Co-Kinetic Journal Issue 68 - April 2016

ISSUE 68 April 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics

C0-Kinetic journal welcome

April 2016 Issue 68 ISSN 2397-138X

editorial

Practical, practical, practical. It’s our mantra and our USP and I’m attacking it with renewed vigour these days. When our authors submit content the first question on the article submission form is “what problem will your article solve for our readers”? And we dig deep, there is no time for airy fairy vagary. If our content isn’t solving problems for you, or helping you to do your job better, more efficiently or more effectively, then we haven’t done our job, it really is that simple.

This Spring issue is packed with ‘practical’. The article from Drs Ian Horsley and Lee Herrington, contains numerous quick reference tables and a detailed method for the qualitative analysis of the single-leg squat. It also includes a client information handout for ACL injury and an early stage rehabilitation leaflet.

The University of St Mark and St John team are back with a review of radial shockwave therapy (along with a handy printable client handout). Jason Masek concludes his 3-part series on the management of femoroacetabular impingement syndrome using postural restoration with an article that’s packed with practical rehabilitation exercises and Dr Mike Turner’s article on tipping the psychological balance in performance athletes is rooted in practical application from the outset. To top it all off there are four certificated elearning quizzes you can use to evidence your learning in your professional development portfolio.

contents 4 Physical therapy journal watch 9 Manual therapy journal watch 12 Preventing and managing anterior cruciate ligament (ACL) injury 18 Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration®: Part 3 26 Understand how radial shockwave therapy can help in rehabilitation of musculoskeletal disorders 30 How to support your athletes to thrive under pressure by tipping the balance 36 Strategies for overcoming barriers to implementing strength and conditioning programmes in youth football 42 Manual Therapy Student Handbook:

Musculoskeletal diagnosis – a pragmatic model of clinical reasoning 50 Social watch - a round-up of some of the best resources on social media

Happy reading :-) Tor Davies, physio-turned publisher Publisher/editor Tor Davies tor@sportex.net Marketing and sales Sheena Mountford sheena@sportex.net Art editor DEBBIE Asher Sub-editor alison sleigh phd Journal Watch bob braMah Subscriptions & Advertising support@sportex.net +44 (0) 845 652 1906

commissioning editors and technical advisors Tim Beames - MSc, BSc, MCSP Dr Joseph Brence, DPT, COMT, DAC Simon Lack - MSc, MCSP Dr Markus W Laupheimer MD, MBA, MSc in SEM, MFSEM (UK), M.ECOSEP Dr Dylan Morrissey - PhD, MCSP Dr Sarah Morton - MBBS Brad Neal - MSc, MCSP Dr Nicki Phillips - PhD, MSc, FCSP

ISSUE 68 April 2016

ISSN 2397-138X

Formerly published as....

medicine & dynamics

is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX, UK Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 https://co-kinetic.com

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

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Twenty female patients aged 18–35 years with patellofemoral pain (PFP) performed 3 to 5 single-leg squats (SLSq) on their most symptomatic limb during a taped (Mulligan knee taping technique) and non-taped (control) condition.

During the eccentric phase of the SLSq, the 3D kinematics (250Hz) of the knee and hip, and the groundreaction forces (1000Hz) and muscle activation patterns (1000Hz) of the gluteus medius, vastus lateralis, and vastus medialis oblique were measured. The tape was applied in standing with the hip and knee internally rotated and knee flexed to 20°. Two superimposed layers of 38mm rigid tape were applied in a spiral fashion under tension from the lateral aspect of the neck of fibula,

The effect of the Mulligan knee taping technique on patellofemoral pain and lower limb biomechanics. Hickey A, Hopper D, et al. The American Journal of Sports Medicine 2016;doi:10.1177/036354651 6629418 [Published online before print 22 Feb 2016] ending on the anterolateral aspect of the femur. The tape passed over the tibia, inferior to the medial joint line and behind the knee. This meant that when the patient assumed a normal standing position, the tape became tighter, altering rotation at the tibiofemoral joint therefore inducing hip external rotation.

Participants’ perceived maximum knee pain was also recorded after the completion of each squat. Betweencondition differences were found for hip kinematics and gluteus medius activation but not for kinetics or vastus medialis oblique and vastus lateralis muscle activity (timing and activation).

Compared with the non-taped condition,

the Mulligan knee taping technique significantly reduced perceived pain during the SLSq. In the taped condition compared with the control, the onset timing of the gluteus medius occurred significantly earlier and peak hip internal rotation was significantly reduced.

Co-Kinetic comment The evidence that manual therapists have been right all along keeps on coming. Taping is a valuable component of the management plan for altering lower limb biomechanics and providing pain relief.

Risk of injuries in paralympic track and field differs by impairment and event discipline: a prospective cohort study at the London 2012 Paralympic Games. Blauwet CA, Cushman D, et al. The American Journal of Sports Medicine 2016;doi:10.1177/0363546516629949 [Published online before print 26 Feb 2016] A total of 977 athletes competing in the sport of athletics were followed during the competition period of the 2012 Paralympic Games. Daily injury data were obtained via two databases: (1) a custom-built, web-based injury and illness surveillance system (WEB-IISS), maintained by team medical personnel; and (2) the organising committee database, maintained by medical providers in the medical stations operated by the London Organising Committee of the Olympic and Paralympic Games. Athlete impairment and event discipline were obtained via the International Paralympic Committee athlete database. Incidence rates (IRs) were recorded as injuries per 1000 athlete-days by impairment, event discipline, sex, and age.

The overall IR was 22.1 injuries per 1000 athlete-days. In track disciplines, ambulant athletes with cerebral palsy experienced a lower incidence of injuries (IR, 10.22) when compared 4

with ambulant athletes from other impairment categories. Athletes in seated throwing experienced a higher incidence of injuries (IR, 23.7) when compared with athletes in wheelchair racing (IR, 10.6). In both track and field disciplines, the majority of injuries did not result in time loss from competition or training. Ambulant athletes experienced the greatest proportion of injuries to the thigh (16.4% of all injuries), observed predominantly in track athletes.

Wheelchair or seated athletes experienced the greatest proportion of injuries to the shoulder/clavicle (19.3% of all injuries; IR, 3.4), observed predominantly in field athletes.

Co-Kinetic comment Injury patterns were specific to the event discipline and athlete impairment or, as we said about the Physiotherapy article, everyone is different. The other important finding was that the majority of injuries did not result in time lost from training or competition. Elite athletes play through injury.

Co-Kinetic journal 2016;68(April):4-7

Physical Therapy Research into practice

Journal Watch A convenience sample of 60 physiotherapeutically naïve, healthy pain-free male participants aged 18–25 years (mean 21.53, SD ± 2.19) were randomly allocated to one of four groups: a control group (no contact), a placebo group (sustained static pressure to L4 vertebra), and two intervention groups receiving a centrally applied posteroanterior mobilisation at L4 applied at either 2Hz or 3Hz for three 1min periods. The 3Hz mobilisations were at 180 oscillations/ min at an average force of 94–109N. The 2Hz mobilisations were at 120 oscillations a minute at an average force of 94–103N. Treatment consisted of three 1min treatments with a 1min rest between applications. Sympathetic nervous system (SNS) activity was

An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb. Piekarz V, Perry J. Manual Therapy 2016;doi:http://dx.doi.org/10.1016/j. math.2016.01.001 [Article in press]

recorded by a blinded data collector by continuous skin conductance (SC) activity levels in the feet using a Biopac MP35 electrodermal amplifier at the plantar surface of the 2nd and 3rd toes which correlate with the L4–5 supplied cutaneous nerve branch, the medial plantar nerve which supplies the palm surface of the toes. The results were that the magnitude of sympathoexcitatory response was greatest for the 3Hz mobilisation (20%) compared with the 2Hz mobilisation (12%), placebo (1%) and control conditions (3%). Only the 3Hz group

demonstrated statistical significance when compared to placebo intervention and the control group.

Co-Kinetic comment An all-male participant group was selected to reduce the effects of oestrogen fluctuations in the menstrual cycle altering SNS activity – what a good thing on the authors’ part. Apparently 42% of physiotherapists use Maitland mobilisations to treat low back pain. What are the others doing then, because ‘hands on’ manual therapy works. Previous studies have investigated the SNS activity and importance of non-opioid endogenous pain inhibition pathways in the mid-brain. This shows that mobilisations affect the SNS.

Sportsman’s hernia? An ambiguous term. Dimitrakopoulou A, Schilders E. Journal of Hip Preservation Surgery 2016;doi:10.1093/jhps/hnv083 [First published online 25 Feb 2016] Groin injuries are commonly seen in athletes and account for up to 6% of all athletic injuries. They are most commonly seen in sports that require repetitive twisting, cutting, rapid acceleration and deceleration movements such as soccer, rugby, ice hockey and Australian Rules football. Many terms have been employed for this condition, such as sportsman’s hernia, sports hernia, inguinal hernia, incipient hernia, cryptic hernia, Gilmore’s groin, hockey player’s syndrome, groin pull, sports groin, chronic symphysis syndrome and athletic pubalgia. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term ‘inguinal disruption’ based on the pathophysiology, whereas lately the Doha agreement in 2014 defined it as ‘inguinal-related groin pain’, a clinically based taxonomy. Diagnosis of the condition is based on the patient’s history and clinical examination. The onset may be sudden but most often is insidious, present for several months with the athletes complaining of a dull, diffuse ache in their groin. The pain is usually unilateral, sharp or burning in nature and radiates to the lower abdomen, proximal thigh, low back, perineum or scrotum. It is exacerbated by athletic activities like sprinting/running, kicking/striking a ball, cutting/ twisting, sit-ups, side-stepping. Coughing, sneezing or other Valsalva-type manoeuvres may worsen the pain. Getting out of bed can be painful but rarely wakes up patients from sleep, as the pain is activity-related and relieved by rest. In Co-Kinetic.com

the early stages, the pain occurs after sports but later can become so intense that athletes are impaired or disabled from training or performing their sport. Look for an obvious bulge in the inguinal area and palpate the pubic tubercle, conjoined tendon, medial inguinal canal, insertion of rectus abdominus or adductor origin for tenderness. Discomfort can be elicited with resisted sit-ups and resisted hip adduction (adductor squeeze test). Examination of the hip can reveal a decreased range of movements (internal and external rotation). Reduced strength of adductor/abductor has also been noticed. There is a strong likelihood of co-existing pathologies including muscle injuries, hip pathologies, low back problems, nerve entrapments, intestinal, genitourinary and gynaecological pathologies. Imaging studies are necessary to rule out other diagnoses. Surgical exploration and repair should be considered if conservative treatment is ineffective. This would include rest, physical therapy with core strengthening and stretching exercises, ultrasound treatment, electrical stimulation, ice, and deep massage with soft-tissues mobilisation.

sCo-Kinetic comment This is another of our favourite ‘all you need to know’ papers. It’s available in open access, so if you are involved in sport it’s a must read.

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Exercise therapy, continuous passive motion machines and aquatic therapy are all used for rehabilitation following rotator cuff (RC) surgery. This study sought to find if there was evidence for the best protocol. The usual medical databases were searched from September 1993 to September 2013 for relevant randomised controlled trials. Narrative synthesis of the data was used to describe the effects of the intervention. The methodological quality and risk of bias of the included studies was assessed using the standardised Physiotherapy Evidence Database scale. Eleven studies met the inclusion criteria. All the studies were of fair to good methodological quality. No one

Rehabilitation following surgical repair of the rotator cuff: a systematic review. Thomson S, Jukes C, Lewis J. Physiotherapy 2016;102(1):20–28

This investigation monitored displacement at sequential depths in thoracic paraspinal tissues parallel with surface load directions. Twenty-four healthy male volunteers with a similar mesomorphic body type between the ages of 23 and 45 were recruited from a Canadian Chiropractic College.

Participants were prone and two experimental manoeuvres were performed sequentially, first with ultrasound recording at the proximate site and secondly with it at the distant site of the paraspinal muscles. The force applied modelled the typical ‘preload’ phase that is designed to induce tension in the underlying tissues before a high-velocity, low-amplitude (HVLA) thrust would be applied. The

Differential displacement of soft-tissue layers from manual therapy loading. Engell S, Triano JJ, et al. Clinical Biomechanics 2016;33:66–72

rehabilitation protocol was found to be superior to another. The findings of this review suggested that following RC repair, patients should expect improvement in pain, ROM and function.

Co-Kinetic comment Look around you. Everyone is different. Their shoulders are subjected to different loads and have been since the day they were born. The way they think, the way they move, the way they heal is different. There is never ever going to be a one size fits all in

direction of force was caudocephalic and secondarily posteroanterior with respect to the subject’s torso.

The total time for the experimental manoeuvre was ≥10s. Surface loading of the torso in combined posteroanterior and caudocephalic directions result in both displacement of tissues anteriorly and in shearing between tissue layers in the plane of the tissues strata to depths that could plausibly affect spinal tissues.

Displacements of tissues more likely arise passively, consistent with load transmitted by the retinacula cutis and epimuscular force pathways.

rehabilitation. That is down to the skill of the therapist.

In the same edition of Physiotherapy is a report on a project that seeks to define ‘normal’ musculoskeletal reference values for healthy humans aged between 3 and 100 [McKay MJ., et al. 1000 Norms Project: protocol of a cross-sectional study cataloguing human variation. Physiotherapy 2016;102(1):50–56]. Forget it – there is no such thing as normal.

Displacements are similar in magnitude to those known to evoke biologically relevant responses in both animal and human studies.

Co-Kinetic comment This is one for the sports scientists because there is a lot of ‘science speak’ in it. For clinicians, the highlights are that tissue displacement between skin and bone during a manual therapy technique was measured and there was displacement of tissue which has the potential for biological impact.

Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Ekstrand J, Waldén M, Hägglund M. British Journal of Sports Medicine 2016;doi:10.1136/bjsports-2015-095359 [Published online first 8 January 2016] Thirty-six clubs from 12 European countries were followed between 2001 and 2014. Team medical staff recorded individual player exposure and timeloss injuries. A total of 1614 hamstring injuries were recorded; 22% of players sustained at least one hamstring injury during a season. The overall hamstring injury rate over the 13-year period was 1.20 injuries per 1000h; the match injury rate (4.77) being nine times higher than 6

the training injury rate. The time-trend analysis showed an annual average 2.3% year-on-year increase in the total hamstring injury rate over the 13-year period. This increase over time was most pronounced for training injuries – these increased by 4.0% per year. The average hamstring injury burden was 19.7 days per 1000h (annual average increase 4.1%)

Co-Kinetic comment This is a wake-up call for coaches: training injuries up, match injuries down. Is it because the medical staff take less risk in training and pull out the players and it gets recorded as an injury? Maybe they should look at the MET research we have also reported!

Co-Kinetic journal 2016;68(April):4-7

Physical Therapy Research into practice

This study followed 14 male members of the Polish National Wheelchair Rugby Team over a 9-month period during which the athletes participated in up to nine training camps and four wheelchair rugby tournaments. The study was based on the Competitive Aggressiveness and Anger Scale, registry of sports injuries consulted and non-consulted with a physician and a demographic questionnaire.

The following observations were made during the 9-month period corresponding to a mean of 25 training and tournament days: (1) wheelchair rugby players experienced primarily minor injuries (n = 102) that did not require a medical intervention, (2) a physician had to be consulted for only four injuries, (3) sports injuries occurred more frequently among offensive players than in defensive players, (4) offensive players showed a tendency to higher levels of anger and aggressiveness than defensive players.

It can be concluded that wheelchair rugby is a discipline associated with a high incidence of minor injuries that do not require a medical intervention.

The incidence rate of injuries during the analysed period was 0.3 per athlete per training day.

Sports injuries in wheelchair rugby – a pilot study.

Bauerfeind J, Koper M, et al. Journal of Human Kinetics 2015;48(1):123–132

Co-Kinetic comment The majority of wheelchair rugby players have had partial spinal severance and do not have full use of all four limbs. There is a film that follows the USA team called ‘Murderball’ which just about sums it up. It is a full contact sport in which the chairs crash into

each other like dodgem cars. If you have never seen wheelchair rugby then go to YouTube and prepare to be astonished that there are only minor injuries. Better still, go to a live game. See GB Wheelchair Rugby (http://gbwr.org.uk) for more details.

Predicting football injuries using size and ratio of the multifidus and quadratus lumborum muscles. Hides JA, Stanton WR. Scandinavian Journal of Medicine & Science in Sports 2016;doi: 10.1111/ sms.12643 [Published first online 6 Jan 2016] Ultrasound imaging examinations were performed on 261 male elite football players from six Australian Football League (AFL) clubs during the pre-season to obtain the size of multifidus at the L5 vertebral level.

A subset of players had the size of their quadratus lumborum muscle (QL) measured at the L5 vertebral level (62 players at the start of the preseason, and 102 players at the start of the playing season). Injury data were obtained from records collected by each club.

A model was developed for prediction of lower limb injuries in football players. Combining size measurements of the multifidus and QL muscles improved predictive power.

Results indicated that a smaller crossCo-Kinetic.com

sectional area of the multifidus muscle was related to the occurrence of an injury in the pre-season and in the season. With the QL muscle a larger cross-sectional area was significantly related to an injury in the pre-season but not in the season. A significant link was found between the ratio of the multifidus and QL muscles, and the incidence of pre-season and season injuries. The sensitivity and specificity of the model in the pre-season were 75% and 85.7%, respectively; values for the playing season were 88.4% and 62.5%.

Co-Kinetic comment It seems that in ‘Aussie rules’, players size is everything. The multifidus size results confirm early findings by the same research team.

The speculated reason for this is because of the role of the multifidus in stabilising the lumbo-pelvic region in running, jumping and cutting activities, which require precise neuromuscular control. The role of the QL is less clear because earlier studies suggested a correlation between decreased size and injury rather than increased in this study. The answer may be in the relative size of multifidus and QL because earlier studies again by the same team suggest that the size of the multifidus muscle has been shown to decrease in response to playing football and the increased QL may be compensation. It’s all a bit confusing but something is going on, so it’s a case of more research to get some definitive answers.

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manual Therapy Research into practice

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Journal Watch The acute effect of local vibration as a recovery modality from exercise-induced increased muscle stiffness. Pournot H, Tindel J, et al. Journal of Sports Science & Medicine 2016;15:142–147

Eleven subjects (5F, 6M; age, 38 ± 9 years; height, 1.74 ± 0.09m; body mass, 73 ± 8kg) performed four bouts of 10 bilateral barbell curl movements at 70% of the one-rep maximal flexion force. The movement went from full extension to full flexion over 1–2s. An arm-to-arm comparison model was then used with one arm randomly assigned to the passive recovery condition and the other arm assigned to the local vibration (LV) recovery condition. This was 10min of 55Hz vibration frequency and 0.9mm amplitude using a hand held mechanical vibration generator (Vibralgic 5, YSY Medical). The head of the vibrator was

applied on the skin in multiple and random directions with the aim for the experimenter to homogeneously treat the whole muscle belly. Subjects were asked to remain fully relaxed during the recovery period.

Biceps brachii shear elastic modulus measurements were performed before exercise (PRE), immediately after exercise (POSTEX) and 5min after the recovery period (POST-REC) using an AixPlorer ultrasonic scanner (version 6.1.1, Supersonic Imagine), coupled with a linear transducer array (4–15MHz, SuperLinear 15–4, Vermon).

Biceps brachii shear elastic

modulus was significantly increased at POST-EX and POST-REC when compared to PRE. No differences were found between passive and LV recovery. LV as a recovery strategy from exercise-induced increased muscle stiffness was not beneficial, probably due to an insufficient mechanical action of vibrations.

Co-Kinetic comment You go to all the trouble of setting this up and don’t try to up the dose to see what happens. Or do a comparison with other recovery modalities.

Seems a bit of a waste.

Targeted exercise interventions in improving injuries, flexibility and strength in female dragon boat paddlers. Broadbent S, Coutts R, Coetzee S. International Journal of Therapy and Rehabilitation 2016;23(1):11 Anthropometry, frequency of injuries, joint flexibility, muscular strength/endurance, and musculoskeletal stiffness/ pain were assessed in 22 recreational female dragon boat paddlers (mean age 56.7 ± 7.0 years) before and after 6 months of individualised strengthening and stretching interventions. Before interventions they completed a questionnaire that asked about, past medical history, exercise history, training distances and intensities including strike rate.

Pre- and post-intervention physiological assessments were completed at the club training facility by exercise physiologists and trained postgraduate students. A tailored strengthening and stretching programme was designed for each participant based on their initial assessment results targeting muscular weaknesses, tightness and/or stiffness/pain. Strengthening exercises were performed two to three times per week, with stretching recommended daily, especially after paddling sessions. Most participants did not belong to a gym or have

Co-Kinetic.com

resistance-training experience and the rowing club did not have a gym, so their programmes were designed to be home-based, using body weight, resistance bands, Swiss balls, household items as ‘weights’ (eg. 1kg containers), chairs and steps. Over the 6 months there were significant improvements in systolic and diastolic blood pressure; shoulder and spinal flexion/extension; hip, knee and elbow flexion; hip flexor/extensor and hip abductor isometric strength; straight-leg raise and sit-and-reach test values; and self-reported pain. The frequency of neck, shoulder, back and wrist injuries decreased significantly.

Co-Kinetic comment This is great on many levels. Firstly it shows that training problems targeted at specific individual needs for specific sports can have dramatic results. Secondly it shows that you don’t need high tech equipment to achieve those results.

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Changes in muscle activity after performing the FIFA 11+ programme part 2 for 4 weeks. Takataa Y, Nakasea J, et al. Journal of Sports Sciences 2016; doi:10.108 0/02640414.2016.114960 6 [Published online before print 28 Feb 2016] Eleven males (age, 29.0 ± 4.2 years; height, 173 ± 6cm; weight, 68 ± 5kg) performed part 2 of the FIFA 11+ programme three times per week for 4 consecutive weeks. Before and after this they were injected with 37MBq of 18F-fluorodeoxyglucose (FDG) intravenously and images were obtained by positron emission tomography–computed tomography (PET–CT). Regions of interest were defined within 30 muscles. The standardised uptake value (SUV) of FDG by muscle tissue per unit volume was calculated, and FDG accumulation was compared between pre- and post-training PET–CT results. The mean SUV in the sartorius, semimembranosus, biceps femoris, abductor hallucis, and flexor hallucis brevis muscles increased but the mean SUVs of the ‘core muscles’ including transverse abdominal and greater psoas showed no statistical difference between preand post-training results.

Co-Kinetic comment What this shows is that performing part 2 of the 11+ increased glucose uptake related to muscle activity in the hamstrings and hallux muscles. The authors speculate that there is some possibility of this change of muscle activity contributing to a decrease in sports-related injuries.

The ‘FIFA 11+’ is a complete warm-up programme which aims to reduce injuries among male and female football players aged 14 years and older. More details can be found at the FIFA 11+ website (http://f-marc.com/11plus/home/). Part 1 consists of running exercises at a slow speed combined with active stretching and controlled partner contacts; part 2 is a set of six exercises, focusing on core and legs strength, balance, and plyometrics/agility, each with three levels of increasing difficulty; part 3 is running exercises at moderate/high speed combined with planting/ cutting movements. Previous studies suggest that 11+ is effective in reducing injuries by 30–50% in teams practising the programme at least twice per week.

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Effect of friction technique on ankle sprain grade II treatment. Mobarakeh M, Mehdi, Hafidz HJOA. Biomedical and Pharmacology Journal 2015;8(2):doi:http://dx.doi.org/10.13005/ bpj/794 Twenty four male athletes aged 20–25 with grade II ankle sprains were divided into two groups. For 8 weeks one group had their injured ankle placed into a brace, the other received 15min of effleurage massage for warmup and friction massage across the injured ligaments. Before and after tests were done for range of motion (ROM), strength and balance using a goniometer, resistance bands and a wobble board. Findings show that treatment (massage) group has “great impact compared to control group.

The implications of this study offer this protocol as a most effective treatment for ankle sprain grade II”.

Co-Kinetic comment The peer-reviewed research

publication industry may well have reached a point where its critical mass implodes. The journal that published this study is one of 160 we are aware of (to date) that have carried papers that may be of interest to our readers.

That is 160 titles not editions. That is an awful lot of research and the quality varies from excellent to utter rubbish. It has reached the stage where if you just want to quote a study to prove a point, any point, you will be able to search Google Scholar and find one. You will also find the contrary view if you want it. In this case the point to make is that a couple of forms of massage are good for sprained ankles. However, if you want to repeat the protocol or quote a study of even moderate quality this is not for you.

Muscle injury is the principal injury type and hamstring muscle injury is the first injury diagnosis during toplevel international athletics championships between 2007 and 2015. Edouard P, Branco P, Alonso J-M. British Journal of Sports Medicine 2016;doi:10.1136/bjsports-2015-095559 [Published online 17 Feb 2016] During 16 international championships held between 2007 and 2015, national medical team and local organising committee physicians reported daily all injuries on a standardised injury report form. Only muscle injuries (muscle tears and muscle cramps) and hamstring injuries were analysed. Of all recorded injuries 40.9% (n = 720) were muscle injuries, with 57.5% of them resulting in time loss. The overall incidence of muscle injuries was higher in male athletes than female athletes (51.9 ± 6.0 vs 30.3 ± 5.0 injuries per 1000 registered athletes, respectively).

Muscle injuries mainly affected the thigh (52.9%) and lower leg

(20.1%), and were mostly caused by overuse with sudden onset (38.2%) and non-contact trauma (24.6%). Muscle injury risk varied according to the event groups. Hamstring injuries represented 17.1% of all injuries, with a higher risk in male compared to female athletes (22.4 ± 3.4 vs 11.5 ± 2.6 injuries per 1000 registered athletes, respectively).

Co-Kinetic comment These types of article are a gold mine of information for coaches and therapists. Training programmes, regular screening and something as simple as regular sports massage can go a long way to preventing some of these injuries. In particular it was athletes in explosive power events, male athletes and older male athletes, who were more at risk of muscle injuries and hamstring injuries so they are the groups who should be targeted.

Co-Kinetic journal 2016;68(April):9-11

manual Therapy Research into practice

Effects of far infrared heat on recovery in power athletes. Noponen PVA, Häkkinen K, Mero AA. Journal of Athletic Enhancement 2015;4:4

Effect of muscle energy technique on flexibility of hamstring muscle in Indian national football players. Adkitte R, Rane SG, et al. Saudi Journal of Sports Medicine 2016;16(1):28–31

Ten national level male athletes from track and field, gymnastics and Finnish baseball (age 22.3 ± 4.5 years) took part in the study. They acted as their own control group in a crossover design study. Five participants performed the first measurement period using the infrared bag and the second measurement period without using it, whereas the remaining five participants vice versa.

There were 2–4 weeks between the measurement periods depending on the participants’ training and training camp schedules. Training and nutrition during the measurement periods were controlled. Their training consisted of strength, power and technique sessions. Performance tests included isometric strength tests, a countermovement jump (CMJ) and a Wingate 30s test. Serum concentration of testosterone, cortisol, sex hormone binding globulin, highsensitivity C-reactive protein and creatine kinase were analysed. The whole-body infrared bag was used (40min at 50°C) every evening on four consecutive days.

The results were that CMJ height and peak power in the Wingate test were greater after the experimental condition. The increase in the testosterone and cortisol ratio between the pre- and post-measurements was significantly greater during the experimental than during the control condition.

Co-Kinetic comment The infrared bag looks like a big sleeping bag and basically provides a personal sauna for one. The authors speculate that the heat has some effects on the function of fast-twitch muscle fibres, especially as these fibres are located in larger numbers in the superficial layers of the muscle than in the deep layers and so are more likely to be heated.

Maybe a hot bath would have the same result.

This starts with the premise that hamstring tightness can lead to hamstring injury. Thirty Indian national football team players who complained of hamstring tightness were randomly selected. They were given 6 days of muscle energy technique (MET) on hamstring muscles with the aim of increasing flexibility. Hamstring length was checked before and after the sessions using the average of three sit-and-reach tests. The MET used was a post-isometric relaxation technique with a hamstring contraction held for 7–10s, followed by the leg being taken into further flexion with 30s hold. The procedure was repeated three times with a 10s rest between each. The results were that there was an increase in hamstring length following the 6 days of MET.

Co-Kinetic comment This starts with the understatement of the year, “soccer is certainly one of the most popular sports worldwide. …compared with other sports, football is a vigorous sporting activity with a relatively high incidence of injury.” It certainly is and so any research into preventing injury is to be welcomed. What many journals from the middle and far east are doing is looking at basic manual therapy techniques, many of which tend to get ridiculed in today’s ‘hands off’ world, and providing an ever-growing evidence base proving their usefulness. Keep up the good work but next time could we have some statistics about how long the treatment effect lasts.

Considerations regarding the use of metabolic equivalents when prescribing exercise for health: preventive medicine in practice. Cristi-Montero C. (2016): The Physician and Sports Medicine 2016;doi:10.1080/00913847.2016.1158624 [Published online 25 Feb 2016] This commentary exposes issues to consider before designing an exercise plan using metabolic equivalents (METs).

It concludes by suggesting that heart rate reserve appears to be a better tool for both prescribing and controlling exercise.

A MET is defined as the amount of oxygen consumed while sitting at rest, and in theory it represents a practical way of expressing the energy cost of physical activities as a multiple of the resting metabolic rate. At least 150min/ week of moderate-intensity exercise is equivalent to 3–6 METs, 75min/week of vigorous-intensity exercise is 6–9 METs. There are other ways to indicate training intensity including VO2max, VO2 reserve (VO2R), maximum heart rate (MHR), heart rate reserve (HRR), anaerobic threshold, aerobic threshold, blood lactate concentration, and rating of perceived exertion.

Some of the problems with MET are the difficulty of establishing a base level, which is influenced by body weight, body composition, resting metabolic rate, gender, level of cardiorespiratory fitness, age, and genetic factors; exercise at moderate and vigorous intensity (3–9 METs) does not take into account the individual’s maximum capacity of work

Co-Kinetic.com

(MCW); METs are absolute values (intensity) and do not consider any characteristics of the individual (eg., weight, age and physical condition).

In contrast, heart rate (HR) is an excellent indicator of the physiological response of organisms to highly diverse biological and environmental situations, which can be measured using simple and inexpensive wrist monitors, Bluetooth applications for smartphones or the manual method of finding the radial or carotid pulse, and can be used to control training load intensity in real time. Resting HR is an excellent indicator of cardiovascular health. HR increases linearly in response to the oxygen and nutrient demands of the body due to the integrated response of the respiratory, cardiovascular and muscular systems. Thus, HR is an excellent indicator and can be used to control training load intensity in real time.

Co-Kinetic comment If you are involved in any way in the prescription of exercise you should read this paper. It gives examples of why HR is good and METs are not so good. It is available in open access. Can we please have a similar paper that debunks BMI, please.

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Preventing and managing anterior cruciate ligament (ACL) injury

Anterior cruciate ligament (ACL) injuries are one of the worst knee injuries to sustain in sport, with less than 50% of athletes returning to sport in the first year following surgery and high rates of reinjury. The process for either reducing ACL injury risk or rehabilitating a patient following an ACL repair, are essentially the same. This article outlines the risk factors for ACL injury, provides tools to help you assess injury risk and recommends strategies for rehabilitation as well as for injury prevention. To help you visualise the function of the ACL we have included four animations that bring the anatomical structure and the injury mechanism to life. You can use the certificated elearning assessment or the ‘journal club’ style group discussion questions at the end of the article as part of your continuing education portfolio and you can support your clients with the two printable patient handouts.

Read this online http://spxj.nl/1iIS8kC knee | lower-limb | handout | 16-04-co-Kinetic | FORMATS WEB MOBILE PRINT

Media contents Series of animations showing ACL function. http://spxj.nl/1iIS8kC 2 x patient advice leaflets on ACL injury. http://spxj.nl/1iIS8kC Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1iIS8kC

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By Dr Ian Horsley MSc PhD, MCSP MMACP CSCS and Dr Lee Herrington MSc PhD, MSCP CSCS

Background Anterior cruciate ligament (ACL; Fig. 1) injuries are one of the most devastating knee injuries sustained while participating in sport. ACL reconstruction (ACLR) remains the standard approach for athletes who aim to return to high level sporting activities (1) and is also consistently used in non-elite sporting populations. Less than half of athletes who undergo ACLR are able to return to sport within the first year post-surgery (2), and around 25% of the athletes returning to sport will have a subsequent second ACL injury within two years (3,4), with the outcomes from second surgery being considerably worse (5).

It is frequently stated that female athletes have a higher incidence of ACL tear than male subjects, estimated to be as much as 8 to 9 times greater, although this is dependent on the sport played (6). The explanations for the different rates of injury in men and women are uncertain, but theories include differences in anatomy, knee alignment, ligament laxity, muscle strength, and physical conditioning.

Other than those hypotheses, gender research has identified that a combination of multiple variables contribute to ACL injury (7), which include neuromuscular control deficits (8), intercondylar notch width (9), tibial slope (10), joint laxity (11) and body mass index (11).

Most ACL injuries occur during non-contact running, jumping and landing tasks (12–17) with inadequate neuromuscular control of the lower limb during these manoeuvres considered a likely cause of injury (8,17–19) . Decreased knee flexion and

Figure 1: Structure and biomechanics of the anterior cruciate ligament (ACL).

(Primal Pictures, 2012)

increased knee valgus, tibial rotation, hip adduction and internal rotation during landing and cutting manoeuvres are commonly seen during ACL injury episodes (13,15,16,20,21) and can increase strain placed on the ACL (22,23).

Tools for the assessment of neuromuscular control The inadequate neuromuscular control can also be task and sport specific; Munro et al. reported that female basketball players display greater dynamic knee valgus values during unilateral landing tasks than female football players which may reflect the greater ACL injury occurrence in this population (24). Because of the taskdependant nature of ACL injury, tools to assess neuromuscular control are of paramount importance to the clinician both for defining risk of injury and for identifying appropriate movement strategies to allow progression (during rehabilitation) to more challenging Co-Kinetic journal 2016;68(April):12-17

Physical Therapy MSK diagnosis, Treatment, Rehabilitation

Most ACL injuries occur during non-contact running, jumping and landing tasks Optimal

QASLS Arm strategy

Excessive arm movement to balance

Trunk alignment

Leaning in any direction

Pelvic plane

Loss of horizontal plane

Sub optimal

Excessive tilt or rotation

Figure 2: Scoring system for the analysis of single-leg loading: qualitative analysis of single-leg squat (QASLS) (L. Herrington, G. Myer, I. Horsley, 2013)

The primary goal of rehabilitation of a patient following ACL reconstruction (ACLR) is to prevent disruption to the graft, the secondary goals being reducing the incidence of the significant comorbidities of patellofemoral joint pain and both tibiofemoral and patellofemoral joint degeneration (osteoarthritis) Co-Kinetic.com

Thigh motion

WB thigh moves into hip adduction

NWB thigh not held in neutral

Patella pointing towards 2nd toe (noticeable valgus)

Patella pointing past inside of foot (significant valgus)

Steady stance

Touches down with NWB foot Stance leg wobbles noticeably

Figure 3: Appropriate and inappropriate movement strategies in the single-leg squat.

WB, weight bearing; NWB, non-weight bearing. (S. Dawson, L. Herrington, 2015)

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Table 1: Risk factors that influence the ability to move with appropriate lowrisk alignment (I. Horsley, 2015; sourced Laible C, et al. Bull Hosp Jt Dis 2014;72:70) Weak muscles: gluteals, quadriceps, foot supinators Poor muscle work capacity: gluteals, quadriceps, foot supinators Over recruitment: hamstrings, hip adductors, trunk flexors Decreased proprioception (joint position sense) Reduced dorsiflexion of ankle Reduced tibial internal rotation

Table 2: Technique factors that influence the way a task is carried out (I. Horsley, 2015; sourced Laible C, et al. Bull Hosp Jt Dis 2014;72:70) Dynamic valgus (medial) collapse of the limb on landingloading activities Excessive trunk movement during landing/loading activities During cutting/change of direction: contralateral (to direction of cut) trunk lean and rotation During cutting/change of direction: a wide foot placement outside of base of support, with medial collapse of leg and decreased knee flexion During cutting/change of direction: failure to decelerate on penultimate foot contact

tasks. The gold standard for assessing movement is 3D motion capture which can provide both movement (kinematic) and force (kinetic) data to accurately define performance.

The use of this equipment is time consuming and requires expensive laboratory facilities and equipment. A number of researchers have begun to develop qualitative assessment tools for assessing neuromuscular control, and these have the major advantage over 3D motion capture of being simple to use, requiring minimal equipment and technical knowledge and are often adaptable so they can be used across multiple tasks. One example is the qualitative scoring system for the analysis of single-leg loading, developed

by Lee Herrington at the University of Salford and the English Institute of Sport [qualitative analysis of single-leg squat (QASLS)] (Fig. 2). The QASLS tool has been shown to have excellent validity when compared to 3D motion capture kinematics during single-leg squatting and landing (25), excellent intra and intertester reliability (26) and strong reliability when assessing real time versus video analysis of singleleg squat (27), sensitivity to change in response to exercise (28) and has been used as a screening tool to prospectively assess for ACL injury.

The scoring sheet used for the QASLS tool is shown in Figure 2 and examples of appropriate and inappropriate movement strategies in Figure 3.

The primary goal of rehabilitation of a patient following ACLR is to prevent disruption to the graft, the secondary goals being to reduce the incidence of the significant comorbidities of patellofemoral joint pain and both tibiofemoral and patellofemoral joint degeneration (osteoarthritis). The least important initial goal would appear to be the return to sport, as if the first two goals are achieved a successful return to sport is more likely, whereas if those issues are not addressed a successful return to sport is highly

Table 3: Technique training reloading paradigm (I. Horsley, 2015)

Specific capability markers Return to sport-specific training criteria

Internal limb loadingcontrol optimisation

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Unilateral load acceptance/control under load

Sport-specific task training

Unrestricted sportsspecific training

unlikely. This contention is strongly supported in the literature with less than 50% of patients successfully returning to sport (in non-elite sports) and the primary reasoning identified is ongoing knee symptoms and fear of reinjury of the knee (29).

Reducing injury to the ACL Griffin et al. (30) have recommended several strategies which may be useful in prevention of ACL injuries: nS pecific training programmes that enhance body control Training needs to involve not just limb but whole body technique analysis and error correction. nT raining and conditioning programmes for male and female athletes even in the same sport may need to be different Males and females are likely to have gender specific deficiencies for example males may have relatively stronger quadriceps and lack strength within the posterior chain musculature, whereas females may lack eccentric quadriceps strength.

These require different conditioning programmes. n I dentification of sport-specific atrisk motions and positions Cutting and change of direction issues may predominate in some sports, whereas landing is the central problem causing ACL injury in others. nD evelopment of strategies for activating protective neuromuscular responses when at-risk situations are encountered Once trained in optimal landing and movement strategies, athletes become very good at ‘passing the test,’ what is less clear is how these movement skills transfer in to sport-specific tasks. Rehabilitation must include sport-specific tasks being carried out in an open skill manner in a random environment to truly mimic the competitive sporting environment.

Laible and Sherman (31) presented a combination of risk factors (Table 1) and technique flaws (Table 2) that could lead to non-contact ACL injuries.

The risk factors could be regarded as Co-Kinetic journal 2016;68(April):12-17

Physical Therapy MSK diagnosis, Treatment, Rehabilitation

intrinsic to the individual and how they influence the way they move, whereas the technique flaws are the way the individual enacts more dynamic movement tasks.

Further to this, insufficient neuromuscular control during dynamic movements has been suggested to be a major factor in both primary (8,32) and secondary (post-surgical) (33) ACL injury risk. During various landing and cutting tasks excessive knee abduction moments (8) and frontal plane trunk displacement (32) have both been predictive of ACL injury. Paterno et al.

(33) found these motion asymmetries and poor movement strategies persisted even following return to sport and were highly predictive of secondary ACL injury. It becomes clear that if the clinician is wishing to reduce injury to the ACL whether that is the native ACL or the reconstructed graft, the processes are likely to be similar, as the risk factors for ‘injury’ are essentially going to be the same.

The first element in reducing the risk of injuring the ACL is to address those risk factors related to the ability to move appropriately. Muscle strength and work capacity deficiencies in the key muscles of the quadriceps, gluteals and foot supinators must be addressed, along with any deficits in the ‘core’ musculature. Range of motion at the ankle and tibia (knee) will need improving along with proprioception and joint position deficits. Once these basic building blocks are in place then the athlete can begin to work on the technique of moving. The schematic for progressive reloading of the patients and development of movement skill are shown in Table 3 and Figure 4.

Loading is initiated with developing internal limb load control; simply, that is undertaking closed chain exercises such as single-leg squats, step-ups, etc., with appropriate limb alignment control. These are carried out initially in a closed skill block practice manner, ie. high repetition with minimal variation, so the high repetition builds tolerance to load gaining capacity to undertake the task appropriately while fatigued.

The patient then starts working on load acceptance, which involves landing on the leg with appropriate alignment.

Initially, this may involve bilateral Co-Kinetic.com

landing progressing to unilateral landing, starting in the sagittal then progressing to frontal and transverse plane landings. These landings start in a closed block manner and progress to open practice: for instance, varying the direction of landing within the practice to fully random, where the participant has to respond to random landing task demands. The full description of this progression paradigm can be found in Herrington and Comfort (34).

Once load acceptance has been mastered and developed into repetitive plyometric activities, then sport-specific aligned tasks can be incorporated. Many different sports have a forward stephop as a key movement skill; the initial rehabilitation aim would be to achieve good alignment carrying out the task.

Then, depending on the sport, this task may be progressed in different direction: a basketball or netball player may land onto the leg and have to simultaneously raise their arms to block a shot or pass (or shoot or pass themselves), a tae kwon do player may have to land and raise a leg to kick an opponent or an arm to block a kick. The practitioner needs then to incorporate sports aligned tasks into these basic movement patterns.

Conclusion Whether aiming to prevent ACL injury or rehabilitate an athlete following ACL reconstruction the fundamental goal of the interventions undertaken are the same: prevent ACL injury. As the most significant modifiable factor in ACL injury is neuromuscular control, developing neuromuscular control in these individuals is, therefore, going to be of paramount importance. In order to develop improved neuromuscular control, the skills must be developed in a progressive manner, which builds from

Closed skill block practice

Open skill block practice

Open skill random

Load tolerance

Capacity building

Performance under fatigue

Figure 4: Technique training within task-progression paradigm (I. Horsley, 2015)

foundations of appropriate strength and flexibility, through internal limb alignment control to landing and cutting skill. By developing these neuromuscular control skills the risk of damage to the ACL is likely to be mitigated as much as possible.

Further resources 1. Herrington L, Myer G, Horsley I. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport 2013;14:188–198.

2. Herrington L, Comfort P. Training for prevention of ACL injury: incorporation of progressive landing skill challenges into a program. Strength and Conditioning Journal 2013;35(6):59–65.

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references http://spxj.nl/21DMQpf

As the most significant modifiable factor in ACL injury is neuromuscular control, developing neuromuscular control in these individuals is therefore going to be of paramount importance 15

THE AUTHORS Dr Ian Horsley MSc PhD, MCSP MMACP CSCS is currently the lead physiotherapist for the English Institute of Sport (North West), and a technical lead. He completed his PhD in 2013 which investigated the intrinsic causes of shoulder injuries within the rugby tackle. He is an associate lecturer at Salford University lecturing on the Sports Rehabilitation MSc, working with Lee Herrington, and continuing upper limb and lower limb research.

Email: ian.Horsley@eis2win.co.uk Twitter: @back_in_action LinkedIn: https://uk.linkedin.com/pub/ian-horsley/14/48b/50b Website: www.eis2win.co.uk Dr Lee Herrington MSc PhD, MSCP CSCS qualified as a chartered physiotherapist in 1990 from Manchester University, having previously completed a degree in Human Biology from Loughborough University. In 1996 Lee was awarded an MSc in Sports Injury and Therapy from Manchester Metropolitan University. He has also been certified by the National Strength and Conditioning Association (USA) as a strength and conditioning specialist and by the Cincinnati Sports Medicine Research and Education foundation as a Sportsmetrics™ trainer (http://sportsmetrics.org).

Currently, Lee is a lecturer in Sports Rehabilitation at the University of Salford and has links with the Manchester Metropolitan University, Prince Faisal Sports Medicine Hospital in Saudi Arabia as well as being a member of the international advisory board to the Journal of Physical Therapy in Sport.

He has worked with elite sportspersons for the last 15 years including time with Great Britain Rugby League and Wigan Warriors Rugby League Club, amongst others.

Lee’s specialist areas of clinical interest are the treatment and rehabilitation of sports injuries, specifically patellofemoral joint pain and rehabilitation following knee surgery (principally ACL and complex ligament reconstruction).

Email: leehphysio@gmail.com Twitter: @leehphysio

Related content o-Kinetic content relating to ACL injury C http://spxj.nl/1U0sGaj CL reconstruction in elite sport - Fisic Conference A Video Presentation 2015 (12 mins) - http://spxj.nl/1kORouh ACL repair - is there a role? - Fisic Conference Video Presentation 2015 (15 mins) - http://spxj.nl/1kOS9nd ACL tears and reconstruction in children and adolescents - Fisic Conference Presentation 2015 (11 mins) - http://spxj.nl/1RvrRTQ Untreated ACL rupture and future osteoarthritis: does surgery change the risk and treatment of ACLdeficiency in the arthritic knee? - Fisic Conference Video Presentation 2015 (17 mins) - http://spxj.nl/1kOYFtT

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Key Points nA nterior cruciate ligament (ACL) injuries are one of the most devastating knee injuries sustained while participating in sport. n Most ACL injuries occur during non-contact running, jumping and landing tasks, with inadequate neuromuscular control of the lower limb during these manoeuvres considered a likely cause of injury. n Because of the task-dependant nature of ACL injury, tools to assess neuromuscular control are of paramount importance to the clinician both for defining risk of injury and during rehabilitation. n The qualitative analysis of single-leg squat (QASLS) tool for scoring single-leg loading compares favourably with the gold-standard technique of 3D motion capture kinematics. n The primary goal of rehabilitation of a patient following ACLR is to prevent disruption to the graft. n The secondary goals of rehabilitation are to reduce the incidence of the significant comorbidities of patellofemoral joint pain and both tibiofemoral and patellofemoral joint degeneration (osteoarthritis). n Training and rehabilitation requires the identification of sport-specific at-risk motions and positions, and strategies for activating protective neuromuscular responses when these situations are encountered. n Development of neuromuscular control skills mitigates the risk of damage to the ACL.

Discussions What’s the point of ACL reconstruction?

Does rehabilitation add any value beyond getting the patients fitter and stronger?

Want to share on Twitter?

Here are some suggestions Tweet this: Female athletes have a higher incidence of ACL tear than males – estimated to be as much as 8 to 9 times greater. http://spxj.nl/1iIS8kC Tweet this: Most ACL injuries occur during non-contact running, jumping and landing tasks. http://spxj.nl/1iIS8kC Tweet this: Inadequate neuromuscular control of the lower limb is considered the most likely cause of ACL injury. http://spxj.nl/1iIS8kC Tweet this: The primary goal of rehabilitation of a patient following ACLR is to prevent disruption to the graft. http://spxj.nl/1iIS8kC Tweet this: The first aspect in reducing ACL injury is to address the risk factors related to the ability to move appropriately. http://spxj.nl/1iIS8kC Tweet this: The development of neuromuscular control skills mitigates the risk of damage to the ACL as much as possible. http://spxj.nl/1iIS8kC

Co-Kinetic journal 2016;68(April):12-17

Client advice handout

Anterior cruciate ligament injury Overview ©2011 Primal Pictures Ltd

The anterior cruciate ligament (ACL) is a strong ligament which runs diagonally through the middle of your knee. It prevents the thigh bone (femur) from sliding out in front of the shin bone (tibia) and also gives rotational stability to the knee, especially when you twist or turn.

It is one of the most commonly injured ligaments, particularly among people playing sport and it’s usually damaged when you slow down very quickly, change direction rapidly or land incorrectly from a jump. Damage can also happen through direct contact or collision, such as a football tackle. It’s commonly injured during sports such as football (soccer), rugby, basketball, netball and skiing.

Treatment ACL reconstruction is usually the treatment of choice for people who wish to return to a relatively high level of sporting activity, have an active job, or where the knee regularly ‘gives way’ and feels unstable. It may also be recommended if you are at risk of osteoarthritis in later life or if you have other damage to your knee.

The reconstruction can improve the stability and function of your knee and usually involves using a graft from a tendon in another part of your leg such as the hamstring or patella tendons.

Not everyone with an ACL tear will need an operation to repair it.

Sometimes physiotherapy, exercises and a hinged knee brace to give your knee support will be all that’s required.

This is likely to be the case if your knee is stable or you have only a partial instead of complete tear of the ligament and you don’t need to play high-level sport or place significant strain on your knee.

Immediate post-operative care For immediate pain relief, over-the-counter painkillers such as paracetamol or ibuprofen are recommended.

You can also apply ice packs or bags of frozen peas to your knee to help reduce any pain and swelling. Don’t apply ice directly to your skin but wrap the ice or ice pack in a damp cloth or towel to prevent ice burns on your skin.

Tibia bone

ACL Meniscus

View looking down the tibia with the main thigh bone (femur) removed

Rehabilitation Regardless of whether your treatment involves surgery or not, rehabilitation will play an essential role in getting you back to your normal daily life. A physical therapy programme will focus on helping you regain knee strength and with that both movement and stability.

If you do have surgery, the early stages of your physical therapy will focus on returning movement to the joint and surrounding muscles. This will be followed by a strengthening programme designed to protect the new ligament. The final phase of the rehabilitation should be focused on the functional demands of the sport or activity that you are returning to.

It usually takes about 6 months to make a full recovery from ACL reconstruction; however, this is very dependent on the individual and how closely you follow the advice of your therapist.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or

as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors accept no liability for any loss, Co-Kinetic.com injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use by any person of the contents of this article. http://spxj.nl/1iIS8kC ©Co-Kinetic 2016

Produced by

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References 1. Hewett T, Di Stasi S, Myer G. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine 2013;41:216–224 2. Ardern CL, Webster KE, et al. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. British Journal of Sports Medicine 2011;45(7):596–606 3. Hui C, Salmon LJ, et al. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for “isolated” anterior cruciate ligament tear. The American Journal of Sports Medicine 2011;39(1):89–98 4. Leys T, Salmon L, et al. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. The American Journal of Sports Medicine 2012;40(3):595–605 5. Spindler KP, Huston LJ, et al. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study.

The American Journal of Sports Medicine 2011;39(2):348–359 6. Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. The Journal of Gender-Specific Medicine 2001;4:25–34 7. Wojtys EM, Huston LJ, et al. Gender differences in muscular protection of the knee in torsion in size-matched athletes.

Journal of Bone & Joint Surgery (Am) 2003;85-A(5):782–789 8. Hewett TE, Myer GD, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American Journal of Sports Medicine 2005;33(4):492–501 9. Souryal TO, Freeman TR. Intercondlyar notch size and anterior cruciate ligament injuries in athletes. A prospective study. The American Journal of Sports Medicine 1993;21:535–539 10. Hashemi J, Chandrashekar N, et al.

The geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint. The Journal of Bone & Joint Surgery (Am) 2008;90(12):2724– 2734 11. Uhorchak JM, Scoville CR, et al. Risk factors associated with noncontact injury of the anterior cruciate ligamentea prospective four-year evaluation of 859 West Point cadets. The American Journal of Sports

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Medicine 2003;31(6):831–842 12. Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: A 13-year review. American Journal of Sports Medicine 2005;33(4):524–530 13. Boden BP, Dean GS, et al. Mechanisms of anterior cruciate ligament injury.

Orthopedics 2000;23:573–578 14. Finestone A, Milgrom C, et al. Overuse injuries in female infantry recruits during lowintensity basic training. Medicine & Science in Sports & Exercise 2008;40(11):S630– S635 15. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the mechanism. British Journal of Sports Medicine 2009;43(6):417–422 16. Krosshaug T, Nakamae A, et al.

Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases. The American Journal of Sports Medicine 2007;35(3):359–367 17. Dierks TA, Manal KT, et al. Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. Journal of Orthopaedic & Sports Physical Therapy 2008;38(8):448–456 18. Myer GD, Ford KR, et al. The incidence and potential pathomechanics of patellofemoral pain in female athletes.

Clinical Biomechanics 2010;25(7):700– 707 19. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy 2009;39(1):12–19 20. Koga H, Nakamae A, et al. Mechanisms for noncontact anterior cruciate ligament injuries knee joint kinematics in 10 injury situations from female team handball and basketball. American Journal of Sports Medicine 2010;38(11):2218–2225 21. Olsen O, Myklebust G, et al. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. American Journal of Sports Medicine 2004;32(4):1002–1012 22. Berns GS, Hull ML, Patterson HA. Strain in the anteromedial bundle of the anterior cruciate ligament under combination loading. Journal of Orthopaedic Research 1992;10(2):167–176 23. Markolf KL, Burchfield DM, et al.

Combined knee loading states that generate high anterior cruciate ligament forces. Journal of Orthopaedic Research

1995;13(6), 930–935 24. Munro A, Herrington LC, Carolan M. Reliability of 2-dimensional video assessment of frontal-plane dynamic knee valgus during common athletic screening tasks. Journal of Sport Rehabilitation 2012;21:7–11 25. Herrington L, Munro A. A preliminary investigation to establish the criterion validity of a qualitative scoring system of limb alignment during single leg squat and landing. Journal of Exercise, Sports & Orthopedics 2014;1(3):1–6 26. Almangoush A, Herrington L, Jones R. A preliminary reliability study of a qualitative scoring system of limb alignment during single leg squat. Physical Therapy and Rehabilitation 2014;1:2 http://dx.doi.org/10.7243/2055-2386-1-2 27. Dawson SJ, Herrington LC. Improving single-legged squat performance: comparing 2 training methods with potential implications for injury prevention. Journal of Athletic Training 2015;50(9):doi:10.4085/10626050-50.9.03 28. Dawson S, Herrington L. Intra and intertester reliability of a qualitative scoring system of limb alignment during single leg squat when analysed in real time and remotely on video. Journal of Sports Rehabilitation (in press) 29. McCulloch A, Phelps K, et al. High school and college level football after anterior cruciate ligament reconstruction: a Multicentre Orthopaedic Outcomes Network (MOON) cohort study. The American Journal of Sports Medicine 2012;40:2523–2529 30. Griffin LY, Angel J, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategy. Journal of the American Academy of Orthopaedic Surgeons 2000;8(3):141–150 31. Laible C, Sherman O. Risk factors and prevention strategies of non-contact anterior cruciate ligament injuries. Bulletin of the Hospital for Joint Diseases 2014;72(1):70–75 32. Zazulak B, Hewett T, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiological study. The American Journal of Sports Medicine 2007;35:1123–1130 33. Paterno M, Schmitt L, et al.

Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate reconstruction and return to sport. The American Journal of Sports Medicine 2010;38:1968–1978 34. Herrington LC, Comfort P. Training for Prevention of ACL injury. Strength and Conditioning Journal 2013;35:59–65.

Co-Kinetic journal 2016;68(April):12-17

Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration®: part 3

By Jason Masek The facts MA PT, ATC CSCS Femoroacetabular impingement (FAI) PRC is a recently understood hip condition, which is believed to contribute to osteoarthritis (OA) of the hip (1–6).

Evidence continues to mount and this association has led to a great deal of concentration in diagnosis and treatment of FAI. The treatment goal is to decrease the mechanical contact between the acetabular edge and the femoral neck (7,8). Increased recognition of FAI and its possible contribution to early OA of the hip over the past several decades has led to advancements in hip arthroscopy to manage FAI. The goal of surgical treatment of FAI, a condition caused by abnormal femoral and acetabular structure, is to try to recreate normal anatomic structure in an attempt to halt the process of mechanical damage.

The goal is to restore left AF IR lower-limb | hip | 16.04-Co-Kinetic FORMATS WEB MOBILE PRINT

ARTICLE WEB LINKS Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration®: part 1 http://spxj.nl/1AMWG0F

Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration®: part 2 http://spxj.nl/1GtFGZJ

Hruska Clinic website http://www.hruskaclinic.com/

Postural Restoration Institute website http://www.posturalrestoration.com/

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This article is Part 3 in a series about femoroacetabular impingement (FAI). The author describes management considerations of lumbo-pelvic-femoral dysfunction in relation to FAI. This will allow the reader to apply Postural Restoration Institute® non-manual techniques when managing such conditions as FAI. Read this online http://spxj.nl/1UOchSC This is accomplished by rounding the femoral head–neck junction, reducing excessive acetabular rim or reorienting the acetabulum, and/or repairing the acetabular labrum (9–14).

It is estimated that over 1 million total hip replacements [also known as total hip arthro-plasty (THA)] are performed worldwide each year (15), and in the United States of America alone it is predicted that between 1995 and 2020 an additional 19 million people a year will be affected by arthritis (16). In the United Kingdom, it is estimated that 91% of initial hip replacements are due to osteoarthritis (17). In the USA more than 310,000 THAs were performed in 2010, and in the United Kingdom about 80,000 are performed annually (18). In the UK, the number of THAs performed will have increased by 40% by 2021, with the greatest proportional increase across the middle ages and very elderly (19).

The number of hip replacements performed in the USA has increased considerably, and the procedure has become more common in younger individuals. The number of THAs tripled for the 55–64-year-old age group from 2000 to 2010, whereas the procedures increased by 205% (from 138,000 to

nearly 311,000) for those aged 45–54, according to the United States Centers for Disease Control (20). By 2030, the demand for primary THAs is estimated to grow by 174% to 572,000 (21,22).

But the number of THA performed on younger adults is increasing and it is estimated that the total number will grow dramatically over the next few years. The percentage of THAs being performed on patients younger than 60 is about 40% and in increasing steadily (23,24).

The predicament The increasing incidence of THA, particularly among younger patients, warrants the need for further study and understanding regarding the underlying causes and mechanisms related to FAI and the progression of OA. Furthermore, the advancements in hip arthroscopy have seemed to overshadow advances in more conservative medical management of FAI. Currently, surgery is considered the first line of treatment with respect to FAI (25–27), with an increased popularity of the arthroscopic approach seen in the last decade: an 18-fold increase in hip arthroscopy among American Board of Orthopedic Surgery candidates noted between 1999 and Co-Kinetic journal 2016;68(April):18-25

Physical Therapy MSK Diagnosis, Treatment, Rehabilitation

2009 (28). Despite advances in hip arthroscopy, there is still a discussion in the literature regarding an effective non-surgical treatment to manage FAI. The better we understand the underlying causes and mechanisms of FAI, the better we will be capable of developing earlier interventions. All too often we fail with conservative treatment, and patients with hip OA progress to total joint arthroplasty.

Surgery can successfully reduce symptoms caused by FAI; however, not all FAI can be completely fixed by surgery alone.

So the greater the magnitude of FAI, the more one is predisposed to developing hip OA; logic would seem to impose the influence of biomechanical changes on OA and its progression.

Faulty joint mechanics is often the underlying cause of development and progression of pathologies such as hip OA. Although information is available for arthroscopic and post-operative management of labral tears, FAI and hip instability (29–34), there is limited research regarding applicable nonsurgical intervention for those with suspected labral tears and/or FAI. Greater attention is needed regarding the important role of mechanical factors related to FAI to potentially prevent or delay OA-related surgery (35). As we continue to become more aware of FAI and its influence on OA, interventions that attempt to normalise lumbo-pelvic-femoral alignment and to correct joint movement may be beneficial to help guide non-operative interventions.

Potential considerations FAI is a mechanical problem that requires a mechanical solution.

Although surgical options have developed considerably to reduce or prevent further joint degeneration, restore structural anatomic abnormalities and eliminate biomechanical factors (9,36–38), there is still a lack of information regarding FAI pathomechanics. It is reasoned that correcting the underlying mechanical pathology in FAI will help delay the progression of hip arthritis (39).

Although hip pathomechanics appears to account for FAI symptoms and Co-Kinetic.com

provide awareness of the development of therapeutic approaches for FAI, there is a lack of biomechanically based treatments with proven effects on both structure and pain. Furthermore, there is limited theoretical information that has been applied in a manner that provides understanding or offers a foundation for clinical decision making regarding the biomechanics that may

Figure 1: Hruska’s left anterior interior chain (left AIC) pattern of the pelvis. (J. Masek, created by sportEX, 2014)

have caused the hip pathology.

There is a basic belief among Postural Restoration® clinicians that structural imbalances and asymmetry in the body can result in painful musculoskeletal conditions such as FAI. Postural Restoration® is based on neuromuscular patterns that may have an undesirable influence on muscle function and structural alignment, potentially imposing abnormal mechanical stresses upon the musculoskeletal system. Use of Postural Restoration® manifests clinically in the form of structural and biomechanical assessments which attempt to resolve these structural factors. It is believed that the misalignments impose excessive stress on the lumbo-pelvic-femoral complex leading to degeneration or dysfunction and eventual THA. Part 1 (http://spxj.nl/1AMWG0F) of this series discussed the patterns of pelvic asymmetry about the pelvic

With the tendency for anterior tilt and forward rotation of the left hemi-pelvis, the position of the pelvic girdle orients the pelvic girdle to the right causing a shift in one’s centre of gravity to the right. The pelvic girdle is directed into a stancelike AF IR position on the right and AF ER position on the left. (J. Masek, 2014)

Figure 2: Left AIC pattern. (J. Masek, created by sportEX, 2014)

(a)

(b)

(c)

(a) Right hemi-pelvis positioned posteriorly, adducted, and internally rotated with right compensatory femoral internal rotation. Left hemi-pelvis positioned anteriorly, abducted and externally rotated with left compensatory femoral external rotation. (b) Right hemi-pelvis positioned posteriorly, adducted, and internally rotated with right femur orientated outwardly. Left hemi-pelvis positioned anteriorly, abducted and externally rotated with left femur orientated inwardly. (c) Right hemi-pelvis positioned anteriorly, abducted and externally rotated with right compensatory femoral external rotation. Left hemi-pelvis positioned posteriorly, adducted, and internally rotated with left compensatory femoral internal rotation.

Figure 3: Left AIC and the effect on the pelvis and femur positioning. (J. Masek, 2015)

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girdle. Emphasis was placed on the arthrokinematics of the left and right acetabular-femoral (AF) and femoralacetabular (FA) joints (40). Postural imbalances between the left and right sides of the pelvis predispose the pelvic girdle to various pathomechanics.

Part 2 (http://spxj.nl/1GtFGZJ) of this series discussed the myokinematics and osteokinematics of the pelvic girdle of a left anterior interior chain (left AIC)patterned individual and how postural asymmetries between the left and right sides of the lumbo-pelvic-femoral complex may directly have an influence and/or predispose the individual to hip impingement (41). Part 2 also proposed

two common types of hip impingement; anterosuperior acetabular-femoral impingement (ASAF) and anteromedial femoral-acetabular impingement (AMFA) similar to the traditional cam and pincer types used in traditional orthopaedic literature (42).

The relationship between an underlying postural pattern of asymmetry and pathomechanics of the lumbo-pelvic-femoral complex was discussed in the preceding articles. Altered hip joint biomechanics and excessive joint loading have long been considered as important contributors to the development and progression of hip OA. Therefore, a

better understanding of how various treatment options influence the loading environment of the hip joint could have practical implications for devising more effective management strategies. As a follow-up to the previous articles, this article will demonstrate nonmanual techniques designed to resolve mechanical factors contributing to FAI. The aim of this article is to allow the application of biomechanical recommendations supporting the use of Postural Restoration® intended to restore against excessive joint loading while offering symptomatic relief and functional improvements for better long-term management of patients with hip FAI.

Postural Restoration® management considerations

90–90 hip lift with hip shift

1. Lie on your back with your feet flat on a wall and your knees and hips bent at a 90° angle.

2. Place a 10–15cm ball between your knees.

3. Inhale through your nose and exhale through your mouth, performing a pelvic tilt so that your tailbone is raised slightly off the mat.

Keep your back flat on the mat.

4. As you maintain a hip lift, shift your left hip down and your right hip up so that your right knee is slightly above the left.

5. Slowly take your bent right leg on and off the wall so that your right thigh comes toward your chest. You should feel the muscles behind your left thigh and left inner thigh engage.

6. Perform 3 sets of 10 repetitions, 1–2 times a day.

Figure 4: Exercise for left AF IR with concomitant left FA IR. (Postural Restoration Institute, 2015. Image used with permission)

Side-lying respiratory scissor slides

1. Lie on your right side with your hips and knees bent at a 90° angle, and place a ball between your knees.

2. Press your right foot slightly into the wall.

3. Inhale through your nose and gently slide your left leg back without letting your trunk rotate back.

4. Exhale through your mouth as you gently push your left knee down into the ball.

5. Inhale again and slide your left leg back further.

6. Exhale and squeeze into the ball again.

7. Repeat this sequence until you have taken a total of 4–5 breaths, in through your nose and out through your mouth.

8. Relax and repeat 4 more times.

Figure 5: Exercise for left AF IR with concomitant left FA IR. (Postural Restoration Institute, 2015. Image used with permission)

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Muscles that provide movement and control of the lumbo-pelvic-femoral complex have the ability to perform in more than one plane. The motion of the FA joint occurs in three planes: sagittal, frontal and transverse, with the greatest motion occurring in the sagittal plane (43). A thorough understanding of functional anatomy and movement patterns of the kinetic chain are critical for the effective evaluation and treatment an individual with FAI. As individuals with FAI often experience symptoms involving repetitive twisting motions, quick accelerating motions, squatting and changes in direction, treatment should address threedimensional movements throughout all three planes (sagittal, frontal and transverse). Improper mechanics as a result from injury and/or adaptations to repeated movements will most likely contribute to an undesirable asymmetrical state.

In the previous articles, anterosuperior acetabular-femoral impingement (ASAF) and anteromedial femoral-acetabular impingement (AMFA) were described (40,41). The subsequent management considerations for these conditions have been proposed by the Postural Restoration Institute® (42,44,45).

Left AIC An individual with a left AIC pattern will demonstrate an anterior tilt and Co-Kinetic journal 2016;68(April):18-25

Physical Therapy MSK Diagnosis, Treatment, Rehabilitation

Right side-lying supported left gluteus medius exercise 1. Lie on your right side with your feet on a wall, hips and knees at a 90° angle and your back rounded.

2. Place your lower arm or a pillow under your head and upper hand on the floor in front of you to help stabilise your trunk.

3. Place a 10–15cm ball between your knees.

4. Push your right foot into the wall.

5. Slide or shift your left hip back as far as you can without arching your back.

6. Press your left knee down into the ball. You should feel your left inner thigh engage.

7. Rotate your left thigh ‘in’ by lifting your left lower leg towards the ceiling. You should feel your left outside hip (buttock) engage.

8. Hold this position for 4–5 deep breaths, inhaling through your nose and exhaling through your mouth.

9. Relax and repeat 4 more times.

Figure 6: Exercise for left AF IR with concomitant left FA IR. (Postural Restoration Institute, 2015.

Image used with permission)

Left side-lying resisted right gluteus maximus exercise 1. Lie on your left side with your hips and knees bent at a 60–90° angle.

2. Place your ankles on top of a 7.5–12.5cm bolster and place your feet firmly on a wall.

3. Place tubing around both thighs slightly above your knees.

4. Shift your right hip forward until you feel a slight stretch or pull in your left outside hip.

5. Keeping your feet on the wall, raise

your right knee keeping it shifted forward. You should feel your right outside hip (buttock) engage.

6. Hold this position while you take 4–5 deep breaths, in through your nose and out through your mouth.

7. Relax and repeat 4 more times.

Figure 7: Exercise for left AF IR with concomitant right FA ER. (Postural Restoration Institute, 2015; image used with permission.)

Retro stairs exercise 1. Stand with your heels placed in front of 15cm stairs and point your toes forward.

2. Advance your left foot on the first step keeping your feet neutral or parallel with each other.

3. Shift your hip back and to the left as you place your weight through your left mid-foot/heel. Your zipper line should be lined up over your left great toe. Keep your left knee pulled in slightly.

4. Keep your back rounded.

5. Begin lifting your right leg to the step keeping your weight shifted over to the left. You should be using your left leg to advance yourself to the next step by pushing slowly through your left mid-foot/heel.

6. Continue to advance up the stairs until you have completed 1 flight always leading with your left foot. You should feel your left outer hip (buttock) engage.

7. Relax and perform 1–2 more flights (10–12 steps).

Figure 8: Single-leg dynamic stance with left AF IR and concomitant left FA IR. (Postural Restoration Institute, 2015; image used with permission.)

Co-Kinetic.com

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Left side-lying, supported left flexed FA adduction with right extended FA abduction 1. Lie on your left side with your right leg straight and your left leg bent at a 60° angle. Your right shoulder, hip, knee and ankle will be lined up.

2. Place 2–3 pillows under your head so that your head is slightly side-bent to the right.

3. Place your left foot on a 5–7.5cm bolster with your foot pressing into the wall and a small bolster underneath your left side.

4. Slightly raise your left knee off of the floor by turning your thigh ‘in’ or by pushing your left foot into the wall and using it as a pivot point. You should feel your left inner thigh and left outer hip (buttock) engage.

5. Keep your left knee raised from the floor and turn your right leg in.

6. Attempt to take your right foot off of the wall. You should feel your right outside hip (but-tock) engage.

7. Hold this position while you take 4–5 deep breaths, in through the nose and out through the mouth.

8. Relax and repeat 4 more times.

Figure 9: Left AF IR with concomitant left FA IR and right FA abduction. (Postural Restoration Institute, 2015; image used with permission.)

Supine hook-lying resisted right gluteus maximus exercise 1. Lie on your back and place your feet on a 5cm block against the wall.

2. Place a band around your knees and a ball between your ankles.

3. Inhale through your nose and exhale through your mouth, performing a pelvic tilt so that your tailbone is raised slightly off the mat.

Keep your back flat on the mat.

4. Maintaining a pelvic tilt, shift your left knee down below the level of your right. You should feel your left inner thigh engage.

5. Keeping your left inner thigh engaged and your right foot flat on

the block, turn your right knee out.

You should feel your right outside hip (buttock) engage.

6. Hold this position while you take 4–5 breaths, in through your nose and out through your mouth.

7. Relax and repeat 4 more times.

Figure 10: Exercise for left AF IR with concomitant right FA ER. (Postural Restoration Institute, 2015; image used with permission.)

Standing supported right gluteus maximus exercise with resisted left proximal hamstring and left knee flexion 1. Anchor tubing around a stable structure and place the other end around your left thigh.

2. Place a 6.5–12.5kg ankle weight around your left ankle.

3. Place your hands on the surface in front of you and round your back.

4. Turn your right foot in at a 45° angle. Maintaining contact with your right shoe arch, shift your body weight onto your right leg. Do not lock your right knee straight, rather keep it slightly bent.

5. Hike your left leg up as if you were pulling your left foot out of mud.

You should feel your left inner thigh and your right outside hip (buttock) engage.

6. Slightly pull back your left leg without using your back.

7. Keeping your left thigh pulled back, slightly bend your left knee. You should feel the back of your left thigh engage.

8. Hold this position while you take 4–9.

Relax and repeat 4 more times.

Figure 11: Exercise for right AF ER with left AF IR (Postural Restoration Institute, 2015; image used with permission.)

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Co-Kinetic journal 2016;68(April):18-25

Physical Therapy MSK Diagnosis, Treatment, Rehabilitation

Standing wall supported left knee flexion exercise with resisted right gluteus maximus 1. Stand with your feet shoulder-width apart and tubing around your knees.

2. Place your right foot flat on the wall behind you.

3. Shift your right knee down and side-bend your trunk to the left.

4. Maintaining the above position, press your right foot/arch into the wall and rotate your right knee out against the resistance of the band. You should feel the muscles on the out-side of your right hip (buttock) engage.

5. Keeping your right knee turned out, begin to squat down by bending your left knee. Place your right hand on the wall for stability. You should feel the muscles on the front of your left thigh and left outer hip (buttock) engage.

6. Hold this position while you take 4–5 deep breaths, in through your nose and out through your mouth.

7. Relax and repeat 4 more times.

Figure 12: Exercise for left AF IR with concomitant right FA ER (Postural Restoration Institute, 2015; image used with permission.)

Standing supported left AF IR exercise with resisted right FA abduction 1. Place your left foot on a 5–15cm step. Keep your weight through your left mid-foot/heel.

2. Place a band around both of your ankles.

3. Place your left foot on the first step and position it slightly behind your right foot.

4. Shift your left hip back and bend your left knee as you pull your left knee in slightly. You should feel the muscles on your left outer hip (buttock), left inner thigh and the front of your left thigh engage.

5. Side-bend your trunk to the left, feeling your left abdominals engage.

6. Maintaining the above position, raise your right foot off the floor and turn your right an-kle out to the side finding contact with your right shoe arch.

7. Slowly squat down by bending your left knee as you bring your right foot out to the side, always keeping your right foot lower than your left.

8. You should feel your left outside hip (buttock), left inner thigh, front of your left thigh and your right outside hip (buttock) engage as you ‘dip’ your right foot down and out to the side.

9. Hold this position while you take 4–5 deep breaths, in through your nose and out through your mouth.

10. Relax and repeat this sequence 4 more times.

Figure 13: Single-leg dynamic stance exercise for left AF IR with concomitant left FA IR and right FA abduction. (Postural Restoration Institute, 2015; image used with permission.)

forward rotation of the left hemi-pelvis (Fig. 1). As a result of this position, the individual will usually demonstrate weakness and lengthening of specific muscles in all three planes. Muscles that provide movement and control of the lumbo-pelvic-femoral complex have the ability to perform in more than one plane. Symmetry is restored when recruitment of specific muscles is engaged between the left and right side of the body. Individuals with a left AIC pattern who are positioned in a state of right acetabular-femoral Co-Kinetic.com

internal rotation (AF IR) and left acetabular-femoral external rotation (AF ER) will most likely demonstrate the following myokinematic relationships: the left hemi-pelvis is positioned in a state of flexion, abduction and external rotation; the right hemi-pelvis is positioned in a state of extension, adduction and internal rotation (Fig. 2). It is desirable that every effort is made to restore proper acetabular-femoral position in all three planes.

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All effort is made to restore acetabularfemoral position in all three planes

on the right. The right hemi-pelvis has become positioned posteriorly in the sagittal plane, adducted in the frontal plane, and internally rotated in the transverse plane. From a Postural Restoration® perspective it is the intent to restore the left hemi-pelvis into a state of left AF IR and the right hemi-pelvis to a state of right AF ER. Along with restoring pelvic position, femoral compensatory activity is reduced so that there is normal femoral internal rotation on the left and femoral external rotation on the right (Fig. 3).

Anterosuperior acetabular-femoral impingement

Individuals who have acquired left AIC pattern lose the ability to perform active AF IR on the left and active AF ER on the right. Therefore, compensatory activity of the femur as it relates to acetabular position occurs. With regards to a left AIC non-compensatory patterned pelvis, the femurs would orientate themselves inwardly on the left and outwardly on the right, secondary to the passively orientated position of the respective acetabulum. In other words, the left acetabulum is rotating forward on an internally rotated positioned femur and compensatory femoral external rotation on an inwardly orientated positioned acetabulum has to occur for forward progression. Likewise, the right acetabulum is rotating backward on an externally positioned femur and compensatory femoral internal rotation on an outwardly orientated positioned acetabulum also has to occur for forward progression.

The left hemi-pelvis has become positioned anteriorly in the sagittal plane, abducted in the frontal plane, and externally rotated in the transverse plane. Left lumbo-pelvic-femoral muscles (such as the hamstrings, left gluteus medius, and left ischiocondylar adductor) have lost their optimal mechanical advantage/leverage to correctly function. The reverse is true 24

An individual with a left AIC pattern will demonstrate an anterior tilt and forward rotation of the left hemi-pelvis (42,44,45). As a result of this position, the individual will usually demonstrate weakness and lengthening of specific muscles in all three planes. In the sagittal plane, attention must be given to the left biceps femoris to restore pelvic position in the sagittal plane (Fig. 4). Contraction of the hamstring provides muscular opposition to the anteriorly tilted left hemi-pelvis.

In the frontal plane emphasis is placed on the left ischiocondylar adductor and the right gluteals. Shifting ones weight over the right hip results in relative adduction and internal rotation of the right hip or right AF IR and abduction and external rotation of the left hip or left AF ER. To return the pelvic girdle to a neutral state, an active contraction of the right hip abductors and/or left hip adductors is required. Recruitment of ipsilateral femoral-acetabular internal rotators with ipsilateral AF IR is required (Figs 5 & 6).

Restoration of the transverse plane requires rotational movements across the AF, FA, and lumbo-sacral joints.

The right gluteus maximus assists in obtaining femoral-acetabular external rotation (FA ER) on the right as well as orientating the sacrum to the left (Fig. 7). The left gluteus medius and ischiocondylar adductor assist in obtaining femoral-acetabular internal rotation (FA IR) on the left to allow for single-leg stance control (Fig. 8).

Anteromedial femoral-acetabular impingement Just as the case with ASAF impingement, in AMFA left biceps femoris recruitment is necessary to restore position of the pelvic girdle in the sagittal plane (Fig. 4). In the frontal and transverse planes emphasis is placed on the left adductors and the right gluteals. More emphasis is placed on the right gluteus musculature to abduct and externally rotate the femur in the acetabulum while adduction and internal rotation of the acetabulum on the femur is maintained on the left side (Figs. 9 & 10). Many skills (running, multidirectional changes, kicking) are performed entirely or predominantly from a unilateral weight-bearing stance.

Thus single-leg dynamic stance activities that incorporate right AF ER with left AF IR are necessary (Figs 11–13).

Conclusion In summary, the recognition, diagnosis, and management of FAI continue to evolve. As the body of evidence expands, so too does our collective understanding of FAI. FAI may be associated with muscular imbalance and, therefore, careful examination of flexibility and strength of important muscles about the lumbo-pelvic-complex is vital to understanding the root cause of impingement and prescribing effective treatment. The Postural Restoration Institute’s® approach to muscular imbalance suggests a possible neuromuscular component to functional impingement due to the predisposition to innate anatomical asymmetries as well as certain muscles being tight or weak.

The literature fails to substantiate that imbalances in the lumbo-pelvic-femoral complex are present in patients with FAI. Furthermore, it also fails to differentiate structural imbalances in regards to the left and right sides of the body.

Although structural impingement sometimes requires surgical intervention, the mechanical factors leading up to the surgery need to be addressed in order to decrease the undue stress and potential compensatory mechanisms upon the anatomic structures of the lumbopelvic-femoral complex. Successful treatment of FAI related to muscular Co-Kinetic journal 2016;68(April):18-25

Physical Therapy MSK Diagnosis, Treatment, Rehabilitation

imbalances is often accomplished by addressing the cause of the problem rather than symptomatic treatment of the pain. It is beyond the scope of this article to fully explain how to treat an individual with a left AIC pattern; however, these three articles should provide the reader with a better appreciation of how the arthrokinematics and myokinematics

of the left and right lumbo-pelvicfemoral complex are interrelated and influence the management of FAI. By understanding muscle imbalances associated with FAI, clinicians knowledgeable in Postural Restoration Institute® concepts can prescribe appropriate techniques for both treatment and prevention.

The Author Jason Masek MA, PT ATC CSCS PRC completed his degree in Physical Therapy from Des Moines UniversitytOsteopathic Medical Center in Des Moines, Iowa, USA. He received his athletic training experience from the University of Nebraska-Lincoln and the University of Minnesota. Jason currently practices at the Hruska Clinic™ Restorative Physical Therapy Services in Lincoln, Nebraska, USA. Jason has developed a strong background in sports medicine and athletic injuries with an emphasis in manual physical therapy. He is a member of the National Athletic Trainers Association, the National Strength & Conditioning Association. Jason has earned the designation of Postural Restoration Certified (PRC) as a result of advanced training, extraordinary interest and devotion to the science of postural adaptation, asymmetrical patterns and the influence of polyarticular chains of muscles on the human body as defined by the Postural Restoration Institute® in Lincoln, Nebraska, USA. Email: jason@hruskaclinic.com Twitter: @HruskaClinic Facebook: Hruska Clinic https://www.facebook. com/Hruska-Clinic-Inc-Restorative-Physical-TherapyServices-194642157232915/

References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the references http://spxj.nl/1RdyskR

Discussions hich muscle restores pelvic position in the sagittal W plane?

Which muscle is the most important muscle when treating AMFA impingement?

Surgery corrects the anatomical structures resulting from FAI but does it correct the mechanical issues leading up to the surgery?

Related content o-Kinetic content relating to FAI C http://spxj.nl/22dnOTN Postural restoration of femoroacetabular impingement Parts 1, 2 and 3 https://co-kinetic.com/profile/18 Femoroacetabular impingement in athletes (FAI) Fisic Conference Video Presentation 2015 (11 mins) http://spxj.nl/1RbLC4d Decision making in surgery for FAI - Fisic Conference Presentation 2015 (13 mins) - http://spxj.nl/1kOKogQ

Key Points n ASFA and AMFA require different management considerations. n Femoral-acetabular and acetabular-femoral mechanics are restored with the use of Postural Restoration® techniques. n There is an increasing incidence of arthroscopic and total hip arthroplasty across the USA and UK. n FAI is a mechanical problem that requires a mechanical solution. n Misalignments impose excessive stress on the lumbo-pelvic-femoral complex leading to impingement and eventually total hip arthroplasty. n Treatment should address movements in all three planes: sagittal, frontal and transverse. n Improper mechanics as a result from injury and/or adaptations to repeated movements will most likely contribute to an undesirable asymmetrical state. n Individuals who have acquired a left AIC pattern lose the ability to perform active AF IR on the left and active AF ER on the right.

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Here are some suggestions Tweet this: Femoroacetabular impingement (FAI) is a recently understood hip condition, believed to contribute to osteoarthritis http://spxj.nl/1UOchSC Tweet this: Not all FAI can be completely fixed by surgery alone. http://spxj.nl/1UOchSC Tweet this: Greater attention to the role of mechanical factors related to FAI is needed to prevent or delay OA-related surgery. http://spxj.nl/1UOchSC Tweet this: Correcting the underlying mechanical pathology in FAI will help delay the progression of hip arthritis. http://spxj.nl/1UOchSC Tweet this: An individual with a left AIC pattern will demonstrate an anterior tilt and forward rotation of the left hemi-pelvis. http://spxj.nl/1UOchSC Tweet this: It is desirable that every effort is made to restore proper acetabular-femoral position in all three planes. http://spxj.nl/1UOchSC Tweet this: Individuals with left AIC pattern lose the ability to perform active AF IR on the left and active AF ER on the right. http://spxj.nl/1UOchSC

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References 1. Anderson SE, Klaus SA, Moritz T. Femoroacetabular impingement: evidence of an established hip abnormality. Radiology 2010;257(1):8–13 2. Beck M, Kalhor M, et al. Hip morphology influences the pattern of damage to the acetabular cartilage. Femoroacetabular impingement as a cause of early osteoarthritis of the hip. Journal of Bone & Joint Surgery (Br) 2005;87:1012–1018 3. Ganz R, Parvizi J, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research 2003;417:112–120 4. Giori NJ, Trousdale RT. Acetabular retroversion is associated with osteoarthritis of the hip. Clinical Orthopaedics and Related Research 2003;417:263–269 5. Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clinical Orthopaedics and Related Research 2004;429:170–177 6. Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. Journal of Bone & Joint Surgery (Am) 1999;81(12):1747–1770 7. Murphy S, Tannast M, et al. Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clinical Orthopaedics and Related Research 2004;429:178–181 8. Philippon MJ, Schenker ML, et al. Revision hip arthroscopy. American Journal of Sports Medicine 2007;35:1918–1921 9. Lavigne M, Parvizi J, et al. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery.

Clinical Orthopaedics and Related Research 2004;418:61–66 10. Beaulé PE, Allen DJ, et al. The young adult with hip impingement: deciding on the optimal intervention. Journal of Bone & Joint Surgery (Am) 2009;91:210–221 11. Espinosa N, Rothenfluh DA, et al. Treatment of femoroacetabular impingement: preliminary results of labral refixation. Journal of Bone & Joint Surgery (Am) 2006;88:925–935 12. Martin HD, Kelly BT, et al. The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Arthroscopy 2010;26:161–172 13. Byrd JW, Jones KS. Arthroscopic femoroplasty in the management of camtype femoroacetabular impingement. Clinical Orthopaedics and Related Research 2009;467:739–746 14. Espinosa N, Beck M, et al. Treatment of femoroacetabular impingement: preliminary results of labral refixation. Surgical technique.

Journal of Bone & Joint Surgery (Am) 2007;89(Suppl. 2, Pt.1):36–53 15. Bulstrode C, Wilson-MacDonald J, et al.

Oxford Textbook of Trauma and Orthopaedics, Oxford University Press 2011. ISBN 978-0199550647 (£331.75). Buy from Amazon http://spxj.nl/20WT0Rh 16. Iorio R, Robb WJ, et al. Orthopaedic

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surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic.

Journal of Bone & Joint Surgery (Am) 2008;90(7):1598–1605 17. National Joint Registry for England, Wales and Northern Ireland. 11th Annual report 2014 http://spxj.nl/1oCH8rb. Part two including data on clinical activity. National Joint Registry 2014. ISSN 2054-183X (Online) 18. National Joint Registry for England and Wales. 9th Annual Report 2012 http://spxj.nl/1UmJTcs. National Joint Registry 2012. ISSN 1745-1450 (Online) 19. Birrell F, Johnell O, Silman A. Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery. Annals of the Rheumatic Diseases 1999;58(9):569–572 20. Wolford ML, Palso K, Bercovitz A. Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–201. National Center for Health Statistics (NCHS) Data Brief 2015;186 http://spxj.nl/1QA2j3L 21. Kurtz S, Ong K, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Journal of Bone & Joint Surgery (Am) 2007;89(4):780–785 22. Nho SJ, Kymes SM, et al. The burden of hip osteoarthritis in the United States: epidemiologic and economic considerations.

Journal of the American Academy of Orthopaedic Surgeons 2013;21(Suppl 1):S1–6 23. Liu XW, Zi Y, et al. Total hip arthroplasty: a review of advances, advantages and limitations. International Journal of Clinical and Experimental Medicine 2015;8(1):27– 36 24. Daras M, Macaulay W. Total hip arthroplasty in young patients with osteoarthritis. American Journal of Orthopedics 2009;38(3):125–129 25. Emara K, Samir W, et al. Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery 2011;19(1):41–45 26. Freeman CR, Azzam MG, Leunig M. Hip reservation surgery: surgical care for femoroacetabular impingement and the possibility of preventing hip osteoarthritis.

Journal of Hip Preservation Surgery 2014;1(2):46–55 27. Hunt D, Prather H, et al. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM & R 2012;4:479–487 28. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. Journal of Bone & Joint Surgery (Am) 2012;94(4):e23 29. Bedi A, Chen N, et al. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient.

Arthroscopy 2008;24:1135–1145 30. Byrd JW. The role of hip arthroscopy in the athletic hip. Clinics in Sports Medicine 2006;25(2):255–278, viii

31. Enseki KR, Martin R, Kelly BT. Rehabilitation after arthroscopic decompression for femoroacetabular impingement. Clinics in Sports Medicine 2010;29:247–255 32. Enseki KR, Martin RL, et al. The hip joint: arthroscopic procedures and postoperative re-habilitation. Journal of Orthopaedic & Sports Physical Therapy 2006;36:516– 525 33. Philippon MJ. New frontiers in hip arthroscopy: the role of arthroscopic hip labral repair and capsulorrhaphy in the treatment of hip disorders. Instructional Course Lectures 2006;55:309–316 34. Sekiya JK, Martin RL, Lesniak BP. Arthroscopic repair of delaminated acetabular articular cartilage in femoroacetabular impingement. Orthopedics 2009;32(9):doi:10.3928/0147744720090728-44 35. Yazbek PM, Ovanessian V, et al.

Nonsurgical treatment of acetabular labrum tears: a case series. Journal of Orthopaedic and Sports Physical Therapy 2011;41(5):346–353 36. Bedi A, Kelly BT. Femoroacetabular impingement. Journal of Bone & Joint Surgery (Am) 2013;95(1):82–92 37. Leunig M, Robertson WJ, Ganz R. femoroacetabular impingement: diagnosis and man-agement, including open surgical technique. Operative Techniques in Sports Medicine 2007;15(4):178–188 38. Matsuda DK, Hanami D. Hip arthroscopy for challenging deformities: posterior cam de-compression. Arthroscopy Techniques 2013;2(1):45–49 39. Brandt KD, Dieppe P, Radin EL. Etiopathogenesis of osteoarthritis. Rheumatic Disease Clinics of North America 2008;34:531–559 40. Masek J. Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration: part 1. sportEX medicine 2015;64:10–18 41. Femoroacetabular impingement mechanisms, diagnosis and treatment options using Postural Restoration: part 2. sportEX medicine 2015;65:18–23 42. Hruska RJ. Impingement and instability http://spxj.nl/1mZwoSL). Postural Restoration Institute course manual 2014.

43. Nordin M, Frankel VH. Basic biomechanics of the musculoskeletal system (4th edn).

Lippincott Williams and Wilkins 2012. ISBN 978-1451117097 (Kindle £38.94 Print £40.99). Buy from Amazon http://spxj.nl/1S3uAVP 44. Hruska RJ. Myokinematic restoration: an integrated approach to treatment of lower half musculoskeletal dysfunction http://spxj.nl/1TGNUcn. Postural Restoration Institute course manual 2014 45. Hruska RJ. Advanced integration http://spxj.nl/1LHEkON. Postural Restoration Institute course manual 2014.

Co-Kinetic journal 2016;68(April):18-25

Understand how radial shockwave therapy can help in rehabilitation of musculoskeletal disorders This article discusses the role that the relatively new treatment modality of radial shockwave therapy (RSWT) can play in rehabilitation of musculoskeletal disorders.

The study presents empirical evidence on the benefits of RSWT in the short term for treating lower limb injuries as measured by perceived reduction in pain and increased functional mobility. This article highlights how effectively RSWT can be used in the early treatment of musculoskeletal disorders and the importance and continued use of traditional rehab modalities following RSWT. You can test your knowledge of the subject using our elearning assessment and include the resulting certificate in your CPD portfolio, as well as print out our professionally produced client advice handout to give to your patients. Read this online http://spxj.nl/1RCFBOo

By Dr Lance Doggart MEd PhD, Andrew Burden BSc and Sarah Catlow PGCE MSc 16-04-co-kinetic | lower limb FORMATS WEB MOBILE PRINT

Media contents YouTube video ‘enPuls – High energy radial shockwave therapy’. Courtesy of YouTube user ZimmerMedizinSysteme. http://spxj.nl/1TCU2kC Client handout: Information about radial shockwave therapy (online leaflet for printing) http://spxj.nl/1pcUuKX Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1RCFBOo

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Introduction Lower limb injury can impact heavily on quality of life particularly in terms of functional mobility. By introducing exercise early in the rehabilitation process a quicker return to activity may be possible (1). Maximising or regaining functional mobility following injury is a key goal of therapeutic intervention and early rehabilitation is paramount in preventing time lost in competitive sport or physical activity.

Radial shockwave therapy (RSWT) emerged from orthopaedic medicine and has quickly become established within mainstream clinical practice as a non-invasive treatment modality. The therapeutic application of shockwaves to musculoskeletal tissues is a modality that has the potential to treat an expanding range of musculoskeletal pathologies (2). The therapy is widely acclaimed to be effective in the treatment of many musculoskeletal disorders as it can shorten a period of treatment and can produce a powerful analgesic effect (3). RSWT emits pulses of energy targeted at damaged tissues to stimulate increases in local blood flow, cellular regeneration and in the reduction of pain. Although the therapeutic effect of RSWT has been reported, most research evaluates the modality using subjective pain scales and focuses on the analgesic outcomes following treatment (4).

There has been limited research measuring the short-term neuromuscular performance outcomes following RSWT (5). For this reason research that evaluates short-term functional mobility outcomes during and immediately after RSWT may be beneficial to the practitioner. Such research could provide practitioners and patients with valuable information for consideration during a course of RSWT and inform post-treatment aftercare. It could also contribute to the

longer term rehabilitation of an injury following RSWT. As such, empirical research and evidence around the functional outcomes of RSWT could inform clinicians and patients about the choice of treatment modality and respective treatments following RSWT.

Aim The aim of this study was to evaluate the effect of a short course of RSWT on the functional mobility of patients presenting with lower limb injury.

Method Twenty participants (n = 20) with a lower limb injury for which a course of RSWT was appropriate were recruited to take part in the preliminary study.

Participants were from a population of patients attending two clinics providing treatment and rehabilitation for life-style or sports musculoskeletal injuries. The participants had a broad range of pathologies with causations not limited to a sporting activity. A control group (n = 10) received a course of ‘conservative’ treatments while the experiment group (n = 10) were treated with a standard course of RSWT. The ‘lower extremity functional scale’ (LEFS) questionnaire was used as a selfreporting tool to record each patient’s assessment of their functional mobility at three stages during the course of treatment (before, during and after).

The experimental group received RSWT using either a BTL-5000 SWT Power, or a Storz Medical MP100 Ultra radial shockwave device by therapists trained and experienced in the use of this equipment. The application parameters of all RSWT treatments were patient dependent and administered according to manufacturer guidelines. The control group were given a range of therapeutic modalities in their treatment plan according to the

Co-Kinetic journal 2016;68(April):26-29

physical therapy Current Trends in Sports Medicine

tABLE 1: LEFS questionnaire scores for control group across the treatment periods (L. Doggart, A. Burden, S. Catlow, 2015) Participant

LEFS score after LEFS score before LEFS score before second treatment course of treatment treatment (Stage 3) (Stage 2) (Stage 1)

1

61

75

75

2

68

69

75

3

72

76

80

4

22

67

69

5

32

25

20

6

38

69

69

7

67

66

64

8

54

58

64

9

65

57

62

10

41

41

50

Mean

52.0

60.3

62.8

Standard deviation

5.53

5.08

5.44

LEFS, lower extremity functional scale

individual patient including therapeutic ultrasound, manual therapy (massage), transcutaneous electrical nerve stimulation (TENS) and mechanotherapy (exercises including eccentric stretching and loading).

Following informed consent, and University ethical approval, all participants were managed through

a thorough clinical assessment and systematic examination to reach a clinical diagnosis. Patients were screened to confirm they had a lower limb injury that met the inclusion criteria for the research study indicating suitably for RSWT. Patients who presented with contraindications to the treatment were eliminated.

Table 2. LEFS scores for the experimental group across the treatment periods.

(L. Doggart, A. Burden, S. Catlow, 2015) Participant

LEFS score after LEFS score before LEFS score before second treatment course of treatment treatment (Stage 3) (Stage 2) (Stage 1)

1

55

60

64

2

23

55

69

3

47

55

59

4

41

55

71

5

45

63

62

6

60

66

69

7

57

70

74

8

46

54

60

9

59

62

63

10

54

73

77

Mean

48.7

61.3

66.8

Standard deviation

10.91

6.75

6.03

LEFS, lower extremity functional scale

Co-Kinetic.com

Radial shockwave therapy (RSWT) emerged from orthopaedic medicine and has quickly become established within mainstream clinical practice as a noninvasive treatment modality The LEFS questionnaire was completed for each participant to gather baseline data on perceived functional mobility, referred to as ‘Stage 1’. The patient was then treated according to their individual treatment plan and the modalities according to their respective group. Patients for whom RSWT was contraindicated were offered conservative therapeutic modalities as an alternative to RSWT and formed part of the control group.

This process of delivering the LEFS questionnaire was repeated at the second appointment 7–10 days after the first treatment, referred to as ‘Stage 2’ and again at 7 days following the second treatment (Stage 3). The timing of this intervention was guided by the RSWT manufacturer treatment parameters that indicated the frequency of treatments within 5–10 days (6).

An analysis of the data collected, via the LEFS questionnaire, was undertaken using a one-way repeated measures analysis of variance (ANOVA,) across the three data collection stages. The differences before, during and after treatment, within and across each group were compared.

Results The 20-question LEFS measures the participant’s perceived level of functional mobility, across a number of day to day activities, on a revised Likert Scale (7). The scale ranges from 0 (extreme difficulty or unable to perform the activity) to 4 (no difficulty in doing the activity). The higher the score the less difficult the activity is as perceived by the participant.

Table 1 indicates a 10.8 score 27

difference from Stage 1 to Stage 3 of the treatment period for the control group. The treatment, therefore, had a positive effect on the mobility of the participants in the control group.

However, statistical analysis revealed no significant change in perceived mobility as measured by the LEFS (P > 0.05) across the three stages.

The experimental group reported an 18.1 point difference between Stages 1 and 3 of the RSWT treatment period (Table 2). This difference was noted as a significant improvement across the three stages of treatment (P < 0.05).

Post-hoc analysis noted that significant changes were seen between all the stages of the treatment period suggesting significant improvement in perceived mobility, from Stage 1 to Stage 2 and Stage 2 to Stage 3.

Figure 1 shows a graphical comparison of the LEFS scores between the two groups.

Discussion and clinical implications Based on the LEFS perceived scores, the data from the experimental group suggest that a course of RSWT significantly improved levels of functional mobility for patients with lower limb injury. The largest reported improvements in functional mobility were noted after the first treatment in both groups (experimental = 32.9% improvement compared to 28.5% improvement in the control group).

At Stage 3, the RSWT group mean

LEFS score (points)

70

61

53

44 Control group 35

Stage 1

Experimental group

Stage 2

Stage 3

Treatment stage Figure 1: Mean LEFS scores for the control and experiment groups across the treatment period. LEFS, lower extremity functional scale. (L. Doggart, A. Burden, S. Catlow, 2015)

28

score indicates that functional mobility improved by a further 9.53% (from Stage 2), whereas the control group showed only a small gain of 3.5%.

Over the full course of treatment for both groups, the mean reported improvement in functional mobility for patients receiving RSWT was 47.5%, compared with a value of 33.3% for those receiving conservative physical therapy. For participants receiving RSWT, the overall mean LEFS score improved by 18.1 points which was twice the value for the control group participants.

There are various factors that could be responsible for the initial gains in functional mobility followed by a gradual tapering of improvement. In this study the RSWT group reported an improvement in functional mobility over the course of the three treatments and that the initial gain was sustained at almost every stage. This suggests an accumulative progression in gains of functional mobility and mirrors the accumulative analgesic effect of multiple RSWT treatments reported by Takahashi et al. (8). Furthermore, Furia et al. concluded that one application of RSWT in the treatment of patella tendinopathy was effective (4). The implication of the findings is that RSWT is highly likely to lead to a perception of increased functional mobility above that perceived through usual treatment modalities.

Clinical application The clinical significance of this study surrounds not only the speed at which functional mobility is perceived to improve but the magnitude of that improvement. RSWT appears to lead to quicker short-term increases in functional mobility and that improvement occurs at an earlier stage in a course of treatment than is otherwise widely reported. This rapid gain in functional mobility was also reported by Avancini-Dobrović et al., who in treating calcific tendinitis with RSWT measured statistically significant improvements in both range of motion and in muscle strength (9).

This increased functional mobility from RSWT may give the clinician and patient the opportunity to introduce early mechano-therapeutic activities,

to potentially load tissue earlier and even possibly during the RSWT course of treatment. There is strong contemporary emphasis on active rehabilitation following injury and the use of therapeutic interventions that use mechano-transduction principles to load musculoskeletal tissue (10). Early functional mobility following an injury facilitates the beneficial aspects of early tissue loading such as advancing collagen synthesis and tissues, particularly tendons, respond favourably (11,12). The proposition of using RSWT in union with exercise-based rehabilitation is highlighted by Leeuwen et al., who suggest the analgesic element of the treatment influences the functional improvement (13).

Conclusion Based on the findings of this preliminary study, RSWT has an effect on perceived functional mobility as reported by patients with lower limb injury. RSWT may not wholly replace the established effective therapies, however, the use of RSWT to obtain quicker gains in functional mobility, specific to lower limb injury, at an early stage of treatment may well allow the patient to engage with a carefully managed rehabilitation plan enabling mechano-therapeutic intervention and the earlier resumption of activity.

The results of this study could inform patient and clinician awareness of the rapid potential improvements in functional mobility that can occur following RSWT treatment.

References 1. Abrahamson E, Hyland V, et al. Progressive systematic functional rehabilitation.

In: Comfort P, Abrahamson E (eds.)

Sports rehabilitation and injury prevention. Wiley–Blackwell 2010.

ISBN 978-0470985632 (Kindle £38.12 Print £36.97). Buy from Amazon http://spxj.nl/1OAdzib 2. Rozenblat M. Shockwave therapy in sports medicine, pp.895–899.

In: Doral MN, Tan-dogan RH, et al., (editors) Sports injuries: prevention, diagnosis, treatment, and rehabilitation. Springer 2012.

ISBN 978-3642156298 (Kindle £171 Print £180). Buy from Amazon http://spxj.nl/1QBER61 3. Notarnicola A, Moretti B. The biological effects of extracorporeal shock wave therapy (ESWT) on tendon tissue. Muscles,

Co-Kinetic journal 2016;68(April):26-29

physical therapy Current Trends in Sports Medicine

Ligaments and Tendons Journal 2012;2(1):33–37 4. Furia J, Rompe J, et al. A single application of low-energy radial extracorporeal shock wave therapy is effective for the management of chronic patellar tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy 2012;21(2):346–350 5. Lohrer H, Nauck T, et al. Comparison of radial versus focused extracorporeal shock waves in plantar fasciitis using functional measures. Foot & Ankle International 2012;31(1):1–9 6. BTL. BTL-5000 SWT Series service user guide. BTL Medical Technologies 2008 101PL01/12/2008EN 7. Binkley J, Stratford P, et al. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Physical Therapy 1999;79(4):371–383 8. Takahashi N, Ohtori S, et al. Second application of low-energy shock waves as a cumulative effect on free nerve endings.

Clinical Orthopaedics and Related Research 2006;443:315–319

9. Avancini-Dobrović V, Frlan-Vrgoč L, et al. Radial extracorporeal shock wave therapy in the treatment of shoulder calcific tendinitis. Collegium Antropologicum 2011;35(2):221–225 10. Khan K, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine 2009;43(4):247–252 11. Heiderscheit C, Sherry M, et al. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention.

Journal of Orthopaedic & Sports Physical Therapy 2010;40(2):67–81 12. Mangine B, Rauch J, Middendorf W. Physiologic factors in rehabilitation, Chapter 2. In: Andrews JR, Harrelson GL, Wilk KE. (eds) Physical rehabilitation of the injured athlete (4th edn). Elsevier 2012. ISBN 9781437724110 1. (Kindle £74.8 Print £78.75) Buy from Amazon http://spxj.nl/1VILkAI 13. Leeuwen J, Zwerver J, van den AkkerScheek I. Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature. British Journal of Sports Medicine 2009;43(3):163–168.

Key Points n Use of radial shockwave therapy (RSWT) results in a greater rate of improvement early in the treatment and rehab process. n Use of RSWT causes a greater magnitude of improvement early in the treatment and rehab process. n The LEFS questionnaire is an objective, valid and reliable method of obtaining patient perceived improvement in the treatment and rehab process. n The LEFS questionnaire could be adapted to provide feedback on different aspects of a treatment and a rehab process specific to the nature of the injury. n Combining RSWT with traditional treatments could be effective and important in the rehab process. n Obtaining patients’/clients’ views on the perceived effectiveness of treatment is an important aspect in the rehab process. n The use of patient feedback and views in comparing treatments can be beneficial for future approaches to the rehab process. n The rate and magnitude of the improvement in functional mobility, following a course of RSWT, will allow the clinician to use mechanotherapeutic modalities earlier in the rehab process.

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research that evaluates shortterm functional mobility outcomes during and immediately after RSWT may be beneficial to the practitioner The Authors Dr Lance Doggart MEd PhD graduated in 1992 with a BSc (Hons) Sport Science from Liverpool Polytechnic (now Liverpool John Moores University). As a research assistant he completed a PGcert in teaching and learning in Higher Education in 1996 and completed a PhD in 2002 on the biomechanics of sports injuries. Lance moved to Plymouth and the University of St Mark and St John in 2001. In 2012 he completed an MEd focusing on the role of the student feedback process. The development of the very successful Sports Therapy and Rehabilitation degrees at the University of St Mark and St John has led his research down the path of Kinesiology tape and predominantly the material properties associated with the tape in relation to injury prevention and rehabilitation.

Email: ldoggart@marjon.ac.uk LinkedIn: https://www.linkedin.com/pub/lance-doggart/52/49b/275 Andrew Burden BSc is a Sports Therapy graduate from the University of St Mark and St John. He is currently studying for an MSc in Medical Ultrasound.

Sarah Catlow PGCE MSc is the programme leader of the Sports Therapy and Rehabilitation degrees at the University of St Mark and St John. The development of these degrees and her clinical work has led her research into the area of Kinesiology tape and the material properties linked to the application of tape in a clinical setting.

Discussions What is the optimal number of treatments for RSWT? What is the physiology behind the effect of the energy impulses?

Why do the energy impulses work so quickly with a relatively high impact?

What are the long-term benefits of using RSWT rather than traditional treatments?

Related content Shockwave therapies for sports injuries http://spxj.nl/1eAa9zg

29

How to support your athletes to thrive under pressure by tipping the balance This article outlines a practical and evidence-based framework that shows individuals who support athletes how to promote positive responses to performance pressure. The ability to deal with pressure is one of the most important things an athlete can develop, and in this article I introduce, explain and practically demonstrate the concept of ‘tipping the balance’. This concept offers simple and effective strategies for enabling your athletes to react well to pressure, bringing together contemporary research evidence and practical experience. Use the certificated elearning assessment as proof of continuing professional development along with the group chat topics as a way of consolidating your understanding and sharing this knowledge with your colleagues. Read this online http://spxj.nl/1iISurh

By Dr Martin J. Turner PhD CPsychol. HCPC Reg

Background As Steve Waugh (inducted into the International Cricket Council Hall of Fame in 2010) intimates in the quote below, thriving under pressure is a vital skill for any athlete performing under the high

psychology | 16.04-Co-Kinetic FORMATS WEB MOBILE PRINT

Media contents Continuing education quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1iISurh

Article weblinks Sport psychology website: The Smarter Thinking Project. www.thesmarterthinkingproject.com Naughton P. Stress appraisal: challenge vs threat http://spxj.nl/21piThY. Believe website, 2013.

30

demands of elite sport. Understandably then, psychology research has strived to understand how pressure influences performance, and of course, how athletes can better cope with pressure when competing. Prominent psychology literature suggests that athletes can react in one of two ways when approaching important competitions: in a challenge state or in a threat state. A challenge state is associated with superior athletic performance compared to a threat state (1), a finding demonstrated across a variety of sports including baseball (2), cricket (3), and golf (4).

“I am always fascinated to watch how a guy handles a pressure situation.

Some players become animated, some train extra hard, some withdraw – but the true greats keep their self-belief, trust themselves and continue to work away, knowing that if the foundations have been established, good form will come.”

Steve Waugh, cricketer (5)

One recent framework that illuminates how athletes can approach pressure as a challenge or a threat is the ‘theory of challenge and threat states in athletes’ (TCTSA) (6). At its core, the TCTSA suggests that when facing pressure situations, athletes engage in a cognitive appraisal process where situational demands (demand appraisals) are compared to personal resources (resource appraisals), dictating a constellation of psychological and physiological responses (7). The demand appraisals comprise danger to esteem (and physical danger), required effort, and uncertainty. Competitive sport triggers demand appraisals, because performance is often evaluated by others (danger to esteem), requires great physical and mental effort (required effort), and the outcome is never certain (uncertainty). The resource appraisals comprise self-efficacy, perceived control, and achievement goals (approach vs avoidance), which are informed by a vast amount of Co-Kinetic journal 2016;68(April):30-35

physical therapy Pain, Brain and Sports Performance

psychology research literature.

If the athlete’s resource appraisals are insufficient to meet the demands, a threat state is activated, triggering a maladaptive pattern of physiological reactivity alongside debilitative emotions and cognitions. In contrast, if the athlete’s resource appraisals are sufficient to meet or exceed the demands, a challenge state is activated, triggering an adaptive pattern of physiological reactivity alongside facilitative emotions and cognitions (6).

But more importantly and ultimately, a challenge state is associated with superior athletic performance.

From the above, it is clear that in order for an athlete to fulfil their potential under pressure, a challenge state is favourable. In my recent book Tipping the Balance, co-authored with Dr Jamie Barker, I put forth a ‘map to achieving peak performance’ (MAPP) that is based on the TCTSA and a vast amount of psychology literature (8). The MAPP offers a step-by-step process for helping athletes into a challenge state. Central to the MAPP process is tipping the balance, which describes the methods by which an athlete can increase their resource appraisals in order to outweigh (exceed) their demand appraisals.

Figure 1 graphically illustrates the MAPP.

MAPP: Step 1 Step 1 ‘Performance situation’ in the MAPP concerns the athlete’s motivation to engage in a particular situation. If the situation has little relevance to the athlete, such that it is not important or engaging, then the MAPP is null and void. The MAPP only comes into play when a pressure situation is imminent (eg. competitive performance), not when the situation is unimportant (eg. routine training drill). At most levels, it is safe to assume that competition is important and motivating for the athlete and, therefore, Step 2 becomes relevant.

MAPP: Step 2 Step 2 captures the athlete’s underlying beliefs and ‘philosophy’ on success and failure. An athlete who holds the beliefs, “I must succeed at everything I do, failure is terrible, I can’t stand not meeting my standards, and I am a failure if I fail” is likely to exaggerate Co-Kinetic.com

the danger present in the situation in his or her demand appraisals.

Greater demands require even greater resources in order to cope, so a more rational philosophy is more useful. For example, an athlete who holds the belief, “I want more than anything to succeed, failure is bad, but I can stand it, and failing does not make me a failure” does not exaggerate the danger and, therefore, is more likely to meet the demands with his or her resources.

MAPP: Steps 3 and 4 Steps 3 and 4 are considered together, as this is where the balance tipping really takes place. The ‘demands’ of competition are relatively stable, depending in part on the athlete’s philosophy at Step 2. For athletes, any competition requires effort, no outcome is certain, and danger is present physically as well as to esteem. However, the ‘resources’ are vastly changeable, and can be increased and decreased continuously before a competition. This has two main implications. First, an athlete can develop their resources in order to tip the balance and get into a challenge state. This is shown in Figure 2 as a set of scales where the resources outweigh the demands. Second, if the athlete does not maintain their resources, the resources can decrease and endanger the athlete of getting into a threat state on approach to a pressure situation. Therefore, developing and maintaining high resources is crucial, and there are many strategies and techniques that athletes can apply in order to do this.

Registered). As part of PST athletes learn a range of techniques that typically draw on cognitive-behavioural approaches and can include imagery, self-talk and concentration strategies (12). In my work, I bring these together in a ‘challenge strategy’ that provides a structure to the development and maintenance of the resources.

Performance situation

Philosophy

Demands

Resources

Mind & body reactions

Self confidence: Belief in your ability to perform well in a given task Control: The extent to which performance is under your control Achievement goals: Striving to achieve or trying to avoid failure

Consequences

Figure 1: Map to achieving peak performance. (Turner MJ, Barker JB. What business can learn from sport psychology.

Bennion Kearny, 2014 ISBN 978-1909125346; reproduced with permission)

Tipping the balance: developing and maintaining resources Evidence indicates that resources are malleable (9), and more notably, can be developed using well-supported psychological strategies (10). In other words, an athlete can learn to approach pressure situations in a challenge state by working hard on their psychological skills (11). Psychological skills training (PST) is considered a vital part of athletic training and is and should be provided by qualified sport and exercise psychologists (British Psychological Society Chartered and HCPC

Demands

Resources

Figure 2: Graphic representation of ‘tipping the balance’.

(Turner MJ, Barker JB. What business can learn from sport psychology. Bennion Kearny, 2014 ISBN 978-1909125346; reproduced with permission)

31

The challenge strategy This challenge strategy is different for every athlete owing to the vast range of psychological skills that can be employed to enhance the resources.

However, below I provide some ideas for how the resources can be boosted on approach to a pressure event.

Importantly, the order in which I present the strategies within the challenge strategy are ‘layered’, allowing the skills to be successfully embedded within an athlete’s performance approach.

By layered, I mean that the strategies are presented in a specific order so as to ensure the effectiveness of the challenge strategy. The following sections draw on PST principles that I have applied in my consultancy work expressly to promote a challenge state in athletes.

Layer 1: What can I control, and when should I focus on my controllables?

Sport is a dynamic, constantly changing and unpredictable environment to work and perform in. So the idea of helping athletes to control what they can in such a volatile setting is appealing

1. Performance environment 10

0

10 9 7.8625

8 7 5.671875

6 5

4.5125

4 3 2 1 0

Performance environment

Opposition

Figure 4: Preliminary data for the control triangle. (M. Turner, 2015)

and potentially crucial for performance.

Indeed, many psychologists working in performance domains, promote the philosophy of ‘controlling the controllables’, which suggests that athletes invest time and effort into aspects of their performance they have control, or autonomy over, rather than those aspects that they do not have autonomy over. This ‘control the controllables’ philosophy is linked to the idea of taking care of processes to ensure effective performance, and even though the outcome is ultimately uncontrollable, by controlling the processes the athlete makes success more likely.

Although it is a popular philosophy, it has been much misunderstood and misrepresented. Some say that you can control everything within your grasp, but if the uncontrollable factors ultimately dictate the result, then what’s the point? Others say that if you get wrapped up too much in controlling everything internal and external to you, then you leave little room for any actual performance related planning. You become a control freak!

The control triangle 10 3. Your performance

10 2. Opposition

Figure 3: The control triangle. The control triangle has three arms concerning different aspects where an athlete’s attention can lie, ranging from zero in the centre to a maximum of 10 at the end of the arm. The athlete is asked to rate from zero to 10 how much they are focusing on a particular arm of the triangle. Hence the amount of focus being given to each element can be visualised and the athlete can be trained to refocus, if necessary, at different stages of training/competition preparation. (M. Turner, 2015. First published in the blog article ‘Controlling sport performance’ on The Smarter Thinking Project website http://spxj.nl/1T37Zty)

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Your performance

In my consultancy work, I have realised a more useful way to use the ‘control the controllables’ philosophy.

Together with Dr Carla Meijen from the University of Kent, I have developed the ‘control triangle’ that asks not “How much control do I have within my performance environment and have I controlled everything I can control?” but rather asks, “What controllables am I focusing on in the lead up to a performance?” This shift towards

a control triangle offers a simple and usable strategy for enhancing an athlete’s perceived control in performance situations, necessary for a challenge state (6). The control triangle can be seen in Figure 3, and more can be read in my blog post ‘Controlling sport performance’ http://spxj.nl/1T37Zty on The Smarter Thinking Project website.

In short, the higher the score on each tip, the higher the focus on that element. Directly before competition, athletes should be focused on what they can control – specifically, they should score highly on the ‘Your performance’ element. In the days before the event, it is OK that athletes focus on the other two elements.

It is necessary to think about the ‘Performance environment’ to consider any constraints or allowances of a performance venue. It is also necessary to focus on the ‘Opposition’ for tactical reasons, but also because thinking about who you will face prepares the mind for the encounter. But in the changing rooms, directly before performance, the most productive element for an athlete to focus on is their performance, as it is the only aspect completely controllable by them.

Visiting all areas on the triangle should be part of an athlete’s preparation for performance over a typical week. But when performance looms and it is time to switch on to the competition, a laser-like focus should be fixed on the controllables for that performance.

Indeed, preliminary data suggest that in the hour before a performance, athletes (n = 32) prefer to focus more on their Co-Kinetic journal 2016;68(April):30-35

physical therapy Pain, Brain and Sports Performance

performance, rather than the opposition or performance environment (Fig. 4).

Layer 2: The ‘big first three’ key performance indicators “Concentrate all your thoughts upon the work at hand. The sun’s rays do not burn until brought to a focus.”

Alexander Graham Bell, inventor of the first practical telephone (13) So, it is better for an athlete to focus on what they can control specifically in the moments prior to pressure performance. But there is a whole host of controllables that they could lament on prior to a competition. Therefore, encouraging them to focus on three things they want to do in the opening moments of the competition can simplify their approach. Importantly, and as discussed above, these three things should be controllable by the athlete as part of their performance.

Also, by having a specific focus going into the performance and making that focus about something they can do, they remove the likelihood of unwanted thoughts and distractions.

An approach focus is vital for getting into a challenge state (6), and research suggests that having an approach focus is related to challenge appraisals (14) and challenge physiological responses (15). An approach focus is about focusing on success, instead of focusing on failure or potential loss (avoidance focus). This can be difficult to achieve because as performance looms, anxiety increases (16), which can trigger unwanted negative thoughts, which can lead to an avoidance focus. So it is important that athletes have a strategy for making sure they are approach focused prior to competing. One effective way of doing this is by using the ‘big first three’ strategy.

The ‘big first three’ strategy is inspired by work I completed with Professor Marc Jones while we were consulting with a rubgy player, who wanted an effective way to find his rhythm at the start of a match. It fundamentally involves two steps.

First, the athlete decides what key performance indicators (KPIs) they need to achieve to ensure an effective performance. It is important that these Co-Kinetic.com

KPIs are controllable by the athlete, as discussed in the previous section, and of course that they are achievable and realistic. It is pointless having unachievable, fairy-tale KPIs, as this will be a waste of focus for any athlete (attention is, after all, a finite resource).

Second, the athlete decides which of the KPIs are achievable in the opening moments of a competition. These opening moments can differ across sports, but in football for example, it might be the first 5 minutes of a half, whereas in tennis it might be the opening game (different KPIs for serving vs returning serve). Once an athlete has arrived at their big three, they should ask themselves the following four questions: 1. I s each one necessary for performing well?

2. I s each one achievable early on in the performance?

3. Is each one controllable by me?

4. I s each one focused on approach goals?

They should aim to answer ‘yes’ to all four questions. For example, some ‘big first three’ targets, recommended for a tee shot on the first hole in the past, have been: 1. N ice assertive body language on the tee box 2. P ositive decision making where you are aiming your shot 3. F lowing execution of your pre-shot routine.

All are an important part of performing well. All are achievable early on in a round of golf. All are controllable by the athlete. All are focused on doing something rather than avoiding something. Athletes find the ‘big first three’ useful in three ways. First it provides them with a focus on what they can control. Second, once they have met these KPIs they find momentum, because the meeting of the KPIs gets them off to the start they want and they can find their rhythm.

Third, because the ‘big first three’ are achievable, thinking about them before the competition helps to install self-efficacy for their performance. The third point here is crucial. It is known that self-efficacy is a key predictor of effective performance (17) and,

therefore, strategies that can enhance self-efficacy are essential.

Layer 3: Pre-competition visualisation “I never hit a shot, not even in practice, without having a very sharp, in-focus picture of it in my head…

First I see the ball where I want it to finish, nice and white and sitting up high on the bright green grass…

I see the ball going there, its path, trajectory, and shape, its behaviour on landing … the next scene shows me making the kind of swing that will turn the previous images into reality.”

Jack Nicklaus, golfer (18) Now the athlete has determined what is controllable and how to focus on those aspects prior to performing, and has distilled this focus into the ‘big first three’. But one strategy that can boost this approach further is the use of imagery (as used by Jack Nicklaus) to increase self-efficacy concerning the KPIs and in essence operationalises the ‘big first three’. Evidence suggests that imagery is an effective strategy for promoting a challenge state [eg.

Williams and Cummings (10)] and is considered a vital source of selfefficacy (19). Imagery can involve rehearsing skills and performances in the mind before they actually take place. Although the mechanisms for the effectiveness of imagery are still under debate, broadly, by imagining competitive situations as realistically as you can (including sights, sounds, and feelings), the brain starts to respond in a similar way to if you were actually facing a competitive situation. If you are able to ‘see’ what you would see in an actual competition, ‘hear’ the same sounds, and ‘feel’ the same things, then you can recreate the mental and physical responses that are experienced in actual competition. So the imagined feelings of control and composure will feel very real and will boost your confidence for that specific situation.

So to strengthen and affirm the focus on the ‘big first three’, those KPIs can be visualised in those moments before performance. But there is some important work that needs to take place before imagery is used to 33

support the ‘big first three’. First, the athlete must learn the skill of imagery.

Second, the athlete must develop their self-efficacy regarding the KPIs using past evidence of successfully meeting those targets. Third, the athlete needs to find time and space in which to use their imagery before performance.

1. Learning imagery The most useful resource I have found for helping an athlete to develop their imagery skills is a chapter by Vealey and Greenleaf (20) in Jean William’s book Applied Sport Psychology: Personal Growth to Peak Performance. Here, the athlete is guided through developing awareness, vividness, and controllability of their imagery. This is important because imagery is not just about seeing yourself perform in your mind before you actually do it; it is about experiencing all the senses and making the imagery as real as possible.

2. Past evidence It is important that the athlete develops ‘Visualisation ammunition’ when preparing for the ‘big first three’. This is a collection of memories that provide evidence that the athlete has in the past achieved the KPIs, thus providing efficacy that they can be achieved again. In self-efficacy theory (21) past-performance accomplishments are the most powerful source of self-efficacy, so it is important to get this stage right. This is a continuous process, which requires the athlete to reflect on performances using a diary, where over time they are able to collate and record many successful KPI attainments for use in their imagery. These memories and reflections provide ammunition for future visualisation, and also help the athlete to reflect on the right aspects of their performances, win or lose.

3. Finding time and space This is vital because it requires the athlete to plan their imagery so that they ensure it happens no matter what. This should be built in as part of a pre-performance routine that can take place at various times/ points in the lead up to competition. But the most effective time for 34

using imagery relating to the ‘big first three’ is in the changing rooms directly before performing. Therefore, the athlete needs to know exactly when they will engage in imagery as the lead up to a competition is a busy time, especially in team sports where team interactions often and importantly take precedence.

At this point in the process of preparing for performance, the athlete has ensured they are focused on what can be controlled, they have distilled this focus into the ‘big first three’ KPIs, and are using imagery to rehearse the KPIs increasing the likelihood of them actually happening.

MAPP: Steps 5 and 6 Steps 5 and 6 of The MAPP are the product of Steps 3 and 4. If the athlete is able to use the three layers to tip the balance (where resources outweigh demands), then they are likely to experience a challenge state and fulfil their potential. In our research, we found that by encouraging people to face pressure with high selfefficacy, high perceived control, and with an approach focus, a challenge state is achieved (9). More on the psychophysiological ramifications of a challenge state can be found in my blog post ‘Resilience’ http://spxj.nl/1oOBEdE on the Accredited Sports Professionals website.

Summary The MAPP offers a framework for helping athletes face competition in a challenge state, which is considered an optimal state for effective performance as suggested in the TCTSA (6).

Crucial to this is the enhancement of resource appraisals, which can be achieved using a three-layer approach to increasing self-efficacy, perceived control, and a focus on approach goals. Athletes should be guided in this strategy by sport psychologists, coaches, and support staff, to ensure that the athlete attains the most effective psychological state (challenge) for competitive performance. Tipping the balance can be achieved in many ways, and this article offers a brief insight into some of the strategies an

athlete can use. In my book Tipping the Balance (8) you can find many more strategies, techniques and ideas that can help athletes to fulfil their potential when it matters most.

Acknowledgements Thank you to Dr Carla Meijen at the University of Kent for collaborating with me on the control triangle and to Antony Miller from Staffordshire University for his efforts collecting preliminary data for the control triangle.

Further resources 1. McGonigal K. The upside of stress: Why stress is good for you, and how to get good at It. Avery Publishing Group 2015 (Kindle £9.49 Print £10.88) ISBN 9781583335611. Buy from Amazon http://spxj.nl/1T38KD1.

References 1. Turner MJ, Jones MV. Stress, emotions and athletes’ positive adaptation to sport: Contributes from a transactional perspective. In: Gomes R, Resende R, Albuquerque A (eds) Positive human functioning from a multidimensional perspective, Volume 1: promoting stress adaptation. Nova Science 2014. ASIN B00QCK4YAE (£140.89). Buy from Amazon http://spxj.nl/1R9Kycb 2. Blascovich J, Seery MD, et al. Predicting athletic performance from cardiovascular indexes of challenge and threat. Journal of Experimental Social Psychology 2004;40:683–688 3. Turner MJ, Jones MV, et al. Who thrives under pressure? Predicting the performance of elite academy cricketers using the cardiovascular indicators of challenge and threat states. Journal of Sport and Exercise Psychology 2013;35(4):387–397 4. Moore LJ, Vine SJ, et al. The effect of challenge and threat states on performance: An examination of potential mechanisms.

Psychophysiology 2012;49(10):1417–1425 5. Waugh S. Out of my comfort zone: The autobiography. Michael Joseph 2006. ISBN 978-0718148331 (£415.77). Buy from Amazon http://spxj.nl/1LkQRg9 6. Jones MV, Meijen C, et al. A theory of challenge and threat states in athletes.

International Review of Sport and Exercise Psychology 2009;2:161–180 7. Blascovich J, Mendes WB. Challenge and threat appraisals: the role of affective cues. In: Forgas JP (ed.)

Feeling and thinking: the role of affect in social cognition, pp. 59–82.

Cambridge University Press 2000. ISBN 978-0521011891 (£34.99). Buy from Amazon http://spxj.nl/1n49o4R Co-Kinetic journal 2016;68(April):30-35

physical therapy Pain, Brain and Sports Performance

8. Turner MJ, Barker JB. Tipping the balance: the mental skills handbook for athletes. Bennion Kearney 2014 (£46.97). ASIN B011MBLIMO. Buy from Amazon http://spxj.nl/1T38NPd 9. Turner MJ, Jones MV, et al. Manipulating cardiovascular indices of challenge and threat states using resource appraisals.

International Journal of Psychophysiology 2014;94:9–18 10. Williams SE, Cumming J. Challenge vs. threat imagery: Investigating the effect of using imagery to manipulate cognitive appraisal of a dart throwing task. Sport and Exercise Psychology Review 2012;8:4–21 11. Turner MJ, Barker JB. Resilience: Lessons from the 2012 Olympic Games. Reflective Practice 2013;14(5):622–631 12. Anderson M. The “Canon” of psychological skills training for enhancing performance. In: Hays KF (ed.) Performance psychology in action: a casebook for working with athletes, performing artists, business leaders and professionals in high-risk occupations, pp. 11–34. American Psychological Association 2009. ISBN 9781433804434 (Kindle £42.36, Print £46.50). Buy from Amazon http://spxj.nl/1KSaaO1 13. Alexander Graham Bell. Retrieved May 21,

2014, from Wikiquote http://en.wikiquote.org/ wiki/Alexander_Graham_Bell 14. Adie JW, Duda JL, Ntoumanis N. Achievement goals, competition appraisals, and the psychological and emotional welfare of sport participants. Journal of Sport Exercise Psychology 2008;30:302–322 15. Chalabaev A, Major B, et al. Physiological markers of challenge and threat mediate the effects of performance-based goals on performance. Journal of Experimental Social Psychology 2009;45:991–994 16. Cerin E, Szabo A, et al. Temporal patterning of competitive emotions: A critical review. Journal of Sports Sciences 2000;18:605–626 17. Weiss MR, Ferrer-Caja E. Motivational orientations in sport.

In: Horn T (ed.) Advances in sport and exercise psychology, 2nd edn, pp. 101–183. Human Kinetics 2002 (£45.00). ISBN 978-0736032988.

Buy from Amazon http://spxj.nl/1TdBNUF 18. Archived newsletters – Mental rehearsal http://spxj.nl/21pEVRE. Positive Mental Imagery, Newsletter January 2002;III(1).

Retrieved May 21, 2014 19. Maddux JE. Self-efficacy theory: an introduction. In: Maddux JE (ed.) Self-efficacy, adaptation, and adjustment: theory, research, and

Key Points n Adaptive reactions to pressure are driven by cognitive appraisal. n A challenge state is associated with superior athletic performance. n Well-researched psychological skills can promote a challenge state in athletes. n A layering of psychological skills offers the best method of helping athletes to deal with pressure. n Athletes able to tip the balance under pressure are more likely to fulfil their potential. n Athletes should develop awareness, vividness, and controllability of their imagery. Imagery is about experiencing all the senses and making the imagery as real as possible. n Body language should be assertive, decision-making should be positive, and a pre-performance routine should be executed. n High perceptions of control are vital, especially in rapidly changing and unpredictable environments such as sport.

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application (pp. 333). Springer 1995.

ISBN 978-0306448751 (Kindle £153 Print £179.50). Buy from Amazon http://spxj.nl/21z6ogn 20. Vealey R, Greenleaf C. Seeing is believing: understanding and using imagery in sports. In: Williams JM (ed.) Applied sport psychology: personal growth to peak performance, 6th edn, pp. 267–304 (£132.99).

McGraw-Hill 2009. ISBN 978-0073376530.

Buy from Amazon http://spxj.nl/1QmBqkx 21. Bandura A. Self-efficacy: the exercise of control. Worth Publishers 1997 (Kindle £110.62 Print 48.99).

ISBN 978-0716728504. Buy from Amazon http://spxj.nl/1Ll4hc0.

The Author Dr Martin J. Turner PhD CPsychol. HCPC Reg is a Lecturer in Sport and Exercise Psychology in the School of Psychology, Sport and Exercise.

He is a BPS Chartered and HCPC registered Sport and Exercise Psychologist, and an active researcher and author. His research and consultancy expertise is within performance under pressure and performance in the face of adversity.

Specifically, stress and emotion is Martin’s specialism, and in particular, how individuals can better cope with pressure situations and adversity with the use of biofeedback and Rational Emotive Behaviour Therapy.

As an applied practitioner he works across a range of sports including football, cricket, rugby, cycling, archery, shooting, and equestrian. He also provides performance psychology to business professionals, and is currently the Lead Sport Psychologist for England Futsal.

Email: m.turner@staffs.ac.uk Twitter: @DrMJTurner LinkedIn: https://uk.linkedin.com/pub/dr-martin-turner/6b/b76/828

Discussions Is it possible for an athlete to perform to their potential in a threat state?

Are some athletes able to face all pressure situations in a challenge state?

What other psychological skills could help athletes to tip the balance?

Here are some suggestions Tweet this: Athletes can react in one of two ways when approaching important competitions: in a challenge state or a threat state. http://spxj.nl/1iISurh Tweet this: The ‘theory of challenge and threat states in athletes’ illuminates how athletes can approach pressure situations. http://spxj.nl/1iISurh Tweet this: An athlete can learn to approach pressure situations in a challenge state by working on their psychological skills. http://spxj.nl/1iISurh Tweet this: It is better for an athlete to focus on what they can control specifically in the moments before pressure performance. http://spxj.nl/1iISurh

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Related content o-Kinetic content on psychology in performance and C rehabilitation - https://co-kinetic.com/tag/psychology Risk, response and recovery: Psychology of sports injury - http://spxj.nl/1cSkzcK It’s all in the mind: Psychosocial interventions to improve recovery - http://spxj.nl/1HdmLFz The psychology of return to play - Fisic Conference Video Presentation 2015 (11 mins) http://spxj.nl/1kOz849

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Strategies for overcoming barriers to implementing strength and conditioning programmes in youth football Football (soccer) is one of the most popular sports in the world but in the UK we have been slower to adopt structured S&C based practices than other high profile sports such as rugby, golf and athletics. Although coaches, players and parents all realise that the modern game is more physically demanding than ever, we’re not prioritising physical development any more than we have done in the past. This article outlines some of the potential reasons for why this may be the case and explains some of the barriers contributing to the situation with the goal of helping you as practitioners, overcome these within your practice. We’ve put forward practical strategies to help practitioners engage coaches and players in S&C practices and enhance the physical development of youth football players. You can consolidate and share your learning with colleagues using the suggested group discussion topics at the end of the article and complete the elearning assessment for inclusion in your continuing education portfolio. To help you put together appropriate S&C programmes, we’ve included 28 videos of individual exercises appropriate for youth footballers, along with a ‘memoryprompt’ summary video containing all 28 exercises grouped together. Read this online http://spxj.nl/1ReM0Ke

By Jamie Salter MSc, CSCS ASCC SPORTS PERFORMANCE | S-C | ADOLESCENT-ATHLETE | 16-04-CO-KINETIC

FORMATS

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MOBILE

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Media contents Video: Prehabilitation exercises for adolescent footballers’ (J. Salter, 2015) Continuing education quizzes This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/1ReM0Ke

Article weblinks Proformance Strength & Conditioning http://www.proformance.pro/education provides useful information regarding long-term athlete development.

Movement Dynamics http://www.movementdynamics.com is a good source of information for general movement competency.

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Introduction TV viewing figures and worldwide participation rates tell us that football is our favourite sport, by a considerable margin. Most of us enjoy the tactical, technical, psychological and physical battles posed by the beautiful game and watch in awe when memorable moments of genius transpire. The majority of these moments often appear to require superhuman feats of athleticism and technical ability, which result from hours of deliberate practice and coaching. Moments such as Cristiano Ronaldo’s now trademark leap above defenders to head the ball home or Eden Hazard’s wonderful balance as he rounds opponents, contribute to why these players are repeatedly in contention for the major honours each year. Although it is clear from the way football has evolved that athleticism and physical ability are crucial to success at the highest level, are we doing enough to nurture the future of

the game? Previous experiences in the sport and anecdotal evidence from practitioners working in football suggest not and that in some cases prescribed ‘strength’ exercises are voluntary with adult players. This worrying notion was alluded to publically during October 2014 when Raheem Sterling discussed his fitness with Forever Sports magazine saying, “I try to not lift too many weights”, and, “I have the odd day where I do work on upper body and stuff like that and try to get myself stronger and fitter” (1). This player is widely regarded as the future of English football and has recently joined Manchester City for over £43m yet his awareness of what benefits strength training can offer seem limited. Yet in other sports, such as golf (Figs 1, 2), tennis and rugby, more rigid strength and conditioning (S&C) protocols are implemented which significantly contribute to athletic success. So, why is football different? Is it the frequency Co-Kinetic journal 2016;68(April):36-41

Physical therapy sports performance

‘I try to not lift too many weights’ and ‘I have the odd day where I do work on upper body and stuff like that and try to get myself stronger and fitter’ (Raheem Sterling, 2015)

of competition? Is it that the sport just hasn’t embraced S&C yet? Or is it that key stakeholders such as parents, players and coaches just aren’t aware of the benefits that a well designed S&C programme can have on performance? This article intends to justify the role of S&C within football and challenge some of the barriers to intervention by providing some practical methods to enhance the ‘buy-in’ within the sport.

Youth football Empirical research published within the last five years (2–5) identified that youth-player selection is being based more frequently upon physical characteristics with speed, power and body composition/anthropometry among the most decisive factors for selection. Deprez et al. observed physical attributes in youth players between 8–16 years old and tracked whether or not they obtained youth scholarships (2). The findings identified

that those players with better physical attributes were more regularly successful in obtaining a contract with 5m speed (d = 0.62) and standing broad jump (d = 0.72) being the most influential factors (Table 1). This applied research trend suggests that coaches, scouts and players realise the demands of the modern game are evolving and that success in the sport involves highly developed aerobic and anaerobic qualities from a young age as well as technical ability.

Talent development programmes implemented by professional clubs are improving and younger players are now more exposed to S&C based practices since the introduction of the ‘elite-player performance plan’ (EPPP) in 2012–13. However, other than ‘lead sport scientist’ and ‘lead strength and conditioning coach’ there is no obligation to employ additional specialist fitness staff at academy level and, therefore, some of these programmes are run by voluntary, inexperienced

internship students who have recently completed, or are about to complete, undergraduate courses. In some cases, but definitely not all, these students may not be supervised by adequately qualified professionals as these higher qualified individuals often work with under-21 (U21) and/or U18

Figure 1: Golfer’s such as Rory McIlroy have strength and conditioning (S&C) programmes. (Credit: Twitter, 2014)

Table 1: Differences in anthropometry and maturity status, physical fitness, and motor coordination between players who end up receiving a professional contract and those who do not. (Deprez et al. A retrospective study on anthropometrical, physical fitness, and motor coordination characteristics that influence dropout, contract status, and first-team playing time in high-level soccer players aged eight to eighteen years. J Strength Cond Res. 2015;29:1692–1704).

Attribute

Body composition (%)

Contracted Non-contracted Effect size mean (n = 29) mean (n = 29) (Cohen’s d) 10.1

11.1

0.38

Countermovement jump (cm)

36.8

35.8

0.24

Sprint 5m (s)

1.05

1.09

0.62

Sprint 30m (s)

4.33

4.41

0.43

Standing broad jump (cm)

230

218

0.72

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Figure 2: A very visual depiction of the results of Rory McIlroy’s S&C programme. (Credit: Twitter, 2014)

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teams, which raises issues surrounding the quality of delivery of a vital aspect of the performance spectrum as adequately qualified staff are vital to the success of a programme (6). Yet with the same group of youth players the EPPP requires a minimum of two full-time UEFA B (Level 3) qualified coaches for category 1 & 2 clubs and usually additional part-time staff on top of this with Youth Award qualifications as well as Level 3 coaching. This raises the question of how much value we are placing on the quality of athletic development during key developmental stages and whether the future of football values the input of S&C practitioners enough. Subsequently, this may manifest itself in a similar way to the Raheem Sterling story above where players are unlikely to truly understand the potential benefits later in their career, maybe a result of the current culture. Maybe if the same emphasis was placed on specialist fitness staff as technical staff we would see a culture-shift in youth football which would enhance the awareness of players, coaches and parents.

Training schedules Much debate exists about the amount of competitive fixtures in elite football, particularly in England. This hectic,

10-month, competitive schedule involves teams often participating in excess of 55 competitive fixtures, making any real S&C interventions difficult. In comparison to other sports, it is easy to understand why S&C in football is lacking at the highest level.

For example, in rugby competitive fixtures are almost exclusively limited to one match per week and the pre-season period is approximately 4–6 weeks longer than football. There is physically no time in the football micro-cycle to fit significant strength and power based training because of the fatigue associated with both the competitive fixtures and the resistance training itself. In season, recovery must take priority over strength based training to ensure that players are suitably regenerated in time for the next competitive fixture. This inability to consistently programme loaded exercises makes it difficult to programme them at all as the fatigue associated with an occasional bout of strength training can last 48–72hours (7), by which time the players are required to compete again and performance may be negatively affected.

This, however, is not the same with youth football. Throughout the Youth Development Phase (YDP)

This applied research trend suggests that coaches, scouts and players realise the demands of the modern game are evolving and that success in the sport involves highly developed aerobic and anaerobic qualities from a young age as well as technical ability

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and the Professional Development Phase (PDP) players are required to partake in 10–14 hours coaching time according to the EPPP, and will mostly play in one competitive match each week. This significant contact time and limited competition provides an ideal opportunity for clubs to develop athletic properties with these young players.

However, work by Brownlee and colleagues tracked training practices of a category 1 academy from U9 to U21 (n = 184) and identified that 97% of training distribution between U9 and U14 was soccer based (8). This did improve between U15 and U21 (26%) where periodisation and recovery from more regular competition was included.

These statistics, albeit from only one academy, highlight the disproportion of time spent developing technical attributes in youth football (which is likely similar in other clubs), despite players and coaches recognising the major impact the physical attributes have on talent selection. Substantial research is available to support the fact that strength training from a variety of methods can affect power and speed performance in team sports, but the impact of this is going to be negligible if only 3% of training time is devoted to developing it and other physical qualities. This links to the debate regarding early versus late specialisation, where much of the research suggests that children should take part in as many different activities as possible <14 years and look to specialise >14 years to develop physical literacy and a varied movement competency (9). Judging by the research above, this is not happening. Obtaining an effective balance between technical, tactical,

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physical and psychological training is a difficult one and there is no correct way of achieving it, but surely it is time that youth football responds to the demands of the game and talent identification methods by devoting more time towards physical development, particularly >14 years.

Barriers to S&C intervention So what are the barriers and why are we not doing more? The answer to this is not a simple one and may be multifactorial in nature but there are clues amongst the research and practices that provide some explanation. Primarily, much of the issue comes down to limited education and exposure of both coaches and players.

In the youth football environment many of the coaches are ex-professional or semi-professional players who are unlikely to have been exposed to many contemporary sport science/S&C coaches or interventions owing to the nature of the game during their careers. Therefore, subconsciously there may be a perception that these new approaches are unnecessary or yield a minimal transfer to onpitch performance, which must be overcome. Although unintentional, it is understandable that coaches who have played the game at a good level are dubious of the methods of an undergraduate internship student that require 25–40% of training time away from pure technical development. This perception can, but does not always, manifest itself within the players if the S&C practices are not completely supported by the coaching staff, placing greater strain on the ‘buy-in’ and compliance of players. This notion

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is endorsed further when players start to piece together the training requirements of adult players and word leaks out that the first team does not always have to complete a gym session, without realising the difference in the development continuum.

Therefore, players’ belief in the field and gym based S&C sessions is damaged, which in turn hits compliance and concentration. This subsequently places further emphasis on the quality of the coach to ensure a positive learning environment and efficient session, leading to a vicious circle.

Early sport science literature referred to the ‘white coat syndrome’, which outlines a negative perception of sport scientists within sports environments and increases anxiety and curiosity surrounding the practices of these professionals. It is believed that this barrier is much reduced but evidence suggests that this does still exist in some settings. Additionally to this, coaches’ knowledge of S&C training may be limited as discussed previously; therefore, they are protective of their players as they may believe strength training in adolescents is not healthy and/or may overload them and lead to fatigue related injuries affecting match performances. Several myths exist in the plethora of information that is available for fitness professionals and one of them surrounds growthplate injuries during youth resistance training. As long as the training practices are prescribed, supervised and use suitable loads there is no risk of injury to young individuals during resistance training. This could involve bodyweight (calisthenics), medicine ball or free-weight exercises but the crucial aspect of the prescription is the

safe instruction and supervision. It is also pertinent to mention that suitably qualified practitioners are required in order to differentiate between players who are pre-, circa or post-peak height velocity. Hence, to prevent injuries and manage training loads it is valuable to have these staff available for players at younger ages.

Guidelines for change Below are some guidelines of how, as practitioners, we can enhance the quality of provision we provide to the players at grass roots level through to category 1 academies. These guidelines are designed to be used to ensure optimum ‘buy-in’ from coaches, players and parents alike. It will take time, and questions will be asked, but by following these guidelines it is expected that you will improve the relationship and transparency between the S&C/sport science staff, coaches and players.

1. Education of players, parents and coaches The primary guideline is to educate the coaches and players as to why you are selecting those activities and, critically, how it will transfer to the pitch. For example, a common situation where coaches may question practitioners concerns screening of players. Often this can take 30 minutes to 1 hour of a session and in some cases longer depending on the screening protocol, which is time that they will not have with the players. If you invite the coaches in to observe and discuss the movements with them, highlighting any movement dysfunction and explain how it is possible to correct this through exercise and how this

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work by Brownlee and colleagues tracked training practices of a category 1 academy from U9 to U21 (n = 184) and identified that 97% of training distribution between U9 and U14 was soccer based (8) videos of individual exercises: Individual videos available on Co-Kinetic.com (J. Salter, 2015) Video 1. Reverse diagonal lunges.

Video 2. Three-point gluteus stretch.

Video 3. Press-up.

Video 4. Jump and hold.

Video 5. Hop and hold.

Video 6. Quadruped leg extension.

Video 7. Glute bridge.

Video 8. Single-leg glute bridge.

Video 9. Groiners with twist.

Video 10. Knee raise into Superman position.

Video 11. Single-leg deadlift.

Video 12. Squat jumps.

Video 13. Cut and hold.

Video 14. Deep squat and hold.

Video 15. Plank.

Video 16. Side plank.

Video 17. Lunge.

Video 18. Squat.

Video 19. Inchworms.

Video 20. Hip flexor stretch.

Video 21. Step-ups onto box.

Video 22. Eccentric step-up.

Video 23. Drop step.

Video 24. Single-leg drop step.

Video 25. Box squat.

Video 26. Single-leg box squat.

Video 27. Lunge to box.

Video 28. Wall drives.

might then manifest itself on the field they will be more forthcoming. Simply taking time away from the coaches is not appreciated, but involving the coaches and allowing them to learn about their players is an opportunity for you to develop that relationship.

Also, the players feel as if there is harmony between the staff, which creates a positive environment. This is just one example of how S&C staff can engage coaches, there are many more opportunities. The more the technical coaches can relate your practices to on-pitch situations the better they will respond.

2. Nuggets of S&C Dropping in bitesize S&C related points or taking smaller 10–15-minute chunks of training time will minimise the impact on the coaching session and prevent a detraction of the relationships formed.

This may be taking a field-based warm-up session incorporating injury prevention (strength based) exercises while the coaches set up the rest of the session, or are part of a carousel of activities one of which is a ‘physical’ station run by the S&C coach. This means that the players are exposed to the content and the technical coaches welcome it, which subsequently helps

Video: Demonstrations of 28 prehabilitation exercises for adolescent footballers.

(J. Salter, 2015)

with the compliance of the players in the session. Also, handouts to players with very short and simple tasks that you can review in upcoming sessions can work well. For example, providing a recovery handout where they must achieve so many points before the next training session can be easily managed at home and S&C staff can individually discuss the recovery done by all players informally. This gives players a choice but also a responsibility for their own recovery, which is regularly checked by S&C staff.

3. Highlight change One of the hardest aspects of developing strength, speed and general athleticism in youth players is how we can quantify the impact the training has had on football performance. It is easy to run sprint tests, perform strength tests and the like to quantify change in those specific areas, but how do we know they are benefitting on the field?

One key guideline for S&C coaches is to highlight good practice regularly.

Coaches are encouraged to provide feedback and specific praise, and S&C coaches are no different. If a player replicates a movement, technique or action that has been covered in an S&C practice – praise it. By stepping in and highlighting this you are providing confidence to the player, as well as demonstrating the transferable nature of your S&C interventions and showing that it has a place within the coaching syllabus. If coaches recognise this, it will not be long before they are more responsive to the work you are doing with players.

Further resources 1. Lloyd RS, Oliver JL. Strength and conditioning for young athletes: science and application.

Routledge 2013. ASIN B00IFXM5ES (£42.89). Buy from Amazon http://spxj.nl/1KXwFRN 2. Joyce D, Lewindon D. High40

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Physical therapy sports performance

performance training for sports.

Human Kinetics 2014 (Kindle £14.30 Print £17.94). ISBN 978-1450444828. Buy from Amazon http://spxj.nl/1pkkJj2 References 1. Portnoi G. Young, gifted and on the attack.

Forever Sports 2014;November:63–71 2. Deprez D, Fransen J, et al. A retrospective study on anthropometrical, physical fitness, and motor coordination characteristics that influence dropout, contract status, and first-team playing time in high-level soccer players aged eight to eighteen years. Journal of Strength and Conditioning Research 2015;29:1692–1704 3. Lago-Peñas C, Casais L, et al.

Anthropometric and physiological characteristics of young soccer players according to their playing positions: relevance for competition success. Journal of Strength and Conditioning Research, 2011;25:3358–3367 4. Unnithana V, Whitea J, et al. Talent identification in youth soccer. Journal of Sports Sciences 2012;30:1719–1726

5. Vandendriesschea JB, Vaeyensa R, et al.

Biological maturation, morphology, fitness, and motor coordination as part of a selection strategy in the search for international youth soccer players (age 15–16 years). Journal of Sports Sciences 2012;30:1695–1703 6. Faigenbaum AD, Lloyd RD, et al. Citius, altius, fortius: beneficial effects of resistance training for young athletes. British Journal of Sports Medicine 2015;doi:10.1136/ bjsports-2015-094621 7. Beneka AG, Malliou P, et al. Muscle performance following an acute bout of plyometric training combined with low or high intensity weight exercise. Journal of Sports Sciences 2012;31(3):1–9 8. Brownlee TE, O’Boyle AC, et al. A Comparison of training practices throughout an elite youth soccer academy. Presented at the UK Strength and Conditioning Association Conference 2015, Kenilworth, UK 9. Mostafavifar AM, Best TM, Myer GD. Early sport specialisation, does it lead to longterm problems? British Journal of Sports Medicine 2013;47:1060–1061.

Discussions Does the youth football programme advocate effective physical development?

Do we place too much emphasis on football-specific development throughout the youth system?

Is football behind other sports from an S&C perspective?

Key Points n The most successful players in football demonstrate extraordinary feats of athletic ability. n Strength and conditioning is sometimes undervalued by professional players and coaches, potentially because of a lack of understanding. n Modern football places greater demand on physical characteristics with regard to talent identification and selection. n Youth football development programmes often utilise students/ inexperienced staff to deliver S&C interventions. n Imbalances exist between technical and physical training time, which may hinder the athletic development of youth players. n Coach and player education/involvement may enhance the ‘buy-in’ in relation to S&C based interventions with youth players. n S&C interventions are effective and safe for youth players if adequately supervised by qualified practitioners. n Highlighting change and providing ‘nuggets’ of information to players and coaches may increase awareness and stimulate engagement of interventions.

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The Author Jamie Salter MSc, CSCS ASCC is the award leader for BSc Sports Therapy at York College and also lectures in Strength and Conditioning at York St John University. Jamie graduated in 2007 with a BSc (Hons) in Science and Football from Liverpool John Moores University before completing an MSc in Strength and Conditioning in 2013. Jamie has extensive applied experience in professional rugby league and football, currently working as athlete development coach at Middlesbrough FC. Jamie is currently researching the implications of training load around peak height velocity in adolescent football players.

Email: j.salter@yorksj.ac.uk

Related content o-Kinetic content relating to the adolescent athlete C https://co-kinetic.com/tag/adolescent-athlete o-Kinetic content relating to strength and conditioning C - https://co-kinetic.com/tag/s-c trength and conditioning training in adolescents S Fisic Conference Video Presentation 2015 (13 mins) http://spxj.nl/1PM5tDH he role of strength and conditioning in training T programmes for young athletes - http://spxj.nl/1HdmgLJ he challenges of youth: psychosocial response to T injury and rehabilitation in youth athletes http://spxj.nl/1cSnpi4

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Manual therapy student handbook: Musculoskeletal dignosis – a pragmatic model of clinical reasoning This article is part of a series on manual therapy (See the ‘Contents panel’ for further details) and takes the reader step-by-step through the process of clinical reasoning and how it aids the identification of the tissue that is the source of the patient’s problems. Combined with a knowledge of common clinical conditions, this process allows the therapist to predict a diagnosis, to direct appropriate treatment at the source of symptoms, and helps in the creation of relevant rehabilitation processes for restoring full functional capacity. http://spxj.nl/1MmbeGv Clinical reasoning

By Julian Hatcher Grad Dip Phys MPhil, MCSP FOM

Although it is imperative that any therapist has the skills to assess a client with a musculoskeletal complaint, it is often a more challenging task to actually come to an accurate diagnosis.

In the previous article in this series ‘Manual therapy: Musculoskeletal assessment’, it was highlighted that three fundamental decisions must be made in attempting to diagnose conditions: 1. About which joint does the lesion lie?

2. In what sort of tissue does the lesion lie? (Contractile/inert) 3. Is the pain reproduced by the test?

16-04-co-kinetic FORMATS WEB MOBILE

The first decision is made following the subjective examination of the client, whereas the process of selective tissue tensioning during the objective examination of the client would give vital information that could point to the diagnosis. The actual process of evaluating the information gleaned from both the subjective and objective assessment, and making sense of it all is what is referred to as ‘clinical reasoning’. Not only does it require knowledge and skill in the mechanics of performing an

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accurate assessment of the client, it also requires sound anatomical knowledge and understanding of the complex variety of clinical features that common musculoskeletal conditions present with. It is rather like an investigator may put together ‘facts’ or evidence around a criminal case.

In this analogy, there are certain key features that help put together some kind of picture to the puzzle: forensic evidence linking a suspect to a crime scene, the concept of motive and opportunity, witnesses – all help build a case. Musculoskeletal assessment findings are somewhat similar, and if we have a specific method of looking through the presented information, we may come to a conclusion more easily. Generally speaking, investigators rarely create a theory or profile before the evidence has been examined; likewise, we would not normally form a diagnosis before we have assessed the client. The method adopted is one of a process of elimination, whereby everything is possible at the beginning,

but as evidence and information comes to light, certain theories can be dismissed as unlikely. Eventually a pattern emerges from the pieces of evidence and so a picture may be deduced from this; similar to the picture created when putting the pieces of a jigsaw together.

This is referred to as the ‘deductive reasoning method’, whereby information is deduced from the evidence presented. There are many other methods of clinical reasoning and further information can be found in Higgs’ book, Clinical Reasoning in the Health Professions (1).

The aim of this article is to give therapists a pragmatic model for clinical reasoning; a way of thinking about the evidence presented from assessment in a logical and deductive manner that may make the diagnosis of musculoskeletal disorders easier.

This process will enable rehabilitators to assess and diagnose many of the common disorders that affect physically active people.

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Primary decisions in diagnosis If the method of assessment follows the model of orthopaedic medicine (2), in which each tissues are conveniently divided into two types (contractile and inert), then at the end of the patient examination the latter primary decisions can be made with some degree of confidence. In this assessment method each tissue is selectively stressed, while at the same time not allowing any tension to occur at other tissues. The following is a list of examples of tissues within the two groups: Contractile: muscles, tendons and all corresponding junctions (musculotendinous and teno-osseous junctions) Inert: bones, capsule, ligaments, cartilage, bursae, nerves and dura mater.

The result of this objective testing allows the therapist to make an initial decision about whether the lesion lies in a contractile tissue or an inert one. If the question is posed, “Does the lesion lie within a contractile tissue?” then the answer would be either yes or no. If the answer is yes, then questions arise such as, “Which part of the contractile tissue is affected?” If the answer is no, then the alternative question is, “Which type of inert tissue is affected?” So we can see that simply dividing tissues into these two rather loose groups helps only to a certain extent, as the answer leads on to further questions that need to be addressed. These questions are secondary decisions that need to be made for a conclusive diagnosis to be achieved.

Secondary decisions in diagnosis If a primary decision is made stating that the contractile tissues are affected, then how is this decision made? Well primarily the objective testing, if done thoroughly, should produce a positive result during one of the resisted tests.

This could either be that the client’s symptoms are reproduced by the test (eg. pain) or that there is apparent weakness of the contractile element (or

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indeed both). It must, however, fit with the subjective history findings too.

For example: Someone who complains of posterior calf pain may indeed have a tear within the gastrocnemius muscle, as they complained of pain on resisted plantarflexion. That test alone would not be enough to determine this, but would need to fit with the findings of the subjective history, which would probably include things like, sudden onset with remembered trauma (mechanism of injury), pain when walking (during push-off phase), pain localised to the gastrocnemius muscle. A different diagnosis is possible for a similarly presenting patient with posterior calf pain, if the history identified a gradual insidious (unknown) onset, with recent history of injury to the same limb some days previously. The differential diagnosis here may be a DVT (deep vein thrombosis).

Equally, if there is no positive result identified from one of the resisted tests during the objective examination, then it can be assumed that the lesion is not within the contractile tissues, and must therefore be within the inert structures.

For this to be true, then one of the passive tests is likely to produce a positive result, ie. pain, or limitation of range of motion (ROM), or an abnormal end-feel for that particular movement.

Again, this in isolation is not enough to convince us of a diagnosis, but must fit with the findings from the subjective history too.

For example: A patient complaining of medial knee pain during a number of passive tests may well have a diagnosis of medial collateral ligament strain. The subjective examination findings may include: sudden onset, pain after prolonged periods of rest which is relieved by movement. However, the diagnosis may be different if a similar patient with medial knee pain describes similar symptoms and behaviour, only the onset was gradual. The differential diagnosis here may well

if we have a specific method of looking through the presented musculoskeletalassessment information, we may come to a conclusion more easily be the presence of osteoarthrosis in the joint.

In order for us to make secondary decisions as to exactly which tissue within either group is affected, we must have some knowledge of how each tissue behaves when it is irritated, inflamed or damaged. The following may be used as a guide to the common clinical features that specific tissues display during examination (both subjective and objective). It is not meant to be definitive and exact as all assessment techniques are not considered to be fully specific, or sensitive. It is meant to be used as a guide where additional clues can be used to form a clearer picture of diagnosis – another piece of the jigsaw puzzle.

Contractile tissues Muscles Muscle tissue may become damaged when fibres are either cut (lacerated), compressed by a blunt object (contusion) or most commonly (3) forced apart through the opposing forces of eccentric contraction (strain).

Interestingly, contusions and lacerations can affect the muscle belly anywhere, strains almost exclusive occur in the musculotendinous junction (4).

Whatever the cause, muscle fibres become torn and this immediately has an impact on their ability to contract and produce force. As a result, resisted testing of the contractile unit is likely to give either a painful response (minor tearing), or a painful and weak response (moderate tearing).

The weakness arises for two reasons:

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n Firstly, the number of actual muscle fibres capable of contracting and contributing to the overall force has diminished due to some being torn, and n Secondly, due to pain inhibition.

Pain inhibition is the phenomenon where painful signals coming from the injured area create inhibitory effects on synapses with the motor nerves supplying the muscle that is injured (or indeed additional agonist muscles).

Much of this is involuntary; however, some may be due to psychological fear and therefore voluntary ‘holding back’ during the resisted testing.

That said, when performing resisted tests, a positive sign is pain and/or weakness. If the testing is repeated numerous times, a similar response is obtained each time; in other words, repeating the test neither makes the painful response worse or better. This response is different from other parts of the contractile mechanism (see later).

When muscles tear, as stated above, it is almost always through some kind of sudden onset involving remembered trauma (and the mechanism of injury may help to indicate the nature and effect of such trauma). Generally speaking, muscles do not build up pain gradually through repeated trauma. Muscles can, however, give pain to subjects when they are in spasm and not necessarily torn; this may be in the form of muscle cramp as in large muscles like the gastrocnemius, or in very small fibres of the erector spinae group of muscles in the spine. In the latter case, the muscle spasm is not necessarily the diagnosis, merely the cause of symptoms and alteration in movements and posture.

Tendons Tendons are responsible for transmitting the forces created by contracting muscles to the relevant bony lever. As a result they are subjected to large forces. In many cases, tendons are also used to ‘focus’ these forces from a relatively large muscle mass to a rather small

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area of application to the skeleton at the teno-osseous junction. In some cases, this repetitive loading becomes too much and micro-tearing of the tendon at this junction occurs, which we recognise as tendonitis. The body of the tendon may also become the source of pain if excessive repeated loading occurs on a degenerate tendon (often more in the body of the tendon, eg. tendo-calcaneus); known as tendonosis. Some tendons have to transmit muscular forces around bony corners and are contained within tendon sheaths. These are ‘tubes’ of connective tissue filled with synovial fluid and designed to allow frictionfree movement of the tendon around such bony corners. This tendon sheath can also be a source of pain – called tenosynovitis. In all cases, the majority of tendon pain may be elicited by a positive resisted test during objective examination, ie. pain and/weakness during contraction. Although this is similar to muscles, a major difference is experienced if the test is repeated many times. Generally, inflamed tendons (and sheaths) become more irritated, the more they are subjected to stress. This means that, for the sake of argument, the 20th test is more painful than the first. Although we would not normally test repeatedly, there may be occasions where such testing is advocated.

More often than not, during the subjective interview, the client reveals that not only does movement irritate them, but continually doing so actually makes them feel worse. At the same time, avoidance of the stressful activity actually relieves pain. This information often releases the therapist of the obligation of performing multiple testing of the contractile elements. The onset of pain is usually described as gradual (unlike muscle tissue).

Imagine a client who complains of pain in the Achilles tendon only after running approximately 10 miles.

It is unlikely that a single resisted test, performed in a clinic scenario, would elicit a painful (hence diagnostic) response, and neither would repeat testing within that same examination. It would be pertinent, in this case, to ask the client

to run to the clinic, where the clinic is approximately 11 miles away from the beginning of such a run. Now the tendon is much more likely to elicit a painful response to a single resisted test.

Inert tissues Bones Generally speaking, bony lesions come under two types: traumatic fractures and pathological fractures. Most traumatic fractures are remembered and the mechanism of injury may indicate which part of the skeleton is affected. The sudden onset of these is a key element of such trauma, and fracture would be suspected if the client has severe pain, exquisite local tenderness, loss of function, colour changes such as bruising, and even possible bony deformity. In the main, clients presenting with fractures are relatively easily identified. However, some clients may describe sudden onset with a mechanism of injury that leads the therapist to think that a sprain of the joint capsule and associated ligaments has occurred. In that case, subsequent passive testing would not differentiate adequately from any of these inert structures.

For example: If a client describes a mechanism of injury that included the foot and ankle being forced into inversion while weight-bearing, passive testing of inversion is likely to produce a painful response, plus the ROM may be limited (by pain and/or swelling), and an abnormal end-feel. This would not differentiate between a fracture of the lateral malleolus and sprain of the lateral collateral ligaments. Subsequent palpation of each structure in turn may produce a different response, which may become the deciding factor.

In pathological fractures, these tend to come from sudden, but insidious onsets whereby no major trauma occurred; the bone fractured under very little relative force. Ultimately, diagnosis of pathological fractures is normally by objective measures such as X-ray examination. Stress fractures,

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however, may be a differential diagnosis to tendonitis as they often occur in circumstances similar to this. That is, a client may describe gradual onset of symptoms following repetitive actions or loading, that is relieved by rest. In this case, simple palpation may provide the differential factor, and subsequent X-ray or isotope bone scan would confirm this diagnosis.

Capsules According to Cyriax, capsules react in a specific way when irritated either through trauma, infection or degeneration (2). His concept is derived around his observations that the capsule apparently ‘shrinks’ and limits motion in what he describes as the capsular pattern. This pattern is a specific pattern of limited movements that is the same for that joint, but different for different joints. For example, all shoulders develop the same pattern, but that is different from the hip joint pattern of restriction. As a result, knowledge of the specific patterns associated with each joint gives valuable diagnostic information. That said, it would not be correct to go on this one aspect of examination findings alone, as this is not specific and sensitive enough to be wholly accurate. When used in conjunction with other findings from the examination, however, this can be extremely valuable to the musculoskeletal therapist.

Essentially capsules are ligaments; they are made of ligamentous tissue, and in many cases, are reinforced in specific areas by named ligaments.

Capsules and ligaments are present in order to prevent excessive movements of joints. As such are susceptible to the forces of injury as much as any other structure. Having said that, the presence of a capsular pattern may indicate that the capsule is involved in the client’s problem, but this is not necessarily through trauma. A capsular pattern alone does not indicate the actual nature of the problem. A capsule may become involved in trauma, in which case a sudden onset is often involved and remembered. In osteoarthritis (OA), the

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The method adopted is one of a process of elimination, whereby everything is possible at the beginning, but as evidence and information comes to light, certain theories can be dismissed as unlikely capsule becomes irritated through the complex process of degeneration of the articular cartilage and associated fibrillation that occurs. In rheumatoid arthritis (RA), the capsule is irritated through the complex pathology of the autoimmune responses causing synovial inflammation.

Another factor to consider in capsular conditions is that they respond to movement, and lack of it, in the same manner as ligaments – as will be explained below.

Ligaments Ligaments prevent unwanted movements, or at least prevent excessive movement, at joints. As such, if they become torn, either partially or completely, they lose this function. As a result, passive testing may reveal pain, and/or laxity when performing the test. In minor (Grade I) tears, most of the fibres remain undamaged and hence are still able to provide significant support to the joint, and laxity (or excessive movement) is not detected; pain becomes the positive response in this case. In Grade II lesions, a more significant number of fibres are actually torn, with the result that the ligament is weakened and laxity becomes apparent. Pain is often present as some fibres (with normal sensation) are still present. Very little pain, and gross laxity often indicates total (or near total) rupture, which is classified as Grade III tearing of the ligament.

In addition to the presence of pain and laxity during passive testing of a joint, client’s with ligamentous problems often describe symptoms of stiffness that may be associated with pain. This often occurs after prolonged periods of rest or static positioning, and initial movement causes an

increase in pain. However, this pain is subsequently relieved by continuing the same movement repeatedly. Indeed, in some cases, clients may complain of the phenomenon of morning stiffness, when their joints feel stiff when they first get up from sleeping, and find that this is resolved after a few minutes of walking around the room or house.

This is particularly common in patients suffering with OA. Therefore, in clinical examination terms, if a passive test is painful, and the ligament is involved, subsequent repeated testing is likely to elicit a diminished response each time the test is performed.

Cartilage There are two types of cartilage found in synovial joints; one is the hyaline cartilage, which is sometimes called articular cartilage as this covers the articular surfaces of the joint components. The other type is fibrocartilage, which is present in some joints such as the labrum of the hip and shoulder, and the meniscus of the knee. The fibro-cartilaginous structures are there to provide an increase in congruity of joint surfaces (making a more exact fit between bone ends) and also to provide a shock-absorbing effect for the joint. This latter function is created by the nature of the cartilage itself, being made of a substance that is designed to display tough resilience to compression and shearing forces.

This is useful in diagnosis in that flakes, fragments or splits in these structures may become trapped between opposing joint surfaces during movement, which manifests itself as a ‘springy’ end-feel to joint motion. It is rather like the ‘bouncing’ effect one experiences when biting unexpectedly into ‘gristle’ found in chicken drumsticks!

These fragments of cartilage, whether

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still attached or free to move around as loose bodies, often move unexpectedly and hence symptoms may come and go, for no apparent reason. When getting trapped between joint surfaces, the pain associated with this is often described as being relatively sharp and intermittent.

In terms of subjective history, it may be that the client with a cartilaginous problem may have an insidious onset of symptoms, or may describe some traumatic event in the past that may have created the fragmentation. This is by no means consistent, and recent developments within arthroscopy techniques have allowed orthopaedic medicine to advance its understanding and knowledge of osteochondral defects much more. More importantly, we have a greater understanding to develop therapeutic strategy to treat cartilaginous problems with better outcomes for the client.

Secondary decisions in diagnosis must fit with the subjective history findings too

Bursae A bursa is a small synovial sac that is extremely thin walled, and contains synovial fluid. Its function is to prevent friction between two tissues, usually muscles against bony surfaces. It can become inflamed either through a single traumatic episode, or more commonly, through repetitive trauma. Once inflamed, anything that squeezes the bursa causes a painful response. This is rather difficult during assessment in that it can be squashed during both passive and resisted tests, giving a rather muddled set of clues for diagnosis.

For example: A client with a psoas bursitis may demonstrate painful responses to passive movements of hip flexion, hip extension and even hip adduction, while at the same time display a pain on resisted hip flexion. This is due to the fact that the bursa prevents friction between the ilio-psoas complex where it â&#x20AC;&#x2DC;poursâ&#x20AC;&#x2122; over the edge of the pelvis and anterior of the hip joint before the conjoint tendon attached to the lesser trochanter. As a result of its position, contraction of the hip flexors would compress the inflamed bursa, as would stretching of the muscle into passive extension. The bursa is also compressed by the soft tissue opposition caused by passive flexion too.

Diagnosis of bursitis therefore requires sound knowledge of bursa locations and of their function and associations with specific musculoskeletal areas.

Unlike ligament pain, the pain response from an irritated bursa is often made worse by repetitive movements, and like tendon pain, often occurs mainly after, or during activity that irritates it.

Where it differs from tendon pain is that it is easily reproduced, and passive tests are equally as painful as resisted test; this is not the case in tendon pain.

Nerves In many respects, simple nerve problems are relatively easy to diagnose as they tend to offer symptoms other than pain (this article

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does not consider the special cases of double crush syndrome to the nerves).

Generally speaking, the function of a nerve is to deliver sensory impulses to the central nervous system from the periphery, or outgoing signals to effectors such as muscles.

If a peripheral nerve becomes compromised in some way, then generally an alteration in its function occurs which manifests as either altered (or loss) of sensation, known as paraesthesia (or anaesthesia), or apparent muscle weakness in muscles that are supplied either wholly or in part by that particular nerve. If a peripheral nerve is compromised, then clients are often able to determine aspect and edge to their symptoms.

For example: A patient diagnosed with carpal tunnel syndrome complains of pins and needles in the palm of their hand (aspect) and in the lateral three and a half fingers only (edge).

If the nerve is compromised more proximately, then the greater the extent of the altered sensation or motor function.

For example: A patient with supracondylar fracture of the elbow that compromises the median nerve may display weakness of most of the forearm and finger flexors, as well as altered sensation on the anterior aspect of their forearm and hand.

If the nerve is compromised within the plexus, say at the posterior trunk, this may give rise to sensation loss on the posterior arm (aspect) but there is no defined area where this begins or finishes (no edge).

Dura mater Continuing the above theme in respect of nerve irritation, then spinal nerves may also give rise to symptoms of paraesthesia that has aspect but no edge; the difference here though is twofold. n F irstly, the symptoms tend to follow segmental patterns of

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referral (dermatomal reference of symptoms). n Secondly, because the spinal nerve roots are themselves covered by a briefly extending sleeve of the dura mater, which is highly sensitive, pain is a significant component of symptoms.

This pain tends to follow radicular patterns of referral (refers into all or part of the dermatome). Any motor loss associated with spinal nerve root involvement, also follows segmental patterns, where the myotome becomes affected, manifesting as weakness within the muscle groups of that particular myotome.

For example: A patient complaining of C5 nerve root irritation may complain of pain radiating down the lateral aspect of the arm (may be as far as the wrist), and may complain of altered sensation within the same dermatome too. If there is accompanying motor function loss too, this would occur within the C5 myotomes; this would be weakness in shoulder abduction and external rotation.

If, however, the dura mater is compromised where it lies around the spinal cord, then this gives rise to pain initially, that may be extra-segmental, and eventually may be compromised to the extent where sensory loss and motor loss occurs also. These too would not follow segmental patterns, so widespread problems may occur.

If the cord itself becomes involved, then there would be corresponding changes to reflexes (exaggerated) and other upper motor neurone signs such as positive Babinski reflex or lack of coordination, etc.

The reasoning process This is the suggested method of cognitive thinking behind this deductive reasoning process. It is described in the simplest manner, and is a guide for the evaluation of the myriad of information gleaned from the subjective questioning and the objective testing of a client.

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Stage 1 Is the lesion within the contractile tissues or the inert tissues?

A) Typically, a positive response to resisted testing (eg. pain or weakness on a specific resisted test) would indicate a contractile lesion.

B) A negative response to resisted testing, while displaying a positive response to passive testing (eg. pain, laxity, limited movement, and pathological abnormal end-feel to movement) would indicate that the lesion lies within an inert tissue.

n

n

n

n

n

n

n

Stage 2 Whether the lesion is considered as being within the contractile tissues or the inert tissues is only part of the process of reasoning. The question now is in which specific tissue does the lesion lie?

A) If the lesion lies within the contractile mechanism, is the lesion within the muscle tissue or the tendon tissue? n If the pain was due to sudden onset and resisted test produces pain and/or weakness, and activity involving said muscle produces these signs and symptoms every time it contracts, and furthermore, repeated bouts of the same activity does not aggravate or ease symptoms, then muscle tissue is likely to be responsible for symptoms. n If the pain was a gradual onset, and continued activity either irritates the symptoms, or causes pain after cessation of activity, then tendon is the likely cause of symptoms in this case.

B) If the lesion lies within inert tissue, is the lesion within bone, capsule, ligament, cartilage, bursa, nerve or the dura? n If passive movements are restricted by severe pain, and is associated with a sudden onset from significant trauma, and accompanied by loss of function, bony deformity, colour changes and localised bony tenderness,

then bone is a likely cause of symptoms.

If there is limited range of passive movements that form the recognised capsular pattern for that joint, then capsule is likely cause of symptoms. These symptoms may include pain and/ or stiffness.

If there is limited pain and/or laxity on specific ligament passive tests, associated with a sudden onset through trauma, then ligament is the most likely cause of symptoms. Symptoms here include pain and stiffness often aggravated by prolonged periods of static positioning, and relieved by movement.

If intermittent twinges of pain are felt by patient that come and go for no apparent reason, and the presence of a springy end-feel to one movement is perceived, cartilage may well be the tissue affected.

If the client complains of symptoms being elicited equally from both passive and resisted movements (offering a muddle of signs and symptoms), then bursa is likely to be the cause of this; especially if associated with a gradual onset.

If there is evidence of paraesthesia or anaesthesia in an area of skin associated with a specific nerve, plus or minus motor weakness in muscles supplied by that same nerve, then nerve is likely to be the cause of symptoms.

If segmental reference of pain is perceived and sensory loss and/ or motor loss is dermatomal or myotomal respectively, then the spinal nerve root is the likely cause of symptoms.

If extra-segmental reference of pain, and paraesthesia or motor loss is not identified in specific and matching dermatomes or myotomes, and there is associated changes to reflex responses, plus signs of lack of coordination to movements, the dura mater and spinal cord is the likely source of the problems.

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The thinking process The flow-chart in Figure 1 gives an idea of how the cognitive thinking process in musculoskeletal assessment may proceed.

Muscle?

Yes Tendon?

Bone?

Contractile lesion?

Capsule?

Ligament?

No

Inert action?

Cartilage?

Bursa?

Nerve?

Dura mater?

Figure 1: A flow-chart showing the thinking process behind musculoskeletal assessment. (J. Hatcher, 2015)

The above is a summary of typical findings presented by musculoskeletal assessment relevant to each tissue type. It is hoped that understanding the findings of both the objective testing and the subjective questioning of clients, and assimilating these in a pragmatic way will give the therapist a logical and progressive way to analyse the information in order to be able to come up with a clinical diagnosis.

Needless to say, this process only really indicates which type of tissue is the cause of symptoms; this process does not indicate the actual diagnosis (for example, the origin of symptoms is the Achilles tendon, but the diagnosis may be tendonitis or tendonosis). It is hoped that this method of reasoning through the assessment findings will enable the therapist to combine their knowledge of common clinical conditions with this cognitive process in order to predict a diagnosis. This enables direct appropriate treatment at the source of symptoms, and facilitates the creation of relevant rehabilitation processes through which full functional capacity can be restored.

Further resources 1. Hatcher J. Musculoskeletal assessment, chapter 11. In: Comfort P, Abrahamson E (eds) Sports rehabilitation and injury prevention. Wiley Blackwell 2010 (Kindle £35.12 Print £36.97).

ISBN 978-0470985632. Buy from Amazon http://spxj.nl/1OAdzib 2. Palmer ML, Epler ME. Fundamentals of musculoskeletal assessment techniques, 2nd edn.

Lippincott, Williams & Wilkins 1998 (£45). ISBN 978-0781710077. Buy from Amazon http://spxj.nl/1NDZSlo 3. Atkins E, Kerr J, Goodlad E. A practical approach to musculoskeletal medicine: assessment, diagnosis, treatment, 4th edn. Elsevier 2015 (Kindle £48.44 Print £50.99). ISBN 978-0702057363 Buy from Amazon http://spxj.nl/1NYy8SS. References 1. Higgs J, Jones A, et al.

Clinical reasoning in the health professions, 3rd ed.

Butterworth-Heinemann 2008. ISBN 978-0750688857 (Kindle £32.39, Print £54.99). Buy from Amazon http://spxj.nl/1NhBpzM 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982.

ISBN 978-0702009358 (£36.90). Buy from Amazon http://spxj.nl/1JSrLz4 3. Garrett WE Jr. Muscle strain injuries.

American Journal of Sports Medicine 1996;24(Suppl 6):2–8 4. Garrett WE Jr, Safran MR, et al.

Biomechanical comparison of stimulated and nonstimulated skeletal muscle pulled to failure. American Journal of Sports Medicine 1987;15(5):448–54.

Recommended reading 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 978-1451109764 (Kindle £69.18, Print £27.82). Buy from Amazon http://spxj.nl/1UANMg7 2. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed.

Churchill Livingstone 2005.

ISBN 978-0443071553 (£87.74). Buy from Amazon http://spxj.nl/1K73UdZ 3. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 9780723436973 (Kindle £42.74, Print £44.99). Buy from Amazon http://spxj.nl/1g8UPJX 4. Magee DJ. Orthopaedic physical assessment, 6th ed.

Saunders 2014. ISBN 9781455709779 (Kindle £49.30, Print £51.89). Buy from Amazon http://spxj.nl/1UAP1vN 5. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill Livingstone 2013. ISBN 978-0702040665 (Kindle £58.13, Print £61.19). Buy from Amazon http://spxj.nl/1g8VFWW 6. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 9780702040672 (Kindle £53.87, Print £56.71). Buy from Amazon http://spxj.nl/1Np97ol 7. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008. ISBN 9780702029592 (£414.04). Buy from Amazon http://spxj.nl/1K75GM7

the process of evaluating the information from the subjective and objective assessment and making sense of it all, is referred to as ‘clinical reasoning’ 48

Co-Kinetic journal 2016;68(April):42-49

manual therapy student handbook

The Author Julian Hatcher Grad Dip Phys MPhil, MCSP FOM is a senior lecturer at the University of Salford and the programme leader for BSc Hons Sport Rehabilitation programme, having created it 1997.

Previously he was senior physiotherapist in Orthopaedic Medicine at Warrington Hospital Trust from 1987–1997.

He also worked in Rugby League (including Great Britain BARLA Rugby League) for 7 years as well running his own Sports Injuries Clinic in Warrington up until 1997.

Julian became a Fellow of Orthopaedic Medicine (FOM) in 2000, and Certified Strength & Conditioning Specialist in 2005. After starting with a Graduate Diploma in Physiotherapy (Grad Dip Phys), he gained his Master of Philosophy (MPhil) from the University of Salford in 2007 and has several publications around the knee particularly concerning topics such as ‘ACL deficiency: detection, diagnosis and proprioceptive acuity’ and ‘Osteoarthritis long-term outcomes’. Julian is also an Honorary Member of British Association of Sport Rehabilitators and Trainers (BASRaT).

Email: J.Hatcher@salford.ac.uk Website: Julian Hatcher, University of Salford, UK http://www.seek.salford.ac.uk/profiles/JHATCHER.jsp

Key Points

Related content

Tweet this: Clinical reasoning enables clinicians to assess and diagnose many common disorders affecting physically active people. http://spxj.nl/1MmbeGv Tweet this: The clinical reasoning process combined with knowledge of common conditions allows treatment at the symptom source. http://spxj.nl/1MmbeGv

ther articles in the Manual Therapy Student Handbook O http://spxj.nl/1ivbIR5 Other Co-Kinetic content for students - http://spxj.nl/1QXQkOx

Discussions ow may the phenomenon of ‘pain inhibition’ affect the H outcome of resisted tests?

If there is a weak but painless response to resisted testing, what are the two most likely diagnostic reasons?

Why do resisted tests need to be both maximal and isometric during diagnostic assessment?

n ‘ Clinical reasoning’ is the process of evaluating the information gleaned from both the subjective and objective assessment. nT he interpretation of the assessment results has to fit with the subjective history findings. This is often a good way to rule out differential diagnoses. nS tage 1 in the reasoning process is to identify the type of tissue involved (eg. contractile or inert). nT ypically, a positive response to resisted testing would indicate a lesion within a contractile unit. nA negative response to resisted testing, while displaying a positive response to passive testing, would indicate that the lesion lies within an inert tissue. nS tage 2 in the reasoning process is to identify the specific tissue in which the lesion lies. nC ombining this method of reasoning through the assessment findings with a knowledge of common clinical conditions should allow a therapist to make a diagnosis.

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CONTENTS PANEL Articles in this series on manual therapy include: 1. Introduction to manual therapy 2. Definitions: mobilisation, manipulation and massage 3. Musculoskeletal assessment 4. Musculoskeletal diagnosis 5. Assessment and treatment of the hip 6. Assessment and treatment of the knee 7. Assessment and treatment of the ankle and foot 8. Assessment and treatment of the shoulder 9. Assessment and treatment of the elbow 10. Assessment and treatment of the wrist and hand 11. Assessment and treatment of the cervical spine 12. Assessment and treatment of the lumbar spine 13. Assessment and treatment of the thoracic spine

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