Co-Kinetic Journal Issue 72 - April 2017 by Co-Kinetic

ISSUE 72 APRIL 2017 ISSN 2397-138X

Formerly published as....

medicine & dynamics

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PATELLAR TENDON PAIN

Journal of Orthopaedic & Sports Physical Therapy 06/02/2017

IS ORTHOPAEDIC MANIPULATIVE PHYSICAL THERAPY NOT FASHIONABLE ANYMORE? LESSONS LEARNED FROM 2016 IFOMPT MEETING AND FUTURE DIRECTIONS Journal of Manual & Manipulative Therapy 01/01/2017

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EFFECTIVENESS OF MANUAL THERAPY FOR CERVICAL RADICULOPATHY, A REVIEW Chiropractic & Manual Therapies 09/12/2016

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2 DO SUBJECTS WITH WHIPLASH-ASSOCIATED DISORDERS RESPOND DIFFERENTLY IN THE SHORT-TERM TO MANUAL THERAPY AND EXERCISE THAN THOSE WITH MECHANICAL NECK PAIN? Pain Medicine 10/12/2016

SAFETY OF LOWER EXTREMITY NEURODYNAMIC EXERCISES IN ADULTS WITH DIABETES MELLITUS: A FEASIBILITY STUDY Journal of Manual & Manipulative Therapy 01/01/2017

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THE EFFECTIVENESS OF MANUAL THERAPY VERSUS SURGERY ON SELF-REPORTED FUNCTION, CERVICAL RANGE OF MOTION AND PINCH GRIP FORCE IN CARPAL TUNNEL SYNDROME: A RANDOMIZED CLINICAL TRIAL

For more details about the data behind this infographic, along with the full search results and information about the Altmetric badge go to http://spxj.nl/2mAkBxW

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COMPARISON BETWEEN THE EFFECTS OF PASSIVE AND ACTIVE SOFT TISSUE THERAPIES ON LATENT TRIGGER POINTS OF UPPER TRAPEZIUS MUSCLE IN WOMEN: SINGLE-BLIND, RANDOMIZED CLINICAL TRIAL Journal of Chiropractic Medicine (Print) 01/12/2016

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EFFECT OF LUMBAR SPINAL MANIPULATION ON LOCAL AND REMOTE PRESSURE PAIN THRESHOLD AND PINPRICK SENSITIVITY IN ASYMPTOMATIC INDIVIDUALS: A RANDOMISED TRIAL

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THE 10 MOST DISCUSSED PIECES OF RESEARCH IN SPORTS MEDICINE (JAN-MAR 2017)

EFFECTS OF MANUAL THERAPY AND EXERCISE TARGETING THE HIPS IN PATIENTS WITH LOW-BACK PAIN-A RANDOMIZED CONTROLLED TRIAL Journal of Evaluation in Clinical Practice 01/01/2017

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MANUAL THERAPY & SPORTS MEDICINE RESEARCH INFORMATION

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50 SOCIAL WATCH OF 42-46 ASSESSMENT THE SHOULDER This article is the eighth from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common shoulder 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/23Nn5qG SHOULDER | 17-04-COKINETIC FORMATS WEB MOBILE PRINT

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

2. Initial observation 3. History

MEDIA CONTENTS Videos 1-13: Techniques for shoulder assessment. J. Hatcher, 2013

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

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

For a full assessment of the shoulder, the therapist must be familiar with the anatomy of the area and perform the observations and examinations detailed in Table 1 and Video 2.

Glenohumeral joint derived from C5 segment Acromioclavicular joint derived from C4 segment Dermatomes C4: top of shoulder C5: lateral aspect of arm to wrist Myotomes C5: deltoid, supraspinatus, infraspinatus C6: biceps, subscapularis C7: triceps, latissimus dorsi, pectoralis major, teres major Face and posture and gait Age and occupation Site and spread Onset and duration Behaviour and symptoms Past medical history (P.M.H.) Bony deformity Colour changes Wasting Swelling

5. Objective examination

Observe/examine state at rest Eliminate shoulder joint: 6 active movements of cervical spine Palpation for heat and swelling (rare) Active elevation through flexion Passive overpressure at full elevation Active through abduction (looking for painful arc)

6. Active tests (for willingness)

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

Lateral rotation Abduction Medial rotation

8. Resisted tests (for pain and power

Abduction – supraspinatus/deltoid Lateral rotation – infraspinatus/teres minor/ posterior deltoid Medial rotation – subscapularis/latissimus dorsi/teres major/pectoralis major Elbow flexion – long head of biceps Elbow extension – long head of triceps Adduction – latissimus dorsi/teres major/ pectoralis major

9. Additional specific tests

CAPSULAR PATTERN The capsular pattern of movement limitation at the shoulder is defined by: Most loss of lateral rotation Next, loss of abduction Least loss of medial rotation.

DETAILS

4. Inspection

Assessment of the shoulder

Treatment of the shoulder

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

Co-Kinetic Journal 2017;72(April):42-46

CAUSES OF CAPSULAR PATTERN Typical causes of capsular pattern movement limitation at the shoulder are shown in Table 2. Treatment choice Mobilisations of the shoulder. Lateral rotation mobilisation in abduction (Video 3) Directions: 1. Patient lying supine, stand at side of bed facing patient’s head. 2. Place inner hand around upper aspect of acromion process and lateral clavicle, place out hand around wrist. 3. Take arm into required limit of abduction. 4. As above, take forearm into lateral rotation while stabilising the shoulder girdle with the opposite hand. 5. Again, it may be helpful to place a pillow below the patient’s forearm as a comfortable block to movement depending on the required grade of mobilisation. Abduction mobilisation (Video 4) Directions: 1. Similar stride stance position to lateral rotation in abduction mobilisation but with outer hand placed around lower aspect of the humerus, lateral to the elbow joint. 2. Place elbow against your body so humerus is fully supported – patient’s forearm is resting on between your body and your upper arm. 3. Take humerus into abduction using your body weight by altering your weight between your forward and backward leg. 4. Grade according to clinical assessment findings.

Co-Kinetic.com

TABLE 2: CAUSES OF CAPSULAR PATTERN AT THE SHOULDER (J. Hatcher, 2013) TYPICAL FEATURES CAUSE Wear and tear to the Osteoarthritis (OA) joint, may be primary, or possibly secondary to previous lesion. Mild capsulitis, possible crepitus.

Rheumatoid arthritis (RA) and other systemic arthropathies

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

Traumatic arthritis (TA)

Trauma often not remembered. Slow onset in the over 40s, time varies. Pain may be severe enough to radiate beyond elbow, and have night pain/difficulty lying on shoulder..

TREATMENT Warm the capsule using appropriate electrotherapy and use Grade B (Maitland Grade III and IV) mobilisation and selfhelp exercises to end of range.

JOURNAL WATCH MANUAL THERAPY

Refer to GP for Rheumatology opinion. If not in acute flare-up, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV). May require mobilisation as pain allows, Grade A–B (I–IV). May require injection, electrotherapy and Grade A and B mobilisations.

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

Video 2: Assessment of the shoulder region (Video with captions but no sound; J. Hatcher, 2013)

Video 3: Mobilisation of the shoulder: lateral rotation (in abduction) (Video with captions but no sound; J. Hatcher, 2013)

Video 4: Mobilisation of the shoulder: abduction (Video with captions but no sound; J. Hatcher, 2013)

14-21 OSTEOARTHRITIS OF THE KNEE

08-1 1 08

MANUAL THERAPY STUDENT HANDBOOK

Assessment and treatment of the shoulder

IN CLINICAL PRACTICE 36-40 ACUPUNCTURE

SHORT

TECHNICAL

LONG APRIL 2017 ISSUE 72 ISSN 2397-138X

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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

INJURIES AMONG WEIGHTLIFTERS AND POWERLIFTERS: A SYSTEMATIC REVIEW. Aasa U, Svarholm I, Andersson F et al. British Journal of Sports Medicine 2017;51(4):211-219 Data was obtained from five databases, PubMed, MEDLINE, SPORTDiscus, Scopus and Web of Science, which were searched between 9 March and 6 April 2015. The eligibility criteria were set to include studies assessing injury incidence and prevalence in Olympic weightlifting and powerlifting. Nine studies were included in the review. Injury was defined fairly consistently across studies. Most studies were of low methodological quality. The spine, shoulder and the knee were the most common injury localisations in both sports. The injury incidence in weightlifting was 2.4–3.3 injuries/1,000 hours of training and 1.0–4.4 injuries/1,000 hours of training in powerlifting. Only one retrospective study had analysed possible risk factors.

YOUTH BASEBALL PLAYERS WITH ELBOW AND SHOULDER PAIN HAVE BOTH LOW BACK AND KNEE PAIN: A CROSS-SECTIONAL STUDY. Sekiguchi T, Hagiwara Y, Momma H et al. Knee Surgery, Sports Traumatology, Arthroscopy 2016;doi:10.1007/s00167-016-4364-y The data for this study came from a self-administered questionnaire returned by 1,582 Japanese youth baseball players (aged 6–15 years old, male 95.6%). A total of 24.8% (n=381) had elbow and/or shoulder pain, 8.5% (n=130) had low back pain and 13.1% (n=201) had knee pain. The prevalence of elbow and/or shoulder pain with concomitant low back and knee pain

Of course they have problems in more than one area. Everything is connected. The moral of the story for therapists is to treat the whole body.

Eighteen players with an average age of 14.50±1.86 years from the same team in Sorocaba, Brazil were followed over a 6-month period. At the beginning and end of that period a Morbidity Survey Report modified for basketball was completed. It showed that 72.2% of players had a leg length inequality and 50% had some kind of injury during this period; among the most common were sprains and muscle strains.

Co-Kinetic comment

The risk of injury in both sports was similar and was low compared to contact sports but there was not sufficient data to speculate about risk factors.

Co-Kinetic comment

LEG LENGTH INEQUALITY AND ITS RELATIONSHIP WITH INJURIES INCIDENCE OF YOUNG BASKETBALL PLAYERS: AN OBSERVATIONAL STUDY. Santos LV, Rossi MF, Oliveira CS et al. Manual Therapy, Posturology & Rehabilitation Journal (formerly Revista Terapia Manual) 2016;doi:http://dx.doi. org/10.17784/mtprehabjournal.2016.14.414

Co-Kinetic comment

A computer simulation model was used to create a set of musculoskeletal simulations to evaluate the efficacy of two strategies for coordinating the ankle evertor and invertor muscles during simulated landing scenarios. Within each condition, the intensity of evertor and invertor co-activity or stretch reflexes were varied systematically. The simulations revealed that strong preparatory co-activation of the ankle evertors and invertors before ground contact prevented ankle inversion from exceeding injury thresholds by rapidly generating eversion moments after initial contact. Conversely,

was 61.2% (n=82) and 51.9% (n=108), respectively. The prevalence increased in the older age groups, with pitchers, catchers and with practice intensity.

It’s worth checking all your athletes for functional or structural leg length discrepancies. It cuts down your injury rates.

PREPARATORY CO-ACTIVATION OF THE ANKLE MUSCLES MAY PREVENT ANKLE INVERSION INJURIES. DeMers MS, Hicks LJ, Delp SL. Journal of Biomechanics 2017;52:17–23 stretch reflexes were too slow to generate eversion moments before the simulations reached the threshold for inversion injury. These results suggest that training interventions to protect the ankle should focus on stiffening the ankle with muscle co-activation before landing.

Co-Kinetic comment This is almost an ‘ankle-special’ Journal Watch. One thing to note is that we have reported five articles from five different journals, which sums up how difficult it is to keep up unless of

course you read ‘Journal Watch’. As to this study, computer simulation could be the way forward as you can’t deliberately stress live ankles to breaking point. Another thing to note is that the musculoskeletal models, controllers, software and simulation results are freely available online at http://simtk.org/home/ankle-sprains and the authors encourage others to use them to explore other injury scenarios. The final thing to note is the statistic quoted in the paper that 70% of ankle sprains are not rehabilitated fully, resulting in further injury, shows that none of this ankle research is relevant if it is not implemented.

Co-Kinetic Journal 2017;72(April):4-11

PHYSICAL THERAPY RESEARCH INTO PRACTICE

Journal Watch SHORTER RECOVERY CAN BE ACHIEVED FROM USING WALKING BOOT AFTER OPERATIVE TREATMENT OF AN ANKLE FRACTURE. Amaha K, Arimoto T Saito M et al. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2017;7:10–14 Forty-seven patients (mean age, 53.9±12 years) who had undergone a surgical operation for an unstable ankle fracture were reviewed retrospectively. Either a plaster cast (PC) (n=25) or a short-leg walking boot (WB) (n=22) was prescribed postoperatively. The time that it took the patient to stand unipedal on the affected side after allowing full weightbearing and to walk without crutches were used for assessment

of functional recovery. The prevalence of postoperative loss of reduction and non-union was also reviewed. Both the times of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, respectively; and WB, 1.4 weeks; PC, 3.1 weeks, respectively). There were no patients with loss of reduction or non-union.

Co-Kinetic comment The authors speculate that the faster recovery in the WB group is

due to an adjustable heel lift. This allows users to change the plantarflexed ankle position slightly (which helps walking on a postoperative swollen ankle) and easy adjustment allows conformity with swelling, so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively.

SPORTS INJURIES TO THE LATISSIMUS DORSI AND TERES MAJOR. Donohue BF, Lubitz MG, Kremchek TE. The American Journal of Sports Medicine 2016;doi:10.1177/0363546516676062 [Epub ahead of print] A search of various combinations of ‘teres major’ or ‘latissimus dorsi’ and ‘rupture,’ ‘tear,’ or ‘injury’ coupled with a number of sports resulted in 25 case reports and 2 case series detailing 55 sports injuries. The majority affected baseball pitchers but injuries were noted in 14 other sports including tennis, golf and cricket, plus some unrelated to sports. Muscle anatomy, function as well as common injury patterns and clinical presentations are well described. Patients often describe a sudden onset of shoulder pain, sometimes precipitated by a palpable or audible ‘pop’, some describe a burning sensation. Cadaver studies show that in some cases the teres major tendon may insert into the latissimus dorsi tendon and the role of both during throwing activities is also noted. Although avulsions, tendon and musculotendinous junction injuries are reported (some serious enough to Co-Kinetic.com

require surgery), the most common injuries are grade 1 and 2 belly strains, which are treated with rest, nonsteroidal anti-inflammatory drugs and physical therapy. Missed time from sport is usually less than 2 weeks. In non-pitchers, the mechanism of injury is forceful resisted shoulder adduction and flexion, causing eccentric contraction of the muscles. This may be precipitated by sudden forced extension or hyperabduction of the shoulder. In pitchers, it is part of the throwing motion. It is speculated that this is caused by eccentric or supraphysiological concentric contraction during the throwing motion.

considerably easier and will bring up all the stuff you are ever likely to need. This is one of the ‘all you need to know’ papers that we both like and recommend for further reading.

Co-Kinetic comment Nice to see a published paper that has given up on the usual subject databases and just gone for MEDLINE® (via PubMed) and Google Scholar. Give them time and they will just search the latter because it makes life 5

BODY FAT CONTENT DOES NOT AFFECT BODY’S MAXIMAL MUSCLE STRENGTH. Choi J, Kim S, Hur S et al. The Korean Journal of Sports Medicine 2016;34(2):153–161

POST-OPERATIVE REHABILITATION OF GRADE 3 MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY. Logan CA, O’Brien LT, LaPrade RF. International Journal of Sports Physical Therapy 2016;11(7):1177 This study tells you all you need to know about major medial collateral ligament (MCL) tears and what to do about them after surgery from week zero to return to play and with the evidence for everything you are going to do thrown in for good measure. Set out in five phases of recovery, it looks at cryotherapy, bracing, weightbearing progression, range-of-motion achievement, muscle activation initiation, training for endurance, strength and power, neuromuscular re-education, return to jogging, plyometric and agility training, and return to play.

Co-Kinetic comment A great piece of work and it’s open access.

Muscle mass was measured from 140 pre-selected people, and 30 males were finally selected and divided into one of four experimental groups: low body fat (group 1, ≤11.9%), low–moderate fat (group 2, 12.0–16.9%), moderate–high fat (group 3, 17.0– 22.9%), high fat (group 4, ≥23.0%). All subjects undertook a one repetition maximum (1RM) test of various strength tests including abdominal, upper and lower back, bench-press and squat. There was no difference in the 1RM of the bench-press between groups, even though values from group 2 were marginally higher (15.9%) than group 1 values (P=0.091). 1RM of squat was higher in group 4 compared to groups 2 and 3, and maximal back muscular strength was higher in groups 1 and 3 than group 2. However, total 1RM values, sum of 1RM obtained from different exercises, did not reveal any statistical differences. No notable correlation was found between percent body fat and maximal muscular strength. There

was, however, a negative correlation of muscular strength between percentage of body fat and relative (per kilogram) body mass, but not with percentage body fat and relative skeletal muscle mass. Therefore, it was concluded that maximal muscular strength is influenced not by fat mass but by skeletal muscle mass.

Co-Kinetic comment Discount for a moment that this study seems to be stating the obvious in the correlation between muscle strength and muscle mass and wonder at the fact that The Korean Journal of Sports Medicine is the 200th journal title we have included in ‘Journal Watch’. Yes, that’s two hundred. The A–Z range runs from the Adapted Physical Activity Quarterly through to Zhong Nan Da Xue Xue Bao Yi Xue Ban which you probably know as the Journal of Central South University Medical Sciences.

PREVENTION OF SOCCER-RELATED ANKLE INJURIES IN YOUTH AMATEUR PLAYERS: A RANDOMIZED CONTROLLED TRIAL. Farhan AF, Stephany MJ, Mahammed SK. Movement, Health & Exercise Journal 2017;6(1):39–45 This trial involved 50 boys (mean age 13.3±0.4 years; body mass index of 20.9±1.5kg/ m2; stature, 1.6±0.1m) from two sport schools, with 4.4±0.5 years’ playing experience. They were randomly assigned to either an experimental (EXP, n=25) or a control (CON, n=25) group. A physical exercise programme designed exclusively for youth male soccer players was combined with education of athletes and coaches to increase awareness of injury risk. The exercises focused on core stabilisation, eccentric training of thigh muscles, proprioceptive training, dynamic stabilisation and plyometrics. The sessions were

15–20 minutes per session (5 times/ week) for 12 weeks. Injuries were documented over a year. Nine ankle injuries occurred in the EXP group and 20 injuries occurred in the CON group corresponding to incidence rates of 0.96 and 2.16 per 1,000 player hours, respectively, which equates to 55% fewer injuries in the EXP group.

Co-Kinetic comment You ask for coach education about ankle injury (see Kalirtahinam D, et al. Does neuromuscular exercise training improve proprioception in ankle lateral ligament injury among athletes? Scientia Medica 2017;27(1):25082 in this issue) and the next paper we read not only confirms the previous

paper but it ends with the following statement, “Coaches and players need better education regarding injury prevention strategies and should include such interventions as part of their regular training”. And just to put the icing on the cake there is another recently published work which suggests that the injury reduction rate in young footballers following the FIFA 11+ programme is as high as 39% (Thorborg K, et al. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. British Journal of Sports Medicine 20167; doi:10.1136/bjsports-2016-097066).

Co-Kinetic Journal 2017;72(April):4-11

PHYSICAL THERAPY RESEARCH INTO PRACTICE

DOES NEUROMUSCULAR EXERCISE TRAINING IMPROVE PROPRIOCEPTION IN ANKLE LATERAL LIGAMENT INJURY AMONG ATHLETES? SYSTEMATIC REVIEW AND META-ANALYSIS. Kalirtahinam D, Ismail MS, Singh TSP et al. Scientia Medica 2017;27(1):25082 Database searches threw up an initial 200 articles which, after closer scrutiny, were narrowed down to 15 articles and from these 5 moderate to excellent quality trials involving 2,459 participants were selected for meta-analysis. The results were an unambiguous ‘yes’ to the title question. There was a statistically significant relationship among athletes regarding the preventive impacts of training on proprioception. Ankle sprain and its complications can be easily prevented with the help of training programmes.

Co-Kinetic comment So why, then, is proprioception training not compulsory in every sport in which you can ‘turn’ an ankle? Coaches please take note.

HEAD INJURIES IN CHILDREN’S FOOTBALL – RESULTS FROM TWO PROSPECTIVE COHORT STUDIES IN FOUR EUROPEAN COUNTRIES. Faude O, Rössler R, Junge A et al. Scandinavian Journal of Medicine & Science in Sports 2017;doi:10.1111/sms.12839 [Epub ahead of print] Data on 7–12-year-olds was obtained from a prospective cohort study over two consecutive football seasons in two European countries and a randomised intervention trial over one season in four European countries. Football exposure and injuries were documented through an online database. Detailed information regarding injury characteristics and medical follow-up was retrieved from coaches, children and parents by phone. Thirty-nine head injuries and one neck injury (5% of all 791 injuries) were documented during 9,933 player-seasons (total football exposure 688,045 hours). There were 11 concussions (27.5%), nine head contusions (22.5%), eight lacerations or abrasions (20%), two nose fractures

(2.5%) and two dental injuries (2.5%). The remaining eight injuries were nose bleeding or other minor injuries. Thirty injuries (75%) resulted from contact with another player, ten injuries were due to collision with an object, falling or a hit by the ball. Whereas 70% of all head injuries (N=28) were due to frontal impacts, 73% of concussions (N=8) resulted from an impact to the occiput.

Co-Kinetic comment. It’s rugby that tends to get all the publicity about concussions but this study shows that they do occur in other sports, albeit not often. It only takes one to be not spotted, though, to ruin a player’s life.

THE LATE SWING AND EARLY STANCE OF SPRINTING ARE MOST HAZARDOUS FOR HAMSTRING INJURIES. Liu Y, Sun Y, Zhu W et al. Journal of Sport and Health Science 2017 [Epub ahead of print] This study aimed to build on earlier work in which biomechanical assessment was conducted using a treadmill. This time they used over-ground running. They used a lower extremity intersegmental dynamics analysis for each body segment. This allowed torques at each joint to be separated into five categories: gravitational torque (GTT), motiondependent torque (MDT), external contact torque (EXT), generalised muscle torque (MST), and net joint torque (NET), which is the vector sum of the four previous components. Their conclusions were that the MST primarily countered the MDT during the swing phase for the knee and hip joints. In late swing, the leg was swinging forward due to its inertia. However, the hamstrings were active and started to extend the hip and flex the knee joints for the subsequent ground contact. This activity of the hamstrings generated a large hip-flexion MDT and a knee-extension MDT at the same time. Further analysis of the components of the MDT showed that MDT at both joints was caused mainly by torques due to the leg angular acceleration. These passive torques applied stress to the hamstring muscles in the opposite direction of contraction at both joints. To counter this negative effect, the hamstrings encountered enormous loads (approximately 10 times the subjects’ average body weight) to control the rapid leg rotation, which created conditions for hamstring injuries. During late swing, the leg angular acceleration led to a tremendous MDT, which caused the hamstring muscles to work eccentrically. This suggests that hamstring strains are associated with high loading caused by the inertial torque MDT.

Co-Kinetic comment A force of 10 times your body weight! No wonder they get hurt so often. The big question now is how are we going to minimise this?

FACIAL TRAUMA IN SPORTS. Leinhart J, Toldi J, Tennison M. Current Sports Medicine Reports 2017;16(1):23–29 Overall, approximately 11–40% of all sports injuries involve the face, and 8% of all facial soft-tissue injuries are sportsrelated. The incidence is even higher in paediatrics where craniofacial injuries represent up to 20% of all sports-related injuries. In the USA such incidents are associated with baseball and softball. A Dutch study indicated that soccer and hockey are the most Co-Kinetic.com

common cause of maxillofacial trauma, and an Irish study found that Gaelic football and soccer are the most likely sports in which to incur facial trauma. They don’t report the incidence of injuries in cricket but it is probably similar to baseball. This paper looks at facial anatomy and injury evaluation, including a protocol to follow.

Co-Kinetic comment This is the sort of ‘all you need to know’ paper that we like. It’s a must read for anyone involved in pitchside trauma and the bonus is that it’s available for free.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

THE EFFECTIVENESS OF MANUAL THERAPY VERSUS SURGERY ON SELFREPORTED FUNCTION, CERVICAL RANGE OF MOTION, AND PINCH GRIP FORCE IN CARPAL TUNNEL SYNDROME: A RANDOMIZED CLINICAL TRIAL. Fernándezde-las-Peñas C, Cleland J, Palacios-Ceña M et al. Journal of Orthopaedic & Sports Physical Therapy 2017;47(3):151–161 One hundred women with carpal tunnel syndrome were randomly allocated to either a manual therapy (n=50) or a surgery (n=50) group. Patients were assessed at baseline and at 1, 3, 6 and 12 months. At 12 months, 94 women completed the follow-up. Analyses showed statistically significant differences in favour of manual therapy at 1 month for self-reported function and pinch-tip grip force on the symptomatic side. Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6 and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group. The conclusion is, therefore, that manual therapy and surgery had similar effectiveness.

Co-Kinetic comment If they both work equally well why would anyone in their right mind choose to go under the knife?

EFFECTS OF KINESIO TAPING® ON KNEE FUNCTION AND PAIN IN ATHLETES WITH PATELLOFEMORAL PAIN SYNDROME. Aghapour E, Kamali F, Sinaei E. Journal of Bodywork and Movement Therapies 2017;doi:http://dx.doi.org/10.1016/j. jbmt.2017.01.012 Fifteen participants (10 females, 5 males) with unilateral patellofemoral pain syndrome (PFPS) were examined and compared under taped and untaped conditions. Kinesio Tape® (KT) was applied to the vastus medialis obliquus (VMO) muscle of the involved leg. Then maximal eccentric and concentric peak torques of quadriceps were measured at 60 and 180°/s angular velocities by an isokinetic dynamometer. Functional performance and pain were evaluated. There was a statistically significant increase in VMO peak torque and also repetition of stepdown test and bilateral squat after using KT. Pain intensity was also decreased significantly following KT application.

Co-Kinetic comment Decrease the pain and you can add other therapeutic interventions, such as mobilisations and exercise. The tape is a winner.

THE EFFECTS OF CERVICAL SUSTAINED NATURAL APOPHYSEAL GLIDES ON NECK RANGE OF MOVEMENT AND SYMPATHETIC NERVOUS SYSTEM ACTIVITY. Bowler N, Browning P, Aguirrebeña IL. International Journal of Osteopathic Medicine. 2017;doi:http://dx.doi.org/10.1016/j.ijosm.2017.02.003 Thirty asymptomatic subjects were recruited and divided into an ipsilateral or contralateral sustained natural apophyseal glides (SNAGs) group. All subjects experienced right C5 SNAGs, sham and control intervention on three separate days. Neck range of motion (ROM), skin conduction (SC) and skin temperature (ST) in the right hand were measured. Right rotation ROM and SC increased following both SNAGs and sham interventions, with increases reaching statistical significance for ROM in the contralateral SNAGs group and for SC in the ipsilateral SNAGs group. No statistically significant differences were noted between ipsilateral or contralateral SNAGs and sham interventions. No significant changes in ST were noted.

Co-Kinetic comment. This research has a snag or two. (Sorry!) The main one is asymptomatic subjects. You can’t fix what isn’t broken.

SWIMMING PERFORMANCE EVALUATION IN ATHLETES SUBMITTED TO DIFFERENT TYPES OF STRENGTH TRAINING. Bertoleti E Jr, Aidar FJ, de Souza RF et al. Journal of Exercise Physiology Online 2016;19(6):1–9 Twenty-four male athletes ages 15 to 16 years who had done more than 3 years of competitive swimming and had participated in national competitions were divided into three groups: (a) 7 swimmers tethered by a rubber device while in the water (RW); (b) 7 swimmers who did a strength training (ST) programme; and (c) 7 swimmers who were the control group (CG). They were tested before the programme and at 4 weeks and 8 weeks into the strength programme over 25 and 50m in a 25m pool with

a controlled temperature of 26–27°C. There were five pool training sessions per week for all participants with extra strength sessions for the relevant groups. There was no difference in the post-test responses between the group that trained while tethered to the rubber device and the group that engaged in a traditional strength training programme. However, there were differences in both groups that engaged in strength training compared to the control group at both time points.

Co-Kinetic comment The findings of this study were not really a shock. They did, however, test the maturational level of the subjects using the Tanner Maturation Scale which uses a ranking based on two items, pubic hair and genitals. There’s an interesting job for a tester! This was done because the authors thought it necessary to understand the influence on treatment variable. Sadly there is no mention in the paper as to whether or not there was an influence.

Co-Kinetic Journal 2017;72(April):8-11

MANUAL THERAPY RESEARCH INTO PRACTICE

Journal Watch THE EDUREP APPROACH PLUS MANUAL THERAPY FOR THE MANAGEMENT OF INSERTIONAL ACHILLES TENDINOPATHY: A CASE REPORT. Sartorio F, Zanetta A, Ferriero G et al. The Journal of Sports Medicine and Physical Fitness 2017;doi:10.23736/S00224707.17.06952-3 [Epub ahead of print]

This is a case study on an active 51-yearold man with chronic Achilles tendinopathy. His clinical assessment was by visual analogue scale for pain during the Achilles tendon palpation test, passive straightleg-raise test, single-leg hop test, PatientSpecific Functional Scale, and Foot and Ankle Ability Measure. He was treated over an 8-week period according to the EdUReP guidelines plus 8 sessions of instrument assisted soft-tissue therapy applied with a solid instrument to the Achilles tendon and to the muscle fibrotic areas previously identified during evaluation. Clinically significant improvements were observed in all

outcome measures, and a resumption of the patient’s usual sports activities without pain or limitations was possible after treatment. Results lasted over a 6-month follow-up.

Co-Kinetic comment The mnemonic EdUReP stands for Education, Unloading, Reloading, and Prevention model. The ‘E’ bit uses a 5 A’s plan of assess, advise, agree, assist and arrange. The ‘U’ is a period of relative rest from chronic repetitive loading. The ‘R’ is controlled reloading. The ‘P’ is prevention, which here means that you keep on top of the other items so it doesn’t happen again.

EFFECTIVENESS OF MASSAGE THERAPY ON THE RANGE OF MOTION OF THE SHOULDER: A SYSTEMATIC REVIEW AND META-ANALYSIS. Yeun YR. Journal of Physical Therapy Science 2017;29(2):365–369

The usual databases were searched for studies in English or Korean using adults with shoulder pain. The interventions were massage therapy given alone or in combination with another treatment. Comparisons included the control groups that did not receive any intervention or that received placebo or another intervention. Outcomes were shoulder range of motion (ROM). The exclusion criteria for data analysis were studies including participants diagnosed with infection, neoplasm, fracture, instability, dislocation, hemiplegia, or postoperative or perioperative shoulder pain, and studies in which the mean and standard deviation could not be calculated. An initial 925 papers were culled until 7 met the inclusion criteria. The total number of study participants was 237 (experimental group, 120; control group, 117). The quantitative duration of massage ranged from 10–45 minutes The effect size estimate showed that massage therapy significantly improved shoulder ROM, especially flexion and abduction. Sports massage showed the largest significant effect in all the outcome variables. It includes techniques like effleurage, petrissage and friction.

Co-Kinetic comment Massage works. Shout it loud.

A PRELIMINARY RANDOMIZED CLINICAL TRIAL ON THE EFFECT OF CERVICOTHORACIC MANIPULATION PLUS SUPERVISED EXERCISES VS A HOME EXERCISE PROGRAM FOR THE TREATMENT OF SHOULDER IMPINGEMENT. Vinuesa-Montoya S, Aguilar-Ferrándiz ME, Matarán-Peñarrocha GA et al. Journal of Chiropractic Medicine 2016;doi:http://dx.doi.org/10.1016/j.jcm.2016.10.002 Thirty men and eleven women (aged 47±9 years old) who had been previously diagnosed with unilateral shoulder impingement syndrome attended 10 treatment sessions for 5 weeks (2 sessions per week). They were randomly divided into either a cervicothoracic manipulation plus exercise therapy (n=21) or home exercise programme (n=20). After 5 weeks of treatment, significant between-group differences were Co-Kinetic.com

observed in a Disabilities of the Arm, Shoulder and Hand score; however, no statistically significant differences were achieved for a Shoulder Disability Questionnaire and pain intensity. Both groups improved with regard to disability and clinical tests (Neers and Hawkins Kennedy) for detecting subacromial impingement syndrome.

Co-Kinetic comment

treatment regimens improved the patients and the cervicothoracic manipulative treatment plus exercise therapy regimen improves intensity of pain and range of motion compared with the home exercise group. This confirms early research. Manual therapy works.

The bottom line here is that both 9

UTILIZATION OF PHYSICAL THERAPY INTERVENTION AMONG PATIENTS WITH PLANTAR FASCIITIS IN THE UNITED STATES. Fraser JJ, Glaviano NR, Hertel J. Journal of Orthopaedic & Sports Physical Therapy 2017;47(2):49–55 This research starts with the fact that in the USA there are 1 million ambulatory patient care visits annually for plantar fasciitis (PF). The study searched the PearlDiver patient-record database for cases using manual therapy and supervised rehabilitation in patients with PF between 2007 and 2011. A total of 819,963 patients diagnosed with PF accounted for 5,739,737 visits from 2007 to 2011, composing 2.7% of all patients in the database. Only 7.1% of patients received a physical therapist evaluation within 30 days of their initial diagnosis. Of the 57,800 patients evaluated by a physical therapist (59.8% female), 50,382 (87.2%±0.4%) received manual therapy, with significant increases in utilisation per annum. The mean was five sessions. A large proportion (89.5%±0.4%) received rehabilitation following physical therapist evaluation.

Co-Kinetic comment PearlDiver is an American healthcare database which claims to have over 4 billion compliant patient records. That raises the question: Why in the UK can’t the NHS manage to get a viable national patient records system in operation? To be fair to the NHS it’s not just them: Her Majesty’s Government doesn’t have a good track record with big IT projects. Meanwhile back at this study, it’s pretty shocking that a major MSK condition has had so little attention from the experts in the field but those who did, did well.

CONTRIBUTION OF DRY NEEDLING TO INDIVIDUALIZED PHYSICAL THERAPY TREATMENT OF SHOULDER PAIN: A RANDOMIZED CLINICAL TRIAL. Pérez-Palomares S, Oliván-Blázquez B, Pérez-Palomares A et al. Journal of Orthopaedic & Sports Physical Therapy 2016;47(1):11–20 Myofascial trigger points (MTrPs) are implicated in shoulder pain and functional limitations, and an intervention intended to treat MTrPs is dry needling. The objectives of this study were to investigate the effectiveness of dry needling in addition to evidence-based personalised physical therapy in the treatment of shoulder pain. One hundred and twenty patients with non-specific shoulder pain were randomly allocated into two parallel groups: (1) personalised, evidence-based physical therapy treatment (n=63); and (2) trigger point dry needling in addition to personalised, evidence-based physical therapy treatment (n=57). Patients were assessed at baseline, post-treatment, and 3-month follow-up. The primary outcome measure was pain, assessed

by a visual analogue scale at 3 months. Secondary variables were joint rangeof-motion limitations, Constant–Murley score for pain and function, and number of active MTrPs. Clinical efficacy was assessed using intention-to-treat analysis. There were no significant differences in outcome between the two treatment groups. Both groups showed improvement over time.

Co-Kinetic comment The dry needling seems to have made no difference but how can you make a difference when you don’t know what you are making a difference to? ‘Non-specific’ shoulder pain is not a diagnosis. Every pain has a source. Someone needs to work harder to find it.

MASSAGE FOR PAIN: AN EVIDENCE MAP. Miake-Lye I, Lee J, Lugar T et al. Department of Veterans Affairs Health Services Research & Development Service 2016;VA ESP Project #05-226 This was a database search looking for the effect of massage on pain. It identified 31 systematic reviews, of which 21 were considered highquality. Some common massage types included Swedish massage,

myofascial therapies, shiatsu, Chinese traditional massage, Thai massage, slow-stroke massage, and more general descriptions of massage. The most common type of pain included in was neck pain (n = 6).

IS NECK MASSAGE SAFE? A RARE CASE OF TETRAPLEGIA AND SPINAL SHOCK AFTER NECK MANIPULATION. Ling TH, Zakaria AF, Abdullah AT. Journal of Orthopaedic Surgery 2017;25(1):doi:10.1177/2309499017690459 This is a very sad story of a 33-year-old truck driver, who was otherwise healthy. He received neck and shoulder manipulation by what is described as ‘a certified traditional healer’ as a treatment for shoulder spasm and pain. Soon after the manipulation, he experienced

tingling and numbness in both of the lower limbs up to knee level which subsequently spread to the upper limbs. He further developed urinary and bowel incontinence. Two days after the manipulation he presented at a Malaysian hospital with paralysis of all four limbs. Radiograph of cervical spine revealed irregular and narrowing of the facet joint of the C4/C5 vertebrae without any vertebral fracture. An MRI showed a hyperacute epidural haematoma, with cord oedema at the same levels. He was treated with a decompression and laminoplasty (C3 to C6). He died on day 3, following surgery (13 days after initial presentation).

Co-Kinetic comment There are risks in cervical manipulation. Various studies quote different incidence rates from a low of 1 in 2 million to as high as 1 in around 400,000. In this case there was a delay in surgical treatment and the authors are of the opinion that an earlier intervention may have had a more successful outcome. It is misleading to title this tragedy as ‘Is massage safe?’ because it was not massage that did the damage but cervical manipulation, which is a different thing altogether.

Co-Kinetic Journal 2017;72(April):8-11

SUBJECT MANUAL AREATHERAPY LINK WHOLE RESEARCH REFERENCE INTOTOPRACTICE ARTICLE

RESPONSIBILITY FOR CHILD AND ADOLESCENT’S PSYCHOSOCIAL SUPPORT ASSOCIATED WITH SEVERE SPORTS INJURIES. Hallquist C, Fitzgerald UT, Alricsson M. Journal of Exercise Rehabilitation 2016;12(6):589–597 Qualitative interviews with coaches, parents and physiotherapists with experience of serious sports injuries in young people aged 12 to 16 years old from different sports were analysed using content analysis. Each group indicated that communication was a major problem and, further, that the role of a coordinator was missing. Coaches felt that they had a lack of education and time; parents described their disappointment in caregivers and personality changes in their children in connection with the injury. Physiotherapists felt that rehabilitation was often used as a substitute for the sport and that they, therefore, had greater responsibility for the child than they had been educated for.

Findings described potential benefits of massage for pain indications including labour, shoulder, neck, back, cancer, fibromyalgia and TMJ disorder. However, no findings were rated as moderate or high.

Co-Kinetic comment The US Department of Veterans Affairs Evidence-based Synthesis A convenient sample of 20 college students (13 male aged 26.0±4.8; 7 female aged 25.4±3.9) engaged in two sets of a squatting exercise to fatigue while holding a 3.63kg (8lb) dumbbell weight for men and a 2.27kg (5lb) for women. The weight was held close to the chest and participants were instructed to lower their torso to a seated position then return upright at a cadence of one repetition approximately every two seconds. After a rest of no more than 3 minutes the right or the left leg was immediately massaged. Effleurage, petrissage, friction and compression manual techniques were used for 10 minutes on the quadriceps and for 10 minutes on the hamstrings and Co-Kinetic.com

Co-Kinetic comment This should be standard reading for coaches and therapists (including doctors) in training. Both groups (and the parents) complained about a lack of education in dealing with injured children. Several physios said that they never talked to any coach; those that did felt that collaboration worked only if there was already an established contact and that they had to maintain contact for a long time to gain the confidence of the coaches. There were also communication problems with doctors, and problems getting help with rapid diagnostics. Shocking, and don’t think that this is just about Swedish kids because this goes on in the UK as well.

Program (ESP) was established to improve healthcare for veterans. Luckily their work also impacts non-veterans, and demonstrates that massage has a role in primary healthcare. It also ends with the oftheard plea to researchers to provide adequate details of the massage and to use larger sample groups.

BIOLOGICAL EFFECTS OF DIRECT AND INDIRECT MANIPULATION OF THE FASCIAL SYSTEM. NARRATIVE REVIEW. Parravicini G, Bergna A. Journal of Bodywork and Movement Therapies 2017;doi:http://dx.doi.org/10.1016/j. jbmt.2017.01.005 The aim of this study was to try to discover how osteopathic manipulative treatment works. One of the theories is that the results are caused by an effect on the fascial system. A literature search was performed using key words relating to the biological effects of fascia and fascial manipulation. Different biological characteristics such as cell shape, nuclear remodelling and inflammation processes consequent to static stretching of the connective tissue were analysed in nine laboratory studies. Eight studies analysed the biological effects of myofascial release on fascia. A further four studies looked at: EMG variability induced by a massage technique, the effect of ‘muscle repositioning’ on EMG, the use of high-frequency ultrasound to observed tissue changes consequent to a manual technique (sensory-motor body therapy), and proposed a 3D mathematical model to explore the relationship between three manual therapy motions and the flow characteristics of hyaluronic acid below the fascial layer. Finally three articles tested the strain and counterstain technique. All of the studies showed some degree of effect on a cellular level.

Co-Kinetic comment So it is clear that something is going on and there is plenty of evidence to prove it. The problem is dose dependency. There is no consensus on techniques and the variables of magnitude, duration and direction of implementation make it difficult to make a definitive statement on clinical efficacy. That, however, is no reason not to use the fascial techniques.

EFFECT OF SWEDISH MASSAGE ON DOMS AFTER STRENUOUS EXERCISE. Holub C, Smith JD. International Journal of Exercise Science 2017;10(2):10 gluteal group, so that each manual technique lasted for 2.5 minutes. The other leg was used as a nonmassaged control. Participants rated their delayed onset muscle soreness (DOMS) 24 and 48 hours later with a single-digit incremental numeric rating scale. The results were that DOMS in the massaged leg at 24 hours was significantly lower compared to the non-massaged leg, but no significant difference at 48 hours existed between the legs. There was actually a slight increase in DOMS from 24 to 48 hours in the massaged leg but not the nonmassaged one.

Co-Kinetic comment Shout it even louder. Massage works. This paper even described the dose of lubricant. ‘A quarter size dollop of Biotone massage lotion’.

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EFFECTS OF MANUAL THERAPY AND EXERCISE TARGETING THE HIPS IN PATIENTS WITH LOW-BACK PAIN-A RANDOMIZED CONTROLLED TRIAL

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OSTEOARTHRITIS OF THE KNEE: A PRACTICAL TREATMENT APPROACH This article discusses the issue of osteoarthritis of the knee, the role of exercise, its relationship (or not) with arthritis and progresses to physical therapy interventions including exercises which should be included as part of a strengthening and stretching plan. The article is supported by videos which show manual therapy techniques that can be used as part of a treatment programme and additional videos that can be used as part of a patient education programme. There is also a downloadable/ printable patient information leaflet. Read this online http://spxj.nl/2ljbsKI Knee pain is a common complaint, especially in the over 50s. Studies have shown that almost half of the over 50s complain of pain in the knee, and in about 25% this lasts for a prolonged period, being termed chronic (1). Chronic knee pain can lead to a significant reduction in quality of life (QOL) and difficulty carrying out common activities of daily living. Although the condition can progress, many risk factors of progression are modifiable. Exercise therapy can improve muscle strength and control of movement, and increase KNEE | LOWER-LIMB | 17-04-COKINETIC FORMATS

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MEDIA CONTENTS Video showing manual therapy techniques for treatment of OA – http://spxj.nl/2ljbsKI Videos showing stretching and strengthening exercises that the patient can perform at home – http://spxj.nl/2ljbsKI Patient Information Leaflet: Osteoarthritis of the Knee – http://spxj.nl/2ljbsKI

BY DR CHRISTOPHER NORRIS PHD, MCSP range of motion. Strength exercise may increase muscle mass and muscle recruitment, providing that the overload on the muscle tissue is great enough. Strength increases to the knee musculature may lessen internal knee forces, modify biomechanics, decrease rate of joint loading and reduce articular cartilage stress (2). Overload during strength exercise may be reduced where pain is a barrier to exercise performance leading to exercise under dosage, often making pain management early on in the condition especially important. Exercise in general may improve QOL, increasing the number and variety of daily living tasks and improving physical function; these factors in turn having positive psychological benefits.

WHAT IS ARTHRITIS? The term arthritis tends to be used to describe any chronic inflammatory reaction affecting a joint. However, the term simply means ‘joint inflammation’, and as such must be qualified by a description of the cause of inflammation. Acute joint injury which causes swelling within the joint may be termed ‘traumatic arthritis’ for example. True osteoarthritis (OA) involves cartilage degeneration, initially with little inflammation, so the term osteoarthrosis is often used nowadays.

This condition must be differentiated from inflammatory states affecting multiple joints, such as rheumatoid arthritis (RA). Joint cartilage is composed of cells (chondrocytes), water, and a matrix consisting of collagen (mainly type II) with proteoglycans (especially aggrecan). Under normal circumstances the matrix undergoes a continuous process of dynamic remodelling, which balances low level degradation with synthesis through enzyme action, and so homeostasis is maintained. When a joint shows osteoarthritic changes, the cartilage overexpresses degrading enzymes upsetting the subtle balance between cellular breakdown and repair. The result is the loss of collagen and proteoglycans from the matrix, causing chondrocytes to proliferate in an attempt to compensate. The initial changes in OA are usually painless and show no gross joint swelling. The tissue affected first appears to be the joint cartilage, which now begins to show an increased water content resulting from degradation (proteolysis) of the cartilage proteins. Mild fraying or flaking of superficial collagen fibres within the hyaline cartilage occurs. This happens first at the periphery of the joint in the non-weight-bearing region. Later,

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PHYSICAL THERAPY

damage (fibrillation) is to the deeper cartilage layers in the weight-bearing areas of the joint, extending down to one-third of the cartilage thickness. Small cavities form (blistering) between the cartilage fibres, which gradually extend to become vertical clefts. If cartilage fragments break off, they may float free in the joint fluid as loose bodies, giving sudden twinges of pain and sometimes the joint feels as if it has locked. The presence of a loose body and the by-products of cartilage destruction causes the synovium (deep joint membrane) to inflame, and it is only now that many patients become aware that a problem exists. At this stage medication and modalities to reduce pain and inflammation can give some short-term relief. Turnover of proteoglycan and collagen within the cartilage ground substance is increased, and the proteoglycan molecules near the fibrillated cartilage are smaller than normal. Mechanically, this altered cartilage is weaker to both compression and tension stresses, but it is still resistant to gliding. As the cartilage thins, the joint space is reduced – a change that is visible on X-ray. The bone beneath the fibrillated cartilage (subchondral bone) becomes shiny and smooth, an appearance called ‘eburnation’. Below the eburnated region the area becomes osteoporotic and local avascular necrosis can cause cyst formation where there is complete bone loss. Osteophytes (bone spurs) covered with fibrocartilage form at the periphery of the joint, and may protrude into the joint space or more frequently into surrounding soft tissue, again a change visible on X-ray. The synovial membrane becomes thickened and its vascularity increases in line with an inflammatory response. The joint capsule demonstrates small tears filled with fibrous tissue, causing thickening and stiffening, often most noticeable first thing in the morning or on rising from prolonged sitting. Contracture usually alters both physiological and accessory movements, the first representing normal joint movement, the second

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joint play. Synovial proliferation alters the consistency of the synovial fluid, giving it a lower viscosity. Injections of hyaluronic acid (HA) are designed to slow this process. Increased growth of blood vessels (angiogenesis or neovascularisation) occurs in OA in bone, synovial membrane and joint capsule. In addition new vessels may also grow across the subchondral barrier dragging nerve fibres with them (3). It is important to realise that the knee joint is adapting. Just as muscles get stronger with increased loading (resistance training), they can get weaker if a joint is painful and a patient loads the knee less. Joints become stiff if they are not moved regularly; ‘motion is lotion’ is an old adage, but very apt here. OA is a condition that is driven by mechanical factors. Alteration to joint loading as a result of training or injury will cause the joint to react and repair, and an equilibrium must exist between stimulus (joint loading) and response (bone change).

STAGES OF OSTEOARTHRITIS Osteoarthritis is normally categorised in stages or grades 1–4 in terms of severity, with 0 being a normal joint (Table 1). Stage 1 is often asymptomatic, but on X-ray mild cartilage changes may be detected, often as a result of an X-ray being taken for another condition such as a ligament injury. Osteophytes may be seen but do not affect joint function. Stage 2 pathology shows further changes on X-ray with greater osteophyte formation and change in subchondral bone density. Bone will often appear whiter on X-ray (sclerosis) and bone cysts may sometimes be seen, and occasional cartilage thinning may be noted. Symptoms may occur on severe joint loading and muscle wasting may be noted where mild pain has encouraged reduced activity. Stage 3 injury will show more severe osteophyte formation and joint-space narrowing. Overall bone shape may change and cartilage erosion is noted, in patches down to subchondral bone. Muscle wasting and joint stiffness are

IN OA, MUSCLE WASTING AND JOINT STIFFNESS IS COMMON common, and should be addressed by rehabilitation. Joint stiffness is seen following prolonged rest (on rising from a chair or waking for example). Stage 4 OA is severe, and can often show complete loss of joint space with severe bone-end deformity. Pain is common following rest and joint loading. Movement range is severely limited and muscle wasting is marked.

WHERE DOES THE PAIN COME FROM? The pain of OA of the knee comes from a number of sources, other than the bone changes seen on X-ray. Irritation and swelling to the bone beneath the joint cartilage, swelling within the joint, and overuse and irritation of the soft tissues (capsule, ligaments, muscles) supporting the joint may all be local causes. However, these will only generate electrical signals in the nerves

TABLE 1. STAGES OF OSTEOARTHRITIS (C. Norris, 2017) Stage Joint changes 1 Minor loss of articular cartilage and minor bone spur growth Mild occasional discomfort when joint is heavily stressed. 2

Some bone hardening (sclerosis) and occasional bone cyst formation Greater osteophyte formation with change in bone density (whitening of bone on X-ray) Mild to moderate pain following intense activity Occasional joint stiffness.

Joint stiffness after prolonged resting Cartilage thinning and some joint narrowing Marked osteophyte formation.

Dramatically reduced joint space Bone-end deformity with severe cartilage loss Frequent mild to moderate pain, occasional severe pain Joint stiffening and movement loss.

Figure 1: Longitudinal distraction mobilisation (C. Norris, 2017)

Figure 2: Therapist-applied capsular stretch (C. Norris, 2017)

Figure 3: Self-applied capsular stretch (C. Norris, 2017)

which supply them. The same signals could be generated by movement or simply touching your knee. As the intensity of these signals increases – a little like turning up the volume on a radio – there comes a point where the body chooses to interpret the signals not as normal, but as threatening damage. When this happens, we would term the sensation we feel as painful, and the point at which this occurs is hugely variable between individuals. The severity of pain that a person with OA feels will be influenced by a number of psychological factors such as fear of the condition getting worse, and the effect it might have on their lifestyle (home, work, sport) for example. Changes in pain processing are also important. This is the way in which the electrical signals are viewed as painful or not. If a patient is a builder, used to heavy work on their knees, they are less likely to view a mild change in feeling of the knee as pain. If the patient is a professional ballerina the day before an important performance, any change in the way the knee feels may be interpreted as pain. In both cases, the electrical signals from the nerves to the brain are the same, but the brain’s interpretation (what the feeling means to the patient) is very different. When the electrical stimuli from the knee due to irritation (noxious stimuli) have been present for some time, the structures involved in feeling them

become hypersensitive. This process is called central sensitisation and may explain why 20% of individuals with severe knee OA who have their knee joints replaced, still complain of longterm pain afterwards (4).

condition of the patella under-surface (patellofemoral joint). The front-to-back (anteroposterior or AP) view looks straight on to the knee, whereas the lateral view looks from the side; both of these may be taken weight-bearing or with weight off the knee. A skyline view (infero-superior) looks between the femur and the patella. Cartilage has a number of functions, one of which is to absorb and redistribute shock. If the cartilage is worn, shock absorbing heel pads or springy shoes may be used to compensate. The X-ray will also show if another injury coexists (co-morbidity), such as a hairline fracture if the patient has had a fall, and if there is swelling (effusion) within the knee which will take time to settle. If a patient has slipped and fallen heavily, this fluid may also contain a small amount of blood (haemarthrosis) which acts as an irritant causing sensory signals to go to the brain. The health of the knee joint bones is also important and the bone density can be assessed from an X-ray. If it is poor, osteoporosis may be present which can require further tests, such as dual X-ray absorptiometry (DXA bone scan), to assess. Looking more closely at the X-ray we may see bone spurs or osteophytes at the edge of the joint, and sometimes bone cysts which appear almost as pockets within the bone. Where the cartilage has worn, the bone beneath becomes stronger and shows up as white indicating bone sclerosis. It is important for a patient to remember that the X-ray appearance does not mean the condition will stay as it is, because the X-ray does not accurately assess pain, muscle strength or confidence in the knee – all of which can improve significantly with rehabilitation.

DO X-RAYS AND SCANS SHOW KNEE PAIN? X-rays and scans will often look for two essential signs in the presence of OA in the knee: osteophytes and joint space narrowing. Some individuals who show marked changes on X-ray report very little pain, whereas others with obvious pain show few radiographic changes (5). The changes on an X-ray which together indicate the presence of OA sometimes explain less than 20% of the pain (4). A positive X-ray does not indicate that the condition cannot be treated, and usually patients can expect significant improvement in their symptoms with treatment such as muscle strengthening, active general exercise and weight loss. A number of features on X-ray may be used to guide treatment. Firstly we can look at bone alignment. Sometimes, an excessive angulation can occur called valgus or knock knee. Although this is not necessarily a problem, if altering the angle by using a shoe insert reduces pain, this may be used as a temporary or more longerlasting measure. Secondly the gap between the bones is assessed. This gap is filled with cartilage which does not show up on X-ray, and where the joint space is reduced, either between the bones of the knee themselves, or between the femur and the patella, this is an indication that the cartilage has thinned. When looking for OA in the knee, a number of X-ray views are normally taken, including one to show the

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Figure 4: Knee bracing (C. Norris, 2017)

Figure 5: Knee bracing with muscle palpitation (tactile cue) (C. Norris, 2017)

Figure 6: Leg extension (C. Norris, 2017)

ARTHRITIS AND EXERCISE

in Finnish distance runners than in non-runners of a similar age. Panush et al. (10) found no greater clinical or radiological evidence of OA in male runners of average age 55 years, and Lane et al. (11) concluded that runners and non-runners showed similar evidence of hip and knee OA. Although chronic mechanical loading may be detrimental to the knee, evidence suggests that recreational running is not a cause of knee OA (12) and may even be used therapeutically in OA patients (13). Chronic knee stress which may be imposed by elite level running is less clear cut. A systematic review of 19 studies looked at MRI scans of knees of distance runners and found no irreversible effects other than temporary proteoglycan depletion which took more than 3 months to recover to baseline. The authors were unable to conclude if this represented permanent structural damage (14). Maintaining the normal mobility and strength of a joint throughout life, and maintaining a healthy BMI (body mass index) could help maintain the health of the joint structures and perhaps delay the onset of OA, and many forms of exercise including running are helpful in doing this. Certainly obese individuals have been shown to be more likely to develop OA, the

increased risk being 4.8-fold in men and 4.0-fold in women (15).

Joint cartilage is continually subjected to impact stress in sport. For example when running a marathon an athlete is said to take 38,000 steps and each time to subject the knee joint to between 4 and 8 times their bodyweight, which equates to almost 5000 tonnes’ force. After a 20km run cartilage volume is seen to reduce by 8% in the patella, 10% in the meniscus and 6% on the tibial plateau, with all cartilage volumes returning to normal within 1 hour of cessation of exercise (6). Joint cartilage is open to continuous microdamage. However, providing the cartilage repair mechanisms outweigh the damage process, the joint will remain healthy. Animal studies have failed to show a direct link between exercise and arthritis. Radin et al. (7) found no evidence of cartilage deterioration in sheep forced to walk for 4 hours daily on concrete for 12 and 30 months. Videman (8) found that running did not affect the development of OA in rabbits. Experimentally induced OA was not increased when the animals were forced to run over 2000m per week for 14 consecutive weeks. Studies on runners have also failed to show any significant difference from non-runners. Puranen et al. (9) found less hip OA Video 1: Distraction technique and capsular release for OA of the knee (C. Norris, 2017)

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Video 2: Strengthening exercises for the knee Part 1 (C. Norris, 2017)

PHYSIOTHERAPY TREATMENT OF THE OSTEOARTHRITIC KNEE Exercise therapy plays the primary pivotal role in the management of OA in the knee, with hands-on techniques and pain-relieving modalities such as acupuncture and electrotherapy often having secondary supporting roles. In the acute (reactive) stage of the condition the knee may be too painful to exercise. The aim in the short term is to allow the joint to settle and relieve pain so that exercise can be used as soon as possible as this gives the longerterm benefit. Small joint movements (joint mobilisation) and gentle sustained lengthening (joint distraction) can often be very relieving; two accessory movements are especially useful, and may also be used as partner exercise following suitable instruction (Fig. 1; Video 1). Capsular stretching is a technique that uses a pivot at the back of the knee. This can be done using the therapist’s forearm (Fig. 2, Video 1) or the patient can apply the stretch themselves using a rolled towel (Fig. 3, Video 2). The knee is gently bent (flexed) against the pivot in a ‘nutcracker’ type action and a Video 3: Strengthening exercises for the knee Part 2 (C. Norris, 2017)

Figure 7: Leg-press with a band (C. Norris, 2017)

Figure 8: Leg-press with a gym ball (C. Norris, 2017)

Figure 9: Supported lunge (C. Norris, 2017)

comfortable stretch is held for 5 to 15 seconds and repeated 3–5 times. The aim is to feel pain reducing and stiffness easing. Joint distraction aims to gently draw the knee bones apart. Although little movement is likely as the knee is a very strong joint, patients who find their pain is worse with prolonged standing (joint compression) may often get relief from distraction. Pain modulation may occur and this type of action introduces a longitudinal glide mobilisation. Oscillation may be continued over a 30–60 second period. If patients are trying this with their partner at home, the force must be quite small as well as put on and taken off slowly to avoid jarring the knee. Exercise therapy may also be used early on for pain reduction. Sitting on the end of a table or bench, patients may gently bend and straighten their knee to move the fluids within the joint and increase circulation to the tissues. This action, called pendular swinging can help to ease pain and stiffness

and is a useful method of targeting non-acute (cold) swelling, where the knee has been stiff and puffy for some time. Perform the action for about 3 to 5 minutes morning and evening until pain has eased sufficiently to begin walking and using more challenging exercise. Even early on, walking itself is an excellent form of pain management with an osteoarthritic knee. People often say that walking makes their pain worse. However, when we look closely at this it is normally prolonged walking, often carrying heavy shopping bags for instance. A short walk in springy shock absorbing shoes will often help to ease stiffness. The knee may ache to begin but this should ease with time. Pacing may be used initially, only walking up to the point of pain onset. If a patient finds their knee aches if they walk for 15 minutes, they should try 10 minutes the next day. Use this approach for 3 to 5 days and then try to increase the time. This approach is called graded exposure and it is a little like building repetitions and sets up in the gym. The aim is to progress as the knee gets stronger. This type of approach, which sets the end of an exercise by pain onset (symptom contingent), is useful in the reactive phase of an injury, but it does have a disadvantage later on. When you move into the recovery phase,

your body may interpret relatively normal sensations as pain. This effect (hypersensitivity and allodynia) can be corrected by exercising for a set time (time contingent) which may involve the patient going through a little pain. In this way the perception of pain can be ‘reset’ so normal sensations are no longer interpreted a pain. Acupuncture is often used by physiotherapists in the early treatment of the osteoarthritic knee, and the results are generally quite good. In a systematic review of seven trials (393 patients) Ezzo et al. (16) concluded that acupuncture was effective for both pain relief and restoration of function, and that real acupuncture was better than sham acupuncture. In a later systematic review of 13 randomised controlled trials (1334 patients) White et al. (17) concluded that acupuncture was superior to sham acupuncture for improving pain and function with chronic knee pain. Some patients find acupuncture enables them to reduce the number of pain killers they take and lets them begin exercise early. Once they can exercise, this takes over from the acupuncture. In this way acupuncture can be used as a precursor to exercise within a multimodal approach. The current NICE (National Institute for Health and Care Excellence) guidelines do not

THE SEVERITY OF PAIN THAT A PERSON WITH OA FEELS WILL BE INFLUENCED BY A NUMBER OF PSYCHOLOGICAL FACTORS

Video 4: Strengthening exercises for the knee Part 3 (C. Norris, 2017)

Video 5: Strengthening exercises for the knee Part 4 (C. Norris, 2017)

Video 6: Proprioceptive and functional strengthening exercises for the knee (C. Norris, 2017)

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Figure 10: Deadlift (C. Norris, 2017)

Figure 11: Barbell squat (C. Norris, 2017)

Figure 12: Goblet squat (C. Norris, 2017)

recommend acupuncture for knee arthritis (18,19) but a network metaanalysis from the NIHR (National Institute for Health Research) stated that acupuncture could be considered as one of the more effective physical treatments for alleviating OA knee pain in the short term (20).

and hold them tight for 3 to 5 seconds before relaxing. Rest and repeat for 5 reps. Remind him to breathe as he tightens and not to hold his breath (Fig. 4, Video 2). If his muscles are very weak, and you only get a flicker of contraction, grip them with your hand. This will help send messages to the muscle to remind it to ‘wake up’ (muscle facilitation) (Fig. 5). Where his knee does not lock out easily, use your flat hand to gently press down on the thigh to encourage straightening. Once it has straightened with help from your hand, instruct him to keep his thigh muscles tight as you remove your hand from his thigh.

straighten, 4 to hold and 2–4 to lower. The lowering phase is important, so the patient should not let the leg simply fall back down. Increase strengthening by adding a small weight on her shin (a weight bag or heavy towel) and have her perform 10 reps (Fig. 6, Video 3). After rest, repeat this (2 sets of 10) and then build to 3 sets of 10, as the patient is able. As the exercise becomes easier the patient needs to remember to increase the weight to keep pace with her strengthening muscles.

SIMPLE KNEE STRENGTHENING A personalised exercise therapy programme should be prescribed after a knee assessment. To facilitate tissue adaptation (for example increased strength, movement range, balance) a training response should be expected (aching, tiredness) and patients should be warned of this. It is common for individuals to interpret pain as negative (hurt and harm) rather than a training response and patient education is essential to manage this. To be effective, exercise must be progressive, and frequency, intensity, time and type (F.I.T.T.) of exercises must change as tissue adaptation occurs. Full strength may take 6 to 12 months to develop and again education should prepare the patient for this.

Knee bracing Have the patient sit on a bed or the floor, with his leg out straight in front of him. Tell him to tighten his thigh muscles and try to brace his leg out straight. If his knee has been swollen, it might not lock out completely straight (compare it to his other leg). He should tighten his thigh muscles (quadriceps)

Leg extension When your patient is able to brace her thigh muscles, she can use them as she bends and straightens her knee (Video 2). She should begin with a small movement, placing a block or rolled towel behind her knee. Instruct her to press the back of her leg down against the towel as she tightens her thigh muscles to straighten her leg and lift her heel from the floor. The straight position should be held for 3 to 5 seconds and then released. Perform 5–10 reps and then rest. The amount of movement can be increased by performing the same leg extension action sitting at the edge of a bed or table. Tell your patient to slowly straighten her knee (concentric action), hold it straight (isometric action) and then bend under control (eccentric action). Use a count of 2 to

PAIN, MUSCLE STRENGTH AND CONFIDENCE IN THE KNEE CAN ALL BE IMPROVED SIGNIFICANTLY WITH REHABILITATION Co-Kinetic.com

Leg-press with band The first two exercises were ‘open chain’ exercises, performed with the foot free. The knee joint is free to move, and it is not compressed. However, eventually the patient will need to load his knee and we then move to ‘closed chain’ actions. The leg-press with a band (Fig. 7, Video 4) or a gym ball (Fig. 8, Video 5) is a good action to bridge the gap, as the patient is pressing against something with his foot, but the resistance is light. Have the patient sit on the floor with his back against a wall. Have him bend his knee and hook an exercise band over his foot and hold it with both hands (tell him to turn his head away from the band for safety – in case it flicks off his foot!). Then he should straighten his leg by pressing against the band. The straight position should be held for 2 to 5 seconds and then the knee bent again under control. Have the patient perform 5–10 reps and then rest and repeat. With this type of closed chain action, the muscles on the front and back of the thigh (quadriceps and hamstrings) work together to control the knee movement, whereas with an open chain action the muscles on one side of the thigh (quadriceps

Figure 13: Step-up (C. Norris, 2017)

with the leg extension action) work in isolation. The closed chain action more accurately mimics the type of action we would perform in our day-to-day tasks such as pushing, pulling, standing from a chair for example and so are termed ‘functional’. Using a thicker resistance band increases the work on the muscles, and eventually the patient will be able to use a gym-based legpress machine.

Supported lunge Have the patient begin this movement by standing to the side of a chair, with the chair back towards her (Fig. 9). The chair is held with one hand and with feet hip-width apart tell the patient to step forwards by about 1m with one leg –the step distance varies depending on leg length. As she steps forwards with one leg, the knee of the other leg should be lowered towards the ground. The eventual aim is for her to place her knee on the ground almost level with the heel of her leading leg so that the shin of her leading leg is about vertical. Have the patient begin by lowering a small distance and gradually build up as she feels capable. As she get stronger, gradually release the chair – change from holding it to just touching it lightly and eventually she can just place her hand over it so it is there if she needs it. The patient then reverses the movement by putting the other leg forwards. The aim is for the lunge to be performed unsupported (hands behind head) and ultimately holding a weight.

Mini-squat Patients often find standing from a chair harder when they have had any type of knee pain. When getting up if the leg muscles are weak they tend to lunge the body forwards, and when sitting down they tend to sit heavily and fall into the seat. This can be

quite dangerous as chairs may slip and people can fall or twist their knee or hip. Strengthening the leg muscles and improving control and balance is the key, and it can be achieved at any age. Once the leg extension has been mastered and the lunge exercise has been started, the patient is ready for the mini-squat. A firm dining chair is used with its back against a wall so it does not slip. Have the patient place his feet hip-width apart and reach both hands forwards as he bends his knees. He should lower himself towards the chair seat until he just touches it (not sit down completely) and then stand up again. If this is too hard, hold his hands for balance, so that he can ‘sit’ towards the seat but not quite touch it. You can even put some solid blocks or books on the seat to raise it up. As he improves he can go further towards the chair. Eventually this action becomes a squat exercise in the gym (Figs 10–12, Video 6), which even elderly patients can achieve with practice.

Step-up When someone has had knee pain, stairs can also be a problem. Going up is normally a bit of a struggle, but coming down can be even worse. This is because when we go upstairs we naturally lean forwards to take our weight into the stair, but coming down we lean back slightly taking our weight onto our heels. The step-up is simply using a staircase as an exercise (Fig. 13). The patient begins by facing the bottom step of a staircase or use a step bench in a gym. Have your patient place one foot on the step (whole of the foot not just your toes) and press with her leg to straighten it and step up. She should keep the same foot on the step, pause in the top position and then step down under control. With this first exercise patients are deliberately stepping up with the right and down with the right – using the same leg. The downwards action must also be a controlled movement. Have the patient practice 3–5 reps keeping one foot on the step and then rest and reverse the action keeping the other foot on (up with the left, down with the left). Once she is able to perform this unaided,

alternate the stepping (up with the right, down with the left). This action uses a concentric action going up and an eccentric action going down. To progress the action the patient turns around and stands on the step. Now, she steps down first, tap your foot onto the floor and then go back up (eccentric and then concentric action). Performing this action facing down the staircase is slightly harder as one’s weight is back, but more important is the fear of falling downstairs, which is worse following a knee injury. This exercise is as much about confidence as it is about muscle strength. Again, we use graded exposure. Have the patient begin with a smaller step, holding onto the banister and looking down at her foot. The aim is to use a deeper step, and perform it while looking up and with folded arms. References 1. Urquhart DM, Phyomaung PP, Dubowitz J et al. Are cognitive and behavioural factors associated with knee pain? A systematic review. Seminars in Arthritis and Rheumatism 2015;44(4):445–55 2. Fransen M, McConnell S, Harmer AR et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review. British Journal of Sports Medicine 2015;49:1554–1557 3. Jones A. The osteoarthritic knee. In Touch 2007;119:16–21 4. Wylde A, Sayers A, Odutola R et al. Central sensitization as a determinant of patients’ benefit from total hip and knee replacement. European Journal of Pain 2016;1:1–8 5. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskeletal Disorders 2008;2;9:116 6. Hohmann E. Long distance running and arthritis. sportEX medicine 2006;30:10–13 7. Radin EL, Eyre D, Schiller AL. Effect of prolonged walking on concrete on the joints of sheep. Arthritis and Rheumatism 1979;22:649 (abstract) 8. Videman T. The effect of running on the osteoarthritic joint: an experimental matched pair study with rabbits. Rheumatology and Rehabilitation 1982;21(1):1–8 9. Puranen J, Ala-Ketola L, Peltokalleo P et al. Running and primary osteoarthritis of the hip. British Medical Journal 1975;1:424–425 10. Panush RS, Brown DG. Exercise and arthritis. Sports Medicine 1987;4(1):54–64 11. Lane NE, Oehlert JW, Bloch DA et al. The

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relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. Journal of Rheumatology 1998;25:334–341 12. Leech RD, Edwards KL, Batt ME. Does running protect against knee osteoarthritis? Or promote it? Assessing the current evidence British Journal of Sports Medicine 2015;49(21):1355–1356 13. Lo G, Driban J, Kriska A et al. Habitual running any time in life is not detrimental and may be protective of symptomatic knee osteoarthritis: data from the osteoarthritis initiative. Arthritis and Rheumatology 2014;66:1265–1266 (abstract) 14. Hoessly LH, Wildi LM. Magnetic resonance imaging findings in the knee before and after longdistance running – documentation of irreversible structural damage? The American Journal of Sports Medicine 2016;doi: http://spxj.nl/2nCiIC2 15. Felson DT. Understanding the relationship between bodyweight and osteoarthritis. Clinical Rheumatology 1997;11:671–681 16. Ezzo J, Hadhazy V, Birch S et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis and Rheumatology 2001;44(4):819– 825 17. White A, Foster N, Cummings M et al. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology 2007;46(3):384–390 18. National Institute for health and Care Excellence (NICE). Osteoarthritis: the care and management of osteoarthritis in adults. NICE Clinical Guideline (CG)59, 2008 19. National Institute for health and Care Excellence (NICE). Osteoarthritis: care and management. NICE Clinical Guideline (CG)177, 2014 (http://spxj.nl/2mUsjzL) 20. Corbett MS, Rice SJ, Madurasinghe V et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis and Cartilage 2013;21:1290–1298.

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: https://uk.linkedin.com/in/dr-christophernorris-aa366115 Facebook: https://www.facebook.com/NorrisAssociates/

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RELATED CONTENT Gait Retraining in Medial Osteoarthritis of the Knee [Article] - http://spxj.nl/1Gt3jBF Untreated ACL rupture and Future Osteoarthritis [Video] - http://spxj.nl/1kOYFtT he Biology of Bone Repair and Regenerative Cell-based Approaches [Video] http://spxj.nl/1Rvxb9O

DISCUSSIONS Is osteoarthritis (OA) knee pain purely physical in origin or are there other factors that you need to take into account? How would this affect your assessment of your patient? What treatments would you consider for patients in the early (acute) stages of OA? What treatments would you consider for patients in the recovery stage of OA? What do you need to communicate to the patient to help their expectation management?

KEY POINTS Knee pain is common, particularly in the over 50s, and can reduce quality of life (QOL). Strengthening the knee musculature (as well as exercise in general) can improve QOL, which can in turn provide psychological benefits. ‘Arthritis’ simply means joint inflammation; osteoarthrosis involves cartilage degradation with little initial inflammation. OA knee pain perception is hugely individual and is affected by a number of psychological factors, as well as central sensitisation. X-radiography findings do not often correlate well with the patient’s pain level. There is no clear link between increased levels of exercise and increased risk of knee OA. Obesity has been linked to an increased risk of OA. In the acute phase, joint mobilisation and joint distraction are useful for providing pain relief, as is early exercise therapy. Early therapy is usually ‘symptom contingent’, whereas exercise therapy in the recovery phase becomes ‘time contingent’. Knee strengthening exercises include knee bracing, leg extension, leg-press, supported lunge, mini-squat and step-up.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Chronic knee pain can lead to a significant reduction in quality of life http://spxj.nl/2ljbsKI Tweet this: In OA, the subtle balance between cellular breakdown and repair is upset http://spxj.nl/2ljbsKI Tweet this: ‘Motion is lotion’ is an apt adage for the OA knee http://spxj.nl/2ljbsKI Tweet this: Central sensitisation may explain why some patients feel longterm pain after joint replacement http://spxj.nl/2ljbsKI Tweet this: Animal studies have failed to show a direct link between exercise and arthritis http://spxj.nl/2ljbsKI Tweet this: Exercise therapy plays the primary pivotal role in the management of OA in the knee http://spxj.nl/2ljbsKI

INTRODUCTION There are two clinical perspectives to consider when assessing the sacroiliac joint (SIJ); the SIJ as a load-transferring mechanical junction between the pelvis and the spine that may cause either the SIJ or associated structures to produce painful stimuli (SIJ dysfunction), and the SIJ joint structures as a source of pain (SIJ pain). The first suggests the joint is malfunctioning in some way and the term ‘dysfunction’ is commonly used to encapsulate the complexity of aberrations believed to occur. Confusingly, SIJ dysfunction and SIJ pain are commonly used interchangeably, as though they have the same meaning. Tests for SIJ dysfunction generally have poor inter-examiner reliability. However, tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard, these are introduced here.

BACKGROUND Altered biomechanics are deciphered by the body as a whole, resulting in adaptive shortening and lengthening of associated structures. The body continues to make adaptations long after the initial injury, and this may be LOWER LIMB | HIP | 17-04-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Sacroiliac Joint Dysfunction Assessment Algorithm 1 http://spxj.nl/2liVOyS Sacroiliac Joint Dysfunction Assessment Algorithm 2 http://spxj.nl/2liVOyS Sacroiliac Joint Dysfunction Assessment eLearning Quiz This article also has a certificated eLearning assessment that can be found in the Media Contents box, or under the eLearning Assessment area in your Account area, on the Co-Kinetic website. The eLearning assessment(s) can be completed on all platforms including mobiles when accessed through the Co-Kinetic site; however, they are NOT accessible through the sportEX mobile app as you have to be logged into the actual website for the results to be recorded and the certificate to be generated. http://spxj.nl/2liVOyS Sacroiliac Joint Pain Patient Advice Leaflet - http://spxj.nl/2liVOyS

SACROILIAC JOINT DYSFUNCTION: A STRUCTURED ASSESSMENT STRATEGY ‘Sacroiliac Joint Dysfunction: A Structured Assessment Strategy’ has been developed from an extract of the author’s book Sacroiliac Joint Dysfunction and Piriformis Syndrome. It includes step-by-step guidelines for more than 10 sacroiliac joint assessment tests giving therapists an ideal structure within which to perform a sacroiliac joint dysfunction assessment. Additional supporting resources include two assessment algorithms, an elearning quiz and a patient advice leaflet. Read this online http://spxj.nl/2liVOyS BY PAULA CLAYTON MSC FA. DIP MAST STT, MSMA (L5) MCSP MACPSM the reason why the athlete in front of you can’t quite put his or her finger on when or how the presenting problem arose, leading to the subsequent label of ‘insidious onset’. The biomechanical adaptations following the initial insult/injury/illness often result in muscle imbalances, which by their very nature inhibit muscle activation or produce overactive or hypertonic muscles (also weak), taking the muscles into a position of being too long and dysfunctional or too short and dysfunctional. Depending on the load being placed on the body and the lines of stress attempting to control the structures (which are dysfunctional), this information will guide you toward your treatment goal. For example, the ligaments and fascia of the pelvis and sacrum (thoracolumbar and abdominal aponeurosis) may be loaded in unfamiliar patterns following injury to the spine, resulting in altered positions of the pelvis … and on it goes. It is clear that the ilia and sacrum are at the centre of sacroiliac dysfunction and pain, but what of the relationship between dysfunction of the sacroiliac joint (SIJ) and the hip joints’ range of movement (ROM)? Without correct alignment of the femur and its

articulation with the acetabulum, and fully functioning ROM, how is the pelvis able to absorb the forces of impact during walking, running, jumping, etc? How do the structures crossing that joint adapt – with inhibition, facilitation, or spasm (1)? The primary function of the lumbopelvic–hip complex is to transfer loads safely while fulfilling the movement and control requirements of a task (2). Coexisting dysfunctions in the areas adjacent to the pelvis – such as movement disorders of the hip, lumbar spine, and neurodynamics – are also very common.

CONSIDERATIONS BEFORE TREATMENT Before proceeding with any form of therapy input it is important that all associated structures impacting on the injured/dysfunctional areas are assessed for their lack of, or excessive involvement in, the symptoms being presented to you by the athlete. In addition, a thorough examination and assessment of the lumbar spine and bilateral hips should have preceded the assessment of the pelvis. You should ensure that you assess the length and power of the structures being presented to you in this article

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in order for you to have a form of ‘outcome measure’ on which to base your therapeutic input: 1. Assess the relevant structures bilaterally for length and power. Use an outcome measure (if appropriate). 2. Using your clinical reasoning (obtained from your subjective and objective findings) decide what your soft-tissue treatment/input will be. 3. Implement that input. 4. Reassess. Using the outcome measure selected (if appropriate). 5. Have you made the change you were looking for? No? Select another ‘tool’ from your physical therapy ‘toolbox’. Reassess. Yes? Stop, do not overwork the tissues. 6. Give the athlete a rehabilitative exercise to help maintain the work you have done. For example, the posterior fibres of the internal oblique invest into the deep layers of the contralateral gluteus maximus via the central layer of the thoracolumbar fascia (TLF), performing as a stabiliser system for the SIJ in low-load activities (such as walking). Therefore, if there is a suspected SIJ problem, assess the obliques.

Palpation Palpation creates an awareness and appreciation of the huge variables that exist in the people we treat. Before charging ahead, think about the following: Check sacral nutation (flexion of sacrum) in static upright weightbearing posture. Nutation is not the same when the person is either prone or supine; this has a huge impact on leg length. Shifting of the trochanter following an ankle sprain or orthotics that do not fit well may contribute to force closure of the SIJ and counterrotation of the ilia, resulting in leg-length inequalities. Iliosacral obliquity can also create the illusion of leg-length discrepancy.

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Leg-Length Assessment The process for assessing leg length (Fig. 1) is as follows. 1. The patient should be supine. 2. Measure from the anterior superior iliac spine (ASIS) to the medial malleolus (true leg length), then extend the measurement down to the bottom of the heel with the ankle in neutral. 3. Assess before and after soft-tissue input and see if there is a change in your results (due to shortening of muscles acting on femur position). 4. True leg-length discrepancy – the patient may be in need of orthotics.

Figure 1: Leg-length assessment

ASSESSMENT OF STRUCTURES OTHER THAN THE SIJ Observations and clearing assessments are used to rule in/rule out the involvement of structures other than the SIJ in the patient’s symptoms, before focusing on the pelvis and SIJ itself. The results of these tests allow you to tailor your therapy to the precise needs of the patient.

Figure 2: Lumbar-flexion assessment

Figure 3: Lumbar-extension assessment

Figure 4: Lumbarside-flexion assessment

Figure 5: Quadrant assessment

Gait 1. In the ideal scenario you will have the opportunity to observe the athlete in all of his or her training sessions [walking, running, sprinting, technical, strength and conditioning (S&C)]. You will have conversations with the coach and other members of the interdisciplinary/ transprofessional team regarding the athlete’s presenting symptoms. 2 Realistically, you are more likely to see that athlete in a treatment area. 3. Look closely at how the athlete walks into your treatment room; if this is not enough, have them walk up and down the hallway. 4 Observing how the athlete is loading through the pelvis and the lower extremities provides valuable information. 5. Expect to see good function: No sign of Trendelenburg gait, where the hip drops on the toeoff leg owing to weak abductors on the contralateral side Good motor control Alignment of lumbar spine, pelvis

(with minimal rotation), and the joints below Head and body producing fluid movement with minimal deviations laterally. 6. You may, however, see indications of failed load transfer: Trendelenburg sign Increased rotation of lumbar spine, pelvis, femur (medial rotation), foot (pronation) Increase in trunk deviation. 7. In addition, standing and sitting observations may include the following that may lead to tissue overload: Increase in lumbar lordosis/ swayback in standing: maximum sacral nutation and symphysis

pubis lying in front of the sternal notch Slumped sitting position: counternutation (extension) of the sacrum.

Clearing the Lumbar Spine 1. Lumbar flexion (Fig. 2) Therapist places two to three fingers on the lumbar vertebrae Athlete flexes lumbar spine Fingers should move apart 2. While in lumbar flexion, add cervical flexion (dural, spinal cord tension) 3. Lumbar extension (Fig. 3) Therapist places two to three (a)

fingers on the lumbar vertebrae Athlete extends lumbar spine Fingers should move closer together 4. Athlete performs right- and left-side flexion (Fig. 4) 5. Athlete performs right and left lumbar quadrant (combined movements/multi-plane) – only do this if you have not yet provoked the symptoms in the previous clearing movements (Fig. 5) Quadrant test: extension, side flexion, right rotation/left rotation, add overpressure (passive endof-range stretch without pain as a barrier) while stabilising the sacrum.

Figure 7: The slump test

Clearing the Hips

(b)

(c)

(d)

Assessing for Quantity and Quality of Movement (Fig. 6) Any loss of range or quality of movement indicates hip involvement, which may be compensatory. 1. Athlete squats (body weight) with heels on and off the ground Excessive lumbar flexion means that there may be a hip-flexion restriction 2. Assess both sides for comparison 3. Full hip flexion in supine position with added overpressure 4. Full internal rotation of the hip in supine position (reduction in range may indicate osteoarthritis) 5. Follow immediately by full external rotation of the hip in supine position 6. Full hip extension in prone position with added overpressure 7. Full internal and external rotation of the hip in prone position.

Neurodynamic Testing

(e) (f)

Figure 6: Assessing hips for quantity and quality of movement

Slump Test The slump test (Fig. 7) assesses the whole nervous system but is most commonly known as the ‘lumbar neural tension test’. The slump test: 1. Applies traction to the nerve roots by incorporating both spinal and hip flexion; pain provocation indicates nerve-root compression when the straight-leg raise (SLR) test is negative 2. Has been found to be more

5. 6.

sensitive than the SLR in patients with lumbar disc herniation (3) Can be uncomfortable and provocative – please ensure: That you do not perform this test unless you have been taught the proper handling skills That the subjective and objective findings indicate a slump test should be performed All contraindications have been taken into account That the ultimate aim of this test is to reproduce the athlete’s symptoms Is performed with the athlete seated on the edge of plinth Hands clasped behind the back Thoracic flexion closely followed by lumbar flexion: puts pressure on the lumbar discs Cervical flexion (with slight overpressure from therapist): puts a stretch on the sciatic nerve Position is held as athlete extends one knee Foot is then dorsiflexed: reproduction of pain anywhere from the lumbar spine to the foot is indicative of potential herniated disc, neural tension, or altered neurodynamics Cervical extension: pain disappears? Confirm findings by reducing neural tension Repeat other side and compare Positive test Reproduction of athlete’s pain Negative test No pain Discomfort in the leg due to normal muscle tightness

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(a)

(c)

(b)

(d)

Figure 8: Overhead squat assessment

Overhead Squat Assessment In this assessment (Fig. 8), the following are typically asymmetrical: Knee valgus [knees point toward the midline (knock knee)] Knee varus [knees point outward, away from the midline (bow leg)] Anterior pelvic tilt Excessive lumbar flexion Asymmetrical weight shift (indicative of SIJ dysfunction).

Ely’s Test Ely’s test is used to rule out rectus femoris as a source of anterior pelvis tilt. 1. Athlete prone and in alignment Therapist places finger and thumb of one hand on the posterior superior iliac spine (PSIS) (Fig. 9a). 2. Therapist passively flexes the knee (Fig. 9b) Heel should almost touch or touch the buttock without any compensation (Fig. 9c) PSIS pushes into the thumb: anterior tilt on the ipsilateral side; tight rectus femoris Hip rotates: tight rectus femoris Hip abducts: tight rectus femoris Therapist needs to address any length deficiencies in rectus femoris 3. Address rectus femoris length. 4. Pain in the lumbar spine? May be the result of: Femoral nerve irritation due to lumbosacral lesion or hip lesion Potential protruding or bulging disc Potential SIJ dysfunction Athlete must be very specific with regard to location of pain 5. Refer patient to relevant practitioner if this is beyond your scope of practice.

ASSESSMENT OF THE PELVIS AND SIJ Having assessed the involvement of structures other than the SIJ in the patient’s condition, it is time to focus on the pelvis and the SIJ itself (See further details in the full version online). Commonly, the complaints from people struggling with an SIJ disorder include pain and heaviness or fatigue in the leg on the affected side, particularly during weightbearing activities. The pain (a)

(b)

(c)

Algorithm 1: Cluster of Laslett Tests. Likelihood of SIJ involvement based on pain provocation tests (Adapted from Laslett et al. Manual Therapy 2005;10:207)

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Figure 9: Position of therapist’s finger and thumb on the PSIS for Ely’s test

86% of patients described pain when carrying a full shopping bag (dynamic loading). 81% of patients described pain when single-leg standing (shear forces with load). 81% of patients described pain when walking for thirty minutes (dynamic loading and shear forces).

Figure 10: Distraction test

A positional analysis of the pelvic girdle should be made before assessing joint mobility, involving palpation of the iliac crests, SIJ and sacrum (See further details in the full version online).

Assessing for SIJ Pain Figure 11: Compression test

is described as being sudden and sharp preventing some people from going about their activities of daily living (ADL). SIJ symptoms rarely travel over to the contralateral side; these are usually isolated to the posterior aspect of the SIJ in question and can refer as far down as the calf and foot, but often refer into to the buttocks, the groin, and around the posterior thigh. People experiencing SIJ pain often adapt their position to reduce their symptoms, which can include regularly having to lean to the side and sit on one buttock or sitting with the legs crossed. Common activity restrictions caused by SIJ pain have been assessed by Mens et al. (4) and knowledge of these will help you to tailor the subjective questioning to delve deeper into the history of the patient’s present condition: 90% of patients described pain when standing for thirty minutes (static loading).

Figure 12: Thigh-thrust test

The latest research strongly supports pain provocation tests as these have shown good reliability individually, but even more so when two or three are done together (Algorithm 1) (5–7). The most relevant and most recent evidence shows that a minimum of three SIJ pain-provocation tests must reproduce the patient’s pain before the pain can be considered as originating from the SIJ (8). If two of the following tests are positive, the SIJ may be considered as likely to be the source of pain (9). If all the tests are negative, the SIJ as the source of the pain can be ruled out (10). Distraction test Compression test Thigh-thrust test Sacral-thrust test. Distraction Test (Fig. 10) This is the most specific test (9). Athlete supine, lying with small pillow under knees (to keep the lumbar spine in neutral) Heels of hands on medial aspects of both ASIS Perform a slow steady

Figure 13: Sacral-thrust test

Figure 14: Gaenslen’s test

posterolateral force through both ASIS (distracting the anterior part of the SIJ and compressing the posterior part) Maintain this force Ask athlete about reproduction and localisation of pain. Compression Test (Fig. 11) Side-lying position, hips and knees flexed Place both hands over the anterolateral iliac crest Apply a slow steady medial force through the innominate-compressing the anterior part of the SIJ and distracting the posterior part Maintain force Ask patient about reproduction of pain Repeat test both sides. Thigh-Thrust Test (Fig. 12) Attempting to elicit pain whilst performing a posterior shearing force to the SIJ of that side. Athlete supine with the hip and knee flexed Thigh 90° to the plinth and slightly adducted Therapist’s hand cups the sacrum, the other arm and hand wrap around the flexed knee Therapist applies pressure down toward the plinth along the line of the vertically oriented femur Repeat both sides. Sacral-Thrust Test (Fig. 13) Attempting to elicit pain while performing an anterior shearing force of the sacrum on both ilia. Athlete in prone position Therapist applies a force vertically downward to the centre of the sacrum.

Figure 15: The stork test

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Figure 16: Active straight-leg-raise

Additional Tests Gaenslen’s Test (Fig. 14) Athlete supine near the edge of the couch Patient’s hip is fully flexed into the abdomen and held there by the patient as the therapist adds overpressure The opposite leg is slowly hyperextended by the therapist over the edge of the bed with overpressure over the knee Test is positive when pain is reproduced over the flexed side.

Assessing for Loss of Function Stork Test (Fig. 15) The stork test (or modified Trendelenburg/one-leg standing (OLS)/ Gillet’s test) and the active straight-leg raise test (ASLR) have both shown acceptable inter-tester reliability. Lee and Lee (2) also assess lateral tilts of the pelvis in both supine and standing positions to test load transfer through the symphysis pubis. The stork test is a motion-control test where both form and force closure mechanisms are assessed by observing how load is managed

through the pelvis in standing. The ability to maintain a stable alignment of the ilium relative to the sacrum when testing the weight-bearing side (self-braced alignment of the pelvic bones) is what is expected. There should be no relative movement occurring in the pelvis during this load-transfer test (this test is also used as a symphysis pubis pain-provocation test) and it should be performed three times to ensure that the same pattern is observed. The ability of the non-weightbearing side (NWB) innominate to rotate posteriorly relative to the ipsilateral sacrum can also be assessed by this test (2,11). Observe the quality of the symmetry between both sides. The stork test is performed as follows. 1. Athlete standing 2. Kneel behind the athlete, and place the heel of your hand on the ilium of the side to be tested 3. Wrap the fingers of that same hand around the ilium and keep them relaxed Place the thumb of the same hand just below the posterior superior iliac spine (PSIS) Place the contralateral (other hand) thumb at S2 Keep both hands relaxed 4. Ask the patient to stand on one leg (the side you are assessing) and bring their knee in line with the belly button 5. Repeat three times-are you getting the same results each time? 6. Repeat on the other side

SACROILIAC JOINT DYSFUNCTION SYMPTOMS RARELY TRAVEL OVER TO THE CONTRALATERAL SIDE (remembering to change your hands around) as you always need a comparison 7. Is the effort the same on both sides? 8. Was the transfer of weight onto the weight-bearing (WB) leg smooth? 9. Did the pelvis stay in the same position? 10. This can also be done leaving the hands in the same position, but placed this time on the side of the body where the hip is being flexed (NWB side). 11. The thumb placed below the PSIS should drop below its original position as the pelvis is rotated backward relative to the sacrum during hip flexion 12. Again compare to the contralateral side, looking for symmetry. Active Straight Leg Raise (ASLR) (Fig. 16) This test assesses load through the pelvis in a supine position. 1. Athlete lifts the nonaffected leg eight inches from the bed and compares the difference in effort experienced when lifting the leg of the affected side. 2. The effort can be scored on a scale of 0–5 (4). 3. The leg should feel light when lifting it off the plinth; there should be no movement of the pelvis in any direction in relation to the trunk or the legs. 4. If this is too difficult or the leg feels heavy, this indicates poor recruitment of both local and global muscles.

Additional SIJ Function Tests These tests have reduced sensitivity and specificity.

Figure 17: Standing flexion test

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Figure 18: Seated flexion test

Standing Flexion Test (Fig. 17) 1. Athlete standing

2. Kneel behind the athlete and: Place the heels of both hands on the ilia Wrap the fingers around the ilia and keep them relaxed Place the thumbs just below the PSIS Keep both hands relaxed 3. Ask the patient to bend forward as far as they can go 4. Repeat three times – are you getting the same results each time? 5. Compare sides, looking for symmetry If the thumbs stay level (move equal distance) during flexion, this is normal/negative If the PSIS moves in cephalad direction on one side during flexion this is indicative of SIJ dysfunction/limited movement of the sacrum on the ilium on that side. Seated Flexion Test (Fig. 18) 1. Athlete seated in the middle of the plinth with feet touching the floor 2. Kneel behind the athlete and: Place the heels of both hands on the ilia Wrap the fingers around the ilia and keep them relaxed Place the thumbs just below the PSIS Keep both hands relaxed 3. Ask the patient to bend forward as far as they can go 4. Repeat three times-are you getting

Figure 19: Hip-abduction test

Figure 20: Hip-extension test

the same results each time? 5. Compare sides, looking for symmetry If the thumbs stay level (move equal distance) during flexion, this is normal/negative If the PSIS moves in cephalad direction on one side during flexion this is indicative of SIJ dysfunction/limited movement of the sacrum on the ilium on that side.

innominate, and contralateral biceps femoris activation leads to transverse plane rotation of the pelvis (clinically seen as an upward movement of the contralateral ASIS). This, in turn, is counteracted by the ipsilateral transversus abdominis and internal oblique; the psoas is active bilaterally (potentially reflecting its stabilising of the lumbar spine); iliacus, rectus femoris, and adductor longus are active ipsilaterally (synergistically). The addition of compression to the pelvis (squeezing of the anterior portion of the innominates, or bringing the ASIS closer together) can enable the leg to be lifted with ease (unless there is already too much compression, in which case this movement may be made even more difficult). Altering the location of the compression forces can assist the therapist in determining where more compression is needed (and where weakness is present) functionally to help load transfer through the pelvic girdle (2) and, therefore, plan an effective treatment programme (Algorithm 2). Lee and Lee (2) suggest compression differences in different areas of the pelvis: Anterior compression – squeezing the ASIS closer together [simulates transversus abdominis (TA)] Anterior compression above the greater trochanter of the hips (simulates anterior pelvic floor) Posterior compression – bringing both PSIS together (simulates multifidus) Anterior compression of left ASIS and posterior compression of right PSIS toward each other (simulates left TA and right multifidus).

The Role of the Psoas in Hip Flexion Hu et al. (12) investigated the role of the psoas in hip flexion using the ASLR test (hip flexion pulls the innominate forward). Historically, this action was considered as being counteracted by the contralateral biceps femoris and the ipsilateral lateral abdominals (pressing the innominate toward the sacrum for increased force closure). Their results highlighted that problems with the ASLR may reflect problems with force closure, abdominal wall activation counterbalances forward rotation of the

Algorithm 2: Adaptations to ASLR to determine where compression may be needed or where too much compression is present (P. Clayton, 2017)

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The compression that is noted to be most helpful for the patient during the ASLR test should be kept in mind when planning the treatment. Keep in mind that if there is too much compression the patient will not do well or may find the task of lifting the leg even more difficult. What if you find that compression (force closure) is reduced? 1. Assess and treat lumbar spine and hips, as these are likely to be hypomobile Compensation or strain on the structures impacting on the SIJ 2. Temporary use of an SIJ belt 3. Walking and swimming activates gluteus maximus Increases tension on the thoracolumbar fascia (TLF) 4. Specific training of gluteus maximus and latissimus dorsi (posterior oblique sling), erector spinae and multifidus (13) Assists force closure Strengthens TLF. What if you find that compression (force closure) is excessive? 1. Overactive global muscles in the lumbopelvic region compressing SIJ? 2. Pain-provocation tests positive? 3. Stork test negative? 4. ASLR negative? 5. Assess and treat connective tissue around the SIJ Soft-tissue work (connective tissue) Hip external rotators if bottom gripping is apparent Muscle energy techniques (MET) Mobilisations and mobility exercises Postural training 6. Reduce hypertonicity in dominant global muscles 7. Stop stabilisation exercises (muscles are already too active) 8. Add in breathing exercises: Costolateral, diaphragmatic breathing. Hip-Abduction Test (Fig. 19) This test is indicated in screening for stability of lumbopelvic region.

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1. Athlete side-lying with lower hip and knee flexed and upper leg extended 2. Leg is lifted actively into abduction 3. Leg should abduct approximately 20° 4. There should be no external rotation (ER), hip flexion, or hip hitching 5. Moderate lumbar erector spinae/ quadratus lumborum (QL) contraction is allowed 6. Positive result if: ER in femur is present – shortening of piriformis ER of pelvis – piriformis and other lateral rotator overactivity/ shortness Hip flexion occurs – psoas, tensor fasciae latae (TFL) overactivity/ shortness Hitching of pelvis before 20° of hip abduction – QL overactivity/ shortening Pain in ipsilateral adductor – adductors shortened. Hip-Extension Test (Fig. 20) This test is indicated for assessing coordinated muscle activation during prone hip extension. 1. Athlete prone with arms relaxed 2. Feet extended beyond plinth 3. Leg is lifted into extension 4. Initial contraction is expected in the thoracolumbar erector spinae muscles (stabilising torso) 5. Full action should be achieved by coordinated activity of the hamstrings and gluteus maximus (GM) 6. Positive result if: Knee flexes – indicative of hamstring shortness- Delayed/ absent (inhibited) GM firing – indicative of overactivity of erector spinae muscles and/or hamstring muscles False hip extension – lower back performs this movement indicative of inhibited GM or erector spinae overactivity Premature contralateral periscapular muscular contraction – indicative of functional lower back instability (recruiting upper torso to compensate for prime mover inhibition).

CONCLUSION/SUMMARY There are two clinical perspectives to consider when assessing the SIJ; the SIJ as a load-transferring mechanical junction between the pelvis and the spine that may cause either the SIJ or the associated structures of force closure to produce painful stimuli (SIJ dysfunction), and the SIJ joint structures as a source of pain (SIJ pain). It is clear that the ilia and the sacrum are at the centre of SIJ dysfunction and SIJ pain and that coexisting dysfunctions in the areas adjacent to the pelvis, such as movement disorders of the hip, lumbar spine, as well as neurodynamics, are also very common. Once you have deduced which structures are in need of input and why, you will find the how in Paula’s book Sacroiliac Joint Dysfunction and Piriformis Syndrome (14).

Acknowledgement All figures have been taken from Paula’s book Sacroiliac Joint Dysfunction and Piriformis Syndrome: The Complete Guide for Physical Therapists, ©Lotus Publishing 2016, and are reproduced here with permission. References 1. Janda V. Treatment of chronic back pain. Journal of Manual Medicine 1992;6:166–168 2. Lee D, Lee L. The pelvic girdle, 4th edn. Elsevier/ Churchill Livingstone 2010. ISBN: 978-0443069635 (£44.32 Print £42.10 Kindle). Buy from Amazon http://amzn.to/2m1nNzv 3. Majlesi J, Togay H, Ünalan H et al. The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology 2008;14(2):87–91 4. Mens JM, Vleeming A, Snijders CJ et al. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 2001;26(10):1167–1171 5. van der Wurff O, Hagmeijer RHM, Meyne W. Clinical tests of the sacroiliac joint: a systematic methodological review—Part 1: Reliability. Manual Therapy 2000;5(1):30–36 6. van der Wurff O, Hagmeijer RHM, and Meyne W. Clinical tests of the sacroiliac joint: a systematic methodological review—Part 2: Validity. Manual Therapy 2000;5(2):89–96 7. Robinson HS, Brox JI, Robinson R, et al. Technical and measurement report the reliability of selected motion- and pain- provocation tests for the sacroiliac joint. Manual Therapy 2007;12:72–79 8. Szadek K, van der Wurff P, van Tulder M, et al. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. Journal of Pain 2009;10(4):354–368 9. Laslett M, Aprill CN, McDonald B, et al. Diagnosis of sacroilial joint pain: validity of individual provocation tests and composites of tests. Manual Therapy 2005;10:207–218 10. Laslett M, van der Wurff P, Buijs EJ et al. Comments on Berthelot et al. review: ‘Provocative sacroiliac joint maneuvers

and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain.’ Joint, Bone Spine 2007;74:306– 307 11. Hungerford B, Gilleard W, Moran M. Evaluation of the ability of physical therapists to palpate intrapelvic motion with the stork test on the support side. Physical Therapy 2007;87(7):879–887 12. Hu H, Meijer OG, van Dieën JH, et al. Is the psoas a hip flexor in the active straight leg raise? European Spine Journal 2011;20(5):759–765 13. Vleeming A, Stoeckart R. The role of the pelvic girdle in coupling the spine and the legs: a clinicalanatomical perspective on pelvic stability (Ch. 8). In: Vleeming A, Mooney V, and Stoeckart R (eds) Movement, Stability and Lumbopelvic Pain: Integration and Research. Churchill Livingstone 2007. ISBN: 9780443101786 (£72.99). Buy from Amazon http://amzn.to/2m1ruVP 14. Clayton P. Sacroiliac joint dysfunction and piriformis syndrome: the complete guide for physical therapists. Lotus 2016. ASIN: B01K0S1OYM (Print £20.98 Kindle £13.14. Buy from Amazon http://amzn.to/2m1msIJ.

THE AUTHOR Paula Clayton MSc FA. Dip Mast STT, MSMA (L5) MCSP MACPSM worked as a senior performance therapist for the English Institute of Sport and British Athletics between 2003 and 2014. She has travelled extensively to Olympic Games (Athens, Beijing and London), Commonwealth Games, World and European Championships with GB track and field as part of the medical team during this time. Before 2003 Paula worked in Premiership and Championship football for 4 years. She has taught on two sports therapy degree programmes, delivered sessions to MSc students and sports medicine students, written a number of articles and has an MSc in Physiotherapy and an MSc in Sports Injury Management. Paula also delivers softtissue masterclasses to senior physiotherapists and soft tissue therapists within premiership and championship football clubs, National Governing Bodies and to soft-tissue therapists nationally and internationally through her company stt4performance.com. Paula is also the author of a book Sacroiliac Joint Dysfunction and Piriformis Syndrome: The Complete Guide for Physical Therapists. Paula also runs very successful sports injury clinics in Shropshire (established in 1994) and Worcestershire with her husband Rick. Email: office@stt4performance.com Twitter: @PaulaClaytonSTT LinkedIn: https://www.linkedin.com/in/paulaclayton/ Facebook: https://www.facebook.com/ STT4Performance

RELATED CONTENT Sacroiliac Joint Dysfunction and Piriformis Syndrome [Book Review] - http://spxj.nl/2h9FwTT Other hip-related content - https://co-kinetic.com/tag/hip

DISCUSSIONS Why is it important to assess the structures associated with the sacroiliac joint (SIJ) before treating SIJ dysfunction? What are the best tests to use to determine that the SIJ is the source of the patient’s pain? Why is the active straight leg raise (ASLR) so useful as a test?

KEY POINTS Adaptations as the result of injury often result in muscle imbalances, the identification of which is necessary for appropriate treatment. The primary function of the lumbopelvic–hip complex is to transfer loads safely while fulfilling the movement and control requirements of a task. Before treatment, all associated structures must be assessed for their level of involvement in the patient’s symptoms. Patients with an SIJ disorder commonly complain of heaviness or fatigue in the leg on the affected side. SIJ symptoms rarely travel over to the contralateral side. People experiencing SIJ pain often adapt their position to reduce their symptoms, which can include leaning to the side. SIJ pain provocation tests include the distraction test, compression test, thigh-thrust test and the sacral-thrust test. Two or more pain provocation test done together demonstrate good reliability for determining whether or not the SIJ is the source of pain. The active straight leg raise (ASLR) assesses load through the pelvis in a supine position. Altering the location of compression on the pelvis can help the therapist to determine which structures need to be strengthened to help load transfer through the pelvic girdle.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Ely’s test is used to rule out rectus femoris as a source of anterior pelvis tilt. http://spxj.nl/2liVOyS Tweet this: Sacroiliac joint dysfunction symptoms rarely travel over to the contralateral side. http://spxj.nl/2liVOyS Tweet this: People with SIJ pain often lean to one side or sit with their legs crossed to reduce their symptoms. http://spxj.nl/2liVOyS Tweet this: SIJ pain provocation tests performed together have better reliability than when done individually. http://spxj.nl/2liVOyS

Tweet this: The ASLR done with compression at different points on the pelvis can identify specific weaknesses. http://spxj.nl/2liVOyS

Co-Kinetic Journal 2017;72(April):22-30

MASSAGE THERAPY

PATELLAR TENDON PAIN: A MASSAGE THERAPIST’S GAME PLAN This article and associated supporting material outlines a massage therapy treatment strategy for patellar tendinosis. In the article the author outlines a restricted reciprocal inhibition condition which is commonly found in people with patellar tendon pain, which leads to altered movement patterns at the lumbopelvic and hip level. The author goes on to describe in detail a technique he has developed to identify the key soft-tissue restrictions in the hip along with a soft-tissue based treatment to unlock the key restrictions resulting from this altered movement pattern. The article is supported by videos and a patient information leaflet. Read this online http://spxj.nl/2lj4vsR SUMMARY AND EXPLANATION OF PATELLAR TENDON PAIN Patellar tendinosis refers to a condition in which one experiences pain over the front of the knee joint; the pain is normally localised to the region of the patellar tendon below the kneecap. Also referred to as the ‘jumper’s knee’, this condition can also be looked at as the inflammation of the patellar tendon. This implies that the patellar tendon, extending from the region below the kneecap joining to the tibia, has been damaged.

KNEE | LOWER-LIMB | 17-04-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Video: Treatment for hip extension restriction – http://spxj.nl/2mvwe9y Video: Treatment for hip abduction restriction – http://spxj.nl/2me3269 Video: Treatment for hip internal rotation – http://spxj.nl/2lw3A8L Patient Information Leaflet: Printable Leaflet – http://spxj.nl/2lj4vsR

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BY STUART HINDS DIPHS(RM), SMA The patellar tendon is an anatomical structure that runs from below the patella, to a tuberosity on the tibia. It is designed to straighten the knee during activities such as jumping, running and walking. The tendons connecting the muscles to bone, transmit the forces generated by the muscle on the associated bone(s). In a case where the force becomes excessive, the tenocytes (tendon cells) will be disrupted. The effect of this excessive force on the tenocytes forces them to change their structure, which weakens them and makes them less able to cope with the force imposed on them. This results in pain, and prolonged pain eventually leads to degeneration of the whole tendon.

Patellar Tendinosis versus Patellar Tendinitis Tendon injuries are currently considered to be degenerative conditions rather than being inflammatory in nature. As is the case for patellar tendinosis, they are referred with the term ‘osis’ to mean degeneration rather than ‘itis’ which means inflammation. Patellar tendinitis

describes an inflamed patellar tendon, patellar tendinosis describes a patellar tendon showing signs of degeneration.

Anatomical Review of Patellar Tendon Pain The patellar tendon is a structure that connects the quadriceps muscles, located at the anterior compartment of the thigh, to the tibia. It extends from the below the kneecap, the patellar bone, to insert on the tibial tuberosity. The rectus femoris and the three vasti muscles (vastus medialis, vastus lateralis and the vastus intermedius) join to form one common tendon, the quadriceps tendon, which inserts on the patella. The patella is the largest sesamoid bone in the body. The quadriceps tendon is referred to as the patellar tendon as it extends from the inferior pole of the patella to insert on the tibial tuberosity, this being a distal insertion. Data from radiological and histological studies show that the posterior proximal fibres of this tendon are the ones that are the most vulnerable in this condition. In situations that involve contraction 31

PATELLAR TENDON INJURIES ARE OFTEN DUE TO SOFT-TISSUE RESTRICTIONS THAT CAUSE ALTERED MOVEMENT PATTERNS AT THE LUMBOPELVIC AND HIP LEVEL of the quadriceps muscle, the patellar tendon will be loaded. These activities include jumping, landing or squatting. It is, therefore, not surprising to discover that patellar tendinosis is common in those who participate in activities that involve a lot of jumping and landing, such as playing volleyball or basketball and as a result is often referred to as ‘jumper’s knee’. Poor flexibility of the quadriceps and hamstrings and a raised kneecap (also referred to as ‘patella alta’) may increase the forces that are transmitted through the patellar tendon, which in turn will increase the risk of patellar tendinosis.

PATHOLOGY IN PATELLAR TENDON PAIN In acute tendinitis there is an active inflammatory process, mostly as the aftermath of an injury, which when treated heals in 3 to 6 weeks. Manifestations of chronic patellar tendinopathy take place 6 weeks to 3 months later. There will be various changes such as an absence of inflammatory cells, it will also tend to heal poorly and the quality and arrangement of collagen fibres will be poor and disorganised, respectively. This may result in a decrease in tensile strength. There will also be neovascularisation (increased growth of new blood vessels) particularly in areas that are poorly vascularised. This is quite common in chronic tendinopathies and it is thought to be one of the key causes of pain in patellar tendinosis. The relationship between the two is yet to

be scientifically proven, but one theory implicates the high levels of glutamate, the neurotransmitter.

Causative Factors of Patellar Tendon Pain A high prevalence of this condition is noted in sports that involve high impact ballistic loading of extensors of the knee. The patellar tendon can sustain microtrauma in instances where it is subject to extreme forces, such as in rapid acceleration or deceleration, landing as well as jumping. Changes that are drastic in nature in terms of their frequency or intensity while training can lead to overstraining of the tendon and, thus, injury. Intrinsic factors such as the flexibility and strength of the tendon have also been implicated but the key causes appear to be external factors, such as improper training surface, overuse, inappropriate use of equipment and insufficient footwear.

Signs and Symptoms of Patellar Tendon Pain The first symptom in patellar tendon pain is the perception of pain. This pain is normally located in the region of the patellar tendon. It may feel sharp during physical activity, for instance when running or jumping, and then tone down to a dull ache after some workouts. There will also be swelling and tenderness in and around the region of the patellar tendon. This may result in the knee feeling tight, especially when it is moved in flexion. It is good to evaluate patients presenting with these symptoms in

THE NAT TREATMENT FOR HIP RESTRICTION IS A SOFT-TISSUE THERAPY PROTOCOL DEVELOPED TO UNLOCK THE KEY RESTRICTIONS IN COMMON ALTERED MOVEMENT PATTERN SYNDROMES SEEN IN HIP JOINT DYSFUNCTION 32

order to diagnose them differently. The Kennedy Scale is used to evaluate patients with patellar tendinosis: 1. Phase 1 – pain after an activity 2. Phase 2 – pain at the beginning and after an activity 3. Phase 3 – pain at the beginning, during and after an activity with the performance not being affected 4. Phase 4 – pain at the beginning, during and after an activity with the performance being affected. All stages will have some degree of thickening of the tendon. The pain in the patellar tendon may cause movement in the affected knee in extension to be restricted. It is useful to remember that the examination of a patient should encompass aspects of history of the present illness, the age of the patient as well as their recent growth spurts, the location of the pain and, last but not least, some special tests to be done. The signs of patellar tendon pain in an athlete are: Pain in the area of the tendon The knee feeling frequently tight Pain experienced early in the workout as well as after its completion Presence of some subtle swelling of the tendon. The most striking physical finding is tenderness being elicited at the inferior pole of the patella or alternatively in the main body of the tendon when the knee is in full extension with the quadriceps being relaxed. After a 90° flexion of the knee, which puts the tendon under tension, the tenderness will be markedly reduced and it may disappear completely.

Demographics of Patellar Tendon Pain The condition is common among the tendinopathies affecting skeletally mature athletes. The frequency of this condition is as much as 20% among jumping athletes. Males and females are affected equally for bilateral tendinopathy. However, for instances of unilateral tendinopathy, the male to female ratio is 2:1. Co-Kinetic Journal 2017;72(April):31-35

MASSAGE THERAPY

This condition is specific to athletes, especially those who take part in sports such as basketball, high or long jump as well as volleyball, to name just a few. Jumper’s knee is occasionally diagnosed in soccer players and rare cases have been found in sports that don’t involve jumping, for instance weight lifting and cycling. There are some risk factors that predispose an individual to this condition, such as: Being male Having greater body weight Genu valgum (‘knock knees’) Genu varum (‘bow legs’) Increased Q angle Patella baja (an abnormally low lying patella) Patella alta (an unusually small patella that develops out of and above the joint) An inequality in the limb length The sole biomechanical impairment that has been linked to this condition is poor flexibility of the hamstrings and the quadriceps Volleyball players who naturally have a greater ability to jump high are, unfortunately, at an increased risk of developing patellar tendon pain.

performance in their careers. It is hoped that something is in the offing for the relief of long-term symptoms with a minimally invasive, effective and safe procedure.

A MASSAGE THERAPY TREATMENT STRATEGY FOR TENDON PAIN It is important to note from the outset that soft-tissue treatment should focus on the findings of a physical assessment of the lumbopelvic area, hip, thigh and knee. Also, treatment options might be driven by the activities of the client and differ slightly depending on the predisposing factors of the sport that the individual is involved in, ie. basketball, running, weightlifting, etc. In my experience of treating patients for patellar tendon and lower limb overuse injuries, I have found that their symptoms have been inevitably attributed to a restricted

(a)

Latest Research into Patellar Tendon Pain Recent research into this condition revolves around a technique involving high-volume image-guided injection for recalcitrant patellar tendinopathy (1). The objective of this research was to assess how effective high-volume image-guided injection was in the middle term in patients with recalcitrant patellar tendon pain. This research concluded that the high-volume image-guided injection at the interface of the deep surface of the patellar tendon and the Hoffa body improved the short-term symptoms and function of the knee affected with patellar tendon pain. This procedure is additionally minimally invasive, effective and safe for relieving short-term symptoms in athletes who have patellar tendinosis. Potentially, this treatment will revolutionise the management of shortterm symptoms of patellar tendinosis to allow athletes to have unaffected Co-Kinetic.com

PATELLAR TENDINOSIS DESCRIBES A PATELLAR TENDON SHOWING SIGNS OF DEGENERATION

(b)

Place client in supine position Hip in 90° flexion Knee in 90° flexion Hand placed at the popliteal surface Opposing hand at the medial ankle surface. Take hip into internal rotation Check for passive restriction. Sites of restriction: Tensor fasciae latae Iliopsoas trigger point attachment lesser trochanter Iliacus trigger point Adductor longus/magnus Deep external rotators.

Figure 1: Assess for hip internal rotation restrictions (S. Hinds, 2015)

Video 1: YouTube video ‘Treatment for hip internal rotation’ (Courtesy of YouTube user Stuart Hinds, Premax.co, 2016). http://spxj.nl/2lw3A8L

Place client in supine position Stabilise opposite leg to be tested Pick up test leg at ankle and walk out into abduction and feel for passive restriction. Sites of restriction: Short adductors Long adductors Lateral hip. Figure 2: Assess for abduction restrictions (S. Hinds, 2015)

Video 2: YouTube video ‘Treatment for hip abduction restriction’ (Courtesy of YouTube user Stuart Hinds, Premax.co, 2016). http://spxj.nl/2me3269

(a)

(b)

Place client in prone position Stabilise the hip with hand over the superior margins of the sacroiliac joint Place the other hand underneath the anterior superior knee Knee to be in 90° flexion Slowly extend hip and assess for passive restriction. Sites of restriction: Anterior hip capsule Anterior thigh Thoracolumbar junction Sacroiliac/iliolumbar region.

Figure 3: Assess for hip extension restrictions (S. Hinds, 2015)

Video 3: YouTube video ‘Treatment for hip extension restriction ’ (Courtesy of YouTube user Stuart Hinds, Premax.co, 2016). http://spxj.nl/2mvwe9y

reciprocal inhibition condition leading to altered movement patterns at the lumbopelvic and hip level. I have, over time, developed a technique to identify the key soft-tissue restrictions in the hip. The Niel Asher Technique (NAT) treatment for hip restriction is a unique soft-tissue therapy based protocol developed to aid in unlocking the key restrictions in common altered movement pattern syndromes seen in hip joint dysfunction. It has been derived from the NAT for treating frozen shoulder. Three altered movement patterns have been identified and the treatment protocols are aimed at unlocking these patterns.

The Three Key Restrictions Critical for Correction of Altered Movement Patterns of the Hip 1. Hip internal rotation restrictions Hip internal rotation restrictions can be assessed by taking the hip into passive internal rotation with the hip in 90 degrees of flexion and the knee in 90 of flexion, the objective is to highlight were the restriction maybe felt at the end of range (Fig 1, Video 1). The potential for restriction is highly individualised, as you can see in the illustration there are many sites of restrictions; locating these and then treating the sites of restrictions allows the final phase of restriction to be treated. This process may take several treatments to several sites. 2. Hip abduction restrictions Hip abduction restrictions can be assessed by taking the hip into abduction and assessing the tonicity in either the short, long adductor group or even in the lateral hip; excessive tension in adductor group will indicate possible inhibition of gluteal medius (Fig. 2, Video 2). 3. Hip extension restrictions Hip extension restrictions can be tested for by taking the hip into abduction and assessing the tonicity in either the short or long adductor group or even in the lateral hip; excessive tension in the adductor group will indicate possible inhibition of gluteal medius (Fig. 3, Video 3).

Co-Kinetic Journal 2017;72(April):31-35

MASSAGE THERAPY

PATELLAR TENDINOSIS IS COMMON IN SPORTS INVOLVING A LOT OF JUMPING, HENCE THE NAME ‘JUMPER’S KNEE’

DISCUSSIONS Discuss the anatomy of the patellar tendon and why its function can predispose participants of certain sports to patellar tendinosis. Create a check-list for aiding diagnosis of patellar tendinosis. Discuss the key restrictions in common altered movement patterns of the hip. Why will they cause patellar tendon pain and how can they be treated?

CASE STUDIES Two case studies are available in the online version of this article, detailing diagnosis and treatment of knee pain. References 1. Mafulli N, Del Buono A, Oliva F et al. High-volume image-guided injection for recalcitrant patellar tendinopathy in athletes. Clinical Journal of Sport Medicine 2016;26(1):12–16.

KEY POINTS In patellar tendinosis, pain is usually localised to the patellar tendon below the kneecap. Patellar tendinosis involves degeneration and patellar tendinitis involves inflammation of the patellar tendon. Patellar tendinosis is more common in sports involving jumping, landing and squatting. The Kennedy Scale is used to evaluate patellar tendinosis. All stages of patellar tendinosis involve some thickening of the patellar tendon. Signs of patellar tendinosis are often: patellar tendon pain, knee feels ‘tight’, pain during as well as after a workout, subtle tendon swelling. Patellar tendon pain is usually the result of altered movement patterns at the lumbopelvic and hip level. The NAT treatment for hip restriction is based on unlocking key restrictions in common altered movement pattern syndromes seen in hip joint dysfunction Key restrictions in common altered movement patterns of the hip are: - hip internal rotation restrictions - hip abduction restrictions - hip extension restrictions.

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RELATED CONTENT Patellofemoral Pain Syndrome: Identifying the Primary Driver of Symptoms and Increasing the Likelihood of Successful Rehabilitation [Article] http://spxj.nl/1NeouQC Managing Patellofemoral Pain Syndrome: Proximal Intervention for the Management of PFPS [Article] - http://spxj.nl/1HchrzZ Patellofemoral Pain Syndrome: What can be Predicted? [Article] http://spxj.nl/2mWUaQI All articles relating to the patella http://spxj.nl/2lOeYrD THE AUTHOR Stuart Hinds DipHS(RM), SMA is has a Certificate in Remedial Massage, a Diploma of Health Science (Remedial Massage) and is one of Australia’s leading soft-tissue therapists with Sports Medicine Australia (SMA). He has over 27 years’ of experience working with elite sports athletes, supporting Olympic teams, educating and mentoring others as well as running a highly successful clinic in Australia treating clients from a wide range of disciplines. It was while working in these high performance arenas that Stuart has developed the highly effective and popular high performance hip protocol which looks at unlocking the key soft-tissue restrictions that develop around the hip. Recognised for his expertise, he regularly lectures on remedial soft-tissue techniques and delivers a range of highly sought after seminars across Australia, supported by online videos and webinars and one-on-one mentoring to help support his colleagues to build successful businesses. Stuart has written many articles especially on the subject of trigger point therapy, pelvic imbalances for cyclists and kinesiology taping for soft-tissue dysfunction to name but a few. Email: contact@stuart-hinds.com Website: www.stuart-hinds.com Twitter: https://twitter.com/stuarth67 LinkedIn: https://www.linkedin.com/in/stuart-hinds9a4ab819/ Facebook: https://www.facebook.com/stuarthindscom-524701860978339/

PATELLAR TENDON PAIN:

A MASSAGE THERAPIST’S GAME PLAN CASE STUDIES

The following two case studies demonstrate the process by which you can assess, diagnose and treat your patient’s knee pain. Also it indicates that hip function is of great importance in the overall function of the patella tendon; biomechanically the patellar tendon can be over-loaded because of insufficiency from other surrounding regions, such as the hip.

Patient 1 Presentation L anterior knee pain 36-year-old male middle-distance runner Training phase for upcoming competition. Signs and Symptoms Slow insidious onset of symptoms Pain at supra patellar tendon pain Pain on end of run, post-run aching Mild awareness on bike Symptoms increased over the 3–4 week period Symptoms increased over the last 2/3 weeks Symptoms 3+ at best, to 6–7/10 at worst. Differential Diagnosis Meniscal irritation Myofascial pain Patellar tendon pain Patellofemoral joint syndrome.

Objective Assessment Hip Assessment +ve Hip extension restriction on L (psoas major/minor) +ve Hip abduction restriction on L (adductor magnus) +ve Hip internal rotation on L (TFL/iliacus) Clear lumbar spine/hip movements Clear foot pronation L>R R anterior ilium R +ve prone knee bend tension at EROM 5 +ve Lunge test L 10cm. Rule out Ligament stability tests (knee) Squats, double/single-leg hopping Trelenburg sign standing Muscle resistive tests, thigh and hip. Treatment Clear R hip using NAT treatment for hip restriction (reciprocal inhibition restrictors) Hip extension restriction on L (psoas major/minor)

Hip abduction restriction on L (adductor magnus) Hip internal rotation on L (TFL/iliacus) Soft-tissue therapy (STT)/trigger point to B quadratus lumborum STT/myofascial tension test (MTT) R to TFL/iliacus internal rotation R MTT rectus femoris Vastus lateralis trigger point assessed for one-legged squat R popliteus trigger point for tibial extension Marked improvement by 4/5 days, symptoms 1/10. Refer to Chiropractor for spinal/ lumboplevic structural restriction Gonstead chiropractic approach – adjust S2. Summary Two key soft-tissue restrictors: hip extension/hip abductors. Due to increased training load, intensity Combination of structural restriction/softtissue adaption/endurance fatigue Gluteus medius fatigue overload of subsidiary muscles.

Patient 2 Signs and Symptoms L anterior infrapatellar pain poorly localised with flex/extension. Aggravating factors: climbing/ descending stairs, squatting, sitting for long periods. Patient had increased number of runs from 2× per week to 4× per week, with interval training on 2 of the sessions. Objective Assessment Hip Assessment +ve Hip extension restriction on L (psoas attachment) +ve Hip abduction restriction on L (adductor longus) +ve Hip internal rotation on L (TFL posterior fibres).

35i

Functional tests: bilateral/single-leg squats + Clarke’s sign, patellar squish test + L AROM flexion\extension with anterior pressure applied to kneecap +L muscle resisted test extension with pain\weakness +L prone knee bend for tightness at the rectus femoris distal attachment Pain on palpation L infrapatellar tendon. Hip Treatment +ve Hip extension restriction on L (psoas major/minor) +ve Hip abduction restriction on L (adductor magnus, pectineus, pyramidalis) +ve Hip internal rotation on L (TFL) Vastus lateralis trigger points TFL trigger point

Rectus femoral myofascial tension technique Gluteal medius/minimus trigger point. Summary Three key soft-tissue restrictors: hip extension/ hip abductors and Internal rotation Due to increased training load, intensity, surface change Combination of soft-tissue adaption/endurance fatigue Ongoing patella tracking issues.

Abbreviations Used in the Case Studies Bold text indicates the main restrictions to the hip and treatment indications +ve, positive AROM, active range of motion B, bilateral EROM, end range of motion L, left R, right TFL, tensor fascia lata. Co-Kinetic Journal 2017;72(April):31-35

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Expand your skill set with acupuncture and further career prospects Attract more patients by offering a more complete treatment option Increase your earning potential

Course Dates & Locations HePAG Foundation Course HePAG provide Acupuncture foundation courses for Sports Therapists looking to add an effective and safe modality to their skill set. Acupuncture can be used in conjunction with a full rehabilitation programme, increasing patient choice. By completing our 300 course, you will gain the in-depth understanding and knowledge necessary to safely administer acupuncture. Over three weekends you will be introduced to the underlying concepts of western medical acupuncture, grounded in current research, clinical trials and case studies. Within the course cost, £650, you will also receive one year’s complimentary membership with HePAG worth £195. @_HePAG Website: www.hepag.org.uk

WREXHAM 3rd - 4th June 2017 10th - 11th June 2017 22nd - 23rd July 2017 PETERBOROUGH 5th - 7th June 2017 17th - 19th July 2017 MAIDSTONE 10th - 11th June 2017 1st - 2nd July 2017 19th - 20th August 2017 PETERBOROUGH 2nd - 4th October 2017 4th - 6th December 2017 BELFAST 27th - 29th October 2017 1st - 3rd December 2017

@HePAGacupuncture

Telephone: 01733 646888

Email: info@hepag.org.uk

ACUPUNCTURE IN CLINICAL PRACTICE:

Are Therapists Missing the Point? While the traditions of acupuncture lie in Eastern medicine and form a key component of traditional Chinese medicine (TCM), this practice is not based on scientific knowledge and can present as too ‘sandals and candles’ for many clinicians who secure their clinical reasoning firmly upon anatomy and physiology. This article explains the proposed underlying neurophysiological mechanisms of acupuncture within the path of pain and then goes on to explore the analgesic mechanism of acupuncture. Accredited training is now available for a wide range of allied health professionals including sports therapists and sports rehabilitators which provides new opportunities for therapists with these qualifications. Training opportunities are discussed later in the article. Read this online http://spxj.nl/2lj9zOh INTRODUCTION

BY JONATHAN HOBBS MSC, MCSP FHEA 17-04-COKINETIC FORMATS WEB MOBILE PRINT

MEDIA CONTENTS Patient Information Leaflet: Acupuncture and Dry Needling http://spxj.nl/2lj9zOh

Traditional acupuncture practice has a rich history that embraces the idea of Taoism and the underlying concepts of qi flow, yin and yang and meridian theory that permeate traditional Chinese acupuncture (TCA). Although this valuable alternative perspective on health can offer insights to injury and disease management, its esoteric language can present as too ‘sandals and candles’ for many clinicians who secure their clinical reasoning firmly upon anatomy and physiology. It is worth considering, though, that the concepts of TCA diagnosis and treatment are merely a part of a larger system of ‘observational consensus medicine’. Although the terminology may seem odd, one should be clear on the belief that there is no ‘Chinese physiology’ and ‘Western physiology’ behind the explanation of any approach, there is just ‘physiology’. An understanding of the underlying mechanisms is essential to best understand the use of Western medical acupuncture (WMA), as opposed to

TCA, as a clinical intervention in 2017. To obtain the full benefit of acupuncture as a treatment approach one must then consider the pathology of any given condition under treatment, to clinically reason the use of the modality. This series of articles will first explain the proposed underlying neurophysiological mechanisms of acupuncture and then proceed to explore its use as a clinically reasoned treatment approach.

THE PATH OF PAIN Any soft-tissue injury to the body will trigger a local inflammatory response within the damaged tissues. Inflammation, being the body’s generic response to any form of trauma, is initiated regardless of the nature of the injury. The purpose of the inflammatory response is to eliminate the initial cause of cellular injury and the subsequent removal of damaged tissue and dead cell debris. It also exists to initiate repair of the damaged tissues and promote the healing process. Acute inflammation presents with five

THE CONCEPTS OF TCA DIAGNOSIS AND TREATMENT ARE MERELY A PART OF A LARGER SYSTEM OF ‘OBSERVATIONAL CONSENSUS MEDICINE’ 36

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classical signs: pain, heat, redness, swelling and loss of function. Following an initial insult the injured tissue creates a stimulation of the sensory receptors of small afferent nerve fibres of A delta (Aδ) and C axon size. These first-order neurons ascend to synapse mainly in the superficial dorsal horn of the spinal cord. These first-order neurons enter the spinal cord at the dorsal root entry zone, via the lateral division of the dorsal roots of the spinal nerves. It is here in the dorsal horn that they combine together to form the dorsolateral fasciculus (tract of Lissauer), which is present at all spinal cord levels. The first-order neurons of Aδ fibre type enter lamina I (and V) and synapse primarily with second-order neurons in lamina I and lamina V of the spinal cord grey matter. The first-order neurons of C fibre type enter the spinal cord and synapse with lamina I cells and lamina II interneurons. The branches of the dorsolateral fasciculus then either ascend or descend one to three spinal cord levels within this tract, to terminate in their target laminae of the dorsal horn. It is there that they synapse either with second-order neurons or interneurons. The axons of the second-order neurons pass across the midline of the spinal cord to the contralateral side in the anterior white commissure, forming the spinothalamic tract (STT). The second-order neurons stem from the dorsal horn and from here the pain signal progresses from the dorsal horn along the ascending STT. The STT transmits pain (as well as thermal and crude touch sensations) to the contralateral ventral posterior lateral nucleus of the thalamus. Although the STT ends at the thalamus, as it ascends through the brainstem it also sends collateral connections to the reticular formation. When the STT reaches the thalamus it synapses with a third-order neuron. The third-order neurons are located within the ventral posterior lateral, the ventral posterior inferior and the intralaminar thalamic nuclei. From this level the signal then ascends from the thalamus onward via the fourth-order neurons of the STT to synapse with fourth-order neurons within the cortex. It is here that painful stimulus can be perceived Co-Kinetic.com

at a conscious level. The projections of the fourth-order neurons of the STT can be diffusely spread to the entire cerebral cortex. This tends to support the hypothesis that pain may affect the whole brain and ‘pain centres’ are not necessarily discreetly localised regions but rather a complex systemic network encompassing many neural structures (1). This is an example of one route by which pain may be experienced. If one considers this mechanism as a credible explanation for the transmission of painful stimuli and subsequently evaluates the proposed mechanisms for acupuncture, a cause and effect model for the clinically reasoned use of acupuncture can be implemented.

THE ANALGESIA MECHANISM OF ACUPUNCTURE An acupuncture needle inserted through the skin into the deeper myofascial structures activates the sensory receptor in the underlying muscle. Following initial insertion of the needle an inflammatory response is initiated and causes the release of a variety of chemicals, one such being calcitonin gene-related peptide (CGRP). CGRP is a potent vasodilator and causes a local increase in circulation which may lead to visual observation of the local phenomenon known as ‘weal’ and ‘flare’ which is similar to a histamine response. This response may also cause a sensation of itchiness in some individuals (2). The increase in circulation is also documented in deeper muscular tissues, which is considered to support local tissue healing (3). The insertion of a needle is then often followed by some form of mechanical stimulus. This stimulus often takes the form of rotation of the needle in an alternating clockwise and anticlockwise manner. The response of the connective tissues to this action is termed mechanical transduction and is considered to be a beneficial component of acupuncture (4). The local mechanical stimulus triggers impulses that transmit to the spinal cord type II and III muscle afferent nerves, also known as small diameter myelinated afferents (Aδ). These cells synapse in the spinal cord with those of the anterolateral tract (ALT),

Needling at acupuncture point ST34 on the ‘stomach channel’ (J. Hobbs, 2017)

AN ACUPUNCTURE NEEDLE INSERTED THROUGH THE SKIN INTO THE DEEPER MYOFASCIAL STRUCTURES ACTIVATES THE SENSORY RECEPTOR IN THE UNDERLYING MUSCLE which in turn communicates with three other areas. These areas, or more commonly termed ‘centres’, are the spinal cord, the midbrain and the pituitary–hypothalamic complex. Within the spinal cord, the arriving Aδ stimulus also transmits signals across collateral connections to intermediate endorphinergic cells which inhibit the substantia gelatinosa (SG)-cell activity via the release of the endorphins, enkephalin or dynorphin but not b-endorphin. Spinal cord endorphins cause presynaptic inhibition of C fibres,

Needling at acupuncture point ST36 on the ‘stomach channel’, medial to lateral view (J. Hobbs, 2017)

IMAGING STUDIES HAVE ALSO DEMONSTRATED THAT THE LIMBIC SYSTEM PLAYS AN IMPORTANT ROLE IN ACUPUNCTUREINDUCED ANALGESIA preventing transmission of the pain signals from the C fibres entering the dorsal horn with the STT. Within the spinal cord the enkephalins and dynorphins that are released by intermediate cells block pain signals (1). This proposed mechanism of segmental analgesia is similar to that of Melzack and Wall’s original description, which discussed the collateral inhibition

Needling at acupuncture point ST36 on the ‘stomach channel’, lateral to medial view (J. Hobbs, 2017)

BOX 1: THE HEALTH PROFESSIONS ACUPUNCTURE GROUP (HePAG) The Health Professions Acupuncture Group (HePAG) is the UK’s only professional body specifically for osteopaths, chiropractors and sports therapists practising Western medical acupuncture. As the only UK association for acupuncture dedicated to a variety of allied health professionals, we are delighted to offer training, member benefits and representation to thousands of, so far unrecognised, medical professionals. We aim to represent our members with law makers, the public, the NHS and private health insurers. The HePAG promotes the integration of evidencebased acupuncture into a holistic treatment programme for the benefit of the patient. Acupuncture is a safe treatment when administered by a competent HePAGregistered health professional.

of pain by the release of γ-aminobutyric acid (GABA) as initialled by Ab fibres (5). The Aδ fibres entering the spinal cord also communicate with the midbrain via the ALT. Ascending ALT transmission stimulates cells within the periaqueductal grey (PAG) which release b-endorphin to excite the raphe nucleus located at the lower end of the medulla oblongata, triggering impulses along the dorsolateral tract (DLT) to release monoamines (M) (serotonin and noradrenalin) within the spinal cord. Postsynaptic inhibition is modulated via noradrenalin, whereas C fibres are presynaptically inhibited via serotonin stimulating further release of met-enkephalin. Noradrenalin has an analgesic effect throughout the spinal cord as its release is diffuse and non-specific in location. Either of the two monoamines released are capable of suppressing pain transmission (1). Imaging studies have also demonstrated that the limbic system plays an important role in acupuncture-induced analgesia (6). The ascending stimulus continues to terminate in the pituitary–hypothalamic complex where it triggers the release of adrenocorticotropic hormone (ACTH) and b-endorphin into the circulation in equal measures. ACTH can then travel to the adrenal cortex where cortisol is subsequently released into the blood which produces anti-inflammatory effects (1). If the acupuncture stimulus is particularly strong, analgesia can be facilitated through the mechanism of diffuse noxious inhibitory control (DNIC), where one pain may inhibit another (7).

ACUPUNCTURE MECHANISM AND NEEDLE PLACEMENT When acupuncture is performed in a region close to the site of pain there is a primary utilisation of the segmental circuits operating within the spinal cord while also bringing in cells from the midbrain and pituitary–hypothalamic complex. When needles are placed in distal points much further away from the painful region, they activate the midbrain and pituitary–hypothalamic complex without the benefit of segmental effects (1). Therefore, it may be generalised that local segmental needling usually gives more intensive

analgesia than distal non-segmental needling does because it uses all three centres. Generally, the two kinds of needling (local and distal) are used together on each patient to enhance one another. This is often the case with traditional acupuncture where local and distal points on the same ‘channel’ or ‘meridian’ are used in the treatment of musculoskeletal pain. This then uses the segmental and heterosegmental mechanisms as previously discussed. The segmental approach triggers inhibitory enkephalinergic cells in the spinal grey matter which are directly contacted by the Aδ primary afferents. The heterosegmental effect is brought about by a neurohormonal mechanism involving the release of b-endorphin and by two descending neuronal mechanisms which are serotonergic and adrenergic. There is also considered to be some involvement of DNIC in the overall analgesic effect (2).

BEYOND ANALGESIA Acupuncture has also been shown to induce a phenotypic switch of muscle macrophages. This causes a reduction in pro-inflammatory cells (M1 macrophages) and an increase in anti-inflammatory cells (M2 macrophages and IL-10), which reduces pain, swelling and inflammation in local tissue (8). Wang et al. (9) showed that acupuncture regulates opioid-containing macrophages and anti-nociceptive mediators in inflammatory pain, further supporting the interaction between acupuncture, pain and inflammation that speeds up healing and the recovery processes. Jeong et al. (10) suggested that acupuncture treatment has an inhibitory effect on cytokine production, as the elevated levels recorded in patients suffering from headaches were reduced to those of a healthy control group following acupuncture treatment. Although this research was specifically conducted in patients with chronic headache, it may be possible to apply these results to the general population. Torress-Rosas et al. (11) stated that sciatic nerve activation with electroacupuncture controls systemic inflammation by inducing vagal activation of aromatic L-amino acid decarboxylase, leading to the production of dopamine in the Co-Kinetic Journal 2017;72(April):36-40

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adrenal medulla. This can provide therapeutic advantages such as controlling inflammation in infectious and inflammatory disorders. This new research also goes some way to explain the biomechanical process initiated by electroacupuncture that influences sepsis. Acupuncture is also thought to accelerate the initial inflammatory response to promote the secondary healing responses in injury, and also helps to control systemic inflammation in inflammatory and infectious disorders including sepsis.

COST EFFECTIVE Acupuncture performed by health professionals is a cost-effective way of delivering acupuncture as the only additional cost following training is for the needles. Using the HePAG (Box 1) discount needles can cost as little as approximately ÂŁ0.02 each (ÂŁ2.11 per 100), and little, if any, additional treatment time is needed, meaning that there is either a minimal or no additional cost to the commissioner or service user. Acupuncture also provides an effective, cost-effective and evidence-based service for patients and maintains patient choice. Offering patient choice is a key objective of the UK government; offering acupuncture as part of existing services provides patient choice without any great cost to the NHS.

SAFETY There has been significant research in to the safety of acupuncture. MacPherson et al. (12) made a survey of 34,407 acupuncture treatments, and reported no serious adverse events (ie. ones requiring hospital admission). In total, there were 43 significant minor adverse events (including nausea, fainting, dizziness, vomiting, increased symptoms and bruising). This equates to only 0.12% (1.2 per 1000), which is an extremely low figure even in comparison to other treatments regarded as very safe, such as medication. Figures on serious adverse events associated with acupuncture were published by White (13). This research combined data from the above studies with further reports, Co-Kinetic.com

and included 4,441,103 treatments in total. White reported 11 serious adverse events (13). More common were mild adverse events such as tiredness and bruising, which both occurred in 3% of treatments. Further evidence of the safety of acupuncture has been provided by Xu et al. (14), who stated that four recent surveys of acupuncture safety among regulated, qualified practitioners confirmed that serious adverse events after acupuncture are uncommon. These surveys covered more than 3 million acupuncture treatments in total; there were no deaths or permanent disabilities, and all patients who suffered an adverse event fully recovered. The more common adverse events are exceptionally minor in nature and pose very little risk to the patient. More significant adverse events are extremely rare. HePAG endorses acupuncture as an exceptionally safe treatment, when practised by a HePAG member.

APPLICATION AND TRAINING Research has shown that a range of musculoskeletal and sports injures benefit from acupuncture, including plantar fascial pain, medial tibial stress syndrome, acute and chronic low back pain, patellofemoral pain, shoulder pain, neck pain, headaches and migraine. From a clinically reasoned perspective, however, the potential exists for it to be used for the treatment of any myofascial pain and dysfunction. WMA is a practice that has its philosophies firmly based in anatomy and physiological principles. This means, therefore, that providing a prerequisite knowledge of anatomy and physiology is in place (ie. graduate sports therapist, osteopath, chiropractor, doctor, nurse, physiotherapist, etc.) a foundation level of WMA can be taught as an accelerated protocol over a few months with a little as six contact days. This is the type of acupuncture that is most commonly employed by

LOCAL SEGMENTAL NEEDLING USUALLY GIVES MORE INTENSIVE ANALGESIA THAN DISTAL NON-SEGMENTAL NEEDLING 39

chartered physiotherapists and other manual therapists clinically at all levels, from treating sedentary individuals to elite Olympic athletes. The next article in the series will discuss the clinically reasoned application of WMA for a variety of common musculoskeletal conditions. References 1. Stux G, Hammerschlag R. Clinical acupuncture: scientific basis. Springer 2001. ISBN: 9783540640547 (Print £40.99 Kindle £29.24) Buy from Amazon http://amzn.to/2lLmhp5 2. White A, Cummings M, Filshie J. An Introduction to Western Medical Acupuncture. Churchill Livingstone/Elsevier 2008. ISBN: 978-0443071775(Priint £36.43) Buy from Amazon http://amzn.to/2mQcq0N 3. Sandberg M, Lundeberg T, Lindberg LG, et al. Effects of acupuncture on skin and muscle blood flow in healthy subjects. European Journal of Applied Physiology 2003;90(1–2):114–119 4. Langevin HM, Bouffard NA, Badger GJ et al. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cellular Physiology 2006;207(3):767– 774 5. Melzack R, Wall PD. On the nature of cutaneous sensory mechanisms. Brain 1962;85:331–356 6. Wang SM, Kain ZN, White P. Acupuncture analgesia: I. The scientific basis. Anesthesia and Analgesia 2008;106:602–610

7. Filshie J, White A (eds). Medical acupuncture: a Western scientific approach. Churchill Livingstone 1998. ASIN: B01A0BF64I (Print £118.63). Buy from Amazon http://amzn.to/2lLpRiU 8. Da Silva MD, Bobinski F, Sato KL et al. IL-10 cytokine released from M2 macrophages is crucial for analgesic and anti-inflammatory effects of acupuncture in a model of inflammatory muscle pain. Molecular Neurobiology 2015;51(1):19–31 9. Wang Y, Gehringer R, Mousa SA et al. CXCL10 controls inflammatory pain via opioid peptide-containing macrophages in electroacupuncture. PLOS One 2014;9(4):e94696 10. Jeong HJ, Hong SH, Nam YC et al. The effect of acupuncture on proinflammatory cytokine production in patients with chronic headache: a preliminary report. American Journal of Chinese Medicine 2003;31(6):945–954 11. Torres-Rosas R, Yehia G, Pena G et al. Dopamine mediates vagal modulation of the immune system by electroacupuncture. Nature Medicine 2014;20(3):291–295 12. MacPherson H, Thomas K, Walters S, et al. A prospective survey of adverse events and treatment reactions following 34 000 consultations with professional acupuncturists. Acupuncture in Medicine 2001;19(2):93–102 13. White A. The safety of acupuncture – evidence from the UK. Acupuncture in Medicine 2006;24(Suppl):S53–57 14. Xu S, Wang L, Cooper E et al. Adverse events of acupuncture: a systematic review of case reports. Evidence-Based Complementary and Alternative Medicine 2013;2013:581203.

RELATED CONTENT Dry Needling [Article] - https://co-kinetic.com/content/dry-needling Acupuncture & Dry Needling: [Patient Information Leaflet] – http://spxj.nl/2lj9zOh

KEY POINTS Acupuncture initiates a variety of physiological responses that can affect pain, inflammation, healing and recovery. Acupuncture analgesia has three main mechanisms: local, segmental and supraspinal. The application of acupuncture is related to anatomical structures and local and central physiological responses. Evidence demonstrates that acupuncture can be an effective treatment for a number of myofascial pain conditions. Research shows acupuncture is a safe treatment. Cost analysis demonstrates acupuncture to be a cost-effective intervention. To obtain the full benefit of acupuncture, one must consider the pathology of the condition under treatment. Acupuncture triggers a vasodilatory response, increasing local circulation, which is thought to support local tissue healing.

THE AUTHOR Jonathan Hobbs MSc, MCSP FHEA graduated in 1999 achieving a first class BSc in physiotherapy and began his acupuncture training in 2000. In 2003 he became an advanced member of the Acupuncture Association of Chartered Physiotherapists (AACP) and in 2004 he was awarded an MSc in acupuncture. Since graduating he has worked in a variety of roles within the NHS, private sector and professional sport. Jonathan is a Fellow of the Higher Education Academy (FHEA), an accredited Health Professions Acupuncture Group (HePAG) tutor and Director of HePAG. He delivers acupuncture foundation courses and CPD within the private sector and NHS and has also had his work published in the Journal of Chinese Medicine. He has previously been an MSc award leader at Staffordshire University, is currently the external assessor for Glyndwr University’s acupuncture BSc and also acts as consultant and sessional lecturer to a number of universities throughout the UK including Keele University School of Medicine. He is also a consultant to physiotherapists in Team GB, the FA and a number of Premiership football and rugby clubs. Email: info@hepag.org.uk Twitter: @_HePAG LinkedIn: Health Professions Acupuncture Group https://www.linkedin.com/company-beta/16174335 Facebook: Health Professions Acupuncture Group https://www.facebook.com/HePAGacupuncture/

DISCUSSIONS What are the three main mechanisms of acupuncture analgesia? What different processes are activated through local and distal needling? Other than pain relief, what additional symptoms and/or conditions has acupuncture been shown to benefit?

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Spinal cord endorphins prevent pain signals from the C fibres entering the dorsal horn http://spxj.nl/2lj9zOh Tweet this: Local segmental acupuncture usually gives better analgesia than distal non-segmental needling http://spxj.nl/2lj9zOh Tweet this: Research suggests that acupuncture has an inhibitory effect on cytokine production http://spxj.nl/2lj9zOh Tweet this: Acupuncture offers patient choice without any great cost to the NHS http://spxj.nl/2lj9zOh Tweet this: Acupuncture is an exceptionally safe treatment when practised by a HePAG member http://spxj.nl/2lj9zOh

Co-Kinetic Journal 2017;72(April):36-40

EVENT WATCH Elevate 2017 to explore the role of sport science in shaping the physical activity agenda Elevate, 10-11 May at ExCeL London will offer attendees the chance to enjoy a free-to-attend seminar programme with a focus on the benefits of crosssector collaboration between physical activity and healthcare professionals. Over 200 expert speakers from the areas of fitness, policy, academia, human performance, health care and local government will share ideas and the latest innovations proven to get people more active.

Encouraging physiotherapists to work collaboratively with fitness industry professionals – Anna Lowe, PHE, Physical Activity Champion at Sheffield Hallam University will chair a panel featuring speakers from Doncaster and Bassetlaw Hospitals NHS Foundation Trust and the Pennine Acute Hospitals NHS Trust. The discussion, will explore the projects, services and best practice to demonstrate how physiotherapists can work collaboratively with fitness industry

explain how advances in the sporting arena can impact everyday life and consumer trends. Speaker organisations including British Cycling, Loughborough University, Team GB and Lucozade Ribena Suntory among others, will explore what we can learn from developments driven by the demands of competition in elite sport, by uncovering research and translating it through examples of advances in science and technology.

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Health promoters, both government and corporate, now have a wide array of benefits to promote physical activity, but getting it to be part of the normal conversation still needs to be improved. We need to explore how the physical activity sector can successfully collaborate with brands to deliver effective, responsible and well targeted programmes to support increased participation. Dr Joe Piggin, Programme Director at Loughborough University

professionals to ensure patients receive the right support, at the right time and manage their needs effectively. The seminar will also provide practical advice on how to remove barriers associated with becoming more active for people with limited mobility, long term conditions and co-morbidities. Highlighting the latest developments in human performance – The Future Performance stream, supported by the English Institute of Sport (EIS) and sponsored by Matrix, will

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Exploring the impact musculoskeletal conditions can have upon carrying out everyday activities - leading experts from Arthritis and Musculoskeletal Alliance, GSK Human Performance Lab, Teeside University, Arthritis Research UK and HUR Health and Fitness will examine the benefits of physical activity for improving musculoskeletal health at every stage of life, exploring the merits for back pain, arthritis, fall prevention and improved quality of life.

The two-day event is supported by Physios in Sport, ISEH, Public Health England, CIMSPA, ukactive and London Sport amongst others. Exhibitors demonstrating their latest equipment, solutions and products aimed at addressing the complex array of challenges associated with physical inactivity include PhysioLab, Cosmed, Cranlea Human Performance, eGym, BodyStat Limited and Firstbeat Technologies. See the full programme and register for your free pass to attend www.elevatearena.com

MANUAL THERAPY STUDENT HANDBOOK

Assessment and treatment of the shoulder This article is the eighth from our Manual Therapy Student Handbook (see the ‘Contents panel’ for further details) and it describes how to assess and treat common shoulder 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/23Nn5qG SHOULDER | 17-04-COKINETIC FORMATS WEB MOBILE PRINT

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

2. Initial observation

Face and posture and gait

3. History

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

4. Inspection

Bony deformity Colour changes Wasting Swelling

5. Objective examination

MEDIA CONTENTS Videos 1-13: Techniques for shoulder assessment. J. Hatcher, 2013

BY JULIAN HATCHER GRAD DIP PHYS MPHIL, MCSP FOM

6. Active tests (for willingness)

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

Lateral rotation Abduction Medial rotation

8. Resisted tests (for pain and power

Assessment of the shoulder

For a full assessment of the shoulder, the therapist must be familiar with the anatomy of the area and perform the observations and examinations detailed in Table 1 and Video 2.

DETAILS

9. Additional specific tests

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

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Treatment of the shoulder CAPSULAR PATTERN The capsular pattern of movement limitation at the shoulder is defined by: Most loss of lateral rotation Next, loss of abduction Least loss of medial rotation.

Co-Kinetic.com

TREATMENT Warm the capsule using appropriate electrotherapy and use Grade B (Maitland Grade III and IV) mobilisation and selfhelp exercises to end of range.

Rheumatoid arthritis (RA) and other systemic arthropathies

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

Refer to GP for Rheumatology opinion. If not in acute flare-up, may use Grade A (Maitland Grade I and II) mobilisations and progress to Grade B (III and IV).

Traumatic arthritis (TA)

Trauma often not remembered. Slow onset in the over 40s, time varies. Pain may be severe enough to radiate beyond elbow, and have night pain/difficulty lying on shoulder..

May require mobilisation as pain allows, Grade A–B (I–IV). May require injection, electrotherapy and Grade A and B mobilisations.

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

Video 2: Assessment of the shoulder region (Video with captions but no sound; J. Hatcher, 2013)

Video 3: Mobilisation of the shoulder: lateral rotation (in abduction) (Video with captions but no sound; J. Hatcher, 2013)

Video 4: Mobilisation of the shoulder: abduction (Video with captions but no sound; J. Hatcher, 2013)

THE BEST TREATMENT FOR BURSITIS AT THE SHOULDER IS INJECTION – DEEP TRANSVERSE FRICTIONS USUALLY MAKE IT WORSE! Medial rotation mobilisation (Video 5) Directions: 1. Again stand at the side of a supine patient. 2. Specifically place cephalad hand around inner aspect of upper arm, fully supporting the weight and slightly abducting the shoulder to allow the elbow to flex. 3. By gently grasping the distal aspect of the forearm just below the wrist, take the forearm in a direction towards your caudad hip, causing the humerus to rotate medially. 4. Again, grade according to assessment. Anterior–posterior (AP) mobilisation (Video 6) Directions: 1. Stand at side of bed with patient lying supine. 2. Gently grasp inner hand around superior aspect of shoulder girdle, and place outer hand over the anterior aspect of the humeral head. 3. Using heel of hand, gently push the humeral head posteriorly using your body weight for pressure while maintaining and stabilising the shoulder girdle with the opposite hand. 4. Grade according to assessment findings. Video 5: Mobilisation of the shoulder: medial rotation (in abduction) (Video with captions but no sound; J. Hatcher, 2013)

Longitudinal mobilisation (in neutral) (Video 7) Directions: 1. Again stand at side of bed with patient lying supine. 2. Place cephalad hand around superior aspect of humeral head, the caudad hand is placed around the anterior aspect of the elbow using your forearm and body to support the patient’s forearm. 3. Gently pull using a shift of your body weight from the cephalad foot to the caudad foot, maintaining pressure from both hands. 4. Grade according to assessment findings. Longitudinal mobilisation (in abduction) (Video 8) Directions: 1. Similar standing position as above at side of bed with patient lying supine. 2. Place cephalad hand around superior aspect of humeral head, the caudad hand is placed around the anterior aspect of the elbow using your forearm and body to support the patient’s forearm, and taking the upper arm into the limit of available shoulder abduction. 3. Again, by gently shifting your body weight from the cephalad foot to the caudad foot, while maintaining a longitudinal pressure from the cephalad hand, push the humeral head in a direction toward the patient’s feet. 4. Grade according to assessment findings.

side of bed with patient lying supine. 2. Place cephalad hand around superior aspect of humeral head, the caudad hand is placed around the anterior aspect of the elbow using your forearm and body to support the patient’s forearm, and taking the upper arm into the limit of available shoulder flexion. 3. Again, by gently shifting your body weight from the cephalad foot to the caudad foot, while maintaining a longitudinal pressure from the cephalad hand, push the humeral head in a direction toward the patient’s feet. 4. Again, grade according to assessment findings.

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

CAUSES OF NON-CAPSULAR PATTERN Common causes of non-capsular patterns movement limitations in the shoulder are: acromioclavicular (AC) joint injury and bursitis.

Acromioclavicular joint injury (Video 10)

Longitudinal mobilisation (in flexion) (Video 9) Directions: 1. Similar standing position as above at

The key clinical features are: Often traumatic injury Pain localised and at end of range of movements, including ‘scarf test’ Pain often over shoulder ‘epaulettes’, C4 dermatome May have difficulty lying on shoulder if irritable Often helped by mobilisations such as AP or PA applied to distal end of clavicle with patient lying supine Sternoclavicular (SC) mobilisation may help as movement at the SC and AC

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

Video 7: Mobilisation of the shoulder: longitudinal caudad (in neutral) (Video with captions but no sound; J. Hatcher, 2013)

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Video 8: Mobilisation of the shoulder: longitudinal caudad (in abduction) (Video with captions but no sound; J. Hatcher, 2013)

joints occur simultaneously.

Bursitis The key clinical features are: Often traumatic injury Subacromial or subscapular, may be acute or chronic Often displays wide range of signs and symptoms May radiate down arm Tests often prove to be confusing and inconclusive Need to differentiate between subacromial bursitis and supraspinatus tendinitis, and subscapular bursitis and AC joint injury Treatment best used is injection; may try electrotherapy – deep transverse frictions usually make it worse!

Video 9: Mobilisation of the shoulder: longitudinal caudad (in flexion) (Video with captions but no sound; J. Hatcher, 2013)

not be remembered May show painful arc Pain on resisted abduction In elderly may be spontaneous rupture or very little trauma which may require surgery. Treatment choice Deep transverse frictions to supraspinatus tendon.

The key clinical features are: Often traumatic, although trauma may

Deep transverse frictions to supraspinatus (Video 11) Directions: 1. Have patient semi-recumbent on bed, with bed reasonably low. 2. Place patient’s affected shoulder into full medial rotation and adduction, by placing arm behind their back. Support around with pillows. 3. Locate valley between the bony points (anterior aspect of acromion process and superior aspect of greater tuberosity). 4. Place index finger of caudad hand directly over site of lesion. 5. Reinforce using index finger of same hand. 6. Place thumb over insertion of deltoid and apply transverse frictional massage,

Video 11: Deep transverse frictions to the supraspinatus tendon (Video with captions but no sound; J. Hatcher, 2013)

Video 12: Deep transverse frictions to the infraspinatus tendon (Video with captions but no sound; J. Hatcher, 2013)

CONTRACTILE LESIONS Common contractile lesions of the shoulder include: supraspinatus tendinitis, infraspinatus tendinitis and subscapularis tendinitis.

Supraspinatus tendinitis

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Video 10: Mobilisations of the shoulder: Accessory glides to the AC joint (Video with captions but no sound; J. Hatcher, 2013)

using influence of body weight rather than arm or hand movements.

Infraspinatus tendinitis The key clinical features are: Often traumatic, although trauma may not be remembered May show painful arc Pain on resisted lateral rotation, and possibly some pain on abduction also Need to differentiate between infraspinatus, supraspinatus and subacromial bursitis. Treatment choice Deep transverse frictions to infraspinatus tendon. Deep transverse frictions to infraspinatus (Video 12) Directions: 1. Have patient prone lying on low bed. 2. Place patient’s affected shoulder into flexion, lateral rotation and adduction, by propping up onto both elbows, reaching out for lateral edge of bed and leaning over affected limb. 3. Locate the bony points (acromial angle and middle facet of greater tuberosity). 4. Place index finger of cephalad hand Video 13: Deep transverse frictions to the subscapularis tendon (Video with captions but no sound; J. Hatcher, 2013)

directly over site of lesion. 5. Reinforce using index finger of same hand. 6. Place thumb over antero-superior aspect of shoulder and apply transverse frictional massage, using influence of bodyweight rather than arm or hand movements.

Subscapularis tendinitis The key clinical features are: Often traumatic, although trauma may not be remembered No painful arc normally Pain on resisted medial rotation May also have pain on ‘scarf’ test, and therefore need to differentiate between subscapularis and AC joint injury. Treatment choice Deep transverse frictions to subscapularis tendon. Deep transverse frictions to subscapularis (Video 13) Directions: 1. Have patient long sitting on bed, with bed medium low. 2. Place patient’s affected shoulder

into anatomical position using forearm. Hold this position using your caudad hand. 3. Locate the lesser tuberosity and place index finger of cephalad hand directly over site of lesion. 4. Reinforce using index finger of same hand. 5. Place thumb over posterior aspect of shoulder apply transverse massage.

FURTHER RESOURCES 1. Mayo Clinic Staff. Rotator cuff injury (http://spxj.nl/2nl1nKo). Mayo Clinic, Rochester MN, USA. 2. Dionysian E. Idiopathic frozen shoulder syndrome

RECOMMENDED READING Owing to space limitations in the print version, the recommended reading list that accompanies this article is available at the following link and are also appended to the end of the article in the web and mobile versions. Click here to access the recommended reading list http://spxj.nl/23Nn5qG.

KEY POINTS The therapist must be familiar with the anatomy of the area in order to perform a full assessment. The capsular pattern of movement limitation at the shoulder is defined by: most loss of lateral rotation; next, loss of abduction; least loss of medial rotation. Causes of capsular pattern at the shoulder are often osteoarthritis, rheumatoid arthritis and other systemic arthropathies, as well as traumatic arthritis. The treatment for capsular pattern is mobilisations of the shoulder. Common causes of non-capsular patterns movement limitations in the shoulder are acromioclavicular (AC) joint injury and bursitis. Common contractile lesions of the shoulder include supraspinatus tendinitis, infraspinatus tendinitis and subscapularis tendinitis.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Common causes of non-capsular patterns movement limitations in the shoulder are AC joint injury and bursitis. http://spxj.nl/23Nn5qG Tweet this: The best treatment for bursitis at the shoulder is injection – DTF usually makes it worse. http://spxj.nl/23Nn5qG Tweet this: Common contractile lesions of the shoulder include supraspinatus, infraspinatus and subscapularis tendinitis. http://spxj.nl/23Nn5qG

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

DISCUSSIONS Why are active tests performed in the shoulder and not in the other peripheral joint assessments? What is the greatest functional loss of movement in people with stiff shoulders? Why is lateral rotation the most important movement to regain? Shoulder impingement is not a diagnosis in itself, but may be the result of many factors; what are those possible factors?

RELATED CONTENT Other Co-Kinetic content for students http://spxj.nl/1QXQkOx

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 Journal 2017;72(April):42-46

MANUAL THERAPY STUDENT HANDBOOK

MANUAL THERAPY STUDENT HANDBOOK Assessment and treatment of the shoulder RECOMMENDED READING 1. Anderson MK, Parr GP. Fundamentals of Sports Injury Management. Lippincott, Williams & Wilkins 2011. 2011 ISBN 978-1451109764 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 (£22.58). 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 (£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 £54.99). 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 £42.92 Print £45.18). Buy from Amazon http://amzn.to/1mwomR2 6. Magee DJ. Orthopaedic physical assessment, 6th ed. Saunders 2014. ISBN 978-1455709779 Kindle £51.35 Print £61.77). 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 978-0702040665 (£46.55 Print £57.79). View on Amazon 2013 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 978-0702040672 (Kindle £45.55 Print £56.99). Buy from 2013 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 (£570.24). Buy from Amazon http://amzn.to/1KfpnbK.

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ENTREPRENEUR THERAPIST

HOW TO GET MORE CLIENTS WITHOUT BEING SALESY 17-01-COKINETIC FORMATS WEB MOBILE

BY TOR DAVIES, CO-KINETIC FOUNDER

INTRODUCTION During the second half of 2016 we surveyed just under 1,000 physical therapists (946 to be exact) and this is what stood out from that survey: 93.2% wanted to increase your number of new customers 76.4% wanted help with marketing to grow your business 74.5% wanted help understanding how to use social media to grow your business 70.6% wanted help developing your business brand 39.2% wanted to sell more to existing customers.

EVERY PHYSICAL THERAPIST WANTS MORE CLIENTS If we want (and need) more clients, let’s just go and get them. Thanks to the stratospheric growth of the internet and the ‘cloud’ we have access to some amazing “software as a service” platforms at incredibly affordable prices to help us run our businesses, promote our services and communicate with our clients infinitely more easily than ever before. The explosion of marketing opportunities resulting from a whole range of social networks means we can get access to prospective clients without spending a dime in most cases. So what’s stopping us getting new clients? We asked, “What is the single one thing you feel is holding you back the most”? The following three answers cropped up in 96% of the responses:

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We spoke to a lot of people in 2016 and it has become clear that as a profession it’s getting harder and harder to build a successful business. There’s a lot of competition to find new clients and there’s so much marketing noise out there already that it’s getting more and more difficult to promote yourself effectively without professional help. Plus as a profession we clearly hate selling ourselves. In this article we show you a way of doing this without ever feeling that you’re selling yourself or your business. We explain how to do it and why it can be so effective at increasing traffic to your website, growing your social media following, building your authority and credibility, expanding your marketing reach, finding new customers and strengthening your relationship with your existing customers. Plus there’s an opportunity at the end of the article to have your digital presence analysed by a marketing professional and in return receive a custom report of the top 5 digital things you do could now that would give you the greatest benefits with the least amount of effort (see Useful Links). Read this online http://spxj.nl/2m53ViT Lack of time Lack of marketing knowledge Lack of confidence in selling yourself And just to make matters worse: With the explosion of alternative physical therapy-orientated degrees, there are now many more practitioners with competing skills, vying for the same pool of customers that you’re after The number of businesses which fail within 5 years is getting higher rather than lower There’s so much noise everywhere that it takes an increasing effort or more ingenuity to capture people’s attention There are estimated to be more than 100 million websites live on the

internet today 2.9 billion Google searches are made every day And 2.7 million blog posts are published every day There are seemingly hundreds of marketing gurus to help you but how do you know who to trust? And worst of all (for our businesses at least) as a professional group most of us would probably prefer to stab needles in our own eyes than to actually have to sell or promote ourselves! So unless you’re lucky enough to have a reputation that precedes you, you know you have to do something. But where do you start? There are so many resources online but how do

you know what the most effective thing is that you can do? And if you can figure that bit out, how do you actually make it happen, especially if technology isn’t really your thing? How do you decide what to focus on or exactly what you want to achieve with your marketing efforts and how on earth do you stand out among all this noise? Time is precious and you want to use what little time you have, in the most effective way possible doing the things that will bring the greatest return on investment. If you run a good business, you’ll also want to be able to measure the return on the investment of your marketing efforts and you’ll want a plan so you can tweak and refine what you’re doing to get even better results. How do we achieve that Nirvana of finding the 20% of effort you need to put in, to get 80% of the results? And how do you do all that without feeling like you’re selling?

THE SOLUTION The team at Co-Kinetic put their heads together with some marketing consultants and came up with a list of things you could do to get more clients including: 1. Bring more visitors to your website 2. Open new lines of communication by growing your social network followers 3. Expand your marketing reach by building your email list 4. Develop loyalty and trust with your current customers 5. Build authority and credibility in your industry 6. Increase the visibility of your brand locally 7. Develop lasting relationships with your clients 8. Strengthen relationships Tr aining with existing and new For a Mar a thon? customers by providing value with no strings attached.

WE CAN HELP

RUGBY HURTS:

BLOOD CLOTS

T RUGBY INJURIES

RCH TELLS US ABOU

WHAT THE RESEA

near we’ve put Championship draws RBS 6 Nations Rugby get you in the mood. As the start of 2017 rugby injuries to help and figures about together a few facts for injury during makes it a war zone act sport, and therefore 1 in 4 players will receive an injury Rugby is a full-cont In an average season, matches. As the average player more the course of a match. 1 or happen during out of the game for half of all injuries which puts them per match and nearly therapists and performs 20-40 tackles why it’s a key topic among physical to see the tackle, it’s easy ers. sports medicine practition

r most with injuries?

Which rugby players suffe

year study According to a three players of injuries affecting clubs in in the top 14 rugby and 2015, France between 2012 and one RUGBY the front row (2 props of the WHEN ARE LY 26% MOST LIKE hooker) account for INJURIES with the hooker injuries total The TO HAPPEN? being the worst affected. No 2 player wearing the According to the research blood, shirt suffers more nearly half of all injuries knee and tackles neck in face, were sustained other the player injuries than any (46.6 per cent) and in position, and is second being tackled accounted and of them. the list of concussion for nearly a third injuries. belief, shoulder Contrary to popular After the hooker, the scrum only accounted fair injuries. the props take their for 2.4 per cent of with share of beatings 1 shirt) during the loosehead (No More injuries occur in incurring more shoulder matches (57%) than other often in injuries than any training, and more the game. position and the tightthe second half of heads

lower leg injuries. and In fact, the front-row up 43% of all half-backs made Fly-halves injury substitutions. s than suffer more concussion and scrumany other position shoulder halves suffering more (with the and knee injuries . front-row) the of exception the On a positive note, incidence of concussion three didn’t change in the 36 and seasons, with between season, 38 concussions per cases two of an average addition each weekend. In injuries the number of blood face dropped by 22%, and injuries fell by 27%. However elbow injuries ly (133%) increased dramatical soared by and hand injuries seasons. 250% over the three d.com

highest (No. 3 shirt) ranking charts. in the ankle injury the Interestingly, while second loosehead props were in suffering only to the hooker injuries, neck and shoulder less in the tightheads suffered more with but categories those

Source:Rugbyworl

WHAT ARE THE MOST COMMON RUGBY INJURIES?

HOW CAN RUGBY NTED? INJURIES BE PREVE balanced

a Make sure to perform programme and structured training flexibility and which involves strength, proprioceptive and endurance, including neuromuscular training when tackling, rucking Correct technique particularly important and scrumming is fitted mouth guard Use a quality, properly that is consistent Participate at a level happen more with your ability. Injuries and players of teams frequently between unequal ability. for the formation of Adhering to the rules the scrum professional Ask your sports medicine questions or injury about any training

Over 40% of injuries are muscular strains or contusions (bruising) 30% are sprains (sprained ankles represent nearly 1 in 7 rugby injuries) Between 5-25% of rugby injuries are head injuries, including concussions

DID

? YOU KNOW

4th Feb 2017 RBS 6 Nations starts took place between The first rugby game (Scotland won!) Scotland and England. no value but allowed Originally a try had to “try” a kick at goal. the attacking team a try into a goal, If successful it converted hence the name. to because they used Rugby balls are oval pig bladders. be made using inflated sport of 3 countries; Rugby is the national r and New Zealand. Wales, Madagasca

IF NOT, WE CAN HELP. CALL US TODAY.

(which represent 44% of all head injuries) In youth aged 10-18 years, 35% of injuries are fractures, of which 24% involve the clavicle. Other injuries include cauliflower ears, dislocations, cuts, scratches and friction burns,

at the opening match The whistle used for the one used by Welsh every World Cup is an England-New referee Gil Evans for Zealand match in 1905. a national anthem The notion of singing originated at a before a sporting event

rugby match. for the highest scoring The current record between the All game ever is the match the 1995 World Cup Blacks and Japan in Japan 145 to 17). (the All Blacks beat

TENDONS REPA IR

And we had to find a way of doing this that never made you feel like you were being salesy! So how can all that be achieved? The answer is surprisingly simple, content marketing. There are lots of definitions of content marketing (you can find some here http://spxj.nl/2m5g5bC) but it’s basically summed up as follows: “Content marketing is focused on creating and distributing valuable, relevant, and consistent content to attract and retain a clearly-defined audience — and, ultimately, to drive profitable customer action. Instead of pitching your products or services, you are providing truly relevant and useful content to your prospects and customers to help them solve their issues.”

INTRODUCING THE CO-KINETIC MARKETING RESOURCES FOR THERAPISTS We set out to: 1. Write valuable, relevant and high quality content 2. Create the material itself for you in the form of articles for your website, email newsletters, social media posts and videos (we’ve even added printable resources including posters, leaflets and postcards for local use) 3. Make it as easy as we could for you to implement. We concentrated on outputs that could most quickly and effectively help you to achieve the following: Build your professional reputation Draw people to you both locally and online AND prompt people to take an action Increase the visibility of you and your brand Give you ways to “wow” your customers.

1IN 1C0AN HELP RUNNERS CES EXPERIEN

EVERY

ASK US FOR DETAILS

HEEL PAIN

Writing valuable, relevant and high quality content We base our content around topical, newsworthy subjects or events taking place in the sporting calendar, as so many of you work with musculoskeletal issues. So far we’ve written content marketing kits for Heel Pain, Rugby Hurts (to coincide with RBS 6 Nations), and Marathon Madness (to coincide with the London Marathon). We’re currently working on content to coincide with the Tour de France Cycling and Wimbledon Tennis. We’ve also created more generic sales-orientated kits around seasonal events such as “Give the Gift of Massage” (Christmas) and “A Gift for the Body From the Heart” (Valentine’s); as well as general all-season marketing campaigns such as Refer a Friend; Customer Feedback and Customer Loyalty Campaigns. For an easy overview of all the campaign material we’ve developed so far in just 4 months since we launched this new initiative go to this link http://spxj.nl/2nIU5zN

The Marketing Kit contents 15+ social media posts - this includes images and text optimised for the six biggest social networks 1 x professionally-designed newsletter or patient handout 1 x email newsletter - prewritten with images and text provided Posters* (A3+A4 sizes) with and without an area for your contact details so you can either use them in your own clinic or add your details and post them in other local areas or complimentary businesses A5 leaflet and A6 postcard* which you can print out and distribute locally. The reverse side of the leaflet is blank for you to add details specific to you. 4 x videos - video is currently the content-king for a whole range of reasons which we’ve talked more about on the next page. * Provided in formats optimised for your own home/office printer as well as for professional printing.

Making it easy to implement Every kit comes with step-by-step implementation instructions and links to Co-Kinetic Journal 2017;72(April):47-49

ENTREPRENEUR THERAPIST

articles and videos that help you make it happen.

SO HOW IS THIS GOING TO HELP YOU? Videos rock the internet right now Google, Facebook and YouTube (which Google owns) are the three biggest websites in the world, and they are in a war to get our attention which means 2017 is turning out to be the year of video. There’s a great article in the further reading section on this topic but in a nutshell, because Google and Facebook are so driven to dominate web traffic they’re both pushing video VERY HARD. Which is why if you feature video on your social networks and website, it’s an instant ticket to A LOT more traffic than you would get without featuring video, not to mention all the other benefits video offers. Which is why every kit we create includes at least four videos (one per week) that you can feature anywhere you like, such as your website, blog or social networks.

Featuring good quality content on your website Offering good quality, relevant, topical content has a multitude of benefits, here’s just a few of them: People are more likely to find your site because Google loves and rewards good content It encourages people to spend more time on your site which helps build brand awareness and trust in your authority It offers value and helps them solve their issues which again increases their trust in you In internet terms, it increases your perceived expertise, authority and relevance which gives you a higher ‘domain authority’ which in turn increases the chances of people finding you on Google People will link to your content which again means more people will visit your site Once people are on your site you can add a ‘call to action’ such as offering a download of a newsletter or patient leaflet in exchange for their email address. This then helps to grow your marketing opportunities. Co-Kinetic.com

Growing your social networks There’s a lot of hype around just how useful building your social networks actually is, however the following points are pretty difficult to argue against: It gives you access to HUGE audiences of people It helps you establish authority and expertise Increases your own website traffic by linking back to your site for more information, which in turn helps your search ranking and generates more leads Builds relationships and develops trust with existing clients Expands your target audience especially new prospective clients Develops brand awareness You can use it to link up with other local businesses with complimentary offers It can be a very cost-effective way of marketing if done well You have a ready-made audience for running special promotions.

CONCLUSION The real beauty of content marketing for us as a professional group in particular, with our particular phobia about self promotion, is that you’re not having to do any selling. You’re simply offering value or as the definition said: “instead of pitching your products or services, you are providing truly relevant and useful content to your prospects and customers to help them solve their issues.” In return you’re boosting your website profile, increasing visitors to your site, making yourself more “findable” through the search engines, building your reputation and authority, strengthening your relationships with your existing clients and helping people. So if there is one single marketing approach we can adopt, this one by far offers the greatest benefits, for the least amount of effort and by using our marketing kits, for an extremely low monthly subscription fee. Happy Campaigning :)

WHAT’S NEXT? If you’re not already making use of our Business Growth Marketing Kits for Therapists hopefully this explains just how they can be used. They’re included as part of the Full Site

Subscription, so if you already have a full site subscription, it doesn’t cost anything extra and you’re good to go. Just go to the Marketing section of the Co-Kinetic site to find the kit you want to use http://spxj.nl/2mwg8sq.. If you don’t already have a full site subscription you can either subscribe for just £49 a month (see link below), or you can buy each kit individually to fit your needs. If each marketing kit brings in just one extra client a month, you’ve covered your costs, anything extra is a bonus.

USEFUL LINKS MindMap showing all the Co-Kinetic Marketing Campaign Resources http://spxj.nl/2nIU5zN More About the Marketing Campaign Kits http://spxj.nl/2mwwama Video Showing How to Access and Use the Marketing Campaign Kits http://spxj.nl/2nryOOP Subscribe to our Full Site Subscription Including the Marketing Campaign Kits http://spxj.nl/2mSV1nr Tell Me the 5 Top Things I can do now to increase my marketing prescence online http://spxj.nl/2mHxwKN

FURTHER READING 10 Content Marketing Benefits, Challenges and Tips http://spxj.nl/2mxWPj7 50 Marketers Define Content Marketing http://spxj.nl/2m5g5bC 8 Powerful Reasons You Need to Use Video Marketing http://spxj.nl/2mwucC8

THE AUTHOR Tor began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham whilst also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London marketing agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences.

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.

THE BEST OF FACEBOOK @evidencedbasedexerciseandtherapy

Until now it is unknown to what extent malpositioning of the scapula is a relevant factor in shoulder instability that should be considered in therapy. The objective of Von Eisenhart-Rothe et al. (2005) study was to analyse 3D-scapular kinematics and humeral head (de-)centering in patients with atraumatic and/ or traumatic shoulder instability and to investigate the correlation between the two factors. http://spxj.nl/2lgGLpv

@AdamMeakins

What do you tell your patients? #Physio http://spxj.nl/2lxxDIf

@tendinopathyrehab

Just load it! (a guest blog by Erik Meira) http://ow.ly/kkvQ3098RuM #tendinopathyrehab http://spxj.nl/2mdRPlY

@JanEkstrand

Injury burden (nr of absence days/ 1000 h), best way of expressing consequences of injuries. Results from #EURO2016 http://spxj.nl/2miT2t4

@MarinusWinters

@AdamMeakins

The physio treatment pyramid... build it up from the bottom first! http://spxj.nl/2m1PF90

THIS Q

Stem cell injection in knee osteoarthritis: a systematic review of the literature OPEN ACCESS http://spxj.nl/2malXgz

IGHLIGHTS H ’S R E T UAR

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: ● Bones, Muscles and Anatomy - http://spxj.nl/2lXuk0v ● ePainAssist Inc - http://spxj.nl/2lX9i1U ● Medical Models Online - http://spxj.nl/2mct1v4

CO-KINETIC ON SOCIAL MEDIA

TWEETS

3,141

https://www.facebook.com/CoKinetic

FOLLOWING

https://twitter.com/sportexjournals

FOLLOWERS

1,152

https://www.linkedin.com/groups/4048152 https://pinterest.com/co_kinetic https://www.instagram.com/co_kinetic/

5,012

Join in!

CHECK OUT ON YOUTUBE: ● ● ● ●

Osmosis - http://spxj.nl/2mhQZFR Speed Pharmacology - http://spxj.nl/2lX68vb physicaltherapyvideo - http://spxj.nl/2lXdu1F www.sportsinjuryclinic.net - http://spxj.nl/2lZon1k

CHECK OUT ON INSTAGRAM: ● ● ● ●

evidencebasedmvmt - http://spxj.nl/2mcH6J4 medshots - http://spxj.nl/2mwE57f rehabscience - http://spxj.nl/2mcLF6j thephysioguru - http://spxj.nl/2lgJFKK

Co-Kinetic Journal 2017;72(April):50

The Business Freedom Blueprint 4 Hour Fast Action Workshop for Busy Health Professionals

What is it? A four hour session which will show you how to: ● Book more clients ● Increase clinic profits ● Boost staff engagement and productivity ● Skyrocket practice efficiency ● Reduce cancellations ● Boost sales and show ups The session will also give you hands-on, practical resources to help put the advice into practice.

When and where? Saturday 6th May - London Sunday 7th May - Manchester

How much?

Each afternoon from 2-4pm there will be a bonus free session on how to increase referrals from fellow medical professionals.

EXTRAS

“Since I have been using Paul’s programme and ideas, our sales went up over 20% highly recommended!” Jacqui Taylor, owner of The Bingley Physiotherapy Practice.

Normally £120, but use the code COKINETIC at checkout to save 50% and attend for just £60. For more information visit: http://www.healthbusinessprofits.com/ freedomuk/

Supported by: TIME-SAVING RESOURCES FOR PHYSICAL AND MANUAL THERAPISTS