athletes in modern sport, many of which can impact on the quality of their injury rehabilitation. In wider society, the media will often celebrate the willingness of athletes to endure pain and injury in order to continue their participation. This stoicism is often commended by people in positions of authority or power over young people (eg. coaches, parents, and teammates), creating a sense of normalisation of sports injury. given the need for young people to appear competent to significant others (17), this normalisation of pain and injury may have significant consequences for young athletes. For example, there sportEX medicine 2015;63(January):12-17

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are suggestions that parental pressure may be a risk factor in overuse injuries in adolescent athletes and that parental misconduct while spectating at games may lead to an increased risk of violence-related traumatic injuries if athletes feel the need to perform socially desirable behaviours (18). There appears to be a tendency in young athletes to perceive social pressures that can affect sports injury rehabilitation (Fig. 1). youth athletes may perceive external pressures to return to competition quickly in order to play in the next big game, and may suffer perceptions of guilt over letting down their teammates if they are unable to meet these external pressures (15). Therefore, the sports injury practitioner may have an important role to play in mediating the perception of demands of coaches, parents and teammates so as to maximise the wellbeing of the injured athlete. Moreover, injured adolescent athletes can often feel a sense of isolation from teammates and coaches during injury periods (15,16), so directly providing and indirectly fostering social support becomes an important element of the work of the sports injury practitioner (see 19).

BuT wHAT IF I COME BACK AND I’M NOT GOOD ENOuGH? Another key challenge of working with adolescents is that they inherently will often want to demonstrate competence to their peers (17). This an important consideration as extended injury periods will impact on the injured player’s perception of their competence (15,16) which may also subsequently affect the athlete’s rehabilitation beliefs or their readiness to return to competition due to factors such as a fear of re-injury (12,21). Should you have any concerns about your athlete’s rehabilitation beliefs, readiness to return to play, or their levels of re-injury anxiety; you may wish to consider using appropriate questionnaires to support your discussions with your athletes (box 3). key competence-related concerns presented by adolescents during rehabilitation include worries about the impact of injury on physical fitness, concerns over technical skill levels, www.sportEX.net

feeling like they are ‘falling behind’ other athletes (either teammates or competitors), the inability to achieve sport-related goals, and the inability to perform to pre-injury levels (box 4) (15,16); all of which are important considerations for the practitioner when working with injured adolescents. If competence-related concerns become too great, the patient may become over-motivated and not comply correctly with the rehabilitation programme, thus increasing the risk of injury. As practitioners, it is important that we can therefore include skills into rehabilitation programmes that will help to enhance the patient’s perceptions of competence by fostering achievement during rehabilitation (box 2, Table 1).

Letting down team mates parental pressure

parental behaviour

Normalisation of pain and injury

Social concerns

Coach pressure

Missing important games

preceived isolation

Figure 1: Social concerns in injury rehabilitation and return to competition. (Gledhill & Forsdyke, 2014)

CONCLuSION As practitioners, we are often faced with a multitude of challenges to successfully rehabilitate our athletes. youth athletes present particular challenges because of the myriad of intra- and inter-personal issues that they face during their everyday life, which can be accentuated when they experience long-term injuries. Due to the amount of time that we will spend with these athletes during rehabilitation periods, we are ideally situated to provide support that may reduce the detrimental psychosocial impact of injuries and to positively frame the injury period as an opportunity to

experience personal and sporting growth and development; to ensure that a full and successful holistic recovery can take place.

BOx 3: QuESTIONNAIRES FOR uSE wITH ATHLETES BEFORE RETuRN TO SpORT/ COMpETITION (gledhill & Forsdyke, 2014) n Sports Injury Rehabilitation belief Scale (SIRbS) [Taylor & May, 1996 (20)] n Injury-psychological Readiness to Return to Sports (I-pRRS) [glazer, 2009 (21)] n Re-Injury Anxiety Inventory (RIAI ) [Walker et al., 2010 (12)].

BOx 4: QuOTES FROM INjuRED ATHLETES [gledhill & Forsdyke, 2014; sourced podlog et al. (15) and gledhill & Forsdyke (16)] Quote

Source

“the recovery was a bit frustrating at times when I knew I couldn’t do things that I used to be able to do”

podlog et al. (15)

“I didn’t feel like I was part of the team”

podlog et al. (15)

“I’m worried that I won’t be good enough. I think I’m more worried about that than I am getting injured again.”

gledhill & Forsdyke (16)

“I always dreaded going into the therapy room, now I can’t wait until I can get in there.”

gledhill & Forsdyke (16)

“I just now feel like thinking is it worth it?”

podlog et al. (15)

“I’ve just learned how to be a better player”

gledhill & Forsdyke (16)

“For me at this stage, it wouldn’t be about winning or losing, it would just be to feel no pain when I play; to , I guess, be more happy when I play and smile.”

podlog et al. (15)

“Twitter has been great. It’s made it so much easier to keep in touch with people and stop me feeling so alone.”

gledhill & Forsdyke (16)

References 1. Forsdyke D. Risk, response and recovery: psychology of sports injury. sporteX medicine 2014;59:10–15 2. caine D, caine c, Maffuli n. Incidence and distribution of paediatric sport-related injuries. clinical Journal of sports medicine 2006;16:500–513 3. Tripp DA, Stanish WD, et al. comparing postoperative pain experience of the adolescent and adult athlete following anterior cruciate ligament (AcL) surgery. Journal of athletic Training 2003;38:154–157 4. Walker n, Thatcher j, Lavallee D. psychological responses to injury in competitive sport: A critical review. Journal of the royal society for the promotion of health 2007;127(4):174–180 5. Manuel jc, Shilt jS, et al. coping with sports injuries: an examination of the injured athlete. Journal of adolescent health 2002;31:391–393 6. brewer bW, cornelius Ae, et al. Age-related differences in predictors of adherence to rehabilitation after anterior cruciate ligament reconstruction. Journal of athletic Training 2003;38(2):158–162 7. Heaney c, green Ajk, et al. A qualitative and quantitative investigation of the psychology content of Uk physiotherapy education programs. Journal of physical Therapy education 2012;26(3):48–56 8. gledhill A, Harwood c. Developmental experiences of elite female youth soccer players. international Journal of sport and exercise psychology 2014;12(2):150– 165 9. valovich McLeod, Tc, bay Rc, et al. Recent injury and health-related quality of life in adolescent athletes. Journal of athletic Training 2009;44(6):603–610 10. podlog L, eklund Rc. The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective. psychology of sport and exercise 2007;8:535–566 11. newcomer RR, perna FM. Features of posttraumatic distress among adolescent athletes. Journal of athletic Training 2003;38(2):163–166 12. Walker n, Thatcher j, Lavallee D. A preliminary development of the Re-Injury Anxiety Inventory (RIAI). physical Therapy in sport 2010;11:23–29 13. Frey M. The other side of adherence: injured athletes who are too motivated. athletic Therapy Today 2008;13(3):13–14 14. brewer bW, van Raalte jL, et al. A brief measure of adherence during sport injury rehabilitation sessions. Journal of applied sport psychology 1995;7:s44 15. podlog L, Wadey R, et al. An adolescent perspective on injury recovery and return to sport. psychology of sport and exercise 2013;14:437–446 16. gledhill A, Forsdyke D. Injury experiences in adolescent female soccer. Abstract accepted to the 19th Annual conference of the european college of Sport Science 16

2014, Amsterdam, The netherlands 17. Weiss MR. psychological aspects of sport-injury rehabilitation: A developmental perspective. Journal of athletic Training 2003;38:172–175 18. Hamstra kL, cherubini jM, Swanik cb. Athletic injury and parental pressure in youth sports. athletic Therapy Today 2002;7(6):36–43 19. Forsdyke D, gledhill A. Reaching out for a helping hand: The role of social support in sports injury rehabilitation. sporteX medicine 2014;61:8–12 20. Taylor AH, May S. Threat and coping appraisal as determinants of compliance with sports injury rehabilitation: an application of protection Motivation Theory. Journal of sports sciences 1996;14(6):471–482 21. glazer DD. Development and preliminary validation of the Injury-psychological Readiness to Return to Sport (I-pRRS) scale. Journal of athletic Training 2009;44:185–189.

FuRTHER RESOuRCES 1. The Psychology of Sports Injury and Rehabilitation by M. ArvinenArvinen-barrow & n. Walker. r routledge 2013. ISbn 978-0415695893 ((print £24.29 kindle £23.08). buy from Amazon http://spxj.nl/1b5ohZA 2. Foundations in Sports Therapy by A. gledhill, n. Mackay, et al. heinemann 2011. ISbn 9782011 (£27.45).buy from 0435046859 (£27.45). Amazon http://spxj.nl/1zFjaH6 3. Sport Psychology: Performance Enhancement, Performance Inhibition, Individuals, and Teams (2nd edn) by n. galucci. psychology press 2014. ISbn 978-1848729780 (print £47.37 kindle £45.00). buy from Amazon http://spxj.nl/1wboUdc 4. From Risk to Retirement: The Psychology of Sports Injury and Rehabilitation by A. gledhill, D. Forsdyke & j. Stebbings. The crowood press 2015. 5. Routledge Handbook of Applied Sport Psychology by S. Hanrahan & M. Andersen. routledge 2013. ISbn 978r 0415484640 (print £31.70, kindle ( £30.12). buy from Amazon http://spxj.nl/1rM9dnI http://spxj.nl/1rM9d 6. The New Sport and Exercise Psychology Companion by T. Morris & p. Terry. fitness

information Technology 2011. ISbn 978-1935412021 (£66.93). buy from Amazon http://spxj.nl/12ewIDe 7. Foundations of Sport and Exercise Psychology (5th edn) by R. Weinberg & D. gould. Human kinetics 2010. ISbn 978-0736083232 (print £58.31, kindle £20.53). buy from Amazon http://spxj.nl/1rMa8xe

THE AUTHORS ADAM GLEDHILL MSC Adam Gledhill is a senior lecturer in Sport and Exercise Therapy at Leeds Metropolitan University where he teaches on undergraduate and postgraduate sport and exercise therapy programmes, with his main teaching foci being based around the psychology of sports injury and rehabilitation, professional practice and research. Adam completed his MSc in Sport and Exercise Science in 2003, has vocational qualifications in sports massage and is currently working towards a PhD examining psychosocial factors associated with talent development in female soccer. Adam has extensive experience of sports therapy, sport and exercise science, and sports coaching qualification development; has experience of providing sport science support to a range of athletes in different sports; and has authored a number of sports therapy, sport science, and sports coaching focussed textbook chapters, peer-reviewed articles and conference presentations. For correspondence please email Adam.Gledhill@leedsmet.ac.uk, and follow his Twitter account: @gleds13. DALE FORSDYKE MSC, MSST MSMA Dale is a lecturer in sport injury management at York St John University and a practising sports therapist within elite female football. He has dual professional body status with the Society of Sports Therapists (SST) and Sports Massage Association (SMA), and has completed MSc qualifications in both sport science, and sports therapy. Dale has previously written sports therapy programmes and has co-authored the book Foundation in Sports Therapy. He is currently undertaking a PhD examining the psychosocial factors influencing sport injury rehabilitation outcomes. For correspondence please email d.forsdyke@yorksj.ac.uk, and follow his Twitter account: @forsdyke_dale

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KEY pOINTS n Children and adolescents are NOT mini-adults. n prevention and rehabilitation programmes should take into account social, emotional and psychological maturity, not just physical maturity. n Younger athletes may be more susceptible to injury because of their lower perceptual skills. n Younger athletes may be more sensitive to injuryrelated stimuli, which may result in heightened injuryrelated distress. n Injuries in young athletes impact on their perceptions of health-related quality of life, not just their sport performance. n Younger athletes may not be able to effectively communicate how injury is affecting them, and report socially desirable information. n As injury can affect an injured athlete globally be aware of signs of meaningful psychological distress and refer if needed. n Strategies to help young athletes maintain their athletic identity during injury may reduce injuryrelated dropout from sport. n Sports injury practitioners, parents, coaches, teammates and the injured athlete all play significant roles in effective rehabilitation and return to competition.

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n Within your own practice how do you differentiate between young and adult athletes? n Reflecting on your experience how have adult and young athletes differed in response to being injured and through the rehabilitation period? n How can suffering a sports injury be a positive developmental experience for younger athletes? n What are the pros versus the cons of using psychosocial strategies with this age group to facilitate rehabilitation? n How can you ensure a young athlete is psychologically and not just physically capable of return to competition? DISCUSSIONS

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

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A pr prA Actic cticA Al model for mA mAnAging tennis elbow TennIs elBow Is noTorIously dIffIculT To TreAT

Tennis elbow (lateral epicondylitis) is a common injury that is notoriously difficult to rehabilitate. This article provides a practical and progressive model for athletes to manage the condition and rehabilitate back to full function. BY MartYn Matthews Msc Bsc, cscs*D anD BoB BraMah Bsc, MsMa MsMM McsP

BackgrounD

once The condITIon Becomes chronIc IT presenTs A much more dIffIculT Injury To mAnAge 18

Tennis elbow (lateral epicondylitis) is an injury to the bony attachment of the wrist and finger extensor muscles that insert via the common extensor origin onto the lateral epicondyle of the humerus. It presents as pain and tenderness in the area, particularly during resisted wrist or middle finger extension, and is associated with a loss of grip strength and function (1). It is thought to occur due to overuse of the extensor carpi radialis brevis inducing repetitive microtrauma on the tendonâ&#x20AC;&#x201C;bone attachment leading to a painful and inflammatory condition (2,3). Activities that require high or consistent grip strength or rotational movements of the forearm (such as tennis, mountain biking, windsurfing, rock climbing, rowing and manual labour) can cause and aggravate the condition (4). In its early phases a short period of rest may be enough for the symptoms to subside; however, once the condition becomes chronic it presents a much more difficult injury to manage with episodes taking from 6 to 24 months to fully recover (5). If the cause of the injury is due to chronic overuse it is possible that what appears to be an acute injury is actually the result of maladaption to load and longer term degeneration of tendon tissue; hence

the potential for effective rehabilitation to take many months with a high risk of recurrence (6). This is at least partly due to many athletes putting up with the problem before moderating treatment or seeking treatment.

the PrograMMe Below is a practical model for managing and rehabilitating tennis elbow that focuses on activities that an athlete can self-administer. In addition to this, a clinically trained practitioner such as a physical therapist or sport rehabilitator may also consider other treatment options including electrotherapy, deep transverse frictions, steroid injections and soft tissue techniques. The overall aim of this programme is to remove the source of aggravation, give the injury time to settle and heal, and then to progressively reintroduce mobility and strengthening activity that prepares the area for functional sportbased activity. It should be stressed that, owing to the sensitive nature of the healing tissue and the high risk of re-aggravating the condition, progression should be slow and that any jumps in progression should be small and well tolerated before advancing further. The programme outlined below is designed to be undertaken with a minimum of specialist equipment. The equipment that is used is readily available in high street shops or on-line retailers.

sportEX medicine 2015;63(January):24-27

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Tennis elbow is a debilitating condition that is notoriously hard to treat and rehabilitate. many athletes live with it on a daily basis before seeking treatment, which can often lead to a greater level of degeneration and make it even harder to recover from. The programme outlined above takes a practical but conservative approach to the rehabilitation of tennis elbow and will be most successful when the source of aggravation is removed, the injury has time to settle and heal, and a slow but progressive mobility and strengthening programme is introduced to gradually prepare the tissue for functional sport-based activity. This approach is particularly important for managing longer term conditions.

progressive strengthening and stretching exercises and ultrasound for chronic lateral epicondylitis. physiotherapy 1996;82(9):522–530 4. weinstein sl, Buckwalter jA. Turek’s orthopaedics: principles and their application, 6th edn. Lippincott Williams and Wilkins 2005. IsBn 9780781742986 (£149.00) Buy from Amazon http:// amzn.to/1xsfcdl 5. murtagh je. Tennis elbow. australian family physician 1998;17:90–95 6. hume pA, reid d, edwards T. epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management, and prevention. Sports medicine 2006;36(2):151–170 7. Tyler Tf, Thomas gc, et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal of Shoulder and Elbow Surgery 2010;19(6):917–922.

References

Further resources

1. hacker e. lateral epicondylalgia: diagnosis, treatment and evaluation. critical reviews in physical and rehabilitation medicine 1993;5:129–154 2. Kraushaar Bs, nirschl rp. current concepts review: tendinosis of the elbow (tennis elbow). clinical features and findings of histological immunohistochemical and electron microscopy studies. the Journal of Bone & Joint Surgery 1999;81:259–285 3. pienimäki TT, Tarvainen TK, et al.

1. Tennis elbow: lateral and medial epicondylitis, nicholas Institute of sports medicine and Athletic Trauma (nIsmAT) website (http://bit.ly/1y56wwg.) 2. páge p. A new exercise for tennis elbow that works! north american Journal of Sports physical therapy 2010;5(3):189–193. (http://1.usa.gov/1urBkKp)

conclusion

DISCUSSIONS

n which anatomical structures are involved in tennis elbow? n Is tennis elbow an acute or chronic condition? n how should rehabilitation from this condition progress? n what physical aids can be used in the recovery programme?

keY Points n tennis elbow is notoriously difficult to treat. n this condition is also known as lateral epicondylitis n tennis elbow is an injury to the bony attachment of the wrist and finger extensor muscles that insert via the common extensor origin onto the lateral epicondyle of the humerus. n it is thought to occur due to overuse of the extensor carpi radialis brevis inducing repetitive microtrauma on the tendon–bone attachment n activities that require high or consistent grip strength or rotational movements of the forearm can cause and aggravate the condition. n if diagnosed early, a short period of rest may be enough. n tennis elbow is often a chronic condition meaning that longer tem degeneration of the tendon may have occurred. n rehabilitation should progress slowly and gently.

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The overAll AIm of ThIs progrAmme Is To remove The source of AggrAvATIon, gIve The Injury TIme To seTTle And heAl, And Then To progressIvely reInTroduce moBIlITy And sTrengThenIng AcTIvITy ThAT prepAres The AreA for funcTIonAl sporTBAsed AcTIvITy

THE AUTHORS MARTyn MATTHEwS MSc BSc, CSCS*D M Martyn is a senior lecturer in rehabilitation at the University of Salford. He has over 28 years experience of providing Sports Science and Strength and Conditioning support to elite athletes and top tier/international teams. He has a particular interest in adopting an integrated and multidisciplinary approach to rehabilitation and performance enhancement. BOB BRAMAH BSc, MSMA MSMM MCSP B Bob is a chartered physiotherapist specialising in sports soft tissue therapy. He has worked in Premiership Rugby and Football and with the GB national teams for Basketball, Volleyball and wheelchair Rugby and the England Cricket team. In addition to a private practice in wigan, Bob is a lecturer in Manual Therapy at the University of Salford and is the Editor of the Journal watch section of sportEX. He was a founder member of the Sports Massage Association and is Vice-Chair of the Chartered Society of Physiotherapy professional network for Massage and Soft Tissue Therapy. 19

tennis elbow aBout tennis elBow Your injury Tennis elbow (lateral epicondylitis) is an inflammation of the outer elbow where the tendon attaches to the bone. It is caused by the repetitive movements and the gripping actions common in tennis, hence the term ‘tennis’ elbow. however it may also occur in other activities requiring repetitive gripping actions. unfortunately rest as a treatment is rarely helpful.

Prevention Try the following modifications to the equipment causing your ‘tennis’ elbow: a lighter racket, increase grip size, use string vibration dampners, reduce string tension, increase racket head size, play with newer balls, more flexible racket shaft, don’t play with wet balls and use softer grip material. These changes refer to tennis rackets but some changes are relevant to tools/work equipment also.

stage 1. unloading and managing pain

cease or modify any activity that aggravates injury. depending on the severity of injury, this may include: n reducing the overall volume of activity or stopping it completely. Try the ‘50% rule’. cut what you are doing by half. either cut the number of training sessions or the load applied during the sessions or a combination of both. If there is still Area most affected in tennis elbow - where several tendons attach to one area of the bone

upper arm

no improvement, cut again by a further 50%. If still no change, then stop the aggravating activity. n using lifting straps when rowing or performing deadlifts (fig. 1). n experimenting with different size or shape grips on the handles, racquets or handlebars that aggravate the injury. n using a lateral epicondylitis cuff (fig. 2) or kinesio tape to provide a false insertion point for the extensor muscles and further help to unload the aggravated attachment during everyday tasks.

Figure 1: The use of lifting straps during indoor rowing can reduce the load on the common extensor origin and allow training to continue without further aggravating the injury. (Photo credit: M. Matthews, 2014)

further advice includes: n frequent ice massage (using a styrofoam cup filled with water and frozen) for short regular intervals (fig. 3).

stage 2. stretching and mobilisation To further relieve pressure or chronic tension on the epicondyle, athletes should begin to stretch and mobilise the surrounding soft tissues. This can involve: n gentle stretching of the finger and wrist extensors. start in a bent arm position and, if this is tolerated with no aggravation, progress to a straight arm position (fig. 4). n light massage of the extensor muscles and surrounding tissues can further reduce any tension or compressive stress on the affected area allowing the injured area to settle. This should not be a painful process. It is noT a ‘no pain, no gain’ situation. further advice includes: n Avoid pain or activities that aggravate the injury. n Ice after each session. n continue to use a cuff or tape for everyday activities.

Figure 2: A tennis elbow cuff can help create a false insertion point for the wrist extensor muscles, thereby reducing any aggravating load on the lateral epicondyle. (Photo credit: M. Matthews, 2014)

Figure 3: Regular ice massage can help reduce pain and swelling and also help prevent neo-vascularisation as the tissues heal and adapt. (Photo credit: M. Matthews, 2014)

stage 3. light eccentric strengthening

Lower arm

Bony part of elbow often called the ‘funny bone’

Side view of the outside of the elbow showing the muscles and tendons responsible for 'tennis elbow’

once the area is more mobile and feels less painful the athlete can start with some light strengthening activity. This can involve activities such as: n self-administered resisted exercises (full range) using the other hand as resistance (eccentric only) (fig. 5). n self-administered resisted exercises (full range) using the other hand as resistance (concentric and eccentric) (fig. 5).

Figure 4: Gentle stretching of the finger and wrist extensors – initially in a bent arm position, progressing to a straight arm position. (Photo credit: M. Matthews, 2014)

sportEX medicine 2015;63(January):24-27

Exercises for

tennis elbow n finger and wrist extensions in a swimming pool (slow, progressing to medium, progressing to fast pace) (concentric). n picking up light objects, eg. picking a cup up by the rim. n lightly gripping objects, eg. bike handlebars/steering wheel, etc.

Figure 5: Self-administered resisted exercises using the other hand as resistance. Start with low resistance and eccentric only progressing to full range, high resistance concentric and eccentric. (Photo credit: M. Matthews, 2014)

continue to: n Avoid pain or activities that aggravate the injury. n Ice after each session. n continue to use a cuff or tape for everyday activities.

stage 4. Moderate load strengthening

Figure 6: Twisting and un-twisting a FlexBar. Start in a wrist flexed position and wind up into wrist extension (concentric) before controlling the elastic unwind back into a flexed position (eccentric). Progress from a limited range to a full range of movement and from a low resistance bar (red) to a higher resistance bar (blue or green). (Photo credit: M. Matthews, 2014)

Figure 7: Elastic band used to provide resisted finger extension – progress by increasing the number of bands. (Photo credit: M. Matthews, 2014)

The following activities can be used to continue to strengthen the area: n low frequency spinning of the standard powerball (the faster you spin the ball, the more forcefully you need to grip, so start at a comfortable level). n Twisting and un-twisting activities (concentric and eccentric). patients can use a range of objects for this including a flexBar (light resistance red) (7) (fig. 6), or household objects such as a towel (concentric only) or a piece of foam pipe insulation. n picking up heavier objects. grip and hold volleyball with splayed fingers. n resisted finger extension (splay fingers, resisted by an elastic band). progress by increasing number of bands (fig. 7). n reverse curls with a broomstick. Athletes can scale the magnitude of grip effort so as not to aggravate injury. continue to: n Avoid pain or activities that aggravate the injury. n Ice after each session. n continue to use a cuff or tape for everyday activities.

Figure 8: The Powerball provides a dynamic grip exercise that challenges the extensor and flexor muscles at a level determined by the frequency of spin. Start at a slower frequency for a limited period. Progress to a higher frequency and a longer period. To challenge further, progress from the standard plastic ball to the heavier metal ball (pictured). (Photo credit: M. Matthews, 2014)

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stage 5. general strengthening for a progression to the general strengthening part of the programme, use the following activities: n rotations on the powerball: medium frequency, progressing to higher frequency. Then use a heavier powerball at low to medium frequency (fig. 8).

n Twisting and untwisting activities through a greater range with higher resistance. Twist and release the red flexBar through a greater range – also allow the other hand to help ‘wind’ up the flexBar so a greater eccentric load can be controlled. progress to the blue flexBar with an emphasis on both concentric and eccentric actions. n reverse curls with barbell. scale the magnitude of grip effort so as not to aggravate the injury. n pinch grip plate weights (start light and increase). n wrist curls and reverse wrist curls. n radial and ulnar deviation movements with a sledge hammer (start with the hand close to hammer head and progress to greater distances as strength increases). continue to: n Avoid pain or activities that aggravate the injury. n Ice after each session. n continue to use cuff or tape for activities that may aggravate the injury.

stage 6. sport-specific strengthening This stage of the rehabilitation programme is to gently reintroduce sport-specific actions. depending on the athlete this may include: n The use of a tennis racquet with an emphasis on back-hand shots. start with a lighter ball and progress to a full weight tennis ball. start with gentle shots and progress to returning shots at higher speed. n pulling on handle bars (as if pulling a wheelie). n Throwing a frisbee. n practising paddling (kayak). start slow and gradually increase the speed. n deadlifting without straps and olympic lifts with lighter weights. continue with the strengthening programme, progressively increasing both the intensity (resistive load applied and range of movement) and also duration. Also continue to: n Avoid pain or activities that aggravate the injury. n Ice after each session. n continue to use cuff or tape for activities that may aggravate the injury.

Proximal intervention for the management of Patellofemoral Pain This article offers the reader an evidence-informed and clinically reasoned review of the current literature with respect to proximal interventions in the management of patellofemoral pain. The evidence clearly backs up this approach, but it is not possible to establish the mechanism of the effect or to identify patient subgroups within which favourable outcomes are more likely. From reading this article you will gain a broader understanding of how hip strengthening can be implemented, targeted to specific individuals and consequently results in more favourable outcomes for your patients. BY Simon Lack mSc, mcSP

introduction

RANDoMIseD CoNTRolleD TRIAls ADvoCATe A PRoxIMAlFoCuseD APPRoACh To The MANAgeMeNT oF PFP 22

Patellofemoral pain (PFP) is reported to be one of the most common presentations within both recreationally active and sporting populations. In one particular study of 2002 running injuries, 16.5% (331 patients) were diagnosed with PFP (1). A 2014 consensus statement of leading researchers and clinicians in the field of PFP further highlighted its high prevalence, particularly among females (2). Despite its high prevalence and positive short-term treatment outcomes, 80% of individuals who complete a rehabilitation programme for PFP still report pain and 74% report a reduction in physical activity at 5-year follow-up. This highlights the need for greater understanding of the condition and more effective long-term management plans to be identified. With the aetiology of PFP widely accepted to be multifactorial (3), these poor long-term outcomes may well represent a failure to address the specific deficits that are contributing to its presence and persistence. Current literature has identified deficits in proximal (hip), distal (foot/ ankle) and local (structures associated with patellofemoral joint articulation)

anatomy to be associated with the development and maintenance of PFP. Prospectively, Noehren et al. reported significantly increased hip adduction angles in runners who developed PFP compared to controls within a cohort followed over a 2-year period (4). In part these findings have been compounded retrospectively, with greater hip adduction angles reported in individuals with a diagnosis of PFP (5). Moderate-to-strong evidence indicates PFP sufferers demonstrate delayed gluteus medius onset times and reduced activation duration during functional tasks (6) offering a potential link between hip muscle function and kinematics. An absence prospectively of hip abductor and lateral rotator weakness (7), however, would suggest that these movement faults may not exclusively be derived from the muscles inability to generate force about the hip. Furthermore, with strength deficits identified within the hip abductors compared with controls without variance in hip and knee kinematics (8), the connection between muscle strength and movement patterns is not firmly established. Randomised controlled trials advocate a proximal-focused approach to the management of PFP (9,10), with a proximal strengthening programme sportEX medicine 2015;63(January):22-26

evidence informed Practice

before specific quadriceps exercise being reported to achieve greater short-term outcomes than quadriceps exercise alone (11). Furthermore, a recent systematic review (12) concluded that consistent moderate to high quality evidence demonstrates proximal strengthening programmes achieve effective pain relief and improved function in the short term compared with knee programmes that achieved only varied effects. Despite these reported successful outcomes, a lack of evidence correlating improvement in strength with changes in lower limb kinematics currently exists.

deviSing a hiP exerciSe Programme The current literature describes a variety of proximal/posterolateral hip strengthening programmes, with the term ‘strengthening’ being used freely to describe the intervention prescribed. This was the topic of some debate within the 2014 PFP retreat, given that many of the interventions described exposed the individuals to insufficient load over many repetitions to be termed a strengthening programme (2). It was felt that interventions such as those used by earl et al. that included exercises such as ‘monster walks’, mini-squats (body weight) and side plank, were more likely to evoke neuromuscular changes, but possibly not result in significant hypertrophy (13). Therefore guidance for devising a posterolateral hip exercise programme from within the literature alone lacks clarity, and the mechanisms of the effects of specific protocols have not yet been defined. A better understanding of the mechanism for the effects of different exercises will enable clinicians to tailor the intervention to address the particular deficit identified in individuals with PFP. Furthermore, with generic intervention periods commonly of 6 weeks, and progressive daily exercises of two to four sets of ten or more repetitions being prescribed (14), the failure of strengthening programmes to be more specific to the individual’s identified strength/movement deficits may well explain why long-term resolution of symptoms is poor for this population www.sportEX.net

within the current evidence base (3). Development of more tailored interventions through improved understanding of the effects of specific interventions may have a significant impact on recovery in the longer term. For example, individuals with good strength, but poor lower limb alignment may achieve better outcomes with a neuromuscular/ movement pattern re-education programme, where as an individual with significant weakness but fair alignment may require a hypertrophy programme. This tailored approach is further discussed later in this article. Despite these shortcomings, the overall picture of proximal exercise-based intervention is consistently positive, with a very recent systematic review concluding, “Proximal interventions provide relief of pain and improved function in the short and long term and therefore physical therapists should consider using proximal interventions for treatment of patellofemoral pain” (12). Furthermore, it has been shown that using a proximal exercise programme before commencing quadriceps strengthening results in improved outcomes compared to a quadriceps-focused programme in isolation (15). In situations where pain limits progression of loading within the quadriceps, use of this proximal approach may facilitate a speedier recovery. once again it is probable that individuals in this specific situation represent a subgroup of PFP patients; however, this has not been validated within the literature and tools for identifying this group have not been defined.

FAIluRe oF sTReNgTheNINg PRogRAMMes To be MoRe sPeCIFIC To The INDIvIDuAl’s IDeNTIFIeD sTReNgTh/ MoveMeNT DeFICITs MAy Well exPlAIN Why loNgTeRM ResoluTIoN oF syMPToMs Is PooR FoR ThIs PoPulATIoN WIThIN The CuRReNT evIDeNCe bAse

Figure 1: Four-point kneeling fire hydrant exercise with resistance band for gluteus maximus activation. (Photo credit: S. Lack, 2014)

neuromuScuLar Programme In an electromyography study that looked at specific exercises commonly prescribed to individuals with PFP, data analysis showed that some exercises result in significantly different neuromuscular activity within different muscles about the hip (16). Altered and delayed neuromuscular activity has been described within PFP patient populations and therefore exercises that preferentially activate specific muscle groups are desirable.

Figure 2: Side lying hip abduction–extension exercise with resistance band for posterior gluteus medius activation. (Photo credit: S. Lack, 2014)

INTeRveNTIoNs To IMPRove hIP MusCle ACTIvITy ThRough NeuRoMusCulAR AND hyPeRTRoPhy PRogRAMMes FoRM A FuNDAMeNTAl PART oF RehAbIlITATIoN

Figure 3: Weighted step down with trunk lean to eccentrically/ concentrically strengthen gluteal muscles and quadriceps. (Photo credit: S. Lack, 2014)

selkowitz et al. performed this electromyographic experiment using fine wire electrodes in the tensor fasciae latae (TFl), gluteus medius and superior gluteus maximus in individuals without PFP (17). They reported that during bilateral and unilateral bridging, quadruped hip extension, the clam, sidestepping and squatting, the gluteal muscles were significantly more active than the TFl. Although this experiment may be useful in guiding clinicians who wish to address specific muscle imbalances, the exercises were performed on individuals without PFP and were repeated only 5 times representing significant limitations for direct clinical utility. In order to achieve neuromuscular adaptations exercises should be of low to moderate load, held or repeated for longer durations and repeated frequently: 1â&#x20AC;&#x201C;2 times daily are advocated. The importance of optimal alignment/muscle recruitment patterns is encouraged to ensure the dysfunctional movement patterns are modified or corrected. The capacity for this style of exercise to achieve these goals is not definitive within the literature; however, clinically it is widely used. Prescription of exercises that elicit greater neural excitability within specific muscle groups, with this frequency, is suspected to result in desirable neuromuscular adaptations. The exercises presented in Figures 1 and 2 look to achieve these adaptations. The negative side of neuromuscular-focused intervention, however, is its susceptibility to reversibility, especially if movement patterns are not or cannot be corrected during this early phase of the rehabilitation process. As with any adaptation within neural pathways, in the early phase they are at risk of being forgotten and need to be built into everyday activity to become fully engrained. having greater muscle capacity (strength/hypertrophy) and improving movement patterns are two ways to facilitate this change in the long term.

hypertrophy programme Figure 4: Weighted straight-leg dead lift, eccentrically/ concentrically loading the hamstrings and gluteal muscles. (Photo credit: S. Lack, 2014)

To achieve hypertrophy within a specific muscle or muscle group, the stimulus needs to exceed the

muscleâ&#x20AC;&#x2122;s capacity to induce overload. overload leads to an immediate local upregulation of mechanogrowth factor (MgF) as described by Khan and scott when presenting the principles of mechanotherapy (18). MgF in turn stimulates satellite cells within the muscle resulting in muscle hypertrophy. Challenges exist within a population of patients in pain to achieve this goal, as often loading the target muscle sufficiently to induce mechanical overload commonly results in exacerbation of pain. Additionally, with closed kinetic chain (CKC) exercises advocated in the rehabilitation of PFP (14), the challenge is even greater, as inevitably CKC exercise loads the patellofemoral joint articulation. however, as articular cartilage is also mechanosensitive through chondrocytes (18), it is plausible that a slowly progressive loading programme could elicit desirable changes within the articular surface, especially if preceding exercise intervention has optimised muscle activation patterns. When prescribing a strengthening programme, therefore, building load sufficient to induce muscle overload while avoiding pain exacerbation form the key principles of programme design. use of other strength training principles may assist in achieving these effects. specificity will ensure that the target muscle or muscle group within which hypertrophy is desired will be stimulated, while minimising unnecessary joint loading on nonspecific strengthening activities. This level of strengthening activity has not been well documented within the literature for individuals with PFP. Figures 3 and 4 show exercises aimed at overloading the proximal musculature sufficiently to induce hypertrophy while minimising excessive joint loading.

movement re-education Modification of movement patterns has received significant attention within recently published literature. largely this has been fuelled by studies that have shown that strengthening-based interventions induce little, if any, measurable kinematic change in the lower limbs (13,19,20). In contrast, as was extensively discussed at the 2013 Patellofemoral Pain Research Retreat sportEX medicine 2015;63(January):22-26

EvidEncE informEd practicE

in vancouver, Canada, “movement feedback interventions during treadmill running may change movement patterns of people with PFP during weight-bearing activities and these kinematic adjustments may reduce PFP symptoms” (2). With prospective data demonstrating increased hip adduction as a risk factor for PFP development (4) and movement retraining shown to be able to modify this kinematic variable (21), this strategy not only represents a potential treatment modality, but also a possible preventive strategy as well. Further research is being completed exploring differing clinical applications of this technique; also how/where strengthening fits into this approach needs clarification. once again, it is very likely that a specific group of individuals will need a combination of both movement reeducation and strengthening, whereas other individuals will need more of one type of exercise and another group more of the other type of exercise in order to make significant improvements.

Who ShouLd We Be directing a hiP Strengthening ProtocoL at? our research group at Queen Mary university london has been reviewing the outcome prediction literature to identify patient characteristics that may be indicative of a favourable outcome following a specific intervention. however, given the relative infancy of work exploring hip-focused interventions, prediction studies for this approach have not yet been completed. The greatest limitation of the literature pertaining to outcome prediction in general is the absence of control groups. Consequently we are unable to determine whether the characteristic(s) identified to predict a successful outcome are indeed predictive or prognostic (ie. individuals with a specific set of characteristics may have favourable outcomes without the particular intervention investigated). Nevertheless, some important considerations for clinical practice were identified. Most notable was that lower pain scores predicted success with quadriceps strengthening exercise and www.sportEX.net

orthoses intervention; however, higher pain scores predicted success using taping. given what we have discussed in this article, use of a neuromuscular programme in non-weight-bearing positions initially, and then progressing into weight-bearing situations, may provide another useful treatment tool to manage individuals for whom high pain levels are a significant limitation to progression through a rehabilitation programme. With only taping intervention shown to be effective for individuals with high pain levels, another treatment modality to add to the toolbox for patients with high levels of pain could prove invaluable. Development of reliable and valid clinical measurement tools, potentially more dynamic in nature [eg. singleleg squat (slsq)], needs to be done within populations of patients in pain. excellent preliminary work has been completed identifying gluteal muscle activation deficits associated with poor performance on the slsq (22), and kinematic alterations in groups with lower scores on a slsq rating scale (23) in asymptomatic individuals. given that experienced clinicians are reported to demonstrate good inter- and intra-tester reliability when assessing hip/pelvic function during this simple clinical test (24), extrapolation of these results may give the clinician rationale for directing interventions proximally. Again further work is being done exploring the clinical utility of this tool and represents exciting potential to deliver more tailored intervention approaches to PFP management in the future.

concLuSion Patellofemoral pain is a common presentation within both sporting and recreationally active populations. Altered movement patterns about the hip have been shown to be a risk factor for PFP development, and that strength deficits are evident in the hip muscles when pain is present. Consequently, interventions to improve hip muscle activity through neuromuscular and hypertrophy programmes form a fundamental part of rehabilitation. Additionally, the use of movement re-education looks to have a key role in achieving favourable

AlTeReD MoveMNeT PATTeRNs AbouT The hIP INCRese The RIsK oF PFP DeveloPMeNT outcomes and possibly addresses the biomechanical component to initial symptom development. These findings look to be an exciting intervention approach to achieving excellent and long lasting outcomes. References 1. Taunton Je, Ryan Mb, et al. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports medicine 2002;36:95–101 2. Witvrouw e, Callaghan MJ, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in vancouver, september 2013. British Journal of Sports medicine 2014;48:411–414 3. stathopulu e, baildam e. Anterior knee pain: a long-term follow-up. rheumatology 2003;42:380–382 4. Noehren b, hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. medicine & Science in Sports & exercise 2013;45:1120–1124 5. barton CJ, levinger P, et al. Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. gait & Posture 2009;30:405–416 6. barton CJ, lack s, et al. gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British Journal of Sports medicine 2013;47:207–214 7. lankhorst Ne, bierma-Zeinstra sM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. Journal of orthopaedic & Sports Physical therapy 2012;42:81–94 8. bolgla lA, Malone TR, et al. hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. Journal of orthopaedic & Sports Physical therapy 2008;38:12–18 9. Fukuda Ty, Melo WP, et al. hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. Journal of orthopaedic & Sports Physical therapy 2012;42:823–830 10. Khayambashi K, Mohammadkhani Z, et al. The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial. Journal of orthopaedic & Sports Physical therapy 2012;42:22–29 11. Dolak Kl, silkman C, et al. hip strengthening prior to functional exercises 25

reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. Journal of orthopaedic & Sports Physical therapy 2011;41:560–570 12. Peters Js, Tyson Nl. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. international Journal of Sports Physical therapy 2013;8:689–700 13. earl Je, hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. American Journal of Sports medicine 2011;39:154– 163 14. harvie D, o’leary T, Kumar s. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? Journal of multidisciplinary healthcare 2011;4:383–392 15. Dolak Kl. erratum: hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial (2011;41:560–570). Journal of orthopaedic & Sports Physical therapy 2011;41:700 16. ekstrom RA, Donatelli RA, Carp KC. electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. Journal of orthopaedic & Sports Physical therapy 2007;37:754– 762 17. selkowitz DM, beneck gJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? electromyographic Assessment

using Fine-Wire electrodes. Journal of orthopaedic & Sports Physical therapy 2013;43:54–64 18. Khan KM, scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports medicine 2009;43:247–252 19. Willy RW, Davis Is. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. Journal of orthopaedic & Sports Physical therapy 2011;41:625–632 20. Ferber R, Kendall D, Farr l. Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome. Journal of athletic training 2011;46:142–150 21. salsich gb, graci v, Maxam De. The effects of movement pattern modification on lower extremity kinematics and pain in women with patellofemoral pain. Journal of orthopaedic & Sports Physical therapy 2012;42:1017–1024 22. Crossley KM, Zhang WJ, et al. Performance on the single-leg squat task indicates hip abductor muscle function. american Journal of Sports medicine 2011;39:866–873 23. Whatman C, hume P, hing W. Kinematics during lower extremity functional screening tests in young athletes - are they reliable and valid? Physical therapy in Sport 2013;14:87–93 24. Whatman C, hume P, hing W. The reliability and validity of physiotherapist visual rating of dynamic pelvis and knee alignment in young athletes. Physical therapy in Sport 2013;14:168–174.

THE AUTHOR SIMON LACK MSc, MCSP Simon is a PhD student at Queen Mary University London (QMUL), studying the interaction of hip and foot biomechanics in the presentation and management of patellofemoral pain. He graduated from Brunel University in 2005 with a degree in Physiotherapy, and went gone on to study for an MSc in Sports and Exercise Medicine at QMUL in 2010. Simon works as a physiotherapist in two London-based private clinics, having previously worked in New Zealand with professional golfers, local rugby and football teams.

DISCUSSIONS

n Through what mechanism do you think a proximal strengthening programme is effective at reducing patellofemoral pain (PFP) symptoms and improving function? n given that intervention programmes found in current randomised controlled trials are unlikely to evoke muscle hypertrophy, what are the potential longer-term risks of a neuromuscular strengthening programme? n What tools could be used to reduce the long-term risk of regression? n What cues have people found effective at modifying movement patterns in individuals with PFP?

online

Further reSourceS

1. video demonstrating single-leg squats to strengthen the gluteal muscles http://spxj.nl/1tDN4eD

2. video showing another method for gluteus maximus activation, lying prone with a resistance band. http://spxj.nl/12eDgC1

keY PointS n Patellofemoral pain (PFP) is common and currently has poor long-term treatment success. n Proximal interventions for PFP are shown to be effective. n the mechanism of the effect is unknown. n movement re-education in addition to a strengthening programme may improve outcomes. n current interventions are unlikely to evoke muscle hypertrophy. n neuromuscular changes are like to be effective in the short term, but may be at risk of regression. n to ensure muscle hypertrophy basic training principles of overload, specificity and frequency need to be considered. n it is plausible that appropriate loading of the patellofemoral joint may result in changes within the chondral surface through mechanotransduction.

sportEX medicine 2015;63(January):22-26

Literature review

ShouLd SportS conSider neuroimaging in the aSSeSSment of concuSSion? This article discusses the current evidence for the short- and long-term effects of concussion in sport and how occurrences of concussion should be managed. The article also considers the potential role of medical imaging in terms of assessing both acute and chronic head injuries. Greater awareness of when medical imaging could be used will aid practitioner’s understanding of its potential contribution while still maintaining the fundamental importance of clinical judgement. BY Jamie Beck BSc mSc Pgc(HeP)

introduction Sport and recreational activities are undertaken by many participants across the globe. The overwhelming majority of those participants will do so without injury and will return to play again on future occasions. The types of sports and recreational activities undertaken vary dramatically with some giving a greater risk of serious injury than others. Sporting injuries vary in nature from the minor to those with potentially life threatening or life altering consequences. Those sports that include repeated high impact collisions or involve deliberate attempts to strike the head give greater potential for intracranial injury which can have both short- and long-term consequences. A newspaper headline of August 2013 referred to ‘Rugby’s ticking time bomb’. The paper discussed the potential consequences of head injuries within this particular sport, describing the link between repeated concussion and early onset dementia, depression and other neurological conditions (1). Anecdotal evidence in rugby union, rugby league, Gaelic football and hurling suggests that the players are getting fitter, stronger and heavier. The rules www.sportEX.net

of these games in some cases have been altered to make play more open and creating greater space between attack and defence, making the game more open and attractive to spectators. One result of this is to create bigger collisions between players at higher speed. Concussion is not a new phenomenon in sport but the former International Rugby Board Chief Medical Officer Dr Barry O’Driscoll warned of a tragedy waiting to happen within rugby union (1). Routine neuroimaging is used in professional boxing to, in the first instance, ensure that fighters who enter the ring are not at increased risk of intracranial trauma. The question posed is that could these images – taken with short-term monitoring in mind – show the potential of a fighter to develop longer term neurological conditions. Routine neuroimaging of participants of other sports is not undertaken but given the popularity of rugby union, rugby league, Gaelic football and, more recently Mixed Martial Arts, cranial imaging could potentially help identify those players at increased risk of both short- and long-term neurological symptoms.

acute PatHologY Intracranial head injury as a direct result 27

ThE COnSEnSUS STATES ThAT nEUROIMAGInG COnTRIBUTES lITTlE TO ThE EvAlUATIOn OF ACUTE COnCUSSIOn BUT ShOUlD BE USED WhEn InTRACEREBRAl OR STRUCTURAl lESIOnS ARE SUSPECTED of sport is a rare occurrence but can be particularly tragic when they occur. Baird et al. published a study in 2010 that gave the statistic of 339 deaths in 57 years in boxing in the United States with a mean age of 24 (2). Given the raison d’être of boxing is to render an opponent unable to defend themselves as opposed to scoring goals or making yardage, the potential for serious intracranial head trauma could be assumed to be greater. A recent case of a 14-year-old schoolboy dying as a result of ‘second impact syndrome’ following a game of rugby union also highlighted that many of those who die from a sporting injury are young (3). Cantu’s 1998 study on second impact syndrome described the condition as occurring when an athlete who sustains a head injury sustains a second injury before the symptoms of the first have cleared (4). The pathophysiology is described as a loss of auto-regulation of blood supply leading to vascular engorgement resulting in increased intracranial pressure and herniation of the temporal lobe or lobes below the tentorium of the cerebellar tonsils through the foramen magnum (4). Magnetic resonance imaging (MRI) is seen as more sensitive to intracranial trauma with computed tomography (CT) scanning being regarded as adequate in this 1998 study (4). Weinstein et al.’s 2013 case report of a 17-year-old American football player who suffered a head injury, described that the patient had complained of persistent headache and fatigue for three days. The CT scan on the fourth day post-injury was interpreted as normal although the player was requested to not engage in practice until symptoms had resolved, a request that was ignored. The patient subsequently became unresponsive with generalised seizure activity at a practice session. Follow-up CT scans reported thin bilateral subdural 28

haematomas before MRI scans at the specialist centre revealed mild downward transtentorial herniation, bilateral subdural haematomas with abnormal T2 signal and restricted diffusion in the medial left thalamus. Midline structures were displaced caudally. Three years post-injury, the player has regained some verbal, motor and cognitive skills. Significantly for imaging, the authors identify that both CT and MRI scanning are not guaranteed to identify the first impact pathology and should not be relied upon to do so. Clinical assessment is regarded as the most important step in identifying those who are at risk of second impact syndrome (5). Culturally, the common sporting pass times of the United States and the UK differ, but it is important that research related to sports such as American football and ice hockey can be related to similar sports practiced in other countries.

neuroimaging in Boxing Boxing has existed in various forms for centuries with greater regulation coming in the last 150 years. Unlike most other sports, the purpose of boxing is to inflict punches on an opponent. Many of those punches are inflicted to the head area. Baird et al. identified a reduction in mortality from head injuries since 1983, citing reasons for this as being shorter professional careers, fewer fights and better overall medical supervision. Such changes do not eliminate the risk of intracranial trauma and the first boxer since 1995 to die in the UK passed away in 2013, despite a normal pre-bout MRI scan (2). In 2009, Jordan identified cerebral contusion as the most commonly encountered injury in boxing with the more significant subdural haematoma, intracerebral haemorrhage, epidural haematomas and diffuse axonal injury being much less common (6). The incidence of intracranial head

trauma is believed to be higher in professional boxing than in the amateur game. The author identifies pre-bout neuroimaging as invaluable in the detection of pre-existing brain lesions alongside neuropsychological testing. Qualified medical personnel including an ambulance should be immediately available and that referees should be able to identify the early stages of concussion (6). Professional rugby matches will also have medical personnel and an ambulance immediately available although not purely for the purpose of evaluating potential head trauma. This will not be the case at matches played at a lower level, nor would resources permit this given the high number of games played. Training of players, match officials and club staff in a similar way to boxing referees in recognising the symptoms of concussion could be a potential way of reducing the risk to players. What is also of paramount importance is that the health of player must come before the result of the game.

cHronic traumatic Brain inJurY and cHronic traumatic encePHaloPatHY In 2000, Jordan associated chronic traumatic brain injury (CTBI) with 20% of professional boxers with particular risk factors including length of career and number of bouts. Pathologically, there are considerable similarities with Alzheimer’s disease, including the presence of amyloid plaques (7). Categorical diagnosis of CTBI can only be undertaken after death but clinical and radiological signs can demonstrate the presence of signs of degeneration (7). McKee et al. (8) noted a similarity between chronic traumatic encephalopathy (CTE) and Alzheimer’s disease. Using the evidence available, they concluded that there is overwhelming evidence that links CTE to repeated brain trauma well before the start of clinical symptoms. The examples they cite are predominantly American football players and boxers but the potential significance for other contact sports is present. In addition to CT and MRI scanning, there is evidence that sportEX medicine 2015;63(January):27-31

Literature review

single-photon emission computed tomography (SPECT) may demonstrate hypometabolism and signs similar to Alzheimer’s disease in younger boxers (8). More evidence will be needed as to the potential of functional scanning in identifying those at higher risk of developing CTE. In 2013, the national Football league (nFl) in the USA reached a settlement with over 4,500 former players in a class action, alleging that the nFl hid research that showed the harmful effects of concussion. The nFl did not accept liability or that the injuries were the result of playing the game. What is significant is the establishment of a duty of care that the regulator may have to those who participate in that particular sport (9). Regardless of the liability issue, this should raise awareness for other regulatory bodies.

tHe role of regulatorY BodieS The rules of boxing have had to change over the years to protect those participants from serious intracranial injury. In the professional game, the number of rounds was reduced from 15 to 12, a mandatory count of eight seconds was introduced to allow referees to make judgements on the fighter’s ability to continue and doctors will routinely assess fighters at the end of each round. Amateur fighters will routinely wear a head guard for each bout (10). Both codes of rugby have brought in changes to make the games safer but the motivation for these has predominantly been the prevention of cervical spine injury rather than head injury. The engagement of scrums has been changed and tackles such as the ‘spear tackle’ or ‘tip tackle’ are outlawed, as is tackling players while in the air. Rugby Union also ensures that any player who is off their feet must be brought back to the ground safely. Rugby players have traditionally shunned the use of head protection and Daneshvar et al. (11) are sceptical as to the effectiveness of such head guards in both codes of rugby in preventing concussion. Wearing of head protection is not mandatory in the professional games but some hurling players can www.sportEX.net

be seen wearing head protection, possibly more to do with the ball travelling at speed than direct collisions. More research will be needed before all participants will be seen with head protection. Specific rule changes to reduce the chances of head injuries occurring in rugby, Gaelic Games or similar sports would be extremely difficult without reducing the intensity of the matches, which could potentially reduce spectator numbers and revenue. Safety has improved dramatically over recent decades and pitch-side medical crews are now commonplace at professional matches. There is increased awareness of concussion and how players demonstrating concussion are handled, although there is some conjecture as to whether cases are handled appropriately. The regulatory bodies and clubs may need to consider the number of matches played over a season (and therefore over a player’s career) with regard to the long-term potential for CTE. The management of players who suffer concussion will also need to be considered, with particular attention to those suffering repeat concussions, including those who play at amateur level. Routine pre-match or pre-season neuroimaging for all participants (as occurs pre-boxing) would be simply undeliverable. More evidence as to whether the imaging would contribute to a diagnosis of either short-term or long-term complications is needed, although (as in boxing) an MRI scan may identify those players at particular risk of intracranial injury. These players will be the rare exceptions and the

mass screening of players remains unrealistic and clinically unjustified.

clinical indicationS of acute Head inJurY Players who are suspected of suffering concussion will normally be assessed by the pitch-side medical team. Who that will be depends on the standard of sport being played. The Zurich Consensus on Concussion in Sport represents the most recent version of international guidance on how concussion is handled. The guidance for on-field or sideline evaluation of acute concussion is listed in Table 1 (12). The consensus states that neuroimaging contributes little to the evaluation of acute concussion but should be used when intracerebral or structural lesions are suspected. It is, therefore, clinical assessment that is of particular importance when examining patients with suspected concussion and how they are subsequently handled following diagnosis. Players are notoriously reluctant to leave the

A RECEnT CASE OF A 14-yEAR-OlD SChOOlBOy DyInG AS A RESUlT OF ‘SECOnD IMPACT SynDROME’ FOllOWInG A GAME OF RUGBy UnIOn AlSO hIGhlIGhTED ThAT MAny OF ThOSE WhO DIE FROM A SPORTInG InJURy ARE yOUnG

taBle 1: on-field or Sideline evaluation of acute concuSSion (12) a. The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles and particular attention should be given to excluding a cervical spine injury. B. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. c. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools. d. The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury. e. A player with diagnosed concussion should not be allowed to return to play on the day of injury. SCAT3, Sport concussion assessment tool 3

CUlTURAlly, ThE COMMOn SPORTInG PASS TIMES OF ThE UnITED STATES AnD ThE UK DIFFER BUT, IT IS IMPORTAnT ThAT RESEARCh RElATED TO SPORTS SUCh AS AMERICAn FOOTBAll AnD ICE hOCKEy CAn BE RElATED TO SIMIlAR SPORTS PRACTICED In OThER COUnTRIES field and coaches can be reluctant to lose their better players in match situations. however, the protection of the player has to be paramount. Referees in both codes of rugby have the authority to order players from the field who are bleeding; it could be argued that a similar rule for those who have suspected concussion could be introduced following better training for match officials.

clinical indicationS of cHronic Head inJurY and cHronic traumatic encePHaloPatHY Gavett et al. (13) link CTE with some sporting activities and military personnel who have been subjected to blast injury. They describe a usual onset in mid-life, earlier than that of Alzheimerâ&#x20AC;&#x2122;s disease, frontotemporal lobar degeneration or frontotemporal dementia. Progression of the disease is slow. The earliest symptoms include impairments in cognition, mood and behaviour. Although many of the symptoms are similar to that of other degenerative diseases, the presence of depressive moods, emotional instability, suicidal ideation and behaviour, and anger management issues which have been associated with CTE have particular impact on a patientâ&#x20AC;&#x2122;s socio-economic and family situation.

concluSion There are two issues that confront contact sports. Firstly, managing the short-term potential consequences of concussion and secondly, managing the long-term potential consequences 30

of repeated head trauma. Greater awareness of concussion in contact sport is becoming apparent. The Gaelic Athletics Authority (GAA) in Ireland produced a GAA player welfare booklet that provides participants with details of how to recognise the signs of concussion (14); this represents a sensible policy of advising those who have limited medical knowledge or awareness of clinical symptoms and who are seeking appropriate professional guidance. The International Rugby Board has also created concussion management interactive learning modules which are available online (15). The national Rugby league in Australia also provides guidance via its website on the management of concussion (16). There has been some debate in the written media as to whether clubs have been abiding by the guidance in place and indeed in some cases, whether the guidance itself is appropriate (1,17). What is clear is that sporting regulatory bodies and medical professional need to work closely together to ensure the safety of the players and that regulatory bodies are responsive to any change in the evidence base as to the management of concussion. Second impact syndrome is extremely rare but awareness of it is important, particularly at games where medical supervision is less than would be seen at a professional game. The short-term effects of concussion are better appreciated than the long-term risk of developing CTE. It is important that regulatory bodies take on board the growing evidence base

that has come from American football and boxing in particular regarding the impact of repetitive head trauma. Given the changes to the rules to speed up play in both codes of rugby, the incidences of concussion are likely to have increased which raises the possibility that players of today may be more susceptible to developing CTE. The role of neuroimaging in the evaluation of concussion is very limited and should only be considered when there is suspicion of intracranial lesion or skull fracture. The management of concussion should be a more clinical decision where the welfare of the player is the only concern. Even in cases of second impact syndrome, the evidence is that imaging would contribute little to the overall management although would inevitably be performed. The role of imaging in assessing long-term development is also limited although both CT and MRI scans may identify some significant signs and rule out other causes of symptoms. The role of functional MRI and SPECT in the assessment of the early signs of CTE has significant potential and further research will be needed in this area, particularly in players who may be at higher risk of developing CTE due to multiple concussions over a long career.

recommendationS Increased awareness of concussion in contact sports is necessary both from a long-term and short-term management perspective. This would include greater awareness of second impact syndrome in players, coaches and match officials. sportEX medicine 2015;63(January):27-31

Literature review

The law makers of contact sports need to consider how the incidence of head injuries can be reduced without affecting the popularity of the sport. This includes consideration as to whether players suffering concussion should be permanently removed from a match situation and whether the amount of games played per season is appropriate. neuroimaging is only necessary when intracranial lesions are suspected and clinical decision making is key in the management of patients with concussion. More research is needed to support the use of functional MRI and SPECT in the assessment of CTE. Regulatory bodies should take an interest in the long-term health of those who have played their sport. Collaboration between such bodies in researching the long-term effects on their participants should be encouraged.

concussions. clinics in Sports medicine 2011;30(1):145–163 12. McCrory P, Meeuwisse Wh, et al. Consensus statement on concussion in sport: The 4th International Conference on concussion in sport held in Zurich, november 2012. British Journal of Sports medicine 2013;47:250–258 13. Gavett BE, Stern RA, McKee AC. Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. clinics in Sports medicine 2011;30(1):179–xi 14. GAA Medical, Scientific and Welfare Committee. GAA Player Welfare. gaelic athletics authority 2008 (http://spxj.nl/1G963X6) 15. International Rugby Board. IRB Concussion management. irB player welfare 2010 (http://spxj.nl/12ln2BU) 16. The management of concussion in rugby league. national rugby League 2013 (http://spxj.nl/1yvk00u) 17. Walker B. Doctor slams nRl over concussion cases. the Sydney morning herald 2013 (http://spxj.nl/1AZnsid).

References

furtHer reSourceS

1. Peters S, Schofield D. Rugby’s ticking time bomb! Fears row as evidence links brain damage and dementia to increasing number of serious head injuries suffered by top players. daily mail 2013 (http://spxj.nl/1waIhWd) 2. Baird lC, newman CB, et al. Mortality resulting from head injury in professional boxing. neurosurgery 2010;67(5):1444– 1450 3. Brady T (2013) Parents’ agony as rugby player son, 14, dies from ‘second impact syndrome’ after playing on for 25 minutes following heavy collision. daily mail 2013 (http://spxj.nl/1yKO8Uv) 4. Cantu RC. Second-impact syndrome. clinics in Sports medicine 1998;17(1):37–44 5. Weinstein E, Turner M, et al. Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Case Report. Journal of neurosurgery: paediatrics 2013;11(3):331–334 6. Jordan BD. Brain injury in boxing. clinics in Spots medicine 2009;28(4):561–578 7. Jordan BD. Chronic traumatic brain injury associated with boxing. Seminars in neurology 2000;20(2):179–186 8. McKee AC, Cantu RC, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. Journal of neuropathology & experimental neurology 2009;68(7):709–735 9. nFl and players reach ‘$765m concussion settlement’. BBc news 2013 (http://spxj.nl/1wut1XF) 10. McCrory P, Falvey E, Turner M. Return to the golden age of boxing. British Journal of Sports medicine 2012;46:459–460 11. Davenshvar Dh, Baugh CM, et al. helmets and mouth guards: the role of personal equipment in preventing sport-related

1. McCrory P, Meeuwisse Wh, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, november 2012. British Journal of

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Sports medicine 2013;47:250–258

(http://spxj.nl/1wvTxZC) THE AUTHOR JAmiE BEck BSc mSc J Pgc(HEP) Pg Jamie is a lecturer in diagnostic radiography at the University of Bradford. He obtained his BSc in diagnostic radiography in 2000 and his mSc in medical imaging in 2011. His main areas of interest are the use of imaging in forensic and trauma medicine. He has particular interest in football, boxing, rugby league and cricket.

n Are we good at diagnosing concussion and other, potentially more serious, head injuries? n Do we always consider player safety as of paramount importance? n What do we know about the contribution of medical imaging in terms of diagnosing and managing head injuries? n Do we know about the laws and guidance that accompany the use DISCUSSIONS of radiation in medicine?

keY PointS n there is heightened awareness of concussion in sports that have previously not thought to have a risk of long-term consequences. n appropriate care is needed in sports participants who demonstrate clinical symptoms of concussion, these include rule changes and training of those in a supervisory role. n there is no evidence that regular neuroimaging would be beneficial without clinical evidence of intracranial lesion. n neuroimaging is not a substitute for appropriate clinical examination. n the use of functional imaging techniques has potential in identifying those at risk of long-term consequences, although more research will be needed. n the continued participation of those with concussion within a sport should be questioned. n match officials could be given the ability to remove players demonstrating concussion-like symptoms in a similar way to those who are bleeding. n regulatory bodies need to give clear guidance in terms of how players should be protected, regardless of game situation. n monitoring participants of contact sport over prolonged periods of time would be beneficial in establishing patterns in relation to chronic developments later in life.

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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our regular research reviewer, physical therapist Joseph Brence, reviews research looking into (i) better diagnosis of subacromial impingement and rotator cuff pathology with clustered tests, and (ii) to what extent pain is an indication of severity of injury.

Clustering signs and symptoms to diagnose rotator Cuff pathology by JosepH brenCe dpt, CoMt, daC Subacromial impingement (SAI) and rotator cuff (rtC) tears are a common cause of pain and disability of the shoulder and may be both traumatic and non-traumatic in origin. It has been reported that 20–30% of individuals between 60 and 80 years old will present with a rtC tear (1,2). Because of the high prevalence, it is crucial that we understand the best clustering of signs and symptoms to accurately identify when injury to the rtC has occurred. this review assesses the best clustering to screen for this pathology.

tests for subaCroMial iMpingeMent In 2005, Park et al. published a study that looked at examination data from 1127 patients who underwent shoulder surgery (3). this data was collected over an 11-year period, and included an analysis of eight clinical tests for subacromial impingement syndrome. the authors then used a forward stepwise logical regression analysis to determine the best clinical tests for predicting rtC pathology. they found that (in a subgroup of the total patients, who received each cluster of special tests) a combination of a hawkins– Kennedy test, painful arc of motion and infraspinatus muscle test yielded the best post-test probability (95%) for any degree of SAI. they identified that when all three tests were positive, the positive likelihood ratio was 10.56. Furthermore, they found that when they

clustered a painful arc of motion, droparm sign, and infraspinatus muscle test, they could produce the best post-test probability (91%) for a full-thickness rotator cuff tear. this had a positive likelihood ratio of 15.57.

tests for rotator Cuff tear A more recent article in the Journal of Manual & Manipulative Therapy, further looked to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multi-tendon (MLM) rtC tear (4). these researchers recruited participants from medical and physiotherapy practices, and had each fill out several outcome tools and undergo a physical examination including multiple orthopaedic tests for the shoulder. these researchers found constant pain and a painful arc of motion (in abduction) to be the strongest individual predictors of a MLM rtC tear. Clustering of history and physical examination variables yielded the highest levels of sensitivity and specificity. For example, when five or fewer of the following variables were present, one could rule out a MLM rtC tear with a sensitivity of 100%. however, when eight of the variables were present, there was a positive likelihood ratio of 4.7 for a rtC tear (increasing to 12.4 and >50 when nine and ten variables are present respectively): n Age >50 years n Shoulder pain and disability index (SPADI) score >48% n traumatic onset of pain n Constant pain

n Night pain disturbing sleep n Painful arc of abduction n Painful resisted abduction or external rotation n No pain during passive external rotation (at 90° of abduction) n External rotation lag sign present n Positive Speeds test. overall, when we use ‘cluster’ signs and symptoms, we can improve our diagnostic accuracy of rtC pathology, which can lead to better overall management of our patients.

CorreCt appliCation of speCial tests as proposed by park et al. (3) It is important to know how to apply these tests and what consitutes a positive result. Hawkins kennedy test: the patient is standing with their arm in 90° of forward flexion. the examiner then gently rotates it into internal rotation. the endpoint for internal rotation was either when the patient felt pain or the rotation of the scapula was felt or observed by the examiner. Positive provocation of pain indicated a positive test. painful arc of motion: the patient is standing and asked to elevate their arm within the scapular plane until full elevation is reached, and then lower it within the same plane. Positive pain or painful catching between 60 and 120° indicated a positive test. infraspinatus muscle test: the patient is standing with their elbow was flexed to 90° and the arm adducted to the trunk in neutral rotation. the examiner

sportEX medicine 2015;63(January):32-33

research review

then applies an internal rotation force to the arm while the patient resists. the test is considered positive if the patient gives way because of weakness or pain or if there is a positive external rotation lag sign. drop-arm sign: the patient is standing and is asked to elevate the arm fully and then to slowly reverse the motion in the same arc. If the arm drops suddenly or the patient has severe pain, the test is considered positive.

References 1. Fehringer EV, Sun J, et al. Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older. Journal of shoulder and elbow surgery 2008;17(6):881–885 2. Sher JS, uribe JW, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of Bone & Joint surgery (am) 1995;77(1):10– 15 3. Park hB, yokota A, et al. Diagnostic accuracy of clinical tests for the different

degrees of subacromial impingement syndrome. The Journal of Bone and Joint surgery (am) 2005;87(7):1446–1455 4. Cadogen A, McNair P, et al. Diagnostic accuracy of clinical examination of features for identifying large rotator cuff tears in primary health care. Journal of Manual & Manipulative Therapy 2013;21(3):148–159.

Do symptoms of pain preD preDict rotator cuff tear severity? As we are learning more about the complexity of pain, we are beginning to better understand that the degree of injury does not always relate to the degree of pain. the International Association for the Study of Pain (IASP) defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. this definition highlights the variability of a painful experience and indicates pain may be a result of actual or potential tissue damage. A recent article published in the Journal of Bone & Joint Surgery sought out to determine if pain levels are related to the severity of rotator cuff pathology (1). In this study, researchers performed a cross-sectional study to examine a cohort of 393 subjects (out of 2,233 potential subjects), who were being provided physical therapy, to treat an atraumatic full-thickness rotator cuff tear. these individuals had had their tear confirmed by MrI and were excluded if symptoms were thought to be related to the cervical spine, scapula, previous shoulder surgery, glenohumeral arthritis, inflammatory arthritis, adhesive capsulitis, previous proximal humeral fracture, symptomatic contralateral rotator cuff tear and dementia. At the initial visit, the subjects completed several forms: detailed

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demographic sheet, Short-Form 12 (SF-12), American Shoulder and Elbow Surgeons (ASES) score (which included a visual analogue pain scale), Western ontario rotator Cuff (WorC) Index, Single Assessment Numeric Evaluation (SANE) score, Self-Administered Comorbidity Questionnaire (SCQ), and the Shoulder Activity Scale. the researchers then evaluated the association between shoulder pain and other baseline factors by running a multivariable linear multi-regression model. the researchers of this study found greater pain to be associated with several things: n An increased number of comorbidities n A lower education level n race. the researchers found the following to have no association with pain: n Measures of tear severity – including the tendons involved (72% of subjects had a tear of the supraspinatus) n Amount of retraction (which was minimal in 48% of subjects and to the midpart of humeral head in 34%) n Presence of humeral head migration (present in 16% of subjects) n Amount of fatty degeneration of the supraspinatus. overall, this study further supports

the notion that the level of pathology does not appear to be influential on the degree of pain experienced. Instead, psychosocial variables appear to be more associated for this reported symptom and taking this into account, may be used in better future management. References 1. Dunn Wr, Kuhn JE, et al. Symptoms of pain do not correlate with rotator cuff tear severity. The Journal of Bone & Joint surgery (am) 2014;96(10):793–800.

THE AUTHOR JOsEpH BREncE DpT, cOMT, DAc J Joseph 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 versus 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.

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