Co-Kinetic Journal Issue 71 - January 2017 by Co-Kinetic

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

journal ISSUE 71 JANUARY 2017 ISSN 2397-138X

Formerly published as....

medicine & dynamics

what’s inside TIME SAVING/PRACTICAL WATCH 49-50 SOCIAL 04-07 JOURNAL WATCH PHYSICAL THERAPY

OF 34-40 ASSESSMENT THE FOOT & ANKLE

PHYSICAL THERAPY RESEARCH INTO PRACTICE

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SOCIALWATCH

ALTERED VERTICAL GROUND REACTION FORCES IN PARTICIPANTS WITH CHRONIC ANKLE INSTABILITY WHILE RUNNING. Bigouette J, Simon J, et al. Journal of Athletic Training 2016;51(11):doi:10.4085/1062-6050-51.11.11 Twenty-four experienced college-aged runners were categorised via selfreported questionnaires into a group with chronic ankle instability (CAI) or absence of CAI (control group). After a warm-up period, all participants ran on an instrumented treadmill for 5 minutes at 3.3m/s. Data was collected during the last 30 seconds. Five continuous trials of heel-to-toe running were identified per participant and averaged for statistical analysis. The main outcome measures were impact peak force, active peak force, time to impact peak force, peak force (milliseconds), and average loading rate. The results were that a difference was

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EYE INJURIES IN SUMMER OLYMPIC SPORTS – A MINI REVIEW. Aoto BAP, Jorge LV, Ferraz CA. Advances in Ophthalmology & Visual System 2016;4(6):000138 doi:10.15406/aovs.2016.04.00138

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This was a literature review looking for documentation of eye injuries in the Olympic sports that were due to be performed at the Rio 2016 Olympics. The usual databases were searched for case reports, series of cases and reviews with no language restriction, published in a 20-year period (1996–2016). Other sports that were not in the list of the Olympic Summer Games - Rio 2016, because they were practised only in Winter Olympic Games, were excluded. The keywords used were ‘athletic eye injuries’, ‘open globe trauma in sports’, ‘ocular trauma’, ‘ophthalmologic injuries’, ‘eye trauma’, ‘trauma in Olympic games’ and ‘eye injuries’. It was found that the USA and England published most

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of the articles. Corneal abrasion/ulcer and conjunctival haemorrhage were the most frequent injuries reported. Boxing was responsible for the most devastating ocular trauma cases. The review of indexed literature showed about 970 eyes with sports-related ocular traumas varying from mild to severe.

Co-Kinetic comment Be honest, hands up if you are involved in pitch-side care and how much do you know about eye injuries? If you do, how about writing an article for us and sharing your knowledge?

found between groups. The CAI group had higher impact peak forces and active peak forces compared with the control group. They also had had an increased loading rate and a shorter time to reach the active peak force. No difference was seen between groups in the time to reach the impact peak force.

Co-Kinetic comment The group with ankle instability produced different vertical ground reaction forces which may predispose individuals to stress-related injuries. If Carlsberg did injury prevention we would screen every runner.

EPIDEMIOLOGY OF SPORTS-RELATED EYE INJURIES IN THE UNITED STATES. Haring RS, Sheffield ID, et al. JAMA Ophthalmology 2016;doi:10.1001/jamaophthalmol.2016.4253 [Epub ahead of print] Between 2010 and 2013 data was collected from Emergency Departments (ED) across the USA. This was 30 million visits annually, at more than 900 hospitals. A total of 120,847 individuals (mean age, 22.3 years), of which 96,872 were males, 23,963 were females, and 12 had missing data, presented with sports-related ocular injury. Of these, it was the primary diagnosis in 85,961 patients. Injuries occurred most commonly among males (69,849, 81.3%) and occurred most frequently as a result of playing basketball (22.6%), playing baseball or softball (14.3%), and shooting an air gun (11.8%). Odds of presentation to the ED with impaired vision were greatest for paintball and air-gun injuries relative to football-related injuries.

Co-Kinetic comment This links nicely with the study we reported on the Olympic sports. As the authors point out, there can be serious life-changing consequences of eye injuries. Given that the highest incidence was basketball, should we be looking at eye protection, especially in young players?

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Could a robot be more effective than a human for #rehabilitation in children? The Melbourne’s Royal Children’s Hospital (RCH) is hosting a qualitative and participatory development trial to measure the effectiveness of robotic therapeutic aid for exercise rehabilitation in children. APA Paediatric Physiotherapist Joanna Butchart speaks with

14-20 PLANTAR FASCIITIS

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Co-Kinetic Journal 2017;71(January):4-7

Journal Watch STRESS-RELATED PSYCHOLOGICAL FACTORS FOR BACK PAIN AMONG ATHLETES: IMPORTANT TOPIC WITH SCARCE EVIDENCE. Heidari J, Hasenbring M, et al. European Journal of Sport Science 2016;doi:10.1080/174 61391.2016.1252429 [Epub ahead of print]

This starts with the premise that back pain (BP) is a common health problem that limits athletes functionally and creates a psychological burden. The physiological and functional aspects have been extensively studied but stressrelated psychological factors have not. A literature search resulted in four relevant articles, of which only two did a specific longitudinal study of the association between BP and psychological stress. Galambos et al. (Br J Sports Med 2005;39:351 doi:10.1136/bjsm.2005.018440) substantiated the relationship between increased mood disturbances and life stress with current BP for the first time in athletes. Heidari et al. (Phys Ther Sport 2016;21:31 doi:10.1016/j.ptsp.2016.03.003) compared the stress levels of athletes with regard to the ‘chronification’ of LBP. Those athletes with an ongoing chronification of LBP showed higher stress values in advance.

Co-Kinetic comment What this study shows is that there may be something truthful in the notion that the low back and the shoulder are emotional joints. People carry the weight of the world on their shoulders and back.

ATHLETIC TRAINING AFFECTS THE UNIFORMITY OF MUSCLE AND TENDON ADAPTATION DURING ADOLESCENCE. Mersmann F, Bohm S, et al. Journal of Applied Physiology 2016;121(4):893–899

This study aimed to provide detailed information on how athletic training affects the time course of muscle-tendon adaptation during adolescence. In 12 adolescent elite athletes (A) and 8 similarly aged controls (C), knee extensor muscle strength and patellar tendon mechanical properties were measured over the course of 1 year at 3-monthly intervals. Muscle strength and tendon stiffness increased significantly in both groups. However, the fluctuations of muscle strength were greater in the athlete group and the uniformity of changes of tendon force and stiffness was lower in athletes. They also demonstrated greater maximum tendon strain and strain fluctuations.

PHYSICAL THERAPY: PAIN, MANUAL BRAINTHERAPY AND SPORTS STUDENT PERFORMANCE HANDBOOK

MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the ankle and foot

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TABLE 1: ASSESSMENT OF THE ANKLE AND FOOT (J. Hatcher, 2013) OBSERVATION/ EXAMINATION 1. Anatomy

Co-Kinetic comment Tissue adapts to the stress placed upon it. Hence, with young athletes the double whammy of variations in mechanical loading and maturation is bound to take a toll, with the problem being an increase in muscle imbalance and the risk of potential injury. It is a challenge for coaches and health professionals.

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FUNCTIONAL AND PSYCHOLOGICAL IMPACT OF NASAL BONE FRACTURES SUSTAINED DURING SPORTS ACTIVITIES: A SURVEY OF 87 PATIENTS. Lennon P, Jaber S, Fenton JE. Ear, Nose & Throat Journal 2016;95(8):324–332

2. Initial observation

n Face and posture and gait

3. History

n Age and occupation n Site and spread n Onset and duration n Behaviour and symptoms n Past medical history (P.M.H.)

4. Inspection

n Bony deformity n Wasting

5. Objective examination

n Observe/examine state at rest and eliminate hip joint n Palpate for heat, swelling and synovial thickening

n Plantarflexion

n Colour changes n Swelling

MEDIA CONTENTS Video: Ankle and foot rehabilitation exercises

J. Hatcher, 2013

FUNCTIONAL ANATOMY A sound knowledge of anatomy is a necessary skill for the competent manual therapist. As a result, the functional anatomy of the region should be revised before continuing with assessment and treatment techniques.

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the ankle and foot are shown in Table 2.

n Dorsiflexion

n Valgus and varus (in full dorsiflexion – close packed position for ankle joint) iii. Midtarsal joint (talocalcaneonavicular and calcaneocuboid) n Dorsiflexion n Plantarflexion n Abduction n Adduction n Inversion n Eversion

Co-Kinetic comment This was a study conducted in Limerick, Republic of Ireland, so there it is no surprise that hurling and Gaelic footie are in the list but there are a lot of rugby and football injuries as well. The stand-out figure is that 33% of patients thought the injury affected their performance.

7. Resisted tests (pain and power)

n Dorsiflexion n Inversion

8. Additional specific tests

Don’t forget to perform any special tests and complete the examination with palpation of the region

Traumatic arthritis (TA)

CAPSULAR PATTERN

The capsular patterns of movement limitation at the foot and ankle are defined below. 1. Ankle n More loss of plantarflexion than dorsiflexion 2. Subtalar joint n More loss of inversion 3. Midtarsal joints n More loss of adduction and inversion 4. First metatarsalpharangeal (MTP) joint (great toe) n More loss of extension 5. Toes n More loss of flexion.

ANKLE | FOOT | 17-01-COKINETIC FORMATS WEB MOBILE PRINT

Treatment choice for the ankle joint n Mobilisations of the ankle.

TYPICAL FEATURES n Wear and tear to the joint, may be primary, or possibly secondary to previous lesion. n Mild capsulitis, possible crepitus.

Rheumatoid arthritis (RA) and other systemic arthropathies

Treatment around the ankle and foot

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

b. Ligament tests i. Ankle joint (for pain and n Inversion and eversion (in plantarflexion – loose laxity) packed position for ankle joint) ii. Subtalar joint

TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE ANKLE AND FOOT (J. Hatcher, 2013) CAUSE Osteoarthritis (OA)

Assessment of the ankle and foot

For a full assessment of the ankle and foot, the therapist should perform the observations and examinations detailed in Table 1 and Video 2.

6. Passive tests (for pain, range and end-feel) a. Gross ankle movements

This was a survey of 217 patients who had experienced a nasal bone fracture over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, whereas the other 103 (77.4%) had undergone manipulation under anaesthesia. Eighty-four percent of the patients (n=87) were contacted by telephone and data was obtained from them. The most common sports associated with these 87 injuries were hurling (n=26; 29.9%), rugby (n =22; 25.3%), Gaelic football (n=20; 23.0%) and soccer (n=13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later. Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of re-injury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether.

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DETAILS n Dermatomes L4: medial side of foot and great toe L5: dorsum of foot and medial 3 toes S1: sole of foot and lateral 2 toes S2: heel n Myotomes L4: foot and toe extensors, and foot invertors L5: toe extensors, flexors and foot evertors S1: plantar flexors and evertors

Video 1 shows surface marking of the anatomical area and will help you with the key structures encountered in this article.

This article is the seventh from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common foot and ankle complaints. As well as listing a comprehensive assessment procedure, the treatments are described in full and have accompanying videos, which provides a great practical resource for the clinician. Read this online http://spxj.nl/1QhCeX9

n Systemic autoimmune disease, causing degeneration and possible joint disruption. n Often severe capsulitis, may lead to joint laxity and deformity.

PHYSICAL THERAPY MSK DIAGNOSIS AND REHABILITATION

n Need to treat for swelling first (exercises and/or electrotherapy).

n Common in the ankle joint.

Dorsiflexion mobilisation (Video 4) Directions: 1. Stand at side of patient with cephalad

Video 1: Surface marking of the ankle region (Video with captions but no sound; J. Hatcher, 2013)

Video 3: Mobilisations of the ankle: plantarflexion (Video with captions but no sound; J. Hatcher, 2013)

BY DR CHRISTOPHER NORRIS PHD, MCSP

n Plantarflexion (in standing) n Eversion

Co-Kinetic sportEX Journal journal 2017;71(January):34-40 2016;68(April):XX-XX

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Chronic plantar heel pain (CPHP) is pain under the front of the heel bone (calcaneus). It is said to account for about 1% of all orthopaedic referrals, and occurs in up to 7% of the adult population in general. In runners, the incidence is slightly higher with 8–10% affected (1,2). Functionally, the plantar fascia (PF)

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PLANTAR FASCIITIS: OVERVIEW

ANKLE-FOOT | LOWER-LIMB | RUNNING | HANDOUT | 17- 01 -COKINETIC FORMATS WEB MOBILE PRINT 5

Video: Heel-raise Exercises for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Supported Lunge for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG

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Video: Quarter Squat Exercise for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG

acts as an important mechanical link between the rearfoot and forefoot. At heel contact, the curved surface of the calcaneus acts as a rocker or roll over shape (3) to help facilitate forward body motion. Similarly, the body weight rolls over the curved ankle (talocrural) joint mortise and ball of the foot [1st metatarsophalangeal (MTP) joint], the combined motion of the three body parts being described as the 3-rocker system (4). As the body weight moves forwards, the foot acts as a mobile adaptor flattening both the longitudinal and transverse arches to absorb load through tissue extensibility. Further forward motion of the body sees the foot change to a rigid lever to prepare for the propulsive phase of gait and toe off. The change from tissue lengthening (adaptor) to tissue tension (lever) comes about as a result of the windlass effect where the PF is wound up around the 1st MTP joint as the heel lifts and the foot moves into plantarflexion. Tension is seen in both the PF and Achilles tendon, which effectively transmits the contractile force created by the calf musculature. As the fascia tightens through the windlass effect, it shortens the foot by

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Induced Muscle Damage Science Translational Medicine 2012-02-01

KINESIOLOGY TAPE DOES NOT FACILITATE MUSCLE PERFORMANCE:

A Deceptive Controlled Trial Manual Therapy 2014-08-22

THE EFFECT OF AROMA HAND MASSAGE THERAPY FOR PEOPLE WITH DEMENTIA Journal of Alternative & Complementary Medicine 2015-09-20

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TO PREVENT SPORTS INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED

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CONSENSUS STATEMENT ON CONCUSSION IN SPORT: THE 4TH INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT HELD IN ZURICH, NOVEMBER 2012

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A Deceptive Controlled Trial Manual Therapy 2014-08-22

CORTISOL DECREASES AND SEROTONIN AND DOPAMINE INCREASE FOLLOWING MASSAGE THERAPY

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REVIEWER: Dan Buchanan BSc BTEC(5) SRMT, MSMA

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ISOMETRIC EXERCISE INDUCES ANALGESIA AND REDUCES INHIBITION IN PATELLAR TENDINOPATHY

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All manual therapists (physiotherapists, sports therapists, sport rehabilitators, osteopaths, chiropractors, soft tissue therapists, bodyworkers). It lends itself particularly well to those working and aspiring to work with elite athletes as this is the context from which Paula has formulated this book. It makes a complicated subject simple and enables the reader to fully understand the influence of the sacroiliac joint (SIJ) and Co-Kinetic.com

its effects upon the neuromyofascial matrix in sporting performance as well as the regular activities of daily living.

OVERVIEW Over 20 years of experience and expertise have been distilled down into an excellent comprehensive and concise reference book on a crucial area of the body. A must read for all practitioners, whether newly qualified or highly experienced.

MAIN CONTENTS The book is divided into seven chapters. The main meat of the book is built around the assessment and treatment of sacroiliac joint dysfunction and piriformis syndrome. This is backed up by thorough up-to-date chapters on fascia, dry needling, dynamic taping, and a useful appendix covering the theory and practice of instrument-assisted softtissue mobilisation (IASTM).

KEY FEATURES/STRENGTHS AND WEAKNESSES Strengths This book is very well structured and easy to use as a reference. Concepts are easy to understand and there are excellent photos and illustrations throughout. There is lots of underpinning knowledge regarding anatomy/physiology and pathology of the SIJ and piriformis –

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THE EFFECT OF AROMA HAND MASSAGE THERAPY FOR PEOPLE WITH DEMENTIA

Journal of Alternative & Complementary Medicine 2015-09-20

SACROILIAC JOINT DYSFUNCTION AND PIRIFORMIS SYNDROME

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it’s not just a book of treatment tips and tricks. This level of background knowledge enables the practitioner to assess more thoroughly and apply treatment techniques much more effectively. It feels much like having Paula with you in your clinical environment. For those who work alone or haven’t had an opportunity to work in an elite multidisciplinary team this is a brilliant thing.

Weaknesses It is possible that more experienced practitioners might quickly scan through this book and think that they have seen lots of the assessment and treatment techniques before. Personally, as an experienced sport rehabilitator and now soft tissue therapist, there were lots of useful assessment and treatment ideas that I benefited from.

BOOK STYLE Much like Paula’s teaching style this book is relaxed and informative. It is very easy to dip in and out of. There are excellent photos of hands-on techniques with the structural anatomy underneath, extra information boxes and detailed anatomy boxes for the relevant muscles and structures acting on and around the hip and pelvis. It would work very well as a teaching/CPD resource for medical departments, colleges and universities.

INTERACTIVE EXTRAS (ARE THERE ANY AND IF SO WHAT ARE THEY?) There are no interactive extras but the book is written and presented in a fresh and modern style.

YOUR OVERALL OPINION I would highly recommend this book to all manual therapists. Working in a similar field, I have looked up to Paula over the years and followed her career. Three

STRUCTURE AND FUNCTION OF THE PLANTAR FASCIA The PF is a thick tissue layer stretching from the calcaneus to the toes. It averages 12cm in length and 2–6cm

Sesamoid

Flexor hallucis Plantar longus oponeurosis

Plantar fascia

Figure 1: Anatomy of the plantar fascia (PF) and the windlass mechanism (Moseley C. sportEX medicine 2013;55:15)

Co-Kinetic Journal 2017;71(January):14-20

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calcaneal tuberosity, and altered tissue signal. MRI has an important use in ruling out co-morbidities such as infection or tumour. US scanning has been shown to be reliable in assessing the progress of a treatment, to indicate tissue changes over a time period (7). Bilateral or atypical heel pain may require laboratory tests such as rheumatoid factor, uric acid, blood count or erythrocyte sedimentation rate (ESR) to assess systemic causes. Table 1 shows alternative names for the condition and differential diagnoses.

MOVEMENT VARIATION IS LIKELY TO ENHANCE FUNCTION MORE THAN THE REPEATED USE OF THE SAME EXERCISE ACTIONS OVER TIME in width. Attaching from a point just behind the inner (medial) tubercle of the calcaneus it runs anteriorly as medial, lateral, and central portions. The PF is divided into a thicker central portion and thinner medial and lateral bands. The medial band is continuous with the abductor hallucis muscle (big toe abductor), the lateral band with the abductor digiti minimi (little toe abductor) (Fig. 1). As it approaches the metatarsal heads the fascia divides into superficial and deep layers, with the superficial layer attaching beneath the skin, and the deep layer dividing into two portions to surround each of the five flexor tendons. Each of these five portions attaches to the base of a proximal phalanx and to the deep transverse ligament, which runs across the centre of the forefoot. On dissection, the PF has been found to extend backwards over the calcaneus as a 1–2mm think band (continuous with the periosteum) to merge with the paratenon of the Achilles tendon (1). Through this linkage, forces within the fascia may be transmitted to and from the myofascia stretching along the length of the posterior leg.

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foot arch. Imaging may be used to assess the condition and to rule out other pathologies. Plain radiograph (X-ray) is non-specific, but will often show a calcaneal bone spur which may be asymptomatic. Bone scan will show increased uptake at the medial calcaneal tubercle and may be used to rule out stress fracture. Ultrasound (US) has the convenience of immediate application, but is far more reliant on the skill of the operator. Typically, it shows fascial thickening and fascial regions which appear darker as they reflect less ultrasound (hypoechoic). Magnetic resonance imaging (MRI) can be used to show swelling (oedema) of the fascia and adjacent fat pad, fascial thickening (usually in the proximal PF), bone marrow oedema to the medial

FOR THERAPISTS: FROM PLANNING TO IMPLEMENTATION

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DIFFERENTIAL DIAGNOSIS OF PLANTAR FASCIITIS Pain in this condition is usually over the calcaneal attachment of the PF or its medial edge. Pain may be localised to the heel as though the athlete is ‘stepping on a stone’, or may present as a burning sensation over the inner

Differential diagnosis ■ Calcaneal apophysitis (Sever’s disease) ■ Calcaneal stress fracture or other bone injury ■ Fat pad syndrome (atrophy, heel bruise) ■ Inflammatory or reactive arthritis (Reiter syndrome/ankylosing spondylitis/psoriatic arthritis) ■ Bone pathology (osteomalacia/osteomyelitis/ Paget’s disease/bone cyst) ■ PF rupture/local tissue infection ■ Tumour (sarcoma) ■ PF fibromatosis (Ledderhose’s disease) ■ Calcaneal or retrocalcaneal bursitis ■ Neural referral lumbosacral, local neuritis, tarsal tunnel syndrome)

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raising the longitudinal arch (Fig. 1). The combination of these effects supinates the foot (high arch) making it more rigid to push from the ground. As the foot contacts the ground again at heel strike, the arch lowers and the foot pronates (flat arch) becoming more mobile to adapt to the uneven ground. The plantar fascia is relaxed as the foot lengthens, to accommodate to the surface. The functional linkage between the PF and posterior leg structures is paralleled by pathology. A positive association between Achilles tendon loading and PF tension has been demonstrated, and chronic stretching and tightness of the Achilles tendon are risk factors for plantar fasciitis (5). Greater tightness in posterior leg muscles is also seen in plantar fasciitis patients (6).

BY TOR DAVIES, CO-KINETIC FOUNDER

41 BOOK REVIEW

ISSUE 70 OCTOBER 2016 ISSN 2397-138X

Alternative names ■ Chronic plantar heel pain (CPHP) ■ Painful heel syndrome ■ Plantar fasciitis ■ Plantar fasciopathy ■ Plantar tendinopathy ■ Plantar enthesopathy ■ Subcalcaneal bursitis ■ Neuritis ■ Medial arch pain ■ Stone bruise ■ Calcaneal periostitis ■ Heel spur ■ Subcalcaneal spur ■ Calcaneodynia

This article outlines the latest incidence statistics for chronic plantar heel pain, explains how the structure and function of the plantar fascia is affected by pathology, outlines a detailed differential diagnosis and then delves into an evidence-based exploration of passive treatment options, exercise therapy and late stage rehabilitation. We have also created an accompanying Heel Pain Content Marketing Kit (http://spxj.nl/2fnESRn) which contains all the material you need to build awareness about Heel Pain and the how physical therapy can speed up the recovery process. This includes a social media awareness campaign, material for an email and a website article, a postal campaign using leaflets and postcards and a poster campaign for your work area and for the areas of any partners you collaborate with. This Kit is included as part of a full site subscription or can be purchased individually for those without a full site subscription. More information about our campaign kits in general can be found here (http://spxj.nl/2fIhRsa) and to read this article online go to http://spxj.nl/2gy2ZjG.

Anterior–posterior (AP) talus mobilisation (Fig. 1) Directions: 1. Similar stance position to dorsiflexion mobilisation but with hands placed around anterior and posterior aspect of ankle region. 2. Specifically place cephalad hand around posterior aspect of distal tibia and fibula, and caudad hand around head of talus. 3. Take talus posteriorly, using other

Video 2: Assessment of the ankle and foot (Video with captions but no sound; J. Hatcher, 2013)

TABLE 1: PLANTAR FASCIITIS NOMENCLATURE AND DIFFERENTIAL DIAGNOSIS (C. Norris, 2016)

PLANTAR FASCIITIS: A PAIN IN THE HEEL

n Treatment to ligaments as necessary and mobilise as pain allows, Grade A–B (I–IV). Plantarflexion mobilisation (Video 3) Directions: 1. Stand at end of bed with patient lying prone. 2. Place both hands around foot and ankle keep fingers around anterior aspect of talus and thumbs on inferior aspect of calcaneus. 3. Take lower leg into extension while plantar-flexing the ankle. 4. It may be helpful to place a pillow below the patient’s foot as a comfortable block to movement depending on the required grade of mobilisation (Grade IIs and IIIs are sometimes referred to as ‘flapping techniques’).

Reward programmes come in all shapes and sizes, some of the biggest customer reward programmes include Airmiles, Nectar, Boots, every supermarket scheme, British Airways, John Lewis Partnership cards, Costa Coffee … everyone’s at it. Generally the overriding goal of any scheme, as we know all too well, is to increase a business’ bottom line; however, the ways in which this is achieved comes in many forms, some more subtle than others. For the purposes of this article we’re going to look specifically at referral, or ‘refer a friend’, programmes and simple loyalty programmes as these are two easy ways to increase your profitability, at very little cost.

Referral vs Loyalty – What’s the Difference? ■ A referral programme uses your existing customers to bring in new

customers through word of mouth. The purpose is to attract new customers at a lower cost. ■ A loyalty programme rewards existing customers for frequently buying your services (or purchasing products). The purpose is to encourage repeat customers and increase loyalty to you as a business or service provider.

PA N

HEEL PAIN: THE 10 MINUTE ASSESSMENT

“One of the side benefits of a referral programme is it also increases loyalty. Customers who refer tend to be more loyal, and loyal customers tend to refer more.”

Why Bother with a Reward Programme? ■ Generally speaking, it costs 5–6 times more to acquire new customers than to retain old ones. ■ Existing customers spend around 60–70% more than new customers. ■ Following Pareto’s Law (or the 80:20

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AUTHOR: Paula Clayton PUBLISHER: Lotus Publishing/North Atlantic Books EDITION: First ISBN: 978-1-905367-64-1 RRP: £18.99 Buy from Amazon http://amzn.to/2gCC7Qn years ago I attended one of her weekend hip and pelvis masterclasses and was impressed that as well as being an excellent practitioner she was a fantastic teacher too. It does not surprise me that she has gone on to write a book on this – her specialist subject. Recently I went to hear Sir Clive Woodward speak on what makes a champion. He made two great points: 1. Champions share their ideas with others. 2. To become a champion at something, imagine you are writing a book on what it is you do. Work out the chapters and then start gathering information, sharing it with your peers, put it into practice and learn from your experiences.

When asked to review this book this advice immediately came to mind. Paula Clayton has been a champion performance therapist for over 20 years working at a highly elite level; the fact that she is willing to share her experience and expertise in the pages of this excellent reference book is an opportunity not to be missed.

THERAPY & SPORTS 08-09 MANUAL MED C NE RESEARCH NFORMAT ON

29-33

WHICH OF THE FOLLOWING WOULD YOU DEEM IT? ■ A ‘Must have’ item

✓

■ A ‘Nice to have’ item

COMBINED MOVEMENT THEORY FOR MASSAGE THERAPISTS

■ Useful but not essential ■ Not essential ■ Don’t bother

REVIEWER BIOGRAPHY Dan is a senior soft tissue therapist with 14 years of experience working in elite and professional sport. He currently splits his time between working for Derby County FC and running his own clinic GoPerform in Reading, UK. Email: dan@go-perform.co.uk

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MANUAL THERAPY MASSAGE THERAPY

COMBINED MOVEMENT THEORY FOR MASSAGE THERAPISTS We have all been in the situation where a patient presents to us with severe pain and impaired motion in a particular direction. We want to relieve their pain but don’t want to do too much treatment and make them feel worse. Combined Movement Theory (CMT) is an examination and treatment framework incorporating spinal manipulation techniques, muscle energy techniques and mobilisation. Patients are placed in comfortable positions and moved in a manner that evokes a brain orchestrated pain inhibition mechanism, quickly. Patients learn that the threat they perceived, with a particular motion, can be simply reduced with movement. Now that we understand the neurophysiological effects of Dr Brian Edwards’ ‘combined movements’, it is clinically reasonable and a valuable tool for anyone interested in addressing specific impairments with specific physical education (Manual Therapy). This article will explain the essential elements of CMT, how to put theory into practice, how to incorporate mobilisation and manipulation, how to detect regular and irregular patterns of spinal movement, and finally how to progress treatments. Read this online http://spxj.nl/2fEoKtm BY DR CHRIS MCCARTHY PHD, FCSP FMACP The concept of ‘combined movements’ examination and treatment was developed by Dr Brian Edwards, a

BOX 1: DEFINITION OF COMBINED MOVEMENT THEORY (C. C. McCarthy, 2016) 2016 Combined Movement Theory (CMT) is an examination and treatment framework that incorporates spinal manipulation techniques, muscle energy techniques and mobilisation. The examination component looks at the influence of the starting and finishing positions on movement impairment and then uses these positions to intervene therapeutically.

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specialist manipulative physiotherapist from Australia and the principles incorporated into the practice of other manual therapists, such as Geoff Maitland (Maitland Concept).

AN INTRODUCTION TO COMBINED MOVEMENT THEORY The spinal positions we adopt to allow full function are three-dimensional and are continuously adapting to the functional demands placed on us. Naturally, the spinal system cannot always immediately accommodate to these demands and consequently shortand long-term impairment can result. In a system that continuously changes position and demands the acquisition of new and challenging positions the integrated control of movement can be compromised. Combined Movement Theory (CMT; Box 1) offers the investigator a framework to examine

the influence of starting and finishing positions on movement impairment and how to use these positions to intervene therapeutically. Figure 1 outlines the process of CMT. When it appears appropriate to intervene with therapeutic spinal movement, be it with muscle contractions, passive mobilisation or manipulative thrust techniques, the starting and ending positions of these movements are crucial. The underlying paradigm of these interventions is that the position in which these movements are undertaken has a superior effect on reducing dysfunction than inducing movement in a random fashion. Although this contention is debated (2), a significant number of clinicians reading this article will believe that the painful position of the spine is related to the patient’s dysfunction and that interventions that take this relationship into consideration may be more effective than the prescription of random movement or generic exercise. This simple assumption leads the quest for appropriate treatment into the realm of specific assessment and induction of spinal motion in spinal dysfunction. Thus, the examination and treatment of spinal dysfunction in presentations where positions and postures are important in its aetiology and maintenance should include a threedimensional assessment of motion. In addition, therapeutic strategies should include a consideration for starting and finishing positions. CMT fulfils these requirements and thus has considerable clinical utility. It is a system of examination that emphasises the expansion of the musculoskeletal examination to fully evaluate the active and passive combinations of physiological and accessory movement of the vertebral column and offers the investigator an

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT ALTERED VERTICAL GROUND REACTION FORCES IN PARTICIPANTS WITH CHRONIC ANKLE INSTABILITY WHILE RUNNING. Bigouette J, Simon J, et al. Journal of Athletic Training 2016;51(11):doi:10.4085/1062-6050-51.11.11 Twenty-four experienced college-aged runners were categorised via selfreported questionnaires into a group with chronic ankle instability (CAI) or absence of CAI (control group). After a warm-up period, all participants ran on an instrumented treadmill for 5 minutes at 3.3m/s. Data was collected during the last 30 seconds. Five continuous trials of heel-to-toe running were identified per participant and averaged for statistical analysis. The main outcome measures were impact peak force, active peak force, time to impact peak force, peak force (milliseconds), and average loading rate. The results showed a difference

EYE INJURIES IN SUMMER OLYMPIC SPORTS – A MINI REVIEW. Aoto BAP, Jorge LV, Ferraz CA. Advances in Ophthalmology & Visual System 2016;4(6):000138 doi:10.15406/aovs.2016.04.00138 This was a literature review looking for documentation of eye injuries in the Olympic sports that were due to be performed at the Rio 2016 Olympics. The usual databases were searched for case reports, series of cases and reviews with no language restriction, published in a 20-year period (1996–2016). Other sports that were not in the list of the Olympic Summer Games - Rio 2016, because they were practised only in Winter Olympic Games, were excluded. The keywords used were ‘athletic eye injuries’, ‘open globe trauma in sports’, ‘ocular trauma’, ‘ophthalmologic injuries’, ‘eye trauma’, ‘trauma in Olympic games’ and ‘eye injuries’. It was found that the USA and England published most

Co-Kinetic comment Be honest, hands up if you are involved in pitch-side care and how much do you know about eye injuries? If you do, how about writing an article for us and sharing your knowledge?

between the two groups. The CAI group had higher impact peak forces and active peak forces compared with the control group. They also had an increased loading rate and a shorter time to reach the active peak force. No difference was seen between groups in the time to reach the impact peak force.

EPIDEMIOLOGY OF SPORTS-RELATED EYE INJURIES IN THE UNITED STATES. Haring RS, Sheffield ID, et al. JAMA Ophthalmology 2016;doi:10.1001/jamaophthalmol.2016.4253 [Epub ahead of print] Between 2010 and 2013 data was collected from Emergency Departments (ED) across the USA. This represented 30 million visits annually, at more than 900 hospitals. A total of 120,847 individuals (mean age, 22.3 years), of which 96,872 were males, 23,963 were females, and 12 had missing data, presented with sports-related ocular injury. Of these, it was the primary diagnosis in 85,961 patients. Injuries occurred most commonly among males (69,849, 81.3%) and occurred most frequently as a result of playing basketball (22.6%), playing baseball or softball (14.3%), and shooting an air gun (11.8%). Odds of presentation to the ED with impaired vision were greatest for paintball and air-gun injuries relative to football-related injuries.

Co-Kinetic Journal 2017;71(January):4-7

PHYSICAL THERAPY RESEARCH INTO PRACTICE

ATHLETIC TRAINING AFFECTS THE UNIFORMITY OF MUSCLE AND TENDON ADAPTATION DURING ADOLESCENCE. Mersmann F, Bohm S, et al. Journal of Applied Physiology 2016;121(4):893–899

FUNCTIONAL AND PSYCHOLOGICAL IMPACT OF NASAL BONE FRACTURES SUSTAINED DURING SPORTS ACTIVITIES: A SURVEY OF 87 PATIENTS. Lennon P, Jaber S, Fenton JE. Ear, Nose & Throat Journal 2016;95(8):324–332 This was a survey of 217 patients who had experienced a nasal bone fracture over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, whereas the other 103 (77.4%) had undergone manipulation under anaesthesia. Eighty-four percent of the patients (n =87) were contacted by telephone and data was obtained from them. The most common sports associated with these 87 injuries were hurling (n=26; 29.9%), rugby (n =22; 25.3%), Gaelic football (n =20; 23.0%) and soccer (n =13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later. Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of re-injury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether.

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THE EFFECT OF A STANDARD WHOLE BLOOD DONATION ON OXYGEN UPTAKE AND EXERCISE CAPACITY: A SYSTEMATIC REVIEW AND META-ANALYSIS. Van Remoortel H, De Buck E, et al. Transfusion 2016;doi:10.1111/ trf.13893 [Epub ahead of print] This study examines the effect of donating blood on exercise. Studies from six databases dealing with a standard whole-blood donation (400–500ml) followed by sub-maximal exercise were reviewed. The outcomes included exercise-related blood variables [haemoglobin (Hb) concentration, haematocrit, and red blood cell count] and endurance exercise variables (sub-maximal oxygen uptake, peak work rate, and time to exhaustion). Overall effects at different time points post-donation were investigated by performing meta-analyses and calculating mean differences. The search identified 6237 references and finally included 18 before–after studies of low quality. Twenty-four to forty-eight hours after a blood donation: (1) Hb concentration was reduced (7% decrease) until 14 days after the blood donation (4% decrease), (2) sub-maximal oxygen uptake (VO2max) was lower (7% decrease), and (3) a reduction in maximal exercise capacity (10% decrease) was present.

Co-Kinetic comment ‘Save a life give blood’. Just wait a while afterwards if you are going to play a competitive game. This doesn’t say don’t exercise, it says your capacity to do so will be reduced.

RETURN TO SPORTS AFTER MULTIPLE TRAUMA: WHICH FACTORS ARE RESPONSIBLE? RESULTS FROM A 17-YEAR FOLLOW-UP. Weber CD, Horst K, et al. Clinical Journal of Sport Medicine 2016;doi:10.1097/JSM.0000000000000373 This was a cohort study of 637 patients at a level 1 trauma centre, to assess the long-term outcome of severe trauma on return to sporting activities (RTS). Data collated on the multiply injured patient included preinjury physical activity, standardised outcome scores, (Hannover score for polytrauma outcome and Tegner activity scale) and clinical follow-up of at least 10 years’ duration. The mean follow-up was 17±5 years. The study included 465 patients, comprising 207 athletic and 258 non-athletic individuals. Mean age at the time of injury was 26±11.5 years and injury severity was comparable between the two cohorts. The deleterious effects on quality of life and the total duration of the rehabilitation process were also similar in athletes and non-athletes. Athletes were more likely to be unable to return to pre-injury activities, or to return to a lower level of sporting prowess post-trauma. We identified knee injuries as the type of musculoskeletal trauma most likely to be career ending for the athlete.

Co-Kinetic comment This one is frustrating because what we would like to know, but probably never will, is the level of rehab the individuals had and what the specific factors were that prevented return to previous levels of activity. Was it really the level of trauma, or a lack of compliance in the rehab programme, or the psychological issues involved in the return?

HE DIES, HE SCORES: EVIDENCE THAT REMINDERS OF DEATH MOTIVATE IMPROVED PERFORMANCE IN BASKETBALL. Zestcott CA, Lifshin U, et al. Journal of Sport and Exercise Psychology 2016;doi:http://dx.doi.org/10.1123/jsep.2016-0025 This is about applying the concepts of defensive terror management to sports. Two experiments were set up. In the first, players took part in two 1 v 1 basketball games between which they were asked to think about either their impending demise or basketball. Games were played on a half court with players matched for size and build. Participants could score points by making a 3-point shot or a 2-point shot. After a basket was made the possession of the ball changed. The experimenter called all fouls and turnovers. The first player to score 12 or more points won the game. Questionnaires were completed before and after the games, including one that determined whether they liked playing basketball and cared about their performance in sports. Questionnaires were analysed and independent coders blind to the experimental conditions reviewed videos of the game and coded the players’ performance in each game. The ‘death thought’ group had an increase of more than 20% in the average points scored in the basketball game between the groups and 40% increase from Game 1 to Game 2 within subjects. The results revealed an effect on scoring points rather than other aspects of playing basketball, such as rebounds, blocks, and turnovers. Consequently a second study concentrated on the results of scoring tasks alone. This time a ‘subtle death prime’ was used. For this the experimenter introducing the task to the players wore a T-shirt with a skull and the word ‘death’ printed on it. A control group were not subjected to the T-shirt wearer. Players who were primed with death scored more points.

Co-Kinetic comment There is nothing new about this concept. It was discussed by Sun Tzu in The Art of War in the 5th century. The example he used is don’t back an opposing army into a blind canyon from which they have no escape or they will have no choice but to ferociously fight to the death. This paper should be commended, however, for starting with a quote from former Liverpool F.C. manager Bill Shankly: ‘Some people think that football is a matter of life and death. I assure you, it’s much more serious than that.’ Terror management theory is about the psychological conflict that results from having a desire to live, but realising that death is inevitable. The terror that this thought produces is managed by embracing cultural values, or symbolic systems that act to provide life with meaning and value. Shankly expresses it better.

Co-Kinetic Journal 2017;71(January):4-7

PHYSICAL THERAPY RESEARCH INTO PRACTICE

RETURN TO SPORTS AND FUNCTIONAL RESULTS AFTER REVISION ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION BY FASCIA LATA AUTOGRAFT. Mirousea G, Rousseau R, et al. Orthopaedics & Traumatology, Surgery & Research 2016;102(7):863–866

MCMURRAY’S TEST AND JOINT LINE TENDERNESS FOR MEDIAL MENISCUS TEAR: ARE THEY ACCURATE? Gupta Y, Mahara D, Lamichhane A. Ethiopian Journal of Health Sciences 2016;26(6):567–572 Sixty patients (41m/19f) who underwent knee arthroscopy during a one year period were included in the study. The age range was 11–70 years (mean, 27.35±11.70 years). Sportsrelated injury was seen in 21 (33.9%) patients, 42.9% had contact injury and 57.1% had non-contact injury. Other than sports-related injury, road traffic accident was 11 (17.7%), fall from height accounted for 12 (19.4%), injury resulting from squatting or getting up from squatting position occurred in 3 (4.8%), spontaneous onset was 14 (22.6%) and other injury pattern formed 1 (1.6%). Duration of presentation varied from 1 week to 96 months, with an average of 19.18 months. Twenty-eight patients (45.2%) underwent arthroscopy in the left knee, whereas the rest had it in right knee. Each patient was clinically examined with McMurray’s test and joint line tenderness. The findings were then matched by the arthroscopic findings. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for medial joint line tenderness in diagnosing medial meniscus tear were 50%, 61.7%, 51.8%, 60% and 56.45%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for McMurray’s test for diagnosing medial meniscus tear were 54%, 79%, 68% , 67.50% and 67.74%, respectively.

Co-Kinetic comment Recently there has been some bad press about the fact that African science and scientists do not get a fair deal. We are, therefore, proud to welcome the Ethiopian Journal of Health Sciences to our roster. Their detailed results indicate that the two tests are not very good predictors of meniscus pathology. They do add that when combined with a good history they may still have diagnostic value. Co-Kinetic.com

This study examined 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multiligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at the end of followup. At a mean 4.6±1.6 years’ follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective International Knee Documentation Committee (IKDC) score increased from 57 preoperatively to 82 at last follow-up, the Lysholm knee score went from 46–90 and the knee injury and osteoarthritis outcome score (KOOS) score at last follow-up was 94.7. All of which suggests that using a fascia lata graft is reliable.

Co-Kinetic comment Apparently the surgical revision rate following ACL surgery is 3% at 2 years and 4% at 5 years, which leaves surgeons wondering which type of graft to use. This study shows that taking the graft from the fascia lata provides a reliable graft in revision ACL surgery. REVIEWING MORPHOLOGY OF QUADRICEPS FEMORIS MUSCLE. Chavan SK, Wabale RN. Journal of Morphological Science 2016;33(2):112–117 This study examined the dissection of 40 lower limbs (20 right and 20 left) from 20 embalmed cadavers. It was found that rectus femoris was a separate entity in all the cases. Both the vastus medialis (VM) and vastus lateralis (VL) were found to have two parts, which were classed as oblique and longus. The quadriceps group had variability in fusion between members of the group and this fusion varied greatly. The insertion level of VM and VL on the patella varied greatly with VL found to be along the whole extent of the lateral border. In one case there was an extension of a fibrous band-like structure from the lower horizontal fibres of VL to the adductor tubercle.

Co-Kinetic comment Don’t believe all you read in anatomy textbooks. 7

British Journal of Sports Medicine 2013-10-07

THE EFFECTIVENESS OF EXERCISE INTERVENTIONS TO PREVENT SPORTS INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS

British Journal of Sports Medicine 2009-04-01

MECHANOTHERAPY: HOW PHYSICAL THERAPISTSâ&#x20AC;&#x2122; PRESCRIPTION OF EXERCISE PROMOTES TISSUE REPAIR

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ANALYSIS OF THE LOAD ON THE KNEE JOINT AND VERTEBRAL COLUMN WITH CHANGES IN SQUATTING DEPTH AND WEIGHT LOAD

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ISOMETRIC EXERCISE INDUCES ANALGESIA AND REDUCES INHIBITION IN PATELLAR TENDINOPATHY

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ANALYSIS OF HEAD IMPACT EXPOSURE AND BRAIN MICROSTRUCTURE RESPONSE IN A SEASON-LONG APPLICATION OF A JUGULAR VEIN COMPRESSION COLLAR: A PROSPECTIVE, NEUROIMAGING INVESTIGATION IN AMERICAN FOOTBALL

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CONSENSUS STATEMENT ON CONCUSSION IN SPORT: THE 4TH INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT HELD IN ZURICH, NOVEMBER 2012

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Medicine & Science in Sports & Exercise 2016-07-06

FOOTWEAR MATTERS

Pediatrics 2016-07-18

THE FEMALE ATHLETE TRIAD

American Journal of Sports Medicine 2016-06-16

THE NFL ORTHOPAEDIC SURGERY OUTCOMES DATABASE (NO-SOD): THE EFFECT OF COMMON ORTHOPAEDIC PROCEDURES ON FOOTBALL CAREERS

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN SPORTS MEDICINE (OCT-DEC 2016)

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THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN POPULATIONS – A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population Pain Medicine 2016-05-10

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN POPULATIONS – A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations Pain Medicine 2016-05-10

MASSAGE THERAPY ATTENUATES INFLAMMATORY SIGNALING AFTER EXERCISE:

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ONE-YEAR OUTCOME OF SUBACROMIAL CORTICOSTEROID INJECTION COMPARED WITH MANUAL PHYSICAL THERAPY FOR THE MANAGEMENT OF THE UNILATERAL SHOULDER IMPINGEMENT SYNDROME: A Pragmatic Randomized Trial Annals of Internal Medicine 2014-08-04

MANUAL PHYSICAL THERAPY VERSUS SURGERY FOR CARPAL TUNNEL SYNDROME: A Randomized Parallel-Group Trial Journal of Pain 2016-05-10

A Deceptive Controlled Trial Manual Therapy 2014-08-22

THE EFFECT OF AROMA HAND MASSAGE THERAPY FOR PEOPLE WITH DEMENTIA

Journal of Alternative & Complementary Medicine 2015-09-20

CORTISOL DECREASES AND SEROTONIN AND DOPAMINE INCREASE FOLLOWING MASSAGE THERAPY

Induced Muscle Damage Science Translational Medicine 2012-02-01

KINESIOLOGY TAPE DOES NOT FACILITATE MUSCLE PERFORMANCE:

THE MECHANISMS OF MANUAL THERAPY IN THE TREATMENT OF MUSCULOSKELETAL PAIN:

International Journal of Neuroscience 2005-01-01

A Comprehensive Model Manual Therapy 2009-10-01

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DO MANUAL THERAPIES HELP LOW BACK PAIN? A Comparative Effectiveness Meta-analysis Spine 2014-01-29

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MANIPULATION THERAPY RELIEVED PAIN MORE RAPIDLY THAN ACUPUNCTURE AMONG LATERAL EPICONDYLALGIA (TENNIS ELBOW) PATIENTS: A RANDOMIZED CONTROLLED TRIAL WITH 8-WEEK FOLLOW-UP. Hsu CY, Lee KH, et al. Evidence-Based Complementary and Alternative Medicine 2016;2016:3079247 doi:10.1155/2016/3079247 Thirty-five patients with a history of lateral epicondylalgia lasting more than 2 months were split into manipulation or acupuncture treatment groups. The manipulation was described as a radial bone adjustment to reverse positional fault and relieve the biceps brachii muscle tension. This was done twice in 1 minute with an interval of 30 seconds. The acupuncture group received six acupoints at named points with the needles being in place for 25 minutes. Both groups received the treatments twice a week for 2 weeks. Outcome assessment was pain relief using a VAS scale during rest, daily activity, and work situations, from the beginning of the study up to 8 weeks, plus a functional impairment [disabilities of the arm, shoulder, and hand (DASH)] questionnaire was used. In addition grip strength was measured using a

This study involved 100 elite, male golfers aged 16–25 years attending a professional gold academy who all had shortened hip flexors as determined by a modified Thomas test and a golf handicap of less than 6. They were randomly assigned to one of three groups. Group 1, the stretch group (n = 34), received myofascial trigger point therapy (MTPT) followed by two different 60-second static stretches of the iliopsoas. Group 2, the ball group (n =33), received MTPT followed by a 60-second static stretch and then a medicine ball exercise. Group 3 were a control group (n=33) who received no intervention but remained in the treatment room for the same amount of time as the intervention groups. The trigger point treatment was described as

hand dynamometer each time before treatment procedure and at the follow-up at 2 and 8 weeks. Both groups demonstrated changes in pain VAS score, grip strength, and the DASH questionnaire. The patients who received manipulation treatment felt pain relief sooner than those who had acupuncture treatments during the first few treatments. The bottom line was that both acupuncture and manipulation are effective, and the difference has no significance at the 8-week mark.

Co-Kinetic comment Manipulation provides effective pain relief in the short term. We knew that but it is always nice to have yet another paper that proves it.

STRENGTH TRAINING FOR PLANTAR FASCIITIS AND THE INTRINSIC FOOT MUSCULATURE: A SYSTEMATIC REVIEW. Huffer D, Hing W, et al. Physical Therapy in Sports 2016;doi:10.1016/j. ptsp.2016.08.008 The usual databases were searched for papers investigating strength-training interventions to treat plantar fasciitis and improving intrinsic foot musculature strength. Seven moderate- to high-quality articles met the eligibility criteria. All studies had substantial differences in their strengthening interventions. Despite no changes in plantar fascia thickness being observed through high-load plantar fascia resistance training, there are indications that it may aid in a reduction of pain and improvements in function. Further research should use standardised outcome measures to assess intrinsic foot musculature strength and plantar fasciitis symptoms.

Co-Kinetic comment This highlights one of the main problems with manual therapy research. There is no consensus to anything so pooling results is difficult if not impossible. Clinically, the strength training is worth a go.

THE SHORT-TERM EFFECTS OF TRIGGER POINT THERAPY, STRETCHING AND MEDICINE BALL EXERCISES ON ACCURACY AND BACK SWING HIP TURN IN ELITE, MALE GOLFERS. A RANDOMISED CONTROLLED TRIAL. Quinn S, Olivier B, Wood WA. Physical Therapy in Sport 2016;22:16–22 being given to the hip flexors using ischaemic pressure for a minimum of 45 seconds of pressure per trigger point identified. The medicine ball exercise was performed with a 4kg medicine ball. The participant started in a squat with his hands holding the ball to the side of the body then he stood up, raising the ball above the head to the opposite side of the body. They did 50 repetitions to each side. The main outcome measures were hip flexor length (HFL), 3D biomechanical analysis of the golf swing, club head speed (CHS), smash ratio, accuracy and distance at baseline and after the interventions. The main results were that backswing hip turn improved in the ball group relative to the control group, accuracy

in the ball group and the stretch group improved relative to the control group. Other performance parameters such as: smash ratio, distance and CHS were not compromised by either intervention.

Co-Kinetic comment This starts with some interesting facts from an earlier paper (Smith & Hillman Phys Ther Sport 2012;13(1):41) which states that the in the physiotherapy unit of the European Golf Tour during a 2-year period, 7,430 golfers were treated, with 71.3% receiving manual therapy-related treatment including: massage (40.7%), manipulation (15.6%) and stretching therapies (15.0%). What this study shows is that a physical therapy intervention won’t harm your gold game and more importantly may improve it.

Co-Kinetic Journal 2017;71(January):10-13

MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch EFFECT OF MUSCLE ENERGY TECHNIQUE AND STATIC STRETCHING ON PAIN AND FUNCTIONAL DISABILITY IN PATIENTS WITH MECHANICAL NECK PAIN: A RANDOMIZED CONTROLLED TRIAL. Phadke A, Bedekar N, et al. Hong Kong Physiotherapy Journal 2016;35;5–11 Sixty patients with mechanical neck pain were randomly allocated to either a muscle energy technique (MET) group or control group. The former group received MET, and the latter group received static stretching. The MET was described as post-isometric relaxation applied to the upper trapezius and levator scapulae muscles for 5 repetitions using 20% of maximal isometric contraction held for 20 seconds. The static stretch was applied passively beyond resistance barrier to upper trapezius and levator scapulae muscles for 5 reps of a 20-second hold. Before both interventions the painful area was heated using a hydrocollator pack at 70°C applied through 6–8 layers of towel for 20 minutes. Treatment was given once daily for 6 consecutive days. Both groups also received an

exercise programme, which included strengthening exercises for deep neck flexors, rhomboids, lower trapezius and serratus anterior done for two sets of 10 reps once a day and stretching exercises for pectoralis muscles of a 20-second hold for 5 reps. Intensity of the exercise prescription was decided depending upon symptomatic response of the patients. Both groups received conventional therapy. Treatment was given once a day for 6 days. Outcome measures were pain as measured via a VAS and a neck disability index (NDI) questionnaire, administered immediately before treatment and again on the 6th day. The results were that VAS and NDI scores showed a significant improvement in both groups but the improvement was greater in the MET group.

STUDY OF THE EFFECTS OF THE HAND GRIP AND FINGER STRENGTHS ON THE FRICTION AND PETRISSAGE-THE MASSAGE MANIPULATIONSOF THE STUDENTS WHO TAKE MASSAGE COURSES: KÜTAHYA CITY EXAMPLE. Erzeybek MS, Kaya F, Yüksel O. In: SHS Web of Conferences 2016;31:01015 doi.org/10.1051/shsconf/20163101015 Thirty-six healthy males (mean age±SD, 19.72±1.56 years) who were students on a 12-week massage course took part in this study. The course was for 1 hour a day, twice a week. Using a dynamometer, grip strength and finger strength was measured pre- and post-course and, of course, it increased.

Co-Kinetic comment This is music to our ears. Not particularly because of the study and its results but because the introduction contains lots of warnings about efficiency to reduce therapists’ pain and fatigue. Here’s a thought, if learning to massage increases hand and finger strength should we be using it as a therapy?

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Co-Kinetic comment This is almost a companion piece to the study we have reported on the effects of manual therapy on shoulder pain in office workers. Chances are that if you have shoulder pain you will have neck pain. What we like about this paper is that it starts with some definitions so it is clear what they are talking about. For example, it quotes the International Association for the Study of Pain definition of neck pain, which is: ‘Pain perceived as arising from anywhere within the region bounded superiorly by superior nuchal line, inferior by an unoriginally transverse line through the tip of first thoracic spinous process, and laterally by sagittal plane tangential to the lateral border of neck’. Now you know where the neck is, note that the causes of pain in it can include awkward occupational postures, anxiety, stress, heavy lifting and physically demanding work. That just about covers everyone that walks through your door. Sadly they add that the source of symptoms in mechanical neck pain is not completely understood, but it may be related to various anatomical structures, particularly zygapophyseal or uncovertebral joints of the cervical spine. The good news, however, is that the use of a muscle energy technique helps.

SOFTBALL PETECHIAE: A NOVEL CUTANEOUS FINDING IN A PATIENT PARTICIPATING IN POST-EXERCISE MASSAGE. Buntinx-Krieg T, Greenwald J. Cureus 2016;8(9):777 This is a single case study involving a 39-year-old healthy male who presented with an eruption on his back consisting of evenly spaced, wellcircumscribed, round, petechial macules. The man was a regular participant in high-intensity exercise followed by self-administered post-exercise massage. He reported using a regulation-sized dimpled softball in order to massage the musculature of his back. It turns out that that the marks on his back were caused by the ball.

Co-Kinetic comment To be fair to the patient he didn’t actually go to the doctor complaining about this; he went for a routine exam and his dermatologist spotted it (pun intended). There is also a comment in the paper about the growing popularity of self-massage with foam rollers and balls because using ‘real’ massage therapists is expensive. Probably not as expensive as the doctor’s bill.

SPECIFIC AND CROSS-OVER EFFECTS OF FOAM ROLLING ON ANKLE DORSIFLEXION RANGE OF MOTION. Kelly S, Beardsley C. The International Journal of Sports Physical Therapy 2016;11(4):544–551

Twenty-six subjects were allocated into a foam rolling (FR) group (n=13) or a control group (CG) (n=13). Ankle dorsiflexion range of motion (ROM) was recorded at baseline with the in-line weight-bearing lunge test for both ipsilateral and contralateral legs and at 0, 5, 10, 15, 20 minutes following either a 2-minute seated rest (CON) or 3×30 seconds of FR of the plantar flexors of the dominant leg (FR). The results showed no significant between-group effect following the intervention but there was a significant within-group effect in the FR group between baseline

and all post-treatment time points. Notably, there was also a significant within-group effect in the contralateral leg up to 10 minutes post-treatment, indicating the presence of a cross-over effect.

Co-Kinetic comment You may know the ‘in-line weight-bearing lunge test’ as the ‘knee to the wall’ test. The authors point out that the actual increase in ROM in both ankles was only small so the foam rolling may not make much of a difference in healthy populations but it may be relevant post-injury when

ankle dorsiflexion is reduced. They speculate that the reason for the cross-over effect is because of an increase in parasympathetic nervous activity through the stimulation of mechanoreceptors, or an increased tolerance to stretch response. Our money, however, is on simple fascial stretching. There are lots of questions raised by this study, such as: Will there be an increased effect with more than one treatment? and Does it make a difference if you use a flat roller surface or a knobbed one? (this study used the latter).

EFFECTS OF MANUAL THERAPY ON SHOULDER PAIN IN OFFICE WORKERS. Go SU, Lee BH. Journal of Physical Therapy Science 2016;28:2422–2425 Thirty-eight office workers who complained of cervical and shoulder pain were randomly divided into two groups: a manual therapy group (n=19) and a shoulder stabilisation exercise group (n=19). All subjects underwent evaluation of the pressure pain threshold in the splenius capitis and upper, middle, and lower trapezius muscles on both sides. This was basically identifying trigger points and then a force

gauge was applied to it to the point that pain was felt. The manual therapy used included soft tissue mobilisation, prone thoracic mobilisation, cervical mobilisation and thoracic manipulation. Stabilisation exercises for the shoulder joint were designed to correct abnormal scapular location by stretching shortened muscles, including the upper trapezius, levator scapulae, suboccipital, sternocleidomastoid, and pectoral muscles and the use of exercises including knee push-up, prone row, modified prone cobra, cow posture, cat posture, cat postures for thoracic mobilisation, dead bug, and flank. Each exercise was performed for 10 seconds per session in 10 sets. Both groups underwent training of two 40-minute sessions per week for 6 weeks. After the intervention, both groups showed significantly increased pressure pain thresholds in the splenius capitis and upper, middle, and lower trapezius muscles on both sides. The manual therapy group showed greater improvements than did the shoulder stabilisation exercise group in the splenius capitis on both

sides, left upper trapezius, middle trapezius on both sides, and right lower trapezius.

Co-Kinetic comment Put aside the title of ‘office workers’. The inclusion criteria for this was people who used IT devices for more than 8 hours a day. These days that probably includes most of the population of the Western world, given that so much leisure time revolves around a variety of devices that can access the internet in one form or another. This study points out that flexion of the spine for extended periods, weakens the flexors and the serratus anterior, rhomboid, middle trapezius, and lower trapezius muscles because of inhibition, while at the same time trapezius, levator scapulae, suboccipital, sternocleidomastoid, and pectoral muscles shorten because of facilitation. This leads to scapular upward rotation, protrusion and elevation, a forward head postures and eventually pain. Help, however, is at hand in the form of your friendly manual therapist.

Co-Kinetic Journal 2017;71(January):10-13

SUBJECT MANUAL AREATHERAPY LINK WHOLE RESEARCH REFERENCE INTOTOPRACTICE ARTICLE

DO PATIENT PROFILES INFLUENCE THE EFFECTS OF MASSAGE? A CONTROLLED CLINICAL TRIAL. DíazRodríguez L, Fernández-Pérez AM, et al. Biological Research for Nursing 2016;doi:10.1177/1099800416643182

DOES KINESIOLOGY TAPE INCREASE TRUNK FORWARD FLEXION? A RANDOMISED PLACEBO CONTROLLED TRIAL. Preece H, White P. Journal of Bodywork and Movement Therapies 2016;doi:http://dx.doi.org/10.1016/j.jbmt.2016.09.011

Eighty Caucasian students with a mean (SD) age of 20.70 (4.50) years were assessed using a cold pressor test to determine their response to stress. This is basically sticking one hand in cold water (4°C) for 60 seconds while blood pressure and other markers are obtained via the dry hand. Individuals categorised as stress responders exhibit an exaggerated cardiovascular response to psychological stress. Fifteen were found to be high stress responders. Fifteen of the low responders were selected to be a control group. They then received a 21-minute myofascial therapy protocol administered by a therapist with 20 years’ experience. The protocol was the application of local pressure to the ear lobule, sustained pressure to the thoracic region to induce myofascial release of deep diaphragmatic tissue and sustained pressure on the sacrum occipitalis to release myofascial spinal cord restrictions. Measurement of dependent variables included heart rate variability (HRV), blood pressure, and salivary markers, such as flow rate, cortisol, immunoglobulin A (IgA), and α-amylase activity (all of which are indicators of stress levels). Stress responders showed a greater post-massage improvement in HRV and in salivary flow rate and IgA in comparison to non-responders.

Thirty-four male participants (mean age±SD, 42±11 years), in physically demanding jobs, asymptomatic of pain, with a history of non-specific low back pain were randomly assigned to: (1) Kinesiology tape (KT) intervention (KTI), or (2) KT placebo (KTP). Trunk flexion data was collected at baseline and immediately following tape application using a modified fingertip to floor technique. Participants were taped according to their group allocation, by the same therapist who was a certified BodyMaster KT practitioner using 5cm Rock Tape (a brand of KT). Shaving of the area preceded application of tape where necessary. All corners of the tape were rounded for better adhesion. Both groups received rubbing of the tape for better skin contact. The only difference between groups was the application method/direction of the tape. The KTI group received two ‘I’ strips of KT bilaterally along the paravertebral muscles from the posterior superior iliac spine (PSIS) to level with T8. With the participant standing in their normal

anatomical position, the tape was attached to the PSIS with no stretch. The KTP group received a single ‘I’ strip of tape in a transverse direction from the left PSIS to the right PSIS. The KTI group demonstrated a statistically significant gain in trunk flexion compared with baseline (2.75cm). Changes from pre- to post-treatment for the KTP were not significant. No statistically significant differences existed between groups post-treatment.

A total of 8 women and 4 men with a mean age of 55.8 years (range 24 to 62) and a mean body mass index (BMI) of 26.0kg/m2 (range 22.5 to 30.1) were included in the study. They were placed into one of four groups. The first was given two treatments at an interval of 14 days, the second group was given two treatments at an interval of 7 days, the third group received four treatments with intervals of 14 days, and the fourth group received four treatments with intervals of 7 days. Treatment was geared to the needs of each patient and

OSTEOPATHIC TREATMENT OF PATIENTS SUFFERING FROM CHRONIC NON-SPECIFIC LOW BACK PAIN: A DOSE-RESPONSE PILOT STUDY. Glomsrød E, Larson S, Jensen R. International Journal of Clinical Pharmacology & Pharmacotherapy 2016;1(115):doi:http://dx.doi.org/10.15344/2016/ijccp/115

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Co-Kinetic comment The KT tape works and it doesn’t really matter that much which direction it is applied in. Does it work because of physiological or psychological effects? Who cares! There is an immediate effect on range of movement which will allow either a window for therapists to do further treatment or allow a worker to work or an athlete to play. What would have been really interesting would have been to repeat this study with other brands of tape.

consisted of high-velocity, low-amplitude spinal manipulation, articulatory techniques, muscle energy techniques and myofascial release techniques. Oswestry disability index (ODI) and the numeric pain rating scale (NPRS) were recorded at baseline and 2 weeks post-treatment. The two treatments with an interval of 14 days resulted in an ODI reduction of only 1.3. The largest reduction in ODI was detected in the four treatments with the 7-day intervals.

Co-Kinetic comment Bottom line here is horses for courses. Some people respond better to certain treatments than others. It doesn’t mean the treatment is bad or that the therapist can’t do it right. This concept plays havoc with gaining evidence for treatment efficacy though, because how can you tell beforehand if your subject is going to respond to your treatment or not? It is why we shouldn’t be writing off treatments because in a low-powered trial it doesn’t seem to work.

Co-Kinetic comment This paper is here because it starts with the magic words, ‘Dose-response studies are needed for pharmaceuticals, but have not been commonly performed in the field of manual therapy.’ That is correct and it is the reason why most of the research we see is not worth the paper it is printed on. Dose is everything. Bottom line was that the effect increased with increases in the number of treatments and reductions in the treatment interval.

PLANTAR FASCIITIS: A PAIN IN THE HEEL This article outlines the latest incidence statistics for chronic plantar heel pain, explains how the structure and function of the plantar fascia is affected by pathology, outlines a detailed differential diagnosis and then delves into an evidence-based exploration of passive treatment options, exercise therapy and late stage rehabilitation. We have also created an accompanying Heel Pain Content Marketing Kit (http://spxj.nl/2fnESRn) which contains all the material you need to build awareness about Heel Pain and the how physical therapy can speed up the recovery process. This includes a social media awareness campaign, material for an email and a website article, a postal campaign using leaflets and postcards and a poster campaign for your work area and for the areas of any partners you collaborate with. This Kit is included as part of a full site subscription or can be purchased individually for those without a full site subscription. More information about our campaign kits in general can be found here (http://spxj.nl/2gZkQwP) and to read this article online go to http://spxj.nl/2gy2ZjG. BY DR CHRISTOPHER NORRIS PHD, MCSP

PLANTAR FASCIITIS: OVERVIEW Chronic plantar heel pain (CPHP) is pain under the front of the heel bone (calcaneus). It is said to account for about 1% of all orthopaedic referrals, and occurs in up to 7% of the adult population in general. In runners, the incidence is slightly higher with 8–10% affected (1,2). Functionally, the plantar fascia (PF)

ANKLE-FOOT | LOWER-LIMB | RUNNING | HANDOUT | 17- 01 -COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video: Low Dye Taping for Plantar Fascia Pain (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Plantar Fascia-specific Taping (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Self-massage for Plantar Fascia Pain (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Heel-raise Exercises for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Supported Lunge for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Quarter Squat Exercise for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG

PHYSICAL THERAPY MSK DIAGNOSIS AND REHABILITATION

TABLE 1: PLANTAR FASCIITIS NOMENCLATURE AND DIFFERENTIAL DIAGNOSIS (C. Norris, 2016) Alternative names n Chronic plantar heel pain (CPHP) n Painful heel syndrome n Plantar fasciitis n Plantar fasciopathy n Plantar tendinopathy n Plantar enthesopathy n Subcalcaneal bursitis n Neuritis n Medial arch pain n Stone bruise n Calcaneal periostitis n Heel spur n Subcalcaneal spur n Calcaneodynia

Differential diagnosis n Calcaneal apophysitis (Sever’s disease) n Calcaneal stress fracture or other bone injury n Fat pad syndrome (atrophy, heel bruise) n Inflammatory or reactive arthritis (Reiter syndrome/ankylosing spondylitis/psoriatic arthritis) n Bone pathology (osteomalacia/osteomyelitis/ Paget’s disease/bone cyst) n PF rupture/local tissue infection n Tumour (sarcoma) n PF fibromatosis (Ledderhose’s disease) n Calcaneal or retrocalcaneal bursitis n Neural referral lumbosacral, local neuritis, tarsal tunnel syndrome)

STRUCTURE AND FUNCTION OF THE PLANTAR FASCIA The PF is a thick tissue layer stretching from the calcaneus to the toes. It averages 12cm in length and 2–6cm

Sesamoid

Flexor hallucis Plantar longus oponeurosis

Plantar fascia

Figure 1: Anatomy of the plantar fascia (PF) and the windlass mechanism (Moseley C. sportEX medicine 2013;55:15)

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Gross attachment of the PF to the calcaneus is via an enthesis (connective tissue junction) formed of fibrocartilage. The fibrocartilaginous layer represents a zone of transition from soft to hard tissue and this region can calcify, a change visible on X-radiography. The PF has structural similarities to ligaments and tendons. Like these structures, it consists of a ground matrix with cells (fibrocytes and fibroblasts) embedded in it. These cells produce

TABLE 2: FACTORS ASSOCIATED WITH THE DEVELOPMENT OF CHRONIC PLANTAR HEEL PAIN (C. Norris, 2016: sourced Irving et al. J Sci Med Sport 2006;9(1):11–22) Strength of association Factor considered Strong

Body mass index (BMI) in sedentary individuals Presence of calcaneal spur on X-radiography

Weak Increased body weight in sedentary individuals Increased age Reduced ankle dorsiflexion Reduced 1st MTP joint extension Prolonged standing in daily living Inconclusive

Static foot posture Dynamic foot motion

TABLE 3: PATHOLOGICAL CHANGES SEEN IN PLANTAR FASCIITIS (C. Norris, 2016: sourced Rathleff et al. Scand J Med Sci Sports 2015;25(3):e292–300) n n n n n

Degenerative changes at the plantar fascia enthesis Deterioration of collagen fibres Increased secretion of ground substance proteins Focal areas of fibroblast proliferation Increased vascularity

Video 1: Low Dye taping for plantar fascia pain (C. Norris, 2016)

collagen (connective tissue), which in the case of the plantar fascia is crimped producing a highly adaptive matrix that may also have a sensory function. The combination of these two features makes it possible that the PF may transmit force passively (like an elastic band) and be able to change its response depending on the stresses imposed upon it. Type I collagen is found arranged longitudinally throughout the PF, with type III in the loose connective tissue and within areas where the PF bundles are arranged haphazardly. Type II collagen is found close to the heel, and very few elastic fibres are present. Hyaluronan (HA) is found between fibres, and fibroblast like cells arranged in the direction of the collagen fibres. The HA may facilitate gliding between the PF fibrous bundles and have an anti-inflammatory nature. It is most likely secreted by fasciacytes. Nerve endings and Ruffini and Pacini corpuscles are found within the PF, more concentrated in the medial, lateral, and distal portions where the PF joins onto muscle. The inner surface, where the muscles of the sole of the foot attach, is more innervated than the outer surface which is continuous with the skin. The PF innervations have been proposed to give it a proprioceptive role (1). The PF is said to be capable of perceiving both foot position and intrinsic foot muscle contraction.

PATHOLOGY OF PLANTAR FASCIITIS A systematic review of factors associated with CPHP concluded that only body mass index (BMI) and calcaneal spur in a non-athletic population had been shown to have a strong association (8). Increased age, decreased ankle dorsiflexion, decreased 1st MTP joint extension and prolonged (a)

standing showed a weak association (Table 2). Calcification of the PF enthesis increases tissue stiffness, a process increased in elderly individuals perhaps explaining the greater incidence of PF in the elderly. Traction (tensile loading) at the enthesis is often considered a causal factor in PF, but shearing and compression stress is likely equally important. Compressive forces are associated with similar conditions, such as tendinopathy (9). The term ‘plantar fasciitis’ itself implies an inflammatory reaction to the fascia (itis being a suffix meaning inflamed in medicine) but there is a question as to whether this is appropriate. Studies have shown degeneration and fragmentation of the fascia with bone marrow vascular ectasia (expansion) at its insertion but, generally, no inflammatory markers are present. Changes have been summarised by Rathleff et al. (2) (Table 3). Such changes imply that the condition may be more accurately termed a fasciosis (-osis, an abnormal state) rather than a fasciitis. This fact is important when treating the condition, as the steroid injections (anti-inflammatory) that are often used to treat plantar pain have a strong association with plantar ruptures (10). In a study of 765 patients with plantar fascia pain, Acevedo and Beskin (11) found 51 patients who had received corticosteroid injection. Of this subgroup 44 suffered plantar rupture, with 68% showing sudden onset tearing and 32% gradual onset tearing. At follow-up, 26 subjects still showed symptoms 1 year after rupture. Rupture as a result of corticosteroid injection can be seen in up to 10% of patients in general (12). As indicated above, normally during mid-stance the foot is flattened, (b)

Figure 2: Low Dye taping (C. Norris, 2016)

Co-Kinetic Journal 2017;71(January):14-20

PHYSICAL THERAPY MSK DIAGNOSIS AND REHABILITATION

(a)

(b)

(c)

Figure 3: Plantar fascia-specific taping (C. Norris, 2016)

stretching the plantar fascia and enabling it to store elastic energy to be released at toe off. However, a variety of suboptimal foot postures (malalignment) may increase stress on the fascia. Excessive rearfoot pronation will lower the arch and overstretch the fascia, and a reduction in mobility of the first metatarsal may also contribute to the condition (13). In addition, weak peronei, often the result of incomplete rehabilitation following ankle sprains, may reduce the support on the arch, thus stressing the plantar fascia. Congenital problems such as pes cavus (high arch) may also leave an athlete more susceptible to plantar fasciitis. PF tension through a prolonged windlass effect may exacerbate the condition, and tightness in the Achilles tendon or a plantarflexed foot position (high-heeled shoes) can produce this. Sports shoes and general footwear may exacerbate symptoms. Inadequate rearfoot control may fail to eliminate hyperpronation, and a poorly fitting heel counter will allow the calcaneal fat pad to spread more at heel strike, transmitting extra impact force to the calcaneus and PF. Degeneration of the fat pad with ageing has been suggested as a risk factor for the condition. Both static and dynamic foot posture have been examined using navicular height, calcaneal angle (pitch) using radiographs, and medial longitudinal arch contour using a footprint test. Looking for an association with the development of CPHP the evidence produced was inconclusive (8). Modification of foot position using orthotics or shoe types should be considered if they modify a patientâ&#x20AC;&#x2122;s symptoms, but used with caution as they may build dependence and distract from one of the primary aims of rehabilitation, which should be to build increased tissue capacity.

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PASSIVE TREATMENTS Taping (low Dye taping) may give temporary pain relief and allow continuation of daily living activities or low-level sport. A systematic review of six trials (14) showed an immediate increase in navicular height (mean 5.9mm) post-application. This was not maintained during exercise, and the authors questioned whether the change was clinically useful. Low Dye taping has also been shown to reduce mid PF strain in a cadaveric study (15). For the classic low Dye method, a strip of zinc oxide tape is placed along the medial edge of the foot proximal to the 1st MTP joint around the back of the calcaneus (heel lock) to finish proximal to the base of the 5th metatarsal (Fig. 2a), a second strip may be used to reinforce if required. Reins are then placed between the longitudinal strips across the sole of the foot, and tension altered to suit requirements (Fig. 2b; Video 1). Metatarsal or longitudinal arch padding may be placed on the sole of the foot prior to tape application to give extra support. PF-specific tape may be applied in a similar fashion. With the foot in its neutral position, one anchor surrounds the heel and the other is placed just behind the metatarsal heads (Fig. 3a). Three strips of tape (medial, lateral and central) are then passed from the anchor over the heel to stop on the posterior aspect of the calcaneum, and tension in each may be varied (Fig. 3b, c; Video 2). A horseshoe-shaped fixing strip secures the tape behind the heel. Additional strips may be placed transversely across the foot from the metatarsal heads to the calcaneal tubercle. Manual treatments such as deep tissue massage, and trigger point therapy for the plantar muscles (quadratus plantae and flexor hallucis) may give some short-term benefit, although the

results are likely to non-specific. Patients can be taught self-pressure techniques using a roller (foam or hard) or ball (tennis or golf ball) placed on the floor with the sole of the foot resting on the object. Self-massage may be applied

Figure 4: Self-massage to plantar tissues (C. Norris, 2016)

Video 2: Plantar fascia-specific taping (C. Norris, 2016)

Video 3: Self-massage for plantar fascia pain (C. Norris, 2016)

Figure 5: Plantar fascia-specific stretching (C. Norris, 2016)

Figure 6: Passive mobilisation of 1st MTP joint and plantar tissues (C. Norris, 2016)

with the legs crossed to expose the plantar surface of the foot (Fig. 4; Video 3). It is unlikely that passive techniques of this type will structurally affect the PF long term, but they may produce neuromodulation to relieve pain and reduce the requirement for medication. Dry needling to the foot and calf musculature has shown some benefit in a randomised controlled trial (16), although the statistically significant difference between groups (Dry Needling versus Sham) was less than the clinically important difference. The authors argued that the small benefit obtained may be offset by pain caused by the needling technique itself (32% dry needling compared to 1% sham). Foot supports including gel heel inserts, longitudinal arch supports, and/ or orthotics may be used to modify weight-bearing forces imposed upon the PF or control excessive pronation. Both custom fit orthotics (CFO) and prefabricated orthotics (PFO) have been shown to produce similar effects in the treatment of PF pain and provide shortterm relief as well as improvement of the foot function index (FFI) (17), PFO being of lower cost and giving immediate access. Gel inserts may be used to provide temporary relief in the short to mid-term (2–52 weeks) [(strong evidence (18)].

EXERCISE THERAPY

Figure 7: High-load training of the plantar fascia (C. Norris, 2016)

Video 4: Heel-raise exercises for plantar fascia strengthening (C. Norris, 2016)

Exercise approaches to plantar fasciitis fall broadly into two categories, stretching and strengthening. Specific stretching is aimed at the PF in isolation. The gastrocnemius–soleus complex is assessed and stretched using a generalised programme if the muscles are found to be tighter than the noninjured side or judged to be below what is considered optimal for a patient’s daily requirement or sport. Specific PF stretching has been shown to be superior to general calf stretching when measured for worse pain, and first-step morning pain on the foot function index (19). Plantar-specific stretching (20) can be performed by having the patient sit and cross the affected leg over the nonaffected. Placing their fingers distal to the MTP joints they flex the toes to draw the foot down into ankle plantarflexion, to mimic the windlass effect (Fig. 5). The stretch is held for 10s and 10 reps

are performed 3 times per day. The PFspecific stretch aims to reduce patient symptoms and may be performed prior to taking the first steps in the morning and following prolonged sitting. Where this protocol interferes with daily living, longer stretches of up to 30–60s may also be used and performed for 5 reps twice each day. The patient palpates the PF with the opposite hand to ensure that tension is placed on the structure, and foot/toe angle may be varied to increase tension. Where the 1st MTP joint motion is very limited, joint mobilisation may be used as a passive therapy, and exercise therapy used to maintain the effect between treatment sessions. A combination of 1st MTP extension and ankle dorsiflexion (Fig. 6) may be performed with the toes extended against a wall, knee pressing over the foot to place the foot into dorsiflexion. Where this relieves symptoms stretching may be of benefit, as limited motion range at the ankle and MTP joint have been shown to have an association with the condition (8). However, prolonged or repeated tensile stress to the PF over the longer term may not be useful, as it can produce compression within the tissue, a factor shown to be associated with tendinopathy-like pain (9). Strengthening may be to the limb in general, or to the plantar foot musculature. High load strength training has also been shown to be effective when targeting the PF in a similar fashion to that used when treating tendinopathy (2). High-load training uses the windlass effect and combines flexion of the MTP joints with a heel-raise action (Fig. 7; Video 4). The connection between the PF and Achilles paratenon found at dissection (1) implies that load will be transferred between the two structures. A slim lift (folded towel or slim plank) is placed under the toes to obtain maximal extension. A heel-raise action is then performed from this starting position using a slow 3–2–3 count of concentric/isometric/eccentric muscle action. The training volume is increased using 12 reps at maximal load to failure, and then 14 days later this is progressed to 10 reps at maximum load, and again after 14 days to 8 reps at maximum load (2). Where patients are not strong enough to perform single-leg heel-raises Co-Kinetic Journal 2017;71(January):14-20

PHYSICAL THERAPY MSK DIAGNOSIS AND REHABILITATION

TABLE 4: LATE-STAGE REHABILITATION OF PLANTAR HEEL PAIN (C. Norris, 2016)

References

Exercise aim

Action

n Balance training

nR ocker board, balance board, balance cushion n Line/beam walk

n Foot–ankle stability

nS ingle-leg standing: - eyes open/closed - arm/trunk movements

n F orce generation through posterior chain

n Squat/deadlift/press actions nD ouble-/single-leg vertical jump (free and weighted) n I n place hop: - forward/back - side/side - hop and twisting - As above using line/beam/low hurdle - Wall/object push (box/prowler)

n Force acceptance through lower limb

n Barefoot landing straight/lateral/rotation

n Foot as mobile adaptor

n Uneven surface walk/run

or pain limits activity, the exercise is regressed to bilateral heel-raises until the necessary strength is obtained. High-load strength training of this type has been shown to be superior to specific stretching using the FFI (a 0–230 point scale: 0 indicating no pain, disability or limitation of activity). Highload training was superior to specific stretching by 29 points on FFI at 3 months post-intervention and 22 points after 12 months (2), showing quicker pain reduction and improvement in function. Once pain has reduced and daily function returned to pre-injury levels, reconditioning is used to build physical resilience and prepare for competitive sport and daily life challenges. The tissue specific rehabilitation described

above is augmented and progressed using weight-bearing barefoot actions to work the intrinsic foot musculature. This can include single-leg standing, multidirectional walking and running (forward/back/side-side/rotation) progressing to bilateral and unilateral jumps of varying breadth (standing broad jump) and height (vertical jump). Varying surface (mats, sand, grass), movement complexity (single-leg standing barefoot with/without upper limb or trunk movement), timing (slow, fast) and load (body weight, external). Movement variation of this type is likely to enhance function more than the repeated use of the same exercise actions over time (Table 4). Videos 5 and 6 demonstrate examples of weight-bearing

Video 5: Supported lunge for plantar fascia strengthening (C. Norris, 2016)

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exercises for strengthening plantar foot musculature. 1. Stecco C, Corradin M, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of Anatomy 2013;223:665–676 2. Rathleff MS, Mølgaard CM, et al. Highload strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine & Science in Sports 2015;25(3):e292–300 3. Hansen AH, Childress DS, Knox EH. Roll-over shapes of human locomotor systems: effects of walking speed. Clinical Biomechanics 2004;19(4):407–414 4. Perry J, Burnfield J. Gait analysis: normal and pathological function, 2nd edn. Slack 2010. ISBN 978-1556427664 (Print £64.25) Buy from Amazon http://amzn.to/2gvFzHv 5. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot & Ankle International 2000; 21(1):18–25 6. Bolivar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot & Ankle International 2013;34:42–48 7. Mohseni-Bandpei MA, Nakhaee M, et al. Application of ultrasound in the assessment of plantar fascia in patients with plantar fasciitis: a systematic review. Ultrasound in Medicine and Biology 2014;40(8):1737–1754 8. Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport 2006;9(1):11–22 9. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? British Journal of Sports Medicine 2012;46(3):163–168 10. Murphy C. Plantar fasciitis. sportEX Medicine 2006;30:14–17 11. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot & Ankle International 1998;19(2):91–97 12. McMillan AM, Landorf KB, et al. Ultrasound

Video 6: Quarter squat for plantar fascia strengthening (C. Norris, 2016)

guided corticosteroid injection for plantar fasciitis: randomised controlled trial. BMJ 2012;344:e3260 13. Creighton D, OlsonVL. Evaluation of range of motion of the first metatarsophalangeal joint in runners with plantar fasciitis. Journal of Orthopaedic & Sports Physical Therapy 1987;8(7):357–361 14. Radford JA, Burns J, et al. The effect of low-Dye taping on kinematic, kinetic, and electromyographic variables: a systematic review. Journal of Orthopaedic & Sports Physical Therapy 2006;36(4):232–241 15. Bartold S, Clark RA, et al. The effect of taping on plantar fascia strain: a cadaveric ex vivo study. Footwear Science 2009;1(Suppl 1):47–48 16. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Physical Therapy 2014;94(8):1083– 1094

17. Lewis RD, Wright P, McCarthy LH. Orthotics compared to conventional therapy and other non-surgical treatments for plantar fasciitis. The Journal of the Oklahoma State Medical Association 2015;108(12):596–598 18. Martin RL, Davenport TE, et al. Heel pain-plantar fasciitis: revision 2014. Clinical Practice Guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy 2014;44(11):A1–33 19. DiGiovanni BF, Nawoczenski DA, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. Journal of Bone & Joint Surgery (American volume) 2003;85-A(7):1270–1277 20. Digiovanni BF, Nawoczenski DA, et al.

KEY POINTS nT he plantar fascia (PF) is an important link between the rearfoot, the forefoot and the musculature of the calf. n The combined motion of the heel, the ankle and the ball of the foot are involved in the three-rocker system for forward movement. n The windlass effect is a mechanical model that describes the lengthening and tensioning of the foot by the PF to allow pronation (and adaption to the ground surface on contact) and supination (and force transfer at toe-off), respectively. n In plantar fasciitis, pain is usually over the calcaneal attachment of the PF or its medial edge. n High body mass index in sedentary individuals and the presence of a calcaneal spur on X-radiography are factors strongly associated with the development of plantar fasciitis. n The changes involved in the PF in plantar fasciitis suggest that the condition should more accurately be termed plantar fasciosis. n Passive treatments for chronic heel pain include taping, manual treatments (such as deep tissue massage, trigger point therapy and self-massage) and foot supports. n Exercise therapy involves stretching the PF and strengthening the surrounding musculature.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Plantar fasciitis pain is often over the plantar fascia calcaneal attachment or its medial edge http://spxj.nl/2gy2ZjG Tweet this: Ultrasound scanning is reliable for assessing plantar fasciitis treatment progress http://spxj.nl/2gy2ZjG Tweet this: The plantar fascia extends back over the calcaneus and merges with the Achilles tendon paratenon http://spxj.nl/2gy2ZjG Tweet this: Plantar fasciitis is a condition more accurately described as plantar fasciosis http://spxj.nl/2gy2ZjG Tweet this: Weak peronei and pes cavus may leave an athlete more prone to plantar fasciitis http://spxj.nl/2gy2ZjG Tweet this: Exercise therapy for plantar fasciitis consists of stretching and strengthening http://spxj.nl/2gy2ZjG

Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Journal of Bone & Joint Surgery (American volume) 2006;88(8):1775–1781.

THE AUTHOR Dr Chris Norris PhD, MCSP is a physiotherapist with over 35 years’ experience. He has an MSc in Exercise Science and a PhD in Backpain Rehabilitation, together with clinical qualifications in manual therapy, orthopaedic medicine, acupuncture, and medical education. Chris is the author of 12 books on physiotherapy, exercise, and acupuncture and lectures widely in the UK and abroad. He is a visiting lecturer and external examiner to several universities at postgraduate level. He runs private clinics in Cheshire and Manchester and his postgraduate courses for therapists are on his website: http://www.norrishealth.co.uk/. Email: cmn@norrishealth.co.uk Twitter: @NorrisHealth LinkedIn: h ttps://uk.linkedin.com/in/dr-christopher-norrisaa366115 Facebook: https://www.facebook.com/NorrisAssociates/

DISCUSSIONS hat is the role of the plantar fascia (PF) in the gait W cycle? What pathological changes are commonly seen in plantar fasciitis and which term do you think is a more accurate reflection of the condition: plantar fasciitis or plantar fasciosis? Why is this important when treating the condition? What biomechanical or congenital problems can increase stress on the PF? What can you do to treat patients with chronic plantar heel pain and what differential diagnoses should you bear in mind?

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Co-Kinetic Journal 2017;71(January):14-20

PHYSICAL THERAPY MSK DIAGNOSIS & REHABILITATION

This article describes a quick and effective assessment process for heel pain that can be carried out in just 10 minutes. More than 10% of the population experiences heel pain and due to the number of structures in the foot and ankle a differential diagnosis can be difficult. This article covers mechanical and non-mechanical causes of heel pain, history taking, examination, investigations and management. It is accompanied by a Quick Reference PDF Booklet of more than 16 summary tables, flow charts and boxes. Read this online http://spxj.nl/2gy8fUd

HEEL PAIN: The 10 Minute Assessment

Heel Pain

History: n History of artificial joint n Recent feverish symptoms n Loss of range of movement n Irritability n Fatigue On examination: n Red, hot, tender joint n Patient may be holding joint rigidly n High temperature n Skin may be red with irregular edges

History: n Night pain n Weight loss n Past history of cancer n Family history of cancer n Possible recent feverish symptoms On examination: n Hard, irregular mass on heel n Cachexia

Consider malignancy Consider infection Urgent referral to orthopaedics required (via 2-week wait rule) Immediate referral to Accident & Emergency required

Figure 1: Determine whether the cause of heel pain needs immediate or urgent management (R. Chatterjee, 2016)

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BY DR ROBIN CHATTERJEE MBCHB MSC SEM MSC MED SCI MRCGP DIPSEM MFSEM Heel pain is a general term used to describe pain and discomfort experienced anywhere in or around the rear of the foot (1). Ten percent of elite athletes and also 10% of the general population are affected by it (1,2). There are 26 bones in the human foot, of which the heel (calcaneus) is the largest (3). The function of the heel is to absorb shock when walking or running. When walking, the stresses placed on your feet can be 1Âź times your body weight and, during your lifetime, you could walk the equivalent of four times around the ANKLE-FOOT | LOWER LIMB | 17-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS TABLE 1: Causes of non-mechanical heel pain (R. Chatterjee, 2016) - http://spxj.nl/2gy8fUd TABLE 2: Causes of mechanical heel pain (R. Chatterjee, 2016) - http://spxj.nl/2gy8fUd

n Onset: did the pain start gradually or suddenly? n Radiation: does the pain move anywhere, and, if yes, where and how? n Description: is it burning, stabbing, sharp or dull? n Is there any associated numbness or paraesthesia? n Has the individual had this kind of pain before and, if so, then what caused it? n What are the relieving and exacerbating factors, eg. movement, footwear, etc? n Where in the heel is the pain? n Is the pain continuous or intermittent? n At what time of day does it get better or worse? n Is there pain at rest? Figure 2: Questions for determining the nature of heel pain (R. Chatterjee, 2016)

n n n n n n n n

Overweight or obese History of diabetes Use of fluoroquinolones Recent change in exercise regime Repetitive motion over a long period of time Poor footwear Jogging/running bare feet Jogging/running at an angle or at a camber

Figure 3: Risk factors for chronic heel pain (R. Chatterjee, 2016)

TABLE 3: CAUSES OF OVERPRONATION OR EXCESS SUPINATION (R. Chatterjee, 2016)

world. These stresses can increase to 2¾ times body weight when running (4). Unsurprisingly the prevalence of heel pain increases as we get older, with a third of over 65s experiencing it (5). Despite being a very common presentation to both doctors and physiotherapists in a primary care setting, the cause of heel pain is often misdiagnosed. This article aims to provide a basic framework for practitioners to help correctly diagnose and manage this everyday ailment.

NOMENCLATURE The ubiquitous terms ‘plantar fasciitis’ and ‘Achilles tendinopathy’ are often used incorrectly to describe heel pain of any cause. With only 10 minutes available in many cases for an initial consultation, particularly in general practice, a basic structure needs to be in mind to help the clinician to quickly and correctly diagnose the cause of heel pain. The pathological cause can be broadly split into two groups: mechanical and non-mechanical. With regards to non-mechanical heel pain, the cause can be categorised into the following groups: rheumatological, infectious, malignant neoplasms, benign neoplasms, neuropathic and vascular (Table 1; available online http://spxj.nl/2gy8fUd). If it is thought that the cause of pain is mechanical, it is helpful to consider the actual site of pain and also the type of pain (Table 2; available online http://spxj.nl/2gy8fUd).

Causes of overpronation

Causes of excess supination

Congenital

Plantarflexed first toe

Obesity

Foot orthoses

Genu varus/valgus

Genu varus

HISTORY

Tibia varus/valgus

Tibia varus

Tarsal coalition

Leg-length discrepancy

At the start of a consultation with an individual with heel pain, it must first be established if the pain will need urgent or immediate treatment. Those who are suspected of having infection or cancer as the cause of heel pain must be referred and seen promptly by the appropriate services. History and examination must be focused to determine the severity of the cause of pain (Fig. 1). Only once infection and cancer have been excluded can the clinician move on and determine the cause of pain. Initially it must be established if the pain is mechanical or non-mechanical. Asking pertinent questions regarding the nature of the pain is crucial in this process (Fig. 2). The clinician must also ensure that

Crisp–Padhiar syndrome Leg-length discrepancy Cerebral palsy Rheumatoid arthritis

TABLE 4: EXAMINATION OF THE THREE PARTS OF THE FOOT (R. Chatterjee, 2016) Area of foot being tested

How

Hindfoot

Inversion and eversion of heel

Midfoot

Rotation of all metatarsophalangeals together in one movement

Forefoot

Flexion and extension of hallux

they have established which risk factors are present in the individual (Fig. 3). Once a thorough history has been obtained, the aetiology of the pain can be deduced and this will lead to appropriate investigations to confirm the diagnosis (Fig. 4).

EXAMINATION Before any examination, consent must be obtained and the clinician should wash their hands. The next stage is to stand directly in front of the patient and carefully inspect the individual. Eagleeyed observation can often produce several clues that can lead to the diagnosis (Fig. 5). For example, claw toe or hammer toe may indicate the possibility of long-term poor footwear or pre-existing diabetes. The shoes that the patient wore to the consultation should also be looked at for any wear and tear. A unilateral and then bilateral calf-raise is observed. If the patient is unable to lift their body weight at least 10 times, then Achilles tendon pathology or tibialis posterior tear or degeneration needs to be considered. Next the patient should be asked to walk up and down the room. This allows the clinician to perform a crude gait analysis. The patient should be observed from head to toe. Any abnormalities anywhere in the body, at any point in the gait cycle should be commented on. In particular spinal position, pelvic tilt, knee or tibial varus and valgus, inversion or eversion of the heel should be noted as well as overpronation or excess supination (Table 3). After the gait analysis, the patient should be advised to lie down in the supine position. The patient should be inspected for any leg-length discrepancy and then the heel should be palpated. Both legs and feet should be palpated from proximal to distal, for tenderness and heat. The foot should be dorsiflexed and plantarflexed both actively and passively. Following this the hindfoot, midfoot and forefoot should all be tested (Table 4). Any resistance or hindrance to a specific movement will identify which muscle group or tendon may be affected. Every joint in the foot should then be examined individually. Pain on palpation over the sinus tarsi may Co-Kinetic Journal 2017;71(January):21-28

PHYSICAL THERAPY MSK DIAGNOSIS & REHABILITATION

Location of heel pain

Plantar

Type of pain

Burning/tingling

Lateral

Sharp/achy

Timing of pain Nerve entrapment

Neuroma

With first weight-bearing steps after rest

Posterior

Midfoot

With prolonged weight-bearing

Insertional

Peroneal tendinopathy

Medial

Involving the ankle

Tarsal tunnel syndrome

Heel pad syndrome

Child/ adolescent

Sever disease (calcaneal apophysitis)

Sinus tarsi syndrome

Adult

Location around Achilles tendon

At rest Insertional Calcaneal stress fracture

Plantar fasciitis

Age of patient

Achilles tendinopathy

Plantar wart

Surrounding

Haglund deformity with or without bursitis

Figure 4: The process of determining heel pain aetiology (Adapted from American Family Physician, 2011-10-15, Volume 84, Issue 8, Pages 909-916)

indicate local or subtalar joint synovitis. Following this, the patient is then asked to move into the prone position. The Achilles tendon should be palpated and compared to the contralateral side. A thickened tendon compared to the other may indicate tendinopathy and pinpoint pain on palpation may indicate a partial Achilles tear (27). Swelling may be felt in a bursitis. The subtalar (talocalcaneal) joint is now examined. This is done by dorsiflexing the foot

to the end point and then supinating and pronating the joint. The ratio of inversion to eversion should be noted (it is normally 3 : 1). There are a number of special tests that can be performed to further help to diagnose the cause of heel pain (Table 5).

INVESTIGATIONS Many of the causes of heel pain can be diagnosed by history and examination

n n n n n n n n

Asymmetry of knee, lower limbs, heel or feet Pes cavus or pes planus Swelling, deformities, bruising or scarring Muscle wasting Resting inversion or eversion of the heel Clawtoe or hammertoe Redness or thickening of skin Splintering or clubbing of toenails.

Figure 5: Observations to note during inspection of foot and lower leg in examination of patient with heel pain (R. Chatterjee, 2016)

HAVING KNOWLEDGE OF THE IDEAS, CONCERNS AND EXPECTATIONS OF THE PATIENT IS PARAMOUNT IN ACHIEVING A SATISFACTORY OUTCOME, AS EACH INDIVIDUAL WILL HAVE A DIFFERENT IDEA AS TO WHAT CONSTITUTES AN ACCEPTABLE RESULT Co-Kinetic.com

TABLE 5: SPECIAL TESTS CONDUCTED IN EXAMINATION OF HEEL PAIN (R. Chatterjee, 2016) Test

Why

How

Royal London Hospital test

To look for Achilles tendinopathy

A swelling due to tendinopathy is most painful when the tendon is put on stretch by ankle dorsiflexion.

Painful arc sign

To distinguish between Achilles tendinopathy and inflammation of the paratenon (sheath surrounding the Achilles tendon)

The thickened or painful portion of the Achilles tendon moves with repeated active plantarflexion and dorsiflexion. If pain or swelling remains in same position despite the active movement then inflammation of the paratenon (ie. sheath inflammation) is more likely.

Simmonds’ squeeze test (also called Thompson’s test)

To diagnose ruptured Achilles tendon

With patient lying prone squeezing calf muscles will NOT cause normal plantarflexion, indicating that Achilles tendon has completely torn.

Windlass test

To check for plantar fasciitis

Pain on passive dorsiflexion of toes (especially hallux), often exacerbated by palpation of the plantar fascia

Tinel’s test

Tarsal tunnel syndrome likely if positive

4–6 taps over posterior tibial nerve will cause paraesthesia

TABLE 6: BLOOD TEST RESULTS IN CERTAIN AILMENTS THAT MAY CAUSE HEEL PAIN (R. Chatterjee, 2016) Alkaline phosphatase

Calcium

Phosphate

Paget’s disease

Osteosarcoma

Osteoporosis

Sarcoidosis

–

Myeloma

–

Osteomalacia

Primary hyperthyroidism

Secondary hyperthyroidism

Tertiary hyperthyroidism Hypoparathyroidism N N, Normal;

STEP 1: PRICE/ POLICE For 48 hours

Raised;

Lowered.

STEP 2: Referral to MDT Lifestyle modifications e.g. weight loss or workplace modifications Padding/strapping Shoe recommendations OTC arch support Oral analgesics Hot/cold therapy Ecccentric stretches Psychological support

STEP 3: Referral to SEM Custom orthotics Night splint Supervised eccentric stretches ESWT Corticosteroid injection PRP injection HVI Acupuncture TENS For 6 months

Figure 6: Stepwise management of heel pain (R. Chatterjee, 2016)

alone. However, sometimes further investigations may be required to confirm the diagnosis. Blood tests are performed first, before any imaging, to rule out many conditions that may cause bone or joint pain (Table 6). In addition to these tests HLA B27 levels may be measured if ankylosing spondylitis is suspected as the cause of heel pain. Anti-cyclic citrullinated (anti-CCP) antibodies can be looked for if rheumatoid arthritis is thought to be causing the symptoms. Acute and chronic inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, respectively) will be raised in most cases of heel pain and so will not help with determining the reason behind the pain. Vitamin D levels should also be checked as hypovitaminosis D is known to cause bony pain especially in areas with low sunlight and in the Asian and AfroCaribbean communities (40).

STEP 4: Referral to orthopaedics

There are several modes of imaging that can be used to help to identify the cause of heel pain (Table 7). The clinician must decide which form is most appropriate based on the information gathered from the patient.

MANAGEMENT Appropriate management of heel pain in a primary care setting often results in the heel returning to its pre-morbid state without requiring any invasive or surgical measures. Having knowledge of the ideas, concerns and expectations of the patient is paramount in achieving a satisfactory outcome. Each individual will have a different idea as to what constitutes an acceptable result. For some, an early return to sport or activity is considered a successful outcome, whereas for others, merely a reduction in pain is an acceptable goal. By addressing any preconceptions or misinformation that the patient may have, compliance with rehabilitation or analgesic programmes is far more likely. For those with nonmechanical causes of heel pain, early referral to an appropriate discipline is required. Once the source of pain has been determined to be mechanical, a stepwise approach to management is needed (Fig. 6). Step 1 is application of the PRICE (protection of joint, rest, ice, compression, elevation) protocol for a period of 48 hours. During this time, the joint should also be offloaded. If Achilles tendon rupture or any fracture is suspected, the individual should Co-Kinetic Journal 2017;71(January):21-28

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TABLE 7: IMAGING IN THE INVESTIGATION OF HEEL PAIN (R. Chatterjee, 2016) Mode of imaging

Advantages

Disadvantages

X-ray (plain radiographs)

n Low cost n Readily available n May help identify calcaneal fracture or bony deformities including degenerative changes n Heel spur can be seen

n Exposure to radiation n Abnormalities that are identified by X-ray may be unrelated to cause of pain, eg. heel pain n Soft tissue damage not identifiable

Magnetic resonance imaging (MRI)

n No radiation exposure n Preferred over CT if soft tissue needs to be identified n Often the investigation of choice as can show inflammation

n Expensive n Often long waiting time to get MRI n Tissue calcification cannot be identified on MRI as bone and calcium do not show up

Computed tomography (CT)

n Preferred over MRI if bony anatomy needs to be identified n Used to identify fracture if radiograph normal but fracture still suspected

n High exposure to radiation n More incidences of allergic reaction to CT contrast than MRI contrast

Bone scan

n Used to identify stress fractures, bony metastases, infections or occult fractures

n Generally non-specific in identifying cause of pain

be referred to see an orthopaedic specialist during this time, as early immobilisation is vital. In step 2, the multidisciplinary team (MDT) should be involved as soon as possible. This includes physiotherapists, podiatrists, GP, dieticians and psychologists and counsellors. The first issue that needs to be addressed is lifestyle

modifications that may provide symptomatic relief. Measures such as weight loss, change in training regime, change in footwear, improved diet or workplace modifications are sometimes enough to significantly reduce the heel pain. The MDT will be able to provide advice on padding and strapping of the joint if needed,

TABLE 8: MEDICATIONS FOR ANALGESIA IN HEEL PAIN (R. Chatterjee, 2016) Type of analgesic

Name of drug

Mode of administration

Simple analgesics

Paracetamol Capsaicin

Oral Topical gel

NSAIDs

Ibuprofen Diclofenac Naproxen

Oral or topical gel Oral or topical gel Oral

COX-2 inhibitors

Celecoxib Valdecoxib Etoricoxib

Oral Oral Oral

GABA inhibitors

Gabapentin Pregabalin

Oral Oral

Tricyclic antidepressant (TCA)

Amitriptyline

Oral

Weak opioids

Codeine Co-codamol Co-dydramol

Oral Oral Oral

Strong opioids

Tramadol Buprenorphine Fentanyl Oxycodone

Oral Topical patch Topical patch Oral or topical patch

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shoe recommendations, home physical therapy, over-the-counter arch support, appropriate use of oral analgesics and anti-inflammatories, stretching exercises and psychological support (41). The FITT (frequency, intensity, time, type) principle is used to establish the amount and type of stretches that is required by the patient. For most

BY ADDRESSING ANY PRECONCEPTIONS OR MISINFORMATION THAT THE PATIENT MAY HAVE, COMPLIANCE WITH REHABILITATION OR ANALGESIC PROGRAMMES IS FAR MORE LIKELY

CONSERVATIVE MEASURES SUCH AS WEIGHT LOSS, CHANGE IN TRAINING REGIME, CHANGE IN FOOTWEAR, IMPROVED DIET OR WORKPLACE MODIFICATIONS ARE SOMETIMES ENOUGH TO SIGNIFICANTLY REDUCE THE HEEL PAIN

TABLE 9: HEAT AND COLD THERAPY AS ANALGESIA (R. Chatterjee, 2016) Heat therapy

Cold therapy

Mechanism of action

n Opens up blood vessels which increases blood flow and therefore oxygen, nutrients and natural anti-inflammatories to area of pain. n Decreases muscle spasms

n Reduces speed of blood flow to area where cold is applied. n This results in reduced pain and swelling.

Method of application

n n n n n n

Hot water bottle Heat pack/pad Hot shower Hot bath Sauna/steam room Heat should not be so hot that it burns skin. n Moist heat tends to penetrate area better than dry heat.

n n n n n

Frequency of application

n As many episodes as possible with each episode lasting up to 20 minutes. Should be a minimum 10-minute intervals between episodes of application.

n As many episodes as possible with each episode lasting up to 20 minutes. n Should be minimum 10-minute intervals between episodes of application.

When and how to use it

n Do not apply directly to skin. Wrap heat device in cloth or towel first. n Do not use on open wounds. n Do not lie down on hot device as patient may fall asleep and burn themselves. n Avoid in first 48 hours after trauma or injury.

n Do not apply directly to skin. Wrap cold device in cloth or towel first. n Should be used in first 48 hours after trauma or injury.

Ice cubes Bag of peas Frozen bag of food Ice pack Gel pack

mechanical causes of heel pain, specific eccentric stretches tailored to the condition are needed. Exceptions to this rule include any disorder where exercise and stretching will increase pressure on the heel and, therefore, exacerbate the symptoms. Examples of this are heel spur, heel pad syndrome, Haglund deformity and retrocalcaneal bursitis. Step 2 should last for 6 weeks (41). Optimisation of analgesia will allow the patient to actually perform the stretches and exercises prescribed at home. A step-up method of analgesia is preferred where weaker topical agents are initially prescribed with stronger oral medications only being given if pain persists (Table 8). There is some debate as to whether non-steroidal anti-inflammatory drugs (NSAIDs) should be given in bony pain. Studies have shown that there may be delayed bone healing or non-unions associated with NSAID exposure. However, a recent systematic review on this topic has advocated its use, as withholding NSAIDs does not have any proven scientific benefit to patients and may even cause harm by increasing requirements of stronger more addictive medications (42). Heat and cold therapies are both useful conservative measures that should be encouraged in addition to pharmacological treatment in the primary care setting (Table 9). This is because, although there is limited evidence regarding its efficacy, these therapies are non-invasive, cheap, readily available and have relatively few side effects (43). Should the patient still be symptomatic then step 3 commences with referral to a Sports & Exercise Medicine (SEM) specialist. In conjunction with the other members of the MDT as well as the patient, custom orthotics, night splints and further supervised eccentric stretches and physical therapy is offered. Alternative therapies such as extracorporeal shockwave therapy (ESWT), corticosteroid joint injection, platelet rich plasma (PRP) injections, high volume injections (HVI) into the Achilles tendon, transcutaneous nerve stimulation (TENS) or acupuncture may be offered at this point. There is limited evidence on the Co-Kinetic Journal 2017;71(January):21-28

PHYSICAL PHYSICAL THERAPY THERAPY MSK MSK DIAGNOSIS DIAGNOSIS && REHABILITATION REHABILITATION

efficacies of these procedures and as such should only be offered after all other avenues have been exhausted. Finally if after step 3 there is still no improvement, referral to an orthopaedic surgeon is made for fasciotomy, nerve release, excision or other procedure.

CONCLUSION Heel pain is commonly seen in the primary care setting. A systematic framework can help the clinician to investigate and diagnose the cause of pain. Mechanical causes of heel pain are managed in a stepwise fashion. Patient education and addressing the ideas, concerns and expectations of the individual are key concepts in ensuring good compliance with treatment regimes and, thus, an optimal outcome. References 1. Agyekum EK, Ma K. Heel pain: a systematic review. Chinese Journal of Traumatology 2015;18:164–169 2. DeMaio M, Paine R, et al. Plantar fasciitis. Orthopaedics 1993;16:1153–1163 3. Nordqvist C. Heel pain: causes, prevention and treatments. Medical News Today 2015 http://spxj.nl/2g53lil 4. A guide to heel pain. The Society of Chiropodists and Podiatrists 2006 http://spxj.nl/2g546aQ 5. Dunn JE, Link CL, et al. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. American Journal of Epidemiology 2004;159:491–498 6. Schlesinger N. Diagnosing and treating gout: a review to aid primary care physicians. Postgraduate Medicine 2010;122(2):157–161 7. Majithia V, Geraci SA. Rheumatoid arthritis: diagnosis and management. The American Journal of Medicine 2007;120(11):936– 939 8. Glyn-Jones S, Palmer AJ, et al. Osteoarthritis. Lancet 2015;386:376–387 9. What is seronegative inflammatory arthritis and how effective is methotrexate in treating it? Arthritis Research UK 2006 http://spxj.nl/2fIZKC4 10. Ralston SH. Paget’s disease of the bone. The New England Journal of Medicine 2013;368(7):644–650 11. Carek PJ, Dickerson LM, Sack JL. Diagnosis and management of osteomyelitis. American Family Physician 2001;63(12):2413–2420 12. Weston VC, Jones AC, et al. Clinical features and outcome of septic arthritis in a single UK health district 1982–1991. Annals of the Rheumatic Diseases 1999;58(4):214–219 13. Bacilieri R, Johnson SM. Cutaneous Co-Kinetic.com

warts: an evidence-based approach to therapy. American Family Physician 2005;72(4):647–652 14. Kerstein MD. Heel ulcerations in the diabetic patient. Wounds 2002;14(6):212– 216 15. Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ 2012;345:e4955 16. Luetke A, Meyers PA, et al. Osteosarcoma treatment - where do we stand? A state of the art review. Cancer Treatment Reviews 2014;40(4):523–532 17. Ewing sarcoma. Bone Cancer Research Trust 2016 http://spxj.nl/2g5p04O 18. Sternberg ML, Sexton JA. Osteochondroma. The Journal of Emergency Medicine 2016;doi:10.1016/j. jemermed.2016.07.105 19. Rossi T, Levitsky K. Osteoid osteoma of the calcaneus: an unusual cause of hindfoot pain in an adolescent athlete. Journal of Athletic Training 1996;31(1):71–73 20. Miyayama H, Sakamoto K, et al. Aggressive osteoblastoma of the calcaneus. Cancer 1993;71(2):346–353 21. Barrett SL, Larson NL. Perioperative posterior heel pain caused by multiple etiologies including a neuroma in continuity of the posterior branch of the sural nerve: a case report. Journal of the American Podiatric Medical Association 2014;104(3):283–286 22. McSweeney SC, Cichero M. Tarsal tunnel syndrome - a narrative literature review. Foot (Edinb) 2015;25(4):244–250 23. Wang Y, Nataraj A. Foot drop resulting from degenerative lumbar spinal diseases: clinical characteristics and prognosis. Clinical Neurology and Neurosurgery 2014;117:33–39 24. DeHeer P. A closer look at heel pain and Baxter’s neuritis. Podiatry Today 2013 http://spxj.nl/2glcNxq 25. Scarvelis D, Wells P. Diagnosis and treatment of deep vein thrombosis. Canadian Medical Association Journal 2006;175(9):1087–1092 26. What is peripheral vascular disease? American Heart Association 2015 http://spxj.nl/2gEv1u0 27. Morton S, Newth A, Majeed A. Pain at the back of the heel. BMJ 2016;352:i1366 28. Boyd RP, Dimock R, et al. Achilles tendon rupture: how to avoid missing the diagnosis. The British Journal of General Practice 2015;65(641):668–669 29. Partial rupture of Achilles tendon. Sports Injury Clinic http://spxj.nl/2gk7E4P 30. Yasui Y, hannon CP, et al. Posterior ankle impingement syndrome: A systematic four-stage approach. World Journal of Orthopedics 2016;18:7(10):657–663 31. Tu P, Bytomski JR. Diagnosis of heel pain. American Family Physician 2011;84(8):898–916 32. Sawyer GA, Lareau CR, Mukand JA. Diagnosis and management of heel and plantar foot pain. Medicine and Health, Rhode Island 2012;95(4):125–128

OPTIMISATION OF ANALGESIA WILL ALLOW THE PATIENT TO ACTUALLY PERFORM THE STRETCHES AND EXERCISES PRESCRIBED AT HOME

THE AUTHOR Dr Robin Chatterjee is a specialist registrar in Sports & Exercise Medicine at the Barts Health NHS Trust in London and also a qualified general practitioner with a special interest in Sports & Exercise Medicine. After graduating in 2003 from the University of Liverpool with an Honours degree in Medicine, he went on to pursue a wide and varied career. Highlights include practising as an anaesthetist in the outback in Australia, gaining experience in dive and altitude medicine, and working at the London Marathon and World Triathlon Championships. In 2008, Dr Chatterjee happened to be present during a terrorist attack in Thailand, where he fulfilled the role of a trauma medic in the field, as well as a regional correspondent for the BBC World Service. He has previously worked as a medical officer for Brentford FC Academy and West Ham United FC Academy and has a particular interest in low back pain. He obtained an MSc in Sports & Exercise Medicine at Queen Mary University of London in 2015, he also obtained the Diploma in Sports & Exercise Medicine and has subsequently been awarded full membership to the UK Faculty of Sports & Exercise Medicine of the joint Royal Colleges of Physicians and Surgeons. Outside of work Dr Chatterjee is a PADI certified diver, an avid football fan and last but not least a doting husband and father. Email: robinchatterjee1@yahoo.co.uk

33. Helgeson K. Examination and intervention for sinus tarsi syndrome. North American Journal of Sports Physical Therapy 2009;4(1):29–37 34. Roster B, Michelier P, Giza E. Peroneal tendon disorders. Clinics in Sports Medicine 2015;34(4):625–641 35. Patla S, Lwin J, et al. Cuboid manipulation and exercise in the management of posterior tibialis tendinopathy. International Journal of Sports Physical Therapy 2015;10(3):363– 370 36. Flexor digitorum longus muscle: foot and

toe pain. The Wellness Digest http://spxj.nl/2gg8RwP 37. Flexor hallucis longus tendonitis. PhysioAdvisor.com http://spxj.nl/2h1hZ7z 38. MacAuley D. Traction apohysitis. In: Bytomski J, Moorman C (eds) Oxford American Handbook of Sports Medicine, p357. Oxford University Press 2010. ASIN: B00E6T0VUU Buy from Amazon http://amzn.to/2gaAesx 39. Lareau CR, Sawyer GA, et al. Plantar and medial heel pain: diagnosis and management. The Journal of the

KEY POINTS n Heel pain is a common presentation in a primary care setting. n Always have a framework on how to categorise what may be the cause of pain in mind prior to the consultation. n If the heel is red, hot and tender and the patient has feverish symptoms then consider immediate referral for infection of the joint. n If the patient has been experiencing night pain, weight loss or a hard, irregular mass on the heel then consider urgent referral in case of malignancy. n Accurate and well-directed history taking and examination is key to correctly identifying the cause of heel pain and, therefore, achieving a satisfactory outcome. n The ideas, concerns and expectations of the patient need to be addressed at an early stage in order to understand what the treatment goals of the patient are and to alleviate any concerns and therefore improve the likelihood of compliance to any rehabilitation or analgesic regime. n A stepwise approach to management should be taken with lifestyle modification and optimisation of analgesia being at the heart of this. n Early involvement of a multidisciplinary team comprising physiotherapists, podiatrists, GP, dieticians and psychologists and counsellors is essential to holistically manage the heel pain. n If Achilles tendon rupture or calcaneal fracture is suspected then early referral to orthopaedics is vital as a period of immobilisation will be needed. n Eccentric stretches are often the exercise of choice in the rehabilitation regime for many causes of mechanical heel pain.

American Academy of Orthopedic Surgeons 2014;22(6):372–380 40. Shah SK, Taufiq I, et al. Vitamin D deficiency and possible link with bony pain and onset of osteoporosis. The Journal of the Pakistan Medical Association 2014;64(12 Suppl 2):S100–103 41. Thomas JL, Christensen JC, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. Journal of Foot & Ankle Surgery 2010;49:S1–S19 42. Marquez-Lara A, Hutchinson ID, et al. Nonsteroidal anti-inflammatory drugs and bone healing: A systematic review of research quality. JBJS Reviews 2016;4(3):doi:10.2106/ JBJS.RVW.O.00055 43. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine 2015;127(1):57–65.

RELATED CONTENT Low Back Pain: The 10 Minute Assessment - http://spxj.nl/2bRhtZL Plantar Fasciitis: A Pain in the Heel - http://spxj.nl/2gy2ZjG Diagnosing Achilles Tendinopathy: A How To Guide - http://spxj.nl/1QIA0m7 Heel Pain Marketing Campaign Kit - http://spxj.nl/2fnESRn

DISCUSSIONS What do you do when you have a patient with heel pain? What lifestyle modifications do you advocate for these patients? How early do you involve the MDT? Do you ask the patient what outcome they consider successful? In other words, are your consultations clinician-centred or patient-centred?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Despite being a very common presentation, the cause of heel pain is often misdiagnosed http://spxj.nl/2gy8fUd Tweet this: When diagnosing heel pain, establish first if the patient needs urgent or immediate treatment http://spxj.nl/2gy8fUd Tweet this: Before any examination, consent must be obtained and the clinician should wash their hands http://spxj.nl/2gy8fUd Tweet this: Many of the causes of heel pain can be diagnosed by history and examination alone http://spxj.nl/2gy8fUd Tweet this: For most mechanical causes of heel pain, eccentric stretches tailored to the condition are needed http://spxj.nl/2gy8fUd

Co-Kinetic Journal 2017;71(January):21-28

MANUAL THERAPY MASSAGE THERAPY

BOX 1: DEFINITION OF COMBINED MOVEMENT THEORY (C. McCarthy, 2016) Combined Movement Theory (CMT) is an examination and treatment framework that incorporates spinal manipulation techniques, muscle energy techniques and mobilisation. The examination component looks at the influence of the starting and finishing positions on movement impairment and then uses these positions to intervene therapeutically.

17-01-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS PDF: Clinical reasoning form - http://spxj.nl/2fEoKtm Video: Post-isometric relaxation for the deep neck flexors - http://spxj.nl/2fEoKtm

Co-Kinetic.com

specialist manipulative physiotherapist from Australia and the principles incorporated into the practice of other manual therapists, such as Geoff Maitland (Maitland Concept).

expanded scope for identification and treatment of dysfunction. The concept of examination and treatment using ‘combined movements’ was developed by Dr Brian Edwards, a specialist manipulative physiotherapist from Perth, Western Australia. The work of Brian Edwards (3) was incorporated into the seminal writings of Geoff Maitland and is seen as an important companion to the ‘Maitland Concept’ (1). Combined movement examination has been shown to have a good level of reliability in the cervical (4) and lumbar spines (5) and some evidence for discriminative validity (6).

ESSENTIAL COMPONENTS OF CMT CMT is defined by a number of essential components discussed below.

Starting Positions CMT encourages the consideration of starting positions in the choice of therapeutic treatments. The consideration of the positions where pain and impairment is perceived starts during the patient interview, continues through the initial examination and throughout the progression of treatment. Home exercise and discharge programmes will continue to emphasise

STEP 1: Establish suitability for this approach n n STEP 2: Establish severity and particular direction of impairment n n

n n n

STEP 3: In the position of most and/or least sensitivity undertake passive movements to assess specific impairments (local pain and resistance to movement) n

the value of specific positioning, as an important part of treatment, to the patient. The simple addition of ‘In’ and ‘Did’ into the process of note taking during treatment will encourage a consideration of starting positions in practice (Fig. 2). The clinical reasoning form (available online – see Media Contents) will help you to plan your examination and initial treatment of your patient. For example: ■ IN: Supine, mid-cervical extension, right side-flexion. ■ DID: Antero-posterior pressure on the right C6 transverse process, Grade 3+, 1×1 minute.

Biomechanical Basis CMT follows a simplified model of spinal segmental biomechanics. CMT will influence the active and passive, physiological and accessory movements of the intervertebral disc, zygapophyseal and interbody joints, surrounding paravertebral muscles and neural system. The capacity of the intervertebral foramen will also be influenced in the extremes of combined positioning. The influence that movement can have on the compression of contents of the intervertebral foramen should be carefully observed during positioning and treatment with combined positioning of the spine resulting in ‘opening’ or ‘closing’ of the intervertebral foramen.

‘High-Dose’ Movement

STEP 4: Undertake a mini-treatment (eg. mobilisation or loading isometric exercise) and assess the effect on the specific impairment. Once the most effective treatment is established, repeat it. STEP 5: When treatment effects begin to diminish, progress to providing a graded exposure to the impaired directions. This is achieved by changing the starting position for treatment. n

STEP 6: Having physically educated the patient that the impairment is less of a threat than had been previously perceived a home stretching/exercise programme is provided, in order that patients can reinforce that message to themselves. In doing so, they will develop movement control into the previously impaired directions. Figure 1: Combined movement examination process (C. McCarthy, 2016)

One of the major advantages of this method of applying movement is the ability to use high-dose movement in conditions that are severely painful. By using starting positions that are biomechanically derived to be painless, greater therapeutic afferent stimulus can be induced than if undertaken in the position of impairment. High-dose movements, in the context of manual therapy, mean that a therapeutic effect is likely to be elicited from the imparted movement. This therapeutic effect will influence mechanical and neurological mechanisms and can have an immediate effect on perception of pain.

Treatment in Resistance When performing a passive movement Co-Kinetic Journal 2016;71(January):29-33

MANUAL THERAPY MASSAGE THERAPY

of a joint there is typically a range of movement that has imperceptible resistance to that movement. As the joint is moved towards the end of its range the periarticular structures and joint capsule will come under increasing stretch. Consequently, a perception of resistance to movement develops. Applied movement in this ‘resistance’ range carries a therapeutic neurophysiological advantage over treating in the earlier part of joint range, related to the number, threshold and type of mechanoreceptors being stimulated (7–9). Thus, CMT encourages the use of this range of movement during assessment and treatment.

Incorporation of Mobilisation and Manipulation Having evaluated the positions that result in dysfunction, the manual therapist can use combined starting positions to mobilise (slow, oscillatory, passive movements), manipulate (slow or fast, small amplitude movements that induce joint surface separation) or induce isometric muscle contractions (muscle contractions that alter muscle activity, post-contraction) to treat the dysfunction (10,11).

Patterns of Movement: Regular and Irregular Patterns of Movement Differentially diagnosing spinal dysfunction is notoriously difficult; however, there is a strong contention that patients can present with typical, distinct and valid patterns of movement dysfunction (12). Patients may present with pain produced with combinations of movements that match the normal coupling of the spine, suggesting that they have an inter-segmental pattern of dysfunction. An example being pain reproduced with flexion and contralateral-lateral flexion. In contrast, patients occasionally reproduce their pain with movements that do not follow the normal coupled movement of the spine (flexion and ipsilaterallateral flexion). The first situation can be described as a ‘regular pattern’ of movements, suggesting an intersegmental dysfunction, whereas the second scenario is an ‘irregular pattern’, with movement characteristics that do not as clearly suggest an interCo-Kinetic.com

segmental pattern (often suggesting a superficial muscular dysfunction). Patients presenting with regular patterns of movement will fall into one of two categories. These categories are beginning to demonstrate some evidence for their usefulness in categorising subgroups of patients within the non-specific low back pain group (12). These patterns have been variously described as ‘closing down’, ‘compression’ and ‘anterior stretch’ patterns (13) or the alternative patterns of ‘opening up’, ‘stretch’ or ‘posterior stretch’ (13,14). Essentially, the former represents a dysfunction associated with ipsilateral movement of the superior segment towards the side of pain, whereas the latter, a dysfunction with contralateral movement away from the side of pain.

Progression of Treatment by Change of Position Treatment that considers the position of dysfunction, requires a consideration of where treatment will need to start and progress towards, in order to reduce the dysfunction. This involves a choice of position that targets a particular mechanism or effect of the treatment, which will commonly need to change as symptomatology changes. Thus, one of the most important priorities in the use of CMT is the change of treatment position in response to change in pain and movement dysfunction. The position in which we are able to start treatment will range from a position diametrically opposite to the position of dysfunction, to the very position of dysfunction itself. In a situation where it is not appropriate to reproduce symptoms (severe pain presentations) treatment can be applied in the position of least dysfunction and using movement that most safely evokes descending, inhibitory pain-mechanisms, shown to reduce nociceptive pain perception (8,15–17). There is strong evidence to suggest that the approach of stimulating high threshold mechanoreceptive afferent information, in a position that does not reproduce pain, will evoke a rapid-acting raising of pain thresholds and thus a perception of comparative analgesia (16). However, the analgesic effects of this approach can be brief and reduce with repeated application of the

IN: LSF, E Right side lying. DID: Fix the superior level by pushing into contralateral lateral glide. Move the inferior level up, under the fixed label by rocking the illiac crest cephalad. © Dr Chris McCarthy 2014

Figure 2: Example of useful notes to take when performing combined movements for lateral flexion (C. McCarthy, 2014)

same technique, due to habituation to the stimulus (18). Thus, typically there is a requirement to change the emphasis of treatment to a process of graded exposure to the movement impairment, reducing pain perception due to central nervous system accommodation and habituation (14). Practically, this process involves changing the starting position for treatment progressively from a position diametrically opposite to the position of impairment towards the direction of impairment. This is undertaken in graded increments, slowly introducing the central nervous system to tolerable amounts of the discomfort associated with the impaired direction

MANUAL THERAPY SHOULD ENCOURAGE PATIENTS TO ENGAGE IN A PROCESS OF SPECIFIC PHYSICAL EDUCATION. Video 1: How to perform a localised contract-relax (post-isometric relaxation) technique for the deep neck flexors (C.McCarthy 2016)

Figure 3: Guided active movement of the low lumbar spine, into extension and right lateral flexion (C. McCarthy, 2016)

until pain is no longer associated with the direction of movement previously impaired. The perceived ‘threat’ is gradually reduced through a process of physical education. Some examples of combined movement treatments are shown in Video 1 and Figure 3.

COMBINED MOVEMENTS: THE THEORY AND THE PRACTICE The use of combined movements with low-back-pain patients involves a number of steps. The theory underpinning its application is grounded in the manual therapy evidence base, making its use attractive. However, although there is good evidence for the reliability of the examination approach and some evidence for its discriminative validity; to date, there has not been a clinical trial addressing the question of relative effectiveness. Regardless, when using the approach there are number of elements to consider.

PATIENTS QUICKLY LEARN THAT SPECIFIC MOVEMENTS CAN REDUCE PAIN AND IMPAIRMENT, AND AS A CONSEQUENCE THE SENSE OF ASSOCIATED THREAT IS REDUCED. 32

■ Selection of patients The approach lends itself to influencing the pain perception of patients with specific sensitivity to particular movements and, thus, those patients typically described as having a ‘mechanical presentation’. The approach is less influential in patients with neuropathic pain and/or central sensitivity or those whose perception is that any movement is threatening or dangerous. ■ Choice of initial treatment is governed by severity of pain With patients in severe pain, initial treatment is aimed at placing the patient in an antalgic position (typically diametrically opposite to position of pain and impairment) and evoking descending inhibitory pain mechanisms. This typically involves stimulation of high-threshold mechanoreceptive, producing important afferent information using oscillatory mobilisation. In non-severe pain mobilisation can be undertaken in the position of impairment. ■ Progression of treatment – specific graded exposure When the therapeutic benefit of mobilisation in the antalgic position has plateaued, the emphasis of treatment becomes one of inducing a graded exposure to the impaired movements. As the patient’s central nervous system habituates to the stimulus, pain (and the patient’s unconscious perception of the level of threat to this movement) reduces and the position of treatment can be progressively changed to upgrade the impaired stimulus, encouraging accommodation and habituation. ■ Encouragement of movement into the previously impaired position Having ameliorated the pain, previously associated with a particular position, the patient will then require appropriate help in learning that this position is now accessible without pain and will need an appropriate stretching and strengthening home programme to repeat the therapeutic encounter. This process encourages the adoption of an active learning style that avoids a passive coping style, while enabling the patient to master skills that they can use to self-manage in the long term. Long-

term repetition of this programme will aid the development of more permanent motor control and physiological tissue adaptation.

SUMMARY CMT is an attractive approach in the management of nociceptively driven spinal impairment. The approach has been in use worldwide, for nearly 50 years, and more recently our neurophysiological understanding of the techniques has begun to catch up with practice. Clinical effectiveness studies are now required to assess the clinical and cost-effectiveness of the approach; however, the underlying mechanisms of how and why the theory may work are reasonable. References 1. Maitland G. Vertebral manipulation, 5th edn. Butterworth-Heinemann 1986. ISBN 978-0750613330 Buy from Amazon (Kindle £42.23 Print £20.75) http://amzn.to/2gz3k1C 2. Kent P, Marks D, et al. Does clinician treatment choice improve the outcomes of manual therapy for nonspecific low back pain: a meta-analysis. Journal of Manipulative and Physiological Therapeutics 2005;28:312–322. 3. Edwards B. Clinical assessment: the use of combined movements. In: Twomey LT, Taylor JR (eds) Physical therapy of the low back. Churchill Livingstone 2000. ISBN 978-0443065521. Buy from Amazon (£14.19) http://amzn.to/2gnS6Op 4. Stamos I, Heneghan N, et al. Interexaminer reliability of active combined movements assessment of subjects with a history of mechanical neck problems. Manual Therapy 2012;17(5):438–444 5. Barrett CJ, Singer KP, Day R. Assessment of combined movements of the lumbar spine in asymptomatic and low back pain subjects using a three-dimensional electromagnetic tracking system. Manual Therapy 1999;4(2):94–99 6. Monie AP, Barrett CJ, et al. Computeraided combined movement examination of the lumbar spine and manual therapy implications: case report. Manual Therapy 2016;2:297–302 7. Bretischwerdt C, Rivas-Cano L, et al. Immediate effects of hamstring muscle stretching on pressure pain sensitivity and active mouth opening in healthy subjects. Journal of Manipulative and Physiological Therapeutics 2010;33(1):42–47 8. George SZ, Bishop MD et al. Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC Musculoskeletal Disorders 2006;7:68 9. Ruiz-Saez M, Fernandez-de-lasCo-Kinetic Journal 2016;71(January):29-33

MANUAL THERAPY MASSAGE THERAPY

Penas C, et al. Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in painfree subjects. Journal of Manipulative and Physiological Therapeutics 2007;30(8):578–583 10. McCarthy CJ. Spinal manipulative thrust technique using combined movement theory. Manual Therapy 2001;6(4):197– 204 11. McCarthy CJ. Spinal manipulative thrust technique using combined movement theory. In: Beeton K (ed) Manual therapy masterclasses: the vertebral column. Churchill Livingston 2003. ISBN 978-0443074035 Buy from Amazon (£39.99) http://amzn.to/2gz3hmy 12. Billis E, McCarthy CJ, et al. Subgrouping patients with non-specific low back pain based on cluster analysis of discriminatory clinical items. Journal of Rehabilitation Medicine 2013;45:177–185

13. Edwards BC. Manual of combined movements: their use in the examination and treatment of mechanical vertebral column disorders, 2nd edn. Butterworth-Heinemann 1999. ISBN 978-0750642903 Buy from Amazon (Print £20.27) http://amzn.to/2gaBBaV) 14. McCarthy CJ. Combined Movement Theory: rational mobilization and manipulation of the vertebral column. Churchill Livingstone 2010. ISBN 9780443068577 Buy from Amazon (Kindle £37.91 Print £45.20) http://amzn.to/2gnSdtq 15. Beneciuk JM, Bishop MD, George SZ. Effects of upper extremity neural mobilization on thermal pain sensitivity: a sham-controlled study in asymptomatic participants. Journal of Orthopaedic & Sports Physical Therapy 2009;39(6):428–438

THE AUTHOR Dr Chris McCarthy PhD, FCSP FMACP is a physiotherapist and clinical fellow at Manchester School of Physiotherapy, Manchester Metropolitan University. After qualifying as a physiotherapist in 1989 he undertook post-graduate training in Biomechanics and Manipulative Therapy at Strathclyde and Coventry Universities before undertaking a PhD degree in rehabilitation within the faculty of Medicine at Manchester University. He teaches internationally on manual therapy and lectures on four of the Masters courses in Advanced Musculoskeletal Practice in the UK. He is a member of the international advisory board for Manual Therapy journal and regularly reviews and publishes papers in the academic field of

manual therapy. He has been made an honorary fellow of both the Musculoskeletal Association of Chartered Physiotherapists and the Chartered Society of Physiotherapy for his contribution to the field of manual therapy. Chris is author of Combined Movement Theory: Rational Mobilisation and Manipulation of the Vertebral Column as well as the chapter on ‘Manual Therapy and Pain’ for the second edition of Elsevier’s popular Pain: A Textbook for Therapists. In addition, he is one of the editors and contributors to the seminal Grieve’s Modern Manual Musculoskeletal Physiotherapy, 4th edition (2015). Email: cmc@combinedmovements.org Twitter: @combinedmover LinkedIn: https://uk.linkedin.com/in/ combinedmovements

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16. Vicenzino B, Collins D, et al. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of Manipulative and Physiological Therapeutics 1998;21(7):448–453 17. Willett E, Hebron C, Krouwel O. The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects. Manual Therapy 2010;15(2):173–178 18. Bialosky JE, Bishop MD, et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy 2009;14(5):531–538.

KEY POINTS n Sensitivity to specific movements can be addressed by reducing the perceived threat of this movement using manual therapy. n Combined Movement Theory (CMT), a method of employing manual therapy clinical reasoning and techniques, enables patients to learn that movement can reduce pain. n Patients are initially placed in pain-free positions and movement is used to evoke brainorchestrated, inhibitory pain mechanisms. n Following this, specific graded exposure to the sensitised motions are encouraged. n Repetition of these motions engages the patient in an active process of physically re-educating themselves. n Examination of spinal dysfunction should include a three-dimensional assessment of motion. n CMT follows a simplified model of spinal segmental biomechanics. n One of the major advantages of this method of applying movement is the ability to use high-dose movement in conditions that are severely painful.

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HERE ARE SOME SUGGESTIONS Tweet this: Start and end positions are crucial when performing therapeutic spinal movements http://spxj.nl/2fEoKtm Tweet this: Combined Movement Theory offers an expanded scope for identification and treatment of dysfunction http://spxj.nl/2fEoKtm Tweet this: Combined movement examination has a good level of reliability in the cervical and lumbar spines http://spxj.nl/2fEoKtm Tweet this: Combined Movement Theory lends itself to treating patients with a ‘mechanical presentation’ http://spxj.nl/2fEoKtm

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DISCUSSIONS When is manual therapy appropriate for patients with spinal pain and what do you think the aims and objectives of the approach are? What are the neurophysiological mechanisms that result in the reductions in perception in pain that are associated with manual therapy? What are your thoughts on the notion that passive movements can be used within an active management approach of spinal pain?

MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the ankle and foot TABLE 1: ASSESSMENT OF THE ANKLE AND FOOT (J. Hatcher, 2013) OBSERVATION/ EXAMINATION 1. Anatomy

2. Initial observation

n Face and posture and gait

3. History

n Age and occupation n Site and spread n Onset and duration n Behaviour and symptoms n Past medical history (P.M.H.)

4. Inspection

n Bony deformity n Wasting

n Colour changes n Swelling

5. Objective examination

n Observe/examine state at rest and eliminate hip joint n Palpate for heat, swelling and synovial thickening

6. Passive tests (for pain, range and end-feel) a. Gross ankle movements

n Plantarflexion

MEDIA CONTENTS Videos 1-11: Techniques for ankle assessment, ankle mobilisation and soft tissue therapy treatment. J. Hatcher, 2013

n Dorsiflexion

b. Ligament tests i. Ankle joint (for pain and n Inversion and eversion (in plantarflexion – loose laxity) packed position for ankle joint) ii. Subtalar joint

7. Resisted tests (pain and power)

n Dorsiflexion n Inversion

8. Additional specific tests

Don’t forget to perform any special tests and complete the examination with palpation of the region

n Plantarflexion (in standing) n Eversion

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Video 1 shows surface marking of the anatomical area and will help you with the key structures encountered in this article.

Assessment of the ankle and foot

For a full assessment of the ankle and foot, the therapist should perform the observations and examinations detailed in Table 1 and Video 2.

Treatment around the ankle and foot CAPSULAR PATTERN

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the ankle and foot are shown in Table 2. Treatment choice for the ankle joint n Mobilisations of the ankle. Video 1: Surface marking of the ankle region (Video with captions but no sound; J. Hatcher, 2013)

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TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE ANKLE AND FOOT (J. Hatcher, 2013) CAUSE Osteoarthritis (OA)

Rheumatoid arthritis (RA) and other systemic arthropathies Traumatic arthritis (TA)

TYPICAL FEATURES n Wear and tear to the joint, may be primary, or possibly secondary to previous lesion. n Mild capsulitis, possible crepitus. n Systemic autoimmune disease, causing degeneration and possible joint disruption. n Often severe capsulitis, may lead to joint laxity and deformity. n Common in the ankle joint.

TREATMENT n Warm the capsule using appropriate electrotherapy and use Grade B (Maitland Grade III and IV) mobilisation and self-help exercises to end of range. n Refer to GP for Rheumatology opinion. n If not in acute flare-up, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV). n Need to treat for swelling first (exercises and/or electrotherapy). n Treatment to ligaments as necessary and mobilise as pain allows, Grade A–B (I–IV).

Plantarflexion mobilisation (Video 3) Directions: 1. Stand at end of bed with patient lying prone. 2. Place both hands around foot and ankle keep fingers around anterior aspect of talus and thumbs on inferior aspect of calcaneus. 3. Take lower leg into extension while plantar-flexing the ankle. 4. It may be helpful to place a pillow below the patient’s foot as a comfortable block to movement depending on the required grade of mobilisation (Grade IIs and IIIs are sometimes referred to as ‘flapping techniques’). Dorsiflexion mobilisation (Video 4) Directions: 1. Stand at side of patient with cephalad Video 2: Assessment of the ankle and foot (Video with captions but no sound; J. Hatcher, 2013)

hand supporting the posterior part of the lower leg just above the ankle. 2. Place caudad hand on sole of foot, close to calcaneus. 3. Use palm of hand to take foot into dorsiflexion. 4. Again, grade according to clinical assessment. Anterior–posterior (AP) talus mobilisation (Fig. 1) Directions: 1. Similar stance position to dorsiflexion mobilisation but with hands placed around anterior and posterior aspect of ankle region. 2. Specifically place cephalad hand around posterior aspect of distal tibia and fibula, and caudad hand around head of talus. 3. Take talus posteriorly, using other Video 3: Mobilisations of the ankle: plantarflexion (Video with captions but no sound; J. Hatcher, 2013)

Figure 1: Anterior–posterior (AP) talus mobilisation (Photo credit: J. Hatcher, 2013)

Figure 2: Posterior–anterior (PA) talus mobilisation (Photo credit: J. Hatcher, 2013)

Figure 3: Midtarsal pronation mobilisation (Photo credit: J. Hatcher, 2013)

hand to maintain position of tibia and fibula. 4. Grade according to clinical assessment findings.

fingers around the talus, the caudad hand is placed around calcaneus. 3. Take calcaneus into adduction while maintaining a static position of the talus and ankle joint with the opposite hand. 4. Grade according to assessment findings.

Midtarsal pronation mobilisation (Fig. 3) Directions: 1. Stand at side of bed with patient lying prone. 2. Place both hands around sole foot keeping cephalad hand around calcaneus and caudad hand around cuboid and navicular. 3. Take forefoot into pronation while counteracting the movement at the hindfoot with the opposite hand. 4. Grade according to assessment findings.

Posterior–anterior (PA) talus mobilisation (Fig. 2) Directions: 1. Same standing position as in ‘Anterior–posterior talus mobilisation’ above. 2. Specifically place cephalad hand around posterior aspect of talus, and caudad hand around distal tibia and fibula. 3. Take talus anteriorly, using other hand to maintain position of tibia and fibula. 4. Grade accordingly. Treatment choice for subtalar joint - Mobilisations of the subtalar joint. Subtalar adduction mobilisation (inversion) (Video 5) Directions: 1. Stand at side of bed with patient lying prone. 2. Place cephalad hand around lower posterior aspect of tibia and fibula with Video 4: Mobilisation of the ankle: dorsiflexion (Video with captions but no sound; J. Hatcher, 2013)

Subtalar abduction mobilisation (eversion) (Video 5) Directions: 1. Stand at side of bed with patient lying prone. 2. Place cephalad hand around lower posterior aspect of tibia and fibula with fingers around the talus, the caudad hand is placed around calcaneus. 3. Take calcaneus into abduction while maintaining a static position of the talus and ankle joint with the opposite hand. 4. Grade according to assessment findings. Treatment choice for midtarsal joints n Mobilisations of the midtarsal joints: talocalcaneofibular and calcaneocuboid joints specifically.

Midtarsal supination mobilisation (Fig. 4) Directions: 1. Stand at side of bed with patient lying prone. 2. Place both hands around sole foot keeping cephalad hand around calcaneus and caudad hand around cuboid and navicular. 3. Take forefoot into supination while counteracting the movement at the hindfoot with the opposite hand. 4. Again, grade according to ssessment findings.

Video 5: Mobilisation of the subtalar joint: adduction/supination and abduction/pronation (Video with captions but no sound; J. Hatcher, 2013)

Video 6: Mobilisation of the midtarsal joints: accessory glides (Video with captions but no sound; J. Hatcher, 2013)

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PHYSICAL THERAPY: PAIN, MANUAL BRAINTHERAPY AND SPORTS STUDENT PERFORMANCE HANDBOOK

Figure 4: Midtarsal supination mobilisation (Photo credit: J. Hatcher, 2013)

Figure 5: Deep transverse frictions to the deltoid ligament (Photo credit: J. Hatcher, 2013)

Midtarsal AP mobilisation (Video 6) Directions: 1. Similar stance position to previous midtarsal mobilisations but with hands placed around anterior and posterior aspect of midtarsal region. 2. Specifically place cephalad hand around inferior aspect of calcaneus, and caudad hand around navicular and cuboid. 3. Take navicular and cuboid combined in an oblique direction toward your cephalad shoulder, maintaining the position of the hindfoot with your opposite hand. 4. Grade according to clinical assessment findings.

position of the navicular and cuboid with your opposite hand. 4. Grade according to clinical assessment findings.

NON-CAPSULAR PATTERN Patterns of movement limitation that do not fit the capsular pattern are therefore described as non-capsular.

CAUSES OF NONCAPSULAR PATTERN Common causes of non-capsular patterns of movement limitation in the ankle and foot include: deltoid ligament sprain and lateral ligament sprain.

Deltoid ligament sprain Midtarsal PA mobilisation (Video 6) Directions: 1. Again, same stance position as previous midtarsal ap mobilisations with hands placed around anterior and posterior aspect of midtarsal region. 2. Specifically place cephalad hand around inferior aspect of calcaneus, and caudad hand around navicular and cuboid. 3. Take hindfoot in oblique direction toward your caudad hip maintaining the

The key clinical features are: n Rare â&#x20AC;&#x201C; pain on passive eversion following eversion injury n May be associated with avulsion fractures.

Video 7: Deep transverse frictions to anterior talo-fibular ligament (Video with captions but no sound; J. Hatcher, 2013)

Video 8: Deep transverse frictions to the calcaneo-fibular ligament (Video with captions but no sound; J. Hatcher, 2013)

Treatment choice n Initially RICE (rest, ice, compression, elevation), then deep transverse frictions.

A COMMON CAUSE OF NONCAPSULAR PATTERN OF MOVEMENT LIMITATION IN THE FOOT AND ANKLE ARE DELTOID LIGAMENT AND LATERAL LIGAMENT SPRAIN Deep transverse frictions to deltoid ligament (Fig. 5) Directions: 1. Sit perched on the end of the bed with patientâ&#x20AC;&#x2122;s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place index finger of caudad hand directly over site of lesion (inferior to medial malleolus). 4. Place thumb on lateral aspect of foot to apply counter pressure (may be uncomfortable). 5. Reinforce with middle finger of same hand and press and apply transverse frictional massage.

Lateral ligament sprain The key clinical features are: n May involve the anterior talo-fibular, calcaneo-fibular or calcaneo-cuboid ligaments n Pain on passive inversion and plantar flexion n Need to differentiate between the different lateral ligaments. Treatment choice n Treatment with deep transverse frictions and exercises, followed by proprioceptive work n If chronic may need Grade C manipulation after deep transverse frictions. Deep frictions to the anterior talo-fibular ligament (Video 7) Directions: 1. Sit perched on the end of the bed

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THE CAPSULAR PATTERN OF MOVEMENT LIMITATION AT THE ANKLE IS DEFINED BY MORE LOSS OF PLANTARFLEXION THAN DORSIFLEXION with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place index finger of cephalad hand directly over site of lesion (anterior to lateral malleolus). 4. Place thumb in postero-medial aspect of ankle to apply counter pressure. 5. Reinforce with middle finger of same hand and squeeze, and apply transverse frictional massage. Deep transverse frictions to the calcaneo-fibular ligament (Video 8) Directions: 1. Sit perched on the end of the bed with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place index finger of caudad hand directly over site of lesion (inferior and slightly posterior to lateral malleolus). 4. Place thumb either resting on dorsum of foot (as shown), or underneath sole of foot to apply counter pressure (may be uncomfortable). Video 9: Deep transverse frictions to the gastrocnemius (Video with captions but no sound; J. Hatcher, 2013)

5. Reinforce with middle finger of same hand and press and apply transverse frictional massage. Manipulation to chronic anterior talo-fibular ligament sprain (Video 7) Directions: 1. Sit perched on the end of the bed with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Apply deep transverse frictions as shown in Video 7 for analgesic effect. 4. Place cephalad hand around lower leg above ankle and stabilise leg using forearm of same. 5. Place caudad hand over dorsum of foot to apply full plantarflexion and full inversion. 6. Manipulation technique is short, quick adduction movement of your elbow towards your side (combined movement of plantarflexion and inversion).

Gastrocnemius tear The key clinical features are: n Usually in medial head, traumatic onset, either direct blow, or strain n Pain on resisted plantar flexion (usually tested in a weight bearing position) n May also have pain on resisted knee flexion n Pain also on passive dorsiflexion of ankle. Treatment choice n Requires RICE initially, then deep transverse frictions, effleurage and may use electrotherapy n Also requires stretching. Deep transverse frictions to gastrocnemius strain (Video 9) Directions: 1. Have patient prone with foot supported on pillow. 2. Place heel of hand directly over site of lesion, [usually musculotendinous (MT) junction of medial head]. 3. Have bed in relatively low position to allow you to ‘dominate the patient’ using your body weight. 4. Reinforce with other hand and apply transverse frictional massage.

Achilles tendonitis

CONTRACILE LESIONS

The key clinical features are: n Pain on standing on toes – particularly when repeated n Can affect sides or anterior part of tendon, or teno-osseous (TO) junction.

Common contractile lesions of the foot and ankle include: gastrocnemius tear, Achilles tendonitis, and peroneal tendonitis.

Treatment choice Deep transverse frictions to relevant part of tendon.

Video 10: Deep transverse frictions for tendocalcaneus lesions (Video with captions but no sound; J. Hatcher, 2013)

Video 11: Deep transverse frictions to lesion of the peroneal tendons (Video with captions but no sound; J. Hatcher, 2013)

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PHYSICAL THERAPY: PAIN, MANUAL BRAINTHERAPY AND SPORTS STUDENT PERFORMANCE HANDBOOK

Deep transverse frictions to tendocalcaneus tendinitis (anterior aspect of tendon) (Video 10) Directions: 1. Patient prone with ankles supported on pillow, not over edge of bed. 2. Place middle finger of right hand to push relaxed tendon over to the left and use middle finger of left hand (reinforced by index finger) to apply transverse frictional massage to the under surface of the tendon. 3. The friction is done by alternately pronating and supinating the forearm. 4. Repeat on the other side by pushing tendon over to the right and using right hand to apply friction to the under surface of the tendon. Deep transverse frictions to tendocalcaneus tendinitis (TO junction) (Video 10) Directions: 1. Patient prone with ankles supported on pillow, not over edge of bed. 2. Place index finger of one hand directly over site of lesion (TO junction), and reinforce with index finger of opposite hand. 3. Place both thumbs on either side of the sole of foot (as shown), to apply counter pressure. 4. Reinforce with middle fingers (if necessary) and apply transverse frictional massage by moving arms from side to side. Deep transverse frictions to tendocalcaneus tendinitis (lateral aspect of tendon) (Video 10) Directions: 1. Patient prone lying with ankles supported over the edge of the bed resting on pillow. 2. Dorsiflex the ankle using your thigh. 3. Curl index finger of one hand around the lateral aspect of the tendon and provide counter pressure with the thumb (as shown). 4. Apply transverse frictional massage by ‘pinching movement’ up and down to lateral sides of tendon.

n Pain on resisted eversion n May have pain on passive inversion. Treatment choice n Requires deep transverse frictions or use of electrotherapy, followed by rest (taped if necessary). Deep transverse frictions to peroneus longus tendon above malleolus (Video 11) Directions: 1. Sit perched on the end of the bed with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place three fingers of cephalad hand directly over site of lesion (enough fingers to cover extent of lesion). 4. Place thumb on medial aspect of leg to apply counter pressure (may be uncomfortable). 5. Press and apply transverse frictional massage. 6. Remember, the tendons in sheath must be frictioned in stretched position (which means plantarflexion and inversion applied and maintained with caudad hand). Deep transverse frictions to peroneal tendons behind malleolus (Video 11) Directions: 1. Sit perched on the end of the bed with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place middle finger of cephalad hand directly over site of lesion. 4. Reinforce using index finger of same hand. 5. Press and apply transverse frictional massage, by alternately pronating and supinating the forearm. 6. Remember, the tendons in sheath must be frictioned in stretched position (which means plantarflexion and inversion applied and maintained with caudad hand).

Peroneal tendonitis The key clinical features are: n May be in several regions – MT junction, around the malleolus, or to junction

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Deep transverse frictions to peroneal tendons below malleolus (Video 11) Directions: 1. Sit perched on the end of the bed

with patient’s non-injured leg flexed up out of the way. 2. Have patient with flexed knee supported on pillow, ankle resting on your thigh. 3. Place middle finger of cephalad hand directly over site of lesion. 4. Reinforce using index finger of same hand. 5. Press and apply transverse frictional massage, by alternately pronating and supinating the forearm. 6. Remember, the tendons in sheath must be frictioned in stretched position (which means plantarflexion and inversion applied and maintained with caudad hand).

FURTHER RESOURCES 1. Stagni R, Leardini A, et al. Role of passive structures in the mobility and stability of the human subtalar joint: a literature review. Foot & Ankle International 2003;24(5):402–409. 2. Alfredsson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British Journal of Sports Medicine 2007;41(4):211–216.

RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. ISBN 9781451109764. (Kindle £55.53 Print £58.45). Buy from Amazon http://amzn.to/1QbemUV 2. Cyriax J. Textbook of orthopaedic medicine, vol. 1: diagnosis of soft tissue lesions, 8th ed. Balliere Tindall 1982. ISBN 978-0702009358. (Print £56.39). Buy from Amazon http://amzn.to/1QbeC6o 3. Boyling J, Jull G. Grieve’s modern manual therapy: the vertebral column, 3rd ed. Churchill Livingstone 2005. ISBN 978-0443071553. (Print £76.38). Buy from Amazon http://amzn.to/1mwohwt 4. Higgs J, Jones A, et al. Clinical reasoning in the health professions, 3rd ed. Butterworth-Heinemann 2008. ISBN 978-0750688857. (Kindle £52.99, Print £46.74). Buy from Amazon

http://amzn.to/1mwokZb 5. Abrahams PH, McMinn RMH. McMinn and Abrahams’ Clinical atlas of human anatomy, 7th ed. Mosby 2013. ISBN 978-0723436973. (Kindle £42.79, Print £45.04). Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 978-1455709779. (Kindle £56.52, Print £59.49). Buy from Amazon http://amzn.to/1Kfpjsn 7. Hengeveld E, Banks K. Maitland’s Vertebral Manipulation: management of neuromusculoskeletal disorders – volume 1, 8th ed. Churchill

Livingstone 2013. ISBN 9780702040665. (Kindle £46.55, Print £57.79). Buy from Amazon http://amzn.to/1Qbf7NB 8. Hengeveld E, Banks K. Maitland’s Peripheral manipulation: management of neuromusculoskeletal disorders – volume 2, 5th ed. Churchill Livingstone 2013. ISBN 9780702040672. (Kindle £46.55, Print £56.99). Buy from Amazon http://amzn.to/1KfplAC 9. Kapandji IA. The physiology of the joints, volume 3: the spinal column, pelvic girdle and head. Churchill Livingstone 2008. ISBN 9780702029592. (Print £182.60). Buy from Amazon http://amzn.to/1KfpnbK

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

DISCUSSIONS What does a positive anterior drawer test at the ankle joint indicate? Why are accessory glide mobilisations used in the foot and ankle? When treating the foot and ankle, why is it important to treat the subtalar and midtarsal joints as well as the talo-crural joint? What is the difference between tendinitis and tendinosis?

KEY POINTS n The therapist must be familiar with the anatomy of the area in order to perform a full assessment. n The capsular pattern of movement limitation at the foot and ankle are defined by: - ankle: more loss of plantarflexion than dorsiflexion - subtalar joint: more loss of inversion - first MTP joint (big toe): more loss of extension - toes: more loss of flexion. n Causes of capsular pattern at the foot and ankle are often osteoarthritis, rheumatoid arthritis and other systemic arthropathies, as well as traumatic arthritis. n The treatment for capsular pattern is mobilisation. n A common cause of non-capsular pattern of movement limitation in the foot and ankle are deltoid ligament and lateral ligament sprain. n Common contractile lesions of the foot and ankle include: gastrocnemius tear, Achilles tendonitis, and peroneal tendonitis.

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

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CONTENTS PANEL ARTICLES IN THIS SERIES ON MANUAL THERAPY INCLUDE: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Introduction to manual therapy Definitions: mobilisation, manipulation and massage Musculoskeletal assessment Musculoskeletal diagnosis Assessment and treatment of the hip Assessment and treatment of the knee Assessment and treatment of the ankle and foot Assessment and treatment of the shoulder Assessment and treatment of the elbow Assessment and treatment of the wrist and hand Assessment and treatment of the cervical spine Assessment and treatment of the lumbar spine Assessment and treatment of the thoracic spine

Co-Kinetic sportEX Journal journal 2017;71(January):34-40 2016;68(April):XX-XX

BOOK REVIEW

BOOK REVIEW SACROILIAC JOINT DYSFUNCTION AND PIRIFORMIS SYNDROME REVIEWER: Dan Buchanan BSc BTEC(5) SRMT, MSMA

TARGET AUDIENCE All manual therapists (physiotherapists, sports therapists, sport rehabilitators, osteopaths, chiropractors, soft tissue therapists, bodyworkers). It lends itself particularly well to those working and aspiring to work with elite athletes as this is the context from which Paula has formulated this book. It makes a complicated subject simple and enables the reader to fully understand the influence of the sacroiliac joint (SIJ) and its effects upon the neuromyofascial matrix in sporting performance as well as the regular activities of daily living.

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INTERACTIVE EXTRAS (ARE THERE ANY AND IF SO WHAT ARE THEY?) There are no interactive extras but the book is written and presented in a fresh and modern style.

YOUR OVERALL OPINION I would highly recommend this book to all manual therapists. Working in a similar field, I have looked up to Paula over the years and followed her career. Three

WHICH OF THE FOLLOWING WOULD YOU DEEM IT? n A ‘Must have’ item

n A ‘Nice to have’ item n Useful but not essential n Not essential n Don’t bother

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN SPORTS MEDICINE (OCT-DEC 2016)

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

MECHANOTHERAPY: HOW PHYSICAL THERAPISTS’ PRESCRIPTION OF EXERCISE PROMOTES TISSUE REPAIR

FOOTWEAR MATTERS Medicine & Science in Sports & Exercise 2016-07-06

American Journal of Sports Medicine 2016-06-16

19TIME SAVING/PRACTICAL 34-40 1

JOURNAL WATCH 49-50 SOCIAL 04-07 PHYSICAL WATCH THERAPY

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CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

Twenty-four experienced college-aged runners were categorised via selfreported questionnaires into a group with chronic ankle instability (CAI) or absence of CAI (control group). After a warm-up period, all participants ran on an instrumented treadmill for 5 minutes at 3.3m/s. Data was collected during the last 30 seconds. Five continuous trials of heel-to-toe running were identified per participant and averaged for statistical analysis. The main outcome measures were impact peak force, active peak force, time to impact peak force, peak force (milliseconds), and average loading rate. The results were that a difference was

In line with our goal of saving you both time and money, here’s our pick of some of the best resources on social media published over the last couple of months.

EYE INJURIES IN SUMMER OLYMPIC SPORTS – A MINI REVIEW. Aoto BAP, Jorge LV, Ferraz CA. Advances in Ophthalmology & Visual System 2016;4(6):000138 doi:10.15406/aovs.2016.04.00138

@DrChrisBarton

TWEETS

3,059 FOLLOWING

@CyclingSurgeon

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Be honest, hands up if you are involved in pitch-side care and how much do you know about eye injuries? If you do, how about writing an article for us and sharing your knowledge?

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The group with ankle instability produced different vertical ground reaction forces which may predispose individuals to stress-related injuries. If Carlsberg did injury prevention we would screen every runner.

1,139

@zlongdpt

Chief Medical Ofﬁcer guidelines for #PhysicalActivity are helping guide the way forward, please RT #ISPAH2016 http://spxj.nl/2gnp5lK

Overhead mobility and stability drill. Press into the foam roller and then roll upward. http://spxj.nl/2fWvrs1

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Oct-Dec 2016

THE 10 MOST DISCUSSED PIECES OF RESEARCH IN SPORTS MEDICINE (OCT-DEC 2016)

A Randomized Parallel-Group Trial Journal of Pain 2016-05-10

PRAC TICAL RESO URCES FOR PHYSICAL AND MANUAL THER APISTS

KINESIOLOGY TAPE DOES NOT FACILITATE MUSCLE PERFORMANCE:

MECHANOTHERAPY: HOW PHYSICAL THERAPISTS’ PRESCRIPTION OF EXERCISE PROMOTES TISSUE REPAIR

TO PREVENT SPORTS INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED

International Journal of Neuroscience 2005-01-01

CONSENSUS STATEMENT ON CONCUSSION IN SPORT: THE 4TH INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT HELD IN ZURICH, NOVEMBER 2012

32.86% 11.66%

409

ANALYSIS OF THE LOAD ON THE KNEE JOINT AND VERTEBRAL COLUMN WITH CHANGES IN SQUATTING DEPTH AND WEIGHT LOAD Sports Medicine 2013-07-05

ISOMETRIC EXERCISE INDUCES ANALGESIA AND REDUCES INHIBITION IN PATELLAR TENDINOPATHY

British Journal of Sports Medicine 2015-05-17

FOOTWEAR MATTERS

Medicine & Science in Sports & Exercise 2016-07-06

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THE NFL ORTHOPAEDIC SURGERY OUTCOMES DATABASE (NO-SOD): THE EFFECT OF COMMON ORTHOPAEDIC PROCEDURES ON FOOTBALL CAREERS

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American Journal of Sports Medicine 2016-06-16

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British Journal of Sports Medicine 2016-06-15

Pediatrics 2016-07-18

162

Medicine

NO. NEWS STORIES NO. GOOGLE+ POSTS NO. BLOG POSTS

ANALYSIS OF HEAD IMPACT EXPOSURE AND BRAIN MICROSTRUCTURE RESPONSE IN A SEASON-LONG APPLICATION OF A JUGULAR VEIN COMPRESSION COLLAR: A PROSPECTIVE, NEUROIMAGING INVESTIGATION IN AMERICAN FOOTBALL

THE TRAININGINJURY PREVENTION PARADOX: SHOULD ATHLETES BE TRAINING SMARTER AND HARDER? British Journal of Sports Medicine 2016-01-12

British Journal of Sports Medicine 2013-04-01

British Journal of Sports Medicine 2009-04-01

of TWEETS Sports NO.

NO. FACEBOOK POSTS

Our thanks to Altmetric for giving us access to this data

REVIEWER: Dan Buchanan BSc BTEC(5) SRMT, MSMA

TARGET AUDIENCE

NEW DEVELOPMENTS IN THE JANUARY ISSUE OF CO-KINETIC JOURNAL

All manual therapists (physiotherapists, sports therapists, sport rehabilitators,

2017

osteopaths, chiropractors, soft tissue therapists, bodyworkers). It lends itself particularly well to those working and aspiring to work with elite athletes as this is the context from which Paula has formulated this book. It makes a complicated subject simple and enables the reader to fully understand the influence of the sacroiliac joint (SIJ) and its effects upon the neuromyofascial matrix in sporting performance as well as the regular activities of daily living.

OVERVIEW

NO. BO O K FACE STS PO

Over 20 years of experience and expertise have been distilled down into an excellent comprehensive and concise reference book on a crucial area of the body. A must read for all practitioners, whether newly qualified or highly experienced.

MAIN CONTENTS

The book is divided into seven chapters. The main meat of the book is built around the assessment and treatment of sacroiliac joint dysfunction and piriformis syndrome. This is backed up by thorough up-to-date chapters on fascia, dry needling, dynamic taping, and a useful appendix covering the theory and practice of instrument-assisted softtissue mobilisation (IASTM).

KEY FEATURES/STRENGTHS AND WEAKNESSES Strengths

This book is very well structured and easy to use as a reference. Concepts are easy to understand and there are excellent photos and illustrations throughout. There is lots of underpinning knowledge regarding anatomy/physiology and pathology of the SIJ and piriformis –

Co-Kinetic.com

BOOK STYLE

Much like Paula’s teaching style this book is relaxed and informative. It is very easy to dip in and out of. There are excellent photos of hands-on techniques with the structural anatomy underneath, extra information boxes and detailed anatomy boxes for the relevant muscles and structures acting on and around the hip and pelvis. It would work very well as a teaching/CPD resource for medical departments, colleges and universities.

INTERACTIVE EXTRAS (ARE THERE ANY AND IF SO WHAT ARE THEY?)

There are no interactive extras but the book is written and presented in a fresh and modern style.

YOUR OVERALL OPINION

I would highly recommend this book to all manual therapists. Working in a similar field, I have looked up to Paula over the years and followed her career. Three

WHICH OF THE FOLLOWING WOULD YOU DEEM IT? n A ‘Must have’ item

✓

n A ‘Nice to have’ item

n Useful but not essential n Not essential n Don’t bother

R IE S

CORTISOLTHE DECREASES EFFECTIVENESS AND SEROTONIN DOPAMINE OFAND EXERCISE INCREASE FOLLOWING INTERVENTIONS MASSAGE THERAPY

NO. MENDELEY2013-10-07 READERS

NO. WIKIPEDIA PAGES PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

For more details about the data behind this infographic, along with the full search results and

A Pragmatic Randomized Trial Annals of Internal Medicine 2014-08-04

MANUAL PHYSICAL THERAPY VERSUS SURGERY FOR CARPAL TUNNEL SYNDROME:

A Deceptive Controlled Trial Manual Therapy 2014-08-22

DO MANUAL THERAPIES HELP LOW BACK PAIN? A Comparative Effectiveness Meta-analysis Spine 2014-01-29

n Colour changes n Swelling

n Plantarflexion

7. Resisted tests (pain and power)

n Dorsiflexion n Inversion

8. Additional specific tests

Don’t forget to perform any special tests and complete the examination with palpation of the region

Assessment of the ankle and foot

For a full assessment of the ankle and foot, the therapist should perform the observations and examinations detailed in Table 1 and Video 2.

Treatment around the ankle and foot

ANKLE | FOOT | 17-01-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video: Ankle and foot rehabilitation exercises

J. Hatcher, 2013

TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE ANKLE AND FOOT (J. Hatcher, 2013)

Rheumatoid arthritis (RA) and other systemic arthropathies

Dorsiflexion mobilisation (Video 4) Directions: 1. Stand at side of patient with cephalad

Video 1: Surface marking of the ankle region (Video with captions but no sound; J. Hatcher, 2013)

43-48

n Systemic autoimmune disease, causing degeneration and possible joint disruption. n Often severe capsulitis, may lead to joint laxity and deformity.

PHYSICAL THERAPY MSK DIAGNOSIS AND REHABILITATION

n Need to treat for swelling first (exercises and/or electrotherapy).

n Common in the ankle joint.

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the ankle and foot are shown in Table 2.

Treatment choice for the ankle joint n Mobilisations of the ankle.

Co-Kinetic sportEX Journal journal 2017;71(January):34-40 2016;68(April):XX-XX

BUSINESS REWARD PROGRAMMES

TYPICAL FEATURES n Wear and tear to the joint, may be primary, or possibly secondary to previous lesion. n Mild capsulitis, possible crepitus.

CAUSE Osteoarthritis (OA)

Traumatic arthritis (TA)

CAPSULAR PATTERN

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

n Plantarflexion (in standing) n Eversion

Video 1 shows surface marking of the anatomical area and will help you with the key structures encountered in this article.

n Dorsiflexion

Alternative names n Chronic plantar heel pain (CPHP) n Painful heel syndrome n Plantar fasciitis n Plantar fasciopathy n Plantar tendinopathy n Plantar enthesopathy n Subcalcaneal bursitis n Neuritis n Medial arch pain n Stone bruise n Calcaneal periostitis n Heel spur n Subcalcaneal spur n Calcaneodynia

BY DR CHRISTOPHER NORRIS PHD, MCSP

ANKLE-FOOT | LOWER-LIMB | RUNNING | HANDOUT | 17- 01 -COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS

Video: Low Dye Taping for Plantar Fascia Pain (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Plantar Fascia-specific Taping (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Self-massage for Plantar Fascia Pain (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Heel-raise Exercises for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Supported Lunge for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG Video: Quarter Squat Exercise for Plantar Fascia Strengthening (C. Norris, 2016) - http://spxj.nl/2gy2ZjG

STRUCTURE AND FUNCTION OF THE PLANTAR FASCIA The PF is a thick tissue layer stretching from the calcaneus to the toes. It averages 12cm in length and 2–6cm

Sesamoid

Flexor hallucis Plantar longus oponeurosis

Plantar fascia

Figure 1: Anatomy of the plantar fascia (PF) and the windlass mechanism (Moseley C. sportEX medicine 2013;55:15)

Co-Kinetic Journal 2017;71(January):14-20

Co-Kinetic.com

BUSINESS GROWTH MARKETING

REWARD PROGRAMMES

FOR THERAPISTS: FROM PLANNING TO IMPLEMENTATION Reward programmes, such as loyalty schemes and referral programmes, are one of the easiest ways to grow your therapy business with relatively little cost. Both involve rewarding customers for buying services. This article contains all the information you need to decide which type of reward programme you should run, explains which customers to target, offers advice on how to set up your reward programme, what to measure to track success, what incentives you could offer as part of the scheme and a stepby-step guide on how to implement the programme. All the resources required to implement any of the campaigns mentioned in this article are also available here http://spxj.nl/2gZkQwP.

21-28

Our ready-made Marketing Campaign Kits for Therapists (http://spxj.nl/2gZkQwP) include: n Print-ready Posters, Leaflets and Postcards you can use to publicise your scheme locally n Social Media Promotional Material to publicise your scheme across the 6 main social networks n Template Text for letters and emails explaining how your reward programme works n Customer Feedback NPS Scorecard n Printable Discount Vouchers in a variety of values and currencies n Customisable Gift Certificates and First Visit Gift Certificate n Voucher Record Form for recording details of vouchers you’ve sent out n How to Leave a Google Review handout. Read this online http://spxj.nl/2g3DJRW

HEEL PAIN: THE 10 MINUTE ASSESSMENT

BY TOR DAVIES, CO-KINETIC FOUNDER

REWARD PROGRAMMES

17-01-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Reward Programme Checklist – http://spxj.nl/2g3DJRW An Epic List Of 47 Referral Programs [Article] – http://spxj.nl/2grLZZy 5 Referral Program Ideas for Driving More B2B Leads [Article] – http://spxj.nl/2goeQ0A How to Create Repeat Bookings and Abundant Referrals [Slide Presentation] – http://spxj.nl/2gAHM8M

Co-Kinetic.com

Referral vs Loyalty – What’s the Difference? n A referral programme uses your existing customers to bring in new

customers through word of mouth. The purpose is to attract new customers at a lower cost. n A loyalty programme rewards existing customers for frequently buying your services (or purchasing products). The purpose is to encourage repeat customers and increase loyalty to you as a business or service provider. “One of the side benefits of a referral programme is it also increases loyalty. Customers who refer tend to be more loyal, and loyal customers tend to refer more.”

Why Bother with a Reward Programme?

n Generally speaking, it costs 5–6 times more to acquire new customers than to retain old ones. n Existing customers spend around 60–70% more than new customers. n Following Pareto’s Law (or the 80:20

MANUAL THERAPY MASSAGE THERAPY

COMBINED MOVEMENT THEORY FOR MASSAGE THERAPISTS

FOR MASSAGE THERAPISTS

We have all been in the situation where a patient presents to us with severe pain and impaired motion in a particular direction. We want to relieve their pain but don’t want to do too much treatment and make them feel worse. Combined Movement Theory (CMT) is an examination and treatment framework incorporating spinal manipulation techniques, muscle energy techniques and mobilisation. Patients are placed in comfortable positions and moved in a manner that evokes a brain orchestrated pain inhibition mechanism, quickly. Patients learn that the threat they perceived, with a particular motion, can be simply reduced with movement. Now that we understand the neurophysiological effects of Dr Brian Edwards’ ‘combined movements’, it is clinically reasonable and a valuable tool for anyone interested in addressing specific impairments with specific physical education (Manual Therapy). This article will explain the essential elements of CMT, how to put theory into practice, how to incorporate mobilisation and manipulation, how to detect regular and irregular patterns of spinal movement, and finally how to progress treatments. Read this online http://spxj.nl/2fEoKtm

The concept of ‘combined movements’ examination and treatment was developed by Dr Brian Edwards, a

17-01-COKINETIC FORMATS

WEB

MOBILE

MEDIA CONTENTS PDF: Clinical reasoning form - http://spxj.nl/2fEoKtm Video: Post-isometric relaxation for the deep neck flexors - http://spxj.nl/2fEoKtm

Co-Kinetic.com

TECHNICAL

specialist manipulative physiotherapist from Australia and the principles incorporated into the practice of other manual therapists, such as Geoff Maitland (Maitland Concept).

NEW DEVELOPMENTS IN THE JANUARY ISSUE OF CO-KINETIC JOURNAL

2017 A NEW V SUAL APPROACH TO NFORMAT ON AND RESEARCH

Our thanks to29-33 Altmetric for COMBINED giving us access to this data MOVEMENT THEORY BY DR CHRIS MCCARTHY PHD, FCSP FMACP

SHORT

TABLE 1: PLANTAR FASCIITIS NOMENCLATURE AND DIFFERENTIAL DIAGNOSIS (C. Norris, 2016)

PLANTAR FASCIITIS: A PAIN IN THE HEEL

n Treatment to ligaments as necessary and mobilise as pain allows, Grade A–B (I–IV). hand supporting the posterior part of the lower leg just above the ankle. 2. Place caudad hand on sole of foot, close to calcaneus. 3. Use palm of hand to take foot into dorsiflexion. 4. Again, grade according to clinical assessment.

Video 2: Assessment of the ankle and foot (Video with captions but no sound; J. Hatcher, 2013)

Co-Kinetic.com

http://spxj.nl/2hdFuKs

ONE-YEAR OUTCOME OF SUBACROMIAL CORTICOSTEROID INJECTION COMPARED WITH MANUAL PHYSICAL THERAPY FOR THE MANAGEMENT OF THE UNILATERAL SHOULDER IMPINGEMENT SYNDROME:

Produced by:

MASSAGE THERAPY ATTENUATES INFLAMMATORY SIGNALING AFTER EXERCISE: Induced Muscle Damage Science Translational Medicine 2012-02-01

THE EFFECT OF AROMA HAND MASSAGE THERAPY FOR PEOPLE WITH DEMENTIA

THE MECHANISMS OF MANUAL THERAPY IN THE TREATMENT OF MUSCULOSKELETAL PAIN:

A Comprehensive Model Manual Therapy 2009-10-01

S STO

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN

POPULATIONS – A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations Pain Medicine 2016-05-10

Journal of Alternative & Complementary Medicine 2015-09-20

S W EET NO.T

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN

POPULATIONS – A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population Pain Medicine 2016-05-10

TRIALSby Source Mentions British Journal

BOOK REVIEW

the full search results and information about the Altmetric badge go to

3 4 5

n Face and posture and gait n Age and occupation n Site and spread n Onset and duration n Behaviour and symptoms n Past medical history (P.M.H.) n Bony deformity n Wasting

n Observe/examine state at rest and eliminate hip joint n Palpate for heat, swelling and synovial thickening

6. Passive tests (for pain, range and end-feel)

BOOK REVIEW SACROILIAC JOINT DYSFUNCTION AND PIRIFORMIS SYNDROME

THE 10 MOST-DISCUSSED PIECES OF MANUAL THERAPY For more details about the data RESEARCH (OCT-DEC 2016) behind this infographic, along with

Produced by:

3. History

NEW

223 72 49 1 0 DECEMBER 2

BOOK REVIEW

DETAILS

n Dermatomes L4: medial side of foot and great toe L5: dorsum of foot and medial 3 toes S1: sole of foot and lateral 2 toes S2: heel

n Myotomes L4: foot and toe extensors, and foot invertors L5: toe extensors, flexors and foot evertors S1: plantar flexors and evertors 2. Initial observation

4. Inspection 5. Objective examination

a. Gross ankle movements

b. Ligament tests i. Ankle joint (for pain and n Inversion and eversion (in plantarflexion – loose laxity) packed position for ankle joint) ii. Subtalar joint

TABLE 1: ASSESSMENT OF THE ANKLE AND FOOT (J. Hatcher, 2013) OBSERVATION/ EXAMINATION 1. Anatomy

Co-Kinetic comment

Co-Kinetic.com

OCTOBER

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PHYSICAL THERAPY: PAIN, MANUAL BRAINTHERAPY AND SPORTS STUDENT PERFORMANCE HANDBOOK

MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the ankle and foot

ATHLETIC TRAINING AFFECTS THE UNIFORMITY OF MUSCLE AND TENDON ADAPTATION DURING ADOLESCENCE. Mersmann F, Bohm S, et al. Journal of Applied Physiology 2016;121(4):893–899

Tissue adapts to the stress placed upon it. Hence, with young athletes the double whammy of variations in mechanical loading and maturation is bound to take a toll, with the problem being an increase in muscle imbalance and the risk of potential injury. It is a challenge for coaches and health professionals.

FUNCTIONAL AND PSYCHOLOGICAL IMPACT OF NASAL BONE FRACTURES SUSTAINED DURING SPORTS ACTIVITIES: A SURVEY OF 87 PATIENTS. Lennon P, Jaber S, Fenton JE. Ear, Nose & Throat Journal 2016;95(8):324–332

3 MONTHS IN THE LIFE OF

ALTMET R

Co-Kinetic Journal 2017;71(January):4-7

‘Text neck’ is becoming an ‘epidemic’ and could wreck your spine. http://spxj.nl/2fIhtvR

This was a survey of 217 patients who had experienced a nasal bone fracture over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, whereas the other 103 (77.4%) had undergone manipulation under anaesthesia. Eighty-four percent of the patients (n=87) were contacted by telephone and data was obtained from them. The most common sports associated with these 87 injuries were hurling (n=26; 29.9%), rugby (n =22; 25.3%), Gaelic football (n =20; 23.0%) and soccer (n=13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later. Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of re-injury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether.

SCO NTION ATTE

947

857 1177

@SpineHealth

#InMotion about the project. http://spxj.nl/2gOtWzS

STRESS-RELATED PSYCHOLOGICAL FACTORS FOR BACK PAIN AMONG ATHLETES: IMPORTANT TOPIC WITH SCARCE EVIDENCE. Heidari J, Hasenbring M, et al. European Journal of Sport Science 2016;doi:10.1080/174 61391.2016.1252429 [Epub ahead of print]

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Journal Watch

R IC

@AustralianPhysiotherapyAssociation

ASSESSMENT OF THE FOOT & ANKLE

PHYSICAL THERAPY RESEARCH INTO PRACTICE

SOCIAL WATCH

SOCIALWATCH

10 years of work in one blog – knee cap pain gold… #TREK #PatientEducation #TEAM_PFP @LaTrobeSEM http://spxj.nl/2gS0ZDf

THE NFL ORTHOPAEDIC SURGERY OUTCOMES DATABASE (NO-SOD): THE EFFECT OF COMMON ORTHOPAEDIC PROCEDURES ON FOOTBALL CAREERS

what’s inside

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Our thanks to Altmetric for giving us access to this data

THE FEMALE ATHLETE TRIAD

MET ALT

409

NO. NEWS STORIES

Pediatrics 2016-07-18

PRACTICAL RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS

British Journal of Sports Medicine 2015-05-17

Produced by:

51.54% 32.86% 11.66% 2.71% NO. GOOGLE+ POSTS 0.72% NO. BLOG POSTS 0.44% NO. WIKIPEDIA PAGES 0.07% NO. FACEBOOK POSTS

READ E

A Comparative Effectiveness Meta-analysis Spine 2014-01-29

SCO RE

DO MANUAL THERAPIES HELP LOW BACK PAIN?

British Journal of Sports Medicine

British Journal of TWEETS Sports NO. Medicine NO. MENDELEY2013-10-07 READERS

ALTMET RIC AT TE

A Comprehensive Model Manual Therapy 2009-10-01

2009-04-01 TO PREVENT SPORTS INJURIES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED CONTROLLED TRIALSby Source Mentions International Journal of Neuroscience 2005-01-01

http://spxj.nl/2gjsqpT

ISOMETRIC EXERCISE INDUCES ANALGESIA AND REDUCES INHIBITION IN PATELLAR TENDINOPATHY

Sports Medicine 2013-07-05

NO. MEN DELEY

EFFECTIVENESS CORTISOLTHE DECREASES AND SEROTONIN DOPAMINE OFAND EXERCISE INCREASE FOLLOWING INTERVENTIONS MASSAGE THERAPY

British Journal of Sports Medicine 2016-06-15

British Journal of Sports Medicine 2016-01-12

ANALYSIS OF THE LOAD ON THE KNEE JOINT AND VERTEBRAL COLUMN WITH CHANGES IN SQUATTING DEPTH AND WEIGHT LOAD

British Journal of Sports Medicine 2013-04-01

STOR IES

THE MECHANISMS OF MANUAL THERAPY IN THE TREATMENT OF MUSCULOSKELETAL PAIN:

Journal of Alternative & Complementary Medicine 2015-09-20

NO. NEW S

THE EFFECT OF AROMA HAND MASSAGE THERAPY FOR PEOPLE WITH DEMENTIA

284

A Deceptive Controlled Trial Manual Therapy 2014-08-22

CONSENSUS STATEMENT ON CONCUSSION IN SPORT: THE 4TH INTERNATIONAL CONFERENCE ON CONCUSSION IN SPORT HELD IN ZURICH, NOVEMBER 2012

ANALYSIS OF HEAD IMPACT EXPOSURE AND BRAIN MICROSTRUCTURE RESPONSE IN A SEASON-LONG APPLICATION OF A JUGULAR VEIN COMPRESSION COLLAR: A PROSPECTIVE, NEUROIMAGING INVESTIGATION IN AMERICAN FOOTBALL

THE TRAININGINJURY PREVENTION PARADOX: SHOULD ATHLETES BE TRAINING SMARTER AND HARDER?

NO. NEW S

KINESIOLOGY TAPE DOES NOT FACILITATE MUSCLE PERFORMANCE:

NO.TWE ETS

A Randomized Parallel-Group Trial Journal of Pain 2016-05-10

Induced Muscle Damage Science Translational Medicine 2012-02-01

NO. MEN DELEY

MASSAGE THERAPY ATTENUATES INFLAMMATORY SIGNALING AFTER EXERCISE:

NO FACEB . O POST OK S

MANUAL PHYSICAL THERAPY VERSUS SURGERY FOR CARPAL TUNNEL SYNDROME:

Produced by:

For more details about the data behind this infographic, along with the full search results and information about the Altmetric badge go to

A Pragmatic Randomized Trial Annals of Internal Medicine 2014-08-04

274

Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations Pain Medicine 2016-05-10

284

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN POPULATIONS – A Systematic

http://spxj.nl/2hdFuKs

ONE-YEAR OUTCOME OF SUBACROMIAL CORTICOSTEROID INJECTION COMPARED WITH MANUAL PHYSICAL THERAPY FOR THE MANAGEMENT OF THE UNILATERAL SHOULDER IMPINGEMENT SYNDROME:

NO.TWE ETS

THE IMPACT OF MASSAGE THERAPY ON FUNCTION IN PAIN

POPULATIONS – A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part I, Patients Experiencing Pain in the General Population Pain Medicine 2016-05-10

NO FACEB . O POST OK S

LONG

BUSINESS GROWTH MARKETING

REWARD PROGRAMMES FOR THERAPISTS: FROM PLANNING TO IMPLEMENTATION Reward programmes, such as loyalty schemes and referral programmes, are one of the easiest ways to grow your therapy business with relatively little cost. Both involve rewarding customers for buying services. This article contains all the information you need to decide which type of reward programme you should run, explains which customers to target, offers advice on how to set up your reward programme, what to measure to track success, what incentives you could offer as part of the scheme and a stepby-step guide on how to implement the programme. All the resources required to implement any of the campaigns mentioned in this article are also available here http://spxj.nl/2gZkQwP.

REWARD PROGRAMMES

17-01-COKINETIC FORMATS WEB MOBILE

Co-Kinetic.com

Referral vs Loyalty – What’s the Difference? n A referral programme uses your existing customers to bring in new

Why Bother with a Reward Programme? n Generally speaking, it costs 5–6 times more to acquire new customers than to retain old ones. n Existing customers spend around 60–70% more than new customers. n Following Pareto’s Law (or the 80:20 43

rule), your loyal customers represent about 20% of your customer group but generate around 70–80% of your revenue. n According to the global statistics company Nielsen, businesses could boost profits by 100% by retaining just 5% more customers. n The probability of selling to a new customer is 5–20%, whereas the probability of selling to an existing customer is 60–70%. n And finally, a loyal customer is 70% more likely to refer your business or services. There are some other good stats at http://spxj.nl/2geomG8, which show why loyalty pays.

So Which Reward Programme Should You Focus on First? People are much less likely to refer if they’re not already loyal customers. So if you’re just starting out and don’t have an existing crop of loyal advocates and repeat customers, then work on building loyalty, trust and encouraging repeat bookings with the customers you have by implementing a loyalty programme. If you’ve been in business a little while and have some solid, reliable, repeat customers, even just a handful, then they’re ripe for a referral programme. For those of you who like to run before you can walk, resist the temptation to do both at once, focus on making one work before you branch out to the other. Although they may seem

BOX 1: MARKETING CAMPAIGN KITS FOR THERAPISTS (T. Davies, 2016) We have created a series of campaign kits to enable you to run the following marketing campaigns: n Refer a Friend Campaign n We’d Love to See You Again Campaign n Customer Feedback Campaign n Gift Certificates and Discount Coupons The Campaign Kits contain all the elements you need to promote awareness of and run a campaign including posters, leaflets, postcards, artwork for emails and blog posts or website article content, and images for social media promotion. Some campaigns will have additional resources like checklists, score cards, vouchers/coupons and other elements that you may need to implement the campaign in full. For more details go to http://spxj.nl/2gZkQwP.

very similar in some ways, they’re really not.

Define What Success of Your Reward Programme Looks Like This is probably the single most important factor when implementing any kind of new reward programme, initiative or service. Before you start, decide what a successful outcome of your programme looks like in practical terms. Be specific and make your goal or outcome ‘SMART’. Specific Measurable Achievable Relevant Time-specific – ie. set a deadline. You could even write this on an A4 sheet and stick it on a wall you look out frequently, to keep you focused (or use our Reward Programme Checklist, which is available online – see Media Contents at the start of this article).

Key Success Indicators of the Best Loyalty Programmes and Referral Schemes n Define your desired outcome before you start (and make it SMART). n Keep it simple both to implement, manage and for the customer to redeem. n Make it personal – make sure it fits with your customer and is relevant to them; equally importantly, make sure it fits with your ‘brand’. n Make sure you tell people about it (but don’t spam them) – sounds obvious but promote it through all your channels, such as newsletters, emails, on your social networks and through posters on your clinic wall (we’ve created a resource pack of posters, leaflets, postcards and social media images – see Box 1). n If you are running a loyalty programme, always make sure they get your best offer – never make them feel that they’re paying more for their loyalty. n If it’s a referral programme then make sure to give them ways they can refer you (we’ve created vouchers, leaflets and postcards – see Box 1). n Make sure they have a good and consistent experience across all the ‘touch points’ they have with your

BOX 2: MAKE SURE YOUR REWARD PROGRAMME SPARKLES (T. Davies, 2016)

S imple P ersonal A ctionable R elevant K now about it! L oyal E asy S MART

business – this isn’t only you, it’s any staff you may have, your website, any partners you might refer them to or partner offers you provide. They all come back to you. n Focus on becoming truly customercentric – offer both your new and your existing customers a service that’s second to none, that way you’ll more quickly convert new customers to loyal and referring customers. n Understand that it’s not a ‘quick fix’ solution. It takes time and commitment to build loyalty but once you have it, it’s worth its weight in gold, quite literally (Box 2). Related Reading: Loyalty Programs Gone Wrong – 10 Common Mistakes to Avoid (http://spxj.nl/2fwUbuy/)

Reward Incentives You could apply any of the ideas in Box 3 to either a loyalty or a referral programme; however, referral programmes don’t generally need the level of sophistication in terms of rewards that loyalty programmes do, because the straightforward model of a special deal for the new ‘referred’ customer combined with a thank you gesture for the ‘referring’ customer often works best. It’s clear, easy to understand, easy to share, easy to redeem and everyone gets an added benefit. Remember: Keep your ‘refer a friend’ programme simple to implement, simple to understand and simple to redeem. Whatever reward/s you choose, make them relevant to your clientele, in context with the service you offer and fit the ethos of your business. Co-Kinetic Journal 2016;71(January):43-48

BUSINESS GROWTH MARKETING

REFERRAL OR ‘REFER A FRIEND’ PROGRAMMES We’ll tackle this one first because it’s the simplest of the two reward programmes; however, it assumes that you already have a selection of clients that are regular, repeat customers with whom you have a good relationship and who trust you. If that’s not the case yet, skip to the ‘Loyalty Programme’ section and start there. Referral programmes can be pretty straightforward and, if you haven’t run any before, it’s best to keep it that way.

Simplicity is Key nS imple to communicate to your existing customers n A simple ‘transaction’ that both your existing customer and newly referred customers understand n Simple for you to administer. In its most simple form the balance of reward (or incentive) is on the new customer you want to attract because the stimulation for your existing (referrer) customer is likely to be mostly altruism, or ‘social gifting’. That said, it’s nice to be able to offer something nice to your referrer.

Make Your Referral Programme Personal Unless you feel you really need to, it’s probably not necessary to make this ‘reward’ monetary in terms of offering a discount on your own services, and in fact many people who are referring you out of respect/altruism would prefer it wasn’t. Instead find something really nice to do for them. It could be as small but as thoughtful as sending them a simple, personal card to say thank you (not one signed by your secretary though, even if you have one, it has to come from you). Alternatively, partner up with another local business who wants to attract new customers and negotiate a deal for people you refer to them (and they could do the same for you). The sorts of people you could partner up with might include: a local bike shop who might offer a free bike check (worth £XX), a £XX discount on a meal at a local restaurant, or a bottle of wine free with a meal, lunch at a local cafe, a free or discounted treatment Co-Kinetic.com

at a local spa, basically any service or product that fits with your business, and where you know your customer will have a good experience. You could even have a selection of ‘gifts’ and ask them which one they’d like. If you wanted to keep the reward ‘in-house’, you could offer them an upgrade on a treatment as a thank you, or a free ticket to a workshop or another event that you or a partner might be hosting. Leverage your contacts and remember that everyone wants new business, so find partners who offer complimentary services and do a twoway referral scheme. Remember this is a loyal client who’s willing to stick their neck out to recommend you, treat that with the respect you feel it deserves. Perhaps you could make your ‘refer a friend’ offer quite exclusive where you give them, for example, three tokens which offer a particularly good benefit to their friends, just make sure not to undervalue or undersell yourself. This might be something you could do in conjunction with a loyalty scheme, if they book X appointments in Y months, you give them a voucher for a free appointment which they could either use for themselves or choose to give it to someone they feel would appreciate it most. You could offer them the choice of two different benefits and let them choose, or you could test two different schemes at separate times: the first might offer a discount to the friend being referred and some sort of value add to the referrer; the second scheme might offer to give that benefit to someone else such as a donation to charity, some sort of local cause you feel fits with your ‘brand’. That way you can see which one is more popular and further refine your offering. Whatever you do, ALWAYS make sure you say thank you. At the very least drop them a personal email or text message to express your gratitude. Most people (regardless of the cynics in the world) want to be altruistic for one reason or another, you just have to give them the opportunity.

Measure the Results Whatever you do make sure you

BOX 3: REWARD PROGRAMME INCENTIVES (T. Davies, 2016) n n n n n n n n n n n

Cash back Discounts, offers, credit against future bookings Exclusivity to events, evening seminars, workshops First chance to capture special offers or promotions Gifts, products, free trials, special discounts B enefits provided through a partnership with another business VIP rate card Added value resources U pgrades – book treatment X and we’ll upgrade to treatment Y Gift cards, vouchers, coupons S ocial gifting, ie. nothing in it for referrer but a feel good factor (can be effective if done well).

measure the results of your programme. If you don’t measure, you have no way to see how effective it’s been or what’s working and refine it to make it even better.

Further Reading: Referral Programme Resources n An Epic List Of 47 Referral Programs [Article] (http://spxj.nl/2grLZZy) n 5 Referral Program Ideas for Driving More B2B Leads [Article] (http://spxj.nl/2goeQ0A)

LOYALTY PROGRAMMES These are ideal for newly qualified therapists or for those of you running a business where you haven’t yet established a group of loyal, repeat customers. For a therapist delivering hands-on services, your loyalty programme should focus on building trust and turning your existing customers into loyal ones who will then, in turn, become the referrers that we’ve discussed above. Most of the loyalty/reward programmes you’ll be involved with in your day-to-day life focus on rewards such as points, cash, airmiles, discounts, etc. However, as a therapist delivering the kind of services you deliver, these sorts of things could be relevant but also could be so much more.

Relationships are the Key to Loyalty Programmes As a therapist delivering physical therapy or massage therapy treatments, you have a much closer relationship with your customers than most other companies 45

do. There is also an implicit vulnerability and trust that comes with the physical contact of our profession. So yes, although you could offer points and discounts for frequent purchases, you could also decide instead (or as well as) to focus on developing the relationship and building the trust you have with your client. This is likely to be far more productive for both of you, than the simple ‘points mean prizes’ approach. Relationships, not rewards, are the key to a successful loyalty programme. Creating the WOW Factor You could scrap the idea of a loyalty programme and just focus on providing a WOW! factor from day 1. If you’re an Apple® convert, you’ll know exactly what I mean, so how about being the ‘Apple®’ of therapists? Think about the best experience you’ve had from customer service, or what the best experience is that you could create for your clients. Put yourself in their seat and set your mind free. The chances are that it doesn’t cost that much to make it happen. Let your customers know that they’re important to you. If they arrive early, or you’re running late, why not offer them a coffee/tea/glass of wine! Who wouldn’t love that? If during the course of their appointment they mention something that’s outside the scope of the treatment but it’s something you can offer authentic, qualified help with, why not send them a link to some information they might find useful. It takes you 2 minutes, but it will make a world of difference to the opinion they have of you. What does it cost to drop them a quick email saying, “You mentioned you were worried about X or interested in Y, and I came across something that I thought you might find useful, here’s the link”? You can still supplement these efforts with some sort of incentive scheme to encourage repeat bookings but, at the end of the day, your focus should be on building the ‘Know, Like, Trust’ factor. The ‘Know, Like, Trust’ Factor This is a simple principle of all sales, friendship and networking. First you get 46

to know someone, then you decide whether or not you like them and then the last stage is that you learn to trust them. It is at that point you become someone they’ll refer and recommend. There are so many ways you could go above and beyond the call of duty without it taking excessive time or costing a load of money. Would you not tell your friends if you had an experience that stood out for you? Other things you could do might include putting on an evening seminar on a topic that’s likely to bring people through the door, this could be seasonal or it could involve some sort of big national event like the London Marathon. If you don’t feel qualified to talk about it, you could partner up with someone locally. Say there’s a new diet on the block and a large number of your clients are women who are conscious about their weight, why not bring in a local nutritionist or fitness professional (who’s qualified in nutrition) to talk about it and answer questions. They get the chance to get in front of new potential clients and you get the brownie points. Just be careful not offend anyone by making it seem like you’re suggesting they should go on a diet! Use your contacts and even your customers (if you think they’d like it). The great thing about physical therapy and massage therapy appointments is that during the course of an appointment you have the chance to find out so much about your customers, what they do, what’s important to them, what they’re worried about, what they’re happy about. Keep personal notes, you never know when it’s going to come in handy. Maybe one of your clients is a great story teller who has just come back from an amazing trip to some far flung country, why not invite 10 of your customers who you know would enjoy the stories, to come and listen to him/her do a short talk or photo presentation? Every interaction is an opportunity to build that relationship. Ask them to friend your Business Facebook page, or follow you on Twitter. If you want to give them a reason to do it, tell them you always publicise your events and any discounts or special offers on there, or share links to information you know they’d find

useful (we’ve created a Connect With Us Template – see below). As you build the relationship ask them if they’ll write a Google Review for you or leave a comment on your Facebook page. All these things contribute to building the Know, Like, Trust factor (the online version includes a How to Leave a Google Review leaflet). Loyalty Programme Resources Online n Connect with Us Template – overprint with the web links to your social networks and ask them to connect with you. n How to Leave a Google Review.

So Which Customers Should You Target with a Loyalty Programme? That’s easy: the ones you have the best relationships with. The ones who you know best, even if they’re not yet at a stage where you could ask them to refer you to a friend. The customers who’ve been to see you most often and/or who you’ve had good results with or that you think you can do most for.

Define What Success Looks Like As we’ve said above, make sure you have a SMART goal. Decide what success of this programme looks like. Do you want to grow the ‘likes’ on your business Facebook page, increase your Twitter followers, increase your number of Google Reviews, increase repeat bookings/customer lifetime value (eg. increase the average number of appointments each customer has), decrease your churn rate (for example the number of people who don’t come back after their first appointment), increase the people rating you 7+ on the Net Promotor Score (see Further Reading for more information) or several of these in one go? Whatever it is, make sure it’s written down and you’re answerable to it.

Other Ways Loyalty Can Pay What we’ve covered above focuses on having very specific and direct outcomes and goals; however, there are a lot of additional benefits to loyalty that may be slightly less obvious.

Co-Kinetic Journal 2016;71(January):43-48

BUSINESS GROWTH MARKETING

DID YOU KNOW

WE HAVE A REFER A FRIEND SCHEME CAMPAIGN KIT? WHAT?

Ready-to-go material to launch and run a Refer a Friend marketing promotion: ● Through your social networks ● Via email ● Locally (with posters and leaflets) ● Through the post (via leaflets and postcards)

WHY? ● A quick to implement professional and ready-to-go campaign DID YOU ● Great looking, professionally produced images and artwork at WE HAVE A a fraction of the cost they would REFER be to create or commission A FRIEND ● All text and images have already SCHfoErMmorEe?details been created for you Ask us ● Choose from 6 different themes ● All images are copyright-free ● Avoid ‘blank page syndrome’ by using our content as a starting point and adapting it for your own needs where desired ● Banish the feeling of “but where do I start?” by following our Step by Step Implementation guide. Refer

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Use it to Collect Data This could include dates of birthdays, what social networks they use, do they share certain demographics, such as age or areas they live in? What does your ideal customer profile look like, particularly the ones that spend most money with you? Can you find an ideal profile and then use this to target similar profiles with your marketing efforts?

customers with a ‘We’d love to see you again’ letter/email. Utilise Down Time Use loyalty initiatives to fill diary gaps and build up work in quiet periods Develop Useful Resources If you develop resources as part of your loyalty campaign, these might be videos of the seminars you host, or blog posts you write for your newsletters or advice handouts you give to patients, why not see how you can use these as part of your wider marketing efforts.

Move Them Through Your Spend Bands Use your loyalty scheme to move them through spend levels. Maybe offer a lowspend entry point and then use your loyalty scheme to get them to upgrade.

IN CONCLUSION

We'd Love to See You Again Campaign Initiate a ‘We’d Love to See You Again’ incentive for your old customers, perhaps some sort of opportunity to do a walk-in consultation or host an evening seminar that you could invite them to. Or do a special discount offer for returning customers. Use our Printable Vouchers to send to lapsed

As you can see reward programmes can be simple as well as effective and can bring huge gains to your business. All the resources required to run this campaign can be found here (these are accessible under a full site subscription or can be purchased individually at the following link http://spxj.nl/2fMtfnc). We also produce a range of Content Marketing Kits for Therapists which cover topics your patients and clients

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Keep your ‘refer a friend’ programme simple to implement, simple to understand and simple to redeem http://spxj.nl/2g3DJRW Tweet this: Make your reward/s relevant to your clientele, in context with the service you offer and fit the ethos of your business http://spxj.nl/2g3DJRW Tweet this: Relationships, not rewards, are the key to a successful loyalty programme http://spxj.nl/2g3DJRW

KEY POINTS nR eward programmes are an easy way to grow your business with relatively little cost. n Reward programmes often take the form of referral (or ‘refer a friend’) programmes or loyalty schemes. n Referral programmes use your existing customers to bring in new clients. n Loyalty schemes reward existing customers who frequently use your services and encourage repeat custom. n If you are just starting out in your business, first work on building a base of loyal, repeat customers. n If you already have some loyal customers, instigate a referral programme. n Make sure that your rewards programme has defined success criteria – make it SMART: Specific, Measurable, Achievable, Relevant and Time-specific. n Keep your reward programme simple. n Make your programme personal. n Loyalty schemes can be useful in other ways, such as for collecting data about your clients and building up work in quiet periods.

may find interesting and which you can use for blog posts, social media marketing and email newsletters http://spxj.nl/2gBEnXd. For more information about what our Content Marketing Campaign Kits for Therapists include, go to http://spxj.nl/2gZkQwP. To see the kits we’ve created so far go to http://spxj.nl/2gBEnXd.

FURTHER READING n 6 Ways You Can Build the Know Like Trust Factor (http://spxj.nl/2gEBgLS) n What is the Net Promotor Score (http://spxj.nl/2g0SGRA) n How to Measure Your Net Promotor Score (http://spxj.nl/2geyui5)

READY-MADE MARKETING CAMPAIGN KITS FOR THERAPISTS THAT COMPLIMENT THIS ARTICLE http://spxj.nl/2gZkQwP: n Refer a Friend Marketing Campaign Kit in two design themes n We’d Love to See You Again Marketing Campaign Kit n We’d Love to Hear Your Thoughts Customer Feedback Marketing Campaign Kit.

RELATED CONTENT eward Programmes For Therapists: Example Case R Studies [How to Guide] - http://spxj.nl/2g3P44s arketing Campaign Kits for Therapists from Co-Kinetic M - http://spxj.nl/2gZkQwP Things You Can Do in Less Than An Hour To Increase 5 Your Google Search Profile and Get New Clients [How To Guide] - http://spxj.nl/2ddylZg THE AUTHOR Tor Davies, BSc, Co-Kinetic Founder started her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK and then went on to complete a BSc in Sport and Exercise Science. After graduation and a relatively short-lived job in marketing, she became a medical journalist where her passion for publishing was born. At 27 she left journalism to set up and publish a sports medicine magazine for GPs called sportEX medicine. Since then sportEX medicine has developed into a bigger journal for physical and manual therapists, now known as Co-Kinetic Journal. In the process of learning to run a publishing company she become a self-confessed techie nerd and has subsequently designed membership management systems, e-learning and ecommerce platforms and at least four content management systems. Her passion and focus is now helping therapists work as efficiently and as effectively as possible to build their businesses and improve their profits. Email tor@co-kinetic.com Twitter @sportexjournals Co-Kinetic Journal 2016;71(January):43-48

SOCIAL WATCH

SOCIAL

WATCH

In line with our goal of saving you both time and money, here’s our pick of some of the best resources on social media published over the last couple of months.

@DrChrisBarton

10 years of work in one blog – knee cap pain gold… #TREK #PatientEducation #TEAM_PFP @LaTrobeSEM http://spxj.nl/2gS0ZDf

TWEETS

3,059 FOLLOWING

@CyclingSurgeon

Chief Medical Officer guidelines for #PhysicalActivity are helping guide the way forward, please RT #ISPAH2016 http://spxj.nl/2gnp5lK

1,139

@zlongdpt

Overhead mobility and stability drill. Press into the foam roller and then roll upward. http://spxj.nl/2fWvrs1

FOLLOWERS

4,953 Join in!

THE BEST OF FACEBOOK @AustralianPhysiotherapyAssociation

@SpineHealth

#InMotion about the project. http://spxj.nl/2gOtWzS

‘Text neck’ is becoming an ‘epidemic’ and could wreck your spine. http://spxj.nl/2fIhtvR

@leehphysio

Interesting article: Fear of Reinjury in Athletes: Implications for Rehabilitation. http://spxj.nl/2gy0JIZ

@mickwhughes

BLOG: ACL injuries in adolescent females. Risk factors and ways to reduce risk #sportsphysio http://spxj. nl/2gxXp0L @exerciseworks

Best investments for Physical Activity: new infographic via @BJSM_BMJ http://spxj.nl/2gOhlNq

@gsingh1902

@muirgray

A MUST READ: Back pain myths via @ToddHargrove http://spxj.nl/2fs1PGM

Say no more #PPFEd16 http://spxj. nl/2gapt9U

@GenWhitson

Wise words to remember folk. Remember to stop and smell the roses along the road of life :) http://spxj. nl/2gayDms

CO-KINETIC ON SOCIAL MEDIA https://www.facebook.com/CoKinetic https://twitter.com/sportexjournals https://www.linkedin.com/groups/4048152 https://pinterest.com/co_kinetic https://www.instagram.com/co_kinetic/

RTER’S THIS QUA

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We’ve highlighted the resources below because they are promoting useful, practical resources across a range of physical and manual therapy topics.

CHECK OUT ON PINTEREST: l PocketAnatomy - http://spxj.nl/2fW751v l StreetAnatomy - http://spxj.nl/2gBgpZN l The stroke exercise and rehabilitation group - http://spxj.nl/2gO50si

CHECK OUT ON YOUTUBE: l l l l

Premax - http://spxj.nl/2gObKXb The Physio Matters Podcast - http://spxj.nl/2gxD63n Stuart-Hinds.com - http://spxj.nl/2fDQjTH PhysiologyZone - http://spxj.nl/2fHSpoR

CHECK OUT ON INSTAGRAM: l l l l

physiocise - http://spxj.nl/2fWcVjb fourniermassagetherapy - http://spxj.nl/2gxIgMY borisrehab - http://spxj.nl/2fWhD0A performancelab_ - http://spxj.nl/2frHRf2

Co-Kinetic Journal 2017;71(January):49-50

BUSINESS GROWTH CAMPAIGNS FOR THERAPISTS WHAT? Ready-to-go materials giving you everything you need to run our business growth campaigns: l Through your social networks l Via email l Locally (with posters and leaflets) lT hrough the post (via leaflets and postcards).

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WHY? l The campaigns are quick to implement, professional, and ready-to-go l You get great looking, professionally produced images and artwork at a fraction of the cost they would be to create or commission l You save time sourcing images, writing text and then figuring out how to pull it all together l All images are copyright-free l Make it your own by adding your own branding and contact details l Avoid ‘blank page syndrome’ by using our content as a starting point and adapting it for your own needs where desired l Banish the feeling of “but where do I start?” by following our Step by Step Implementation guide.

HOW? Each campaign can be purchased individually or access the full set of campaigns through a monthly subscription.

FOR MORE DETAILS GO TO

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