Issue 18 - Winter 2017 by Football Medicine & Performance Association

football medic & scientist The official magazine of the Football Medical Association

Issue 19 Winter 2016/17

In this issue: Hamstring Injury Predictors Ischaemic Preconditioning Multidisciplinary Rehab Respiratory Problems

Exclusive:

ëŀċÊĹĎħāǝ Ňċëǝ5őŇőļë

Tony Strudwick’s vision for the role of sports science within the game

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

Legal ƺǝ!çőáÊŇĎĭħǝƺǝ ëáļőĎŇĦëħŇǝƺǝëğğàëĎħā

Contents

FMA FOOTBALL MEDICAL ASSOCIATION

Welcome 4

Members News

State of Play Eamonn Salmon

Features 8

Does Ischaemic Preconditioning Improve Exercise Performance Scott Cocking

12 Reshaping the Future of Sports Science Football Tony Strudwick 19 Detecting & Treating Respiratory Problems to Maximize Elite Football Performance Dr. John Dickinson, Anna Jackson & Dr. James Hull 24 Microfracture in the Knee Andrew Davies 26 Multidisciplinary Rehabilitation: A Case Study of a Proximal Biceps Tendon Rupture Matthew Bramhall, Tom Smith & Dr. Benjamin Rosenblatt 34 Comparison of Functional Isokinetic Strength Ratios Against Flexibility as Predictors for Hamstring Injury in Professional Male Soccer Players David Fevre, William Ford, Matthew J Hancock 41 Where Are They Now? Hugh Allen

COVER IMAGE Birmingham Cityâ&#x20AC;&#x2122;s Paul Robinson and head of Sports Science Dave Carolan Paul Roberts/EMPICS Sport Football Medical Association. All rights reserved. The views and opinions of contributors expressed in Football Medic & Scientist are their own and not necessarily of the FMA Members, FMA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMA. For permissions contact admin@footballmedic.co.uk.

SPONSORED BY

CHIEF EXECUTIVE OFFICER As we go to press with this our 19th edition of Football Medic & Scientist it is clear that our magazine has now become a respected and viable publication. The constant evolution of each and every edition illustrates the diversity and focus of our production which now occupies a unique space as a voice and forum for opinion as well as of academic interest. I was recently asked how we decide what goes to print and how we source articles of interest for each edition. In considering submissions, we have to look at our demographic and our appeal to a multidisciplinary audience â&#x20AC;&#x201C; medics, therapists, scientists, nutritionists, psychologists, podiatrists and a host of other interested parties within healthcare provision to our industry. We need to be aware of, and publish accordingly, the work of colleagues from different sports, and also remember our associate members, many of whom are newly graduated and eager to learn at a different level to more experienced readers. News and opinions are important but so is the personal touch in hearing where members are now and their observations â&#x20AC;&#x153;from the standsâ&#x20AC;?. We need to think beyond football and sometimes sport, so that we keep an interest in the work of colleagues in the NHS, in academia and in private practice since these are the fields that many of us will enter into on leaving the game. Add to this the need to have a strong and appropriate commercial focus in order to bring to our attention new products and companies with innovation, means we have a multifaceted and multifunctional approach to our evolving publication. What is important for us is looking after the best interests of our Members and readership, which means diversity of content and dissemination of information that applies to all, while at the same time keeping an eye on the bigger picture. Eamonn Salmon CEO Football Medical Association feature

Pictured: Tony with former Manchester United player-coach Ryan Giggs.

RESHAPING THE FUTURE OF SPORTS SCIENCE IN FOOTBALL FEATURE C>=H BCAD3F82: 7403 >5 ?4A5>A<0=24 <0=274BC4A D=8C43 The announcement that The Science + Football Conference 2017 will merge with the FMA Conference & Awards on the 27th and 28th May represents a positive step in defining the future of football and sports science. Moreover, it represents an opportunity for a group of scientists working within football to create a meaningful and much needed movement.

or almost every association in existence today there was a beginning moment when a group of people banded together for a common purpose, perhaps around a conference table or a hotel bar, and declared, â&#x20AC;&#x153;We need our own association.â&#x20AC;? This subject matter has been close to my heart for many years (and beers) and takes me back to the beginning of a journey.

World Congress of Science and Football in 1987 represented a major shift forward in effecting a link between theory and football practice, being the first occasion when representatives of all the football codes came together for a common purpose. Since then the event championed by the late Professor Tom Reilly, has been held every four years. The aims of the movement in science and football were to:

The Origins of Sports Science and Football

Historically football has been viewed as being inappropriate for scientific investigations. Three decades ago, the football environment was one in which the scientist was likely to be greeted â&#x20AC;&#x2DC;at worst with suspicion and hostility and at best with muted scepticismâ&#x20AC;&#x2122; (Reilly, 1979). The first

football medic & scientist

feature

To bring together scientists whose work is directly related to football and practitioners keen to obtain current information about its scientific aspects. Bridge the gap between research and practice so that scientific knowledge about football can be communicated and applied. Debate the common threads among

the football codes, both in research and practice. Sport science is a discipline that studies the application of scientific principles and techniques with the aim of improving sporting performance. The study of sport science traditionally incorporates areas of physiology, psychology and biomechanics but also includes other topics such as sports nutrition. Sports science also helps practitioners understand the physical and psychological effects of a sport thereby providing the best techniques for a sport and the most appropriate methods of preventing injuries to an athlete involved in the performance of the sport. The application of sports science has a selfevident part to play in improving football performance. Important features of a

Pictured: Watfordâ&#x20AC;&#x2122;s Valon Behrami lies injured on the pitch in a January fixture against Stoke City. It was later confirmed that he had received a hamstring injury.

COMPARISON OF FUNCTIONAL ISOKINETIC STRENGTH RATIOS AGAINST FLEXIBILITY AS PREDICTORS FOR HAMSTRING INJURY IN PROFESSIONAL MALE SOCCER PLAYERS FEATURE/DAVID FEVRE, WILLIAM FORD, MATTHEW HANCOCK ABSTRACT Background Hamstring injuries are a frequent problem for professional soccer players and whilst it is agreed there are multiple risk factors for injury, there is debate over the relative strengths of individual factors as predictors for injury. Studies have suggested that the functional isokinetic strength ratio of the hamstrings and quadriceps is a strong indicator of prospective hamstring injury. Hypothesis The aim of this study was to utilise this approach to determine if 3 separate flexibility tests would be better at predicting hamstring injury than the proven functional isokinetic strength ratio (Hecc/Qcon). Methods

The 3 flexibility and single isokinetic tests were performed on 18 male professional players aged 18-21 from an English professional soccer team (U-21 team) and compared with their retrospective injury history. Results Of the 4 screening methods used, the eccentric hamstring/ concentric quadriceps (Hecc/Qcon) strength ratio and the Erector Spinae Muscle Shortness Test (ESMST) were found to have a significant correlation with the incidence of hamstring injury. The remaining flexibility tests, the Sit and Reach Test (SRT) and the Hamstring Knee Angle Test (HKAT) showed no significant correlation. Conclusions The results of this paper suggest that whilst

SUMMARY BOX Pictured: Sunderlandâ&#x20AC;&#x2122;s Victor Anichebe signals to the following an injury, during their December game against Burnley . He was later found to have a hamstring problem.

What are the new findings? This study shows how the use of a simple flexibility screening tool can be effective in forewarning a medical team the individual athletes within a specific training/age group who carry a bigger risk of hamstring injury in a specific susceptible anatomical myofascial train How might it impact on clinical practice in the near future? Screening of athletes needs to be repeatable, simple to carry out and correlate to injury patterns in a particular sport. In this study the use of Erector Spinae Muscle Shortness Test (ESMST) as a screening tool is shown to be as effective as a proven isokinetic procedure and incorporates all the aforementioned factors to be effective. Additionally it requires smaller financial overheads and less academic interpretation making it a more widely available screening tool for a larger number of clinicians

certain flexibility and isokinetic tests can be utilised as predictors for hamstring injury, the correlation between flexibility/strength and injury is still inconclusive. Keywords Screening, soccer, professional football, lower extremity, hamstring injury

INTRODUCTION Hamstring injuries are a common and often recurring problem in athletes 1, 18. They can impact performance, or even prevent certain sporting activities. Therefore it is beneficial to the athletes themselves and their sporting teams to limit the occurrence of injuries. There are multiple methods of hamstring screening, but there is debate over which methods have a greater efficacy 7. A recent paper by Croisier (2008) found that the eccentric hamstring/ concentric quadriceps (Hecc/Qcon) strength ratio was a strong indicator for hamstring injury 2. However there is also research that supports the inclusion of flexibility as a significant indicator for hamstring injury as well. 3, 4, 32 In this study, data obtained from the under 21 squad of a professional English soccer club was used to compare the Hecc/Qcon strength ratio with 3 selected techniques of assessing hamstring flexibility as a predictor for hamstring injury. The 3 flexibility techniques include the Sit and Reach Test (SRT), Hamstring Knee Angle Test (HKAT) and the Erector Spinae Muscle Shortness Test (ESMST) which are all screening tests currently used by the medical team of the club at present. AIM OF THE STUDY This retrospective cohort study was performed in order to compare players Hecc/Qcon strength ratios to 3 differing flexibility tests; SRT, HKAT, ESMST, to see which was a better predictor of

hamstring injury. LITERATURE REVIEW Advanced search terms and phrases were used to look at the studies that were the most relative to the study. Phrases included â&#x20AC;&#x153;hamstring injuriesâ&#x20AC;?, â&#x20AC;&#x153;use of isokinetic data for screeningâ&#x20AC;?, â&#x20AC;&#x153;reliability of isokinetic dataâ&#x20AC;?, â&#x20AC;&#x153;risk factors for hamstring injuryâ&#x20AC;?, â&#x20AC;&#x153;risk factors for recurrent hamstring injuryâ&#x20AC;?, â&#x20AC;&#x153;hamstring injuries in soccer playersâ&#x20AC;?, â&#x20AC;&#x153;prevention of hamstring injuriesâ&#x20AC;?, â&#x20AC;&#x153;screening of hamstring injuriesâ&#x20AC;?. The hierarchy of evidence was also applied when discussing conflicting results, favouring studies such as systematic reviews and meta-analyses to case reports. Various sources were used to assess the reliability of isokinetic strength testing, as it formed the basis of this study 5, 6. The primary literature that was used to support the inclusion of isokinetic screening was a study conducted by Jean-Louis Croisier (2008) detailing functional isokinetic strength ratios. This study aimed to determine if the detection of muscular strength imbalances in football players could be a predictor of future hamstring injury, as well as determining whether or not correcting this imbalance could reduce the incidence of hamstring injury 2. This was proposed as there is controversy over the relationship between muscle injury and strength disorders 10,11,12,13, as it is uncertain if strength disorders are the causative agent, or if they arose because of injury. Studies show that strength disorders were found in around

70% of hamstring injuries after the injury was sustained, but it was unclear if these disorders had preceded the injury or not 2, 14. The prospective cohort study was conducted over a five year period, using players from professional teams in multiple countries. Only players who passed the initial assessment were included and out of those 687 players, 462 players went on to receive a full follow up and were included in the results. To ensure validity, the methods of taking isokinetic measurements remained the same for all players, as did the criteria used to define the incidence of a hamstring injury and for the definition of an imbalanced strength profile. There were some limitations for this study, one of which being that the measurements were gathered using many different physicians across the clubs. The study also suffers from attrition bias, as there were multiple drop-outs for several different reasons. It was found that the players with an imbalanced strength profile had significantly increased frequency of hamstring injury compared to those with a normal profile. Additionally, players who had undergone subsequent compensatory training to correct this imbalance had a reduced injury frequency compared to those who had no training. Furthermore, when repeated isokinetic control tests were used to measure the effects of the compensatory training until strength imbalance was resolved, the frequency of injury reduced to a similar figure for those without

Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 0333 456 7897 Email info@footballmedic.co.uk Web www.footballmedic.co.uk Chief Executive Officer

Eamonn Salmon Eamonn@footballmedic.co.uk

Executive Administrator

Lindsay McGlynn Lindsay@footballmedic.co.uk

Project Manager

Angela Walton Angela@footballmedic.co.uk

Design

Soar Media - www.soarmedia.co.uk

Marketing/Advertising

Charles Whitney - 0845 004 1040

Photography

PA Images, Francis Joseph, Football Medical Association

Contributors

Scott Cocking, Tony Strudwick, Dr. John Dickinson, Anna Jackson, Dr. James Hull, Andrew Davies, Matthew Bramhall, Tom Smith, Dr. Benjamin Rosenblatt, David Fevre, William Ford, Matthew J Hancock, Hugh Allen

Publisher

Academy Print & Design www.academy-print.co.uk

ĦëĦàëļŀǛǝħëŝŀ

MEMBERS’ NEWS

DAVE FEVRE TAKES RETIREMENT

ne of the most enduring characters in sports medicine has final stepped down from the main stage.

Dave Fevre, who as a Physiotherapist has been a stalwart of professional football for over 30 years administered his last game recently with Blackburn Rovers. Longtime colleague Grant Downie reflected:

‘I have had the pleasure knowing Dave 30 years & we both started in professional sport around the same time. We visited each other regularly during our varying posts and Dave was always only a phone call away from offering good sound advice. I think Dave was a leader in setting best practice standards in performance medicine/rehabilitation and was always ready to embrace new research and how things could be delivered to a better standard, without getting

caught up in gimmicks that at times flood our area. I am proud to have had Dave as a valued colleague, but more importantly as a friend. His values and standard of work are an example for all to follow “ Dave however, will still be in contact with colleagues and the game, in particular through his role with the FMA, so it’s not quite retirement just yet!

RECRUITMENT UPDATE

n reviewing a number of member services that we are able to offer, one of the key areas we have identified to enhance is the recruitment service we currently operate. At present, the FMA job facility is utilised and visited by a large number of members and clubs themselves are keen to access our database which is of course the perfect resource. But while the placing of jobs, the priority notification to members before anyone else and the access to clubs of our database is terrific, our recruitment service is about to extend way beyond its current format. The landscape for recruitment within our field is changing and is set to follow the same pattern as that of Managers and executives within the game. Already this season there have been appointments made via search and find services offered by various agencies and we believe this trend will continue. It is vital therefore that we keep our members at the

forefront of the jobs market. For this reason and to ensure our members are at the forefront we have been in discussions with a leading sports search firm that specialise in the placement of sports medicine and performance professionals. We are discussing options to launch a number of services in partnership with them which will give members access to a wider choice of sports medicine & performance roles both nationally and Internationally; search & selection services; CV filtering and appraisal services; plus general career guidance should a member find themselves outside of the game. This is a very positive and exciting prospect and members should recognise that they are part of one of the best databases for medicine and science in world football - one which our domestic Clubs and emerging football nations will be only too delighted to access in recruiting their personnel.

NWFA AWARD FOR JOYCE

r Joyce Watson of Accrington Stanley was the winner of the North West Football award for medical and science, held at Old Trafford last November. Dr Watson, who had been nominated on a previous occasion collected her award from Dan Walker and Fabrice Muamba and received due praise from Stanley manager John Coleman, who acknowledged her commitment and loyalty to the Club over the past 15 years.

football medic & scientist

EFL APPOINT MEDICAL ADVISOR

NEW WEBSITE

nnouncing a new website says one thing: that we have grown and evolved so much our current site is no longer able to keep up! And this is very much the case here again. While some of the features will be familiar, there are several additions which will be of real value to members and visitors to the site. ~

~ ~

A brand-new forum has been introduced which will provide members a platform to discuss and inform of topics of interest. A new careers section will act as a guide for aspiring practitioners to plan their careers in the game. Easier registration and ability for

~ ~ ~

members to change their profile details. Improved navigation around the site. Extended web and media platforms. have been built in order to facilitate better educational interaction. The Football Medicine Register enables Members and the general public as well as those in grassroots football to seek out practitioners with experience and knowledge of the professional game who are now in private practice.

In the main, we will be able to amend content of the website within the office, which will ensure a much more relevant, interactive and updated site for members to engage with. www.footballmedic.co.uk

he Football League (FL) have appointed Dr Richard Higgins from Sheffield Wednesday FC as their medical advisor. In a move that replicates that of the Premier league, who appointed Dr Matt Perry some time ago, the FL have recognised the need for expert opinion in order to navigate future discussions and any impending changes to our industry within football. This is a much-needed appointment and gives us all the direct line to the FL which has been sorely lacking in recent years. The FMA has offered its full support to Dr Higgins and are certain we will work together in the coming seasons.

AMENDMENT

n the last issue, it was quoted that Will Royall had been Head of Fitness at Derby County, Birmingham City and Hull City. This should have read Wigan Athletic, Sunderland and Hull City and was an administration error. Our apologies.

FMA BACKS SPORTS MEDICINE PUBLICATION

he Elsevier editorial team would like to update you on the progress of their exciting new sports medicine book provisionally entitled â&#x20AC;&#x153;A Comprehensive Guide to Sports Physiology and Injury Management: an interdisciplinary approachâ&#x20AC;? This textbook will be split into two parts, Part 1: Physiology and Part 2: Injury Management. Some of the confirmed Authors include: ~ FPh]T 3XTbT[) <XP\X 3^[_WX]b =5; ~ 0SP\ FTXa) 0b_TcPa ~ BcTeT <R2PXV) 421 ~ 1ahP] 4]V[XbW) <XSS[TbQâ^dVW ~ 9^W] 5TPa]) 2WT[bTP ~ =XRZ 0[[T]) A^hP[ 1P[[Tc ~ 4P\^]] 3T[PWd]c) D23 8]cTa]PcX^]P[ Ankle Consortium. ~ ?9 FX[b^]) <d]bcTa AdVQh 2[dQ ~ 0ZQPa ST <TSXRX) 5d[WP\ 5^^cQP[[ 2[dQ ~ BX\^] <PabW) 6X[\âT 6a^X] 7Ta]XP 2[X]XR ~ ?Pd[ 6^SUaTh) BfX]S^] 52 ~ ?aÛ 6aPWP\ B\XcW) B^RXTch Û B_âcb Therapists.

The publication is still looking for potential Authors/Contributors and would welcome ideas from all FMA members. As a rough guideline, they are looking for potential authors to contribute their expert opinion on areas that they are passionate about, whether this be rehab, treatment, anatomy, injury incidence, the call for change etc. They are looking to produce a clinically useful text, the most important aspect being writing about topics that hold currency with sports medicine professionals around the world. ~ ~ ~ ~

Word count: 5000 words. Illustrations max 8. Expert opinion rather than reuse of white paper material. Cross-contamination / pollination is certainly welcome with a theme that is salient to those sports / disciplines / anatomy involved. Chapter can be written on anatomical region or common injuries in that sport (ankles in ballet etc.) or about a particular pathology - the choice is yours.

~ ~ ~ ~

Outline of chapter is to be ideally submitted over the next 8 weeks. To include the leading figures in the field of sports medicine. 6 month period for submittal of initial draft. 3 to 6 month period of editorial revisions.

Please also feel free to suggest others you think would be suitable to write in the book. Johnny Wilson Chief Editor Email: johnnywilson55@hotmail.com Tel: +44 (0)7807 694 556 Twitter: @jo78wi FMA: As the representative body for medicine and science in professional football, we have always championed the opinion of practitioners who are engaged directly with players and sports performers. Indeed, learning from those with such engagement is the backbone of our annual Conference. In upholding that same ethos, and with a unique insight extoling excellence in our field, this reference manual has our full support and endorsement as a text for all our members to use.

football medic & scientist

ĦëĦàëļŀǛǝħëŝŀ

STATE OF PLAY FEATURE/EAMONN SALMON

hen the FMA – or LMedA as we were initially called – was set up 6 years ago it was envisaged that we would effectively become a lobby group to effect change in our working environment for the betterment of all concerned. It was also anticipated that we would be highlighting issues to the Players Football Association (PFA), the Football Association (FA), the Football League (FL) and the Premier League (PL) with the aim of getting our message across that all was not what it seemed within our day to day work; in particular where our clinical and ethical obligations were challenged or compromised. While we are campaigning for change our approach has now taken a very different route to that which we envisaged. This is essentially because of a complete change in the landscape concerning governance and the duties of Professional Football clubs as employers. Two years ago, the appointment by the Premier League of a medical advisor set in place a pathway for change that in time

will likely affect all of us. Indeed, this appointment was an acknowledgement by the PL of the need to consider the medical and science framework within the game. A series of discussions and meetings within the Premier League over the past 2 years has resulted in support for a collaborative approach on achieving “best practice” in medicine and employment. This recognises the existing statutory duties of Clubs as employers in the provision of a safe working environment and the value of working together to address and effect change. In short, this process and its outcomes will determine our working environment and practice in the future. The FMA has always held a strong belief that medical and science issues should be addressed by medical and science people. To this end the FMA has been engaged in frequent discussions and meetings to keep track of developments and make sure we understand the complexities of the process.

The Premier League has established a Medical Working Group to provide guidance to their 20 Clubs and a further steering group consisting of the Football Association, the Premier League, the Football League and the Players Football Association is to develop guidance for the wider professional game. Once the initial framework for progress is established, the FMA will be looking to assist this group in developing systems and guidance to support best practice. The Football League has also very recently appointed a medical advisor. Now that the structures exist within the leagues to develop and share good governance there is every reason to believe the momentum will extend throughout the professional game. It is early days but the principles are sound and we trust that this mechanism will serve to deliver the necessary change that was one of the many reasons the FMA was established in the first place.

ÿëÊŇőļë

Pictured: Paris Saint-Germain’s Thiago Silva (second right) and Lucas (right) during a training session ahead of the UEFA Champions League group stage match at the Emirates Stadium, London.

DOES ISCHAEMIC PRECONDITIONING IMPROVE EXERCISE PERFORMANCE? FEATURE/SCOTT COCKING, QATAR The effect of ischaemic preconditioning (IPC) on exercise performance is an increasingly popular topic in sports science. This article will present the key practical considerations for using IPC prior to sports performance, supported by discussion of both the current literature findings and potential mechanisms that may underpin changes in human performance. THE SEARCH FOR ERGOGENIC STRATEGIES IN SPORT

xtremely fine margins exist in sport, with under one hundredth of a second historically being the difference between gold and silver medals in Olympic events such as swimming, rowing, 100 m and 400 m track (to name a few). Consequently, the competitive nature of elite sport in the present era pushes/encourages athletes and sports scientists to find novel strategies (where legally permitted) to maximise competitive performance. Periodised training programmes developed by coaches and scientists plan to ensure optimal performance occurs on competition day. Regardless of training preparation, certain pre-competition strategies exist, capable of further enhancing performance. The problem with some proven ergogenic aids is that they often carry complications or lack practicality in applied competitive settings (i.e. potential antidoping violations or technological limitations). Ergogenic/preconditioning strategies come in many forms (nutritional supplementation, post-activation potentiation, prior highintensity exercise priming and passive heating/cooling).

BACKGROUND OF IPC IPC is a method whereby brief episodes of ischaemia (either 3 x 5 or 4 x 5 minutes of arterial blood flow occlusion interspersed with 5 minutes of reperfusion) are administered to a limb in order to increase a tissue’s tolerance to prolonged ischaemic exposures. IPC represents a hormetic biphasic dose-response phenomenon and reduces tissue infarct size following both local (at the site of ischaemia) and remote (RIPC – away from the site of ischaemia) interventions in which the myocardium has been subjected to prolonged ischaemic insult1,2. The first study to apply IPC to an exercise model found a 3% improvement in V02 max and improved time to exhaustion during an incremental cycling ramp test3. These findings were the first to suggest IPC could be seen as a potential ‘priming’ strategy (i.e. improving physiological readiness for exercise) for certain exercise tasks. While non-significant findings have been also reported4-10, a recent systematic review and meta-analysis reported a positive overall effect on exercise performance11. The question still arises as to how to best use

this strategy (how to actually perform IPC) in order to achieve optimal results.

PRACTICAL ISSUES TO DATE There are some key practical considerations when applying IPC. To date, variation in exercise performance following IPC is likely to be the result of inconsistencies in its use prior to exercise. Further investigation into IPC dose-response, cuff placement, occlusion area and the amount of time needed between exercise and IPC may offer vital insight, allowing athletes to maximise any performance enhancing stimulus that occurs.

IPC DOSE Doses of 3 x 5 minute or 4 x 5 minute occlusion bouts have been performed12,13. While these doses have resulted in both beneficial and negligible exercise performance findings3,4,10,14, a recent systematic review and meta-analysis suggests that use of either 3 or 4 sets of IPC is equally effective with regard to exercise performance outcome11.

football medic & scientist MUSCLE MASS OCCLUSION AREA D]X[PcTaP[ P]S QX[PcTaP[ [X\Q ^RR[dbX^] protocols have been used with varying success in determining improvements in exercise performance. The observation of beneficial effects in rowing, maximal swimming performance and underwater swimming13,15 following unilateral limb occlusion raises uncertainty about whether the employment of bilateral vs. unilateral limb occlusion is a key methodological determinant of IPC. Of all performance studies to date reporting negligible findings following IPC, only two employed a unilateral IPC protocol7,16. A recent study by Kraus et al was the first to compare two separate RIPC conditions on repeated Wingate performance and found performance improvements following bilateral RIPC vs. placebo (SHAM) when compared to unilateral RIPC. It is worth noting that the sample size (n=29 vs n=14, respectively) and ratio of males to females (21:8 vs 6:8, respectively) were larger in the bilateral RIPC condition, potentially influencing statistical findings and performance outcome. The suggestion that an area ‘threshold’ of muscular mass exists during ischaemia in order to enhance performance following IPC remains unproven and requires further investigation12.

CUFF PLACEMENT Depending on exercise modality, the cuff can be placed locally (applied to the exercising limb) or remotely (applied to the nonexercising limb). Local IPC has been shown to improve V02 max and power output by 3% and 4% respectively, during incremental cycling tests3,12, 5 km time trial (TT) treadmill running performance by 2.5%14, and exercise capacity in time to exhaustion cycling tasks by 8% to 15.8%17,18. Successful improvements in exercise performance or capacity following RIPC include: handgrip exercise time to exhaustion19; rowing 1000 m TT performance and underwater swimming distance15. It remains unclear whether applying occlusion directly to the exercising limbs is more beneficial compared to occlusion in the nonexercising limbs.

Figure 3.

approximately 2 to 4 hours20,21. No study has previously investigated different rest periods prior to either aerobic or anaerobic exercise bouts, making it difficult to clarify the impact rest duration has on exercise performance. Further studies are required to determine the effect of the length of the rest period between IPC and exercise.

WHICH SPORTS MAY BENEFIT FROM IPC AND WHY? Apnoeic sports (breath-hold sports) To date, there are three studies investigating the effect of IPC on exercise capable of inducing static or dynamic apnoea. The first study assessing the effects of RIPC on swimming performance found a significant improvement in 100 m swimming time (0.7 seconds), but no change in repeated 200 m efforts13. The improvement in sprint swimming was not matched with alterations in lactate, leading the authors to speculate whether RIPC has the ability to improve mitochondrial

metabolism, something which has yet to be confirmed in any human exercise models. A well-designed study recently found 6 x 50 m maximal swimming sprint performance was significantly improved following IPC (3 x 5 minutes at 220 mmHg), but not following placebo (SHAM) or control trials22. The SHAM condition consisted of 2 x 2 minute cuff inflation periods at 10 mmHg separated by a 1 minute occlusion bout at 220 mmHg. Doing this allowed participants to experience similar perceptual pain without inducing changes in muscle oxygen saturation or stimulating ischaemia-induced tissue protection22. IPC augmented swimming velocity without altering stroke rate, stroke length or number of breaths, implying improved muscular work, which is also reported in cycling exercise17. The third study concluded muscle ischaemia is an important preparation for physical activity, after finding IPC (performed on one forearm) enhanced static breath-hold by 17% and underwater swimming distance (dynamic apnoea) by 8%15. In this study by Jean St Michel et al, underwater swimming distance was improved without an increased time under water, again suggesting an improvement in metabolic efficiency.

TIMING PRIOR TO PERFORMANCE

Non-apnoeic sports (Non-breath-hold sports)

Following completion of IPC, the ‘rest’ duration prior to starting exercise varies across studies ranging from 5 to 90 minutes. Of all practical considerations, rest-to-work duration has arguably been given the least attention as a potential mediator of IPC-induced changes in exercise performance. The influence of rest duration on aerobic exercise performance enhancement is currently unclear, however longer rest time and effect size of anaerobic performance improvement shows a linear tendency (i.e. the longer the rest, the better the performance)11. If the mechanisms responsible for improved tissue protection are also responsible for improvements in exercise performance, it would seem the manipulation of rest duration would serve no benefit, as cardio-protection is immediately active following acute IPC exposure and lasts for

The entrained nature of breathing is often not present in land-based performance tasks. Nevertheless, to date there are 11 studies reporting significantly improved exercise performance in activities such as cycling to exhaustion, repeated Wingate tests, rowing TT performance, 5 km treadmill running TT performance, resistance exercises, isometric leg exercises and handgrip time to exhaustion tasks3,12,15,17-19,22-25. In contrast, nine studies show negligible changes in exercise performance tasks including repeated sprint ability (running and cycling), 5 km track TT running and incremental cycling to exhaustion4-10,26,27. The reason for variation in land-based exercise performance remains unknown. Although, it was reported that there is an overall positive effect on both aerobic and anaerobic (defined by authors as > 30 seconds)

Figure 2.

ÿëÊŇőļë exercise, while sprint (defined by authors as < 30 seconds) exercise showed no positive response following IPC exposures11. It may well be that an optimal exercise intensity exists, independent of modality, to match any physiological/mechanistic changes that potentially prime the body for exercise following IPC exposures. As it stands, non-apnoeic performance results remain relatively unclear after the administration of IPC compared to apnoeic sport performance, although it should be acknowledged there is an extremely limited number of research publications investigating the effects of IPC on apnoeic sports performance to date.

WHY WOULD IPC HELP AN ATHLETE PERFORM? Blood flow and vascular responses Besides the novel suggestion of altered cardiac biomarker response28, there is currently no evidence to suggest IPC can alter cardiac function during exercise, suggesting any changes in blood flow or oxygen delivery during exercise are primarily mediated through changes in vascular function11,12,27,29,30. A remote preconditioning effect reportedly occurs following high-intensity or interval exercise, but not continuous exercise31. Interval exercise prevents endothelial reperfusion injury, preventing a 40% reduction in flowmediated dilation in healthy individuals following 20-minute upper body prolonged ischaemia. It is proposed that IPC can mimic these results through inducing similar patterns of muscle deoxygenation31, de-saturation15 and a larger shear stress response30; all of which contribute to improved endothelial function. The extent to which IPC can contribute to blood flow changes during exercise in skeletal muscle is still unclear. RIPC increases skeletal muscle blood flow during reperfusion following prolonged ischaemia, preventing reductions in flow-mediated dilation following highintensity exercise29. In contrast, when handgrip exercise to failure was improved following RIPC vs placebo (SHAM) (198 ± 70 vs 179 ± 66 seconds, respectively), additional feedback from ultrasound Doppler and near-infrared spectroscopy showed no improvements in blood flow or microvascular balance between oxygen utilisation during the exercise bout19. The maintenance of endothelial function following 5 km TT running, suggests improved exercise performance may be related to improvements in nitric oxide bioavailability14,19. Enhanced nitric oxide levels reduce both local and systemic muscular oxygen cost during exercise32,33 through alterations in skeletal muscle mitochondrial efficiency34. While there was no change in blood flow in a short handgrip time-to-exhaustion protocol19, the mechanistic insight to blood flow response during large muscle-mass exercise remains unknown, especially during high-intensity, strenuous exercise, where performance may become limited by blood flow35.

Skeletal muscle adaptation Recently, three key studies have reported enhanced skeletal muscle deoxygenation

Figure 1.

dynamics paired with significantly improved exercise performance (time to exhaustion). It therefore appears that alterations in oxidative mitochondrial metabolism with IPC may be a key mechanism underpinning improved exercise performance. Recently, Cruz et al17 found an 8% improvement in cycling to exhaustion at peak power output that was matched to an IPCinduced improvement in amplitude of the V02 slow component, rather than accelerated phase II oxygen kinetics, as previously hypothesised. The authors speculated that this may spare a portion of finite anaerobic energy stores during the cycling bout. This hypothesis is partly supported by Kido et al18 who suggested IPC may partially reduce the skeletal muscle oxygen cost following findings of an IPC-induced reduction in the amplitude of deoxyhaemoglobin/ deoxymyglobin during moderate-intensity cycling exercise. Interestingly, both high-intensity exercise and IPC cause large amounts of shear stress on the endothelial wall, in turn leading to augmented nitric oxide production, derived from endothelial nitric oxide synthase. While supplementation of nitric oxide metabolite compounds and increased nitric oxide bioavailability is beneficial to exercise performance, it also reduces local muscular oxygen cost by improving energy efficiency in the mitochondria34. Therefore, we might speculate that improvement in skeletal muscle energy production is related (at least in part) to local shear-stress-related mechanisms. Similarly, high-intensity exercise prior to competition induces a priming response in the form of accelerated muscle oxygen response36 and associated mitochondrial enzymatic activation in skeletal muscle37. Interestingly, excess capacity of mitochondrial respiration, when compared to in-vivo V02 max only exists during maximal exercise38. It would therefore seem that, during maximal aerobic exercise, an improvement in oxygen delivery, not mitochondrial function, may be key in improving performance17. Effects of IPC on mitochondrial flux capacity during exercise is currently unclear and warrants further investigation, via both invivo and in-vitro muscle biopsy samples.

Nervous system Enhanced vastus lateralis activation (measured with electromyography) following IPC17 suggests positive alterations in central nervous system activity. It was hypothesised that inhibition of spontaneous discharges from opioid-mediated muscle afferents could result in an overshoot in central motor drive allowing a higher proportion of skeletal muscle recruitment to take place during intense exercise bouts17. Neurally-mediated alterations

that occur following IPC have, to date, only been documented in clinical research, with the neural pathway being a proposed route of IPCinduced tissue protection following a prolonged ischaemic stimulus. However, the concept of IPC-induced nociceptive alteration (at either the muscular level or in the nervous system) is certainly intriguing when relating to feedback mechanisms during high-intensity, demanding exercise. While potentially being a damaging adaptation for pacing, it could benefit events which require all out work for extremely short periods (< 4 minutes).

FUTURE IPC DIRECTIONS AND APPLICATIONS As ischaemic preconditioning continues to show promise in the laboratory environment, more organisations may look to employ it in applied performance settings. However, there are some key questions that are yet to be answered including: What is the effect of IPC when combined with other performance-enhancing ergogenic aids (caffeine, beetroot juice etc.)? What effect does IPC have on truly elite individuals when performing specific performance tasks? Research groups may look to employ IPC interventions with development squads, where there may be a greater margin for testing new performance-enhancing strategies prior c^ R^\_TcXcX^]b D]cX[ SPcP PaT R^[[TRcTS X] these more elite populations, it is only possible to speculate on how and when IPC might be used in the elite setting. Current scientific data suggest competitors in apnoeic sports may likely benefit from this intervention, with research to date focusing on competitionspecific performance tasks. While observations such as improved cycling time to exhaustion tasks provide promising insight to altered physiological capacity, that in itself may not carry enough specificity to support the use of IPC in land-based athletes (cyclists and runners) prior to important competitions.

This article was originally published in the Aspetar Sports Medicine Journal, available from www. aspetar.com/journal. All copyright is property of Aspetar and may not be reproduced without permission.

football medic & scientist REFERENCES Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 1986; 74:1124-1136. Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemicâ&#x20AC;&#x2122;precondition ingâ&#x20AC;&#x2122;protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation 1993; 87:893-899. de Groot PCE, Thijssen DHJ, Sanchez M, Ellenkamp R, Hopman MTE. Ischemic preconditioning improves maximal performance in humans. Eur J Appl Physiol 2010; 108:141-146. Clevidence MW, Mowery RE, Kushnick MR. The effects of ischemic preconditioning on aerobic and anaerobic variables associated with submaximal cycling performance. Eur J Appl Physiol 2012; 112:3649-3654. Gibson N, White J, Neish M, Murray A. Effect of ischemic preconditioning on land-based sprinting in team-sport athletes. Int J Sports Physiol Perform 2013; 8:671-676.

running performance. Med Sci Sports Exerc 2012; 44:2084-2089. Kjeld T, Rasmussen MR, Jattu T, Nielsen HB, Secher NH. Ischemic preconditioning of one forearm enhances static and dynamic apnea. Med Sci Sports Exerc 2014; 46:151-155. Kraus AS, Pasha EP, Machin DR, Alkatan < :[^]Ta A0 CP]PZP 7 1X[PcTaP[ D__Ta ;X\Q Remote Ischemic Preconditioning Improves Anaerobic Power. Open Sports Med J 2015; 9. Available from: www.benthamopen.com/ ABSTRACT/TOSMJ-9-1 Accessed September 2015. Cruz RS de O, de Aguiar RA, Turnes T, Pereira KL, Caputo F. Effects of ischemic preconditioning on maximal constant-load cycling performance. J Appl Physiol 2015; 119:961-967. Kido K, Suga T, Tanaka D, Honjo T, Homma T, Fujita S et al. Ischemic preconditioning accelerates muscle deoxygenation dynamics and enhances exercise endurance during the work-to-work test. Physiol Rep 2015; 3:e12395-e12395.

Gibson N, Mahony B, Tracey C, Fawkner S, Murray A. Effect of ischemic preconditioning on repeated sprint ability in team sport athletes. J Sports Sci. 2015; 33:1182-1188.

Barbosa TC, Machado AC, Braz ID, Fernandes IA, Vianna LC, Nobrega AC et al. Remote ischemic preconditioning delays fatigue development during handgrip exercise. Scand J Med Sci Sports 2015; 25:356-364.

Lalonde F, Curnier DY. Can anaerobic performance be improved by remote ischemic preconditioning? J Strength Cond Res 2015; 29:80-85.

Hausenloy DJ, Yellon DM. The second window of preconditioning (SWOP) where are we now? Cardiovasc Drugs Ther 2010; 24:235254.

Tocco F, Marongiu E, Ghiani G, Sanna I, Palazzolo G, Olla S et al. Muscle ischemic preconditioning does not improve performance during self-paced exercise. Int J Sports Med 2015; 36:9-15.

Loukogeorgakis SP, Panagiotidou AT, Broadhead MW, Donald A, Deanfield JE, MacAllister RJ. Remote ischemic preconditioning provides early and late protection against endothelial ischemiareperfusion injury in humans. J Am Coll Cardiol 2005; 46:450-456.

Seeger JPH, Timmers S, Ploegmakers DJM, Cable NT, Hopman MTE, Thijssen DHJ. Is delayed ischemic preconditioning as effective on running performance during a 5km time trial as acute IPC? J Sci Med Sport 2016. [Epub ahead of print]. PaixĂŁo RC, da Mota GR, Marocolo M. Acute effect of ischemic preconditioning is detrimental to anaerobic performance in cyclists. Int J Sports Med 2014; 35:912-915. Salvador AF, De Aguiar RA, LisbĂ´a FD, Pereira KL, Cruz RS, Caputo F. Ischemic preconditioning and exercise performance: a systematic review and meta-analysis. Int J Sports Physiol Perform 2016; 11:4-14 Crisafulli A, Tangianu F, Tocco F, Concu A, Mameli O, Mulliri G et al. Ischemic preconditioning of the muscle improves maximal exercise performance but not maximal oxygen uptake in humans. J Appl Physiol 2011; 111:530-536. Jean-St-Michel E, Manlhiot C, Li J, Tropak M, Michelsen MM, Schmidt MR et al. Remote preconditioning improves maximal performance in highly trained athletes. Med Sci Sports Exerc 2011; 43:1280-1286. Bailey TG, Jones H, Gregson W, Atkinson G, Cable NT, Thijssen DHJ. Effect of ischemic preconditioning on lactate accumulation and

Ferreira TN, Sabino-Carvalho JL, Lopes TR, Ribeiro IC, Succi JE, da Silva AC et al. Ischemic preconditioning and repeated sprint swimming: a placebo and nocebo Study. Med Sci Sports Exerc 2016. [Epub ahead of print]. Patterson SD, Bezodis NE, Glaister M, Pattison JR. The effect of ischemic preconditioning on repeated sprint cycling performance. Med Sci Sports Exerc 2015; 47:1652-1658.

PLoS One 2014; 9:e105361. Hittinger EA, Maher JL, Nash MS, Perry AC, Signorile JF, Kressler J et al. Ischemic preconditioning does not improve peak exercise capacity at sea level or simulated high altitude in trained male cyclists. Appl Physiol Nutr Metab 2015; 40:65-71. Cocking S, Landman T, Benson M, Lord R, Jones H, Gaze D et al. The impact of remote ischemic preconditioning on cardiac biomarker and functional response to endurance exercise. Scand J Med Sci Sport 2016. [Epub ahead of print]. Bailey TG, Birk GK, Cable NT, Atkinson G, Green DJ, Jones H et al. Remote ischemic preconditioning prevents reduction in brachial artery flow-mediated dilation after strenuous exercise. Am J Physiol Heart Circ Physiol 2012; 303:H533-H538. Jones H, Hopkins N, Bailey TG, Green DJ, Cable NT, Thijssen DHJ. Seven-Day Remote Ischemic Preconditioning Improves Local and Systemic Endothelial Function and Microcirculation in Healthy Humans. Am J Hypertens 2014; 27:918-925. Seeger JPH, Lenting CJ, Schreuder THA, Landman TRJ, Cable NT, Hopman MTE et al. Interval exercise, but not endurance exercise, prevents endothelial ischemia-reperfusion injury in healthy subjects. Am J Physiol Heart Circ Physiol 2015; 308:H351-H357. Bailey SJ, Winyard P, Vanhatalo A, Blackwell JR, DiMenna FJ, Wilkerson DP et al. Dietary nitrate supplementation reduces the O2 cost of low-intensity exercise and enhances tolerance to high-intensity exercise in humans. J Appl Physiol 2009; 107:1144-1155. Bailey SJ, Fulford J, Vanhatalo A, Winyard PG, Blackwell JR, DiMenna FJ et al. Dietary nitrate supplementation enhances muscle contractile efficiency during knee-extensor exercise in humans. J Appl Physiol 2010; 109:135-148. Larsen FJ, Schiffer TA, Borniquel S, Sahlin K, Ekblom B, Lundberg JO et al. Dietary inorganic nitrate improves mitochondrial efficiency in humans. Cell Metab 2011; 13:149-159. Grassi B. Regulation of oxygen consumption at exercise onset: is it really controversial? Exerc Sport Sci Rev 2001; 29:134-138.

Tanaka D, Suga T, Tanaka T, Kido K, Honjo T, Fujita S et al. Ischemic preconditioning enhances muscle endurance during sustained isometric exercise. Int J Sports Med 2016. Available from: www.thieme-connect.de/DOI/ DOI?10.1055/s-0035-1565141 Accessed June 2016.

Jones AM, Berger NJA, Wilkerson DP, Roberts CL. Effects of â&#x20AC;&#x153;primingâ&#x20AC;? exercise on pulmonary O2 uptake and muscle deoxygenation kinetics during heavy-intensity cycle exercise in the supine and upright positions. J Appl Physiol 2006; 101:14321441.

Marocolo M, Willardson JM, Marocolo IC, Ribeiro da Mota G, SimĂŁo R, Maior AS. Ischemic preconditioning and placebo intervention improves resistance exercise performance. J Strength Cond Res 2016; 30:1462-1469.

Gandra PG, Nogueira L, Hogan MC. Mitochondrial activation at the onset of contractions in isolated myofibres during successive contractile periods. J Physiol. 2012; 590:3597-3609.

McDonald MA, Braga JR, Li J, Manlhiot C, Ross HJ, Redington AN. A Randomized Pilot Trial of Remote Ischemic Preconditioning in Heart Failure with Reduced Ejection Fraction.

Boushel R, Gnaiger E, Calbet JAL, GonzalezAlonso J, Wright-Paradis C, Sondergaard H et al. Muscle mitochondrial capacity exceeds maximal oxygen delivery in humans. Mitochondrion 2011; 11:303-307.

ÿëÊŇőļë

Pictured: Tony with former Manchester United player-coach Ryan Giggs.

RESHAPING THE FUTURE OF SPORTS SCIENCE IN FOOTBALL FEATURE/TONY STRUDWICK - HEAD OF PERFORMANCE, MANCHESTER UNITED The announcement that The Science + Football Conference 2017 will merge with the FMA Conference & Awards on the 27th and 28th May represents a positive step in defining the future of football and sports science. Moreover, it represents an opportunity for a group of scientists working within football to create a meaningful and much needed movement.

or almost every association in existence today there was a beginning moment when a group of people banded together for a common purpose, perhaps around a conference table or a hotel bar, and declared, “We need our own association.” This subject matter has been close to my heart for many years (and beers) and takes me back to the beginning of a journey.

The Origins of Sports Science and Football

Historically football has been viewed as being inappropriate for scientific investigations. Three decades ago, the football environment was one in which the scientist was likely to be greeted ‘at worst with suspicion and hostility and at best with muted scepticism’ (Reilly, 1979). The first

football medic & scientist model, such as devising training programs, monitoring performance, and establishing preparation for competition are informed by such knowledge. A key role role of sports science in football is to utilize scientific principles to maximize individual performance and player preparation. Practitioners can then manipulate the training process effectively in order to achieve these objectives. In 1992 the establishment of the Premier League signaled a change in the relationship between football and science. A greater intensity emerged as football’s commercialization process intensified. The value of players increased exponentially as did the financial rewards and losses for staying in the Premier League. As a result, these developments necessitated a greater investment in medical and scientific facilities and resources. Since the establishment of Premier League, there has been a shift towards systematic methods of preparing elite players. Contemporary coaches have been exposed to scientific approaches to preparing teams for competition. There are certainly a number of examples of ‘good practice’ in elite English football. Indeed, coaching practice that for many years was based largely on tradition, emulation and intuition is now giving way to a scientific evidence based approach. This shift has resulted in better informed practitioners working with teams, stronger links with scientific institutes and more coaches being willing to accept the changing role of sports science in elite football. 2017 will be my 20th year in professional football. This journey has taken me from an internship within the Academy of Coventry City (possibly the first internship in the history of English football, and indeed the [^fTbc _PXS c^ P a^[T Pc <P]RWTbcTa D]XcTS back within the Academy setting. I now have a self-defined, over-estimated job description that has Head and Performance in the same title. It seems to be the norm today! There have been seismic changes in the football landscape and indeed the role of sports science. What has not changed however is the desire to search for innovative ways to improve player performance through sports science principles. I have always maintained that a sports science service plays a significant role in football success. As a group of professionals, we have a critical eye for detail and an incessant desire to improve human performance. This should translate well into any backroom team environment. More recently, I have met some incredibly talented practitioners who are servicing elite footballers as good as any athlete in any sport across the globe. Football no longer trails behind rugby, athletics or American sports in terms of intellectual property and/or skilled practitioners. Nevertheless, there has to be a point in which we start to evaluate the current impact of sports science on the professional game. Has the perception of sports science in football

changed? Do the current influx of sports scientists totally understand the complex interaction between head coach and players? Do they fully understand the impact of the service? Or, has sports science lost its way with an over-inflation of its self-importance (particularly in a data rich high tech society)? These issues were raised recently in a Sports Discovery blog, warning of the catastrophic consequences of poor sports science in professional football:

‘Once a service has been ill-sold to 25 people, it can be a tough challenge to salvage credibility, so the service provider aims to over-deliver to try and fulfill expectations, often with great difficulty’. Jonathan Bloomfield I do feel a sense that sports science needs to shape and redefine its position in contemporary professional football. It also needs to take stock where it has been, where it now sits and indeed where it wants to go in the future. More importantly, sport science in professional football requires an identity, representation, defined pathways and a common need. An urgency or common need prompts people to work together to pursue goals and interests. For us, it might be an individual or team crisis, a need to certify professionals, a platform to share ideas, a need to search for career opportunities, or the desire to split away from a parent organization. As new industries, professions, and causes emerge, so do new associations to represent them.

Whatever the impetus, the decisions made by the founders during the start-up period will have a profound impact on the success, effectiveness, and longevity of the new organization. Quite simply, associations are peoplegroups of people who find strength in numbers while sharing common interests of industries, professions, or best practice. Associations are founded upon the principles of representation and common interest that are the heart of the human experience. By definition, associations exist for the mutual protection and advancement of their members. They call themselves a host of names - associations, organizations, federations, alliances, networks or unions. Although they come in many shapes and sizes, they are all associations, sharing the twin goals of helping their members and advancing their area. Over the years, I’ve had many conversations with like-minded people such as John Goodman, Professor Barry Drust and Chris Barnes bemoaning the lack of motivation at the English Football Association to really give us a voice, representation and a platform to define our association. Thus, the merging of the Science and Football Conference and the FMA will be welcomed and embraced by many across elite football. This is particularly important for the new breed of highly educated (and indeed self-confident) practitioners looking for opportunities to progress and indeed thrive within the echelons of the professional game. The traditional bases of football are changing fast. Innovation in products and services is more challenging by the day.

ĂżĂŤĂ&#x160;Ĺ&#x2021;Ĺ&#x2018;ÄźĂŤ Expectations go on rising. Football clubs have more and more data on hand but they have far less room for errors in execution, so decision-making has to be sharper and better informed. All in all, these factors call for superior analytics and deeper scientific insights into what makes a team successful. Analytics will involve the extensive use of data, statistical and quantitative analysis, explanatory and predictive model, and fact based management to drive decisions and actions. The analytics may be input for human decisions or may drive fully automated decisions. It must be stressed that analytics and intuitive decision-making need not represent two diametrically opposed paradigms. Nonetheless, contemporary coaches and sports scientists will have first-hand experience of how the intelligent use of analytics can improve asset acquisition and management, talent management, operational performance, and even injury prediction. It is imperative then, that sports science in football continues to promote itself as a positive service. The alternative is an oversubscribed, undervalued service that fails to engage with players, coaches and clubs alike. Football scientists should provide information for the subsequent action by both coach and player. In order to achieve this, the player, coach and scientist should be conversant with the procedures involved. Engagement of all parties is critical to improving performance. There also has to be a consideration for all those involved in football preparation of â&#x20AC;&#x153;how much is too much?â&#x20AC;? Even though we will have sophisticated protocols, technology and analytics, there has to be an appreciation that professional football participation

Pictured: Leicester City players training in GPS vests.

is a human pursuit. Somewhere between the magic sponge and sports science lies common sense and solid practice. At what point does all this become overwhelming, where athletes are turned into machines and become too mechanical, losing their enthusiasm, spontaneity, creativity, and diminish their natural talents because they are focused on everything except playing the game? The future will be complicated, but we should not lose sight of player engagement, interaction and bloody good sports science! On the 11th May 2016, the Mail Online published an article claiming sports science and a current culture of over protection is robbing current and future generations of â&#x20AC;&#x2DC;robustnessâ&#x20AC;&#x2122;. The accepted wisdom is that players in the modern game are the most athletic they have been, largely through superior professionalism and the conditioning provided by modern training techniques. This apparent contradiction then suggests a misalignment within the football industry of the current failure of sports science at the applied level. Then, of course there has been a remarkable reshuffling of established order within the Premier League last season. Claudio Ranieriâ&#x20AC;&#x2122;s Leicester City won the Premier League by creating an effective bond between playing staff, coaching staff and indeed medicine and sports science. In whatever manner they developed their unique sports science model; they nonetheless developed a system that allowed the manager to play his strongest assets week in week out. The above dichotomy represents a need to clarify the service provision of sports science in football. A requirement to define our services and be crystal clear on our key

deliverables. Where does sports science go from here? Where do we go beyond the data to inform decisions? And is there a line between risk management and player intervention that shouldnâ&#x20AC;&#x2122;t be crossed? Clearly, a common need is to have an active association where these issues are discussed, raised and debated within a professional framework. The Future of Sports Science and Football At an elite level of football, the next decade will see improved coach education, sports science knowledge and player management. In addition, elite teams will move towards high-performance environments where the development of systematic performance models and increased accountability are commonplace. Innovations in player preparation are more challenging by the year and expectations continue to rise. Therefore, player preparation has to be sharper and better informed. All in all, these factors call for superior â&#x20AC;&#x2DC;Football Scienceâ&#x20AC;&#x2122; support models and deeper insights into issues relating to the management of soccer performance. Sports science is now the most popular STVaTT R^dabT X] cWT D: fXcW '! X]bcXcdcX^]b offering subject related courses. Estimates show that somewhere between 9000 and 15000 students will exit sports science undergraduate courses each year. Added to this, the inflationary increase of more and more students undertaking a Masters course in the area, means another 1200 MSc students will graduate each year. So the talent pool doesnâ&#x20AC;&#x2122;t get any smaller, if anything it becomes more concentrated (Steve Ingham, 2015). Therefore, we have a responsibility within professional football to create career pathways and future platforms for talented young sports scientists. We also have a responsibility to push the boundaries of our own subject matter to improve the football experience of players and staffs alike. The introduction of The Elite Player Performance Plan (EPPP) in 2011 has contributed to an enhanced understanding of how Sports Science can be integrated into the coaching process and presents the future generation an opportunity to develop both players and sports scientists within elite football. Considered as the first major overhaul of the Englandâ&#x20AC;&#x2122;s youth development system in over 13 years, the EPPP was created out of a desire by the games key stakeholders to â&#x20AC;&#x2DC;produce more and better home-grown playersâ&#x20AC;&#x2122; for the English professional leagues. It aims is to deliver an environment that promotes excellence, nurtures talent and systematically supports the development of young players capable of playing first team football. The EPPP sets out specific processes and criteria that support the implementation of core themes considered necessary to the development of elite young players between the ages of 9 to 21 years. Amongst others these include enhanced access to age specific football

football medic & scientist coaching, physical and mental development programmes which specialist age group coaches and support staff delivers. Recognition of the Sports Science disciplines within the EPPP is evident in the mandatory requirements within the Audit process that awards a tiered categorisation grade. The level of categorization determines the number of qualified Sports Science staff an Academy is required to employ. For example, a Category One Academy requires a Head of Sports Science and Medicine as well as a Lead Sports Scientist, a Strength & Conditioning Coach and two Performance Analysts. In addition to levels of staffing, age specific sport science protocols such as physical screening, performance testing, psychological profiling and the integrated use of GPS and match analysis need to be in evidently in use to attain a category status Involvement of the Sports Science team in the development process facilitates an opportunity to support and advise the coach, support staff, and ultimately the player. As well as a strong knowledge base and practical understanding of how sport science theory can be applied to the developing player, it is vital that practitioners have the necessary skills to communicate with others and work effectively as part of support team. Sports science staff will be involved in a variety of situations from individual player performance review meetings to educational workshops for staff, players and parents. It is therefore vital they have an understanding of both cultural and contextual factors, as well as an ability to translate and interpret complex issues such as testing results or training data into clear, relevant and applicable advice and guidance. For this, there is a requirement for a body of knowledge to tap into to act as an index or reference point. As a structured long-term player development the EPPP provides sports science with an opportunity to generate valuable insights in to the components associated with the progression of elite young players. The application of research methods by sports science staff can provide a robust and evidence based mechanism to monitor, evaluate and feedback all aspects of the academy programme such as performance testing, growth and maturation screening, training load and intensity, and educational attainment. The findings generated can provide accurate insights for all stakeholders within the game on how the youth development system as a whole and the players within it are progressing. The need within the EPPP staffing structure for a Head of Sports Science & Medicine may lead to a sports scientist taking on departmental management and leadership responsibilities. Here the development of new skills in areas such as long-term strategy planning, budget management and performance reviews will be necessary. The EPPP has provided guidelines and a framework for sports science to support the Coaching process

Pictured: Leicester City First Team Science & Conditioning Coach - Andrea Azzalin.

within the elite academy structure. The challenge for sports scientists is to continue working as part of a multidisciplinary team to create a long-term development programme that meets the holistic needs of elite young football players. The FMA - Building The Foundation The idea behind this article is to create momentum among the sports science community to become more involved with the FMA and to engage at levels in line with physiotherapists and medics. The aim of the FMA is to address all aspects of the working environment on behalf of its members and to act as a guiding force in determining the pathway in which improvements are made. Raising standards is of paramount importance and implementation of best practice can alleviate many of the issues that concern us in the applied football environment. The personal and professional welfare of its members is of paramount importance to the FMA. Working in an environment that often demands duties way beyond that of a practitioners’ normal remit means that Members are particularly at risk of stress and fatigue. The FMA is a well-connected organisation both within and beyond football and can assist members with any personal or professional enquiry in a discreet and confidential manner. They field dozens of calls each season assisting members who are experiencing difficulties in their work environment and this is now a valuable service they provide to members.

Member benefits include: 1.Legal Representation from industry expert FMA Lawyers 2.Free contract appraisal by their legal team 3.Access to the job section on the FMA website – now THE place to find jobs 4.Members receive an email alert/push notification when each new job is listed 5.Discounted rates on FMA listed courses and conferences 6.Monthly online CPD delivered to your inbox 7.Your FMA CPD portfolio maintained 8.Your profile listed on the FMA site 9.Guidance on career pathways - all disciplines 10.Quarterly magazine “Football Medic and Scientist 11.Monthly eNewsletters 12. Priority place at our annual Conference 13.Discounts on benefits and services 14. FOOTBALL MEDICINE REGISTER listing. This is important for anyone who exits the game and wishes to find work in the private sector. Building an association is much like starting a business. It requires hard work and careful planning, however when people band together for a common goal, they realize they can achieve far more collectively than by working alone. The FMA are set to play an important part in negotiations with key stakeholders shaping the future of the game (PFA, FA, PL, FL). It’s time to build our association and have a voice at the table. Having witnessed first hand the ever-evolving landscape of science in football, this call to arms comes at a point of divergence where sports science needs to take stock of the direction it wants to go.

football medic & scientist

ÿëÊŇőļë

“D

uring my 17 years working in professional football, there has been a seismic shift in how Sports Science is both conducted and perceived. As a relatively young industry, however, we still face significant obstacles in achieving best practice, and credence with the more established facets of football support teams. To effectively overcome these hurdles, we need a body of direction, knowledge and experience. The merging of Football & Science event with that of the Football Medical Association (FMA) can be a catalyst for more Sport Scientists to join the FMA, stimulating a more united and prosperous future. We now need help to improve our own community by uniting behind the FMA. The FMA has engagement with the PL, FA and PFA where it can act as a body of knowledge and is able to use its voice to help maximise the influence of Sports Science to achieve best practice. Momentum is dependent on mass so we should join the FMA and help them, to help us, promote our discipline within the professional game. Dr Tom Little

“T

his Science and football Conference evolved into an event that clearly demonstrated the passion and enthusiasm for both an academic and applied programme of education and this was indeed the foundation of the Science & Football events subsequent success. The lack of guidance and support for scientists around this time saw Clubs recruiting from Rugby/athletics /EIS without recognizing the unique intricacies that make football the sport it is. In 2010 we delivered our 1st Science + Football Conference at the University of East London and quickly established an audience looking for insights, support and engagement and the Conference was the perfect platform. I’m delighted that the FMA have picked up the baton and are driven to support this hard working community adding strength to their incredibly strong association. I’ve always believed more can be achieved collaborating than working in isolation and hope this is the case giving the sports science community a strong voice for the future within the FMA framework. Jon Goodman

“I

would strongly encourage all Sport Scientists, Fitness coaches, S&C Coaches and Performance Analysts to read this excellent article put together by Tony Strudwick. Sports Scientists are now viewed as a central component of club support services, but while some support us with CPD many do not and there is a strong risk of staff stagnating in isolation.

“T

The Football Medical Association (FMA) is the only multidisciplinary professional body for Applied Practitioners working in Football and are making great strides in developing a CPD framework. They are in regular contact with the FA, the Premier League and the PFA regarding issues which matter to our profession Tony’s article provides a compelling case to consider joining the FMA. I can only echo his sentiments, and hope they resonate among all colleagues in our discipline.

he insightful and emotional article written by Tony provides a great synopsis of the journey sport science has made, it’s current location and it’s future challenges within football. While one could argue that it’s acceptance is now clear from it’s widespread inclusion within the clubs in the UK it is clear from those close to the discipline that there remain significant challenges for it to be fully established. The reasons for these challenges are many and varied but one thing is clear - that these issues will not be addressed without the practitioners who are involved in the day to day support of players, medical staff, coaches and managers having a coherent voice with which to address the key decision makers within the game.

Chris Barnes

Prof. Barry Drust

football medic & scientist

ÿëÊŇőļë

Pictured: Player undergoing EVH challenge.

LUNG BUSTING: DETECTING AND TREATING RESPIRATORY PROBLEMS TO MAXIMIZE ELITE FOOTBALL PERFORMANCE FEATURE/DR. JOHN DICKINSON, ANNA JACKSON AND DR. JAMES HULL Over the course of a match a player will complete multiple sprints sometimes with little recovery between efforts. To a large extent the physiological performance of a football player is determined by their ability to supply oxygen to the working muscles and remove waste products during periods of sprinting and recovery.

uring high intensity phases of activity a player’s ventilation rate will reach between 80 - 85% of their max. An efficient respiratory system is therefore fundamental to ensure performance is sustained over the course of training and matches. However, it is common for football players to have conditions such as exercise induced asthma (EIA) or inspiratory disorders. If a player experiences EIA and/or other causes of problems with breathing during a match their physiological performance will be compromised, as will their recovery post-match. Therefore, it is imperative elite football players are investigated for

respiratory disorders and they receive optimum therapy once detected. EIA is an airway disease that results in a reduced expiratory airflow (i.e. limits ability to breathe out) and is very common in elite footballers. Indeed, our studies have shown that EIA seems to consistently affect one third to half of elite football players (Dickinson et al 2013; Jackson et al 2015). This prevalence is significantly greater than the general D: _^_d[PcX^] PbcW\P _aTeP[T]RT ^U ( 0bcW\P D: P]S Xc Xb P R^]bXbcT]c UX]SX]V that EIA remains under-detected and misdiagnosed in elite football players (Ansley et al. 2012)

There are a number of triggers that cause EIA (see table 1). When football players, who are susceptible to EIA, play in the presence of these triggers they initiate an inflammatory response that leads to the constriction of the smooth muscle that surrounds the lower airways. The constriction of airway smooth muscle and inflammation narrow the airway leading to increased airway resistance, which results in a reduced expiratory air flow. Typically this response is most pronounced after continuous exercise but can occur during a football match, especially if a player is moving from an intense phase of play to a recovery phase of play. EIA

ÿëÊŇőļë can compromise football performance by reducing the body’s ability to supply oxygen into the blood stream to be used by working muscles and expel waste products of exercise. So how do you know if you have a player with EIA? Although symptoms are a poor predictor of EIA some players may experience coughing, expiratory wheeze, excess mucus production, chest tightness and difficulty to breath. Many players may not recognise these symptoms and put a post training/match cough and tight chest down to simply ‘working hard’.

Table 1: Environmental Triggers for EIA ~ 7XVW bdbcPX]TS eT]cX[PcX^] aPcT ~ 3ah PXa ~ 2^[S PXa ~ 7XVW _^[[T] R^d]c ~ ?^[[dcX^] ~ ?aTbT]RT ^U RWTbc X]UTRcX^] ~ 3dbc We know that using symptoms alone to diagnose EIA results in 49% of elite football players to being mis-diagnosed (Ansley et al. 2012). A secure diagnosis of EIA must therefore involve an objective airway challenge that demonstrates the presence of airway obstruction and the reversibility of the obstruction when treated with an inhaler such as salbutamol. The gold standard test to diagnose football players for EIA is called a Eucapnic Voluntary Hyperventilation (EVH) Challenge (figure 1). This challenge involves the assessment of maximal lung function before and following an EVH challenge. The EVH challenge requires a player to breathe at 85% of their maximal voluntary ventilation for six minutes. The air (21% O2, 5% CO2 and 74% N2) inspired during the test is delivered from a compressed gas canister and is designed to ensure the player does not experience syncope. The dry inspired air (2% humidity) accompanied by the high ventilation rate provide the EVH challenge with a high sensitivity and specificity to aid the diagnosis of EIA in football players. Although the EVH test may not be readily available in clubs it is possible to ask service providers to deliver EVH assessments club training grounds or alternatively players can be referred to specialist centres such as the Centre for Health and Human Performance, 76 Harley Street, London (www.chhp.com). Other measures performed at the CHHP include assessment of inflammation of the airways with a specialist test measuring exhaled nitric oxide; termed exhaled nitric oxide (FeNO). Once a player has a secure diagnosis of EIA they are able to use a variety of inhalers to attenuate airway inflammation and smooth muscle constriction. The inhaler therapy players are prescribed will vary depend on medical history, symptoms

Pictured: Gillingham FC undergoing pre-season asthma screening.

Case Study: A male professional, championship level football centre back, age 30, was assessed as part of an EIA screening programme in his club. He had a previous diagnosis of asthma but had never completed an objective airway challenge. He reported symptoms only when pollen levels were high. He had a current prescription for inhaled Salbutamol, which he used infrequently. The player underwent a respiratory assessment which comprised measurement of exhaled Nitric Oxide (FeNO) and a Eucapnic Voluntary Hyperpnoea (EVH) challenge. In the same week he also completed a submaximal Yo-Yo intermittent recovery test (YYIRsubmax). After 12 weeks the player repeated the EVH and YYIRsubmax tests. The player continued training and match play throughout. At the time of testing the player reported they were not experiencing any symptoms Their baseline FEV1 was 82% of predicted value. Baseline FeNO was 181 ppb indicating significant airway inflammation. The player completed the EVH challenge and had a fall of 40% in FEV1 from baseline. The EVH test confirmed the presence of moderate EIA. It was explained to the player the importance of engaging in using prevention therapy to treat inflammatory processes that drive his EIA. The player was prescribed 200 µg beclomethasone and 50 µg salmeterol to be inhaled in combination twice daily. They were advised to inhale 200 µg salbutamol prior to intense training or a match. At the 12 week follow-up his resting FEV1 had improved to 102% of predicted value. His FeNO had decreased to 37 ppb. Following a repeat EVH challenge whilst using the prevention therapy the player’s fall in FEV1 following the EVH challenge was now 16%. The YYIRsubmax showed an improved performance both in a reduction in player load of 13% (pre = 108.2, post = 93.61) and Heart Rate indices: HRmax pre = 205, post = 197 and HRmean pre = 181, post = 167, all indicating a reduced physical effort at the same workloads following the 12 weeks of using appropriate therapy. In conclusion, this case illustrates the value of a simple objective airway provocation challenge highlighting the player was under medicated for the severity of his EIA. The implementation of appropriate treatment resulted in reduced EIB severity, reduced airway inflammation and improved physical performance during the YYIRsubmax test. This case study demonstrates the use of objective airway challenges can improve detection and treatment of EIB, which results in improved aerobic performance.

football medic & scientist and result of objective test. Additional interventions may include diets high in fish oils (Mickleborough et al.2006), avoidance of triggers and conducting a vigorous warm-up 30 minutes before training or matches (Mickleborough et al. 2007). When treatment is optimised they will be able to train and compete without their performance being compromised by EIA. Exercise respiratory symptoms, as discussed above, are not exclusively explained by EIA. A player who is reporting feeling ‘tight chested’ and a bit wheezy during training or a match may not necessarily be suffering from EIA. In our study (Ansley et al. 2009), 49% of a cohort of elite British-based professional football players were found to have an inappropriate diagnosis of an asthma related condition. Other common conditions that can mimic asthma include: dysfunctional breathing (DB) and exercise induced laryngeal obstruction (EILO). Table 2 highlights the similarities and differences between EIA, DB and EILO symptoms. It is also common to see players who have EIA but whom also have DB and/or EILO. If a player has confirmed EIA and is using appropriate inhaler therapy for EIA but still experiences symptoms it may be they also have DB and/or EILO. Thus, increasing and escalating their asthma therapy is inappropriate.

Specialised tests are required to differentiate between EIA and the other potential causes. If DB is suspected then a personalised breathing programme comprising breathing techniques, posture and inspiratory muscle training has been found to be beneficial (Dickinson et al. 2007). If laryngeal obstruction is

Table 2: Differences between EIA, DB and EILO symptoms EIA

DB/EILO

Occurs 5 -10 minutes after exercise

Occurs during strenuous exercise and resolves within 5 minutes of stopping exercise

Wheeze on expiration

Wheeze on inspiration

Fall in lung function post exercise

No fall in lung function post exercise

Sound is primarily from the chest

Sound originates in the neck

Symptoms relieved after inhalation of β2agonists

Symptoms remain after inhalation of β2agonists

suspected treatment may consist of breathing training (similar to dysfunctional breathing) and the use of certain medication. In severe cases it is possible to perform an operation to reduce EILO. In summary, it is our clinical and research experience that breathing problems cause a significant limitation to elite player performance in many cases. This often remains undetected and simply attributed to a player ‘working hard’ or being ‘out of shape’. An objective airway challenge and measure of airway inflammation can detect EIA and if EIA is the cause of the problem then inhaler treatments will allow players to improve their performance and compete at a level similar to their non-EIA counterparts. It is also important to detect non-asthma causes of breathing difficulties (e.g. dysfunctional breathing or exerciseinduced laryngeal obstruction) In these cases breathing re-training can be massively beneficial. Once optimal treatment has been initiated players should be able to play and compete at the highest level symptom-free.

References Ansley L, Kippelen P, Dickinson J, Hull J. (2012). Misdiagnosis of exercise induced bronchoconstriction in professional soccer players. Allergy. 67:390-5 Dickinson, J., Whyte, G. and McConnell, A. (2007). Inspiratory Muscle Training: A simple cost effective treatment for Inspiratory Stridor. British Journal of Sports Medicine, 41, 694-5 Dickinson, J., Drust, B., Whyte, G. & Brukner, P. (2013). Chapter 54: Screening English Premier League Football Players for Exercise Induced Bronchoconstriction. In Numone, Drust and Dawson. Science and Football VII, Routledge, page no. 341-346, ISBN 978-0415-68991-5 Jackson, A., Hopker, J. & Dickinson, J. (2016) Exercise-Induced Bronchoconstriction: Impact on Health and Performance. XXV International Conference on Sports Rehabilitation and Traumatology. Football Medicine Strategies: Return to play. Mickleborough, T., Lindley, M., Ionescu, A. & Fly, A. (2006). Protective effect of fish oil supplementation on exercise-induced bronchoconstriction in asthma. Chest,129, 39-49. Mickleborough, T., Lindley. M. & Turner, L. (2007). Comparative effects of a highintensity interval warm-up and salbutamol on the bronchoconstrictor response to exercise in asthmatic athletes. Int J Sports Med, 28,456-62.

Dr. Dickinson and Dr. Hull run a Respiratory Clinic at the Centre for Health and Human Performance where they regularly see athletes who report exercise induced respiratory symptoms. To find out more information, or book an appointment, please email info@chhp.com or call 0207 637 7677. Anna Jackson is a PhD student at the University of Kent investigating the impact of asthma therapy on the airway health and exercise performance of athletes with EIA Pictured: Player having maximum lung function assessed.

FMA FOOTBALL MEDICAL ASSOCIATION

ĂżĂŤĂ&#x160;Ĺ&#x2021;Ĺ&#x2018;ÄźĂŤ

Pictured: Blackpoolâ&#x20AC;&#x2122;s John Herron holds his knee during a a game against Oldham Athletic at Bloomfield Road in February, 2016.

MICROFRACTURE IN THE KNEE FEATURE/ANDREW DAVIES This presentation concerns microfracture as a treatment for chondral defects in the knee. It discusses indications, the technique, rehabilitation and results. What is Microfracture? Microfracture surgery is a technique for encouraging the repair of articular cartilage by creating tiny holes (fractures) in the subchondral bone plate by tapping a pick or an awl into the lesion gently with a hammer. Blood and bone marrow seep out of the holes, which the body treats as an injury, to form a super-clot that releases cells that form fibrocartilage, rather than the original hyaline cartilage. History This concept of fibrocartilage repair to heal a defect was first promoted by Pridie who, in 1959, described a perforation technique that involved drilling into the subchondral bone plate. Dr Richard Steadman (of the BcTPS\P] 2[X]XR EPX[ 2^[^aPS^ DB0 wanted an alternative chondral resurfacing technique and took the procedure further by developing the modern microfracture technique, which is arthroscopic, so minimally invasive, quick and relatively simple.

Microfracture Rationale and Advantages Microfracture also has low patient morbidity, is cost effective, has a high long-term clinical success rate and does not preclude later treatments.

~ ~

aligned limb rehab focused patient.

Contraindications Reasons for not doing microfracture include:

The advantages of microfracture are that it: ~ ~ ~ ~ ~

is easier than drilling and can reach all surfaces produces less heat necrosis than drilling provides a rough surface for super-clot attachment maintains subchondral plate integrity allows access to growth factors and mesenchymal stem cells.

Indications Indications for the use of microfracture as a treatment modality include: ~ ~ ~ ~

presence of a symptomatic full thickness chondral defect defect size of less than 2 square cm acute defect young patient

~ ~ ~

axial malalignment (osteotomy is better) partial thickness lesion inability to use contralateral limb being over 65 years old.

SO WHAT DO WE SEE: Microfracture chondroplasty at 4 weeks Typical Patient A case-study example of a typical patient involved a very active man who had trochlear damage down to the bone and who refused to accept becoming inactive. After a long discussion about the options, microfracture was performed. Initially, the damaged are has to be given clear crisp margins and then the calcified chondral area was scraped away. After this, the area is jabbed with the microfracture pick to create

football medic & scientist holes at 4 mm spacing, perpendicular to the subchondral bone plate. The tourniquet is released to check for bleeding from the holes, which is necessary for formation of the super-clot. If the bone is soft enough to push the awl in without using the hammer, this indicates bone that is not healthy. Rehabilitation The ideal tibial/femoral rehab protocol would involve 6â&#x20AC;&#x201C;8 hours per day on a continuous passive motion (CPM) machine and flexionâ&#x20AC;&#x201C;extension exercises of 500 repetitions three times a day, along with only touch weight-bearing for 6â&#x20AC;&#x201C;8 weeks. This is unrealistic for most patients, except professional athletes and possibly very highly motivated amateurs who can afford the time and money. However, the static bike with no resistance is a good alternative for providing the cyclical motion with no load. The reason for the activity is so produce, from the big lumpy clot, a smooth congruent surface that glides. If the limb is immobilised, the big clot will not get worn down and the joint will clunk and click. The other restriction is no impact activity or b_âc Uâ % \^]cWb D]Uâcd]PcT[h PQ^dc half of the patients ignore this advice and decide to go for a little run or try some sport. If the patellofemoral joint is then damaged, the patient has to stop their CPM and be braced at 0â&#x20AC;&#x201C;20Â° for 6â&#x20AC;&#x201C;8 weeks. The patient has to do some very gentle unloaded supervised training, they canâ&#x20AC;&#x2122;t do any strength training for 4 months and again it is 6 months until impact sport. Science The science behind microfracture is that it is a repair, not a regrowth, and fibrocartilage is produced rather than the original type II hyaline cartilage. The curettage of the calcified chondral layer is very important. OUTCOMES Initial outcomes Originally, reports indicated that 90% of the outcomes following microfracture were good to excellent, and at 5 years, they are just as good as autologous chondrocyte implantation (ACI), which is as good as membrane-induced autologous chondrocyte implantation (MACI), or mosaicplasty, which is osteochondral grafting. However, potentially, the evidence suggests that collagen quality is better with MACI and ACI. Clinical use of microfracture Then came a number of papers, such as Steadmanâ&#x20AC;&#x2122;s, showing improved outcomes following microfracture (1), and Knutsenâ&#x20AC;&#x2122;s showing that it was at least as good as ACI (2). Findings at 5 years In 2007, Knutsen and colleagues published a paper of a clinical analysis of results comparing ACI and microfracture after 5 years (3). Their level 1 evidence showed a significant improvement for both groups,

Pictured: Manchester Unitedâ&#x20AC;&#x2122;s Marcus Rashford holds his knee after taking a knock during the 2016 FA Cup Final.

the physical component of the Short Form36 suggested that microfracture is better, and that the failure rate is about the same (about 1 in 5 will fail by 5 years) but that ACI failed earlier. The alternatives to microfracture The alternatives to microfracture are ACI, MACI and osteochondral grafting. Abrasion chondroplasty can be disregarded now and the various regenerative techniques such as MaioRegen have not been doing particularly well. Long-term follow-up and meta-analysis Knutsen and colleagues have also performed a long-term study with follow up after 16/17 years, and found that microfracture is still better than the ACI, with fewer total knee replacements needed in the microfracture group (4). However, there were concerns about whether any of the procedures delay progression of osteoarthritis. Riboh and colleagues performed a large meta-analysis and found that at microfracture and ACI outcomes were the same at 2 years, but that advanced repair techniques performed better at 5 and 10 years (5).

membrane, and that it will be combined with microfracture. This will entail acellular membranes on a microfracture bed, so that the membrane is populated by autologous growth factors and stem cells in one small operation â&#x20AC;&#x201C; a biologically enhanced microfracture. Realistically, currently, microfracture is simple and, for the majority of people, it is a good solution and works relatively well. The only exception is that the literature is clear that children with osteochondritis desicans should have ACI.

Mr Andrew Davies Consultant Knee Surgeon MB ChB FRCS (Eng) FRCS (Tr & Orth) Mr Davies specialises in reconstructive surgery and sports injury to the knee. His surgical interests include ligament repair and joint replacement and he has particular expertise in reconstructive surgery and sports injury.

The Future The future of knee chondral damage repair is probably going to be a MACI-type product, there is probably going to be a better

ÿëÊŇőļë

Pictured: Southampton’s Charlie Austin lies on the ground with an injury during their UEFA Europa League group match against Hapoel Be’er Sheva in December.

MULTIDISCIPLINARY REHABILITATION A CASE STUDY OF A PROXIMAL BICEPS TENDON RUPTURE FEATURE/MATTHEW BRAMHALL MSC, ASCC, TOM SMITH BSC, MCSP HCPC AND DR BENJAMIN ROSENBLATT PHD, ASCC Working in a multidisciplinary team can be frustrating and difficult at times. Creating a team requires a clear strategy with objectives and boundaries and good communication.

o ensure a functioning and useful team, members must be constantly aware of their working relationships with each other and the impact they have on the player and their teammates. This case study involves an elite football player in a Premier League team with a complex hamstring injury and shows how a criteria-driven rehabilitation model is a practical approach to coordinating a multidisciplinary team and helping an athlete solve problems that are limiting their rehabilitation. The article is packed with practical tables covering most elements of the rehabilitation protocol and clearly demonstrates the effectiveness of using objective markers and criteria for progression within the rehabilitation process.

INTRODUCTION It is widely acknowledged that rehabilitation from sports injury to returning to competition should be criteria-driven and hierarchical in nature (1). Athletes competing in professional and elite sport have a wide variety of sports science, medical and coaching practitioners at their disposal in order to help them achieve the highest level of sports performance possible. Indeed, a multidisciplinary rather than an individualdiscipline focused approach to rehabilitation provides preferential outcomes in stroke and lower back rehabilitation (2,3). Within each phase of rehabilitation, athletes present with complex problems that limit their progression through each stage of rehabilitation.

This article demonstrates how a criteriadriven, multidisciplinary, problem-solving approach, was used to rehabilitate a professional footballer’s complex hamstring injury. By adopting a problem-solving approach, the sometimes complex nature of injury rehabilitation can be simplified by identifying which physical parameters need to change and how best to achieve this change. Furthermore, by using a problem solving approach, specific rehabilitation objectives can be targeted and achieved, thus reducing the chances of fundamental elements being overlooked due to focusing only on the injury itself. The article presents several examples of using evidence based practice and practice-based evidence to

football medic & scientist

Pictured: Manchester City’s Ilkay Gundogan receives treatment for an injury before leaving the pitch during the Premier League match against Watford in December.

TABLE 1: PLAYER’S INJURY HISTORY (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Date

Injury history

2008

Fused right 1st metatarsophalangeal joint (non-surgical)

Notes

2012

Left RF proximal reattachment following partial rupture

RTP at 166 days

2014a

5×5mm oedema of long head of right BF at MT junction, no architectural disruption

RTP within 12 days

2014b

150mm longitudinal area of oedema of long head of right BF associated with partial fibre disruption at MT junction

During maximal velocity sprint RTP within 45 days

2014c

10×10mm oedema of long head of right BF at MT junction, no architectural disruption

During sprint acceleration RTP within 23 days

2014d

Right BF and ST tendon insertion partial tear

During high-speed running Two platelet-rich plasma injections RTP within 102 days

2014 (Current injury)

Functionally complete, acute tear of the intramuscular portion of the conjoined tendon of the BF and ST, 72mm distal to the origin

Surgical repair 7 days post-injury. RTP 157 days post-surgery

BF, biceps femoris; MT, musculotendinous; RF, rectus femoris; RTP, return to play; ST, semitendinosus

achieve a successful rehabilitation outcome, while highlighting the importance of early involvement of the multidisciplinary team when planning rehabilitation programmes. The following case study of a professional football player outlines a complex individual case history, the constraints and considerations of the rehabilitation process and the problem solving approach used in order to return the player to competitive match play. The case study also provides an insight into the value of a collaborative approach to player rehabilitation between a physiotherapist, strength and conditioning coach, nutritionist and members of the technical coaching staff. CONTEXT D]STabcP]SX]V P] PcW[TcT{b Ud[[ RPbT WXbc^ah is important as it may help to determine some of the multifaceted causes behind the most recent issues that an athlete faces. This particular athlete was a 19-year-old male professional footballer, contracted to an English Premier League club. He has aT_aTbT]cTS WXb R^d]cah Pc D ( [TeT[ 7Xb injury history is described in Table 1. Figures 1–4 show the extent of the injury using MRI. CRITERIA-DRIVEN APPROACH TO RETURN TO COMPETITION A criteria-driven rehabilitation model was selected as a practical approach for coordinating the multidisciplinary team and ensuring that the player had the

ÿëÊŇőļë TABLE 2: PHASES OF REHABILITATION: OBJECTIVES AND PROGRESSION CRITERIA (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Phase

Entry criteria

Objective

Assessment

Rationale

Exit Criteria

Immediately postoperation

Tissue healing and restoration of joint range

Straight leg raise (Passive: weeks 1–4) (Active: week 4+)

Biarticular muscles being lengthened across two joints, neural structures also under tension

Full weight-bearing and range of motion

Active knee extension (Hip 90° flexed) (From week 4)

Starting with hip already flexed, extension of the knee will demonstrate the limitation of soft tissue structures without incorporating neural tension

10 Weeks postsurgery, full weight-bearing and full range of motion

Global and local muscle work Isometric single-leg hamstring capacity bridge.

Isometric trunk hold (McGill, 2010) 3

50% Improvement in hamstring and trunk capacity

90s Single-leg bridge

Hamstrings force production Isokinetic concentric knee & stiffness flexion (60/240)

Football-specific conditioning

Risk of hamstring injury due to sport-specific neural deconditioning, relative muscle weakness and fatigability (Elliot et al., 2011)

120s hold without any technical deviations

Capacity to produce high force and velocity contractions

<10% difference

120s hold without any Trunk conditioning is required technical to reduce stress going deviations through pelvis (McGill, 2010)

Isokinetic eccentric knee flexion (60/240)

Capacity to tolerate high strain at high forces and velocities

Completion of progressive sprint and change of direction drills

Develop a capacity for football-specific ‘match-based’ training

Consistent exposure to Develop a tolerance for highhigh-speed running and sprinting speed running and sprinting

120s Single-leg bridge

Symptom free completion of technical drills with no changes in clinical markers Between 75–85% of maximum match high-intensity distance per session over a period of 3–4 weeks

Return to competition

Elliot, et al. Am J Sports Med. 2011;39:843 McGill. Strength Cond J. 2010;32:33

biomechanical and physiological capability of completing the increased activity demand before engaging with that work. The full criteria-driven return to competition model is detailed in Stage 1 The key objectives of the initial stage of rehabilitation were to promote tissue healing, neural mobilisation and maintain muscle activity and blood flow, while minimising the formation of adhesions to the sciatic nerve, the collection of oedema and avoiding wound infection. This all had to be delivered within the surgeon’s constraints of knee and hip flexion range of motion (ROM) and weightbearing status (Table 3). Weeks 7–10 were focused on retraining a normal gait pattern after weaning from crutches, while regaining normal joint ROM at the hip and knee by addressing the soft tissue tightness through specific, progressive mobilisation. Alongside this, early isometric strengthening work progressed to closed-chain concentric exercises, hydrotherapy was used for rehabilitation and conditioning, and trunk stability training was increased. Stage 2 Following the return to an appropriate functional joint ROM, the player entered the

second stage of the rehabilitation process. The aim for this stage was not only to develop and increase the work capacity of the hamstring muscle group, but to increase the players overall tolerance to physical work: both physiologically and muscularly. Individuals who have high capacities and tolerance for work are more robust and they also recover more quickly, both during exercise and between exercise exposures (ie. matches) (4). To determine the capacity of the hamstring muscle group, a singleleg bridge test was used. The single-leg bridge (SLB) test was similar to the one previously described by Hallet (5); however, the measure used in the current case study was an isometric position held for time as opposed to repetition number, as used by Hallet. The target threshold used was 120 seconds as this has been shown to provide an appropriate base of fatigue resistance from which to build other physical qualities such as force production and power. Furthermore, it has been suggested that following periods of time away from match play, players may be at risk of hamstring injury due to sport-specific work done and how that work relates to actual performance. As the player had a history of injuring his hamstring muscles while sprinting, we felt it important that we gave him regular exposure to sprinting in order to condition

his neuromuscular system to the specific biomechanical demand. PROBLEM-SOLVING APPROACH TO REHABILITATION This section describes some of the problems that arose during the different stages of rehabilitation and how they were resolved by the multidisciplinary team. No rehabilitation is linear or straightforward and the key to successful and sustained return to competition is being able to identify the problems, apply critical thinking to identify a strategy or intervention and then put a measurement in place to ensure that the issue has been resolved. Stage 1 At approximately 10 weeks post-surgery, the player complained of a constant background, nagging low backache which was difficult to localise. The complaint of back pain was respected, and a lumbar spine MRI arranged to investigate its possible involvement. The scan showed an L4/5 disc protrusion, with discogenic abutment of the right L5 nerve (Fig. 5). Epidural steroid injection has been found to alleviate symptoms and allowed the return to highlevel sport of 89% of American football (NFL) players with lumbar disc herniation

football medic & scientist (8). As a consequence, a spinal specialist was consulted who recommended the epidural steroid injection. Within 10 days of the procedure, the player’s back pain settled and he was able to fully engage within his rehabilitation. During the rehabilitation planning process, this lumbar spine pathology had to be considered carefully, as appropriate strengthening programmes for the biarticular hamstrings group had to be designed, avoiding any loading of a flexed or rotated lumbar spine, as well as the avoidance of unnecessary compressive axial loading. Stage 2 Capacity assessments were undertaken approximately every 4–5 weeks throughout the rehabilitation process. D_^] X]XcXP[ PbbTbb\T]c cWT _[PhTa showed poor levels of muscle capacity in both hamstrings and a large left-to-right imbalance (Fig. 6). There is emerging evidence that muscle hypertrophy can be achieved using low loads and high training durations (9). This is due to the large muscle activity required to sustaincontractions in the presence of fatigue (10). Additionally, varied practice can enhance skill performance compared to practice with little variety (11). As a consequence, a circuit of multiple exercises was developed to challenge the athlete’s capability to stabilise the pelvis with the trunk and gluteals, and extend the hip and flex the knee with the hamstrings (Table 4). The volume of work was periodised over a 4–5 week period before reassessment to ensure that the hamstrings were always receiving the necessary stimulus to facilitate an adaptive response (Table 5). The progression of hamstring muscle capacity is shown in Figure 6. Trunk capacity was developed using a variety exercises, some of which have been previously described by McGill (7), and the same

TABLE 3: ROM RESTRICTIONS AND WEIGHT-BEARING STATUS, WEEKS 1–6 POSTOPERATION (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Week

Knee flexion ROM

Hip flexion ROM

WB status

90° to full

Not beyond 60°

NWB

90° to full

Not beyond 60°

NWB

60° to full

Up to 90° with KF

NWB

60° to full

Up to 90° with KF

NWB

30° to full

Beyond 90° with KF

NWB

0° to full

Combined HF/KE as comfortable

Partial

HF, hip flexion; KE, knee extension; KF, knee flexion; NWB, non-weight-bearing; WB, weight-bearing

TABLE 4: EXERCISE SELECTION TO IMPROVE HAMSTRING CAPACITY AND RATIONALE (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Exercise

Rationale

Single-leg gym ball curl

Loading of proximal hamstring to maintain hip extension, while controlling knee flexion and extension

Bridge walkouts

Dominance of hip extension required more proximal loading of hamstring with eccentric lengthening

Single-leg bridge marching

Loading of proximal hamstring to maintain hip extension, while maintaining a fixed knee angle

Single-leg box bridge with opposite leg swing

Dominance of hip extension required more proximal loading of hamstring

circuit-based method as for the hamstring muscle group (Table 6). Target thresholds of 180 seconds and 120 seconds were required for the anterior and lateral trunk respectively.Table 7 shows initial and most recent assessment values. Following the development of appropriate levels of muscular capacity, the player was then able to focus on developing his force production and muscle stiffness qualities, and be reintroduced to pitch-based conditioning work. Stage 3 At 15 weeks following surgery, the athlete demonstrated a similar deficit in peak torque regardless of contraction mode or

TABLE 5: PERIODISATION OF HAMSTRING CIRCUIT LOADING IN ORDER TO FACILITATE CHRONIC ADAPTIVE RESPONSE (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Week (post-surgery)

Load

14–17 3 rounds

10 seconds on each exercise

18–20 3 rounds

15 seconds on each exercise

21–25 3 rounds

20 seconds on each exercise (weeks 21 & 22) 25 seconds (weeks 23–25)

26–31 3 rounds

30 seconds on each exercise

TABLE 6: EXERCISE SELECTION TO IMPROVE TRUNK CAPACITY AND RATIONALE (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Exercise

Rationale

Gym ball pot stir

Development of trunk capacity while reducing compressive forces on the spine and resisting rotation, flexion and extension

Side planks

Isometric strength development to resist lateral flexion of the trunk

Double leg lower

Eccentric loading of the hip flexors while maintaining a neutral spine position

Front planks

Development of trunk capacity while reducing compressive forces on the spine and resisting rotation, flexion and extension

velocity (with the exception of high-speed eccentric) (Fig. 7). This indicated that regardless of the mechanism, the neuromuscular system was unable to produce similar amounts of force on both legs. As the player also had very low muscular capacity (Fig. 6), the conditioning circuits were used to address this imbalance. Following 5 weeks of training, peak torque had increased across all isokinetic testing modalities (Fig. 7). As a consequence, more focus was placed upon reducing the asymmetry and placing greater strain loads through the tissue using exercises which replicated the mechanism of injury. Extensive research has been conducted trying to identify the most appropriate exercises that can be used to rehabilitate injured hamstrings. Askling et al. (12) reported that rehabilitation exercises that focused on muscle lengthening were more effective than conventional exercises that shortened muscles. Given that the player in this case study sustained his injury during an action that resulted in extreme muscle lengthening, it was decided, in conjunction with the strong supporting research evidence, that exercises involving muscle lengthening would be the most appropriate type of exercise to form the majority of the rehabilitation programme. The programme included a number of ‘traditional’ eccentricbased exercises, such as the Nordic hamstring; however, it also included exercises such as ‘the diver’ and ‘the glider’, both of which were used and found to be effective by Askling et al. (12). It was felt that these exercises were appropriate for the player in question as they allowed eccentric loading of the

football medic & scientist

ĂżĂŤĂ&#x160;Ĺ&#x2021;Ĺ&#x2018;ÄźĂŤ

Pictured: Middlesbroughâ&#x20AC;&#x2122;s Viktor Fischer goes down injured during their December Premier League match against Swansea City at the Riverside Stadium.

hamstrings while maintaining a neutral lumbar spine. The exercises outlined also avoided any axial loading of the spine. The reason for lengthening exercises being so effective for this type of hamstring injury is due to the maximal dynamic loading of the hamstring involving movements at the hip and the knee (12). Table 8 describes the rationale for exercise selection in order to resolve the specific issues that the player faced. Stage 4 D_^] aTcda]X]V c^ b`dPS caPX]X]V SPX[h meetings with the technical coaches were held to discuss the playerâ&#x20AC;&#x2122;s involvement in each session to manage his reintegration P__a^_aXPcT[h D_^] aTcda]X]V c^ caPX]X]V cWT player was not receiving the planned stimulus of sprint and high-intensity distance (Table 3), due to the nature of a session or his role within the session (Fig. 8). In order to maintain specific conditioning of his hamstrings, the player was given top-up sessions of straightline running in order to provide a conditioning stimulus. The volume and intensity of work was determined by identifying the â&#x20AC;&#x2DC;shortfallâ&#x20AC;&#x2122; between sprint distance performed in the session that had just been completed and the average sprint distance obtained from previous match data. The shortfall was then broken down into set distances to be achieved during a set time, for example 5 Ă&#x2014; 50m sprints, each to be completed in 10 seconds with a walk recovery. Only by having access to this data were we able to prescribe top-up sprint work to be done each week so that he received an appropriate level of sprint stimulus each week.

TABLE 7: ANTERIOR AND LATERAL TRUNK ASSESSMENT SCORES POST-SURGERY (IN SECONDS) (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Assessment

14 Weeks

31 Weeks

Anterior Trunk

104s

180s

Lateral Trunk: Left

85s

99s

Lateral Trunk: Right

90s

120s

TABLE 8: HIGH-FORCE HAMSTRING EXERCISES AND RATIONALE FOR SELECTION (M. Bramhall, T. Smith, B. Rosenblatt, 2016) Exercise

Rationale

Nordic lowers

Development of eccentric strength while maintaining hip extension

The glider

Developing eccentric strength while maintaining a fixed-knee angle and neutral lumbar spine

The diver

Eccentric loading of the hamstring with hip flexion and neutral lumbar spine

Glute Ham Developer hip extension (bilateral progressed to unilateral, progressed with perturbations)

Isometric hamstring strength allowing for hip flexion to extension without spinal loading

CONCLUSION The purpose of this article is to demonstrate how a multidisciplinary team can solve the problems that an athlete faces in rehabilitating a complex injury. By identifying strict entrance and exit criteria to the progressive stages of rehabilitation,a problem-solving framework was established to help the athlete progress through the stages. In this example, the multidisciplinary team planned the exit and entrance criteria and used the data and clinical information that they collected at each stage in order to

identify the most appropriate strategy to progress the athlete. In conclusion, a criteria-driven rehabilitation model is a practical approach to coordinating a multidisciplinary team and helping an athlete solve the problems that are limiting their rehabilitation. Originally published in July 2016 issue of Co-Kinetic journal. www.co-kinetic.com

ÿëÊŇőļë

I ħëëçëçǝŇĭǝĜħĭŝǝŝċŨǂ This was the question which Nik Rose kept asking himself as he lay in a hospital bed fifteen years ago recovering from a shattered patella. Once admitted, he was tended to every two hours with ice packs and clingfilm. And yet, no one had an answer to his question beyond the ubiquitous First Aid protocol ‘Rest Ice Compression Elevation’.

hese observations and ruminations led inventor Nik Rose to begin his exploration to better understand cooling, compression and warming as aids to rehabilitation.

“I have always had huge respect for how the human body works but we need intelligent technology to work with it. “When I began to investigate this area there was simply no data. This was particularly true in relation to how much cooling, compression or warming should be delivered and when during rehabilitation.”

football medic & scientist

to stay injury free and get match fit quicker.

“I have become obsessed with precision and how we manage delivery of energy to the body as a means to understand and aid recovery.” By delivering hot or cold in a controllable way, the energy sent to the body from the system and to the system from the body is measurable. “This ‘toolkit’ gives rehabilitation specialists the opportunity to understand how energy is accepted and rejected by the body during recovery from an injury or surgery both during the more ‘receptive’ acute phase and the subsequent ‘defensive’ repair phase. This means we can quantify recovery.” From his own experience and extensive research and development, Nik Rose has created PHYSIOLAB ®. The device, which Nik Rose has created, provides rehabilitation professionals with a toolkit delivering temperatures anywhere between 6° and 40°c alongside compression of up to 75 mmHg to accelerate soft tissue repair. “Whilst there are other machines available which deliver cold, warming and compression nothing in the market did all three efficiently and, more importantly, there was no intelligent control and feedback.” PHYSIOLAB ® is the only device to provide intermittent temperature in a repeatable and controllable way from extreme cold to heat in a matter of seconds under independently controlled constant compression. “The high impact nature and athleticism of elite sport means there is huge pressure on players

Having developed this data tracking mechanism, Nik Rose hopes that medical professionals and physiotherapists will use PHYSIOLAB ® to analyse data and build up a body of research.

“By using the tangible data from our device, I really hope professionals will be able to create a better understanding to deal with a patient’s recovery depending on where he/she is in the recovery phase and when protocols should be adjusted for maximum efficacy and efficiency. In this way, we can drive clinical practice forward.” To continue the conversation call Physiolab on 01908 263331 or visit www.physiolab.com Nik Rose is an inventor and industrial designer creating a brand with true vision and integrity. He is passionate about researching and designing cutting edge technologies that deliver tangible benefit to end users, developing a trusted brand in the Human Performance Equipment market.

ÿëÊŇőļë

Pictured: Watford’s Valon Behrami lies injured on the pitch in a January fixture against Stoke City. It was later confirmed that he had received a hamstring injury.

COMPARISON OF FUNCTIONAL ISOKINETIC STRENGTH RATIOS AGAINST FLEXIBILITY AS PREDICTORS FOR HAMSTRING INJURY IN PROFESSIONAL MALE SOCCER PLAYERS FEATURE/DAVID FEVRE, WILLIAM FORD, MATTHEW J HANCOCK ABSTRACT Background Hamstring injuries are a frequent problem for professional soccer players and whilst it is agreed there are multiple risk factors for injury, there is debate over the relative strengths of individual factors as predictors for injury. Studies have suggested that the functional isokinetic strength ratio of the hamstrings and quadriceps is a strong indicator of prospective hamstring injury. Hypothesis The aim of this study was to utilise this approach to determine if 3 separate flexibility tests would be better at predicting hamstring injury than the proven functional isokinetic strength ratio (Hecc/Qcon). Methods

The 3 flexibility and single isokinetic tests were performed on 18 male professional players aged 18-21 from an English professional b^RRTa cTP\ D ! cTP\ P]S R^\_PaTS fXcW their retrospective injury history. Results Of the 4 screening methods used, the eccentric hamstring/ concentric quadriceps (Hecc/Qcon) strength ratio and the Erector Spinae Muscle Shortness Test (ESMST) were found to have a significant correlation with the incidence of hamstring injury. The remaining flexibility tests, the Sit and Reach Test (SRT) and the Hamstring Knee Angle Test (HKAT) showed no significant correlation. Conclusions The results of this paper suggest that whilst

SUMMARY BOX What are the new findings? This study shows how the use of a simple flexibility screening tool can be effective in forewarning a medical team the individual athletes within a specific training/age group who carry a bigger risk of hamstring injury in a specific susceptible anatomical myofascial train How might it impact on clinical practice in the near future? Screening of athletes needs to be repeatable, simple to carry out and correlate to injury patterns in a particular sport. In this study the use of Erector Spinae Muscle Shortness Test (ESMST) as a screening tool is shown to be as effective as a proven isokinetic procedure and incorporates all the aforementioned factors to be effective. Additionally it requires smaller financial overheads and less academic interpretation making it a more widely available screening tool for a larger number of clinicians

football medic & scientist

Pictured: Sunderland’s Victor Anichebe signals to the following an injury, during their December game against Burnley . He was later found to have a hamstring problem.

hamstring injury. LITERATURE REVIEW Advanced search terms and phrases were used to look at the studies that were the most relative to the study. Phrases included “hamstring injuries”, “use of isokinetic data for screening”, “reliability of isokinetic data”, “risk factors for hamstring injury”, “risk factors for recurrent hamstring injury”, “hamstring injuries in soccer players”, “prevention of hamstring injuries”, “screening of hamstring injuries”. The hierarchy of evidence was also applied when discussing conflicting results, favouring studies such as systematic reviews and meta-analyses to case reports. Various sources were used to assess the reliability of isokinetic strength testing, as it formed the basis of this study 5, 6. The primary literature that was used to support the inclusion of isokinetic screening was a study conducted by Jean-Louis Croisier (2008) detailing functional isokinetic strength ratios. This study aimed to determine if the detection of muscular strength imbalances in football players could be a predictor of future hamstring injury, as well as determining whether or not correcting this imbalance could reduce the incidence of hamstring injury 2. This was proposed as there is controversy over the relationship between muscle injury and strength disorders 10,11,12,13, as it is uncertain if strength disorders are the causative agent, or if they arose because of injury. Studies show that strength disorders were found in around

ÿëÊŇőļë muscular imbalance. This would indicate that a low Hecc/Qcon ratio is a modifiable risk factor for hamstring injury 2. The classic SRT has been found to have a moderate validity for assessing hamstring flexibility, but poor validity for assessing lower back flexibility 15, 16. It has been shown to be a reproducible test 20, but some studies disagree that it is a valid assessment of hamstring flexibility 27, particularly in men 19. There is debate as to which SRT variation is the best as a hamstring flexibility measure 21, 22 . Certain studies have found the modified SRT to have some superior qualities to the classic SRT 23, though a recent meta-analysis found the classic SRT to be a better indicator of hamstring flexibility than the modified SRT 15. DbX]V cWT bTPaRW T]VX]Tb _aTeX^db[h described, no literature could be found describing the HKAT, so any comments on the validity of the test are without supporting evidence. It is suggested that others studies may want review the validity of the HKAT in testing for flexibility. There is limited information on the ESMST, with the majority originating from the same author 8, 31, so again it is hard to evaluate the validity of this test. The ESMST assesses the superficial back line, which consists of a line of fascia starting at the plantar surface of the foot, travelling up the posterior aspect of the body and finishing at the frontal brow ridge of the skull 24. The function of this tract is to extend the body into an upright position 24 . Dysfunction in the superficial back line can lead to muscle weakness and injuries in muscle groups across the body 24. From the injury records of the club, injuries associated with the structures of the superficial back line accounted for 27% of the total injuries in the 2008-09 football season and 31% of the total injuries in the 2009-10 football season.32 METHODS Functional Hecc/Qcon ratios obtained from the 18 players at the start of the season were compared with the retrospective hamstring injury record of the squad. In order to provide a valid comparison to the results of Croisier, the measurements were taken in as similar a method as possible. Isokinetic measurements of the eccentric hamstring strength and the concentric quadriceps strength, measured in foot-pounds, were performed using a Biodex System 4 Pro dynamometer (Biodex Medical Systems, Shirley, NY). A warm-up involved pedalling on an ergometric bicycle and light stretching, followed by a brief acquaintance with the dynamometer. Test speeds of 30°/ sec for the eccentric hamstring and 240°/sec for the concentric quadriceps were utilised to give a mixed speed functional ratio for 5 repetitions. The highest peak torque measured was used to calculate the ratios. The cut-off measurement of a Hecc/Qcon ratio of less than 0.89 was chosen as it is identical to that used in Croiser 2008. This is the value suggested as one of the definitions of an imbalanced strength profile, which would imply a higher predictive risk of future

hamstring injury 2. The relationship between hamstring injuries and abnormal hamstring flexibility was then analysed using the 3 following tests:-

1)The SRT required a sit-and-reach box and measures the maximal distance reached forwards by the subject’s fingers ahead of the zero mark on the sit-and-reach box scale, the distance measured in centimetres (Figure 1.). The zero mark was not placed at the level of the feet of the subject as not all players would be able to reach that far forwards. To perform the test requires the subject to sit on the floor with both legs fully extended ahead of their body. Items of footwear were removed and the soles of the feet were placed flat against the box, with the knees locked and pressed to the floor. With the palms facing to the floor and the hands both in line and side by side, the subject reaches forward as far as possible. This needs to be a continuous flowing movement 25 . The measurement is taken to the nearest centimetre reached by the fingers. To obtain a scoring system the mean measurement of the squad was calculated and one standard deviation either side of this value defined the range for a normal measurement. Any values above or below this range represented either reduced or increased flexibility. The players were categorised into the groups labelled ‘Good’ and ‘Substandard’. The ‘Good’ group contained the players found to be within the normal range of measurements and the ‘Substandard’ group contained the players with reduced or increased flexibility. Players with reduced or increased flexibility were placed in the same group because research suggests both increased and decreased mobility can increase the chance of injury 4, 9.

2) The HKAT (Figure 2 and 3) gives an indication of the stride length of the player and thus functional flexibility. The procedure requires the subject to lie down on a bed with one of their heels touching the leg of the bed. They then raised the contra lateral leg at a right angle to the bed with the hands supporting the femur whilst extending the lower leg as

far as possible. The player was photographed performing this test for each leg and the hamstring-knee angle was measured from the picture with a goniometer. The player had to remove socks and items of footwear in order to prevent restriction of the view to medial malleolus of the ankle. To remove the influence of the hip flexor muscle group, the angle between the line through the greater trochanter of the femur to middle of the medial joint line and the line of this point through to the medial malleolus was then measured. To obtain a scoring system for this test, the mean measurement of the squad was calculated and 1 standard deviation either side of the mean defined the range for a normal measurement. Again, the players whose measurements fell inside this range were placed in the ‘Good’ category for this test and any players outside of the normal range were categorised as ‘Substandard’. This is because players with a significantly reduced hamstring-knee angle were considered as having abnormal flexibility.

3) The ESMST (figure 4) was used to test for shortness of the erector spinae muscles and the associated postural muscles. The subject was seated on a treatment table, with the legs extended fully and the pelvis vertical. The subject was then asked to reach their fingers towards their toes and flex their neck 31, 32 (see Fig 4). A photograph was then taken and the body shape was assessed by a charted physiotherapist experienced with the PMST scale. In order to properly assess body shape, the patient must remove items of upper body clothing and footwear. This test can isolate the sections of the myofascial track in the superficial back line where muscle tightness is present. The test is scored from A-H, with A representing an ideal posture and B-H indicating muscle tightness in one or more areas of the superficial back line. The players in this study were labelled A-H. and then subcategorised into groups A and B-H.8, 31

A Normal length of posterior muscle groups B Tight gastrocnemius and soleus; indicated by inability to dorsiflex the feet C Tight hamstring muscles, causing posterior tilting of the pelvis D Tight erector spinae muscles in the lower back

football medic & scientist E Tight hamstrings; slightly tight lower back muscles with overstretched upper back muscles F Slightly tight lower back muscles with stretched upper back muscles and hamstrings G Tight lower back muscles, tight hamstrings and tight gastrocnemius/soleus H Very tight lower back muscles; indicated by presence of lordosis even in flexion 31 The measurements for each of the 4 tests were acquired during a pre-season assessment and the retrospective hamstring injury data was gathered around the midpoint of the 2014-2015 English soccer season, which was approximately equivalent to a 5 month interval. The requirement in this study for inclusion as hamstring injury was modelled on the criteria described in Croisier 2008, requiring simultaneous completion of the following criteria: â&#x20AC;&#x153;(1) physical examination showing pain on palpation, passive stretch, and active contraction of the involved muscle; (2) diagnosis supported by ultrasonography or magnetic resonance imaging; (3) a period of 4 weeks of missed playing time for the involved player.â&#x20AC;? 2 All players gave consent for the use of their results on the aforementioned tests and of their injury history for this study. LIMITATIONS The main limitation in this study was the relatively small sample size, as there were 19 professional soccer players in the group, only 18 of which were eligible for analysis. If multiple squads were available to test the screening methods, the reliability of the study would have been improved. A further limitation was in the SRT, as the standard test does not account for large variances in arm and leg length. This can be accounted for by performing the modified SRT 15, but unfortunately the required facilities for this were not available. When measuring the HKAT, human error should be accounted for as well, first in marking where to measure from and then the actual reading from the goniometer. However this error was reduced by ensuring the same person measured the angle in the same way each time from the computer image. Also there was not a recognised grading system for the SRT and HKAT in professional athletes and so the categories only applied to the specific sample of players involved in the study. Therefore those who were in a substandard category for a flexibility test, may have had above average mobility but have a poor score in comparison to the rest of the squad. When measuring posture using the ESMST it is possible some of the players may have been in the wrong category due to the discrete and subjective nature of the variable. This error was again reduced by having the same Chartered Physiotherapist who has experience in using the test categorise the players. The comparative study for isokinetic strength ratios worked prospectively, whereas this study worked retrospectively which is another limitation, as the order of events may have altered the results. Additionally the injury assessment was

RESULTS AND ANALYSIS Out of the 19 players initially included in the study, only 18 fulfilled the selection criteria for the final results analysis as insufficient isokinetic data was gathered on the excluded player. For the remaining 18 players in the study 4 sustained hamstring injuries, which prevented the individual from training or playing for a minimum of 48 hours, in the 5 months after testing. The statistically selected parameters for each screening test are shown in Table 5 and the screening results for each individual test are shown in Tables 1-4. The data from these tables is used to find the risk ratio for hamstring injury between the good and substandard groups and these risk ratios are compared directly in table 6. The Hecc/Qcon ratio and ESMST were found to be effective assessments for hamstring injury screening. The data indicates that having a low Hecc/Qcon ratio doubles the risk of hamstring injury, whereas being classified as having a poor ESMST score increases the risk of injury by 3 to 4 times. The SRT and HKAT were not found to be useful tools in assessing for hamstring injury. TABLE 1 Category

Players, n (n=18)

Injuries, n (n=4)

Without injury, n (n=14)

Injury Frequency, %

Good

16.7

Substandard

33.3