April 2014 SPNZ Bulletin

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ISSUE 2 l APRIL 2014

BULLETIN FEATURE TOPIC: Applied Sports Performance – Injury Prevention www.spnz.org.nz SPNZ EXECUTIVE COMMITTEE President

Hamish Ashton

Secretary

Michael Borich

Treasurer

Michael Borich

Website & IT

Hamish Ashton

Committee

Timofei Dovbysh Justin Lopes Dr David Rice Bharat Sukha Kara Thomas

Welcome to the April 2014 Bulletin EDITORIAL By new president Hamish Ashton

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ASICS GRANT

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CODE OF CONDUCT

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MEMBERS ’ BENEFITS

EDUCATION SUB-COMMITTEE Dr David Rice - chair Dr Angela Cadogan Dr Grant Mawston

BULLETIN EDITOR Aveny Moore

SPECIAL PROJECTS Monique Baigent

Karen Carmichael

Deborah Nelson

Kate Polson

Amanda O’Reilly

Pip Sail

Louise Turner

Greg Underwood

LINKS

Online Journals

FEATURE Chris Whatman - movement screening in athletes for prediction of injury risk

Recurrent Hamstring Injuries – an Overview of Considerations By keynote speaker Adjunct Professor Craig Purdam

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Lumbar Bony Stress Injury in Cricketers by Dr Angela Cadogan

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RESEARCH PUBLICATIONS

List of Open Access Journals

JOSPT: Volume 44, No. 4, April 2014

McGraw-Hill Books and order form Asics Education Fund information IFSPT JOSPT

CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz

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SPNZ SYMPOSIUM REVIEWS

Sports Physiotherapy NZ

Asics Apparel and order form

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ASICS Asics Report - 2013 Australasian Podiatry Conference

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AWARDS SECTION

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CONTINUING EDUCATION Continuing Education Calendar

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APA CPD Event Finder

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CLASSIFIEDS

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EDITORIAL

By Hamish Ashton, President SPNZ

A warm welcome to all our Members. This is my first editorial since accepting the position as president at our recent AGM that was held during our Symposium in March.

Firstly I would like to thank Dr Angela Cadogan for all the work she has done as president over the last few years. Angela has put a great deal of time and effort into helping grow SPNZ and increase the benefits that you, as members, now receive. She was instrumental in getting our Level 1 Sports Courses off the ground. I know a number of members have participated in at least one of the three going and feedback has been good. We will continue to develop this so that there is a pathway for sports physiotherapy development.

I would also like to thank Dr Tony Schneiders, who stepped down, for his time and commitment over many years. Tony has been involved for such a long time it will not be the same without him. I would like to wish him success in Australia with his new ventures.

As we had a number of committee leaving, some new faces were invited on to the exec committee at the AGM. Over the next few issues they will get introduced more formally but a warm welcome to Justin Lopes and Tim Dovbysh.

We are still down one so if anyone feels they would like to contribute something back please contact us.

Our 3rd Symposium is now over and I would normally be sitting back reflecting on how it went. I am instead reflecting on being the president and what we need to do to continue moving forward as a group. Luckily for me we already have a few new initiatives on the go, one of which is an agreement with Sports Medicine Australia in which we have access to their newsletter. As our bit we have been asked to provide some input into its contents by way of articles so if you have any stories let Michael Borich or me know.

On the symposium I was grateful that the forecast storm mainly passed over us while we were indoors and didn’t scare anyone off coming. Our two Australian speakers did a fantastic job for us, not only with their clinically relevant content of their key note addresses, but also the workshops they held. Some of the other speakers made us really think about the broad nature of sports physiotherapy especially with encouraging lifetime exercises and how we could use our knowledge, not just with the population, but taking it beyond this to lobbying for change in our urban plans. Saturday night finished off with a great panel discussion. As well as our two Aussie friends and medical input from our “resident” sports physician – Ben Speedy – we had five national physiotherapists from as many sports sharing their knowledge and opinions with us. Check out our Facebook page for photos of the weekend.

I have also be asked to introduce myself so I will try to give you brief overview, hopefully without it sounding like my CV. I have been working with teams since 1995 starting with football when I lived in Auckland. While there I had the opportunity to work with Singapore and Papua New Guinea Football sides when they came out to NZ. This provided the opportunity for me to see beyond just being a club physio. I have since worked with New Zealand teams from Beach and Indoor Volleyball and Waka ama in New Zealand, as well as travelling with Rowing, Football and our Youth Olympics overseas. Probably due to circumstances more than anything I have spent time on the sideline with football, basketball, league, netball and hockey. I feel having worked with different codes give a much bigger insight to sports physiotherapy than if I had stuck with one.

From SPNZ’s perspective I was involved with the Auckland branch of NZSOPA before we first became a SIG. My wife and I then moved to Tauranga and I dropped out of things until my knowledge in websites was harnessed and I was brought onto the committee to create our initial website. Since then I have overviewed IT for the group and have been responsible for running our Symposiums.

I am very keen for SPNZ to continue to develop their education programme, as this gives especially our younger physiotherapists the education and pathways I didn’t have coming through as a sports physio. With IFSPT recognising specialist sports physiotherapists and our board now having a specialist category – albeit under the title musculoskeletal at present – I see great opportunities for our members to grow their expertise and have more opportunities over the next few years both in NZ and internationally.

ASICS GRANT

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ASICS EDUCATION FUND A reminder to graduate members that this $1000 fund is available twice a year with application deadlines being 31 March and 31 August.

Through this fund, SPNZ remains committed to assisting physiotherapists in their endeavours to fulfil ongoing education in the fields of sports and orthopaedic physiotherapy.

For further information, please contact Bharat Sukha at: physiosport@ihug.co.nz

CODE OF CONDUCT Sports Physiotherapy in New Zealand now has a code of conduct

By Dr Lynley Anderson Senior Lecturer Bioethics Centre University of Otago Sports Physiotherapy New Zealand (SPNZ) now has a code of conduct (SPNZ Code of Conduct 1). This code recognises that sports physiotherapists face some complex issues in the delivery of sports physiotherapy. As sports physiotherapists are aware, coaches, athletes, fans and others can have objectives that strongly differ with those held by the physiotherapist. These differences may result in pressure on a physiotherapist that will encourage deviation from good clinical practice and traditional obligations to the welfare of the patient. These place the sports physiotherapist in a difficult situation, and one where guidance has been scarce.

The NZSP Code of Conduct has its origins in the real experiences of sports health care providers, and in Lynley’s experience in code development. Lynley had previously carried out research with sports doctors in NZ and was responsible for drafting the Australasian College of Sports Physician’s Code of Ethics 2008. This experience gave some background to the kinds of ethical challenges experienced by sports health care workers. In 2011 Lynley went on to write the Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct. The development of this code required obtaining an understanding of the ethical issues of physiotherapists at the coalface, that is, those in clinical practice. Focus groups were carried out with each special interest group and this included senior members of SPNZ. It was from this group that the ethical issues for sports physiotherapists became obvious.

Some might argue that sports physiotherapy do not need their own code, but should refer to the Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct. However the Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct is an overarching document and is designed to give general guidance on situations common to most areas of clinical practice. As such, it will not have the capacity for expanding into specific areas. Also, due to the complex nature of sport described earlier that can impact on care provision, SPNZ considered that further assistance is required specifically for this group. Having their own code also allows for the provision of material that is specific to the sporting arena and as such, is not relevant to physiotherapists working in other areas. This will include guidance on performance enhancing drugs and fair play in sport. The Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct remains the document for general guidance, but for specific guidance on sporting matters, a physiotherapist would be advised to access the NZSP Code of Conduct.

Following a decision to develop a code of conduct specific for SPNZ, a small group of senior sports physiotherapists (Dr Angela Cadogan, Dr Tony Schneiders, and Michael Borich) met with Lynley on a regular basis to progress the development of the code. Once the code was in draft form, legal advice was provided by Dr Jeanne Snelling (University of Otago). The first draft was sent out for consultation with stakeholders in the latter half of 2013 and were changes made in response to that process.

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CODE OF CONDUCT CONTINUED FROM PREVIOUS PAGE...

The newly launched Sports Physiotherapy NZ Code of Conduct has some specific purposes. This code expresses the shared values of the group. It can be used as a shield that protects physiotherapists from demands from coaches and others when asked to behave in a way that is against the values of the profession. Because the code spells out the standard of behaviour expected of physiotherapists working in the area, the code can be used to judge the actions of members they feel are acting outside established parameters.

This code of conduct, like other professional guidelines and codes, gains its status through endorsement by the profession but also through the Code of Health and Disability Services Consumers’ Rights. Right 4 states that ‘Every consumer has the right to have services provided that comply with legal, professional, ethical and other relevant standards’. This means that if a complaint is made to the Health and Disability Commissioner about the actions of a physiotherapist, the Commissioner will refer to the codes to judge the actions of a sports physiotherapist.

There are some particular highlights in the SPNZ Code of Conduct including:  

Good patient care: Including working with children; and people with mental health issues.

Relationships with patients: including communication; and acting professionally in social situations with patients.  Employment structure and relationships: including dealing with contractual demands; working in good faith with employers.  Confidentiality and privacy: including guidance regarding sharing health information with others; and providing care in public spaces.  Scope of practice: including working under standing orders when carrying and distributing medications in the absence of a doctor.  Risk taking: including responsibilities and guidance for how to respond when athletes wish to take risks to their health.  Fair play in sport: including banned performance enhancing substances; honesty and integrity.

This is cause for celebration as we think this may well be the first of its kind in the world. Other jurisdictions are now looking to this code to see whether something similar may work for them. The authors of this code consider that this code should undergo a regular cycle of review to ensure it is up-to-date and useful to practitioners and their patients.

References: Health and Disability Commission. (1996). Code of health and disability services consumers’ rights. Wellington: Health and Disability Commission.

Aotearoa New Zealand Physiotherapy www.physioboard.org.nz/docs/

Code

of

Ethics

and

Professional

Conduct

(2011)

http://

Australasian College of Sports Physicians Code of Ethics (2008) http://www.acsp.org.au 1. Sports Physiotherapy New Zealand. (2013). Sports physiotherapy code of conduct: Physiotherapy New

Zealand, Wellington. Retrieved from http://sportsphysiotherapy.org.nz/sportsphysiotherapy.org.nz/ documents/Sports-Physiotherapy-Code-of-Conduct.pdf

SPNZ is on Facebook

Check us out at

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MEMBERS ’ BENEFITS

There are many benefits to be obtained from being an SPNZ member.

For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/ Starting now, in each Bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.

Free full text online access to JOSPT JOSPT is one of the top physiotherapy journals in the world. Scholarly and peerreviewed, JOSPT features the latest evidence-based research and clinical cases in musculoskeletal and sports-related health, injury, and rehabilitation, including physical therapy, orthopaedics, sports medicine, and biomechanics. With 12 issues over the year it strives to offer high-quality research, immediately applicable clinical material, and useful supplemental information in a variety of formats.

Australian Sports Physio Association Magazine - Sports Physio Members receive 4 yearly copies of the Australian Sports Physio Association Magazine – Sports Physio. This is a great magazine with articles by sports physiotherapists and associated practitioners that work on the coal face with athletes. There is always an interesting story either on a sport or on a condition what ever your interest.

SMA Sport Health Magazine Through an arrangement with Sports Medicine Australia we have just formalised Members will now receive online copies of their magazine/newsletter which is full of useful articles and knowledge. Look out for it in your inbox shortly

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FEATURE CHRIS WHATMAN - movement screening in athletes for prediction of injury risk

Chris Whatman graduated from Auckland in 1991. He gained his MAppSc (Sports Physiotherapy) from the University South Australia in 1995 and his PhD from AUT University in 2012 Chris’ early sport physiotherapy involvement was as team Physiotherapist for a number of rugby clubs including Hamilton Old Boys and Pakuranga senior teams. Subsequently he was a physiotherapist with Auckland Rugby (various teams) and then when in the UK spent time with the Scottish Rugby Union and Fulham Football Club Academy. He was also an accredited physiotherapy provider in the NZ Academy of Sport when it was initially established. Chris is a long standing member of Sports Medicine NZ and currently holds a position on the national executive. He is also the associate editor of the New Zealand Journal of Sports Medicine.

Chris is currently a Senior lecturer, Sports Performance Research Institute NZ, School of Sport and Recreation, Auckland University of Technology.

Please describe your current role and how you ended up there.

I currently teach in the undergraduate Bachelor of Sport and Recreation (Sport and Exercise Science major) and Bachelor of Health Science programmes at AUT’s North Shore Campus. I also supervise postgraduate students at the Masters and PhD level. Additionally I am a member of AUT’s Sports Performance Research Institute NZ (SPRINZ), a multidisciplinary research team conducting research focused on applied sports performance, where my focus is injury prevention. SPRINZ has close links with High Performance Sport NZ and other national sports organisations and health providers. SPRINZ is located at the AUT Millennium campus on Mairangi Bay (formally known as the Millennium Institute of Health) – see http://www.sprinz.aut.ac.nz. As well as research I was also involved in the set-up of the Running Mechanics Clinic which is also based at the AUT Millennium campus offering state of the art equipment to help improve running efficiency and prevent injuries.

After qualifying as a physiotherapist I worked in the hospital setting and private practice in New Zealand for two years and then enrolled in a Masters in sports physiotherapy at the University of South Australia. After completing my Masters I returned to Auckland to work at

Unisportsmed in St Johns and after two years there headed to the UK where I did locum work in various private clinics and also spent time with the Fulham Football Academy and the Scottish Rugby Union. On my return from the UK I returned to the then Adidas Sports Medicine Clinic and also took up a part-time lecturing position with AUT. Subsequent to this AUT offered me a fulltime lecturing position and as a new university there was an increasing requirement for research.

What are your specific areas of interest/research?

My current research interests include movement screening in athletes (especially young athletes) for prediction of injury risk with a particular focus on the lower limb and overuse problems. Below is a list of some of the recent/current research projects I am involved in (we have recently formed a Netball Research Group in collaboration with Netball NZ and thus have a number of netball related projects): 1.

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Performance analysis and movement screening in secondary school netball.

The effect of fatigue on biomechanical risk factors for knee injury in netball.

The effect of reduced ankle dorsiflexion and ankle bracing on lower extremity mechanics in elite secondary school netball players.

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Chris Whatman - - movement screening in athletes for prediction of injury risk CONTINUED FROM PREVIOUS PAGE. 4.

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The acute effects of two eccentric hamstring exercises on indicators of hamstring muscle damage.

The use of hand held dynamometers in HPSNZ Risk factors for overuse injury in elite adolescent ballet dancers.

Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests.

The reliability and validity of physiotherapist visual rating of dynamic pelvis and knee alignment in young athletes.

My PhD looked at the ability of physiotherapists to visual rate lower extremity functional tests such as the small knee bend and lunge. The original idea for thesis came out of my work as a clinician where I was heavily influenced by the work of Shirley Sahrmann using a lot of her assessment techniques. I was always interested in the reliability/validity of these types of movement assessments and they didn’t seem to get as much attention as intervention studies in the literature - they had been somewhat overlooked (this was back in the early 2000’s – there have been several studies since). I was also driven by colleagues complaining time and again that there’s not enough research that has a “use in the clinic Monday” application! Thus the aim of the thesis was to investigate physiotherapy visual ratings of lower extremity dynamic alignment. We also considered it important to establish that the movements being rated visually were repeatable by clients (this involved 3D kinematic measures of movement), across a range of ages – to show clients presented with a consistent pattern of dynamic alignment that was then worth visually rating.

The key finding was that the movements are repeatable with simple instructions and physiotherapists can make reasonably reliable and valid ratings if they use a dichotomous scale with well-defined criteria – our best evidence was for ratings of pelvic frontal plane position and knee position relative to the 2nd toe [1] Do you have specific information regarding screening tools/injury prevention strategies that would be useful for our members to consider?

Further to my comment above the conclusion of my PhD contained the following summary recommendation for clinicians: For physiotherapists in clinical practice wanting to use

a visual rating method supported by the best current evidence we would recommend use of the SKB (double or single leg) or SLS, using a protocol with acceptable kinematic reliability and a dichotomous scale to rate the position of the knee and/or pelvis. This is the most valid method for visually rating the dynamic lower extremity alignment of healthy individuals in the clinic, without the use of video pause and rewind.

Additional recommendations included: 

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As first choice use the SKB (double and/or single leg), with our simple instructions to maintain a functional head, trunk and arm position and standardise hip and knee flexion range of motion.

If the assessment requires additional tests use a lunge or hop lunge.

Use video slow motion and/or pause if assessing faster movements such as a drop jump.

Focus on dichotomous ratings of knee and/or pelvis position.

Where possible repeat tests should be performed by the same physiotherapist (intra-rater is better than inter-rater reliability).

Where possible use physiotherapists with the most clinical experience.

What do you think are the key elements in successfully preventing injury?

I think the key is probably getting athletes to buy into what we are telling them – athlete and coach education are vitally important – there have been several recent papers on the importance of the coach in injury prevention strategies. Movement screening is certainly a hot topic and below is an extract from a recent editorial I wrote in the New Zealand Journal of Sports Medicine titled “Is the screen clear enough to see the road ahead?

“Many authors have for some time promoted the notion of screening athletes to identify dysfunctional movement patterns before pain or functional problems occur. All physiotherapists will be familiar with the work of Shirley Sahrmann who advocates assessment of the movement system, recently suggesting it should be checked as often as your teeth [2]. Movement pattern screening to identify athletes at greater risk for the likes of ACL injury and other lower extremity injuries (especially overuse injuries) is now widespread and considered a key strategy in all major sports. Studying the single leg squat (small knee bend, single limb mini squat or whatever CONTINUED ON NEXT PAGE.

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Chris Whatman - - movement screening in athletes for prediction of injury risk continued...

CONTINUED FROM PREVIOUS PAGE. your favourite term) as a screening test has been a popular topic for many research groups. The test seems reasonably reliable and some have shown it to be useful in identifying increased risk of patellofemoral dysfunction but there is a lack of prospective evidence.

A challenge to the concept of screening the movement system comes from biomechanists who advocate the value of increased movement variability. They have questioned the view pain and dysfunction result from failure to attain a specific movement pattern. Several authors have suggested reduced movement variability may adversely affect joint health by causing systematic loading on the same areas of articular cartilage raising the risk of chondral damage and osteoarthritis [3]. While this is an interesting notion my impression is the variability they mention is very small in magnitude and while it may be beneficial it’s probably not clinically measurable. Furthermore I doubt the term variability means the same to a clinician as it does to a biomechanist – it would be an interesting conversation! Perhaps there is an optimal movement pattern (appropriate relative motion between segments in a chain) within which some athletes may have increased micro variability and thus these two ideas are not necessarily at odds. My coaching colleagues also speak of the benefits of having variability in movement patterns during the game situation.

Again I don’t see this being at odds with the concept of trying to achieve optimal movement in some fundamental patterns. It does however highlight the need for various disciplines to communicate regularly – the multidisciplinary sports medicine, physio, science and coaching conferences of the past seem a lost opportunity!

Disappointingly there is little quality prospective evidence available showing we are good at predicting those at greater risk based on movement pattern screening. Is this because the screen actually doesn’t predict injury or are their other factors at play? There are likely many other factors and a couple were highlighted in a recent edition of BJSM. One is the role that genomics play in identifying those at risk of injury. A podcast with Professor Malcolm Collins from the University of Cape Town (freely available to all on the BJSM website) gave an interesting summary of his work showing there is increasing evidence genetic profile contributes to an athlete’s susceptibility to tendon and ligament injury (genes contributing to the differences in the structure of collagen fibres for example). Most of the research has apparently focused on genetic markers for

overuse tendon injuries and there are protective as well as harmful genes. There is no doubt a lot of work still needing to be done in this area including genetic profiles of different ethnic populations. Professor Collins was quick to correct the misconception that genetic profile will one day predict injury risk but rather that it could be used alongside other information to aid risk rating or identify how an athlete will respond to treatment – the environment is still important, movement screening still has a place!

Another factor of interest in the same edition of BJSM was the new tool for better recording of overuse injuries.

Ronald Bahr and his team from Oslo have reported on a new questionnaire which appears far superior to traditional injury reporting mechanisms where overuse injuries are concerned [4]. Inappropriate tools for recording overuse injuries may be another factor why past studies have failed to show links between movement patterns and injury risk – particularly risk of overuse injury which is most relevant to movement screening.

So next time you see an athlete with a less than ideal movement pattern but a clean injury history – don’t despair! It’s likely this athlete is blessed with a combination of micro movement variability, good genes and exposure that allows him or her to fly under the radar. Thus when combined with other information you may still be able to see the more likely road many athletes are on by looking through the movement screen.”

The most published screening tool in the literature is the Fundamental Movement Screen (see http:// www.advanced-fitness-concepts.com/fms.pdf), there is also a version of this modified by Scandinavian physiotherapists [5] and HPSNZ rehabilitation use a combination of a physiotherapy musculoskeletal screen and a movement competency screen (the original version of the movement competency screen can be found at http://www.sportingpulse.com/get_file.cgi?id=1454102 and the movements in the updated version can be viewed at h t t p : / / w w w . yo u t u b e . c o m / w a t c h ? v=albIOZKfkhg ). There is certainly more work to do on the reliability and validity of movement screening and for those interested this topic featured in a recent commentary by Dr Paul Gamble (strength and conditioning coach and author) in the NZ Journal of Sports Medicine which can be accessed at http://student.ucol.ac.nz/ library/onlineresources/NZJSM/NZJSM%20Vol%2040% 20No%202%202013.pdf#page=29.

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Chris Whatman - - movement screening in athletes for prediction of injury risk CONTINUED FROM PREVIOUS PAGE. Finally I’m always keen to conduct research that focuses on topics of interest to clinicians and that has a “use in the clinic on Monday” message so if any of the sports physiotherapists out there have a burning question feel free to drop me an email ( chris.whatman@aut.ac.nz ) or alternatively write a case study for the journal!

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References Whatman, C., P.A. Hume, and W. Hing, Kinematics during lower extremity functional screening tests in young athletes – are they reliable and valid? Physical Therapy in Sport, 2013. 14: p. 87-93.

Sahrmann, S.A., On "The physical therapy and society summit (PASS) meeting..." Kigin CM, Rodgers MM, Wolf SL; for the PASS steering committee members. Phys Ther. 2010;90:1555-1567. Physical Therapy, 2011. 91(3): p. 432-3; author reply 433-5.

Glasgow, P., C.M. Bleakley, and N. Phillips, Being able to adapt to variable stimuli: the key driver in injury and illness prevention? British journal of sports medicine, 2013. 47(2): p. 64.

Clarsen, B., G. Myklebust, and R. Bahr, Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire. British journal of sports medicine Frohm, A., et al., A nine-test screening battery for athletes: a reliability study. Scandinavian Journal of Medicine & Science in Sports, 2011.

Opening of SPRINZ lab, TV One News Young athlete SKB

Lab 2013

3D marking young athlete

3D model SKB

SKB

SPNZ SYMPOSIUM REVIEWS

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Recurrent Hamstring Injuries – an Overview of Considerations Presented by keynote speaker Adjunct Professor Craig Purdam, reviewed by Karen Carmichael Craig is the head of Physical Therapies for the Australian Institute of Sport with a special interest in tendon injuries, hamstring injuries and overuse injuries. He has worked closely with Jill Cook, and his presentation followed on well from the information on tendons that Jill presented at the previous SPNZ symposium. Her chapter, written along with Craig, in the latest edition of Bruckner and Khan is well worth reading.

As we all know recurrent hamstring injuries can be frustrating for all concerned. Craig is working to look at factors that may contribute to recurrence and chronicity. In his presentation he touched on four areas that may contribute to recurrence.

He presented a range of research and talked through a variety of theories and ideas behind recurrences of hamstring injuries.

His key point was that no singular approach is likely to work, and there are is a mix of problems. It cannot be ignored that everyone is individual. Unfortunately, randomised controlled trials do not address multifactorial issues and individuality very well, so many of the aspects raised are from smaller case studies.

The four main areas for consideration are:

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Muscles strength considerations Tissue repair - including severity, site and healing Kinetic chain dysfunction

Modifiers of hamstring tone, activation and pain Tissue Repair Severity of injury is known to play an important role in return to play times and recurrence rate. A number of studies have found that increased volume of lesion and increased length of lesion lead to longer rehabilitation and higher rate of recurrence.

Another factor which Craig stressed was to respect significant over stretch injuries, and possible avulsion injuries.

New research also looked at the role of the hamstring common/central tendon (or aponeurosis); the time taken to heal in injuries involving this tendon was significantly longer. These injuries involving the aponeurosis can have incomplete healing leading to recurrence at low loads. They look as though they will do better with longer periods of immobilisation earlier, so it is important to try and identify these in the initial stages of rehabilitation, the studies used MRI and US for imaging.

Muscle Strength Considerations There was some debate about muscle testing, quads/hamstring ratios and ways to test. On Biodex testing it was found there that the optimum angle was significantly less of the injured leg and outer range torque was significantly reduced, although there was no significant difference in peak torque. Clinically, he suggested hand held dynamometers as being useful, although they do have their limitations especially with your bigger, stronger athlete. Another option for testing is using pressure cuffs.

Kinetic Chain Dysfunction The information on the role the kinetic chain has on hamstring injury was interesting with some significant factors still needing further research.

Research still needs to be continued in areas such as objective hip extensor tests. There are not really any good tests for glut max other than the Biodex, which most of us do not have access to. How do we test for synergy between the hamstrings and glut max and what should we be looking for? What is the role of adductor magnus? What are the relationships and synergies amongst the hamstring group itself, as well as the calf relationship?

The relationship with adductor magnus looks like it may be interesting although clinically we don’t tend to look at it.

Craig noted that adductor magnus may present with up-regulation, and this may be compensatory for hamstring dysCONTINUED ON NEXT PAGE.

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Recurrent Hamstring Injuries – an Overview of Considerations continued‌ function and weakness, but how do we go about assessing this? More work needs to be done, but it is an interesting thought to remember when looking at those chronic hamstrings.

Another area to keep in mind is the relationship between the individual hamstring muscles. They may not all work as a block, and there can be selective activation of various hamstring muscles. An example of this was nordic curls, which were shown in one study to work the short head of biceps femoris and semi-tendinous, but not working semimembranous as well as they could be. It appears it may be important, therefore, to rehabilitate in more than the sagittal plane.

Poor gastrocnemius contribution was also an area that more research was needed, with questions raised in regards to this. It was noticed that a gait pattern in running of over-striding with a low, clawing action should be looked at.

These athletes tend to bottom out on hop. The athlete should be able to do around 30 in the heel raise test (which is the mean for an active population) unfortunately there are no good strength and power tests.

A good point raised repeatedly by Craig in both his talks was the need for adequate recovery periods in rehabilitation and training. There is a need to allow sufficient recovery time with gastrocnemius, and more than four good training sessions a week was shown to actually reduce capacity.

Modifiers of Hamstring Tone, Activation and Pain.

So what about the role of the lumbar spine? We know that the lumbar spine and possibly Sacro-iliac joint can have a role in chronic hamstring problems, but what is that role exactly and how to we measure it? The role of the back in hamstring problems was not clearly explained, but there appears to be some changes in cortical mapping. This can be looked at with standard sensory mapping tests such as light touch, cold, two point discrimination, sensory mapping and flash cards.

Other modifiers can be the spinal or peripheral joints, fascia and trigger points, and biopsychosocial influences.

So in summary it can be seen that a singular approach to recurrent hamstring injuries is not the way to go. There are a huge range of factors that have a role to play; and there are still many gaps in the research. You cannot look at all these factors in a single visit.

Clinically, we perhaps should be looking at earlier imaging for those potentially large tears, looking to see if the central tendon is involved, and then managing these much more conservatively. There is a need to be aware of avulsion and over stretch injuries. We need to ask at what stage do we send them back onto the sports field or track, and how do we measure this in terms of strength and power, to minimise the risk of recurrence, how do we balance that with the needs of the team and individual to get back into the competition? Thought needs to be given to all the kinetic factors and strengthening of all the components along with consideration on how we are doing this (eccentric, isometric, through range, more than the sagittal plane, appropriate rest intervals) is it specific for the problem presenting, and are there any underlying neurological considerations.

This was a thought provoking and worthwhile presentation, it will be interesting to see how the research goes over the next few years to fill in some of the gaps highlighted.

Reviewed by Karen Carmichael BSc, BPhty, M(SportsPhysio)

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SPNZ SYMPOSIUM REVIEWS

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Lumbar Bony Stress Injury in Cricketers Presented by Dr Angela Cadogan, reviewed by Monique Baigent The incidence of lumbar bony stress injury (LBSI) is high in the adolescent and young cricketer population. The statistics show that 82% of elite young fast-bowlers (17 years) have some form of posterior element pathology (Foster et al., 1989). In comparison 51% of club and International players (Engstrom et al, 2007) and 42% of amateur and professional players have LBSI (Gregory et al., 2004).

LBSI is commonly seen on the opposite side of the bowling arm, L4 and 5 are the most at risk vertebrae. The combination of hyperextension and either rotation or lateral flexion renders the pars interarticularis vulnerable Adolescents younger than 18 years are at risk of developing this injury as their IVDs are more elastic placing higher shear forces through the vertebrae, there is incomplete ossification of their neural arch (occurs after 20 years of age) and there is an increased rate of bone remodelling in this population. The incidence of stress fracture/spondylolysis in adolescents presenting with posterior back pain is 47% compared to 5% in those over 21 who are more prone to disc injury (50%).

LBSI can progress from a stress reaction to a stress fracture, from unilateral to bilateral and finally to a complete Spondylolysis or spondylolisthesis. The consequence of failed healing can result in lost match time at elite level, recurrent/undiagnosed stress # and further to various co-morbid pathologies including facet joint hypertrophy and central and/or foraminal stenosis that are being more frequently seen in ‘older’ fast bowlers (mid-20’s), therefore early detection is important.

If the patient is an elite bowler with LBP opposite to the side of their bowling arm, pain aggravated with activity, less than 20 years old, with a recent increase in bowling and a mixed bowling action or large lateral flexion angle at the time of front-foot landing along with any red flags an urgent referral is appropriate. If a patient has the above but no red flags then an x-ray is advised. If the x-ray is positive (any patient with a ‘complete’ fracture) send them to a sports physician for an MRI or CT scan. If the x-ray is normal and the elite patient doesn’t respond to treatment over 2 weeks refer them onwards. This is the same for the non-elite player or an adolescent with these signs; however the recommendation here is at 4-6 weeks if there is no improvement in symptoms.

Diagnosis relies more on the clinical history rather than any physical exam and a referral is important if there is a concern. The key subjective signs are LBP/stiffness opposite to bowling arm. The pain often settles quickly (days) after provocation, and aggravating factors may only be bowling with symptoms not improving/worsening despite rest.

Bone healing is estimated 3-6 months and presence of bony oedema on MRI indicates good potential for bony healing. Principles for management of LBSI for adolescent cricketers are rest from all impact activities (to allow bony healing), managing bowling workload or volume, good pre-season preparation (conditioning and gradual increase in bowling volume), introducing rest (non-bowling) days during the season, managing participation in other impact sports, and working on flexibility and core stability.

Reviewed by Monique Baigent BHsc (Physiotherapy)

MISSION STATEMENT Mission for Active New Zealanders Sports Physiotherapy New Zealand promotes safe participation in physical activity, exercise, recreation and sport for participants of all ages and abilities for the maintenance of a healthy lifestyle and for optimal sporting performance.

Mission for Members SPNZ’s mission is to empower our members in the provision of high quality sports physiotherapy services to participants of all ages and abilities involved in sport, exercise and recreation through the promotion of excellence in education, research, clinical practice and specialisation.

RESEARCH PUBLICATIONS

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JOSPT www.jospt.org JOSPT ACCESS All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website.

You will have needed to have followed the information within that email in order to create your own password.

If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have.

If you have just forgotten your password then first please click on the “Forgotten your password” link found on the JOSPT sign on page in order to either retrieve or reset your own password.

Only current financial SPNZ members will have JOSPT online access.

Current Issue: Volume 44, Number 4, April 2014

RESEARCH REPORT Changes in Biochemical Markers of Pain Perception and Stress Response After Spinal Manipulation Effects of Functional Stabilization Training on Pain, Function, and Lower Extremity Biomechanics in Women With Patellofemoral Pain: A Randomized Clinical Trial Short-Term Changes in Neck Pain, Widespread Pressure Pain Sensitivity, and Cervical Range of Motion After the Application of Trigger Point Dry Needling in Patients With Acute Mechanical Neck Pain: A Randomized Clinical Trial Clinical Observation of Standing Trunk Movements: What Do the Aberrant Movement Patterns Tell Us? Knee Extension and Stiffness in Osteoarthritic and Normal Knees: A Videofluoroscopic Analysis of the Effect of a Single Session of Manual Therapy Adult-Acquired Flatfoot Deformity and Age-Related Differences in Foot and Ankle Kinematics During the Single-Limb Heel-Rise Test Spatial-Temporal Gait Characteristics in Individuals With Hip Osteoarthritis: A Systematic Literature Review and Meta -analysis Increased Patellar Tendon Microcirculation and Reduction of Tendon Stiffness Following Knee Extension Eccentric Exercises PERSPECTIVES FOR PATIENTS Neck Pain: Dry Needling Can Decrease Pain and Increase Motion

MUSCULOSKELETAL IMAGING Upper Extremity Deep Venous Thrombosis

ASICS

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ASICS REPORT

CHRIS BISHOP Podiatrist – Leading Edge Physical Therapy Researcher – Biomechanics and Neuromotor Labs, UNI SA

Synergising research and clinical practice the event that was APodC 2013.

In the first week of June, Sydney played host to the 2013 Australasian Podiatry Conference at the Sydney Convention and Exhibition Centre. Whether attending to gain CPD points, catch up with long lost friends or to further advance your understanding of contemporary and future podiatric practice, APodC 2013 provided something for everyone. It was clear that 2013 was targeted towards the practicing clinician. When I attend conferences, it’s usually to present the latest findings out of our research lab, but it was refreshing to sit back for once and be an onlooker. This put me back in the attendees shoes and instead of frantically finishing PowerPoint presentations or workshop prep, I was able to more actively participate in most of the conference proceedings. I was able to ask myself; which workshops did I want to go to? What plenary sessions were of interest? and who did I want to see in the trade? So what were my highlights? What do I think was new at APodC in 2013? What was presented that would change how I do things on Monday? For the purpose of this newsletter, I’m going to review my top four podium presentations in terms of their direct translation into clinical practice, flag some new concepts and identify those studies that I thought went undervalued and deserved more attention.

A Delphi consensus: prescribing functional foot orthoses for the symptomatic pes planus adult Helen A Banwell, Karl Landorf, Shylie Mackintosh, Dominic Thewlis Journal of Foot and Ankle Research 2013, 6(Suppl 1):O 1 (31 May 2013) www.jfootankleres.com/content/6/S1/O1Helen is a PhD student at the University of South Australia and was awarded the Best Paper of the 2013 conference.

What I find intriguing about Helen’s research (and indeed her presentation) is the desire to take the concept of custom foot orthotics and make them ap-

FORERUNNER September 2013

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ASICS REPORT cont ’ d pplicable to the research environment. Too often I doesn’t allow for the numerous theories and approaches to foot orthotic therapy. Enter Helen’s bold attempt to gain consensus in the profession with regards to prescribing functional foot orthoses for the symptomatic flat foot. Now it’s easy (and true) to say that you never prescribe an orthotic for a flat foot but instead you prescribe an orthotic to treat the pathology (which is often caused by and/or results in the pathology). However what Helen has been able to do is set the foundation for future work and potentially standardisation. With 26 agreed prescription variables based on expert opinion, what her research provides is a description of when to prescribe certain cast and/or orthotic modifications. Time will tell but perhaps we’re that step closer to seeing foot orthotics used in research that represent those used in clinical practice.

Tibiofemoral kinematics: the effect of footwear and foot orthoses during runningLaura Hutchison, Rolf Scharfbillig, Hayley Uden, Chris Bishop Journal of Foot and Ankle Research 2013, 6(Suppl 1):O17 (31 May 2013)www.jfootankleres.com/content/6/S1/ O17I haven’t included this paper just because I’m a co-author but more to recognise Laura’s fantastic achievements as an award winner at the conference and furthermore to encourage other students to get up onto the podium and present the amazing honours and post grad research that I know is being conducted in Australia. Laura conducted a pilot study looking at the proximal effects of footwear and foot orthoses during running. This study evolved from numerous discussions about the concept of ‘maximallist’ or ‘motion control’ footwear and what does it actually do given the clinical benefits (specifically at the knee) received by individuals who wear supportive shoes. What really surprised me about the findings of this study is that the stability (or medially posted) shoe actually had more of an effect on the knee joint in terms of reducing tibial internal rotation (which is coupled with foot pronation) than the custom made orthotic. Despite the pilot nature of the research, these results have direct implications for the management of rotational based knee pain in runners. Perhaps the footwear we prescribe/ recommend to our patients is having more of a biomechanical effect than we think. Additionally, I think the next fascinating step is to take this into the realms of pathology to see whether any associated biomechanical effects correlate with symptom reduction.

Plantar heel pain: an update of its aetiology and diagnosisKarl B Landorf, Andrew M McMillan, Hylton B Menz Journal of Foot and Ankle Research 2013, 6(Suppl 1):O18 (31 May 2013)www.jfootankleres.com/content/6/ S1/O18A great presentation by a great researcher! Karl Landorf is based out of LaTrobe University and his research group has really been at the forefront of plantar heel pain research for over a decade. What I liked about this presentation was the method of presentation and in particular his unique ability to identify the important aspects for the clinician. Karl presented a synthesis of the research conducted in his group, principally based around the role of imaging which has been a large part of Andrew McMillan’s PhD efforts. What I have really been arguing lately is the ability to, and methods used in the diagnosis of plantar heel pain and this presentation reconfirmed that. Plantar fasciitis is a diagnosis of inflammation, and despite the histopathology literature clearly indicating inflammatory infiltrate is not present, the term fasciitis continues to be used in clinical practice (incorrectly). Even if the term is fasciosis, this change in fascia presentation cannot be seen without imaging. So really the crux of where we are at with plantar heel pain is that if the clinical examination is negative for pain of neural origin, medical imaging is required to be able to make a specific diagnosis. Plantar heel pain is this clinical term that encompasses a wide variety of pathologies – it’s not a diagnosis. As clinicians we need to get to the bottom of the presenting problem and given our prescribing abilities, I think Karl (as well as many other researchers around the world) make it very clear that we need to embrace medical imaging (and, specifically in the case of plantar heel pain, ultrasound) given the benefits it can provide in the diagnostic process.

Power generation of the midfoot in children wearing sports shoes Caleb Wegener, Andrew Greene, Joshua Burns, Benedicte Vanwanseele, Adrienne E Hunt, Richard M Smith Journal of Foot and Ankle Research 2013, 6 (Suppl 1):O35 (31 May 2013) www.jfootankleres.com/content/6/S1/O35 Caleb is a researcher out of the University of Sydney and is well known at podiatry conferences for presenting his honours and now PhD research. Although I hear there’s more of the story to be told in time, what I find fascinating is the proximal compensations that Caleb has identified. We know children have complex walking and running patterns and these change over time as the musculoskeletal system develops, but what Caleb tells us is that children compensate for a loss/reduction of midfoot

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ASICS REPORT cont ’ d power in shoes by increasing power generation at the ankle. I see this as having two direct implications; firstly Caleb identifies the potential for overuse of the Achilles tendon which in this population has a direct implication in the development / management of Severs Disease. Secondly, and on a more global scale, what does this mean for the design of Children’s shoes? I’ll leave that to Caleb and the designers!

Even with the quality of the papers presented on the podium, I always try to also embrace the poster sessions. You always seem to find that one unique paper which you get caught up in a discussion about for 20 odd minutes. The presentation of posters at conferences has long been considered second rate to the offer of a podium position, but the format provides the ability to engage with attendees and have detailed discussion in regards to a concept or topic without the distraction of meal breaks or cocktail drinks which is usually when you hit up podium speakers! At APodC 2013, and especially given the high content of high risk and diabetes related papers, there was one particular paper that caught my eye: Is it how they walk? Biomechanics in diabetic peripheral neuropathy: a review of the literature Malindu Fernando, Robert Crowther, Peter Lazzarini, Kunwarjit Sangla, Margaret Cunningham, Jonathan Golledge Journal of Foot and Ankle Research 2013, 6(Suppl 1):P4 (31 May 2013) www.jfootankleres.com/content/6/S1/P4 The diabetic and high risk foot is such a big area of podiatry, with the focus being on wound care and the prevention of complications (i.e. amputation). But, I highlight this particular poster to ask how often we look past the presenting complaint of an annual diabetes screening or wound dressing and consider the biomechanical changes in the gait patterns of those patients presenting to us who don’t necessarily report/complain of pain during gait. We know there are active processes happening at a cellular level, so what effect do these changes have on the way me move and are they likely to cause us an issue? A great review by Malindu Fernando and co-authors looked at the lower limb biomechanics of patients who had diabetic peripheral neuropathy. Of the 25 papers they reviewed, there was consensus that patients with diabetic peripheral neuropathy walked slower which directly reduced the stride rate. They also had reduced knee extension and, due to early activation of the gastrocs complex, had active sagittal plane movement of the ankle. The consequent flexed knee position (i.e. reduced knee extension) is likely to move

initial foot contact with the ground towards the midfoot/ forefoot, which likely explains the increase in forefoot plantar pressures (as well as the incidence of ulceration) seen in this population. So rather than just managing the direct symptoms (i.e. callus/wound debridement), perhaps we also need to momentarily look away from the foot and wander proximally up the kinetic chain to see if we can make changes in gait (i.e. methods to facilitate heel strike) which will indirectly reduce forefoot pressures which in turn lead to ulceration. It makes sense and demonstrates that biomechanics and gait analysis are just as important in the high risk individual as it is in the elite athletes who use it for performance enhancement. Finally, the wow factor, that thing you look at and suddenly realise that you are in a modern world dominated by technology. At every conference I attend there is always that one paper that presents the fancy gadget, app or alternative use of a household item which can have a place in the clinic. At previous conferences we have seen the Nintendo Wii be used as a force platform and we’ve seen the XBox Kinect used as a motion analysis system, Ubersense and Dartfish came out with iPad/ iPhone apps less than $10 to do video gait analysis and now we have the app that enables us to use our iPhones as digital goniometers as a means to measure joint range of motion!

The TiltMeter app is a novel and accurate measurement tool for the weight bearing lunge test Cylie Williams, Antoni Caserta, Terry Haines Journal of Foot and Ankle Research 2013, 6(Suppl 1):P17 (31 May 2013) www.jfootankleres.com/content/6/S1/P17 Williams and co-authors take a standard clinical measure of ankle joint dorsiflexion, pull out there iPhone with a preloaded free App (TiltMeter) and report excellent ICC’s (ICC = > 0.8) when compared to a digital inclinometer. I can’t wait for Apple to get a hold of this and see the new range of devices available for clinical use! Overall APodC 2013 provided the ability for researchers to translate their findings into clinical practice. I commend Stef, Brenden and the rest of the committee for organising a clinically relevant conference as too often the translation of research knowledge into clinical practice is either completely forgotten, or unjustifiably overlooked. As a profession we need to embrace research, because in an evidence based world it’s the foundation of what we do, but at the same time researchers need to place more emphasis of the effect of their results rather than a bunch of significant p-values. After attending APodC 2013, I really believe the podiatric professional has been provided a new forum in Australia to bring research and practice even closer together and for that I say thank you.

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AWARDS SECTION AUT EDUCATION AWARD WINNER 2013

An AUT initiated change in 2013 to the SPNZ Education Award saw the award change from that purely of a research project winner to that which involved other aspects of personal development such as self experiences and contributions to the community in the fields of sports physiotherapy. Nomination was through fellow peers.

The 2013 winner was Sam Osbourne who was a very delighted recipient of $500.00. Along with an excellent academic record, Sam was also selected for a summer studentship research award. Sam is a top level sailor who narrowly missed selection for the London Olympics and is heavily involved coaching this sport to special needs children.

SPNZ wishes Sam all the best for her future endeavours.

OTAGO EDUCATION AWARD WINNER 2013 Age-related changes of the glenoid labrum: a narrative review Jaimee Northcott, Nichole Gillespie, Laura Due, John Lim, Peter Chiu Supervisor: Dr Gisela Sole, PhD, FNZCP Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand This is a summary of the research project by Ms Northcott, Gillespie, Due, and Mr Lim and Chiu, as partial fulfillment towards their BPhty degree.

For further information, please contact Gisela at Gisela.sole@otago.ac.nz .

INTRODUCTION Injuries to the glenoid labrum have been extensively described in the literature since the mid-1980s1, 2 and can be incurred through a traumatic incident, such as falling on an outstretched arm, or develop insidiously. 3 With the recent emergence of sophisticated imaging processes and availability of arthroscopy, it appears that there has been an increased reported incidence of labral repairs. For example, increases have been reported up to 464% from 2002 to 2010 in New York State4 and a national increase of 105% from 2004 to 2009.5 When diagnosing musculoskeletal conditions, it is important to consider normal anatomic variations of implicated structures and also the age-related changes in these structures. The goals of this narrative review were thus, to determine the normal variations of the glenoid labrum and the natural changes it undergoes with age.

A number of common variations were found for the superior labrum. 6-8 The first variation involved the presence of the sub-labral foramen, defined as a sulcus between the anterosuperior portion of the labrum and the glenoid articuCONTINUED ON NEXT PAGE.

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AWARDS SECTION OTAGO EDUCATION AWARD WINNER 2013 cont ’ d

lar cartilage.6, 7, 9-11 Smith et al.12 confirmed this observation with MRI which found that the sub-labral foramen most likely being part of a degenerative reorganization process. The second variant recorded was the presence of a thickened “cord-like” middle glenohumeral ligament (MGHL). In comparison, the normal MGHL is classically described as flat, or “sheet-like”.7 The third variation noted has been termed the “Buford complex”, characterized by the complete absence of labral tissue at the anterosuperior aspect of the labrum, in conjunction with a cord-like MGHL.7 It is thought that these anatomical variations may cause glenohumeral biomechanical alterations and may predispose the shoulder to other associated abnormalities.7 Across the literature it was clearly evident that the glenoid labrum is circularly attached to the glenoid rim, with no irregularities up until the age of 10 years. 6, 9 Changes to the labrum already appear in the second decade, evident as fissures, detachments or tears, increasing in severity and number with age. Pfahler et al. 9 showed that these lesions start superiorly and anterosuperiorly and eventually progress to involve the whole circumference of the glenoid cavity. Between the ages of 30-50 years, tears and defects begin to develop at the superior and anterosuperior aspect of the glenoid labrum. After 30 years, there may be some loosening of the upper part of the labrum which increases in age. After 50 years it was noted that the labrum becomes thinner and absent in some areas. 13 The glenoid labrum is inconsistently fixed to the glenoid rim in the person over 60 years of age. 9 A study by Miniaci et al.14 evaluated the MRI findings of the labrum in both shoulders of asymptomatic professional baseball pitchers without significant prior shoulder injury. Results show that 45% of the throwing shoulders and 36% of the non-throwing shoulders of young pitchers had a SLAP lesion. There was no significant difference between the throwing and non-throwing shoulders of the individual athletes. Compared to a non-athletic population however, the incidence of SLAP lesions in the professional baseball pitchers is high. Training and conditioning in baseball players frequently involves both upper extremities. It has been postulated that this increased activity and stress from such training lead to the increased incidence in SLAP lesions in the non-throwing shoulder.14 Clinical implications The clinician assessing a patient with a shoulder disorder needs to decide whether labrum abnormalities should be considered the pathological source of the patient’s symptoms or whether they are “normal” age-related variations.

This review has found that normal anatomical changes of the labrum are common, starting much earlier than usually considered, namely the second decade, increasing with age. While a sublabral recess was found to be common in the older population, it was suggested that if it was located anterior to the head of the biceps tendon, it should be considered a normal variant. A Type II SLAP lesion is diagnosed when the sublabral recess extended posterior to the biceps tendon.11 For throwers, the high incidence of labral abnormalities demonstrated on MRI by Miniaci et al. 14 indicated that only a small percentage of these have “normal” labra and those authors suggested that the mere presence of abnormalities do not confirm symptomatic pathological findings. Caution is thus needed when interpreting findings of these with imaging or arthroscopy. Results from several studies indicate that changes to the glenoid labrum are of minimal clinical relevance if the person examined is clinically asymptomatic. Such changes should be considered a normal and age-dependent physiologic process.9 Assessment of injuries of the labrum is further challenged by low accuracy of many of the diagnostic procedures. For imaging of the labral capsule ligamentous complex, magnetic resonance arthrography (MRA) has been suggested to be most accurate.15 However this procedure has also been shown to have low sensitivity of 65% for glenoid labrum tears subsequently confirmed with arthroscopy in young patients with anterior shoulder instabilities. 16 Further, most of the clinical tests for the labrum lack sufficient accuracy. 17-19 Considering labral lesions to contribute towards a patient’s symptoms is thus complicated by two main issues: lack of accuracy of diagnostic tests and also lack of clarity what may entail “normal” changes. If there is doubt regarding the possible association between symptoms and signs of labral abnormalities, it could thus be suggested that a conservative approach should be used in the first instance, such as treating the impairments associated with the patient’s shoulder pain. Only if these are not successful, should further interventions, such as surgery, be considered.

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OTAGO EDUCATION AWARD WINNER 2013 cont ’ d CONCLUSION Findings of this review indicate that there is a need for more specific classification systems for the anatomical variations of the labral region. Only after the normal anatomic patterns of the labrum are understood, can true pathologic variants be appropriately identified. The literature clearly demonstrates an increase in the grading of tears and structural defects with age, starting in the second decade. Emphasis throughout the literature was placed on the fact that the mobile and loosely attached superior labrum is not always to be considered as abnormal, unless there is an irregular or detached labrum. Based on these findings, initial management of patients with shoulder pain considered to be associated with labral changes should be conservative, before considering surgical repair.

REFERENCES 1. Andrews, JR, Carson, WG, Jr., McLeod, WD. 1985. Glenoid labrum tears related to the long head of the biceps.

Am J Sports Med 13: 337-341.

2. Snyder, SJ, Banas, MP, Karzel, RP. 1995. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 4: 243-248.

3. Dutcheshen, NT, Reinold, MM, Gill, TJ. 2007. Superior labrum anterior posterior lesions in the overhead athlete: current options for treatment. Oper Tech Sports Med 15: 96-104.

4. Onyekwelu, I, Khatib, O, Zuckerman, JD, et al. 2012. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. J Shoulder Elbow Surg 21: 728-731.

5. Zhang, AL, Kreulen, C, Ngo, SS, et al. 2012. Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med 40: 1144-1147.

6. Cooper, DE, Arnoczky, SP, O'Brien, SJ, et al. 1992. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am 74: 46-52.

7. Rao, AG, Kim, TK, Chronopoulos, E, McFarland, EG. 2003. Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. J Bone Joint Surg Am 85-A: 653-659.

8. Davidson, PA, Rivenburgh, DW. 2004. Mobile superior glenoid labrum: a normal variant or pathologic condition?

Am J Sports Med 32: 962-966.

9. Pfahler, M, Haraida, S, Schulz, C, et al. 2003. Age-related changes of the glenoid labrum in normal shoulders. J Shoulder Elbow Surg 12: 40-52.

10. Clavert, P, Kempf, JF, Wolfram-Gabel, R, Kahn, JL. 2005. Are there age induced morphologic variations of the superior glenoid labrum About 100 shoulder arthroscopies. Surg Radiol Anat 27: 385-388.

11. Kreitner, KF, Botchen, K, Rude, J, et al. 1998. Superior labrum and labral-bicipital complex: MR imaging with pathologic-anatomic and histologic correlation. AJR Am J Roentgenol 170: 599-605.

12. Smith, DK, Chopp, TM, Aufdemorte, TB, et al. 1996. Sublabral recess of the superior glenoid labrum: study of cadavers with conventional nonenhanced MR imaging, MR arthrography, anatomic dissection, and limited histologic examination. Radiology 201: 251-256.

13. Prodromos, CC, Ferry, JA, Schiller, AL, Zarins, B. 1990. Histological studies of the glenoid labrum from fetal life to old age. J Bone Joint Surg Am 72: 1344-1348.

14. Miniaci, A, Mascia, AT, Salonen, DC, Becker, EJ. 2002. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med 30: 66-73.

15. Pavic, R, Margetic, P, Bensic, M, Brnadic, RL. 2013. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury 44 Suppl 3: S26-32.

16. Jonas, SC, Walton, MJ, Sarangi, PP. 2012. Is MRA an unnecessary expense in the management of a clinically unstable shoulder? A comparison of MRA and arthroscopic findings in 90 patients. Acta orthopaedica 83: 267-270.

17. Hegedus, EJ, Goode, A, Campbell, S, et al. 2008. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med 42: 80-92; discussion 92.

18. Hanchard, NC, Lenza, M, Handoll, HH, Takwoingi, Y. 2013. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane database of systematic reviews (Online) 4: CD007427.

19. Sandrey, MA. 2013. Special Physical Examination Tests for Superior Labrum Anterior and Posterior Shoulder Tears: An Examination of Clinical Usefulness. J Athl Train.

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CONTINUING EDUCATION CALENDAR

Upcoming courses and conferences in New Zealand and overseas in 2013 & 2014.

For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/

LOCAL COURSES & CONFERENCES When?

What?

Where?

17-18 May 2014

KT1&2 Hamilton

Hamilton

24 May 2014

RockTape (Kinesiology) Taping 1 day Seminar

Auckland

24-25 May 2014

NZMPA - Mulligan Concept Parts A and B

Wellington

1 June 2014

University of Otago - Postgraduate Study - Tackling Obesity - Supporting

Nationwide

Healthier Lifestyles - GENX733 9 June 2014

PhysioScholar - Diagnosis of shoulder pain in primary care

Nationwide

13-14 June 2014

Vestibular Rehabilitation Advanced Course

Wellington

19-20 June 2014

Kinesio Taping - KT 3 Hamilton

Hamilton

APA CPD EVENT FINDER SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and conferences at APA member rates. This includes all webinars and podcasts (no travel required!).

To see a full list visit the APA and SPA Events Calendar Course

Town

Criteria Driven Rehab & RTS Following Reconstruction of ACL

Camberwell

Drugs in Sport - What You Need To Know

Nedlands

The Thoracic Spine in Sport

Bentley, WA

18 May 2014

Kent Town, SA

19 May 2014

Camberwell

24 May 2014

How RTUS Changes the Management of Impingement Syndromes Dance Network Foot and Ankle Focus Course

Dates

, NSW

22 April 2014 6 May 2014

, WA

, NSW

Radiology Update

St Leonards ,NSW

27 May - 10 June 2014

Sports Level 1

Bruce, ACT

31 May - 1 June 2014

Injury Surveillance and Monitoring in Rugby League

Eight Mile Plains

, QLD

2 June 2014

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CLASSIFIEDS POSITIONS VACANT TAURANGA Bureta Physiotherapy One of our staff members’ unplanned return to the UK is your gain!

Young, dynamic, enthusiastic team require motivated full time physiotherapist for busy centrally located clinic with great reputation for manual therapy, dry needling, rehab and sports focus. Great team atmosphere with fantastic reception staff. We are strongly committed to professional development with a regular in-service and training programme along with support and assistance towards further education. Sports medicine opportunities are available and encouraged. Experienced physiotherapists with post graduate qualifications/Masters to work alongside.

We are looking for an energetic, passionate physio with good communication skills, a keen interest in sports physiotherapy and overall health and wellness along with a hands on approach to physiotherapy.

For further information please contact Jacinta Horan on jacinta@buretaphysio.co.nz or 021623627. www.buretaphysio.co.nz

AUCKLAND Shakespeare Physiotherapy + Sports Rehab We have a vacancy for a musculoskeletal Physiotherapist to join our team.

Shakespeare Physiotherapy + Sports Rehab offers a chance to work in a strong team environment with post graduate qualified Physiotherapists.

We are seeking a motivated therapist with a strong desire to continue learning and work in a group environment.

You must have great communication skills and be skilled at working with other disciplines.

There is a busy caseload offering a variety of conditions from acute injury and post-surgical rehab to injury prevention and performance analysis. We have strong links to our local medical fraternity and surgeons, in addition to individual coaches of athletes.

We have a regular in-service program with strong peer support and you will be expected to commit to ongoing professional development.

If you think you have the desire and skills and would be interested in the position please contact Dene Coleman: 09 4864652 or dene@shakespearephysio.co.nz

AUCKLAND VACANCY – PHYSIOSPORT, EAST TAMAKI. NEW GRADUATES WELCOME. An opportunity to work in a multicultural environment with an experienced physiotherapist who also has teaching experience. As such, continuing education and mentoring are strong essentials alongside flexible working hours and a relaxed atmosphere. Treatment is manual therapy and rehabilitation based for a range of injuries (not just sport!).

New graduates will be eased into their workload to allow an adequate learning experience.

The clinic is located in an established large medical centre with ongoing GP support.

For all enquiries and further information, please contact Bharat Sukha on 09 2744900 or physiosport@ihug.co.nz

Advertisements appearing on this page are not necessarily endorsed by SPNZ

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CLASSIFIEDS POSITIONS VACANT TAURANGA Physiotherapy Locum Position - Tauranga CBD

Locum required to cover annual leave for the full month of May, with the possibly of further locum work thereafter.

Generous appointment times allow for an emphasis on manual/manipulative physiotherapy and exercise prescription encompassing full rehabilitation in the onsite rehabilitation gym. Clinical team consists of physiotherapists, massage therapists, nutritional advisor, fitness trainer and full time reception.

Work along-side physiotherapists who have experience working with national and international athletes and sports teams. You will also have the opportunity to work with some of the BOP’s top athletes and sports teams.

Excellent remuneration offered. We are negotiable as to whether you will be paid on a per patient or hourly basis.

We are looking for a competent, hard-working individual with high work ethic, excellent communication and enthusiasm who can step in pick up a full patient load and work within our great team. Private practice experience in New Zealand is imperative.

Forward your CV and covering letter to: Craig Newland craig@foundationclinic.co.nz

TAURANGA Sports physiotherapy position in Tauranga CBD Here is a unique and exciting opportunity to work in a recently established sports physiotherapy and rehabilitation clinic situated in the Tauranga CBD. Due to a rapidly expanding clinic “Foundation” is in need of another high quality sports physiotherapist. The position will involve working with some Bay of Plenty’s top premier sports clubs as well as an international rugby and cricket academy.Generous appointment times allow for an emphasis on manual/manipulative physiotherapy and exercise prescription encompassing full rehabilitation in the onsite rehabilitation gym. Clinical team consists of physiotherapists, massage therapists, nutritional advisor, sport scientist and full time reception.

Work along-side physiotherapists who have experience working with national and international athletes and sports teams. The successful applicant will receive on-going support as part of our mentoring program.

The position is permanent full time. Start date ideally beginning of May but can be negotiable. Employees will be paid a base retainer, so there’s no stress about income as you grow your patient list. Allowance for CPD also included.

We are looking for a competent, hard-working individual with high work ethic, excellent communication and enthusiasm who is keen to learn and enhance their clinical skills. New Grads with appropriate musculoskeletal and/or sports experience welcome to apply.

All applications will be treated with utmost confidentiality.

Forward your CV and covering letter to Craig Newland craig@foundationclinic.co.nz

AUCKLAND Back To Your Feet Physiotherapy Ltd Back To Your Feet Physiotherapy Ltd is an ACC accredited physiotherapy and sports clinic based in central Auckland who are looking for an enthusiastic and reliable part time (aprox half time) physiotherapist to start as soon as possible. The successful applicant will be able to work independently but will benefit from a significant mentoring and CPD programme.

Please direct any questions or email your CV Justin at back2yourfeet@ihug.nz