Co-Kinetic Journal Issue 93 - July 2022 by Co-Kinetic

1999

2022

ISSUE 93 JULY 2022 ISSN 2397-138X

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PRACTICAL

12-13

WELLBEING POSTERS WITH CANVA TEMPLATES

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MALE PELVIC DYSFUNCTION: ARE KEGEL EXERCISES A HELP OR A HINDRANCE?

46-51

SALES IS NOT ABOUT SELLING, BUT ABOUT BUILDING TRUST AND EDUCATING

50-51 MARKETING WORKSHEETS

35-45

14-25

CALF MUSCLE STRAIN INJURIES

4-11

UPPER QUADRANT ASSESSMENT FOR MYOFASCIAL DYSFUNCTION: PART 1

JOURNAL WATCH

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ISSUE 93 JULY 2022 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 OPEN

This is about an active 9-year-old girl who fell off the top of a jungle gym, head and shoulder first. The diagnosis was metaphyseal-diaphyseal fracture with displacement of the left humerus, her non-dominant side. She is described as being active, spending about 5 hours a week doing various physical activities. At the time of first treatment she was no longer complaining about pain; however, weakness in isometric resisted tests at the glenohumeral joint (GHJ), and tissue stiffness resulting from the surgeries, resulted in reduced active and passive ROM in the left shoulder. Numbness and tingling were also present in posterior and anterior aspects of the hand. A physical assessment noted some observations about postural behaviour, with bilateral elevation of shoulders,

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= OPEN ACCESS

MASSAGE THERAPY EFFECTIVENESS IN REHABILITATION ON HUMERAL SHAFT FRACTURE IN A CHILD: A CASE STUDY. Geoffroy-Legeay H. International Journal of Therapeutic Massage & Bodywork 2022;15(1):54–65 increased lordosis, and kyphosis, and anteriorly rotated left GHJ. The drop arm test was positive indicating a possible supraspinatus tear. It could also show myofascial trigger point referrals limiting the child to hold the arm in the abducted position; however, the child was able to sustain the abducted position with the full can test. Gerber’s lift-off sign indicated weakness for the subscapularis tendon, the child being unable to resist the therapist’s pressure by extending the elbow. Also, Apley’s inferior scratch test indicated limitations in shoulder medial rotation and adduction and highlighted a winging scapula. In addition to physiotherapistprescribed strengthening exercises, massage treatment commenced 19 days after she had stopped wearing a sling for support. There were 7

sessions of 45 minutes. The actual protocol changed dependent on the girl’s progress but included manual lymph drainage, myofascial release, effleurage and petrissage and frictions to her surgery scars.

Co-Kinetic comment We have a number of case studies in this edition. They are always welcome because the evidential gold standard of a double blind randomised controlled trial is almost impossible to achieve for any form of manual therapy on real patients. A good case study shares clinical practice and has the only result that matters – did the patient get better or not. An added bonus with the good ones is that they promote ideas that readers can try. This is one of those. It is detailed in the assessment of the consequences of the injury and subsequent surgery and gives an in-depth timed description of the treatment protocol that others can repeat.

EFFECTS OF TIME-OF-DAY ON REPEATED SPRINT PERFORMANCE OF AROMATHERAPY MASSAGE APPLIED YOUNG FUTSAL PLAYERS. Bayer R, Eken Ö. Pakistan Journal of Medical & Health Sciences 2022;16(02):384–389 Twelve male athletes (age, 20.50±1.78 years; height, 171.92±2.23cm; weight, 67.92±2.42kg; BMI, 23.06±0.77), who exercised regularly for 5 days a week and had played futsal for at least 4 years, participated in the study. In the leadup to the study they were asked to continue with their normal exercise activity but to avoid strenuous activities for the 24 hours before the start. All took part in the three protocols which were completed 72 hours apart. Repeated sprint tests (RST) of 6×20m were done at 09.00 in the morning, 13.00 in the afternoon, and

17.00 in the evening. RST values were calculated using a combination of the fastest sprint time, total sprint time and percent change from the first sprint to the last sprint. There was a non-massage protocol (NM) during which the subjects jogged at a low tempo for 15 minutes. A Swedish massage protocol (SM) during which subjects jogged at 40% of maximal heart rate for 5 minutes then received 10 minutes of massage using baby oil. An aromatherapy massage protocol (ATM) during which the protocol was the same as the SM but using lavender oil. For both of the massage protocols 5 minutes were allocated to the upper limbs and 5 to the lower. Techniques were effleurage, friction, petrissage and pressure

applications. The results showed that there was a statistical difference between RST values observed at different times of the day after NM, SM and ATM protocols. The ATM protocol was found to be more effective particularly when applied in the evening.

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Co-Kinetic comment Although there is a lot to appreciate in the study and the idea of assessing the performance differences at certain times of the day was a good one, it suffers from a common fault in massage research in that there is no attempt to work out the dose of the treatment. Effleurage, petrissage, etc, are not in themselves a measure of dose, they are delivery system for putting force into tissue and that depends on the depth at which the therapist is working. There is no mention of this in the study.

Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

Journal Watch INJURIES PATTERN AND HEART RATE VARIATION IN ELITE JUDO ATHLETES: A KOREAN PROSPECTIVE COHORT STUDY. Park KJ, Jeong DN. Science & Sports 2022;doi:10.1016/j. scispo.2022.03.001

Data were collected from 2018 on elite judo athletes at the Korean Training Institute. The athletes were assessed by sports medicine doctors, and data were stratified according to sex, weight class and injury location. Measurements were recorded concerning heart rate, total power, low frequency, high frequency and low frequency/high frequency ratio. The study included 213 elite judo athletes whose 593 injuries (annual average, 2.78 injuries/athlete) were recorded. In general, injury rate was similar between the lightweight and heavyweight classes. When all athletes were considered, most injuries occurred in the lower extremities (38.79%), followed by the upper extremities (30.69%), trunk (23.44%), and head and neck area (7.08%). Injury severity was significantly different among the weight classes and body regions. The association between injury incidence rates was statistically significant in total power and low frequency. Heart rate variation was found to affect injury incidence. Low total power and low frequency increased the risk of sports injury.

Co-Kinetic comment Hopefully coaches, around the world not just in Korea, will use this to build injury prevention programmes. As an added bonus, if you want to improve your language skills the English and French versions are alongside each other in one paper.

A total of 44 patients took part in this trial. All had shoulder pain and prolonged immobilisation due to shoulder rotator cuff surgery or fracture of the proximal humerus. They were split evenly between a myofascial and control group. Both undertook Codman pendulum exercises, latissimus dorsi and external rotator muscle strengthening exercises, shoulder rotation exercises with a ball on a table, active mobility exercises in flexion and abduction with shoulder ladder and shoulder mobilisation exercises with 0.5, 1 and 2kg medicine balls. The control group were treated with passive, active-assisted, and active movements in flexion, abduction and rotation movements within the patient’s pain threshold. The myofascial group received 15-minute sessions of what is described as myofascial release above the levator scapulae, subscapularis, Co-Kinetic.com

A RARE ANATOMICAL FINDING OF UNDESCRIBED ACCESSORY PALMARIS LONGUS IN THE DISTAL FOREARM: A CASE REPORT. Allahham S, Alyazji ZTN, Aljassem G et al. Plastic and Reconstructive Surgery–Global Open 2022;10(4):e4240

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A 24-year-old man presented to the Emergency Department of Hamad General Hospital, Doha, Qatar, with right forearm laceration with multiple cut structures for which he was admitted for exploration and repair. Intraoperatively, flexor digitorum superficialis of the third, fourth and fifth digits, flexor carpi radialis, and palmaris longus were injured‚ and all of them were repaired. However, an aberrant muscle – which was also injured – was noted. It originated from the distal third of the radius on its medial aspect to insert into the palmar fascia; pulling this muscle’s tendon resulted in tightening of the palmar fascia in the same way as the palmaris longus.

Co-Kinetic comment It is nice to be told every now and then that our anatomy knowledge is not quite right. Muscle anomalies are not uncommon. This study has lots of pictures so if you are involved with hand care its worth a look.

EFFICACY OF MYOFASCIAL THERAPY AND KINESITHERAPY IN IMPROVING FUNCTION IN SHOULDER PATHOLOGY WITH PROLONGED IMMOBILIZATION: A RANDOMIZED, SINGLE-BLIND, CONTROLLED TRIAL. Sumariva-Mateos J, León-Valenzuela A, Vinolo-Gil MJ et al. Complementary Therapies in Clinical Practice 2022;48:101580 pectoralis major and minor, as well as what is described as superficial myofascial release on the trapezius, supraspinatus, deltoid, infraspinatus, and teres major and minor muscles. Outcome measures were the QuickDash questionnaire, visual analogue scale for pain and ROM of the shoulder measured at baseline, weeks 4, 8 and 12. The results showed a significant improvement in functionality and ROM in both groups, although only at the 12-week point did the myofascial group achieve a clinically

and statistically significant reduction in pain.

Co-Kinetic comment It is not clear how many treatment sessions each group received. In the discussion they state, “The variables were measured once a month until 4 months of treatment”, yet the results section only gives data up to the 12-week mark. That’s a pity, because it looks like both types of hands-on treatment work.

SPORTS CHIROPRACTIC MANAGEMENT OF OSTEOARTHRITIC KNEE PAIN IN A MASTERS LEVEL TRIATHLETE/RUNNER: A CASE REPORT. Smith G. Chiropractic Journal of Australia 2022;49(1):57–70 A 51-year-old, female Master’s level triathlete and distance runner, presented with right knee pain of 6 months’ duration. It had caused her to stop running. An MRI scan revealed severe medial osteoarthritis with subchondral bone oedema at the medial femoral condyle, full thickness chondral loss and mild pes anserine bursitis, indicating grade 4 on the Kellgren–Lawrence classification scale of knee osteoarthritis. She had a past medical history of a car crash at the age of 22 which resulted in hip and sacrum fractures. Radiological examination of this area 2 years ago revealed normal bone density and a deformation of the left ischium. Since she started running 7 years ago, she has had multiple lower limb stress fractures. Her only

medication was hormone replacement therapy, and she reported no red flag issues. A comprehensive clinical examination revealed muscle weakness of the gluteus medius, iliopsoas and rectus femoris muscles, various ROM discrepancies between her left and right sides, and a different shoe wear pattern on the right to the left. Her running patterns show signs of lumbopelvic instability (contralateral hip drop) and overstriding. Management included 6 weeks of running gait retraining, specific corrective exercise prescription and monitoring and gradual progression of exercises and running load. At the end of 6 weeks, the athlete reported subjective improvements in knee pain and running capacity.

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Co-Kinetic comment The author reports that the athlete had visited another therapist who had basically fobbed her off with, “Don’t run”. She was able to cycle or swim for 1 hour daily but stated that her goals were to: “Be able to run”, stating “I could go through life not cycling, but not running”. Her knee OA is not going to get better but this report shows that examination and treatment of everything else going on in her kinetic chain was able to get her back to running. Great work by her more enlightened therapist.

COMPARING THE EFFECTS OF COLD THERAPY AND HAND AND FOOT MASSAGE ON POSTOPERATIVE PAIN AMONG PATIENTS WITH MAJOR SURGERIES. Miri A, Masoudi R, Kheiri S et al. Journal of Multidisciplinary Care 2021;10(3):95–98 The present study aimed at comparing the effects of cold therapy and foot and hand massage on postoperative pain (POP) among patients with major surgeries. Ninety patients who underwent thoracoabdominal surgery were randomly assigned to one of the following groups: (i) control, (ii) cold therapy, and (iii) foot and hand massage. Participants in the control group received routine care services, whereas participants in the cold therapy group received the same care plus 20-minute local cold therapy (an ice bag on the surgical incision) three times a day for 48 hours, and participants in the massage group received routine care plus twenty-minute hand and foot massage three times a day for 48 hours. POP was assessed before and 48 hours after the study intervention using the McGill pain questionnaire. The results showed that there was no significant difference among the groups respecting the pre-test mean score of POP. The mean score of POP

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significantly decreased in all groups and the amount of decrease in the intervention groups was significantly more than the control group.

Co-Kinetic comment Sadly the massage protocol is not described but it does reduce pain. This supports previous research especially a paper from 2018 on pain reduction with massage following tibial shaft fracture [Pasyar N, Rambod M, Kahkhaee FR. The effect of foot massage on pain intensity and anxiety in patients having undergone a tibial shaft fracture surgery: a randomized clinical trial. J Orthop Trauma 2018;32(12):e482–e486]

EFFECTIVENESS OPEN OF MAITLAND AND MULLIGAN MOBILIZATION IN CERVICAL RADICULOPATHY PATIENTS. Niaz M, Zafar A, Sadiq U et al. Pakistan BioMedical Journal 2022;5(2):77–79 Two hundred patients (124 males, 76 females), aged 30 years or above and diagnosed with cervical radiculopathy were randomly allocated to either a 2-week programme of Maitland mobilisation or Mulligan mobilisation. Post-treatment pain levels were reduced, and ROM increased in both groups with a greater increase in the Mulligan group.

Co-Kinetic comment Three cheers for any paper that shows the effectiveness of manual therapy techniques and this one does, but why oh why is the only description of the techniques “small magnitude oscillating and distracting movements” for Maitland and “MWM … accessory mobilisation to a peripheral joint by a physical therapist while the patient generates active movements simultaneously”. Not good enough. Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

Fifty subjects aged 18–50 years with a history of pain, paraesthesia and numbness of less than 3 months in the upper limb with cervical or periscapular discomfort were treated with rotations, lateral glides in neutral, posteroanterior glides, posteroinferior medial glides, anterosuperior anterior glides, and anterosuperior anterior glides at Maitland grade 3 or 4 for 30 seconds each. They also received 5 minutes of cervical traction, cervical stabilisation exercises, isometric exercises to the cervical area and exercises to the scapulothoracic muscles. For good measure Kinesio tape was applied

EFFECT OF KINESIO TAPING IN PATIENTS WITH CERVICAL RADICULOPATHY: A LONGITUDINAL STUDY. Pajnee K, Kalra S, Yadav J. Journal of Clinical & Diagnostic Research 2022;16(3):KC01– KC04 from the occiput along the extent of the patient’s area of discomfort or paraesthesia. There were three treatment sessions spread over 4 weeks. Neck disability index (NDI), numeric pain rating scale (NPRS) and disability of the arm, shoulder and hand (DASH) questionnaire were the outcome measures taken at 0, 2 and 4 weeks. All the variables showed significant improvement between different intervals.

Co-Kinetic comment Don’t believe everything you read. The patients improved, which is great for them, but there is no way of knowing if this was down to the tape. Maybe the title of this work should be “Throwing the book at patients with cervical radiculopathy”.

EFFECT OF KOREAN MEDICINE TREATMENTS FOR FAT PAD SYNDROME OF KNEE JOINT: A CASE REPORT. Lee JH, Lee SK, Park EY et al. Journal of Acupuncture Research 2022;39(1):53–58 A 49-year-old female presented with bilateral knee pain that was worse on the right. She was not taking any medication, had no family history, had no underlying diseases, and received no other treatment for knee pain. MRI scans revealed that on the right she had soft tissue oedema in the anterior suprapatellar fat pad and Hoffa’s fat pad, medial collateral ligament injury, and tendinosis of the patellar tendon. She was diagnosed with fat pad syndrome, given the absence of any other articular condition/disease. An MRI of the left knee showed no major abnormality

except for a sprained anterior cruciate ligament. Her treatment was a cocktail of Korean medicine techniques, acupuncture and electric acupuncture for 15 minutes twice a day, pharmacopuncture (1ml of Shinbaro a purified extract from a mixture of six oriental herbs) also twice a day. Three daily doses of another herbal medicine, a session a day of Chuna therapy (a form of manual manipulation similar to chiropractic) to relieve tension in the muscles around the knee joint and hamstring. She also received myofascial release and muscle energy technique

The objective in this study was to determine which of several exercise prescription methods, without direct professional supervision, might best instruct adolescents to correctly engage in upper limb motor execution on outdoor flexion– extension equipment. A total of 54 adolescents from a middle socioeconomic level in northwest Spain participated. They were randomly assigned into three groups who received either video instruction, instruction via images or written panel instructions. Observational methodology in videographic analysis was used to evaluate the mistakes participants made in motor execution with each instructional method. Participants who relied on video instructions committed fewer errors than those who relied on panel instructions. The video method prevented loss of information that occurred when instructional images were used.

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around the knee joint and hamstring muscle and deep fascial meridian therapy, which involves herbal medicine steam therapy for 30 minutes. The treatments lasted for a month by which time the woman reported much reduced pain and improved function.

Co-Kinetic comment Three cheers for the Korean Health System because it put in some effort here. Can anyone tell us if this is normal or just because someone was writing a paper on it? From the patient’s point of view it doesn’t matter which of this encyclopaedia of treatments worked but for the rest of us it would be nice to know. Some more research please.

EFFECT OF TEACHING METHOD ON EXERCISE EXECUTION IN ADOLESCENTS’ USE OF OUTDOOR FITNESS EQUIPMENT. Gutiérrez-Santiago A, Paramés-González A, Prieto-Lage I. Perceptual and Motor Skills 2022;doi:10.1177/00315125221098635

Co-Kinetic comment What a great study. The authors suggest including a QR code on outdoor fitness equipment in open-air parks to permit users to download an explanatory video to their mobile phones. It’s the way forward. Co-Kinetic.com

IS MASSAGE AN EFFECTIVE INTERVENTION IN THE MANAGEMENT OF POST-OPERATIVE SCARRING? A SCOPING REVIEW. Scott HC, Stockdale C, Robinson A et al. Journal of Hand Therapy 2022;S0894-1130(22)00005-9 Scarring is a normal part of the wound healing process, but aberrant wound healing can result in hypertrophic scarring which is characterised by an excess of collagen formation and appears erythematous, raised and thick within the boundaries of the original wound. The changes in cosmetic appearance, continuing pain, loss of movement due to contracture or adhesion and persistent pruritis can significantly affect an individual’s quality of life and psychological recovery following the injury. Those with scars are more likely to experience anxiety and depression, with individuals feeling stigmatised and seeking to hide their scars from others, thereby affecting their ability to participate in social and work activities. To answer the question about the efficacy of massage for scars, the usual medical databases plus ProQuest Dissertations & Theses Global, and the Joanna Briggs Institute were searched from inception to December 2020. Twenty-five studies met the inclusion criteria, reporting

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on a combined sample of 1515 participants, although only two directly addressed hand or wrist scars (92 participants). All the studies reported favourable outcomes for scar massage including reducing pain, increasing movement and improving scar characteristics. However, the quality of the studies judged by a PEDro score indicate a variable quality of evidence. One of the main issues in pooling results was that across the 25 studies, a total of 45 different outcome measures were used.

Co-Kinetic comment According to this paper there are 312.9 million operations performed annually worldwide. That is a lot of surgical scars and the incidence of hypertrophic scarring following surgery is reported as between 40 and 94%. Scar massage is a potentially cost effective and an easily implemented intervention by those trained to do so.

LOW LYING PUBIC TUBERCLE: A PREDICTOR OF DEVELOPMENT OF INGUINAL HERNIA. Verma M, Purohit N, Vashisht MG et al. IP Journal of Surgery and Allied Sciences 2022;3(4):107–111

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This case control study was conducted using 100 patients with an inguinal hernia and 100 healthy individuals as controls. All were males. The two groups were statistically comparable in respect to age, height and weight. All were subjected to ultrasonography of the inguino-scrotal region, kidney, urinary bladder, prostate and any abdominal lump. They were asked to lie supine so that their anterior superior iliac spines were level. A line was drawn on the anterior abdominal wall connecting the two. Then the pubic tubercle on the side of hernia was marked by palpation and the vertical distance between this point and the marked line measured. Similar measurements were done on controls. The mean value of distance was significantly greater in the hernia group suggesting that people with a low-lying pubic tubercle are at high risk of developing inguinal hernia.

Co-Kinetic comment Many (if not all) of the therapists reading this will have gone through the embarrassment of being shown how to palpate the symphysis pubis (if you haven’t, Google it). This shows that there is good reason for doing it. How you prevent a hernia in the at-risk group is another matter.

CASE REPORT: VERTEBRAL ARTERY DISSECTION AFTER USE OF HANDHELD MASSAGE GUN. Sulkowski K, Grant G, Brodie T. Clinical Practice and Cases in Emergency Medicine 2022;6(2):159–161

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A 27-year-old female presented to an Emergency Department in Las Vegas with a 2-week history of progressively worsening headache, neck pain and dizziness. She denied any recent trauma but had recently begun using a hand-held massage gun on her neck over the preceding 3 weeks. During her physical examination, vital signs were all within normal limits, demonstrated full ROM of the neck without pain, had no audible carotid bruit, no notable swelling, ecchymosis, or midline cervical spinal tenderness to palpation. She had a Glasgow coma scale of 15 and was alert and oriented to person, place and time. She had a normal cranial nerve exam, full strength in the upper and lower extremities, normal reflexes and no ataxia. She had a negative Romberg test and normal, rapid alternating movement testing and finger-to-nose testing. Her blood and electrolyte count were normal. A CT scan demonstrated no notable abnormalities but a CT angiogram revealed a long segment of irregular stenosis of the right vertebral artery extending from the second to the fifth cervical vertebra, most compatible with a vertebral artery dissection. It was concluded that she had damaged herself with repeated use of a handheld percussive massage gun.

Co-Kinetic comment Arterial dissection is a potential cause of stroke. Vertebral artery dissection usually occurs with minor trauma but has been seen with cervical manipulation. Maybe it is time that massage guns came with a health warning.

Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

NANOMATERIALS AND RESEARCH ON THE REPAIR OF BASKETBALL SPORTS LIGAMENT INJURY. Xing Z. Journal of Nanomaterials 2022;1797629

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This article mainly studies the repair effect of nanomaterials on basketball sports ligament injuries. Nanofibre scaffolds were implanted in sports-injured rabbits, and their healing, growth and proliferation of damaged cells was observed along with the compatibility of nanofibres with cell tissues, so as to determine if nanomaterials have an impact on sports injury repair and the interaction between nanomaterials and cells. Twenty healthy rabbits were given sports related ligament injuries and epidermal wounds. Ten of them were implanted with a nanofibre scaffold and the others used as a untreated control. The results showed that the implantation of nanofibre scaffolds can greatly accelerate cell proliferation and differentiation and promote the healing of sports-damaged tissues; nanofibre scaffolds have good histocompatibility, so the use of nanomaterials can promote the repair of sports ligament injury in basketball sports.

Co-Kinetic comment Apparently the use of nanomaterials to reconstruct artificial ligaments is the current research hotspot of sports injury repair. Basically biodegradable polymer fibres are weaved together to make a thread and then a 3D printer is used to create the implant. It is the stuff of science fiction. Despite the title, the paper has little to do with basketball. In fact we didn’t know rabbits played basketball. Do they play in the NBA (National Bunny Association)?

A COLLEGE STUDENT WITH CHEST AND NECK PAIN. Tsai TY, Lee CW, Lee YK et al. Annals of Emergency Medicine 2022;79(6):e115–116

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A healthy, 21-year-old college student presented to the emergency department with acute chest and neck pain. He was afebrile, with a blood pressure of 115/57mmHg, a pulse rate of 99 beats/min, a respiratory rate of 16 breaths/min, and a peripheral oxygen saturation of 99%. A physical examination revealed a supple, tender neck without palpable crepitus, and his breathing sounds were vesicular symmetrically. Following an ultrasound scan of his neck and a chest X-ray he was diagnosed with spontaneous pneumomediastinum (SPM) and cervical subcutaneous emphysema. He was discharged after symptom management and prophylactic antibiotics 4 days later, and was asymptomatic at 1-month follow-up.

Co-Kinetic comment This is one of the conditions you may never see but you should be aware off. Pneumomediastinum is defined as free air within the mediastinum, not associated with trauma. Usually, it causes severe chest pain below the sternum, that may radiate to the neck or arms and breathing difficulties which together are described in some of the literature as ‘frightening’. The pain may be worse with breathing or swallowing. It can be brought on by asthma, vomiting and exercise and has recently been reported in Covid-19 patients. It can also be spontaneous, as it seems to have been here (although the chap reported that he had visited a karaoke club so maybe he was a tad over exuberant in his performance). It is most prevalent among males aged 5–34: the prime sporting population.

PREVALENCE OF AND PREVENTION FOR WORK-RELATED UPPER LIMB DISORDERS AMONG PHYSICAL THERAPISTS: A SYSTEMATIC REVIEW. Waller E, Bowens A, Washmuth N. BMC Musculoskeletal Disorders 2022;23(1):453

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Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a search was made of PubMed, CINHAL, EMBASE and Google Scholar for articles about work-related upper limb disorders (WRULDs) among physical therapists (PTs). Two hundred and eleven studies were assessed. They had sample sizes from 29 PTs to 2593 PTs with a majority of these studies having a higher female to male ratio. They were spread across numerous geographical locations including Nigeria, India, USA, UK, Korea, Australia, Italy, Kuwait and Israel. Twelve studies were included in the review. Thumb disorders had the highest prevalence (7.6–52.5%), followed by wrist and hand disorders (5–66.2%), shoulder disorders (3.2–45.2%), and elbow disorders (4–16%). Reported risk factors included treating a high volume of patients and frequent performance of manual therapy techniques. Consequences included interference with PTs’ personal and professional activities while coping strategies involved alterations to the work environment, techniques used, and workload.

Co-Kinetic comment This should be a wake up call to for all PTs. Look after yourself. The study states that most PTs adopt a reactive strategy more frequently than a preventive one. By then it is too late. There are ways around using your vulnerable joints or at least reducing the load going through them.

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Nine healthy men aged between 20 and 30 years old were recruited and randomly assigned to a control group (n=5) and massage group (n=4). All were physically fit, without injury and had not received a massage in the previous week. Before the exercise protocol, participants performed a standardised 5-minute warm-up on a treadmill at a speed of 6km/h. Then, they did a knee extension and flexion isokinetic exercise on an isokinetic dynamometer at 180°/s with the goal of 30 consecutive repetitions or until participants reach voluntary tiredness. Following this they did a 10-minute standardised cool-down by stretching both the calf and thigh muscles. Then, a 10-minute massage was performed on the rectus femoris muscle of the quadriceps and the biceps femoris muscle of the hamstrings of the dominant thigh. The control group did not receive a massage and were requested to rest for 10 minutes in the seated position. Heart rate was recorded as the beat-to-beat interval (R-R interval) by a heart rate monitor device for 5 minutes while lying quietly in the supine position. During the recording, participants were not allowed to talk or to move their bodies. Ectopic beat artefacts correction threshold level ±0.25s was conducted. Heart rate variability (HRV) spectral analysis was performed at baseline, pre-exercise, post-

ACUTE MASSAGE STIMULATES PARASYMPATHETIC ACTIVATION AFTER A SINGLE EXHAUSTIVE MUSCLE CONTRACTION EXERCISE. Mat Isar NEN, Abdul Halim MHZ, Ong MLY. Journal of Bodywork and Movement Therapies 2022;30:105–111 exercise and immediately post-intervention. The HRV was presented as low-frequency (LF) peak (Hz), power (ms2), power (normalised unit; n.u.), and high-frequency (HF), peak (Hz), power (ms2), power (n.u.) as well as LF/HF ratio. Spectral power analysis showed there were no significant differences in the LF indices and LF/HF ratio with massage. HRV normalisation data revealed a within-subject difference with massage. What this means in English is that massage caused an immediate parasympathetic activation during recovery from a single, exhaustive muscle contraction exercise. Hence, massage may be used to potentiate recovery.

Co-Kinetic comment Twenty men were originally recruited but 11 dropped out, which is a pity because it leaves a tiny sample on which to base conclusions. The massage protocol is well described with the depth graded as medium. The autonomic nervous system with its two main divisions, the parasympathetic nervous system and sympathetic nervous system, is responsible for regulating all unconscious bodily functions such as heart rate, blood pressure, digestion, respiration, metabolic and endocrine responses, among others, so a beneficial alteration is a positive intervention. Another tick in the ‘good’ box for massage.

AN EXAMINATION AND CRITIQUE OF SUBJECTIVE METHODS TO DETERMINE EXERCISE INTENSITY: THE TALK TEST, FEELING SCALE, AND RATING OF PERCEIVED EXERTION. Bok D, Rakovac M, Foster C. Sports Medicine 2022;doi:10.1007/s40279-02201690-3 The talk test (TT), feeling scale (FS) and rating of perceived exertion (RPE) are selfreported subjective measurements of training intensity. This review is intended to provide basic information on reliability and construct validity of the three. The key points are that self-reported subjective methods are easy-to-use tools for prescribing exercise intensity without the need for prior exercise testing. The TT and RPE are reliable and valid measures for demarcation of first and second ventilatory or lactate thresholds and can, therefore, be used to elicit homeostatic disturbances associated with moderate, heavy and severe intensity domains during continuous exercise. Studies about the validity of the FS to demarcate moderate and heavy intensity domains during continuous exercising show equivocal findings, but its use is certainly welcome for controlling the exercise intensity in sedentary and low-active individuals. The TT and RPE can effectively be used to prescribe and monitor intensity for continuous exercise up to 60 minutes in the moderate intensity domain and up to 30 minutes in the heavy intensity domain, while the FS can be used to control for the intensity of exercise that would provide better adherence to long-term exercising.

Co-Kinetic comment As the authors point out, there are numerous objective methods to determine exercise intensity, but they all require anchor measurements prior to the exercise. These don’t, so they may be more practical. According to the USA Center for Disease Control the TT is exercise you can do while talking but not singing.

Co-Kinetic Journal 2022;93(July):4-11

RESEARCH INTO PRACTICE

MINIMALLY INVASIVE FASCIOTOMY FOR SYMPTOMATIC TIBIALIS ANTERIOR MUSCLE HERNIA. Maffulli N, Quaranta M, Poeta N et al. The Surgeon 2022;doi:10.1016/j.surge.2022.01.005 Twenty-two consecutive athletes/ patients (17 males and 5 females) (median age 24.5 years; range from 16 to 35 years) who had undergone fasciotomy for management of leg pain secondary to a unilateral muscle hernia (MH) of the tibialis anterior muscle were enrolled in this study. The sport activity was running in 5 patients, ballet in 3, martial arts in 3, keep fit aerobics in 3, soccer in 1, badminton in 3, squash in 3, and cross training in 1. The median duration of symptoms before surgery was 11 months (from 6 to 27 months). The reason for their referral was given as MH in 5 patients, chronicexercise-induced compartment syndrome in 4, post-traumatic subperiosteal haematoma in 2, tibialis anterior tendinopathy in 1, peroneal tendinopathy in 1, chronic muscle strain in 1. No precise diagnosis had been formulated in the remaining 8 patients. All patients had been managed conservatively with compression stockings, bandages, Kinesio taping, strapping, various physiotherapy modalities, restriction of the inciting exercise and rest for a median of 8 months (range from 6 to 11 months). All patients referred pain during prolonged sporting or working sessions

and generally became asymptomatic within a few minutes with rest. In all but three patients, careful gentle palpation of the area of the hernia identified the hernial orifice. For MH in the tibialis anterior, with the patient on an examination couch and the legs hanging from the edge of the couch, the active dorsiflexion of the foot makes the hernia more evident. The actual diagnosis of MH was confirmed by imaging. Treatment was day-case fasciotomy surgery, weight-bearing as comfortable using elbow crutches for 14 days, then over the next 4–6 weeks patients were prompted to gradually return to walking, jogging, and agility training. Sport-specific training was allowed at 8 weeks, sport participation was allowed not before 14 weeks. Before surgery, patients were unable to practise sport activity with continuity, and their daily physical activities were affected. At the last follow-up, (median time of 23 months; range, 12–49 months), 16 of 22 patients (73%) had returned to sport and or normal physical activities. Of these, 11 had returned to pre-injury levels, two had reached higher levels of sport compared to their pre-injury status, and three had returned to sport

at lower level but their normal physical activities were not affected.

Co-Kinetic comment For the surgeons among you there is a full description of the op and lots of pictures. For the rest of us the best thing about this paper is that it gives an insight into the condition. Tibialis anterior muscle herniation often presents as a distinct palpable swelling or nodule over the muscle especially with weight-bearing and muscle contraction and as the list of referral conditions shows, it can often be mistaken for something else.

SURVEY OF CONFIDENCE AND KNOWLEDGE TO MANAGE PATELLOFEMORAL PAIN IN READERS VERSUS NONREADERS OF THE PHYSICAL THERAPY CLINICAL PRACTICE GUIDELINE. Willy RW, Hoglund LT, Glaviano NR et al. Physical Therapy in Sport 2022;55:218–228 The object of this exercise was to determine if physical therapists took any notice of clinical practice guidelines (CPG). It was an online survey of mainly USA therapists who were asked Likert-based or open-ended questions regarding the diagnosis, prognosis, risk factors, and management of individuals with patella femoral pain (PFP), as well as confidence for managing individuals with PFP, especially the ability to identify beneficial and non-beneficial interventions. The responses were dichotomised into participants

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who read (READERS) and did not read (Non-READERS) the CPG for the management of individuals with PFP. The survey completion rate was 82% leaving 494 participants who completed the survey. Of these, 48.8% and 51.2% were classified as READERS and NonREADERS, respectively. The results showed that most respondents held inaccurate beliefs about risk factors and prognosis; however, READERS’ beliefs better aligned with the CPG than Non-READERS’. Most respondents correctly agreed that hip and knee

exercise was the recommended treatment strategy; yet Non-READERS believed in implementing unsupported passive treatments. READERS reported greater confidence in managing individuals with PFP, delivering evidence-based interventions, identifying less beneficial treatments, and locating evidencebased resources than Non-READERS.

Co-Kinetic comment. Be honest, how well do you know the clinical practice guidelines for your industry? In the UK they are published by the National Institute for Health and Clinical Care Excellence (NICE). Check out https://www.nice.org.uk/ There are a lot of them.

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l Physical therapist l Friends l General practitioner/primary l Men’s health charities health care provider and support groups The information contained in this poster is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2022

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Calf Muscle Strain Injuries Calf muscle strain is a common sporting injury that can result in significant downtime for the athlete and also has a risk of recurrence if not managed properly. This article will allow you to understand why certain injuries occur to different parts of the calf muscle, and how to assess and treat calf muscle injury for your patient’s optimal return to sport with minimal risk of reinjury. Risk factors and prevention are also discussed allowing you to minimise your athlete’s risk of injury in the first place. Read this article online https://bit.ly/3yeSqHN By Kathryn Thomas BSc MPhil All references marked with an asterisk are open access and links are provided in the reference list

alf muscle strain injury (CMSI) is one of the most common muscle injuries in high-performance athletes, across a variety of sporting disciplines. It is an injury that contributes to substantial downtime for the athlete, with a high mean time to return to play (RTP), more than three months in some cases. Further compounding the impact of CMSI can be the occurrence during critical periods in the competitive season, athletes’ susceptibility to recurrence and subsequent lower limb injuries, for example hamstring strain (1,2,3*,4). Published research on lower-body injury has provided frequent updates on the rehabilitation of high-profile areas, such as the hamstring muscle and Achilles tendon. Despite its prevalence, and CMSI being problematic across a number of sports, there is a dearth of research to adequately guide clinicians. The past decades have seen a focus of research on epidemiology and risk factors associated with CMSI. Although this evidence is valuable in developing prevention strategies, it forms only one component of dealing with an athlete with calf strain. As yet, only a low level of research using randomised

CALF MUSCLE STRAIN INJURY (CMSI) IS ONE OF THE MOST COMMON MUSCLE INJURIES IN HIGHPERFORMANCE ATHLETES, ACROSS A VARIETY OF SPORTING DISCIPLINES 14

clinical trials is available regarding clinical decision-making, causation, assessment and management. In the absence of quantitative research, integrating perspectives and experiences from expert clinicians may be a valuable tool. Hence, the addition of qualitative research may be a powerful instrument to fill the gaps and guide practice. For CMSI, it would seem critical that better guidelines directing identification, management and prevention be established because failed management (ie. a recurrent CMSI) results in an average two-week longer RTP, and the risk of subsequent CMSI is elevated for months (2,5,6*). This article aims to highlight the current perspectives and practices (from both quantitative and qualitative evidence) to guide CMSI diagnosis, management and prevention.

A Bit of Perspective

In the late 1800s when calf strain injuries were first described it was known as ‘tennis leg’ owing to the occurrence associated with the sport. Although still notable in tennis, calf strain has since been reported with far greater numbers in sports including American football, Australian football, basketball, soccer and running, for example. It is more prevalent among athletes aged 22 to 28 years of age, more frequently affects men and has a recurrence rate of approximately 19–31% (3*,5,6*,7*). Most often rehabilitation is conservative, with a recovery period that ranges from Co-Kinetic Journal 2022;93(July):14-25

PHYSICAL THERAPY

immediate RTP to multiple months of missed training or playing time (3*,4,7*,8*). It appears that injury to the individual triceps surae muscles may be sport- or activity-dependent. The predominant CMSI in American football is isolated gastrocnemius strain, whereas in Australian football isolated soleus muscle strain is more common (6*,9*). In addition to this, gastrocnemius strain is associated with high-intensity running, acceleration, and deceleration activities – thereby being activity dependant. Soleus strain, however, is more likely to occur during steady-state running activities (6*). This observation may be substantiated by the fibre composition of the muscles and their respective biomechanical functions. The gastrocnemius muscle, responsible for knee flexion and ankle plantar flexion, is dense in fast-twitch muscle fibres, adapted for rapid contraction and response. However, the soleus muscle is dense in slow-twitch muscle fibres and regulates plantar flexion, in a postural control manner, during the gait cycle.

Pathophysiology

Gastrocnemius Strain

When the gastrocnemius muscle is fully stretched, a sudden contraction of the tensioned muscle can rupture the medial head at the musculotendinous junction. Thus the common pathogenesis of a gastrocnemius tear involves knee extension with a sudden, ballistic ankle/foot movement from dorsiflexion to plantarflexion. Since the medial head of the gastrocnemius muscle has a greater contribution to muscle activity it is more prone to injury than the lateral head. Studies have shown a 2:1 ratio of tears to the medial head compared with the lateral head (7*,10*).

Soleus Strain

The mechanism for soleus rupture is associated with overuse, and is thus a subacute injury. It may be caused by repetitive, passive dorsiflexion of the foot with the knee bent (10*). This posture is often observed in runners when running uphill. Most often a soleus strain is of gradual onset and a cumulative effect; however, acute strain can manifest in fatigued athletes (10*).

Plantaris Strain

An isolated rupture of the plantaris muscle is relatively rare but can occur at the proximal muscle belly or the midportion of the plantaris tendon (10*). Similar to a gastrocnemius tear, the pathogenesis involves knee extension with ballistic foot plantar flexion. In the case of an isolated lesion athletes can retain a full range of motion (ROM) without loss of strength. Most often a plantaris injury is diagnosed with concomitant traumatic knee injuries, including lesions of the anterior cruciate ligament or the posterolateral corner (7*,10*).

Subjective Assessment and Presentation

During the initial examination of CMSI, steps should be taken to firstly identify the primary muscle involved (eg. soleus vs gastrocnemius); this may be determined by a combination of patient and injury history, examination and what triaging actions (eg. immediate immobilisation, imaging) were performed.

Table 1: Initial subjective examination (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Domain

Key areas

Baseline outcomes

1. Presenting injury

i. History of onset

The presence (yes/no) of an inciting incident. If yes, the mechanism of injury The duration of symptom onset: immediate; cumulative; days

ii. Self-reported symptoms

Symptom qualities and intensity: pain; unresolved ‘tightness’ or ‘cramping’; paraesthesia; numbness Location(s) of symptoms: focal; diffuse Perceived level of severity or functional impairment

i. Intrinsic factors

Non-modifiable factors: history of CMSI; chronological age; training age; ethnicity; other injury history, including recurrences (foot, ankle, knee, spine, hamstring, quadriceps, adductor) Modifiable factors: mobility; strength-power capacities; fitness/conditioning to running and ballistic activities

ii. Other predisposing factors

Recent period of relative off-loading or immobilisation (eg. illness, surgery, injury); monitoring or ‘wellness’ flags: fatigue, recovery, sleep, illness; impairments or functional restrictions related to current clinical/ sub-clinical state: 1st MTPJ, plantar fascia, ankle, Achilles, knee, bone stress, spinal

i. Extrinsic factors

Demands of the sport: playing position, playing style, stage of the season; recent and long-term history of training and competition

ii. Other contextual factors

Change in footwear and/or orthotics Potential for training error: large changes in exposure or unaccustomed stimuli (eg. running surface; eccentric exercise)

2. The injured athlete

3. The injury context

CMSI, calf muscle strain injury; MTPJ, metatarsophalangeal joint.

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1. Acute Strain of the Gastrocnemius

l Mechanism of injury (described above). l Possibly an audible pop at the time of the injury. l Dull to severe pain and swelling in the posterior lower limb within 24 hours. l Pain can be latent, manifesting only after the athlete tries to stand, walk, or plantar flex the foot. l Unable to perform a heel raise on

the affected side. l Tenderness at the musculotendinous junction, in severe cases a palpable defect in the medial head. l Mild to severe ecchymosis can appear at the rupture site.

2. Soleus Strain

l Typically subacute. l Presents with muscle tension and tightness. l Poorly localised pain on palpation. l Gradual pain development over the course of days to weeks.

l Mild swelling and disability. l Tenderness deep within the lateral calf, distal to the gastrocnemius muscle. l Muscle contraction tested is with the knee in maximal flexion, such that the soleus muscle becomes the primary contributor to plantar flexion.

3. Isolated Plantaris Strain l Rare and often clinically indistinguishable from a gastrocnemius strain.

Table 2: Initial objective examination (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Domain

Key areas

Baseline outcomes

1. Observation

i. Local observation

Relative calf bulk (size, shape); observable signs of severe CMSI; observable signs of other injury (eg. contusion, Achilles rupture or tendinopathy)

ii. Other structures

Relative muscle bulk (size, shape) compared to contralateral limb: posterior gluteus maximus, hamstrings, quadriceps Altered gait pattern

i. Tenderness

Discrete location if discernible: gastrocnemius (medial, lateral), soleus (usually more distal and lateral), Achilles tendon; pain; maximum length of tenderness (cm); symptom quality Palpable defect indicates a possible muscle retraction with complete fibre disruption Palpable contractions that are spasmodic and involuntary indicate muscle cramps

ii. Tactile qualities

Focal spasm; palpable defect or deformity: Achilles tendon, medial gastrocnemius, superficial triceps surae confluence; evidence of direct injury where relevant (eg. contusion)

2. Palpation

3. Stretch tolerance

Non-weight-bearing ROM (°); pain; other symptoms; symptom quality i. Passive dorsiflexion: KF, KE ii. Knee-to-wall lunge Weight-bearing ROM and asymmetry (cm); pain; other symptoms; symptom quality

4. Isolated function

iii. Straight-leg stretch at wall

Weight-bearing ROM asymmetry (cm); pain; other symptoms; symptom quality

i. Isometric contraction: KF, KE

Non-weight-bearing plantar flexion: capacity, pain, other symptoms With KE isolate gastrocnemius With KF isolate soleus contraction

ii. Single-leg calf raise: KF, KE

Weight-bearing plantar flexion: capacity, pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate: (a) double-leg, (b) double-leg concentric, single-leg eccentric, (c) single-leg calf raise Look for sickle sign and toe clawing during calf raises Bent-knee calf raise isolates soleus muscle

5. Dynamic capacity i. Plyometric function

ii. Locomotive activities

Capacity; pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate for jumping and hopping: (a) double-leg vertical, (b) single-leg vertical, (c) single-leg horizontal Capacity; pain; other symptoms; symptom quality; antalgic strategy Graded as appropriate: (a) walking, (b) submaximal jogging, (c) linear run through, (d) cutting and change of direction, (e) sprinting, (f) maximum acceleration from inert position

Notes: °, degrees measured using goniometer; antalgic strategy, observable presence of antalgic strategy (yes/no); capacity, the ability to perform the task (yes/no); KE, knee position in extension; KF, knee position in flexion; pain, check: (1) presence (yes/no) and (2) extent (VAS:x/10); other symptoms, eg. ‘tightness’, ‘cramping’, or neural symptoms elicited; symptom quality, eg. focal versus diffuse.

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PHYSICAL THERAPY

l Imaging is required for a definitive diagnosis. l Possible audible pop at time of injury. l Patient may retain full ROM without reduction in strength. Table 1 shows what to consider in an initial subjective examination of a patient with suspected calf strain. Clinical presentations that could have some signs and symptoms similar to CMSI include direct injuries like a contusion, delayed onset muscle soreness, other lower leg muscle strains and an Achilles tendon tear or tendinopathy. Posterior leg pain can originate from other muscles including the popliteus, peroneus longus and deep posterior compartment or lateral compartment (including tibialis posterior, flexor hallucis longus, flexor digitorum longus, peroneals). Medial gastrocnemius tenderness is common on palpation and can be normal, even in uninjured athletes (7*,8*). Although the diagnosis of calf strain is often based on clinical findings, imaging is valuable to confirm the location of the strain and the grade of the injury. The information may help to guide the choice and duration of rehabilitation, and influences RTP considerations. Imaging may detect intramuscular fluid collection or connective tissue defects which are associated with delayed RTP. In elite sports, the decision-threshold for imaging is low (8*). It is preferred to wait 24–48 hours post-injury to confirm if it is warranted and to gain a thorough impression of injury severity before presenting biases inherent in imaging results. Magnetic resonance imaging (MRI) may be used as the gold standard, followed by ultrasound (which has the benefits of ease of use and rapid results), to establish the extent of disruption and injury pathology. However, over time the most valuable prognostic information comes from the rate of functional progression (8*). The use of imaging can be counter-productive as many athletes present with tissue changes that may not have been pathological, symptomatic or related to the current injury. The degree of tissue change seen during imaging does not Co-Kinetic.com

THE GASTROCNEMIUS MUSCLE, RESPONSIBLE FOR KNEE FLEXION AND ANKLE PLANTAR FLEXION, IS DENSE IN FAST-TWITCH MUSCLE FIBRES, ADAPTED FOR RAPID CONTRACTION AND RESPONSE positively correlate with symptom severity (11,12). This can result in catastrophising, overly cautious rehabilitation programmes and a negative psychological bearing on the athlete (8*).

Objective Assessment and Physical Examination

The initial objective examination should be used to refine the clinical impression of injury location, severity and directed

immediate management – this includes what have they done since the injury, were they immobilised, did they cease or continue play, etc. (Table 2). Traditionally, muscle strains have been graded, but one should not be defined or limited by the grade initially given upon diagnosis – see Table 3. Injury grades for CMSI and recovery times in Meek et al. (7*; https://bit.ly/3xLDPU7). Although the injury grade may guide rehabilitation

Baseline examination Rate and maintenance of symptom resolution: 1. Palpation tenderness 2. Stretch intolerance 3. Isolated calf function 4. Dynamic calf capacity

Periodic clinical re-evaluation

During rehabilitation 1. Performance-related factors (eg. strategy, competition schedule, position) 2. Cumulative recovery from rehabilitation 3. Psychological readiness

At the time of return to play

Final return to play prognosis

1. Injury type: index versus recurrent CMSI 2. Mechanism of injury 3. Clinical +/– imaging findings 4. Aetiology: risk domains, risk and predisposing factors 5. Eventual demands of competition/sport

Objective milestones, where relevant: 1. Foundation strength-endurance, motor control 2. Loaded strength and power capacities 3. Plyometric function 4. Running activities (velocity- and endurance-based) and fitness capacities 5. Tolerance of injury mechanism, if relevant

1. Data-informed consensus among key stakeholders: Athlete, coach, medical and fitness staff

Figure 1: Evaluating prognosis after calf muscle strain injury (CMSI)

Numbered points refer to the primary themes and/or concepts that influence decision-making at each stage. (Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7)

THE DESIGNATED GRADE OF MUSCLE INJURY MAY GUIDE BUT SHOULD NOT DEFINE OR LIMIT REHAB/RTP DECISIONS and RTP, many athletes improve at different speeds, based on multiple factors including age, past injury history, motivation and fear. The grade should not hold someone back nor should it push an individual on if they are not ready to RTP within the given time frame. Typically, once assessed and diagnosed, the very next questions are:

Injury onset

When can I run again? When can I play sport again? Will I be ready for next weeks game? Initially, one shouldn’t feel pressured into giving definitive timelines and a prognosis in the early stages. It is necessary to disseminate information to the athlete and any interested parties. At baseline, early expectations should be stated broadly; for example information about RTP can

Clinical and functional progression

be described as ‘none’ (ie. following an on-field assessment), ‘short’ (possibly a week or two) versus ‘extended’ (possibly 6–8 weeks) (8*). During rehabilitation, the prognosis can be refined, using functional progression milestones and ongoing assessment. The rate of resolution of pain-free walking is a good indicator of progress. Identifying other potential risk factors and concomitant impairments may hinder progress through rehabilitation (8*). The final prognosis should be confirmed at the time of RTP and should be a consensus. Rather than

Shift from medical to performance model

Injury prevention

Foundation calf and lower limb function Loaded strengthening Loaded power, plyometrics and ballistic exercises Locomotion Acute injury l Prevent further structural damage (ie. worsening the pathology) l Effective therapeutic loading as early as is clinically reasonable (eg. NWB and WB plantar flexion) l Normalise walking pattern (if relevant) l Educate stakeholders: anticipated prognosis, functional progression milestones & contraindications

Early rehabilitation l Actively resolve basic signs, symptoms & impairments l Redevelop foundation calf function & capacity (eg. single-leg calf raise strengthendurance, Smith machine strength) l Progress locomotion, including stair climbs and walking drills l Address other modifiable deficits or factors that may impact risk of recurrent CMSI and/ or other subsequent injuries

Intermediate rehabilitation l Sustained resolution of signs & symptoms l Return to running l Progressive rate of loading while building running volume & intensity (eg. plyometrics and ballistic exercises, run drills, power sled)

Return to Return full training to play l Reintegrate to full l Consensus training over ≥1 reached among session, pending stakeholders for injury severity final RTP clearance, l Prioritise sportsto meet the related calf capacities: primary outcome: strength, endurance, (1) return at an power, plyometric elite standard qualities of performance l Running fitness, immediately, & volume and intensity (2) no adverse of sports-related events at RTP (eg. running activities – recurrent CMSI including graded or a different exposure to the subsequent injury) mechanism of injury l Balance exposure (if any) between onfield and offfield activities (eg. loaded calf strengthening and running)

Post return to play l Mitigate the risk of adverse events during the ‘high-risk’ window l Transition to ongoing injury prevention model involving individualised athlete monitoring, load management & exercise selection

1 2 34 56 ATHLETE MONITORING

Figure 2: Overview of optimal management of CMSI, following six phases

NWB, non-weight-bearing; RTP, return to play; WB, weight-bearing. (Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7) 18

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PHYSICAL THERAPY

pathology and/or re-imaging being the determining factor, RTP should be based on performance-related factors, psychological factors of the athlete, residual fatigue, competition readiness, and limited training chronicity (13,14,15). Thus, a staged approach may more accurately determine prognosis (Fig. 1). This approach may (i) prevent injury recurrence due to overly aggressive rehabilitation or premature RTP; (ii) prevent unnecessarily conservative RTP time frames due to ongoing assessment; and (iii) allow performance-related factors to be considered and planned for (8*,16*).

Rehabilitation and RTP

Very, very rarely is surgery required in the management of CMSI. Nonoperative management is effective for the majority of CMSIs. The early stages of treatment may follow a ‘PEACE and LOVE’ protocol (https://bit.ly/34SQIyK) (17*). Over the course of rehabilitation, the

clinical management may shift focus from a medical mindset (protect the injury, prevent further damage, bleeding, sweeling, pain) to prioritising performance and then preventing reinjury after RTP. It is believed that best management should be context/sport-dependant, individualised and strongly influenced by the athlete’s intrinsic characteristics and external factors (8*). Irrespective of injury characteristics, early loading of CMSI results in faster recovery and may reduce pain and improve confidence (18*,19). It has been suggested that management should progress through six phases with the ultimate goal being successful RTP – which is deemed as (1) RTP as soon as possible; (2) restoration of athletic performance to the expected level; and (3) no adverse events, be it reinjury or other subsequent lower limb injury (Fig. 2) (8*).

Rehabilitation Principles 1. Early Loading

Early loading is perceived to fast-track

THE SOLEUS MUSCLE IS DENSE IN SLOW-TWITCH MUSCLE FIBRES AND REGULATES PLANTAR FLEXION, IN A POSTURAL CONTROL MANNER, DURING THE GAIT CYCLE

Table 3: Early loading exercises for CMSI rehabilitation (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Early loading Examples

Objective Normalise gait pattern

First step to restoring normal movement patterns

Find their optimal starting point for loading

How much load ? Find their barrier and work just below it, this may change daily Start loading on day 2 or 3 Isometric only, exercise band work only Or if they can do double-leg calf raises, start there with two-leg weight-bearing exercises Or if they can do single-leg calf raises, start there with single-leg weight-bearing exercises

Prescribe multiple loading bouts throughout the day

Aim for 4 loading sessions per day, pain free and without detriment the following day

Use activation exercises to prevent inhibition

Gastrocnemius especially is highly susceptible to pain inhibition and wasting Activation can be non-weight-bearing and isometric

Foundation exercises build to dynamic actions of muscletendon unit

Once 2 sets 15 repetitions slow and controlled single-leg calf raises can be done, add: l 1 set of oscillations ‘up top’ ‘middle’ ‘down below’ to plantar grade l Oscillations off a step in full dorsiflexion l ‘ Drop and catch’ at different positions Retraining balance and proprioceptive function, the foot intrinsic muscles and deep lower leg muscle exercises will aid in improving dynamic control

Condition uninjured bodyparts

Do not allow de-training of other muscles where possible. Keep their routine simple modify the activity

Avoid excessive eccentrics and passive stretching in the early stages

Pain may inhibit the athlete recovery physically and emotionally

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Achieve accepted strength threshold Eg. Single-leg calf raise capacity and/or loaded calf strength

Tolerant of repeat hopping Eg. Vertical hop test for a number of repetitions or duration

Absence of other clinical signs and symptoms Eg. Weight-bearing dorsiflexion range of motion

✓ Begin n

running

✗ Further n

rehabilitation required

Figure 3: Determining readiness to run after CMSI

(Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*), reproduced under the Creative Commons Attribution 4.0 International License, https://bit.ly/3bjavN7)

symptom resolution and disability associated with CMSI (18*,19). Illustrations of some of the exercises mentioned in Table 3 can be found at Green and McClelland et al. (8*). The single-leg calf raise underpins advanced functional rehabilitation and should, therefore, follow strict cues (See Video 1 and Green and McClelland et al. (8*)): 1. Perform work along the axis of the second metatarsal. 2. Maintain neutral foot and ankle positions throughout the prescribed range. 3. Control the loading rate (eg. 1 second up; 1 second down). Things to watch for as indicators of poor calf muscle function or control/ recruitment include sickle sign (progressive inversion or adduction of the foot), clawing toes (excessive reliance on deep foot flexors), and reduced eccentric control (8*). Poor calf or lower limb control may be evident through the entire kinetic chain; athletes may extend their lumbar spine during calf raises or they won’t be stiff in their pelvis (gluteal muscles) and quadriceps. These signs highlight other areas that need to be addressed during the strengthening phase of rehabilitation (8*).

Table 4: Loaded strengthening exercises for calf muscle strain rehabilitation (Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*))

Loaded strengthening Examples

Objective Maximising capacity is first priority

Straight-leg or bent-knee calf raises Small loads with 10–15 or 10–12 reps Increasing loads, reduce reps to 3 or 4 sets of 6–8 reps

Sport-specific strengthening

Strength-endurance required for prolonged running and work (eg. Australian football, football/soccer) versus maximum force-generating capacity for shorter durations (eg. rugby, sprinters)

Consider horizontal and lateral load capacity

Particularly in sports with rapid acceleration or cutting (eg. rugby) l Leaning-tower position calf raises

Single-leg strength is foundation for dynamic exercises

Fewer double-leg exercises as dynamic movement involves all single-leg activity l Single-leg jumping and hopping

Soleus strength is critical for all athletes

Soleus strength capacity and endurance is critical for problem calves, severe calf strains (even if gastrocnemius strain), athletes with history of calf injuries, or lower limb injuries

Load compound exercises

In preparation for movement and sport, incorporate entire kinetic chain, gluteal, hamstring, quadricep and hip flexor muscles l Squats, lunges, pulleys

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2. Loaded Strengthening

Once an early benchmark of singleleg calf raise capacity (body-weight only, 20–25 repetitions continuous) is achieved, then adding load can progress (20). Common starting points include a Smith machine and seated calf raise machine. Progression can be made by increasing loads and moving from a flat foot surface to an inclined surface to alter the ROM. See Table 4 for further details regarding loaded strengthening exercises. It is believed that eccentric loading can be augmented with heavy isometric strengthening at various MTU lengths and altered whole-body positions (eg. ankle dorsiflexion, knee flexion, trunk lean) (8*).

3. Loaded Power, Plyometrics and Ballistic Exercises

Firstly, this involves re-exposing the calf to volume and its ability to contract and work repeatedly in a sport-specific manner. Secondly, this ensures that the muscle can generate sufficient force at sufficient speed (the rate of loading) to safeguard its spring-like mechanism. The calf is the first point of loading in the kinetic chain, which is maybe not considered critical in rehabilitation. Proximally, multiple muscles and structures can jointly absorb the loads of dynamic movement; however, the calf muscle requires sufficient elastic properties to tolerate the running loads alone. Plyometrics and explosive

exercises (loaded and unloaded) are necessary to restore elastic function. Dynamic exercises involving predominantly vertical actions, should be followed by exercises involving greater horizontal, lengthening, and stiffness demands (8*). Two main exercise streams have been identified: 1. r epeated stretch-shortening-cycles (SSCs) over small length excursions (or pseudo-isometric), associated with a rhythmic MTU action (eg. single-leg pogos); and 2. s ingle or several SSCs over larger length excursions (eg. single-leg countermovement jump, forward hopping) associated with an accelerative MTU action (8*). A novel concept would be to develop both instantaneous and repeated power of the calf MTU for sports that require both of these qualities, such as Australian football, soccer and long sprinters. This may, however, present a clinical challenge owing to the competing adaptations that these qualities require (8*).

4. Running Rehabilitation

Running prematurely has been cited as a leading cause of early recurrent CMSI (8*,21*). A slight delay in commencing running, may result in a lower risk, without negatively impacting rehabilitation time frames (13). The

Table 5. Objective testing options to evaluate power qualities at RTP after CMSI

(Sourced from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*)) Vertical

Horizontal

Instantaneous

SL CMJ SL DJ SL concentric-only jump SL box-jump height

Single hop for distance Resisted acceleration Resisted SL push off

Repeated

SL CMJ: 5–10 reps SL hopping: reps or time Loaded squat jumps

Forward hops in-series: 5–10 reps SL bounding distance: reps or time Broad jumping Resisted SL catch-ups

CMJ, countermovement jump; DJ, drop jump; SL, single leg.

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Video 1: How good is your calf function? What is the norm & common compensations? (Courtesy of YouTube user Physiotutors) https://youtu.be/apRDvOLqTrE

three primary elements for ‘running readiness’ include strength, hopping capacity and the absence of other clinical signs and symptoms (Fig. 3). A more comprehensive build-up before running may enhance outcomes, without extending RTP timeframes (8*,13). Low-load locomotion should be started as early as possible, in the form of ‘normal gait’ walking, stair ascents, toe walking, loaded walking using kettlebells or dumb-bells, bear-crawls, lunge-walk drills. Normally running drills can be performed at walking speeds including ladder-based drills, ‘under-overs’, ‘ecky-shuffle’, side skips and grapevine on their toes. In preparation for running, visualisation and verbal queues using words like ‘pitter patter’ may help prevent the athlete from plodding initially (8*). Prescribing an athlete to ‘jog, slowly’ may do more harm initially. Slower continuous running can result in plodding, which produces high impact forces in the calf and can predispose to fatigue-related recurrence of injury. Submaximal run throughs (60% effort; 8×80m) may be more productive when starting running again. Increasing the number of sets of shuttle runs (3 sets of 8×80m submaximal runs) can be a way of building volume without plodding or sprinting (8). Six ‘rules of thumb’ have been identified as a guide to running rehabilitation after CMSI: 1. Initially run on alternate days. 2. Avoid ‘plodding’ early. 3. Do not progress volume and intensity on consecutive days. 4. Schedule off-field exercises (eg. 21

loaded strengthening) after running. 5. Shape running progressions to meet the demands of the sport – don’t overshoot with excessive volume. 6. Avoid sudden changes in conditions, such as the surface and footwear (8*). Over time, running rehabilitation can involve gradual exposure to greater volume and intensity, with prescriptions aligned to rehabilitate the entire spectrum of activities performed in the sport, including sprinting (not early due to the high contractile forces), cutting, acceleration and endurance.

Table 6: Clinical checklist to determine RTP following CMSI

(Adapted from Green B, McClelland JA, Semciw AI et al. The assessment, management and prevention of calf muscle strain injuries: a qualitative study of the practices and perspectives of 20 expert sports clinicians. Sports Medicine – Open 2022;8(1):10:doi:10.1186/s40798-021-00364-0 (8*))

✓or ✗

RTP criteria Symptom resolution and psychological readiness

l Self-reported symptoms: VAS 0/10 (pain, tightness, ‘cramping’ sensation) l Self-perceived readiness & confidence to return to performance

Residual clinical signs and impairments

l Palpation tenderness: VAS 0/10, length: 0cm l Weight-bearing ankle dorsiflexion ROM: normalised knee-to-wall lunge (cm) and straight-leg stretch, asymmetries ≤10% l Single-leg calf raise test from the floor*: capacity (≥30 repetitions), asymmetry ≤10%

Normalised strength-power qualities

l Loaded strength: sport-specific benchmark (knee extended, knee flexed) l Power: normalised vertical and horizontal calf function; instantaneous and repeated tests; asymmetries ≤10%

Reconditioned for exposure to sport demands

l Running conditioning: total volume, volume across speed bandwidths, accelerations, decelerations l Intensity of running and other dynamic activities: cutting, reactive agility, jumping, maximum velocity, maximum acceleration l The mechanism of injury

Successful re-integration into full training

l Return to full training for ≥1 session, pending the length of the rehabilitation period l Consensus among stakeholders about readiness to perform at the required level (eg. elite vs sub-elite vs amateur)

VAS, visual analogue scale, whereby ‘0’ represents no symptoms and ‘10’ represents the maximum of symptom severity. ✓, achieved during rehabilitation; ✗, not achieved and further rehabilitation may be required. *Note: testing single-leg calf raise capacity from the floor (rather than a step) was perceived to limit the potentially significant impact of individual variation in ankle dorsiflexion ROM. 22

RTP Decisions

As mentioned earlier, while endeavouring to establish a prognosis for an athlete, fixing a date or time for RTP can be very challenging. Ongoing assessment is required but ultimately the decision to RTP should be a consensus between the athlete, therapists, coach and other stakeholders (22*). RTP is essentially weighing up the risk of ‘do I wait and rehab longer’ or ‘if I RTP now will I re-injure myself or be ok?’ Ideally an athlete will have had a time of full return to training to gauge load tolerance and functional improvement. Objective testing may be of value to aid RTP decisions, bearing in mind side-to-side asymmetries often exist even in healthy individuals which may confound outcomes (4). Objective tests assessing instantaneous and repeated power capacities are useful following CMSI (Table 5). Experts have compiled a checklist that may aid in determining RTP readiness, with emphasis that decisions should be strongly guided by exposure to sport-specific activities (Table 6) (8*,15). A recent study of elite Australian football players showed that not all calf strains responded to the same time frames for RTP. Calf strains from running activities needed longer recovery periods than calf strains from non-running activities, irrespective of the muscle injured (6*). It may be assumed that running activities involving high-intensity and steady-state running, acceleration, deceleration, or cutting has greater tissue disruption of the muscle-tendon unit and thus require longer times for RTP (6*).

Risk Factors and Injury Prevention for CMSI

Athlete reinjury is always a concern, but especially with CMSI, which has a recurrence rate of approximately 19– 31% (2,3*,5). Reinjuries are associated with even longer recovery times and often involve older, more experienced players (7*). Premature RTP increases the risk of reinjury as tissues have not completely healed (5). An appropriate rehabilitation timeline must consider other factors including, sport-specific Co-Kinetic Journal 2022;93(July):14-25

PHYSICAL THERAPY

demands, player position, seasonality, and athlete psychology (5,23*). A study by Green and Lin et al. (14) showed reinjuries to be almost exclusively following soleus muscle strain (91.4%). The cumulative incidence for reinjury was highest within 2 months of the index/primary strain (46.9%) (14). Interestingly, having a history of previous CMSI at the time of the index/primary strain was the only predictive factor for reinjury. The strongest risk factor for reinjury is a recent history of CMSI, followed by a past history of CMSI. Increased risk of reinjury persists beyond 15 weeks after RTP. Increasing age is an independent risk factor for calf muscle strain with an odds ratio of 1.6 (2). An identification of the risk factors, combined with aetiological factors, may be a practical approach to injury prevention, as a single factor acting alone is rarely the cause (24*,25*,26*). The potential impact of intrinsic and extrinsic factors acting on the individual and their exposure include: 1. Intrinsic factors 1.1. Non-modifiable l increasing age l decreased training age l history of CMSI l history of lower limb injury l ethnicity l genetics l general hypermobility lo ther injury history or sub-clinical state 1.2. Modifiable l increased body mass index (BMI) l decreased calf strength l decreased co-ordination l decreased compound strength l decreased calf power capacities l decreased function during ballistic and plyometric activities l decreased running capacities l increased fatigue (acute and cumulative) l running biomechanics or technique l knee-to-wall lunge l distal impairments l proximal impairments 2. Extrinsic factors 2.1. Activity related l preseason period Co-Kinetic.com

l demands of sport l player position/role l competition schedule l training errors (running workload) l recent immobilisation l equipment (footwear) l environment (surface) 2.2. Non-activity related l performance culture l coach expectations (8*,27,28,29,30). The four most-prevalent factors that may have a significant impact on injury recurrence (and their reasons) include: l increased age: this is the result of decreased tissue quality (atrophy), stiffness, decreased fascia length and reduced recoverability; l previous CMSI: due to inhibition, decreased strength and power capacity, altered tissue dynamics, decreased tissue length and extensibility; l other injury history: decreased capacity altered mechanics, persistent deficits (in lumbar spine, hip, knee, ankle or foot); and l exposure history: recent immobilisation or interruption training (surgery or illness), novel or unfamiliar stimuli, training design, match schedule/congestion, decreased training chronicity (8*). A universal injury prevention programme does not exist for calf muscles. The barrier to implementing traditional prevention strategies for CMSI is that ‘protective’ calf qualities undergo fluctuations. Screening and ongoing athlete monitoring of all or any of the above risk factors should underpin optimal management. This approach permits individualised prevention using load management and exercise selection strategies, while considering the multitude of factors that impact an athlete’s risk profile (eg. behavioural qualities, training design, individual skill, coach expectations/ club culture and environmental factors) (25*,31,32). Overall, chronic and uninterrupted exposure to the athlete’s sport combined with specific activities involved in that sport are considered the most important strategies for resilience to CMSI (8*). Historically, research has shown

that pre-participation stretching may improve ROM and muscle compliance, which was believed to protect against muscle strain. Although stretching supports muscle performance in elastic movements like hops or leaps, it is associated with decreased muscle power in concentric contractions such as steady-state cycling or jogging (33,34*). For this reason, the benefits of stretching alone are unclear. However, combining stretching with dynamic and sport-specific pre-participation drills may be able to restore stretchinduced performance loss (34*).

Conclusions

CMSI is a common condition. In high-performance athletes, calf strain contributes to missed practice, playing time or competition. Timely diagnosis and treatment can improve outcomes and can facilitate earlier return to sport. Optimised clinical reasoning at the time of injury, using a structured approach diagnosis and estimating prognosis is advised. Management following CMSI should involve

A UNIVERSAL INJURY PREVENTION PROGRAMME DOES NOT EXIST FOR CALF MUSCLES, SO THE APPROACH SHOULD BE TAILORED TO THE INDIVIDUAL 23

transitioning the athlete through phases extending beyond specific calf strengthening, to general strength and sport-specific work, dynamic ballistic and plyometric work, and progressive running rehabilitation. Early loading, within the athlete’s ability, is deemed safe and promotes early symptom relief and faster recovery. The final RTP decision should be a consensus, driven and informed by the athlete, therapists and their entire support team. A universal prevention programme may not be possible owing to diversity in calf demands between sports and individuals. A multifaceted approach involving individualised load management and exercise selection, as well as sportspecific training, and greater ‘on-field’ conditioning could provide the best preventive effect. References

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