Lifestyle Fitness PT Issue 04 by Lifestyle Fitness Personal Training

Upper Limb Injury And Rehab Special

Containing

Shoulder And Rotator Cuff Injury Diagnosis And Treatments

Elbow & Wrist Injury, Diagnosis And Treatment

9 Components Of Better Running All With Video Explanations + Much More

ISSUE 4

THIS ISSUE IS A PT GOLDMINE FOR LEARNING

MARCH 2014

CONTENTS

Contents 04 13 27 38 41 44 48 55

Rotator Cuff & Shoulder Injuries. Rehab And Treatment. Elbow & Wrist Injuries. Rehab And Treatment. Client Protocol. ACL Biomechanics. Why Meal Replacement Plans Will Never Work. 9 Ways To Run Better. Fighters Corner. PT Directory.

March Editorial As a PT, one of the turning points in my career was the point I started to offer pain management as part of my product offering. Pain is a far more powerful motivator than pleasure and learning how to administer relief to lower back, shoulder and or knee injuries can broaden your client base, enhance the value of the work you do and diversify your skill set, not to mention the stimulation of the challenge that a client may bring. In this months issue, we take a close look into joint injuries and plausible methods of rehabilitation that you can study and learn and begin to explore with further.

This is arguably one of the most rewarding careers available, not least due to the emotional and physical improvements that any client can make, but its imperative you continue to strive forwards and learn all you can. This is particularly important if you are delivering a high volume of Personal Training. Infact there is a correlation between accelerated learning and development and increased session delivery, there is also a correlation in greater retention of PTâ&#x20AC;&#x2122;s who study more. Make sure you use every opportunity to add to your exiting skill sets from reputable sources.

All the best Andy McGlynn LSF-PT Group Director

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The Rotator Cuff & Shoulder

It is essential to have the correct insurance when diagnosing and treating any MSK injury or ailment. This information is for informative purposes and to help anyone currently studying exercise, rehab and therapy, or those who are newly qualified. 4

The Rotator Cuff & Shoulder

The rotator cuff is located within the shoulder joint and is one of the most common causes of shoulder pain and weakness. There are three main conditions that affect the rotator cuff these being tendonitis/tears and impingement. Before we talk about the rotator cuff we will have a look at the shoulder itself, the shoulder joint is technically named the glenohumeral joint, and this is where the head of the humerus sits with the glenoid making a ball and socket.

is stabilised by three ligaments and helps with scapula movement. The sternoclavicular joint joins the clavicle with the manubrium, allowing mobility of the pectoral girdle. Finally the scapulothoracic joint, which is not a true synovial joint mearly an articulation of the convex surface of the thoracic cage and concave surface of the anterior scapula. The main injuries that occur to the rotator cuff will affect the GH joint solely but other joint disruption can occur, particularly in odd mechanisms of injury. Now we have seen the bones that make the shoulder we will look at the rotator cuff itself, the muscles of the rotator cuff are: Supraspinatus Infraspinatus Subscapularis Teres minor

The glenohumeral (GH) joint

As you can also see the other bones that surround this joint are the scapula and clavicle, the glenohumeral joint is the joint that most people think of when they say â&#x20AC;&#x153;shoulder jointâ&#x20AC;? however there are others that are in the area which may also be involved in injury. The acromioclavicualr joint joins the acromion of the scapula to the clavicle, technically a gliding joint it

The rotator cuff muscles combine together to help maintain stability within the shoulder joint itself, but they are also very important in joint movement. Each muscle of the rotator cuff has a different origin yet they all act upon the humerus bone, many speak of the rotator cuff tendon, this is just what many call the combination of all 4 muscles. The origins of each of the rotator cuff muscles: Supraspinatus Supraspinious fossa of the scapula. Infraspinatus Infraspinatous fossa of the scapula. Subscapularis Subscapular fossa of the scapula. Teres minor Lateral border of scapula. Now we know a bit about the shoulder joint and what makes up the rotator cuff tendon, let us get on with the injuries. We will start with probably the most common ailment that effects the rotator cuff which is tendonitis.

The Rotator Cuff & Shoulder

Tendonitis of the rotator cuff Tendonitis is caused by inflammation of all, some or one of the muscles of the rotator cuff. Tendonitis commonly comes on suddenly and can cause acute weakness at the shoulder joint. Tendonitis is prevalent in those who perform a lot of actions with the shoulder joint or those who place great stress on the major shoulder muscles. Tendonitis is an overuse injury and therefore can be avoided in the most part, it is possible that repeated injuries to the rotator cuff through long standing untreated tendonitis may lead to calcification of the muscle in question.

Main symptoms of tendonitis of the rotator cuff are commonly acute onset of pain especially in movement. Many who perform shoulder press actions will get this worse and the pain will usually make these persons drop the weight they are carrying (not great for the head). Tendonitis and tears go hand in hand with rotator cuff injury and if pain is accompanied with rapid weakness especially in specific aspect of shoulder movement you can be pretty sure you have a tear. People most at risk of the injury occurring are: Bodybuilders, weightlifters, tennis players, squash players, hockey players, shot put, javelin throwers, power lifters, basketball

players………………..the list goes on. Anyone can get tendonitis but those who have to use their hands above their head for sport or training will struggle the most with the injury. Now as a PT how often have you been asked by a client or possible client “how can I sort this shoulder problem out?” or “I have a dodgy shoulder, what can I do?” We wouldn’t recommend messing with anything you don’t think you’re capable of, but the majority of shoulder pain is caused by tendonitis of the rotator cuff or by osteoarthritis (OA), if the client has OA they will have probably already been to the docs and got the diagnosis. But what of the rotator cuff, how can you first tell your client that this is tendonitis or a tear?

The Rotator Cuff & Shoulder

Drop arm test Hold your arm straight out (abduction) to your side at 90 degrees with thumbs down. Always do both arms at same time, bring

arms down slowly if one arm suddenly drops due to weakness you can say there is some form of rotator cuff tear going on.

The Rotator Cuff & Shoulder

Empty can test Hold your arm straight out (abduction) to your side at 90 degrees with thumbs up, now have someone press upon the wrists in a downward motion, repeat this with a thumbs down position. If there is a drop in one of the arms, or shaking within one of the arms then the test is positive for a rotator cuff tear.

These two tests are great for instilling confidence in your client as it shows that you know what you are talking about and that you are showing them attention where their GP may not.

These tests are commonly used and whilst they measure a tear they will also give a sign of tendonitis. However to really impress and get to the bottom of if whether it’s the whole rotator cuff tendon or just one specifically you will need to know each of their actions.

Test – Place pressure upon a full range of internal rotation starting from the hand laterally going more medially, apply light force throughout the range. If there is pain throughout or in specific spots you can positively say that there is subscapularis injury involvement.

Supraspinatus – Main agonist in abduction of the arm at the GH joint, mainly the first 10-15 degrees of the arc.

Teres minor/infraspinatus – lateral rotation of the GH joint.

Test – Place pressure upon the client’s wrist as the try to abduct the arm in the first 10-15 degrees of movement, if there is severe pain in this part and less pain when repeated at 60-90 degrees who can positively say that the supraspinatus is most likely inflamed. Subscapularis – internal rotation of the GH joint.

Test – See subscapularis test and mimic but in the opposing fashion, from medial to lateral with force being applied throughout. Any pain would indicate injury involvement of the infraspinatus/teres minor muscle. The deltoid muscle is also involved with the above movements, and so are other major muscles. However deltoid tears and tendonitis would go hand in hand with a rotator cuff injury.

The Rotator Cuff & Shoulder

So you have managed to tell your client what is wrong with their shoulder, now how are you going to treat this condition? Well this is tough because there are many variables, such as how long have they had the injury, how bad is the injury. If the injury has occurred within 24 hours: Rest, I am afraid the best option for your client is to rest the shoulder joint, you can advise on using ice to help with pain. Painkillers are fine, with NSAIDS being the first choice for muscular injuries. So ibuprofen would be preferable to paracetemol or asprin. How long should they rest? Rest depends on the severity and client, we would recommend at least 4 days rest after any major onset of shoulder pain. When the client returns to you after this period, repeat the test, there should be some improvement. Depending on this improvement you can then start rehabilitation. Short overview of muscles required in rehabilitation exercises for the rotator cuff: The muscle groups targeted in a conditioning program include: • Deltoids (front, back and over the shoulder)

• Trapezius muscles (upper back) • Teres muscles (supporting the shoulder joint)

you can safely restart your original programme remembering that the client will be weaker than before, unless the programme was not resistance based.

• Supraspinatus (supporting the shoulder joint)

If you are ever unsure always ask an appropriate person, physio, GP etc.

• Infraspinatus (supporting the shoulder joint)

Now we have looked at the rotator cuff tendonitis and tears, we will have a short look at prevention.

• Rhomboid muscles (upper back)

• Subscapularis (front of shoulder) • Biceps (front of upper arm) • Triceps (back of upper arm) PTs will know what exercises to use to strengthen all the muscles listed and if you are in need of a PT check our PT directory in the magazine, now you know what each of the rotator cuff muscles actions are you can use that to your advantage. We would recommend in the first 7 days of rehab concentrating on muscles that surround the effected muscle, for example if the pain occurs in abduction thanks to a bad supraspinatus we would not recommend any resistance work in abduction instead concentrating on movements that work other muscles around the area such as biceps and triceps which should not require a great deal of abduction. Now in reality the only way you know that your client is getting better is by repeating the tests outlined, when the client has no pain or weakness and the tests are negative

Supplementing your programme with light resistance shoulder rotational exercise is a great way to help strengthen certain rotator cuff muscles, these should be done on a day where you are not training upper body muscles. Why not add in three sets of 20reps cable or dumbbell internal and external rotation after your cardio or legs sessions, it will not take much time but will save weeks of missed training later down the line. Now many believe that when they perform lat raises there supraspinatus will also improve, whilst this is very true, many train lat raises with a force or swing at the beginning of the rep, this is the part of the rep where the supraspinatus is working its most. The largest reason for rotator cuff injuries is imbalances where the major muscles such as the deltoid, pectorals and triceps have increased to an extent where the rotator cuff muscles struggle and become worn. 9

The Rotator Cuff & Shoulder

It is important to work these small muscles as they will help you down the line in your chosen sport and training. As a PT you may want to chuck some of these into your client’s workout to help prevent injuries down the line. And remember if you start feeling any twitches or weaknesses in your shoulder when lifting you may want to rest, struggling through could lead to injury, you know your bodies don’t let them down. Rotator Cuff Impingement The rotator cuff tendon passes through the subacromial space, this is a space that is underneath the part of the acromion aspect of the scapula.

problems with the bones themselves such as bony spurs, and if the rotator cuff becomes inflamed due to injury it may swell causing impingement in the subacromial space.

cause pain more anteriorly on the shoulder if the patient suffers from biceps long head tendonitis.

Main symptoms of impingement syndrome includes general shoulder pain, usually a chronic pain which becomes worse when attempting to perform activity and when sleeping, it is possible that some people will hear popping or cracking in the shoulder joint especially when lifting anything over head.

Take the client’s arm from shoulder joint to 90 degree abduction, with flexion at the elbow of 90 degrees and finally 70-80degrees external rotation from the shoulder joint.

So if you have a client that is complaining of symptoms that resemble this, what should you do? Well here are a few tests that you can carry out to try and diagnose the problem: Neer’s impingement test (supraspinatus)

In the case of impingement syndrome, the rotator cuff becomes trapped in this subacromial space. When this occurs the muscles scrape against the scapula which leads to inflammation and therefore finally leads to injury to these muscles, if this continues without any treatment the tendons will tear. Impingement is normally caused by problems with the joint space such as arthritis, it can also be caused by

Take the clients arm and put it in slight abduction, then passively take the arm flexing at the shoulder, so that the arm is straight next to the clients ear, the palm is commonly placed facing away from patient (internal rotation). When the arm is raised the supraspinatus muscle is compressed against the inferior and superior aspect of the acromion. If the patient complains of pain in the lateral shoulder, especially after the first 90degrees you can say the test is positive for impingement of the supraspinatus. This test can also

Shoulder Internal Impingement Test (IRRST)

1st – put pressure just below the back of the clients hand whilst supporting the elbow, ask the client to externally rotate into your pressure for 5 seconds. 2nd – put pressure just below the palm of the clients hand whilst supporting the elbow, ask the client to internally rotate into your pressure for 5 seconds. If the client suffers from weakness and/or pain during the 2nd aspect (internal rotation) part of the test you can say with some positivity that this is a non-outlet impingement. This would indicate that a tear in the rotator cuff may be present causing the humeral head to sit in the wrong position, it is also plausible that this could indicate biceps tendon rupture and possible hypertrophy or swelling of the rotator cuff.

The Rotator Cuff & Shoulder

Impingement relief test This is a good test for patients that have minimal pain, or those who feel that they are getting twinges when working out, especially in overhead exercises. First tell the patient to actively take their arm to full abduction at the shoulder joint and

note when the patient feels pain, this can be done in any plane. This can also be done with shoulder internally and externally rotated. Find the movement that causes the patient the most discomfort, now repeat this movement but apply a downward

force upon the humeral head. If pain is now alleviated thanks to this downward pressure you can say with some positivity that the patient is suffering with impingement.

Similar to tendonitis, rest is vital in the situation of impingement of the rotator cuff, if the rotator cuff is inflamed and this is the reason for the impingement rest may actually cure the problem as the swelling subsides. It is vital that you maintain movement within the shoulder we would just recommend staying away from resistance. NSAIDs are paramount

in helping bring down both pain and inflammation, if you or your client symptoms persist and get worse then a trip to the GP is necessary, this is especially true if range of movement becomes worse day by day. In certain circumstances surgery is required to open up the subacromial space, usually known as a decompression operation.

Rehabilitation and prevention are similar to those of tendonitis so we would recommend following the plans set out there, again if you are in need of an expert, LSFPT has many that across the UK that can help.

PT Essentials The Big Review: Fit Pro Client Recipes Fit Pro Client Recipes is the new & innovative nutrition plan builder taking the world of PT’s by storm. It transforms the way you create nutrition plans for your clients, automatically branding every recipe with your logo. We review the good and the bad points for you here. What You Get: 

FPCR gives you an online recipe system that rebrands all recipes with your logo.

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This is the simplest way to create nutrition plans for your clients yet. It takes less than 5 minutes to upload your logo and custom footer. In fact you could get at least three different packs straight off the bat in less than 15 minutes all printed up and ready to go from the dashboard. So for busy PT’s this is a great feature.

Every recipe is macro counted and the calculators automatically add up calories when you add a recipe to a pack so it’s a point and click pack builder.

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The recipes are so good clients will actually want to stick to the meal plan meaning they actually keep shifting the fat. This system means you can get clients to eat real food that fits their lifestyle and family commitments without compromising on macro counts or risking ‘cheat days’. That means more great results for your clients (and you!)

Most major nutrition systems are included and there are plenty of recipes available even for systems like paleo, IIFYM, vegan, dairy or gluten free diets.

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Search by nutrition system and meal type to add recipes to your pack.

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Create your own recipe packs to sell as eBooks or to clients.

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Video documentaries with some of the world’s leading nutrition experts & PTs

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The good:

There are loads of help video tutorials so that makes getting the best out of the system easy.

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There are 4 different ways to calculate the calorie count for your clients which include the exclusive Alan Aragon calculator. That bits great but the recipe list to create your bespoke pack isn’t as sexy as the latest recipes display. The pack when its created has the same layout for the recipes though so your clients will never know the difference. The sales page to choose your membership options is a turn off for some. But you only have to see that once so don’t let that put you off trying the system.

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MSK injuries to the wrist and forearm

Elbow & Wrist Injuries

Following the theme of this issue, we decided to look at common injuries, diagnosis and treatment of the hand and elbow and everything in-between.

MSK injuries to the wrist and forearm Let us start with some anatomy of the hand and wrist. The anatomy shown above are the bones that make up our hand and wrist, as you can see the wrist has 8 bones making it up, these are known as the carpal bones:

S-Scaphoid

Tra-Trapezoid

L-Lunate

C-Capitate

Triq-Triquetrium

H-Hamate

P-Pisiform

An easy way to remember these and in order is to use this little number.

T-Trapezium

Some Lovers Try Positions That They Canâ&#x20AC;&#x2122;t Handle

MSK injuries to the wrist and forearm Know we have had a look at the bones of the wirst and hand we will now show you the nerves that pass over the wrist and hand, these are important to know for injuries.

The radial nerve â&#x20AC;&#x201C; The radial nerve is a nerve that mainly supplies the upper arm, originating from the posterior cord of the brachial plexus and effects the majority of the back of the hand as well as the thumb along with the median nerve. So we have looked at the nerves, now we need to look at some of the

ligaments and muscles. There are a ridiculous number of ligaments and muscles in the forearm, writs and hand, we would not expect anyone besides anatomists to be able to memorize them all and their origin/ insertion. However let us out lay a few important ones:

This shows the areas that these three nerves have emphasis over, this is vital knowledge when trying to differentiate which nerve may be the culprit for causing problems in your hand and arm. The Ulnar nerve â&#x20AC;&#x201C; The ulnar nerve is a nerve that runs next to the ulnar bone of the forearm, the ulnar nerve is an unprotected nerve and the largest in the body, therefore injury is common, the ulnar nerve connects fully with the 5th digit (little finger) and the adjacent half of the ring finger. The median nerve â&#x20AC;&#x201C; One of the main nerves that originates from the brachial plexus, the median nerve is the only nerve that passes through the median canal. Therefore it is the nerve involved in carpal tunnel syndrome. 15

MSK injuries to the wrist and forearm So anatomy wise I think it is safe to say there is plenty there, and therefore there is plenty to go wrong. So let us start talking about common pathologies that occur at the wrist/ hand: Carpal Tunnel Syndrome (CTS) CTS is entrapment of the median nerve that leads to pain, parenthesis and numbness. Whilst many agree that CTS is caused by compression of the median nerve it is not the most well understood pathology of our time. The median nerve travels through the carpal canal and becomes compressed, however the mechanisms behind this are unclear. There seems to be connections with genetics and environment, with higher correlations with obesity, pregnancy, manual labour and hypothyroidism. Carpal tunnel syndrome should not be confused with tendonitis which is also common around the same area but the symptoms will have more emphasis on pain rather than numbness and tingling, with intermittent numbness being the number one complaint from patients suffering from CTS, this numbness is commonly across the thumb and index finger, and usually occurring at night. There are also reports of patients suffering with burning sensations in hand, thumb and index finger, a loss grip strength is also noted. Carpal tunnel syndrome

if left untreated may lead to atrophy of the thenar muscles and permanent median nerve damage will occur. Some believe that thoracic outlet compression of the median nerve may also lead to these symptoms. However in general carpal tunnel syndrome will be diagnosed instead of any other, as carpal tunnel has specific objective symptoms which can easily be labelled. As mentioned before the cause of CTS is still out for question, with many possible options to the reason behind the pathology. You may find that clients that complain of symptoms are those involved with manual work. The CTS – WORK link There is a constant debate about CTS and work, factors that may incur CTS are: vibration, repetitive tasks, direct trauma, posture and force through the joint. Many believe that the CTS is not caused by a one off injury, but more of an accumulation of movements with wrist involvement involving forceful or resistance based activities. However repetitive movements are a common cause of tendonitis and this cannot be ruled out as a possible other diagnosis. There is a direct correlation of CTS and those involved with repetitive manual work however the exact cause is very difficult to establish.

Other conditions that have CTS association Many other diseases are associated with CTS, and client properties including, carpal tunnel size, habits, heredity and age. Examples of other diseases associated with CTS are: Pregnancy – women may experience CTS due to high progesterone levels and water retention that may swell the synovium. Rheumatoid arthritis – RA can cause inflammation of flexor tendons which may entrap the median nerve. Hypothyroidism – deposition of mucopolysaccharides from generalised myxedema surrounds the tendons and the perineurium of the median nerve all if which pass through the carpal canal. Fractures – Previous wrist fractures can cause impingement of the median nerve, especially during the healing process where bone callouses can cause impingement. Ramkumar fluid retention – fluid retention from hypothyroidism, amyloidosis and diabetes mellitus all have association with CTS. Tumours – ganglion or lipoma can cause compression of the nerve in the carpal canal, however this is rare and only occurs in around 0.8% of cases. Acromegaly – Bone and muscle can grow around the carpal canal and 16

MSK injuries to the wrist and forearm cause compression. Obesity – Those who are classified as obese with a BMI of > 29 are 2.5 x more likely to suffer from CTS than those with a BMI of < 20. This does not relate to those who are high on the BMI due to lean body mass (Hypertrophy etc.). So we have gone through CTS now we will go through how to diagnose CTS: Phalen’s test – This test is performed by extending (reverse phalen’s) or flexing the wrist slowly all the way through to full range of movement, pain with associated numbness/ tingling down the middle finger, thumb and ring finger are positive signs for CTS.

Durkan Test (CCT) – this test is done by applying firm constant pressure to the palm over the median nerve for up to 40 seconds, this can bring on the symptoms.

MSK injuries to the wrist and forearm Tinel’s sign – a combination of tinel’s sign and the Phalen’s test are a good way to go in discovering CTS. Tinel’s test is done by applying small taps to the skin over the flexor retinaculum to bring on the symptoms of tingling and numbness. This is less effective than the Phalen’s test at bringing on symptoms but has greater specificity.

When looking for CTS it would be wise to remember that if pain is the number one symptom than it is unlikely that CTS is the major cause. CTS will bring on numbness and tingling as the predominate symptoms.

Preventative measures Methods that can be employed to help prevent CTS consist of trying to minimize repetitive stressors upon the wrist and using certain aids during work such as wrist supports and compression. It is also advisable that repetitive manual workers take regular breaks and rest the wrist joint to help prevent irritation. Early nutritional treatments such as increasing natural anti-inflammatories like turmeric, also increasing B vitamins and omega-3 may help prevent CTS. It is possible that CTS is not preventable as it may be down to genetics, in which case we would still recommend trying some natural antiinflammatories to help reduce pain. Treatments Most treatments for CTS involve injected steroids, surgical intervention and splints, currently there is limited evidence for the usage of

ultrasound therapy and exercise therapy as an effective treatment for CTS. Splints were very common treatment pre-2000, however many people refused the usage due to the restriction that it causes. It is far more common to use a combination of NSAID’s and trying to restrict forced movement, however if this fails then more aggressive treatment is required which is normally surgical intervention. However it may be beneficial to wear a brace whilst training to help prevent excess force through the wrist and will help prevent hyper extension and flexion. Most can deal with CTS with conservative treatments such as NSAIDs, steroids and braces, however surgery is also a good option. Chronic untreated CTS will lead to muscle wasting and irreversible numbness of the hand, those who have surgery can be happy in the fact that reoccurrence of CTS is rare. 18

MSK injuries to the wrist and forearm De Quervain’s syndrome This condition has many names such as gamer’s thumb, radial styloid tenosynovitis, mothers wrist and washerwoman’s thumb. Symptoms of this syndrome are normally noted to be pain, swelling and tenderness over the radial (thumb) part of the wrist, many complain that they suffer from bad grip strength. Similar to CTS, De Quervain’s syndromes cause is not totally established, many believing that the main reason for this syndrome

is repetitive strain of abduction and extension of the thumb. Excessive pushing and pulling during manual labour have been established to correlate with the syndrome. It is possible that excessive texting and video game usage may also be linked with the syndrome along with piano playing, knitting and golf. The condition appears to effect women more than men, and can occur during and post pregnancy, hormonal changes are purported to be the cause of this.

The two tendons that are involved in De Quervain’s syndrome are the abductor pollicis longus and the extensor pollicis brevis. Both of these muscles have similar actions on the thumb, they allow movement of the thumb away from the hand (radial abduction). These tendons pass through the wrist in synovial sheaths, the inflammation of these sheaths are what is known as De Quervain’s syndrome. So how can we diagnose such a problem?

Finkelstein’s test The Finkelstein’s test is used to test for tenosynovitis in the extensor pollicis longus and the extensor pollicis brevis. Take your client in either standing or sitting, the client will then form a fist around the thumb. You should stabilize the forearm by having one hand at the elbow and one hand on the mid forearm. The client should then move the wrist into ulnar deviation, if there is pain located around the radial styloid and distal lateral forearm the test is positive for De Quervain’s syndrome.

MSK injuries to the wrist and forearm Treatments

Scaphoid Fracture

Diagnosis

Conservative management of the syndrome uses corticosteroid injections to help relieve pain, and this seems to be a decent long term management tool for 50% of patients. Surgery includes opening the sheath of the first dorsal compartment which in most patients relieves symptoms. Treatment and prevention can come under the same umbrella, with many stating that strengthening exercises, braces and adapting repetition in work.

Scaphoid fractures occur at the carpal bone called the scaphoid, scaphoid fractures are the most common form of carpal fracture, pain is normally localised around the base of the thumb and is usually accompanied by swelling in the area. Fractures occur either due to forced hyperextension of the wrist joint or direct impact to the bone itself. A fall on to an outstretched hand (FOOSH injury) is the most common cause of a scaphoid fracture. Scaphoid fractures are categorised by the fracture location.

A scaphoid fracture test can be performed on anyone who is complaining of pain at the base of the thumb, localised pain will be found in the anatomical snuffbox which is located at the base of the thumb.

MSK injuries to the wrist and forearm If you have a client or yourself find that you recently had a fall or impact to the wrist and have localised pain within the snuff box, making your way to hospital is a good idea as an x-ray is required. Some fractures will not occur on x-rays until 10 days after the initial injury. It is very important that scaphoid fractures are treated swiftly and correctly as complications can arise: Avascular necrosis (AVN) A common complication of scaphoid fractures is AVN, the chance of occurrence is down to where in the scaphoid the fracture is located: 1. Proximal 1/3 have a 30% incidence of AVN 2. Middle 1/3 has a moderate risk association with AVN 3. Distal 1/3 fractures have rare occurrence of AVN.

AVN causes the bone to die due to a lack of blood supply, this will lead to complete bone collapse eventually, and this will lead to severe disability at the wrist joint. Non Union If a scaphoid fracture goes undiagnosed and untreated the scaphoid fracture may not fuse, this may eventually lead to wrist osteoarthritis.

Treatments & Prevention Treatment represents the location of the fracture and displacement of the fracture, most scaphoid fracture that have minimal displacement have a good union rate when immobilised, usually in a cast. Prevention is tricky as this is an acute accidental injury, however it is imperative that the fracture gets diagnosed and treated to prevent complications. Certain sports gloves now have â&#x20AC;&#x153;scaphoid protection systemâ&#x20AC;? (SPS) which is a method of protecting the scaphoid from injury in extreme sports, perfect for cyclists. So we have had a look at the most common injuries in the hand and wrist that you may come across yourself and with clients, so let us move on to the elbow, let us first take a look at the anatomy of the elbow.

MSK injuries to the wrist and forearm It is important to remember and use the anatomical knowledge that you can gain as it helps you understand injuries in more depth, and if you are a trainer will help you understand the injuries of your clients. So we wouldnâ&#x20AC;&#x2122;t be covering common elbow problems if we didnâ&#x20AC;&#x2122;t talk about: Tennis Elbow Tennis elbow is also known as lateral epicondylitis, clients will complain of tenderness around the lateral aspect of the elbow, and is usually caused due to degeneration of the tendon connecting the extensor carpi radialis brevis (ECRB) to the elbow at the lateral epicondyle. Main symptoms of tennis elbow include, pain at the lateral epicondyle, pain at the proximal lateral forearm when lifting weights or using the wrist in extension, some complain that pain is worse in the morning and may have associated stiffness at the elbow. The cause of tennis elbow is commonly thought to be caused by repetitive movements at the elbow joint causing micro tears in the tendon (see video), however research also shows that direct blows, and acute exertion of the extensor carpi radialis brevis are also major factors. It is also possible that the radial nerve that travels down the lateral side of the forearm has an association with the pain caused by tennis elbow.

Diagnosis There a few tests which can be done to help decide whether or not you or a client has tennis elbow. Tennis Elbow Finger Test This test is performed by placing force upon the 3rd digit whilst the client attempts to extend the digit, the test is considered positive if the client complains of pain in lateral aspect of the elbow and in the proximal aspect of the lateral forearm.

MSK injuries to the wrist and forearm Wrist extension test (cozenâ&#x20AC;&#x2122;s test) Very similar to the above test this time pressure should be applied to the dorsum of the hand whilst the client exerts force trying to extend at the wrist. Again this test is positive if pain occurs at the lateral aspect of the elbow and/or proximal part of the lateral forearm.

Treatment Eccentric exercise using a bar may be beneficial in the treatment of tennis elbow, a 2009 study was so successful trialling this that they stopped the study due to significant improvements. 1. Fix a resistance band firmly under the clientâ&#x20AC;&#x2122;s foot and tell them to hold the other end in their hand in pronation. Make sure elbows are straight as possible over knees and allow the wrist to go towards the floor. 2. Tell the client to allow you to move the wrist passively stretching the resistance band. This stage can be done with the client using their other free hand. 3. Slowly let the band pull the wrist down towards the floor (should take around 3 seconds)

not actively move the wrist using the muscles of the effected arm. This exercise should be done twice a day for 4 days of the week, at a rate of 15 reps 4 sets with 60s rest periods.

Attached to the back of this magazine is a research paper that needs to read by anyone interested in helping with tennis elbow.

It can take a good few weeks for this to work (8+) however after this period 70% of those who complete the programme no longer suffer from tennis elbow.

It is very important that the client do 23

MSK injuries to the wrist and forearm Some people with tennis elbow have complete remission after 6-24 months without any treatment, however others will be left with a chronic and constant pain which eventually leads to severe grip weakness and a loss of range of movement. The usual medications are also indicated for tennis elbow, the most common of which are NSAIDs, whilst many report an improvement in pain, there is limited evidence that the treatment helps the problem at all. Prevention Learning correct technique in sports which require great deals of wrist action is paramount in preventing the disorder. Other methods of prevention are: 1. Decreasing playing time. 2. Overall good shape and limiting muscular imbalances. 3. Strengthening of pronator quadratus, pronator teres and supinator 4. Strengthening of surrounding joint muscles such as biceps and triceps.

Golfers Elbow

Diagnosis

Golfer’s elbow is known as medial epicondylitis, it occurs on the medial side of the elbow on the medial epicondyle. It is therefore similar to tennis elbow but just on the opposing side. The common flexors of the forearm control fingers and wrist, they insert into the medial epicondyle of the humerus, when this aspect becomes inflamed it is known as golfer’s elbow.

Finger flexion test A similar test to the tennis elbow test, however this test is performed with flexion of the finger rather than with extension. If there is pain on the medial epicondyle then the test is considered positive for golfer’s elbow.

The condition itself is known as golfer’s elbow due to the golf swing causing stress upon the common flexor tendon, it is also known as pitchers elbow due to stress placed upon the tendon when throwing an object. Whilst golfer’s elbow is less common than tennis’s elbow it is still fairly common in those involved with baseball, golf, climbing and bodybuilding. It is vital that those involved with sport treat golfer’s elbow quickly as there is potential that the problem may worsen leading to permanent muscle weakness especially at the wrist.

5. Using appropriate supports and braces when playing sports.

MSK injuries to the wrist and forearm Wrist flexion test Again similar to the tennis elbow test, this time with wrist entering flexion, if there is pain in the medial epicondyle of proximal medial aspect of the forearm the test can be described as positive for golfer’s elbow.

Treatments First hand treatments rely on NSAIDs, heat & ice and elbow straps/tape, golfer’s elbow is an overuse injury and therefore the most important aspect of healing is to rest from the actions causing the injury to worsen. Simple exercises (SEE VIDEO) can be employed to help improve strength in the flexor-pronator muscles and to improve ROM. There are surgical options available if the condition persists and become chronic, however less than 10% require this option, prognosis is commonly good with conservative treatment and rehabilitation exercise. Ulnar Nerve Entrapment As the name suggests this is a condition where the ulnar nerve becomes trapped, depending on where the nerve is trapped will determine the symptoms. When the

nerve is compressed at the elbow it is known as cubital tunnel syndrome not to be confused with carpal tunnel syndrome, even though some may use CTS for both. Entrapment here leads to numbness down the small finger (5th digit), this numbness may only occur at night or during certain exercises, however this can get worse finally leading to the little finger curling up, the ring finger may also become affected and this can also become number and begin to curl up.

When the ulnar nerve is compressed at the wrist it is known as Guyon’s canal syndrome due to the ulnar nerve passing through the Guyon’s canal in the wrist, this can exhibit burning within the wrist. Diagnosis can be made from symptoms, however it is difficult and many may believe they have carpal tunnel syndrome. It is true that people with one nerve compression often suffer from another making diagnosis difficult. 25

MSK injuries to the wrist and forearm Tinels Sign Test You can perform the Tinels test on the ulnar nerve by tapping on the medial epicondyle, a positive test would be if the clientâ&#x20AC;&#x2122;s symptoms are reproduced, numbness and/or tingling down the forearm. Treatment Rest is key in this situation, stretching exercises and massage on the forearm can relieve symptoms and offer respite from the problem. Trying to find triggers of the symptoms is important, as these will only make symptoms worse.

Just For Trainers & Therapists

PT Client Protocol We have set up below a protocol for trainer and coaches who may wish to start assessing clients with injuries, certain aspects are specific to the shoulder and elbow. Remember that only a medical doctor can diagnose ailment, illness and injury, however having the knowledge to help clients through their ailments is a great tool, you may want to start working closely with your local GP surgery. There are also numerous therapy courses out there and some are better than others, get in touch with us if you are unsure on what courses to go on to build your therapy knowledge. A good method of knowing which courses have some quality is to look if they are accredited by one of the following:

Ideally this should all be done in a private room/cubicle Client enters gym – Check GAIT (the way the client walks), antalgic, trendenemberg, flat foot. Check facial signs Any obvious signs of discomfort or injury, for example are they wearing bandages, strapping, cast, waling with a stick. Make sure you get the personal detail etc.

the line on what they feel their pain is now. You should also ask about pain when the injury occurred and pain after any triggers. Did you hear anything when the injury occurred? A pop, crack etc. Was anyone else around when the injury occurred? Have you had any previous treatment? Did you get any immediate treatment? RICE? Any swelling around the injury?

Now start asking about the injury:

How long ago did the injury occur?

24 hour pattern?

Any loss of movement?

Sleep?

Effect Daily living?

Where does it hurt?

Ask about past medical history

How did the injury occur?

PAST MEDICAL

Society of Sport Therapy (SST)

On what surface?

British Association of Sport Rehabilitators and Trainer (BASRaT)

What pain are you in, VAS (0-10)?

Thyroid, Heart, Rheumatoid Arthritis, Epilepsy, Asthma, Diabetes.

Charted Society of Physiotherapy (CSP) HCPC (physiotherapy) So let’s take a look a quick break down of that protocol:

VAS = visual analogue scale 0 – no pain 10 – excruciating pain. To make a VAS, get a ruler and draw a 10cm line with 0 at one end and 10 at the other, ask the client to put a mark on

Dysarthria = trouble talking. Diplopia = double vision Dysphagia = trouble swallowing Drop attacks = fainting etc.

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Dizziness

Scoliosis = S shape spine

Any previous Injuries?

Dosage? Where from? How long have you been taking?

Skin disorders

Talk about lifestyle

Flat foot deformity

Allergies

Hobbies, Sports, Life, Job etc.

High arc

Bone disorders (osteoarthritis, rheumatoid, paget’s disease, acromegaly etc.)

Look for objective signs

Check the movement the client has:

Scars

Cauda Equnina = A bunch of spinal nerves in the lumbar/sacral/coccygeal part of the spine. Disturbances cause numbness and tingling in the lower limbs, possible bowel/bladder disturbances.

Rubour (redness)

Active range = Patient does the movement, (Works contractile tissues)

Swelling Muscle mass Muscle deformities/imbalances Varus legs (bow legged) legs go out

Talk about pharmaceuticals

Valgus legs (leg goes in, knocked knee)

Are you taking any medication?

Lordosis = back goes in

Are you taking any medication for the injury?

Kyphosis = Back comes out

Normal arc

Passive range = Therapist does the movement – (works non contractile) Resisted = Work the middle range isometrically, then inner range isometrically, then outer range isometrically. The concecentric through the range. Use the - Oxford scale 0 – 5.

OXFORD SCALE 1 - Flicker of movement 2 - Through full range but not against gravity 3 - Through full range against gravity 4 - Through full range with some resistance 5 - Through range with full resistance

Just For Trainers & Therapists

When looking at movements passively you are looking for different end feels:

the knee held in extension, in which motion is stopped by the hamstrings.

END FEELS

Springy block - This end feel is the sensation of motion stopping short of where it should, accompanied by a rubbery or springy sensation at the end. It occurs most often in joints in which a piece of loose cartilage (like the meniscus in the knee) may be blocking full motion and causing the limbs to “bounce back” a bit.

Bone to bone - This is the sensation when motion is stopped by two bones contacting one another. An example is the end feel for extension of the elbow. Muscle spasm - When muscles are in spasm, they may abruptly halt motion prior to what should be the normal range of motion. It is likely that pain will be felt at the end of this range, because the muscle in spasm will be stretched. Capsular - This is the end feel described for range of motion limited at the end by the joint capsule. The sensation often described is a “leathery” feel to the end of the motion, such as in external rotation of the shoulder. A true capsular end feel occurs when the joint capsule is the primary limitation to the end range of motion. Some authors have called this end feel the “tissue stretch” end feel and extended it to other tissues, such as muscles, that may stretch normally at the end of their range of motion. An example of the tissue stretch with muscles would be hip flexion with

Tissue approximation - This is the end feel in which motion is stopped by two masses of soft tissue pressing on one another. An example is in flexion of the elbow, in which the elbow flexors and wrist flexors press on each other to limit further motion. Empty - This end feel has no mechanical limitation to the end of the range, but the client will not let you go any farther because of excessive pain. An example would be in shoulder impingement, in which pain from the supraspinatus tendon being compressed will limit how far the arm can be abducted. Mechanically there is no further restriction, but the pain will prevent the individual from allowing further motion.

Shoulder specific movements – Abduction = take arm away from body holding forearm and shoulder. Adduction = take arm towards body then across. Flexion = take arm in front of body. Extension = take arm behind body Lateral rotation = take arm in rotation with arm bent at elbow, arm comes away from body. Internal Rotation = take arm in rotation in towards the body with arm bent at elbow. Horizontal flexion and extension = arm goes across body in flexion, arm goes away from body in extension, arm is outstretched. Horizontal internal rotation = this is a movement that is done with elbow bent and arm in 90 degrees, arm moves down in rotation so hand goes towards floor. External is opposite.

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SHOULDER GIRDLE Elevation = lifting up into a shrug. Depression = pulling down. Retraction = pulling inwards at chest. Protraction = pushing away from chest. Patient may be standing sitting or on bed. In shoulder girdle movements patient is sitting or standing with therapist behind. ELBOW Flexion = Bicep curling movement Extension = Triceps extension movement Pronation = palm down Supination = palm up WRIST (patient in sitting across from therapist) Flexion = hand supinated then thumbs press to move hand up. Extension = hand pronated then push on palm to move hand back. Ulna deviation = Hand goes out Radial deviation = hand goes in.

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Major Anatomy and Muscles Association of upper body MAJOR MUSCLE Trapezius

ORIGIN external occipital protuberance

INSERTION posterior, lateral 1/3 of clavicle

along the medial sides of the superior nuchal line

acromion superior spine of scapula

ligamentum nuchae (surrounding the cervical spinous processes)

ACTION elevates scapula upward rotation of the scapula (upper fibers) downward rotation of the scapula (lower fibers) retracts scapula

spinous processes of C1T12 Latissimus dorsi

spinous process of T7-L5 upper 2-3 sacral segments

lateral lip of the intertubercular groove

iliac crest

adduction of humerus medial rotation of the humerus extension from flexed position

lower 3 or 4 Ribs

downward rotation of the scapula Pectorals major

medial 1/3 of clavicle

tubercle

humerus

anterior aspect of manubrium & length of body of sternum

clavicular fibers insert more flexion of the arm from distally; sternal fibers more extension (clavicular proximally portion)

cartilaginous attachments of upper 6 ribs external obliqueâ&#x20AC;&#x2122;s aponeurosis

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MAJOR MUSCLE Pectorals minor

ORIGIN INSERTION outer surface of ribs 2-5 or medial aspect of coracoid 3-5 or 6 process of the scapula

ACTION depresses & downwardly rotates the scapula assists in scapular protraction from a retracted position stabilizes the scapula

Levator scapulae

Rhomboid minor

transverse processes of C1-C3 or C4

superior angle of scapula toward the scapular spine

spinous process of C7 & T1

medial margin of the retract scapula scapula at the medial angle

ligamentum nuchae

elevates the scapula extends and/or laterally flexes the head

supraspinous ligament Rhomboid major

spinous processes of T2-T5 medial margin of the retract scapula scapula at the inferior angle supraspinous ligament

Serratus anterior

fleshy slips from the outer costal aspect of medial surface of upper 8 or 9 ribs margin of the scapula

Deltoid

lateral, anterior 1/3 of distal deltoid tuberosity of clavicle humerus lateral boarder of the acromion

Supraspinatus

scapular spine supraspinous fossa muscle fascia

uppermost of three facets of the greater tubercle of humerus

protract scapula stabilize scapula assists in upward rotation abducts arm flexion and medial rotation (anterior portion) extension and lateral rotation (posterior portion) abduction of arm (first 1520째) stabilizes glenohumeral joint

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MAJOR MUSCLE Teres minor

Teres major

Coracobrachialis

Biceps brachii

ORIGIN middle half of the scapulaâ&#x20AC;&#x2122;s lateral margin

INSERTION ACTION lowest of three facets of the lateral rotation of the greater tubercle of humerus humerus stabilizes the glenohumeral joint assists in adduction of arm

inferior, lateral margin of the crest of lesser tubercle scapula ( just medial to the insertion assists in medial rotation of of latissimus dorsi) arm

coracoid process of the scapula long head- supraglenoid tubercle and glenohumeral labrum

assists in extension from an flexed position medial shaft of the humerus flexes the humerus at about its middle assists to adduct the radial tuberosity bicipital aponeurosis

supinates forearm from neutral

short head- tip of the coracoid process of the scapula

Brachialis

lower 1/2 of anterior humerus

humerus flexes the forearm at the elbow (when supinated)

stabilizes anterior aspect of shoulder

ulnar tuberosity

flexes shoulder (weak if at all) elbow flexion (major mover)

both intramuscular septa

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MAJOR MUSCLE Triceps brachii

ORIGIN long head - infraglenoid tubercle of the scapula

INSERTION posterior surface of the olecranon process of the ulna

lateral head - upper half of the posterior surface of the deep fascia of the shaft of the humerus, and antebrachium the upper part of the lateral intramuscular septum

Pronator teres

medial head - posterior shaft of humerus, distal to radial groove and both the medial and lateral intramuscular septum (deep to the long & lateral heads) humeral head: lateral aspect of radius at the middle of the shaft upper portion of medial (pronator tuberosity) epicondyle via the CFT

ACTION long - adducts the arm, extends at the shoulder, and a little elbow flexion lateral - extends the forearm at the elbow medial - extends the forearm at the elbow

ateral aspect of radius at the middle of the shaft (pronator tuberosity)

(common flexor tendon) medial brachial intermuscular septum ulnar head - coronoid process of ulna antebrachial fascia Supinator

lateral epicondyle of humerus supinator crest of ulna

proximal portion of anteriorlateral surface of the radius

supinates the forearm

radial collateral ligament annular ligament antebrachial fascia

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Special Tests (shoulder) The empty can test Hawkins Test = Subacromial impingement, rotator cuff. Scarf Test = forced cross body adduction in 90degrees flexion, pain in the extreme motion over the ACJ, then there is ACJ pathology. Patte’s test = 90 degrees flexion, flexed elbow, and resist external rotation. Tests infraspinatus + teres minor/posterior cuff. Speed’s test = supinated arm flexed forwards against resistance then resistance placed on arm, to test the bicipital groove, if pain there indicates bicep tendon pathology.

Gerber’s lift off test = push examiner’s hand away from “hand behind back position” (eliminates pectoralis major) – subscapularis/anterior cuff.

of movement shoulder, gleno-humeral joint.

Scratch test = patient tries to scratch up the back as far as possible, range

Special tests (elbow) Tennis elbow test – extensor radialis longus is tested by pressure on the middle finger resistance is down, if there is pain on lateral side of elbow then there is a positive tennis elbow. Golfers elbow test – pain in medial side of elbow Tinnels sign = test median nerve, numbness and tingling is a positive test, tap above wrist on joint line. Phalens sign – carpel tunnel syndrome Valgus and Varus test for medial and lateral ligaments of elbow. 36

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After completing this thorough protocol (which should take 45-60minutes) you will have to come to a conclusion on next steps â&#x20AC;&#x201C; A good rule is that if you have any doubt about your skill always ask an appropriate person or refer to the GP. Once your client has been to the GP and perhaps got a diagnosis that matches your suspicion you can start with performing the correct rehabilitation/treatment for the client. Remember to keep using the tests to see if improvement is taking place.

ACL Biomechanics

In issue 1 we looked at a case study of an injured player with a torn ACL, we will now do a literature review on ACL injuries. 38

ACL Biomechanics

This literature review is to evaluate the possible treatment and rehab of an athlete with an ACL ligament injury, this review will include biomechanical theories and biomechanical methods of treatment. An ACL ligament injury occurs in the ACL which is one of the main ligaments of the knee, on the topic of main causes of an ACL injury Mclean SG et al (1994 pg 23-36) states: The majority of ACL injuries occur due to an athlete rapidly decelerating followed by a quick change in direction...other methods of ACL injury are due to twisting on landing on a stiff leg, injuries occurring commonly if the leg is in a valgus position. When an athlete lands flat on their heels the force goes up the tibia into the knee, while the straight-knee position places the lateral femoral condyle on the back-slanted portion of the tibia. The resultant forward slide of the tibia relative to the femur is restrained primarily by the now-vulnerable ACL. When the ACL becomes injured the first 48 hours whilst in the acute stage of the injury the athlete must use the PRICE Protocol to bring down swelling and relieve pain this is supported by T. Green et al (2001 pg 128-129). The ACL injury will cause instability and a loss of proprioception in the surrounding muscle, due to the injury causing a loss of Range of Movement (ROM) the rehab and treatment must include a method of progression. The ACL will

change the athlete biomechanically by changing the method of gait in which the athlete walks and runs, T P Andriacchi (2006 pg 81-83) states that an athlete with an injured ACL will adopt an antalgic gait and add more pressure to the uninjured to side to allow a relief to the injured knee this will lead to unbalance. A method that will improve the proprioception and therefore balance back into the core and injured knee would be to use the wobble board states A Caraffa et al (1996 pg 76-80). The use of a wobble board could be used first as by trying to balance with both legs and by going into a squat position to lower the centre of gravity and help with balance. Carolyne A et al (2005 pg 103-105) believes that by using a wobble board in standing position the proprioceptors and core muscles become fired up and lead to strengthening and an increased equilibrium, this would lead to an improvement biomechanically with a better gait due to strength increases with muscles and proprioceptors. However Wester JU et al (1996 pg 6073) states that in a randomized study by using a wobble board to improve recovery of ligaments after injury is very low , however it also states that an improvement in equilibrium is noted which may improve the chance of an athlete returning to their sport. The progression of the wobble board program could be the use of increasing the height of the athleteâ&#x20AC;&#x2122;s centre of gravity to make the

exercise harder, O carron et al (1997 pg 23-44) states that the lower the centre of gravity an object has the greater equilibrium it has, therefore by increase the height of the centre of gravity the object becomes less stable. This will help the progression side of using the wobble board to help increase muscle strength and the proprioceptors, the next stage to progress the exercise would be to use only one leg on the wobble board, Horstmann G A (1990 pg 643-650) states that by decreasing the surface area covered structures become less stable. Therefore by taking away one leg in this case the good leg the injured leg will have to work harder and therefore improve faster using the wobble board. Another method in which the athlete could help improve gait and balance and bring strength back to the knee and a good way to test the posture changes due to the injury would be BIODEX Balance System, according to M R Hinaman (2000 pg 26 â&#x20AC;&#x201C; 33) states that the BIODEX balance system can show up inequalities and instabilities between the two different legs... this data can be used to show up injuries and balance problems caused by them. The BIODEX system can be used to improve balance of the injured athlete as it has many pre-installed exercises which cause vary instability and therefore there is a method of progression in the treatment and improvements can take place. W JC Cachupe et al (2001 pg 97-108) 39

ACL Biomechanics

states that the new BIODEX balance system 4 is a very accurate and precise piece of equipment which is very helpful in working with athletes that have muscle imbalances or are prone to injury. Because the injury will cause the injury to lose ROM then a good way to both measure and use to improve the ROM would be to use the isokinetic dynamometer (IKD) machine. This machine can be used to see how much ROM has been lost and how much strength is being outputted from the muscles. This is very handy in helping the athlete improve their gait and restore imbalances caused by the injury back to a norm. Feiring DC (1990 pg 298-300) states that the IKD machine can be used to improve strength in the muscles and it will show up the differing results in injured sides to good sides. In conclusion the athlete has many options to help improve their chances of returning to normal fitness, the injury will cause biomechanical problems and there are biomechanical methods to help improve these problems. After 4-6 weeks of treatment of the types of treatment outlines in the review the athlete should improve greatly and depending on the severity of the injury in the first instance return to their chosen sport soon after.

References M C Lean, Timothy E. Hewett, PhDGregory D. Myer, Kevin R. Ford (1994), Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes, Am J Sports Med April 1994 vol. 33 no. 4, pg 23-36. Toni Green, Kathryn Refshauge, Jack Crosbie and Roger Adams, (2001) ,A Randomized Controlled Trial of a Passive Accessory Joint Mobilization on Acute Ankle Inversion Sprains, PHYS THER Vol. 81, No. 4, April 2001, pg 128 - 129.

MR Hinman (2000), BIODEX balance system in treating injuries , Journal of Sport Rehabilitation, 9(3), August 2000, pg 26-33. Wendy J. C. Cachupe ; Bethany Shifflett; Leamor Kahanov; Emily H. Wughalter, (2001), Reliability of Biodex Balance System Measures, Measurement in Physical Education and Exercise Science, Volume 5, Issue 2 June 2001 , pages 97 – 108. Feiring DC, Ellenbecker TS, Derscheid GL(1990),Testretest reliability of the biodex isokinetic dynamometer, 1990;11(7), pg 298-300.

A. Caraffa, G. Cerulli, M. Projetti, G. Aisa and A. Rizzo (1996), Prevention of anterior cruciate ligament injuries in soccer A prospective controlled study of proprioceptive training, Knee Surgery, Sports Traumatology, Arthroscopy, Volume 4, Number 1 / March, 1996, pg 76-80. Andriacchi, Thomas P PhD; Briant, Paul L MS; Bevill, Scott L MS; Koo, Seungbum MS (2006), Rotational Changes at the Knee after ACL Injury Cause Cartilage Thinning,. Clinical Orthopaedics and Related Research, January 2006, Volume 442, Issue, pg 81-83. Carolyn A. Emery, J. David Cassidy, Terry P. Klassen, Rhonda J. Rosychuk and Brian H. Rowe (2005), Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial, CMAJ • March 15, 2005; 172 (6) pg 103-105. Wester JU, Jespersen SM, Nielsen KD, Neumann L (1996), Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study, J Orthop Sports Phys Ther. 1996 May;23(5), pg 60-73. O Caron, B Faure, Y Brenière (1997), Estimating the centre of gravity of the body on the basis of the centre of pressure in standing posture , Journal of Biomechanics, 1997, Volume 30, Issue 11, pg 60-73. Horstmann GA, Dietz V (1990), A basic posture control mechanism: the stabilization of the centre of gravity, Electroencephalogr Clin Neurophysiol. 1990 Aug;76(2), pg 643-650.

Meal Replacement Shakes

Why meal replacement shakes will never work but will always sell

CONTENTS

From a psychological perspective Meal Replacement products sound appealing. They have cleverly targeted marketing to prey on the individuals who are hoping for a quick fix or a solution to being unhappy with their body shape, size and composition. At no point do they address these individuals’ relationships with food or help and coach them into better habits with food for a weight loss which will be sustainable long term. They don’t ever want these individuals to stop drinking their shakes, and when they do, the weight comes back. In a lot of cases more weight than before. It is important as PT’s we acknowledge the place of wonder supplements in the market as invariably at some point our clients will be presented with the opportunity to buy these products. While the clients we have had long term will stick by us regardless, the newer clients or the clients who are still in the contemplation or planning stages of their lifestyle change when presented with a cheaper, simpler alternative may well feel their commitment waiver. As educated fitness professionals it is our job to be able to understand the market and advise them of the potential hazards of these meal replacement products. There are hundreds of different brands of MRP and all of them state the same

health benefits and work on a similar principle (although theirs will be better than their predecessor because of reason a, b, c and so on) In the most part MRPs fundamentally prescribe 2 shakes and 1 600 calorie evening meal. Thus the client is surviving on 1000-1200 calories (including snacks) per day. This leads to the first issue with MRP: 1200 Calorie diets are a problem for sustained fat loss: As you know most individuals will have a caloric requirement of far more than 1200 calories. By ingestion just this many calories and in some cases less these products/programmes will create such a deficit in their required energy intake that their metabolism will begin to slow down. This puts an increased amount of stress on the body which causes an increase in the stress hormone cortisol which in turn promotes fat storage around the middle. MRPs Vs Real Food: MRPs cannot be compared to real food despite their amazing health claims. The satiety of an MRP has been proven to be significantly lower than with a solid food based meal. They generally create a larger insulin spike due to the ingredients in the shakes and the hunger regulator Ghrelin was reportedly higher when a liquid meal replacement was taken

causing a stronger desire for more food. This is evident in the completion rates for these MRP programmes with many participants not feeling able to complete the programme despite the marketed health benefits. This creates a feeling of failure, impacting on self-confidence and potentially deterring these individuals from trying a different more sustainable approach due to fear of repeated failure. Unsustainable WEIGHT loss: Most clients will have a desire to ‘lose’ weight, what they really want or need to do is improve their body’s composition and lose fat while gaining lean muscle tissue. By replacing a solid protein source with a very low calorie shake the body reacts by taking the missing nutrients from a source in the body, normally the muscle tissue. So while some of the weight that may initially be lost will come from fat, some of it will also have come from muscle. While we know that this will further damage the clients metabolism as the body continues to be in a catabolic state all the client will see is that their weight on the scales is decreasing without understanding why their shape is not really improving the way they hoped it would. Chemical interference: As professionals in the fitness 42

Meal Replacement Shakes

industry we aim to make our clients and ultimately our nation a healthier one. By educating people one at a time how to eat optimally, feel better have more energy and feel happier we are making that change. How many times do we tell clients to avoid processed foods and chemicals? Look at the ingredients of a MRP there are lots of synthetic substances in them and this simply wreaks havoc without gut health and our digestive system making the body more acidic and increasing the risk of developing cor-morbidities. Clients are ultimately more likely to reap the health benefits of tailored solid food nutrition, detoxification and hydration. It is vital that Personal Trainers understand the process of digestion, hormonal influences and nutritional balance for achieving client’s optimum body composition which will be sustainable in the long term. These shakes are a big money industry and will always sell as long as there are people happy to promote and sell sub optimal nutrition to clients for a profit. Just as there will always be people who need help there will always be a scientific quick fix on offer. As pros we need to be able to put up an educated counter argument that clients can trust. Understand and read further around the subject as for each selling point of these ‘Amazing shakes’ there is at least one negative.

References: Tieken SM, Leidy HJ, Stull AJ, Mattes RD, Schuster RA, Campbell WW. Effects of solid versus liquid mealreplacement products of similar energy content on hunger, satiety, and appetite-regulating hormones in older adults. Karine Spiegel, PhD; Esra Tasali, MD; Plamen Penev, MD, PhD; and Eve Van Cauter, PhD. Brief Communication: Sleep Curtailment in Healthy Young Men Is Associated with Decreased Leptin Levels, Elevated Ghrelin Levels, and Increased Hunger and Appetite Available from: http://isites.harvard.edu/fs/docs/icb.topic197607. files/Due_Wk_11_Nov_28/SPIEGEL_2004.pdf Keisuke Suzuki, Channa N. Jayasena, and Stephen R. Bloom. The Gut Hormones in Appetite Regulation TAYLOR ORR. Fad Diets: A Losing Battle Available from: http://www.psmag.com/navigation/health-andbehavior/fad-diets-a-losing-battle-23918/ Lisa M Davis, Christopher Coleman, Jessica Kiel, Joni Rampolla, Tammy Hutchisen, Laura Ford, Wayne S Andersen, and Andrea Hanlon-Mitola. Efficacy of a meal replacement diet plan compared to a food-based diet plan after a period of weight loss and weight maintenance: a randomized controlled trial. Available From: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2851659/ By Louise Worboys, Personal Trainer at Lifestyle Fitness Chesterfield 07850355798 www.derbyshire-personal-training.co.uk

9 Components To Run Better

Flexibility – Flexibility is important to have in all soft tissues, these include muscles, tendons and ligaments. When these have limited flexibility your joints will have limited range of movement (ROM), which can lead to bad running and walking biomechanics. So make sure stretching is in your regime for any sport, even if you are not one for exercise we recommend spending time stretching muscles out to help prevent injury and loss of ROM in daily life. Posture- Posture is the way in which you hold yourself, when it comes to running this is key! Many consider good posture to be those with spines that are neutral and do not require the muscles to strain to maintain this. Poor posture can lead to severe muscle imbalances and leads to poor circulation to muscles, leading to less oxygen uptake which is vital in endurance sports. Leg motion – It is important to make sure stride length is not too wide, this may make sense as it allows further distance with less strides, however it can lead to injuries to the knee and hamstring. A long stride will also cause the natural bend in the knee to be lessened which will lead to more force travelling through the knee joint. Cadence – try to maintain a steady pace and maintain a good stride length, you want to be able to produce

enough force to propel your body forward without having to use excess force to produce this you must be landing with the heel and coming off from the toe, this motion allows a perfect method of thrust without as much as force.

Sense – it is important when running that you listen to your body, if you are feeling twinges or clicks it would be better to stop and assess the situation instead of attempting to struggle through. Injuries that may take a few days to heal can become injuries that take 6months to a year to heal because people decide to train 45

9 Components To Run Better

on them. Mental focus – It is important to keep focus in running, when we run for long periods our running biomechanics changes due to a combination of physical fatigue and mental fatigue. Now dealing with physical fatigue is difficult if you’re determined to continue your run, however when we lose mental focus are technique changes and can become dangerous, leading to injury. Injuries in football games occur predominantly in the first 10minutes (inadequate warm up) and last 10minutes (physical and mental fatigue). If your body is getting tired allow your mind to stay focused to try and maintain good running technique.

into the habit of good breathing for your running style. Oxygen is key in keeping your body fuelled throughout your run, so make sure you are taking the stuff in! Relaxation – getting fired up for a sprint or race is great, but when it comes to endurance relaxation is your friend. You want to run with your muscles as loose as possible, and you can do all the massages and stretching you want but as soon as your mind starts to come out of relaxation your muscles will start to tense again.

Co-ordination – it is important to allow your upper body and lower body to work in tandem, this co-ordination is great for good running technique, it allows good oxygen uptake and works the muscles in a way that there is development in all muscles. Breathing – One of the most important aspects when running is to remember to breathe correctly, this is also one of the first techniques to go when mental fatigue kicks in. Try and take breaths in a controlled manner, maybe count the breaths you are taking a minute and try and stick to a good rhythm, before long you will get

Fighters Corner

Interview with Shawn Porter - IBF World welterweight champion 48

Fighters Corner

EBOX - You won the world title against Devon Alexander as a huge underdog, in a pre fight interview you did with us you said you were going to make it rough and make it the hardest fight of his career, did everything go to plan for you in the fight? Porter - We watched some of his previous fights like the Bradley fight and formed a game plan and executed our game plan very well and we made it our kind of fight so everything went good!

EBOX - The majority of fans thought you won the fight by wide margins, was you surprised by the close scorecards? Porter - I knew I won the fight so I didn’t pay too much attention to the scorecards.

EBOX - What was the deal with your amateur beef with Devon Alexander? Porter - It was a small beef from when we were small kids, long story short we were at a tournament but were not supposed to fight but his coach and my coach got together and decided we would fight and some wrong information was exchanged on his coach’s part he ended up being a year older than me, something like

that but we were like 8 or 9 years old, the gloves felt like pillows back then but they feel like bricks right now.

welterweight tree, which opponents would you like to face in the future ? Khan, Bradley, Maidana etc)

BOX - Was it sweeter beating Alexander considering your previous amateur beef ?

Porter - My answer to all of these is, I don’t worry about the matchmaking stuff I can get a voluntary defence in if I want before Kell Brook becomes my mandatory, but right now I just train hard and do my job in the ring, and I let my team do their thing!

Porter - I never thought about that fight at all until you asked me, pre fight, during the fight or after the fight. It was just a great win and a new world title!

EBOX - How has life changed for you since you won the world title? Porter - I wouldn’t say it’s changed, but it’s been fun getting to share my blessings with Northeast Ohio and show them that one of their own is representing for them on a world stage!

EBOX - I have a 3 part question for you now Shawn, Future fights must be on your mind, 1) I heard a rumor that you could be giving Adrien Broner a title shot coming off his loss to Marcos Maidana, is there any truth in that? 2) Your next mandatory is UK’s Kell Brook, are you confident about making this fight happen? 3) Know your at the top of the 49

Fighters Corner

Umar Kemilainen is a Finnish undefeated Cruiserweight boxer looking to make a comeback in the sport of boxing after being forced to leave boxing through injury, in this interview we talk to Umar about his sparring sessions with James Degale and the possibility of Degale Vs Chavez Jr EBOX – Tell me about your sparring session with James Degale

good enough movement to offset Chavez Jr ?

Umar – up to know I have only sparred him once, but they asked me to come back because i gave a real good showing of myself. He has a really a really high work ratio in sparring, he shows good movement in the ring and is a very accurate puncher from distance but lacks punching power. So a bigger guy like myself has to get up close and put it on him.

Umar – well yes definitely, Chavez has really poor movement, he only has mass on fight night and a very big frame to work with, I mean he is a technically sound boxer but he isn’t near James Degale’s standard and I wouldn’t say he is explosive enough to hurt Degale and put him away.

EBOX – You said you had to pressure Degale, what happened when you did that?

Umar – well you can see it in the majority of his fights like his last one, its less noticeable in our sparring session but I would say it’s his stamina, he starts too fast and fades in the middle rounds and tries to rally late on and it didn’t work against George Groves and he gave a few rounds away in the middle rounds and got caught with silly shots against Dyah Davis too but its all to do with his high work rate in the early rounds, if he was a bigger puncher he would stop most people within 4 or 5 rounds because he dominates with his good technique.

Umar – well he has speed and incorporated movement, but I have speed to match his speed but he is also a strong guy who can fight on the inside, put it like this, if the situation calls for it he can fight dirty. EBOX – What was Degale’s best attributes? Umar – its his high work-rate and he also likes to go to the body which can slow bigger guys like me down but he also has very good movement and is an accurate puncher EBOX – would you say Degale has

EBOX – what are James Degale’s worst attributes?

Umar – like I said he isn’t a big puncher and Chavez Jr like his dad can take a punch so I don’t think there is much chance Degale could stop or hurt Chavez Jr, he should just try to outpoint him over the 12 round distance instead. EBOX – How could Chavez win ? Umar – well James Degale has stamina issues and Chavez is a big guy so if he can apply pressure and lean his weight on Degale then he could gas him out and take him out in the championship rounds. At times James Degale can sit on the ropes too much in the second half of the fight, Degale cannot do that when Chavez is chasing him down, and his trainer should drill him away from those ropes in training. You can get in touch with Umar Kemilainen on Twitter @umarkemilainen

EBOX – could Degale hurt Chavez Jr? 50

Fighters Corner

Styles make fights in boxing You may have heard the saying “styles make fights” and that couldn’t be any truer, there are many different styles that make up the sport of boxing. The following boxing techniques and styles are:

to control the pace of a fight and use it to their advantage.

Pure Boxer / Counterpuncher

Boxer Puncher

This type of style embodies the whole science of boxing. Boxers that use this style use their smarts in the ring to maintain a safe distance between themselves and their opponents, and they pick their spots to attack.

A boxer puncher is similar to a pure boxer in the sense that they have the above average ability to box, but they also have good punching power which they will utilize. They can break opponents down slowly or can even knock out their opponents with a single well placed shot.

The attributes needed to be a good Pure Boxer/Counterpuncher include: Great footwork – To control the opponent’s movement, to defensively get out of trouble and to change defence into attack quickly. Reflexes – Some boxers drop their hands and leave their chin exposed which can be used as a trap to lure the opposition in, use their reflexes to escape danger and counter punch the opposition into submission. Timing – Speed kills but sometimes timing the perfect punch can be just as effective if not more effective. Ring smarts – being able to read your opponent is very important, knowing how they are going to attack and defend is integral to being a counterpuncher. They have the ability

This boxing style would be favoured against Brawlers/Sluggers, but isn’t effective against other Counterpunchers or Boxer Puncher

Attributes needed to be a good Boxer Puncher include: Good Footwork – different types of movement are needed, fighters need to be on their toes to get out of danger and need to be able to cut the ring down effectively when attacking Punching Power – this style depends more on wearing opponents down and punching power is needed to do this Adaptability – you cannot knock out everyone you fight, sometimes a change of tactics is needed in terms of self-preservation and boxing a back foot fight could be a very smart idea if you cannot overpower an opponent Athleticism – this style is based on athleticism; speed, power and

movement This boxing style is most effective against Counterpunchers because it takes a long time for them to work out their style. Unfortunately this style isn’t always effective against Brawlers/Sluggers because a lot of the time Boxer Punchers do not on average have the chin to go to war with Brawlers/Sluggers and at some point they will and will pay for it. § Brawlers/Sluggers Perhaps one of the most exciting styles to watch is that of a brawler/ slugger. They can generally lack one or more of the following: Great footwork, defensive abilities, ring smarts and speed. However, they make up for it by using attributes such as: Heart – there is nothing more demolising then hitting your opponent with everything you have and they are still coming forward, people are mentally defeated before being physically defeated. Punching Power – this style depends on both wearing opponents down and knocking your opponent out inside the distance, fighters who use this style do not have the primary objective of trying to win decision. relentless pressure – this is done to break the opponent by taking their stamina away, usually fighters 51

Fighters Corner

who use this style work effectively switching from head to body to reduce movement, drain stamina and the heart of their opponent, while also testing the chin of the opponent. Great Chin - Often, Sluggers have a lot of defensive flaws which leaves them open for counterpunches, so the ability to take a good deal of punishment is essential. Brawlers/Sluggers are most effective against Boxer/Punchers but are least effective against Counter-Punchers unless the fighter in question has a weak chin.

Fighters Corner

Urban Martial Arts 1. MCMAP

3. Kyokushin Kaikan

MCMAP is the United States ‘Marine Corp Martial Arts Program’. This battle tested form of martial arts has been developed and used in the world’s most dangerous war zones and has been proven to be extremely effective especially against armed attackers or when you run out of bullets yourself. A number of UFC champs have tried seeking out MCMAP training, though it’s techniques are relatively well guarded and are no doubt not allowed in the octagon. Unfortunately if you want to train in MCMAP you may have to sign up for the US Marines for 4 years, though you will absolutely be assured to come out a fit killing machine, well unless it kills you first.

Kyokushin Kaikan, Karate is definitely one of the toughest base martial arts around. Schools offering Kyokushin Kaikan, Karate are as far from a McDojo as you can get. No easy belt gradings here. Kyokushin Kaikan is known for its full contact sparring with bare knuckles and it’s 50 & 100 man fights in order to pass graduations.

2. Muay Thai Muay Thai kickboxing is certainly one of the most brutal forms of martial arts in existence. Not many rules here and no points deducted for hitting your opponent as hard as you possibly can. Definitely not for those afraid of pain. Muay Thai’s use of elbows and knees can prove to be extremely deadly.

4. Krav Maga Krav Maga is the Israeli Special Forces form of tactical hand-to-hand combat. Training in Krav Maga will absolutely teach you how to kill with your bare hands in seconds even when up against an opponent armed with a knife or gun. Krav focuses exclusively on hitting weak points such as the throat, spine and temples. There is pretty much nothing learned in Krav that would be allowed in the UFC, far too deadly

Fighters Corner

March Bout List March 1st

8th March

Magdeburg, Sachsen-Anhalt, Germany

Alamodome, San Antonio, Texas, USA

Max Schmeling Halle, Prenzlauer Berg, Berlin, Germany

Robert Stieglitz Vs Arthur Abraham

Julio Cesar Chavez Jr vs Brian Vera

Yoan Pablo Hernandez Vs Pawel Kolodziej

The 3rd in a series of fights between these two Super-Middleweight fighters with both fighters taking one victory each. Arthur Abraham is going in for his last hurrah, while Stieglitz kept his career at the top level alive after demolishing Abraham in a fashion no other fighter in the world has before. Scottish Exhibition Centre, Glasgow, Scotland, United Kingdom Ricky Burns Vs Terence Crawford The biggest test of both fighter’s career for the WBO Lightweight title, Crawford the slick and skilful American is coming to Scotland to try and take the belt away from Ricky Burns, not many American fighters fight effectively outside the United States and although he is the favourite and not many boxing fans expect much from Burns, this is a huge potential banana skin

Julio Cesar Chavez Jr is trying to keep his career alive by giving a rematch to Brian Vera who was extremely unlucky to lose to Chavez in a very controversial decision. Chavez needs to succeed here to move onto world title contention. Orlando Salido Vs Vasyl Lomachenko Orlando Salido is making his first defence against Vasyl Lomachenko in only Lomachenko’s 2nd fight, while he does boast an unbelievable amateur career with a career record of 3961, with his only loss avenged twice, Orlando Salido on the other hand is a veteran of 55 professional fights.

The Cuban boxer Yoan Hernandez makes another defence of his title against Pawel Kolodziej, this isn’t the greatest fight in terms of competitively but there are great fights to be made in the Cruiserweight Division

21st March Kusadasi, Turkey Odlanier Solis Vs Tony Thompson A tough heavyweight fight, Cuban fighter Odlanier Solis is taking on American Veteran Tony Thompson, both fighters are at a crossroad and the winner will keep their careers alive and move forward to a possible World Title fight, it’s hard to say where the loser goes.

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LSFPT Directory Looking for a PT or coach? Always choose an LSFPT for your needs, highly skilled, fully insured and always developing! Just click on the buttons below to find our trainers in your area. LUKE BLAYLOCK Carlisle Trainer Grade: Personal Trainer Trainer Qualifications: Level 3 Personal Trainer 07788258299 Facebook -: https://www.facebook.com/ LukeBlaylockPersonalTraining Hi, I’m Luke, I am a level 3 Personal Trainer. The gym and training is my passion, it’s something I love and enjoy. There is no better feeling than working out in the gym and seeing results, I’ve been training myself for 5 years, I always have a goal when I train, key factors are motivation, and determination a really well set out training programme and a good understanding of nutrition. The main areas I specialise in are weight training, bodybuilding and nutrition but I cover all aspects of fitness and Personal Training. When dealing with clients I make sure the sessions are tailored to my client’s goals and I want to make sure my client reaches their goals. My sessions are intense but enjoyable, I ensure my clients leave feeling fully satisfied following every session. If you see me around the gym don’t hesitate to ask any questions, I’m here to help!

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LINDSAY STEELE Carlisle Trainer Grade: Personal Trainer Trainer Qualifications: NASM certified Personal Trainer 07792899783 FB -: https://www.facebook.com/UricaFitness Twitter- : https://twitter.com/uricafitness My passion is to help people improve their health, fitness, appearance, and achieve the best quality of life. Are you wanting to achieve fat loss, weight loss, muscle definition, tone? Do you want to be more mobile, fitter than youâ&#x20AC;&#x2122;ve ever been, and reduce those niggles in your body you always seem to have? Whatever your reasons, with my help we can get you there. I work with a broad range of clientele of different age, gender and fitness level. Sessions are tailored to suit your needs, goals and body type. We discuss your aims, objectives, likes, dislikes, postural analysis, diet and medical background in a complimentary initial appointment to then develop you a health and fitness program specific to suit your requirements and goals. Rest assured that regardless of your age, current health status, or level of fitness, I will closely guide, motivate and teach you the correct techniques to safely and efficiently achieve your goals.

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DEAN MCLAUGHLIN Carlisle Trainer Grade: Personal Trainer Trainer Qualifications: Level 3 Personal Trainer Number: 07506460312 Email: dean_mclaughlin2010@yahoo.com Our goal is to assist you in achieve your personal goal or target. I have a wealth of experience in high intensity training which assists in fat burning, strength conditioning, power and muscle growth, I have the ability to achieve the full potential with of my clients making them feel positive after every training session. I have 100% success rate with all my clients and if clients do not achieve results I offer a money back guarantee. Both together we can achieve your ultimate goal. Today can be the day you wake up and live your dream.

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LIZ MORTON Tamworth Trainer Grade: Personal Trainer Trainer Qualifications: Diploma in Personal Training, Kettlebell Instructor Training. MOBILE - 07581 370828 FB-: https://www.facebook.com/LizMortonPT I am a qualified personal trainer, scuba diver and skier who enjoys making exercise fun but effective. After losing 20 pounds and gaining a keen interest in fitness and nutrition, I completed a diploma in Personal Training. I am extremely passionate about helping you to achieve your goals whether you are new to exercise, returning to exercise after a break or you are already a regular gym goer, using new and innovative techniques whilst supporting positive lifestyle choices. I work with my clients to ensure they are confident in using the gym and that we achieve their goals together. Contact me to book your complimentary consultation to see exactly how I can help you become the best possible you.

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Tristan Bennett Lightwater Leisure Centre Trainer Grade: Personal Trainer. Trainer Qualifications: Level 3 Personal Trainer, Sports Nutrition. 07968032368 FB-: https://www.facebook.com/TristanBFitness Twitter -: https://twitter.com/tristan_b_fit My knowledge base is centred in body recomposition â&#x20AC;&#x201C; muscle gain and fat loss â&#x20AC;&#x201C; through training and sports nutrition. There are basic principles that have to be understood, such as the nutritional demands of a successful fitness programme and the amount of rest that is required, an aspect often overlooked. It is important to recognise that everyone is an individual and will respond differently to training and nutritional approaches. From this perspective I have been able to create individualised training and nutrition plans, and I have yet to find someone who hasnâ&#x20AC;&#x2122;t benefited from having a programme specifically tailored to themselves. To be able to teach, motivate and inspire people to step outside of their comfort zone, and to set goals and help them achieve them greatly excites me, and is something I am truly passionate about.

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Lisa-Marie Collingwood Canterbury eastkentdancefitness@gmail.com 07747 607507 Lisa has a wealth of experience in the Fitness Industry having trained clients for weight loss and wellbeing for over 7 years. She has coached, mentored and help rehabilitate a variety of clients with different issues such as arthritis, obesity, clinical injuries, pregnancy and the general population. Lisa has an understanding and passion to assist client’s mental strength and co-ordination using a variety of methods to help instil confidence and the state of ‘readiness’ to train for goal setting. Lisa’s other passion is instructing dance fitness classes such as ETM, Zumba Level 1, Level 2, Zumba Core & Glutes, Zumba for kids, Zumba ‘in the Circuit’ , Functional Training and Spinning. Other qualifications include training for frail and the elderly. Lisa has graduated 3 times; Bournemouth University, Imperial College London and Canterbury Christchurch University.

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Daniel Luke Wakefield Gym: Wakefield Trainer grade: Personal Trainer Trainer Qualifications: Level 3 Personal Trainer Email: daniellukefitness@gmail.com Phone: 07803 306173 FB-: https://www.facebook.com/pages/Daniel-LukeFitness-Personal-Trainer/532414486776536 Twitter-: https://twitter.com/danielafsar My name is Dan and I am a 24 year old fitness / physique competitor and Optimum Nutrition sponsored athlete, who is based at Lifestyle Fitness Wakefield. After attending the gym for a period of time with no real guidance or structure I decided to pursue a career in Personal Training, and have never looked back. I have a real passion for helping others achieves something they once thought was impossible.

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DANNY TYMON Wakefield NAME: Daniel James Tymon GYM: WAKEFIELD TRAINER GRADE: PERSONAL TRAINER danny21tymon@hotmail.co.uk Mobile: 07860615800 I am an outgoing person who enjoys motivating, encouraging and to enthuse others. I feel that I have excellent communication skills as I am diplomatic and approachable. With knowledge of nutrition, weightmanagement, supplements, healthy diet, lifestyle issues, exercise, and a keen interest in how the body adapts to fitness. My passion is to help improve the health and fitness of others. I have experience of working with a variety of specialist groups to include older adults, teenagers and people with disabilities or referred by doctors. I have a great deal of energy and perseverance as I teach boot camps on a Monday and Friday morning for Fit4Life Academy coaching and delivering personal one-onone fitness sessions. I also teach fitness classes to include Muay Thai, Spinning, Kettlebells, Circuits, Pump FX and Boxercise to name a few. I have a good sense of humour and a drive to support clients 100% to get to where they want to be!

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VICTORIA HUDSON Barnsley 07747806790 FB-: https://www.facebook.com/vickyhudson?fref=ts Victoria transformed herself with exercise and nutrition, she can now help you reach your transformation goals. After 8 years in the Royal Navy and being part of the female Military Boxing team she left and pursued her passion for health and fitness. Victoria is an energetic and friendly personal trainer specialising in female weight loss, after going on her own weight loss journey through realistic diet plans, and exercise routines with the aim of changing you and your body for life. Her style of training is diverse and always different getting you to results you want. Not only does she offer great 121 personal training sessions but also small group personal training - believing training with a friend will get results faster! She also has a passion for delivering great group exercise classes with a small group creating a great atmosphere but still offering some of the benefits of personal training whilst keeping it affordable! In her spare time she trains at a Crossfit gym and uses her own group exercise classes to keep her fit and healthy.

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J Shoulder Elbow Surg (2010) 19, 917-922

www.elsevier.com/locate/ymse

ELBOW

Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial Timothy F. Tyler, MSPT, ATCa,b,*, Gregory C. Thomas, DPT, CSCSa, Stephen J. Nicholas, MDa, Malachy P. McHugh, PhDa a b

PRO Sports Physical Therapy, Scarsdale, NY Nicholas Institute for Sports Medicine and Athletic Trauma (NISMAT), New York, NY Backround: Isokinetic eccentric training of the wrist extensors has recently been shown to be effective in treating chronic lateral epicondylosis. However, isokinetic dynamometry is not widely available or practical for daily exercise prescription. Therefore, the objective of this study was to assess the efficacy of a novel eccentric wrist extensor exercise added to standard treatment for chronic lateral epicondylosis. Materials and methods: Twenty-one patients with chronic unilateral lateral epicondylosis were randomized into an eccentric training group (n ¼ 11, 6 men, 5 women; age 47 � 2 yr) and a Standard Treatment Group (n ¼ 10, 4 men, 6 women; age 51 � 4 yr). DASH questionnaire, VAS, tenderness measurement, and wrist and middle finger extension were recorded at baseline and after the treatment period. Results: Groups did not differ in terms of duration of symptoms (Eccentric 6 � 2 mo vs Standard 8 � 3 mos., P ¼ .7), number of physical therapy visits (9 � 2 vs 10 � 2, P ¼ .81) or duration of treatment (7.2 � 0.8 wk vs 7.0 � 0.6 wk, P ¼ .69). Improvements in all dependent variables were greater for the Eccentric Group versus the Standard Treatment Group (percent improvement reported): DASH 76% vs 13%, P ¼ .01; VAS 81% vs 22%, P ¼ .002, tenderness 71% vs 5%, P ¼ .003; strength (wrist and middle finger extension combined) 79% vs 15%, P ¼ .011. Discussion: All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy. This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic lateral epicondylosis. Level of evidence: Level I, Randomized Controlled Trial, Treatment Study. 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral epicondylosis; eccentric; physical therapy

Tennis elbow, or lateral epicondylosis, is a common condition that is characterized by pain at the lateral epicondyle, aggravated by resisted muscle contraction of the *Reprint requests: Timothy F. Tyler, MSPT, ATC, PRO Sports Physical Therapy, 2 Overhill Road Suite 315, Scarsdale, NY 10583. E-mail address: shoulderpt@yahoo.com (T.F. Tyler).

carpi radialis brevis. The estimated annual incidence in the general population is 1-3%.2,9 A variety of specific treatment strategies have been described over the years, including bracing,10,19 corticosteroid injections,5 topical nitric oxide patch,15 repetitive low-energy shockwave treatment,6,16,18 surgery,14 and isolated eccentric training.8 Additionally, standard physical therapy includes wrist

1058-2746/$ - see front matter 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2010.04.041

918 extensor stretching, isotonic wrist extensor strengthening, ultrasound, cross-friction massage, heat, and ice.20 Isolated eccentric strength training has been shown to be effective for treating Achilles,1,12 patella,17 and shoulder tendonopathies.12,21 A common factor in the eccentric exercise programs utilized in these studies was that the exercises could be performed at home without the need for expensive equipment or regular physical therapy visits. Recently, isolated eccentric training was also shown to be effective in treating chronic lateral epicondylosis.8 However, the eccentric training utilized an isokinetic dynamometer, which necessitated patients coming to a clinic for treatments. Since isokinetic dynamometers are expensive and not widely available, this may not be a viable treatment option for many patients with chronic lateral epicondylosis. When home based isolated eccentric training with elastic resistance was used, it was not found to be more effective than stretching alone.13 Therefore, the purpose of this study was to assess the efficacy of a novel eccentric wrist extensor strengthening exercise added to standard treatment for chronic lateral epicondylosis.

Materials and methods Twenty-one patients with chronic unilateral lateral epicondylosis participated in the study and were randomized into an Eccentric Group (n ¼ 11, 6 men, 5 women; age 47 � 2 yr) and a Standard Treatment Group (n ¼ 10, 4 men, 6 women; age 51 � 4 yr). (All subjects gave written informed consent and the protocol was approved by Institutional Review Board of the Lenox Hill Hospital, #L050648.) Patients were included if they were diagnosed with lateral epicondylosis symptoms for greater than 6 weeks. Lateral epicondylosis was diagnosed using the following tests: (1) pain on palpation at the lateral epicondyle, (2) pain on resisted wrist extension, and (3) pain on resisted middle-finger extension. Subjects needed to test positive on all 3 tests to be included in the study. Patients with a history of fracture, dislocation, surgery, bilateral elbow pain, cervical spine pathology, osteoarthritis, or previous steroid injection to the elbow less than 6 weeks prior were excluded.10 Two patients had prior physical therapy (1 in each group), 4 patients had a prior corticosteroid injections (3 in Eccentric Group, 1 in Standard Treatment Group), 1 patient had used a counterforce brace, and all patients had taken nonsteroidal anti-inflammatory medication. The remaining 13 patients had no prior treatment for their lateral epicondylosis. Ten patients developed lateral epicondylosis from playing tennis, 7 golf, 2 weight training, and 3 from activities of daily living.

T.F. Tyler et al. extensor strengthening. The strengthening and stretching exercises were also prescribed as a home exercise program. Treatments were continued until patients had resolution of symptoms or were referred back to their physician with continued symptoms. The isolated eccentric strengthening exercise was performed using a rubber bar (Thera-Band FlexBar; The Hygenic Corporation, Akron OH) which was twisted using wrist flexion of the uninvolved limb and slowly allowed to untwist with eccentric wrist extension by the involved limb (Figure, A-E). Each eccentric wrist extensor contraction lasted approximately 4 seconds (ie, slow release). Both upper extremities were reset for the subsequent repetitions. A 30-second rest period was timed between each set of 15 repetitions and 3 sets of 15 repetitions were performed daily. Intensity was increased by giving the patient a thicker rubber bar if the patient reported no longer experiencing discomfort during the exercise.

Outcome measures The Disability of Arm, Shoulder, and Hand Questionnaire (DASH) was used to determine the degree of disability caused by the lateral epicondylosis. Subjects were asked to report the pain level during their primary provocative activity. Pain was assessed using a Visual Analog Scale (VAS) graded from 0 to 10 (0 ¼ no pain and 10 ¼ severe pain). The DASH questionnaire and VAS were completed prior to and after the treatment period.

Strength testing Wrist extension and middle finger extension strength were measured bilaterally with a hand-held dynamometer (Lafayette Manual Muscle Tester; Lafayette Instruments, Lafayette, IN). Wrist extension was tested with the forearm resting on a support surface and the hand in full wrist extension in a gravity resisted position. In this position a manual break test was performed with the dynamometer. Middle finger extension strength was tested with both the forearm and hand resting on a support surface. The middle finger was fully extended in a gravity resisted position and a break test was performed with the dynamometer. A smaller resistive pad was attached to the dynamometer for applying the resistive force during middle finger extension strength testing. The average of 3 repetitions was recorded for the involved and noninvolved sides for wrist extension and middle finger extension, and reported as percent deficits ([(noninvolved-involved)/noninvolved] ) 100).

Physical therapy treatment All patients received wrist extensor stretching, ultrasound, cross-friction massage, heat, and ice during their physical therapy visits. Additionally, the Standard Treatment Group performed isotonic wrist extensor strengthening and the Eccentric Group performed isolated eccentric wrist

Tenderness measurement Tenderness was assessed using a probe attachment to the hand-held dynamometer. With the forearm on a supported surface, the probed was placed just distal to the lateral

Eccentric exercise for chronic lateral epicondylosis

919

Figure (A) Rubber bar held in involved (right) hand in maximum wrist extension. (B) Other end of rubber bar grasped by noninvolved (left) hand. (C) Rubber bar twisted by flexing the noninvolved wrist while holding the involved wrist in extension. (D) Arms brought in front of body with elbows in extension while maintaining twist in rubber bar by holding with noninvolved wrist in full flexion and the involved wrist in full extension. (E) Rubber bar slowly untwisted by allowing involved wrist to move into flexion, ie, eccentric contraction of the involved wrist extensors.

epicondyle. Pressure was then applied and stopped at the point at which the patient reported discomfort. Three trials were performed on the involved and noninvolved sides and mean values were calculated. The percent deficit between the involved and noninvolved side was computed and reported as the measurement of tenderness ([(noninvolvedinvolved)/noninvolved] ) 100).7 All pre- and post-treatment outcome measures (DASH, VAS, strength, tenderness) were made by the same physical therapist, who was blinded to the patientâ&#x20AC;&#x2122;s randomized treatment assignment and not involved in their direct care.

Statistics Mixed model analysis of variance (ANOVA) with Bonferroni corrections for subsequent pairwise comparisons was

used to examine the effect of eccentric training on all dependent variables. Results are reported as mean SD. The reliability of the strength and tenderness measurements was assessed by computing the standard error of the measurement (SEM) from the repeated tests (pre-treatment and post-treatment) on the noninvolved side. The absolute SEM and the SEM as a percentage of the mean strength and tenderness values is reported. Based on previous work,20 it was estimated that 15 patients per group would be sufficient to detect a 40% difference in DASH score improvement between groups at P < .05 with 80% power. Similarly, using previously published VAS pain data on patients with chronic lateral epicondylosis, it was estimated that a 20% difference in VAS pain (2 points on a 10 point scale) could be detected between groups at P < .05 with 80% power.8 These were the primary dependent variables.

920 Table

T.F. Tyler et al. Effect of eccentric training versus standard treatment of dependent variables Eccentric treatment

DASH (0-100) VAS pain (0-10) Wrist extension strength deficit (%) Middle finger extension strength deficit (%) Combined strength deficit (%) Tenderness deficit (%) Mean � SD reported.

Standard treatment

Treatment by time

Pre

Post

Pre

Post

38 � 29 Treatment effect 6.7 � 2.8 Treatment effect 30 � 11% Treatment effect 17 � 24% Treatment effect 24�15% Treatment effect 51�26% Treatment effect

9 � 21 P ¼ .002 1.3 � 2.7 P ¼ .0001 9 � 23% P ¼ .005 1 � 33% P ¼ .18 5 � 20% P ¼ .003 15 � 33% P ¼ .005

38 � 30 Treatment effect 6.3 � 2.8 Treatment effect 28 � 19% Treatment effect 12 � 22% Treatment effect 20 � 16% Treatment effect 40 � 28% Treatment effect

33 � 22 P ¼ .33 4.9 � 2.7 P ¼ .015 21 � 25% P ¼ .43 13 � 31% P ¼ .84 17 � 18% P ¼ .36 38 � 34% P ¼ .82

Results Demographics There were 11 patients in the Eccentric Group (6 men, 5 women) and 10 patients in the Standard Treatment Group (4 men, 6 women). Groups did not differ in terms of age (47 � 2 yrs vs 51 � 4 yrs, P ¼ .32), duration of symptoms (6 � 2 wks vs 8 � 3 wks, P ¼ .7), number of physical therapy visits (9 � 2 vs 10 � 2, P ¼ .81) or duration of treatment (7.2 � .8 wks vs 7 � 0.6 wks, P ¼ .69).

Outcome measures Improvements in DASH Scores were significantly better for the Eccentric Group versus the Standard Treatment Group (mean improvement 76% vs 13%, Treatment by Time P ¼ .01; Table). In the Eccentric Group 5 patients had >90% improvement in DASH scores (100% ¼ complete resolution of symptoms), 3 patients had 50-90% improvement in DASH scores, and 3 patients had <50% improvement in DASH scores. No patients in the Standard Treatment Group had >90% improvement in DASH scores, 3 patients had 50-90% improvement in DASH scores, and 7 patients had <50% improvement in DASH scores.

Pain

P ¼ .01 P ¼ .002 P ¼ .18 P ¼ .21 P ¼ .011 P ¼ .003

Standard Treatment Group had >90% improvement in VAS, 3 patients had 50-90% improvement, and 7 patients had <50% improvement.

Strength Prior to treatment patients had marked weakness in wrist extension (deficit 29 � 3%, P < .0001). Improvement in wrist extension strength was not different between the Eccentric Group versus the Standard Treatment Group (Treatment Group by Time P ¼ .18; Table). However, for the Eccentric Group, wrist extension strength deficits improved from 30 � 11% to 9 � 23% (P ¼ .005) but did not improve for the Standard Treatment Group (28 � 19% to 21 � 25%, P ¼ .43). Patients also had weakness in middle finger extension prior to treatment (14 � 5%, P ¼ .008). There was no apparent improvement in middle finger extension strength (P ¼ .17), with no difference in strength change between the Eccentric and Standard Treatment Groups (Treatment Group by Time P ¼ .21). However, the improvement in the combined strength deficit for wrist and middle finger extension was greater for the Eccentric Group (24 � 15% improving to 5 � 20%) than the Standard Treatment Group (20 � 16% improving to 17 � 18%, Treatment Group by Time, P ¼ .011).

Tenderness Similarly, improvement in VAS for pain was better for the Eccentric Group versus the Standard Treatment Group (mean improvement 81% vs 22%, Treatment by Time effect P ¼ .002; Table). In the Eccentric Group, 6 patients had >90% improvement in VAS (100% ¼ complete resolution of symptoms), 3 patients had 50-90% improvement, and 2 patients had <50% improvement. No patients in the

Prior to treatment the force required to elicit discomfort just distal to the lateral epicondyle was 39% lower on the involved side versus the noninvolved side (P ¼ .007), indicating increased tenderness. Following treatment tenderness was reduced in the Eccentric Group (ie, it took a greater force to elicit discomfort) but unchanged in

Eccentric exercise for chronic lateral epicondylosis the Standard Treatment Group (Treatment Group by Time, P Âź .003; Table).

Reliability The SEM for wrist extension strength was 15.7 N, which was 10% of the mean value for the noninvolved side. The SEM for middle finger extension was 3.4 N, which was 23% of the mean value for the noninvolved side. The SEM for tenderness was 20.6 N, which was 19% of the mean value for the noninvolved side.

Discussion The eccentric exercise program introduced in this study proved to be an effective method of treating chronic lateral epicondylosis. All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy, compared with physical therapy without the isolated eccentric exercise. This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic lateral epicondylosis. A prescription of 3 sets of 15 repetitions daily for approximately 6 weeks appeared to be an effective treatment in the majority of patients. There are many different approaches to the treatment of chronic lateral epicondylosis, such as phonophoresis or iontophoresis,4 corticosteroid injections,5 extracorporeal shockwave therapy,6,16 topical nitric oxide,15 and bracing.3 These are commonly provided independently or as part of standard physical therapy. Compared to isolated eccentric strength training, treatments such as iontophoresis, phonophoresis, extracorporeal shockwave therapy, corticosteroid injections, or topical nitric oxide are expensive, require direct medical supervision, and, in some cases, have significant side effects. While the efficacy of isolated eccentric training for the treatment of tendinopathies in various joints has been clearly established,1,11,12,17,21 the additional benefit of this treatment is that it can be performed as part of a home program and does not involve continued medical supervision. Not only does this provide a cost benefit, but treatment dosage is not limited by the patient having to come to a clinic or needing direct supervision. With respect to eccentric training for chronic lateral epicondylosis, Croisier et al8 compared isokinetic eccentric wrist extensor training to standard physical therapy. Pain reduction, disability questionnaire scores, and muscle strength were significantly better in the eccentric group. The effects of eccentric training on pain scores were very similar to the present study. Interestingly, the control groups in both studies also showed similar

921 changes in pain. Different disability questionnaires were used, and those results are not directly comparable. Additionally, Croisier et al8 chose not to measure wrist extension strength pre-treatment and only compared groups post-treatment, at which point the eccentric group were 1-10% stronger on the involved side while the standard treatment group were 28-38% weaker on the involved side. In the present study, the Eccentric Group was 9% weaker on the involved side post treatment while the Standard Treatment Group was 21% weaker on the involved side post-treatment. The reliability data from the noninvolved side indicated that the wrist extension strength measurement was more reliable than the middle finger extension strength. Accordingly, the results showed significant changes in wrist extensions strength but no significant changes in middle finger extension strength. Thus the lack of effect on middle finger extension strength may be subject to a type II error. An obvious limitation of the present study is the small sample size. Based on previous research, it was estimated that 15 patients per group would be needed to demonstrate a 40% difference in DASH score improvement between groups at P < .05 with 80% power; therefore, the goal was to recruit 15 patients per group. However, the physical therapists providing direct patient care anecdotally observed consistently poor outcomes for patients in the standard treatment group and consistently good results for patients in the eccentric group. Based on these observations, it was deemed appropriate to terminate the randomization, with 21 of the intended 30 patients having completed the study. This decision was based on the observation that patients in the Standard Treatment Group were having an unacceptably poor outcome. The subsequent data analysis supported this observation. None of the dependent measures showed a significant improvement in the Standard Treatment Group. By contrast, outcomes for the patients in the Eccentric Group were clearly good. Given the stark contrasts in outcomes between the Standard Treatment and Eccentric Groups, it was deemed unnecessary to continue the randomization. The poor results for the control group can be attributed to the limited provision of supervised physical therapy and reliance on unsupervised home program exercises. The average duration of treatment was approximately 7 weeks for both treatment groups; but, during this period, the average number of physical therapy visits was 9 for the eccentric group and 10 for the control group. Clearly, an average of 1.4 visits per week over 7 weeks was inadequate for the control group. Provision of additional supervised physical therapy may improve the results with standard treatment. Additionally, given that the follow-up period was only 7 weeks after the initiation of treatment, and that lateral epicondylosis has a high recurrence rate, the current results should be viewed as evidence for

922 short-term efficacy of eccentric strengthening. It remains to be determined if this treatment approach provides similar efficacy in the long term.

Conclusion In conclusion, these data provide further evidence for the efficacy of eccentric training for tendinopathies. While isokinetic eccentric training has been shown to be an effective treatment for chronic lateral epicondylosis,8 this treatment option may not be available, may be too expensive, or may be impractical for many patients. By contrast, the novel eccentric exercise used in this study offers an inexpensive, practical treatment option with excellent results.

T.F. Tyler et al.

10.

11.

12.

Disclaimer 13.

None of the authors, their immediate families, and any research foundation with which they are affiliated have received any financial payments or other benefits from any commercial entity related to the subject of this article. We would like to thank the Hygenic Corporation for the donation of all the flexbars for completion of this study.

14. 15.

16.

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