SEPNZ Bulletin December 2020 by Sports & Exercise Physiotherapy NZ

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SEPNZ BULLETIN

ISSUE 18, DECEMBER 2020

STUDENT EDITION: P5, 8 and 11!

Patellar Tendinopathy in Volleyball Neuromuscular injury prevention program in football Preventing Hamstring Injuries in Football

p16 BACK TO THE GRAM

p21 CLINICAL REVIEW

p23 UPCOMING SEPNZ COURSES

www.sepnz.org.nz

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CONTENTS SEPNZ MEMBERS PAGE See our page for committee members, links & member information

EDITORIAL: By SEPNZ President Blair Jarratt

FEATURE ARTICLES: Patellar Tendinopathy management in Volleyball Players

Performing a neuromuscular injury prevention program may reduce common lower limb injuries in football players.

Preventing Hamstring Injuries in Football.

GRAM REVIEW: Back to the Gram!

MEMBER BENEFITS: Asics Professional Buyers Program

ASICS FOOTWEAR REVIEW: CHARCOT FOOT GT-4000 2

CLINICAL REVIEW: Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft

UPCOMING SEPNZ COURSES

RESEARCH PUBLICATIONS: BJSM November 2020 - Volume 54 - Issue 21

MCGRAW HILL MEMBER BENEFITS

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EDITORIAL Kia ora and welcome to our December SEPNZ Bulletin! With all the negative talk of 2020, it easy to get carried away in the year that will be remembered for maybe the wrong things. This year has been a significant milestone for SEPNZ, and 2 of our members. After five years in the making, we now have awarded the SEPNZ Sports Physiotherapy Certificate award. Congratulations to Colin Hancock and Katie Geese. Thank you for the years of commitment to our program.

We have included on page 23 the upcoming SEPNZ courses and keep an eye on our website for the SEPNZ symposium 2021 - developments to come...... To pack out your summer reading, we have a bumper issue of the bulletin celebrating our students. Yes, we still have our super helpful App review, an ASICS footwear review and a clinical review from Pip Sail. Every year we devote the December bulletin to our physiotherapists who have spent the last year in study. This year despite the challenges in education, we have a massive issue that is a testament to learning and improving our professional knowledge. We have had some fantastic submissions for our student feature article. We were tasked with the difficult decision to pick one of these — it’s fair to say we failed at that as the quality of all 3 meant we couldn't decide so we have published them all. Thank you Melanie Voney, Laura Thomson and Michael Petersen for your articles that give us insights into patella tendinopathy, prevention programs for lower limb injuries and preventing hamstring injuries.

Continuing with our student theme Congratulations to the recipient of our SEPNZ research award for AUT- David Lalor for his work on median nerve displacement during upper limb neural mobilisation. SEPNZ Executive members Emma Lattey and Justin Lopes were there on the night to present this award. In November, we asked for your photos in sport to go into the running to be the published face of the 2021 SEPNZ BJSM edition. Congratulations to our photo comp winner Janet Wagstaff - her photo is featured in our bulletin cover titled "Salmon Fishing in Twizel". This picture is incredible and a winner with our executive. It is the perfect depiction of serenity and calm that we will all crave after the Christmas parties. We have decided to open up this competition to entries received all year so if you take a great pic, forward it to our editor to go in the running no matter when you take the pic! (SEPNZ would love to feature your shots on our cover however if you wish to be in the running for BJSM, please check our website for requirements/ and specifications). This is the time to throw the feet up for a little bit - take a breath and enjoy some time with family and friends. Well, that's a wrap for 2020, we made it.

Kind Regards Blair Jarratt SEPNZ President

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FEATURE ARTICLES

Student Edition: Patellar Tendinopathy management in Volleyball Players. Melanie Voney Mel qualified as a physiotherapist in Switzerland and undertook this year’s study at a full-time basis. Patellar tendinopathy (PT) is defined as a chronic, painful and degenerative overuse injury to the patellar tendon (Cook & Purdam, 2009). With a prevalence of 40 to 50% in jumping sports where high loads are placed on the knee extensors, such as volleyball, PT is one of the most common injuries that could lead to performance impairment or the end of an athletic career (Lian et al., 2005). Based on the assumption that eccentric exercises would load the tendon more intensively than concentric exercises and thus allow the tendon to adapt to higher loads, Stanish et al. (1986) were the first to try a purely eccentric rehabilitation programme in 1986. The positive results were later confirmed by Alfredson et al. (1998). Since then, eccentric exercises have been the cornerstone of tendinopathy management (Kjaer & Heinemeier, 2014). However, not all athletes with PT showed a positive effect after eccentric loading. As a result of unsuccessful therapy and the high recurrence rate of PT, new therapeutic approaches such as isometric or heavy slow resistance exercises have gained attention in the literature due to their positive clinical results (Magnusson & Kjaer, 2019; Malliaras et al., 2015). This leads to the question whether eccentric exercises are justifiably preferred in the rehabilitation of volleyball players with PT. Hereinafter, this assignment will describe how different types of rehabilitation programmes (eccentric, isometric, heavy slow resistance) might affect athletes with PT. Possible changes in tendon characteristics and clinical outcomes such as pain and function will be discussed.

fibre cross-linking could contribute to an improvement in tendon stiffness. As a consequence, the muscle-tendon force transmission could be increased, which could result in a higher force development of the muscle (Kjaer & Heinemeier, 2014; Knaux et al., 2011; Langberg et al., 2007; Maffulli et al., 2010; Magnusson & Kjaer, 2019). In addition, Lee et al. (2020) identified a correlation between these alterations in tendon characteristics and an improvement in the Victoria Institute of Sports Assessment -Patella (VISA-P) score and pain by 35% and 49%, respectively. Victoria Institute of Sport Assessment-Patella is a valid and reliable assessment tool for determining pain and function in individuals with PT (Hernandez-Sanchez et al., 2014). More importantly, these improvements were reflected in the high patient satisfaction and the return to pre-injury athletic level (90% and 73% respectively) (Bahr et al., 2006; Jonsson & Alfredson, 2005). Conversely, Kubo and Yata (2017) found no statistically significant improvement in tendon stiffness (1289±544N/mm to 1457±440N/mm, p=0.246). A small sample size and the inclusion of only healthy tendons could be possible reasons for these contradictory results. However, these findings support the hypothesis that an eccentric rehabilitation programme could influence collagen type I synthesis in pathological tendons but not in healthy tendons in order to maintain tendon tissue balance (Cook & Purdam, 2014; Langberg et al., 2007; Zhang et al., 2014). Nevertheless, the underlying mechanism of pain relief after eccentric loading remains unknown.

Eccentric rehabilitation programme Eccentric exercises are the most frequently used treatment approach in the rehabilitation of PT. Muscle strength and tendon stiffness were significantly increased by 61-77% and 12% respectively after an eccentric exercise programme (Lee et al., 2020; Malliaras et al., 2013). It should be noted that high intensity eccentric exercises around 80% of the one repetition maximum achieved better results than low-load eccentric exercises (Jonsson & Alfredson, 2005). A hypothesis proposed that eccentric loading may cause high-frequency oscillations, which are associated with tendon remodelling facilitation by increasing collagen type I synthesis. The aforementioned structural tendon changes could be the result of increased collagen synthesis, which could indicate a matrix remodelling of the tendon to protect it from increased stress (Knaux et al., 2011; Langberg et al., 2007). Furthermore, increased intratendinous collagen

Despite all the positive effects, an eccentric exercise programme performed twice daily, which was carried out during the competitive volleyball season, could neither improve pain nor VISA-P score after 12 weeks (Visnes et al., 2006). Interestingly, Kongsgaard et al. (2006) reported an improved VISA-P score after a 12-week eccentric rehabilitation programme completed preseason. There is considerable debate about the frequency of exercise in athletes with PT. Most eccentric exercise programmes are performed twice a day, seven days a week. This contradicts histological studies, which claim that without a 24-48-hour rest period between exercises, collagen fibre net loss may occur, making the tendon more prone to injury (Magnusson & Kjaer, 2019; Magnusson et al., 2010). The effect of a daily eccentric training during the competitive season could lead to excessive strain on the patellar tendon due to insufficient rest periods. The absence of matches in the preseason might ensures the CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLE necessary rest period for matrix remodelling. Heavy slow resistance rehabilitation programme Another treatment approach would be the combination of slow eccentric and concentric movements with heavy loads at around 70-80% of the one repetition maximum, as it is the case in heavy slow resistance training (HSR) (Kongsgaard et al., 2010; Malliaras et al., 2015). Athletes with tendinopathic tendons showed a smaller density of fibrils. Interestingly, after a 12-week HSR programme fibril density increased significantly by 70% and tendon stiffness was significantly reduced by 9%. No statistically significant difference in fibril density was found at the 12week follow-up compared to healthy athletes (Kongsgaard et al., 2010). More importantly, HSR could alter the crosslink profile of the tendon as showed by the elevated concentration of collagen. These detections demonstrated a possible raise in the synthesis of tendon collagen (Kongsgaard et al., 2009; Kongsgaard et al., 2010). As a result, the reduction in tendon stiffness could be explained by a possible increase in the crosslink quantity, due to an increase in matrix turnover and an increased production of new tendon fibrils (Kongsgaard et al., 2010) In contrast, healthy individuals showed no change in mechanical tendon properties after HSR (Mannarino et al., 2019). These findings support the hypothesis that PT treatment based on loading can normalise the extracellular matrix and may be associated with an improvement in selfperceived pain and functional impairment (Zhang et al., 2014). In comparison with a 12-week eccentric programme, HSR demonstrated similar outcomes in pain reduction and improvement in VISA-P score in athletes with PT at the six -month follow-up. More importantly, the satisfaction of the participants in the HSR group was significantly higher compared to the eccentric group (70% and 22% respectively) (Kongsgaard et al., 2009). A possible explanation for the high level of satisfaction in the HSR group could be that participants are more likely to attend a thrice weekly training rather than a twice daily training seven days a week. Moreover, the required rest period for collagen synthesis would be maintained which in turn could lead to clinical improvements. However, with no report on adherence and fewer questionnaire follow-ups in the eccentric group, the results should be taken cautiously. Another advantage of HSR is that the quadriceps femoris muscle and the patellar tendon are loaded eccentrically and concentrically, which is a more functional treatment approach than isolated eccentric training (Kjaer & Heinemeier, 2014; Malliaras et al., 2015). Isometric rehabilitation programme Patellar tendinopathy management in athletes, especially during the volleyball season, is difficult due to the high tendon load. Athletes are often reluctant to do painful eccentric exercises or to stop sport activities for a certain time. Isometric exercises put a high load on the muscle without provoking the tendon or increasing the pain (Babault et al., 2001; Cook & Purdam, 2014; Rio et al., 2015). A significant pain reduction was found immediately after isometric exercises (Numeric pain rating scale 7/10±2.04 to 0.17/10±0.41, p=0.004). Additionally, maximal voluntary isometric contraction improved by 18%

(Rio et al., 2017). A theory suggests that the muscle inhibition of the quadriceps femoris muscle at the motor cortex is higher in athletes with PT than in healthy subjects (Rio et al., 2016; Rio et al., 2014). A possible biochemical reaction in the tissue post isometrically could alter the functional balance of receptor-controlled channels and ion channels. These alterations could trigger the release of the short-interval intracortical inhibition (SICI), which is mediated by low-threshold GABAA receptors at cortical level. As a consequence, increased mobilisation of the motor neuron pool would lead to a reduction in descending motor inhibition of the quadriceps femoris muscle, which could result in an immediate pain reduction (Goodwill et al., 2012; Pitman & Semmler, 2012; Rio et al., 2015; van Ark et al., 2016). A four-week isometric training programme did not cause any change in tendon structure despite statistically significant improvement in pain intensity and VISA-P score (van Ark et al., 2016; van Ark et al., 2018). These results support the hypothesis that a reduction in pain perception does not automatically mean a simultaneous improvement in the structure of the patellar tendon. Isometric training may not be able to change the catabolic and anabolic balance, which would be necessary for increased collagen I synthesis (Magnusson & Kjaer, 2019; Magnusson et al., 2010; van Ark et al., 2018). On the contrary, Kubo et al. (2001) and Seynnes et al. (2009) identified morphological changes in pathological tendons after isometric training. This discrepancy might be due to difference in measurement tools (real-time ultrasound, MRI, ultrasound tissue characterization scan), difference in measuring points and difference in intervention duration (four weeks, nine weeks, twelve weeks). More importantly, tendons have a slow metabolism. Therefore, it is possible that structural changes will not occur until four weeks (Magnusson & Kjaer, 2019; van Ark et al., 2018). Interestingly, van Ark et al. (2018) questioned whether structural changes will actually occur. It is possible that the reduction in pain solely happens due to a possible release of the SICI. Both heavy slow resistance and isometric exercises induced immediate pain improvement. While this improvement lasted for at least 45 minutes after isometric exercises, HSR exercises did not result in sustained pain relief (Rio et al., 2015). In contrast to the short-term effect, no statistically significant differences were found between the two modalities after four weeks of training (Rio et al., 2017; van Ark et al., 2016). van Ark et al. (2016) suggested that isometric contraction may have a greater effect on acute pain, while HSR exercises may have a gradual reduction in pain. Compared to eccentric loading, the current literature supports the use of isometric exercises during the competitive volleyball season for athletes with PT to reduce pain before or after training/ games. Apart from the analgesic effect, isometric exercises might have a psychological impact. Athletes could have more confidence in the performance of exercises, which could improve adherence and thus could lead to a better compliance (Cook & Purdam, 2014; Rio et al., 2017). van Ark et al. (2018) emphasised that clinical improvements can occur independently of changes in tendon structure. As a result, PT rehabilitation should be CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLE based on clinical outcome changes, such as pain, function and strength, rather than imaging changes. More importantly, progress occurs regardless of the type of contraction (eccentric, eccentric-concentric, isometric). Therefore, it could be argued that the load intensity, the duration and frequency of the exercise programme is more important than the type of muscle contraction itself. An individualised and gradually increasing rehabilitation programme, ranging from isometric to high loaded eccentric exercises, could be more beneficial than a conservative programme approach involving only one type of muscle contraction. However, until the pain and injury mechanism of PT is fully understood, it is difficult to establish an adequate and effective rehabilitation protocol or preventive strategies. Moreover, the success of a rehabilitation programme depends on the athlete's exercise adherence. Athletes with PT reported that they performed 72% of the prescribed isometric exercises during the volleyball season (Rio et al., 2019). While athletes who underwent an eccentric programme completed 66% of the recommended exercises, the exercise adherence rate of the HSR was 75% (Bahr et al., 2006; Kongsgaard et al., 2009). Reasons for differences in exercise adherence could be the frequency of exercises (two times a day versus three times a week) or whether the exercise programme was supervised (some sessions supervised versus none). The exercise adherence and the aforementioned results of the different rehabilitation programmes highlight the importance of patient education in PT management. If athletes know what to expect and that treatment requires discipline and adherence to exercise, they may be more willing to fully implement the rehabilitation programme. The current literature shows that high exercise adherence allows a more satisfactory outcome and a higher probability of returning to pre-injury level (Kongsgaard et al., 2009). Consequently, the physiotherapist must be a coach, motivator and educator in one. Surprisingly, there is a lack of high-quality research on PT management in volleyball players. Consequently, the majority of the studies included were of moderate to good quality, published in good to high-quality peer-reviewed journals. The lack of a "real" control group and often no comparison to healthy athletes could lead to a reduction in the power and clinical significance of these studies. Furthermore, a relatively small sample size and often only male participants were included, which makes it difficult to generalise the results. Owing to the study design blinding was not possible. Although it was clearly communicated when and how the weight/load should be increased, participants were not supervised during the exercises. It should be considered that some athletes may have been anxious due to pain and therefore may not have followed the rehabilitation programme as instructed. These circumstances may have affected the clinical outcome. More importantly, duration of the rehabilitation protocol (four to twelve weeks), exercise selection within the same type of muscle contraction protocol, exercise intensity (low load versus high load), exercise frequency (three times a week up to twice a day, seven days a week) and duration of knee pain (less than four weeks to over 36 months) varied widely among the included studies, making comparison difficult despite similar results. Most of the

studies had no follow-up after six months or more. Therefore, the long-term effect of the rehabilitation protocols is unknown. In conclusion, each exercise protocol had certain benefits. Isometric contractions can trigger an immediate pain reduction which lasts at least 45 minutes. This immediate analgesic effect could be useful in treating athletes during the competitive volleyball season. Whereas eccentric exercises, which loads the tendon more intensively than isometric exercises, are more likely to have an adverse effect during the season. However, eccentric training could stimulate the synthesis of collagen type I, which could have a positive effect on the healing process in the preseason. Heavy slow resistance exercises are more functional than isometric or eccentric exercises alone. Moreover, HSR showed a positive effect on fibril density, which is reduced in tendinopathic tendons compared to healthy tendons. Nevertheless, all exercises resulted in a reduction of self-perceived pain and an improvement in function. It should be noted that there is a lack of highquality studies regarding PT management. Furthermore, the different study designs make comparison difficult despite similar results. Consequently and surprisingly, the question whether eccentric rehabilitation programmes are preferable to other exercise programmes in the treatment of volleyball players with PT cannot be answered with the current literature. Acknowledgement: Completed towards requirements of the PHTY542 Sports Physiotherapy paper, School of Physiotherapy, University of Otago. References available on request.

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FEATURE ARTICLES

Student Edition: Performing a neuromuscular injury prevention program may reduce common lower limb injuries in football players. Laura Thomson Laura currently works at Rototuna Physiotherapy.

Introduction Football is played by over 400 million people across the globe making it the most popular sport worldwide (Sadigursky et al., 2017). At all levels and ages, there is a high risk of injury due to the physical demands of the sport (Sadigursky et al., 2017). It is estimated that 60-90% of football injuries arise in the lower limb. The most common injuries occur in the thigh (hamstrings), knee (anterior cruciate ligament (ACL)), ankle and groin (Gebert, et al., 2018). The majority of these injuries are non-contact injuries resulting from muscular fatigue, muscular imbalances or ineffective warm-up prior to playing (Sadigursky et al., 2017). This highlights the need for cost effective preventative measures to be aimed at reducing non-contact injuries (Gebert et al., 2018). Promising neuromuscular training programs such as the FIFA 11+ injury prevention, have shown to reduce non-contact injuries in football players by 32-95% (Owoeye et al., 2014). These programs are growing in popularity worldwide. This essay will look at whether neuromuscular training programs reduce common lower limb injuries in football players. First, the efficacy of the Fifa 11+ program on overall lower limb injuries will be discussed. This will be followed by a look at the evidence for neuromuscular training in the prevention of specific lower limb injuries. Areas of the lower limb that will be discussed include the knee (ACL), hamstring, ankle and groin. Finally, the main findings of the reviewed research, its limitations and implications for future research and clinical practice will be discussed. FIFA 11+ and overall lower limb injuries The FIFA 11+ is the most popular neuromuscular program used worldwide (Sadigursky et al., 2017). It has been shown to reduce overall lower limb injuries in male and female football players, with adherence playing a large

role in outcomes (Owoeye et al., 2014; Silvers-Granelli et al., 2018; Steffen., 2012). Owoeye et al. (2014) found that players who performed the FIFA 11+ had a 48% reduction in lower limb injuries compared to regular warm-up (95% CI, 0.34-0.82, P=0.004). Adherence averaged 60-70% (1.6 sessions) over the season (six months). Ankle, thigh, overuse and non-contact injury rates were reduced most. This cluster randomised controlled trial (RCT) was strengthened by its large sample size including 20 premier division football teams (414 male players, aged 14-19). Contamination between groups was minimised with design as an RCT, however monitoring adherence meant researchers were not blinded. Furthermore, the participants of this study were all males, therefore the results may not be transferable to females. However, similar results were found in female football teams in a RCT by Steffen et al. (2012). This study found that players with high adherence (2.2 sessions per week) were 68% less likely to have a lower limb injury (IRR=0.32, 95% CI 0.11-0.95) during the season (four months). This study also had a large sample size, 226 female football players (aged 13-18 years). Another strength of this study was the recording of high, moderate and low adherence. In comparison, Owoeye et al. (2014) recorded average adherence. Higher adherence participants may have had better outcomes. The effects of adherence in male players has been further explored by Silvers-Granelli et al. (2018). In this RCT of 27 collegiate football teams, adherence was significantly negatively related to injury rates (p= 0.004). Players with high adherence (>2 sessions per week) were significantly less likely to become injured compared to the low adherence group who completed <1 session per week (p= <0.001). Adherence was recorded by team rather than individual players which is a limitation, as it assumes all players were present at each session. This study was conducted over a ten-month season. Season length differs CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLE between countries and this difference is notable in these studies. Whether exposure to longer seasons relates to injury rates is unknown. These three studies demonstrate that the FIFA 11+ is effective for both genders in reducing lower limb injuries. Further to this, they highlight that adherence to the program is associated with improved outcomes. Knee injuries ACL injuries and other severe knee injuries can be extremely costly and cause a significant loss of time from sports (Silvers-Granelli et al., 2017). Neuromuscular programs have demonstrated the potential to reduce ACL injuries in both male and female football players (SilversGranelli et al., 2017; Walden et al., 2012). A retrospective RCT (Silvers-Granelli et al., 2017) found implementing the FIFA 11+ significantly reduced knee injuries (p= <0.001), with a 77% reduction in ACL injury rates. An overall adherence of 2.19 sessions per week was recorded for this large sample size of 61 football teams (1525 males). Contamination may have been possible as the FIFA 11+ program is readily available to anyone worldwide. This study is applicable to male collegiate football players, which is a limitation, as females are twofold more likely to incur an ACL injury (Walden et al., 2012). There is currently limited literature investigating the use of the FIFA 11+ for the prevention of knee and ACL injuries in females. However, Walden et al. (2012) have shown a 64% reduction in ACL injuries in female football players with a similar 15-minute neuromuscular program. These results increased to 83% when adjusted to include only players with high adherence (>1 session per week). Likewise, there was only statistically significant reductions in severe knee injuries with high adherence (p= <0.001). This RCT consisted of a large sample size (4564 players aged 12-17) that was cluster randomised to avoid contamination. These studies are limited by lack of monitoring of what exercises the control group were performing. This may have influenced the results. Further to this, ACL injuries are a rare occurrence. Therefore, both studies are limited by the low incidence of ACL injuries during data collection. Furthermore, there was poor recording of adherence to either program. The ideal adherence rate to reduce injuries is therefore unknown. These studies demonstrate a reduction in ACL and knee injuries when football players perform a neuromuscular training program. Adherence may impact the extent to which injuries are reduced. Ankle, hamstring and groin injuries There are limited studies investigating whether the FIFA 11+ reduces the rates of ankle and hamstring injuries. Nouni et al. (2018) conducted a cohort study, including two men’s football teams (43 players per team). Teams exposed to the program incurred 50% less (injury rate (IR) 2.26 injuries/1000 training and playing hours) lateral ankle ligament (LAL) injuries compared to a control (IR of 3.14 injuries/1000). Likewise, the exposed team had a 56.4% reduction in hamstring injuries compared to the control. This study is limited by a small sample size. These findings are in line with a study mentioned earlier (Owoeye et al., 2014) which also suggested the FIFA 11+

significantly reduces ankle and hamstring injuries in football players. In both studies, the players participated in 1.5-1.6 sessions per week. These studies found that the FIFA 11+ can reduce ankle and hamstring injuries, but the effects of adherence is yet to be determined. Although there is limited research investigating whether the FIFA 11+ reduces hamstring injuries alone, the use of Nordic hamstring exercises (NHE) in the FIFA 11+ is supported in other literature (Petersen et al., 2011; Van der Horst et al., 2015). NHE have shown to significantly reduce hamstring injuries in a ten-week pre-season program, followed by weekly sessions during the season (12-months) (Petersen et al., 2011). The NHE group incurred 15 injuries, compared to a control group with 52 injuries (RR, 0.293, 95% CI, 0.150-0.572, P=0.001). There was also a reduction in the re-occurrence of hamstring injuries (p= 0.003). This study sample was large (942 players, 50 teams). Contamination was reduced by RCT design and there was 91% adherence in the intervention group, which is greater than in previous studies (Petersen et al., 2011). However, recording of adherence did not continue past the ten-week period. Reduced adherence to the program during the season may have influenced results. Furthermore, exposure time was not assessed and may be associated with injury risk. Similar results were found in another RCT (Van der Horst et al., 2015), showing significant reductions in hamstring injuries over a 13-week NHE program (odds ratio, 0.282; 95% CI, 0.110-0.721, P = .005). Sample size was large (40 football teams, 589 players), with high adherence of 91%. Injuries were not physically examined by a medical professional. Therefore, results may have been affected by underreporting of mild or minimal injuries. These two studies suggest that NHE are effective in reducing hamstring injuries and may therefore play an important role in the FIFA 11+ program. The addition of NHE to the FIFA 11+ may also reduce re-occurrence of hamstring injuries (Petersen et al., 2011). Both studies are strengthened by large sample sizes, high adherence, and randomisation to reduce contamination. However, they only include young male participants. Research into the effects of the FIFA 11+ and groin injuries is limited. Although the most common groin injuries are related to weakness in the hip adductors, there are no specific exercises in the FIFA 11+ to target this muscle group (Horay et al., 2017). A recent study suggests that the FIFA 11+ does not increase hip adductor strength unless there is an addition of the Copenhagen exercise (CE) (Horay et al., 2017). The CE significantly increased hip adductor strength in 22 male football players (p= 0.01) compared to no strength increases in the 23 players performing the standard FIFA 11+ (p=0.69). The author suggests that the FIFA 11+ may benefit from adding a simple adductor strengthening exercise such at the CE. This study was limited by a small sample size in young males and only looked at strength increases. Therefore, only implies that the CE may reduce groin injuries. However, a larger study was later conducted in 625 male football players which showed that CE may reduce groin injuries in male football players by 41% (P=0.008) (Horay CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLE et al., 2019). Adherence rate was 73%. The preventative effect may have been larger if adherence was higher. This study included players with previous groin injuries making it a more realistic representation of the football population. Diagnostic information was not recorded, and injuries were not specified. Therefore, some groin injuries may not have been adductor related. These studies show that the addition of CE may reduce groin injury rates in male football players and would be a good addition to the FIFA 11+ program. The results are limited to young males and may not be applicable to female players. Whether the CE or FIFA 11+ reduce groin injuries in female football players is unknown.

Discussion Although the literature suggests significant benefits for neuromuscular programs in injury prevention, there are limitations to these studies. The studies included in this essay were investigated in young football players. These studies may only be clinically applicable to younger players, as young athletes have not yet developed good movement patterns and strength. Therefore, these programs may have a greater benefit in a younger than an older population (Soligard et al., 2008). This is evident in a study looking at injury prevention effects of the FIFA 11+ on Veteran football players (average age of 45 years). This showed no significant reduction in injuries when the FIFA 11+ injury prevention program was implemented (Hammes et al., 2015).

Most of these studies were also limited to male players. Results may not be transferrable to female players. However, it is important to note that the FIFA 11+ was first studied in the female football population. Here it demonstrated significant reductions in injury by 32% (Soligard et al., 2008) and 68-72% (Steffen et al., 2013). Due to the positive results, the program was tested in male football players and therefore research after 2010 has been predominantly focused on the male population. Studies assessing the FIFA 11+ as an intervention were limited by different study lengths and poor control over exercises performed in the control groups. The football seasons in these studies ranged from four to ten months. It is unknown whether preventative effects of the FIFA 11+ may be impacted by playing exposure during the length of each season. Grade level, gender, changes in adherence throughout the season and delivery of the program may also affect the results. Further research should aim to investigate these variables. Another limitation was that exercises completed by the control groups were not monitored. Therefore, the control groups may have performed similar exercises to the FIFA 11+. The FIFA 11+ is readily available to anyone worldwide so it is impossible to avoid potential contamination. The research evaluated suggests that neuromuscular injury prevention programs may significantly reduce common lower limb injuries in young male and female football players. Adherence to neuromuscular programs appears to have a significant effect on the extent to which a program reduces injury risk. This was particularly evident in the FIFA 11+ program where higher adherence resulted in lower injury risk. Average adherence rates to

this program varied between 1.5- 2.2 sessions per week in these studies, with more sessions being performed in the high adherence groups (Nouni et al., 2018; Owoeye et al., 2014; Silvers-Granelli et al., 2017; Silvers-Granelli et al., 2018; Stefffen et al, 2012). The optimal adherence level to the FIFA 11+ program is still unknown and may differ between males and females. NE appeared to reduce both acute and re-occurring hamstring injuries and may be a welcomed addition to the FIFA 11+ (Petersen et al., 2011). The program is however lacking specific hip adductor strengthening exercises to help reduce groin injuries. The CE may be an appropriate addition to the FIFA 11+ (Horay et al., 2017; Horay et al., 2019). Neuromuscular programs have the potential to reduce knee and ACL injuries in both males and females, although this is an area that needs further research, particularly in the female population who are at higher risk of these injuries (Walden et al., 2012). For all areas, future research needs to focus on the female population.

Conclusion Overall, neuromuscular training programs have demonstrated an ability to reduce overall common lower limb injuries including hamstring injuries, ankle injuries, knee injuries and groin injuries. Football clubs should encourage the use of the FIFA 11+ and other neuromuscular injury prevention programs as a warm and training program for football players to help reduce the incidence of injuries. It is important that easy to administer, cost effective and time effective injury prevention strategies such as the FIFA 11+ are implemented into football trainings. This is particularly important regarding ACL injuries and other severe knee injuries as they can be extremely costly and cause a significant loss of time from sports. Adherence to injury prevention programs can influence the rate of injuries and is therefore an essential element. To assess the validity of these interventions in clinical practice future research should focus on the optimal levels of adherence for injury prevention in both male and female players. Acknowledgement: Completed towards requirements of the PHTY542 Sports Physiotherapy paper, School of Physiotherapy, University of Otago. References available on request.

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FEATURE ARTICLES

Student Edition: Preventing Hamstring Injuries in Football. Michael Petersen Michael is a University of Otago trained musculoskeletal physiotherapist undertaking his Sports Physiotherapy post graduate studies. Michael has worked in two private practices including Sports Med Invercargill and Back In Motion Dunedin.

Introduction Football is the world’s most popular sport with FIFA (footballs international governing body) in 2000 reporting 200million+ people actively participating (Dvorak et al., 2000). Twenty years on, given both the rise in population and female participation this number is only likely to have grown. Although football is the world’s most popular sport the risk of injury in football is high. Study’s investigating the incidence of injuries in football are numerous, with hamstring injuries (HSIs) being reported as the dominant cause of loss of play time. Ekstrand et al. (2011) showed the injury incidence in professional footballers to be 8.0 injuries/1000hr with HSIs being the most common at 12%. Therefore, a team of 25 can expect around seven HSIs per season, 48% of which take 7-28+days to recover. Loose et al. (2019), reported the injury incidence of semiprofessional footballers in Germany to be 9.7/1000hr with thigh strains accounting for 18.2% of all injuries. Given the high level of HSIs reported in the literature it becomes evident that as sport physiotherapists minimising HSI risk is of growing concern. Although the amount of research around reducing HSI is growing, no clear guidelines on how best to minimise HSI risk exist. This critical review seeks to evaluate the current evidence around different modalities including strengthening, manual therapy and passive therapies and their ability to reduce HSI risk. Hamstring Injuries in Football The hamstrings encompass three muscles; the biceps femoris long head (BFLH) / short head (BFSH), semitendinosus (ST) and semimembranosus (SM). Research investigating which hamstring is most commonly injured is lacking. However, a study found by Petersen et al. (2013) looked at HSIs in footballers using ultrasound. They found that 58% of HSIs occurred in the biceps femoris muscle (BFM) with 56% of these recorded as being in the muscle belly, while 29% of HSIs involved ST. Despite the small sample size (51 footballers) all scans were conducted in hospitals via radiographers with 10+

years of experience indicating a high standard of methodology. This result suggests a need for research looking at interventions targeting the BFM and ST. In terms of muscle activation there is growing evidence looking at hamstring activation during exercise. MendezVillanueva et al. (2016) and Fernandez-Gonzalo et al. (2016) both used MRI to assess muscle activation over four exercises (nordic drop, straight leg deadlift, two foot flywheel curl and cable hip extensions). Exercises were chosen to show hamstring activation in different angles of knee and hip range of motion (ROM). Both concluded that exercises involved in knee flexion (nordics and flywheel curls) focused more on ST and BFSH. Considering the research done by Petersen et al. (2013) these type of strengthening exercises along with interventions targeting the BFM and ST are what sport physiotherapists need to focus on. Strengthening to Reduce HSI Risk One of the main tools sport physiotherapists have is their advanced knowledge of strengthening and conditioning muscles to build strength and attempt to minimise injury risk. The most extensively researched intervention for minimising risk of HSIs in football is strengthening via nordics. From previously stated work this exercise targets the more at risk muscles, so theoretically it should be protective. Hasebe et al. (2020), Petersen et al, (2011) and Van Der Horst et al. (2015) each studied if performing nordic drops would reduce hamstring injury rate in footballers with slightly differing results. Petersen et al. (2011) presented that performing a protocol of nordic exercises pre and during the season provided a decreased risk of HSI during the season (odds ratio (OR) =0.293; 95% confidence interval (CI) (0.150-0.572) p< .001). This result was supported by Van Der Horst et al. (2015) who also showed that nordics produce a protective result against HSIs (OR=0.282; 95%CI (0.1100.721) p=.005). In contrast Hasebe et al. (2020) failed to find a statistically significant result. They also only indicated the relative risk (RR) of HSIs as only being 1.14 CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLES lower than the control groups (95%CI 0.26–4.97 p=0.83). These studies demonstrated high compliance rates (ranging from 88-91%), good methodology, large sample sizes and diverse populations ranging from 259 school kids to 942 professional footballers. The general consensus of the literature therefore suggests nordics as being protective against HSIs in footballers. A debate could be had as to the low protective factor presented by Hasebe et al. (2020). When interpreting this result it is important to note that the total number of HSIs in this study were much lower than expected from previous studies which may be due to the different demographic or load of the school children. Research around other forms of strengthening to reduce HSI risk is less comprehensive with only singular studies found. Van de Hoef et al. (2019) investigated whether adding a plyometric bounding program to training could decrease HSI risk in footballers. Over the course of a football season the bounding program showed no statistically significant protective benefit from HSIs (OR=0.89, 95%CI (0.46‐1.75) p=0.48). These results however could be due to low compliance of completing the program (71%) or possible poor quality of exercise completion. Studies by Freeman et al. (2019) and Macdonald et al. (2019) looked at hamstring strength gain differences between different strengthening protocols but failed to follow athletes to report on the number of HSIs obtained during a season. Freeman et al. (2019) compared nordics to sprint training as both have periods of maximal eccentric activation of the hamstrings. After 8 weeks both protocols had increased eccentric strength, however nordics provided a greater increase +9.8% (p=0.01) compared to sprint training +6.2%(p=0.01). Macdonald et al. (2019) found that a romanian single leg bridge (RSLB) protocol increased hamstring endurance greater than players undergoing nordic exercises in those with a previous HSI. After 6 weeks of strengthening the number of single leg bridges completed increased for the RSLB group by 23.7% (90%CI 9.6-39.6) compared to the nordic group which increased by 0.3%(90%CI 6.6-25.6). This study had a small population size however and although the findings are important it can be argued that the RSLB does not involve the optimal muscle activation targeting BFM and ST. Currently there is limitation of extensive research for different strengthening programs in a cohort methodology. This means a protocol of nordic exercises is the best method of strengthening to minimise risk of HSI as this has been shown to be protective through a football season. With this knowledge, sport physiotherapists working with footballers should implement a nordic exercise program due to its protective benefits in preventing HSIs. Other strengthening which has not been as extensively researched could still be added for variety. Examples include sprinting for football functional eccentric strength or the RSLB (which has been suggested to increase hamstring endurance after injury).

including massage, dry needling, cupping among other muscle/joint loosening techniques attempting to reduce tightness and risk of injury. Research looking at the effect manual therapy has on injury risk is minimal. No studies looking at manual therapy reducing HSIs during football were found and studies available focused on manual therapy techniques to increase hamstring extensibility to reduce HSI risk. Barlow et al. (2004) and Hopper et al. (2005) investigated the effect of two different massage techniques and their effect on hamstring ROM. Barlow et al. (2004) presented that generic massage made no statistically significant increase in hamstring ROM during sit and reach (p=0.663) with 11 healthy males. Contrastingly the Hopper et al. (2005) study of 50 female hockey players showed dynamic soft tissue massage does acutely increase ROM during passive knee extension (group x response (F)=7.66, p=0.01). This result however was not sustained over a 24hr period. Studies on less traditional manual therapies are lacking. Williams et al. (2019) investigated if cupping could increase hamstring length in footballers. Using a sample of 25 footballers no statistically significant increase in acute hamstring ROM during SLR from cupping when compared to a control group was found (t =−.961, p=.35). Geist et al. (2017) investigated if dry needling would increase knee ROM by improving hamstring extensibility in asymptomatic people. It was noted that no guidelines were known for dry needling so a smaller pilot study comparing two dry needling techniques was carried out first which is a limitation in this study. The study also does not specify which hamstrings were dry needled. An increase in ROM was gained for both groups but was statistically insignificant when compared between groups (p=.55) indicating the increase may be due to motor learning. Results from these papers should be acknowledged with care. All four studies had small population sizes and Geist et al. (2017) had noticably flawed methodology. Small population sizes can inhibit ability to prove trends as outliers can have a larger effect on the end result. More importantly each study failed to report that there is no existing evidence supporting whether an increase in hamstring extensibility in athletes with “normal” hamstring length can reduce the risk of HSIs in football. This makes any applicable results theoretical. Despite the popularity of manual therapy techniques there is currently no compelling evidence in the literature for its ability to reduce the risk of HSIs. Further studies examining the effect of manual therapies over a football season is needed to show their effect on the risk of HSIs. Subsequently for physiotherapists the use of manual therapies to help prevent HSIs currently relies on the potential for acute increase in ROM that theoretically may decrease HSI risk. Evidently the use of manual therapy in an injury preventative setting at this time should only be used for athlete preference, or from previous clinical results.

Manual Therapy to Reduce HSI Risk

Passive Therapies to Reduce HSI Risk

An attribute separating physiotherapy apart from other health professionals is knowledge of manual therapy. Sport physiotherapists use a range of manual skills

Passive interventions are among the ever growing tools available to sport physiotherapists when trying to minimise the risk of injury. Passive therapies range from old CONTINUED ON NEXT PAGE >>

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FEATURE ARTICLES techniques such as stretching to newer techniques such as laser therapy. Research in this area is beginning to expand with newer and more technologically advanced methods being investigated and developed. One of the most common passive therapies used to try and prevent HSIs is stretching. The literature surrounding stretching is conflicting. Arnason et al. (2007) produced the only paper to date that looked at if static hamstring stretching over a football season would decrease the expected incidence of HSIs. Between teams who followed the stretching protocol and control teams there was no statistically significant decrease in HSI risk found (RR:1.53, 95%CI (0.76–3.08) p=0.22). In contrast Ruan et al. (2018) found that completing a static stretching program caused a right shift in the length-torque curve (effect size (d)=1.22, p=0.05). This is thought to reduce HSI risk by reducing eccentric contraction muscle damage via reducing sarcomere strain. Both studies have their imitations. The Ruan et al. (2018) application of results is theoretical as they did not follow a cohort of athletes to see if this would reduce risk of HSIs. Arnason et al. (2007) does not state that they specifically advised the control team not to stretch and with stretching being such a normal warm up activity it is unclear if the control group over the season didn’t perform some intervention which would skew the results of the study. More advanced passive treatments have been investigated with limited applicable results. Pérez-Bellmunt et al. (2019) identified that incorporating electrical stimulation to proprioceptive neuromuscular facilitation (PNF) stretching provided greater hamstring extensibility than PNF stretching alone (p<0.05). Platelet-rich plasma (PRP) injections are a more recent passive therapy attempting to reduce re-injuries by injecting a concentrated serum of the patients own platelets into the injured site to provide more effective healing. Hamilton et al. (2015) used two groups of athletes with hamstring injuries making both complete a strengthening program. One group also received a PRP injection. Both groups reported similar rates of re-injury with no statistically significant protective results from the PRP injection being shown at two months (OR=0.821 95%CI (0.107-6.293) p=0.850) and 6 months (OR=1.44 95%CI (0.221-9.388) p=0.703). Another experimental passive intervention to reduce HSI risk is photobiomodulation therapy (PMT) which uses low level lasers to theoretically induce improved healing. Dornelles et al. (2019) put forward that using PMT before football could reduce hamstring fatigue which in turn would reduce HSI risk. Results showed that eccentric hamstring strength after football reduced by 8.72% (p=0.001) in the control group and only 4.85% (p=.005) in the PMT group. Although these studies put forward significant results these should be interpreted with caution. Pérez-Bellmunt et al. (2019) and Dornelles et al. (2019) both failed to follow athletes to see if the increase in hamstring extensibility or decrease in fatigue reduces incidence of HSIs during a football season. There are also no studies relating increased fatigue to increased HSI risk with the causation only have been shown indirectly and theoretically. These studies fail to show a direct protective correlation between passive treatments and reducing HSI risk, however studies were either limited as singular studies or unsupported by previous knowledge such as if hamstring tightness is a factor in HSIs. As sport

physiotherapists it is important to look at these limited results and reason that passive treatments at this stage show no protective benefit. However as there is no evidence of negative impact it would be unwise to prevent athletes from performing these as they personally may find it beneficial potentially from a pure psychological or performance angle. Conclusion The role of the sport physiotherapist is forever growing with a key role being to try minimising injury in sport. Over the years the incidence of HSIs has remained high, putting pressure on sport physiotherapists to formulate a protocol that is protective. The literature surrounding the minimization of HSI risk is in general is lacking and methodically flawed. Manual and passive therapies have shown little to no effect in protecting against HSIs however most of these had small population sizes, failed to have previous evidenced based knowledge and did not follow athletes over a season. These modalities relied more on theoretical evidence which as a sport physiotherapist could be unwise to depend on. Currently the only protective modality with quality evidence is strengthening, in particular nordics. Regardless of this protective measure the incidence of HSIs has yet to decline which may be due to poor compliance, poor technique or other intrinsic / extrinsic factors such as increased load which have not been extensively studied. Future research on manual and passive therapies need to take a cohort study approach following athletes through a season. Studies on HSI risk factors especially on hamstring extensibility / fatigue is also needed for us to be able to draw conclusions on if manual and passive therapies should work. To summarise sport physiotherapists working with a team need to be adamant that a protocol of strengthening is completed pre-season to ensure they are actively trying to reduce the risk of HSIs. The use of other modalities can still be used in conjunction for player preference and belief but should not be sold as a quick fix. Acknowledgement: Completed towards requirements of the PHTY542 Sports Physiotherapy paper, School of Physiotherapy, University of Otago. References available on request.

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SPECIAL PIECE

SEPNZ Student Night SEPNZ education committee ran a student night for our student members on 22nd September. Below is a review of the night by two of our student reps, Olivia WhelanHenderson and Emma McDougall who also introduce themselves below.

The SEPNZ Student Night was an awesome opportunity for physiotherapy students across the country who are interested in the field of Sports and Exercise Physiotherapy to listen to various speakers. There was a fantastic line-up of speakers who shared their experiences and stories to help broaden the understanding of what a career in Sport and Exercise physiotherapy may look like and ways in which they got to where they are. At Otago University the students had the opportunity to come in, in person to the School of Physiotherapy where a zoom link was live streamed and the guest speakers from Otago were live. We also had the opportunity to connect online via zoom. At AUT the students had the opportunity to join over a zoom call from home to listen to the different speakers. It was interesting listening to how each speaker had a different journey to get to where they are today, and how there is no one set path. A major message that we took away from listening to the speakers was to take up every opportunity and to make the most of it. One of the highlights of the evening for both of us was Pete Gallagher the All-Blacks Physio presentation which I found inspiring. Overall, we found it a great opportunity to ask questions to a range of different speakers who have been involved in sports physiotherapy. It gave great insight into the profession which is important for students who will be entering the workforce in the next few years.

My name is Olivia WhelanHenderson and I have just completed, my third year of physiotherapy at Otago University in Dunedin, next year I am moving to Christchurch for placement to complete my final year of my degree. I’m interested in a career in Sports Physiotherapy.

My name is Emma McDougall and I have just completed my first year of studying Physiotherapy up at AUT. I am originally from Rotorua and am looking forward to working with and learning more about the sport and exercise area of physio.

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SPECIAL PIECE

SEPNZ Research Award SEPNZ provide a research award each year which can be applied for throughout the year. We would like to congratulate David Lalor on his final year AUT Physiotherapy research project which won the award for 2020. Below is a summary is a summary of his 4th year research project as required by the SEPNZ Research Award. Title: Assessment of median nerve displacement and strain during upper limb neural mobilisation exercises using B-Mode ultrasound imaging, invivo Authors: David Lalor (AUT), Richard Ellis (AUT), Peter McNair (AUT), Antoine Nordez (University of Nantes, Fr.) Summary: Current literature supports neural mobilisation exercises as conservative management for peripheral nerve pathology, but the biomechanical efficacy of these of these techniques has yet to be explored in full. A greater understanding of how to maximise their benefit within a healthy population would likely inform how best to conservatively manage peripheral nerve pathology. The primary aim of this study was to investigate the in-vivo effects of different upper limb neural mobilisation exercises on median nerve excursion and strain. Other objectives included analysis of the effect of shoulder position on these variables, and the overall reliability of ultrasound imaging to measure longitudinal median nerve excursion in healthy participants. B-mode ultrasound imaging was used to assess median nerve excursion between the mid forearm and distal upper arm as healthy participants executed a series of movements which were designed to emulate traditional neural mobilisation exercises. Cervical and wrist movements at two shoulder positions (45 + 90 degrees abduction) allowed participants to perform a 1-ended slider, a 2-ended slider, and a tensioner neural mobilisation. There were statistically significant differences found in median nerve excursion between neural mobilisations, with 2-ended sliders producing greater excursion than 1-ended sliders, and tensioners producing the least excursion. The only exception to this was at 90 degrees shoulder abduction, where 1-ended and 2-ended sliders showed no statistically significant difference in median nerve excursion at the forearm location. Interestingly, there was no statistically significant difference in median nerve excursion when neural mobilisations were compared between shoulder

positions. There was also no statistically significant difference in strain when comparing any of the neural mobilisations, or between shoulder positions. However, it was interesting to note a trend towards sliding mobilisations producing the greatest median nerve excursion with minimal strain, while tensioning mobilisations tended to yield decreased median nerve excursion and increased strain. The reliability of using ultrasound imaging to measure median nerve excursion and strain was found to be moderate to excellent (ICC = 0.57-0.96). These findings add to the literature base advocating the efficacy of sliding mobilisations, which generally promote increased median nerve excursion with minimal increase in strain. The future integration of shear wave elastography will allow an investigation into median nerve stiffness during neural mobilisation, and its relationship with corresponding median nerve excursion and strain. This, alongside the additional clinical context provided by the current paper, may inform improved management of peripheral nerve pathology. For more information on this work, please contact David Lalor (daveylalor@outlook.com) or Richard Ellis (richard.ellis@aut.ac.nz). For more information on how to apply for the Research Award please see the SEPNZ website.

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APP REVIEW

Back to the Gram ... The Australian Edition by Emma Lattey The team here at SEPNZ have decided to branch out with our reviews to include social media Sports Physiotherapy influencers that are worthwhile following. To finish of the year here is my pick of two of the best Aussies from Insta :–

mickhughes.physio

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Most of you would have heard of Mick Hughes who works as a titled Sports Physiotherapist at The Melbourne Sports Medicine Centre and is responsible for one half of the team that produced the Melbourne ACL Rehabilitation Guide. Mick started his career as an Exercise Physiologist and so his feed and his methods are full of great exercise prescription advice and demonstrations. He is a big fan of keeping rehab simple and effective with progressive overload and promotes loading principles to encourage physios to prescribe well thought out rehabilitation for the athletes we treat – but predominantly his posts are related to ACL injuries. Personally, I direct many of my ACL patients to Mick’s Instagram page as there is a lot of excellent ACL content and information for all levels of understanding. Mick posts very regularly and has latest research blurbs with access to the articles if you sign up for free to his journal club @learn.physio.

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APP REVIEW

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physioresearch

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The Physio Research page is a daily-ish dose of the latest musculoskeletal physiotherapy-related research blurbs which provide eye-catching and informative information to your Instagram feed. The posts are a great mix of subject matter with many sports related.

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Physio research is linked to physio-network.com which is backed by some of the big hitters in Australian physiotherapy research like Peter O’Sullivan and Peter Malliaras. Physio Network have their own Instagram page with more followers, but I prefer the layout and information provided here.

MEMBER BENEFITS

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There are many benefits to be obtained from being an SEPNZ member. For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/

In each bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.

The ASICS Professional Buyers Programme is designed to enable Sport & Exercise Physiotherapy New Zealand members the opportunity to experience our shoes first hand and to assist in referring the most suitable shoe/s to your patients. By registering for the Professional Buyers Programme, you will: ASICS Performance Footwear/ASICS Sportstyle Footwear Receive 4 voucher codes per year, 2 every six months. Each voucher will give you 40% off the retail price of one pair of shoes up to $300 Recommended Retail Price. Vouchers must be redeemed online at www.asics.co.nz Additional Product Offers: Birkenstock Footwear Receive 2 voucher codes per year, 1 every six months. Each voucher will give you 30% off the retail price of one pair of shoes up to $200 Recommended Retail Price. Vouchers must be redeemed online at www.birkenstock.co.nz Smartwool Socks Receive 2 voucher codes per year, 1 every six months. Each voucher will give you 30% off the retail price for your choice of socks (Recommended Retail Price). Vouchers must be redeemed online at www.smartwool.co.nz

Register Here Full terms and conditions can be found on the Professional Buyers Programme registration page. If you are already a member of the Professional Buyers Programme you will receive your vouchers in July and February. For first time registered member, we run a report at the end of each month which picks up the newly registered members. You should then receive your vouchers by the middle of the following month. REGISTER HERE

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Asics

Charcot Foot GT-4000 2

Thanks to Asics for this latest footwear review from Anthony Ng.

of a gross foot deformity, resulting in vast valgus malalignment, notably arch collapse with a rocker bottom appearance. This often results in increased stiffening of the foot, along with associated ligament changes altering the natural forces of gait which will lead to further lower limb complications. The best strategy is to avoid this condition from occurring and diagnose early for prophylaxis. If Charcot’s foot has already occurred and settled, the deformity of the foot structures will need to be continually supported. If you have any suspicion of a patient whom you deem will develop this condition, the treatment is more therapeutic to stop, prevent or preserve the foot from deteriorating. Surgical intervention is recommended for the most serve foot disfigurements where all other non-surgical options are exhausted. As the deformity mainly occurs at the Lisfranc joints, STJ and MTJ there will be the tendency for the foot to move medially. ASICS has engineered the new GT-4000 version 2, which provides the stiffening strength required at the rear and midportion of the shoe to help support those foot structures during the forces of plantar loading.

Charcot foot is a significant foot complication of Diabetes which involves a direct inflammatory response affecting bones, soft tissues and joints of the foot and ankle. The pathophysiology is unknown however, Charcot’s tends to develop from trauma, increased weight bearing along with neuropathy. If healthcare professionals are unable to identify the condition at the acute phase to prevent the foot changes, it will result in significant deformation primarily occurring at the Lisfranc joints, STJ or mid tarsal region of the foot. The damage to the foot skeletal shape can be

The GT-4000 uppers and correct midsole shore densities helps correct alignment and influences the pressure distribution to prevent subsequent disorganization of the foot from further deformity and provide those at risk with supportive footwear before this condition can eventuate. The strong midfoot truss offers reduced torsional twisting to increase stabilization and strength occurring around the mid tarsal region. This will provide the desirable control and help support those associated with a rocker bottom deformity. This condition is associated with a lack of absorbency. Shock attenuation is required to provide comfort for those interlocking joints and bones throughout the gait cycle. The chosen foam offers durability and effective energy return providing comfort. CONTINUED ON NEXT PAGE >>

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Asics

The ideal pitch profile will not create additional trans ferred forces as the unstable foot moves through gait. The 2E width fit adds extra depth and girth to accom modate structural changes that may have occurred or provide the space for any accommodative custom fabricated devices.

Finding the correct footwear can be difficult, the GT-4000 provides some of the ideal requirements for this condition. GT-4000: Solid rigid constructed rear, with a durable dual-density midsole offers the desirable support thought out the medial and lateral longitudinal arch which extends through to the propulsive phase. Other conditions that this shoe may be benefit include:

Amputation to hallux: is associated with the structures of the midfoot to move medially. Altered pressure distribution occurs during the initial phase of propulsion causing the foot to move in a valgus direction, ultimately affect the timing of the gait cycle. The GT-4000 encompasses a strong extended midfoot component which improves sagittal alignment.

Flexible flatfoot with hallux Valgus: Notable weakening of foot muscles, causes ineffective transfer of energy which alters the timing of the foot during dynamic gait; this often makes normal push-off impossible. Ineffective sagittal plane motion causes increase foot deformity resulting in Hallux Valgus (HAV). Support required from distal midfoot to proximal forefoot.

Posterior Tibial Dysfunction: Normally related to adults with an acquired flat foot deformity. resulting in tendon degeneration/ elongation changes. The presentation of a valgus deformity will require a supportive constructive shoe to improve foot alignment in providing a more positive ergonomic ride. Pronation: Able to effectively control kinematics of pronation and reducing tibial rotation. Capable of replacing the need for orthotic therapy. STJ Ligament Injury : Usually associated with a major traumatic sprain. Irritation occurs over the anterior ankle, with loss of strength in dorsiflexion. Supportive footwear to regain ankle hold and control. Anthony Ng B.Sc (Pod), B.Ed, Dip Tch

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CLINICAL REVIEW

Complications After Anterior Cruciate Ligament Reconstruction and Their Relation to the Type of Graft A Prospective Study of 958 Cases Romain Rousseau, MD, Charlotte Labruyere, MD, Charles Kajetanek, MD, Olivia Deschamps, MD, Konstantinos G. Makridis, MD, MSc, PhD, and Patrick Djian, MD

The American Journal of Sports Medicine 2019;47(11):2543-2549 DOI:10.1177/0363546519867913

By Pip Sail Complications and adverse effects after Anterior Cruciate Ligament (ACL) reconstruction are well known. The purpose of this cohort study is to analyse them in relation to the type of graft. After an isolated rupture of the ACL similar functional outcomes are obtained with the use of hamstring tendon, patella tendon, quadriceps and iliotibial band (ITB) grafts.1,36,38 90% of patients have normal knee function restored, 80% return to sports and 55% return to competitive sports. Despite this, there are several associated complications including surgical revision, that have the potential to create major effects on functional status and patient quality of life. This prospective study included 958 patients over a 2 year period with isolated rupture of the ACL with or without associated meniscal lesions. The type of graft chosen by the surgeon was based on the age of the patient and the type of sport they played. Partial weight bearing was allowed for the first 6 weeks progressing to full weight bearing as tolerated. Bicycling and jogging started 3 months after surgery in combination with muscle strength exercises. Pivot non-contact sports were allowed at 6 months and contact sport at 8-9 months. The patients were reviewed at 6 weeks and 3,6,12 and 24 months by an independent surgeon. Adverse events and complications included anterior knee pain, joint stiffness, secondary meniscal lesions, pain attributed to hardware, ACL re-rupture, bone complications, thromboembolic complications, haematomas and infection. The total rate of complications and adverse events was 39%. The total surgical revision was 28%. The surgical revision rate was significantly higher in the STG group than in the PT group.

DISCUSSION Complications after ACL have been recorded in several studies.1,9,11,12,14,23,25,30 Anterior knee pain is the most frequent complication effecting up to 50% of patients most likely due to the harvesting of PT grafts although also present in some STG patients. Mohtadi et al30 studied 330 patients and found no significant difference between PT and STG graft groups likely due to type of fixation used. Other authors demonstrated that anterior knee pain resolved within 2 years post ACL reconstruction.8.14,15,17,39 The decease in pain over time must be thoroughly explained to patients to reduce concern. Arthrofibrosis is also a common complication post ACL reconstruction, causing significant functional deficit11,27,32 and an increased rate of surgical revision. However the prognosis after surgical debridement was good at the 2 year follow-up. There was no difference between the PF and STG groups CONTINUED ON NEXT PAGE >>

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CLINICAL REVIEW in the extension deficit however there were more cases of Cyclops nodule in the STG group. Secondary meniscal lesions usually occur as a result of new trauma. In this study the majority happened early after the ACL reconstruction and seemed to occur in patients who already had an antecedent meniscal lesion and were independent of the graft type and likely to be due to the lack of scar formation in the pre-existing lesion and the subtle instability putting more stress on the lesion. Patients are exposed to the risk of re-rupture on return to sports activities. Participation in pivot and pivot/contact sports particularly at a high level , is one of the most important predictive factors of new ACL rupture3,26,35 and more recently it has been shown that meniscal deficiency is another predictor of graft failure in single bundle anatomic ACL reconstruction33 Time to return to sport and compliance with the specific rehabilitation protocol may also contribute to the graft re-rupture. In this study the STG group had more re-rupture cases although their activity was less competitive than the PT group. Patella fracture occurs in patients with the PT graft in less than 0.5%. This complication may effect rehabilitation and functional outcomes causing chronic anterior knee pain and stiffness.28 CONCLUSION The total rate of complications after ACL reconstruction was 39% and surgical revision was 28% within a 2 year period. Problems with hardware material were more common in the STG group, leading to an increased rate of surgical revision. Anterior knee pain was initially higher in the PT group but not significantly different after 2 years. The re-rupture rate was statistically higher in the STG group. Rupture of the contralateral ACL was higher in the PT group possibly due to the return to a higher level of sport. The rate of adverse events is high and prolonged rehabilitation and follow-up is justified to diagnose and treat these events early. A full set of references is available on request

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UPCOMING SEPNZ COURSES Please note these are the proposed courses for 2021. With the current COVID-19 situation this could also change. Once we are confirmed to go ahead registrations will be open via PNZ.

Sideline Management 20 & 21 March 2021 Auckland This course is for registered physiotherapists who work with individual athletes, or on the sideline at sports games or events who want to upskill in the areas of pregame preparation, first aid, acute injury assessment and management, and post event recovery strategies. By the end of the course you will have all the tools you need to manage pre-event preparation, postevent recovery and to confidently assess, manage and refer common sporting injuries and wounds.

The Sporting Upper Limb 27 & 28 February 2021 Auckland

This course will provide you with advanced skills in the assessment and rehabilitation of sporting injuries involving the upper limb. It covers pathomechanics, diagnostic imaging, initial management, rehabilitation progressions and key considerations for return to training and sport. Topics covered will include subacromial pain (e.g. swimmers shoulder); internal rotation deﬁcits and micro-instability (e.g. throwing/ racquet sports); dislocations/labral tears/fractures (e.g. contact sports) multi-directional instability; common extensor tendinopathy in sport and common wrist injuries in sport.

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RESEARCH PUBLICATIONS

British Journal of Sports Medicine December 2020; Vol. 54, Issue 24 ORIGINAL RESEARCH

GUIDELINES

Estimating the global economic benefits of physically active populations over 30 years 2020–2050)

World Health Organization 2020 guidelines on physical activity and sedentary behaviour

Marco Hafner, Erez Yerushalmi, Martin Stepanek, William Phillips, Jack Pollard, Advait Deshpande, Michael Whitm ore, Francois Millard, Shaun Subel, Christian van Stolk

Fiona C Bull, Salih S AlAnsari, Stuart Biddle, Katja Borodulin, Matthew P Buman, Greet Cardon, Catherine Carty, JeanPhilippe Chaput, Sebastien Chastin, Roger Chou, Paddy C Dempsey, Loretta DiPietro, Ulf Ekelund, Joseph Firth, C hristine M Friedenreich, Leandro Garcia, Muthoni Gichu, Russell J ago, Peter T Katzmarzyk, Estelle Lambert, Michael Leitzmann, Karen Milton, Francisco B Ortega, Chathuranga Ranasinghe, Emmanuel Stamatak is, Anne Tiedemann, Richard P Troiano, Hidde P van der Ploeg, Vicky Wari, Juana F Willumsen

Levels of domain-specific physical activity at work, in the household, for travel and for leisure among 327 789 adults from 104 countries Tessa Strain, Katrien Wijndaele, Leandro Garcia, Melanie Cowan, Regina Guthol, Soren Brage, Fiona C Bull Joint associations of accelero-meter measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middleaged and older individuals Ulf Ekelund, Jakob Tarp, Morten W Fagerland, Jostein Steene Johannessen, Bjørge H Hansen, Barbara J Jefferis, Peter H Whincup, Keith M Diaz, Steven Hooker, Virginia J Howard, Ariel Chernofsky, Martin G Larson, Nicole Spartano, Ramachandran S Vasan, IngMari Dohrn, Maria Hagströmer, Charlotte Edwardson, Tho mas Yates, Eric J Shiroma, Paddy Dempsey, Katrien Wijndaele, Sigmund A Anderssen, I-Min Lee EDITORIALS Putting physical activity in the ‘must-do’ list of the global agenda Emmanuel Stamatakis, Fiona C Bull

Making the case for ‘physical activity security’: the 2020 WHO guidelines on physical activity and sedentary behaviour from a Global South perspective Estelle

Victoria

Lambert,

Tracy

Kolbe-

Alexander, Deepti Adlakha, Adewale Oyeyemi, Nana

REVIEWS

Maximising the impact of global and national physical activity guidelines: the critical role of communication strategies Karen Milton, Adrian E Bauman, Guy Faulkner, Gerard Hastings, William Belle w, Chloë Williamson, Paul Kelly How can global physical activity surveillance adapt to evolving physical activity guidelines? Needs, challenges and future directions Richard P Troiano, Emmanuel Stamatakis, Fiona C Bull How does occupational physical activity influence health? An umbrella review of 23 health outcomes across 158 observational studies Bart Cillekens, Matthias Lang, Willem van Mechelen, Evert Verhagen, Maaike A Huysmans, Andreas Holtermann, Allard J van der Beek, Pieter Coenen

Kwame Anokye, Shifalika Goenka, Patricia Mogrovejo, De borah Salvo New global physical activity guidelines for a more active and healthier world: the WHO Regional Offices perspective Riitta-Maija Hämäläinen, João Breda, Fabio da Silva Gomes, Gyanendra Gongal, Wasiq Khan, Romeu Mendes , Leo Nederveen, Nivo Ramanandraibe, Binta Sako, Steph en Whiting

http://bjsm.bmj.com/content/54/24 All articles are accessible via our website https://sportsphysiotherapy.org.nz/members/bjsm/

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SEPNZ Bulletin December 2020

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