SPNZ Bulletin December 2015

SPNZ BULLETIN PAGE

Issue 6 December 2015

Review BJSM Learning Modules

Feature Mike Lovell - Tries to Triathlons

Case Study Triathlete Trouble FEATURE TOPIC: Triathlon

SPNZ Bulletin December 2015 Issue

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SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President

Hamish Ashton

Secretary

Michael Borich

Treasurer

Timofei Dovbysh

Website

Blair Jarratt

Sponsorship

Bharat Sukha Kara Thomas

Social Media

Timofei Dovbysh

Committee

Monique Baigent Justin Lopes

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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 2016 and 31 August 2016.

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

An application form can be downloaded on the SPNZ website

CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz SPNZ Bulletin December 2015 Issue

sportsphysiotherapy.org.nz.

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Contents FEATURE TOPIC: Triathlon

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

2

EDITORIAL

By SPNZ President Hamish Ashton

4

MEMBERS’ BENEFITS Join SPNZ and Receive the Following Benefits

5

FEATURE Mike Lovell—Tries to Triathlons

6

In this issue:

PLANET OF THE APPS BJSM Learning Modules

9

CASE STUDY Triathlete Trouble

11

SMA CONFERENCE GRANT Learnings from the 2015 ASICS Sports Medicine Australia Conference

14

SPRINZ Faster and Fitter for Summer!

17

ASICS ASICS Report: CSI episode 21 - What is the Truth about Widths?

18

CLINICAL SECTION- ARTICLE REVIEW Concentric Exercises for the Treatment of Tendinopathy

19

RESEARCH PUBLICATIONS JOSPT Volume 45, Number 12, December 2015

21

BJSM Volume 49, Number 24, December 2015

22

CLASSIFIEDS Job Vacancy

SPNZ Bulletin December 2015 Issue

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Editorial Hamish Ashton, SPNZ President

Season’s Greetings to you all!

As the year come to a close, it is an appropriate time to look back over the last year and recognise those who have contributed to the success of SPNZ in who we are and what we do. The first name that comes to mind when doing this is Michael, our secretary. Michael does an amazing job for us and without him we would probably flounder rather than continuing to push forward in growing and developing our SIG. This was even more obvious this year when he was overseas for a period of time and not always available.

This created some slow patches for us during the year but with him back in town we are ready for 2016.

I would also like to thank the rest of the exec for their hard work. We have had a few fresh faces on board this year, and it is nice to see they have come on board to work and help us develop our group. Being on an exec is often a thankless task with us balancing family work and other duties. However, without this dedication we wouldn’t be here, so thanks to you all.

A big thanks also goes out to Aveny and our bulletin team. If you are like me and belong, or have belonged, to a number of other groups, you can appreciate the work the team puts in to getting the bulletin out every two months. It is quite a production and I am sure you will all agree it is an excellent newsletter. As well as the team that produce this I must also say a big thanks to those members that have provided the stories either through case presentations or feature articles. Regularly, in our feedback from the members, case studies are asked for, so I hope you appreciate the time the authors put into these for you.

Following on from that probably comes some of our new benefits that are still quite under-utilised. Last year we set up a LinkedIn Group for our members.

This area is closed, meaning only our members can access it. On it go the case studies and other information for your benefit. This is also an area that we can communicate and discuss ideas. As yet we don’t have an official mentoring process for sports physiotherapists but this is a way to ask questions and discuss ideas with the group.

One of the other things that we offer is our “Find a Physio” page. This is for you to advertise your interests and expertise to the greater world (well NZ public anyway). Often, if you are an employee you don’t get the chance for your name to be on top of the list – here your name is listed rather than the clinics. We are currently pushing the profile of our website to enable these type of things to feature more prominently SPNZ Bulletin December 2015 Issue

on searches so the more names we have listed the better this service can be utilised. If your name isn’t listed and you wish for it to be added email me for the link (help@spnz.org.nz ).

On our Benefits page later in this issue is a list of some of the key benefits of your membership. So have a look and remind yourself of what we have to offer as you tick that SPNZ box on your membership renewal form when it comes out from PNZ. There are some exciting things to look forward to in 2016. We, as an exec, will strive to continue bringing you more great benefits through the year. We are in the process of organising a speaking tour of the country by two prominent speakers – look out for more details next year. This will be a “members first” event so make sure you remember to re-join to get priority attendance.

You may have noted that our symposium has not been advertised. The next one will be in 2017 as next year is the second PNZ joint conference where we will have a sports ‘stream’ running so didn’t want to clash with this. We are currently looking at venues and key note speakers.

With our level one SPNZ sports physiotherapy courses now solid in our calendar and no foreseeable hiccoughs, our level two course are due to start in the second half of next year. Look out for them. Members, as with all our courses, will get advance notification for them.

That brings us to the end of anther year. Best wishes for Christmas and I hope you have a safe and relaxing holiday period, and a successful New Year.

Hamish

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Members’ Benefits

Re-join SPNZ and continue to receive the following benefits: Free: Online JOSPT access for all members of SPNZ Monthly journals plus ‘Clinical Practice Guidelines’ special reports and more Free: Online BJSM access for all members of SPNZ Fortnightly journals plus Podcasts, educational videos, interactive quizzes PowerPoint presentations and more

Great for extra CPD points Online copies of Sports Medicine Australia Magazine “Sport Health” 4 times per year Aspetar—bi-monthly hard copies of Aspetar delivered to your front door

Don’t forget to tick SPNZ when you renew your PNZ Membership all this for just $80  Regular SPNZ sports bulletin newsletters by email including clinical updates, latest research, clinical interviews and local case studies

 Up to date information via the SPNZ web site - links to free education opportunities  Education fund available to members only to help with funding for CPD activities (course and conference attendance, research etc)

 Advanced notification of sports physiotherapy positions across all levels

 ASICS shoes and clothing at members’ rates. McGraw Hill 25% medical book discount  Free online “Find a Sports Physio” listing  SPNZ Facebook page and Twitter account to keep you up to date  LinkedIn ‘closed’ sports physiotherapy discussion group  Discounted SPNZ courses and much, much more...

SPNZ Bulletin December 2015 Issue

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Feature TRIES TO TRIATHLONS Mike Lovell DIP. PHYTY, PGDIP HSC, DIP. MT I essentially gravitated into physiotherapy after being an enthusiastic but average runner at high school and realising that physiotherapy could lend itself to being involved with athletes at a high level. I missed out on being accepted at the end of 7th form and so began the first year of what was back in the day a comprehensive nursing diploma. I was accepted into Auckland physio school second time around and then the journey began, notwithstanding a few speed bumps along the way! I failed my first year and had to repeat the year. In those days we were in a 3 year diploma programme and from memory the degree programme began 2 years later. I always maintained that with me completing the 4 years I could have been eligible for the degree at the end, but Fran Elkin (Head of Physiotherapy) couldn’t see the humour in this and so I graduated from the Auckland School of Physiotherapy in 1991 with a diploma. I then completed my Dip.M.T. in 2000, and went on to complete my PGD (Musculoskeletal) in 2006. In the final year of my PGD my wife was also completing her post-grad and we had a 2 month old second child which made for challenging times. On more than one occasion I had to pull an all-nighter to submit an assignment and then head to the clinic and treat a full day of patients.

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

At present I am one of two full-time physiotherapists employed by the Chiefs Rugby Team for the duration of the Super season. Prior to the 2015 season I had been involved on a part-time basis (three and a half days per week) for six seasons. The part-time role worked very well in that I was able to continue to work in our two clinics we have in Hamilton maintaining contact with “normal” patients and keeping in touch with the staff. If it wasn’t for the very capable physiotherapists & reception staff we have I wouldn’t be able to continue in this fulltime role-they do a great job of keeping the clinics running smoothly!

How I ended up involved with a Super Rugby side after no personal rugby experience apart from as a Manawatu country school boy is still a bit of a puzzle. I worked in Takapuna for 1 year after graduating and then headed down to Hamilton in early 1993 for a 1 year stint in private practice at Sports Med Physiotherapy before intending to head overseas to the UK with a mate.

I met a young lady from Taupiri (now my wife!) after about 6 months and it wasn’t long before I was roped into being physiotherapist for the Taupiri Seniors while Warren Gatland was coaching the side. At this point I knew nothing about Waikato rugby apart from the fact they had a very (!!) colourful rugby jersey, and they had fanatical supporters who enjoyed their cowbells - very odd!

One thing led to another and I spent time with numerous SPNZ Bulletin December 2015 Issue

Waikato Rugby age group teams (an apprenticeship of sorts), Waikato Rugby League, Waikato Netball, and the Waikato Men’s Basketball Team before landing back in rugby with the Waikato NPC Team in 2001. I continued with them for a few years and also picked up the physiotherapy role for the New Zealand Triathlon Team from 2002-2014. I was fortunate enough to go to the Beijing and London Olympics with the Triathlon Team where supporting athletes for their day in the sun was a fantastically satisfying opportunity.

At present I’m entering my eighth season with the Chiefs Super Rugby Team, and am part of a medical team consisting of Dr Kevin Bell, our sports physician, and Kevin McQuoid who has come on board this season as the second team physiotherapist.

What are your specific areas of interest/research?

Because I’ve personally come from a running/triathlon background I’ve had a pretty serious interest in lower limb injuries and associated muscle balance. I attended a Steve White Muscle Balance weekend in 1995 which was a major catalyst for me to encourage looking beyond the injury and to explore the causative factors.

Becoming involved with the triathlon team forced me to continue to explore this area, as unlike contact sport, triathlon injuries have multi-factorial causes which often require teasing out information from the athlete and the coach(es) in relation to training/race volume, body composition, swim mechanics, bike position, footwear etc.

Having access to a biomechanist and podiatrist was a fantastic opportunity to cross pollinate ideas and

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Feature TRIES TO TRIATHLONS continued... solutions in this field. We would conduct annual screening weeks where we would use a multidisciplinary team to build a complete picture of the athlete.

What are the types of injuries you commonly see?

Triathletes tend to have a fair proportion of lower limb injuries along with the odd swimmers’ shoulder and stiff thoracic spine (commonly due to cycling, but also due to being on social media or emailing for long hours in between trainings!). When I initially began in 2002 we had a spate of about 15 lower limb stress fractures over a 4 year period. High cycling and running training volumes coupled with a very aerobically and anaerobically fit athlete was a bit of a recipe for disaster, especially if the athlete’s trunk and lower limb stability was compromised. Completing my PGD in 2006 gave me a chance to look at other associated factors including lower limb bone density and calf strength. I found that our triathletes who came into the sport from a competitive swimming background potentially had less bone mineral density than your average weight bearing couch potato given that they spent up to 4 hours per day in a water supported environment. Combine this with poor antigravity musculature, a massive cardiac output and an insane mental drive to succeed and we had a recipe for a stress fracture.

Relative calf strength was an associated area that I began to notice also influenced the development of lower leg injuries. We soon realised that if a young athlete entering our triathlon programme could not achieve at least 20 single leg calf raises (off the floor in bare feet) with ease, then they were going to struggle with increases in running volume. With triathlon on the elite stage there is also a step up from U19 level (750 m swim/20 km bike/5 km run) to U23/Open Elite level (1500 m/40 km/10 km). As the U19 athlete transitions into the U23/Elite level there is an associated increase in cycle/ run volume which on the back of poor calf weakness can result in a spike in lower leg injuries.

Rugby does have its fair share of overuse injuries too.

These are commonly achilles and patellar tendinopathy, and the occasional stress reaction/fracture. There is obviously the contact component involved with rugby and associated traumatic injuries. Backs tend to have more the calf and hamstring strains and tears while the forwards will have higher numbers of lower back and neck injuries.

In the Super Rugby environment I have also noticed even though we have very strong athletes (who are able to bench press up to 200 kg and squat over 200 kg) they are also surprisingly weak in the area of pelvic and hip SPNZ Bulletin December 2015 Issue

control, and calf strength 3-4 years ago we were having some of our players struggling to achieve even 15 single leg calf raises without fatigue!

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

A knowledge of the biomechanics of the sport, intricacies of muscle control around the given sport, a good rapport with the coach and athlete (knowledge around changes in training volume and intensity, personal stressors) are all a good starting point.

As noted above I developed a triathlon specific version of the HPSNZ musculoskeletal screening tool. Within the Chiefs we have developed a similar tool which we conduct pre-season and reassess at 2-3 monthly intervals. This will give us a profile of the player and then in conjunction with our S&C team we prescribe pre/ post-workout exercises aimed at the likes of hamstring and calf weakness, hip and trunk strength. Due to the nature of the sport with knee and ankle injuries we are continually working on a player’s awareness of the need to continually address lower limb proprioception. We still have players that cannot balance one leg eyes closed for 30 seconds without losing control!

After attending Kristian Thorberg’s work shop about 2-3 years ago at an SMNZ conference I initiated weekly groin testing on our Chiefs players as a monitoring tool specifically aimed at picking up early signs of groin weakness. We use a simple blood pressure cuff inflated to 20mmHg and players self-test and record their own scores. If player’s scores decrease by 20-30mmHg over a week or begin to trend downwards we decrease time on their feet until their score normalises. This was based on an Australian Football (soccer) paper which found that a decreased score correlated with the development of groin pain 9-10 later.

Roald Bahr’s work with Nordic hamstring strength is something we pay attention to in the players gym programmes. This is programmed in several times per week. Our expectation is that our players should be able to at least 25 single leg butt lifts (heel on chair, hip and knee flexed to 90º) when screened initially in our programme. The Oslo Sports Trauma Research Center has great resources around hamstring and ACL prevention research which is where Roald is based.

We are also very aware of a players training age. Some come into our environment with only 1-2 years of gym based lifting, or low time on field training hours, and we are very aware of overloading them at an early stage in their career. This has paid off in the areas of preventing achilles, lower back and shoulder injuries. Our coaching and S&C staff understand this and customise training for CONTINUED ON NEXT PAGE

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Feature TRIES TO TRIATHLONS continued... the younger players, and aware that some players are a work in progress over the next 1-3 years.

Related to the lifting environment within the Chiefs we have become very aware of players hip ROM, particularly in the area of flexion relative to their squatting ability. I noted several years ago that we were having younger academy players developing lumbar disc injuries due to (a) lifting early morning due to work commitments (increased intra discal volume early morning), and (b) poor hip flexion and attempting to achieve 90º knee flexion for an optimal squat. Couple this with an increased awareness of FAI (femoroacetabular impingement which is often the cause of anterior hop and groin pain) and now we are taking a very aggressive approach to how deep we let our players squat!

Are you involved in performance aspects for your clients?

In regard to our Chiefs’ environment we are spoilt as we have two physiotherapists and three strength and conditioning trainers full time, along with Kevin Bell, our sports physician in a half time role. Having the luxury of walking out of the physio room directly into the gym, or into the doctor’s room to discuss a player’s injury and ongoing management is fantastic and surely beats numerous emails and phone calls like we all often have to take care of. We also have David Galbraith, our sports psychologist who is particularly important when we have to deal with an athlete with a long term injury, or even worse, a season ending injury in the early stages of the season. We diarise weekly full management meetings to discuss players, and interact often on a twice daily basis between the medical and S&C teams to ensure trainings are adequately prescribed for injured players.

Daily wellness measures that players are expected to complete also track player fatigue and sleep quality.

Combined these with adequate hydration and recovery and we feel we are doing a very good job at minimising the risk of training injuries.

What are the key attributes you feel are required to work with elite level athletes?

I think it could be easy to overcomplicate the relevance of desirable attributes when being involved with elite teams, but put simply, I think that a passion for the sport and a desire to help the athlete can sometimes surpass superior technical manual therapy skills. The ability to be

SPNZ Bulletin December 2015 Issue

focussed, single minded and stay calm and relaxed for the athlete and coach is huge. Being able to discern what is important for the athlete to know, and what might tip them over the edge if you tell them pre-competition is very important!! That athlete spends countless years building towards a World Championships/ Commonwealth Games/Olympic Games only to have their campaign shot down in flames because of poorly thought out remark from the team physiotherapist!

What do you see as the major challenges for sports physiotherapy?

Sports physiotherapy faces numerous challenges from within and without the profession. We constantly battle with ourselves as providers of high quality, specialised services to the elite athlete and the general population, but we struggle to charge ourselves out at a rate that would generate a high enough income to justify our experience and possible post-graduate study. We worry about what other physiotherapy clinics nearby may be charging, yet chiropractors and osteopaths charge one and a half as much, if not twice as much, as what we are charging our clients.

Developing our skills in the area of gym based exercise programming is very important to progress rehabilitation for our patients and players, and also to ensure we stay abreast of the personal trainers that have the potential to invade our space. They may be able to prescribe exercises and progression but our knowledge of pathological musculoskeletal tissue, cardiac and respiratory illness is far superior.

My concern is that we need to ensure we are personally familiar with gym based exercises and this requires us to actually get in to a gym ourselves! Not all of our patients need to learn how to do a power clean, but prescribing squats, deadlifts, lunges and single leg Romanian deadlifts for lower back, hip and knee patients is a very functional skill set that our patients need to learn effectively for everyday life. Unless we can perform these lifts adequately ourselves, we will be unable to teach them adequately and trouble shoot the technical aspects.

Of course being a sports physiotherapist at an elite level needs its own backup team and I am give full credit to my staff for keeping the clinics running while I am committed with the team.

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Planet of the Apps Your monthly App review

by Justin Lopes - Back To Your Feet Physiotherapy, SPNZ executive member.

Hi team, We are fortunate to have such a close relationship with BJSM and the BJSM journal always has a few great editorials and articles to keep you current. This month we have a guest reviewer, Tim Dovbysh, who is reviewing the BJSM learning modules. BJSM also offer apps on both the Android and Apple platforms, and are a great source of CPD activity. I personally use the podcasts more than I use the app, and was interested in what Techsavvy Tim had to say about the Learning Modules (which I realise are not an app but I think with a little poetic license we can get away with it). hAPPy Christmas!

App: BJSM Learning Modules Introduction Hidden away on the BJSM website are some great resources to supplement the collection of research papers that BJSM publish. After you create an account on BMJ learning with your SPNZ membership, you will get a personal homepage from which you can access learning modules. You can either browse through the catalogue of modules manually, or set up your profile (profession and speciality) to have modules recommended for you based on your interests. Each learning module is based around a research article that you read then answer a series of multiplechoice questions based on the content. BJM state the entire process can take up to an hour. Once your answers are submitted you are given a % score of questions answered correctly (and the correct answers). A certain amount of accuracy is required to pass. Your BMJ portfolio (on your homepage) keeps track of the modules you have done.

The idea behind this was so professional accreditors could see the completion of the modules as points/hours put in towards evidence of CPD.

Where to start: http://sportsphysiotherapy.org.nz/sportsphysiotherapy.org.nz/documents/BMJ-Learning-Registration-SPNZ.pdf Where to go next: http://bjsm.bmj.com/site/education/index.xhtml or http://sportsphysiotherapy.org.nz/members/bjsm/ Cost:

FREE with your subscription to SPNZ

What it is used for:

To supplement the content published in BJSM

Pros: 

Recommended readings/modules based on your interests



Content is relevant to your clinical practice



Log/portfolio of modules you have completed



The ability to add modules to a “reading list” as a reminder to read later



Evidence based, peer reviewed, regularly updated



Questions don’t take long too answer once you’ve read the relevant paper

Cons: 

Set up can take a few steps (but is easy once you’re in)



Only modules linked to BJSM are available (as opposed to other journals owned by the BMJ parent body)

SPNZ Bulletin December 2015 Issue

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Planet of the Apps Continued from previous page…

How Techsavvy Tim uses the Learning modules: Essentially I use this two ways. I if happen to find some free time then I’ll either do a manual search for a topic of interest or look at a recommended topic. I’ll then read the paper and go through the questions to see if I’ve understood it, according to BJM. The other way (and my preferred option) is to scan the current issue contents page.

Certain papers will have a link that looks like this [BMJ Learning: Take the Test] under them. This means that if I’m interested in reading that paper, I could answer a few questions to see if the content has stuck!

Overall Rating: 4/5 After Techsavvy had raved about the BJSM Learning modules I had a go myself… I really liked the way you can do a test on the article you have just read. The results can be saved as a certificate or into your own profile. If you use the Logitapp you can upload the certificates to your profile there. You can also export a csv or excel file which compliments the ones you can produce from Logitapp.

I recommend you all give it a go, it doesn’t take long to set up your account and save to bookmarks and then you can record all your independent learning. Download the BJSM app for easy access to podcasts and all the other benefits from BJSM. SPNZ is proud to be associated with BJSM and are pleased to be able to offer electronic subscriptions to our members, meaning you will never have an excuse not to stay current… the only difficult decision is how to fit so many good articles into your already busy week!

As always if you have a great app you would like to share, or one that you would like reviewed please send me through the details.

Cheers, Justin

SPNZ Bulletin December 2015 Issue

For further discussion on this App check the SPNZ LinkedIn forum page Click here

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Case Study Triathlete Trouble Introduction Triathlon is the most modern among the endurance sports. The combined practice of swimming, cycling and running facilitates the distribution of stress forces over several parts of the body. Initially it was believed that triathlon would reduce the occurrence of overuse injuries compared to the practice of a single discipline. However, injuries in triathlon are common and about 90% of actively training triathletes will have an acute or overuse injury over the course of the year (1). In fact, it has been reported that overuse injuries amongst triathletes have a higher incidence than on single-sport athletes possibly due to higher average training hours and the complexity of dominating the technique of three different disciplines. The running stage of triathlon is considered the most important leg of the race as running time is usually the best predictor overall triathlon success. It is in this final stage that competitors experience the most fatigue and muscle tightness and are therefore at their most vulnerable to injury. In fact running is the discipline most commonly associated with injuries in triathlon and knee injuries account for more than a third of all running injuries.

It has been reported that iliotibial band syndrome (ITBS) is a common lower limb injury in age group triathletes. ITBS is believed to result from the constant friction of the ITB and underlying bursa or lateral synovial recess over the lateral femoral epicondyle. It is the most common cause of lateral knee pain in runners and comprises between 1.6 to 12% of all running-related injuries. Biomechanically, it is believed that the posterior edge of the band impinges against the lateral epicondyle just after footstrike in the gait cycle. The friction occurs at, or slightly below, 30° of knee flexion. This can produce irritation and a subsequent inflammatory reaction, especially in the region beneath the posterior fibers of the ITB, which can be felt to be tighter than the anterior fibers. The symptoms usually come on after a reproducible time or distance and consist of a sharp pain or burning on the lateral aspect of the knee. Occasionally, there will be swelling and thickening of the tissue where the band moves over the lateral femoral condyle. Early on, the symptoms will subside shortly after the run is over, but will return with the next run. If allowed to progress the pain can persist even with daily walking and particularly when ascending and descending stairs.

A succesful treatment intervention of ITBS needs to explore related risk factors such as training errors, sudden increases in training intensity or volume, changes in footwear, the addition of hills or running on steeply cambered roads. If the ITB sufferer is a triathlete inadequate bike biomechanics such as an inappropriate frame size, saddle position or cleat pedal misalignment need to be examined. A good understanding of the technical characteristics of triathlon, the demands of the transitional phases between disciplines, particularly the bike-run transition and the different training loads dictated by the race distance, olympic versus long distance triathlon, is essential for effective prevention and management of any injuries in triathlon. An insight on the athlete’s background and previous injury history can also provide clues with regards to their discipline efficiency and muscle elasticity.

Patient Presentation M was a 43 year old female of 8 years experience in triathlon with a sporting background in netball, touch, rugby and athletics. M was training to represent New Zealand in the 40 to 44 age group 70.3 (1.9 km swim, 90 km bike, 21.1 run) World Championships in September. This goal was part of a build up to compete on her first Ironman distance (3.8 km swim, 180 km bike, 42.2 run) in Taupo in March. M presented to physiotherapy in early August with a 3 week history of increasing sharp lateral right knee pain when running with a progressing feeling of tightness on the lateral aspect of her thigh. M symptoms were only present when running, initially she stopped running for 1 week but as soon as she resumed running the symptoms returned. The condition was worsening and at the time of consultation the pain stopped her from running after 45 min and was present while walking for a few hours.

M was not taking any medications and apart from a left ankle lateral ligament reconstruction 2 years before she was in good health and had never experienced a similar injury in the past.

SPNZ Bulletin December 2015 Issue

When questioned about her training habits M was running 3 times a week between 1 h to 2 h each time and she had increased her running volume gradually with the maximum volume reached around the time her symptoms developed. M had not made any changes to her running footwear but on further questioning she reported doing all her runs on a cambered road always with the camber on the right. The road surface was always asphalt and the terrain undulating. Prior to the development of symptoms M had also had her bike fitted to improve her aerodynamic position and her bike seat had been adjusted to a higher position.

On clinical examination M presented with tenderness on palpation over the distal right ITB and a positive Ober’s test. On biomechanical analysis M was unable to squat past 60 degrees of knee flexion and she presented with a quads dominant pattern. During a single leg squat M presented with an increased hip adduction and knee internal rotation that was more pronounced on the right. There was no pain during either movement. On strength testing the main findings CONTINUED ON NEXT PAGE

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Case Study Triathlete Trouble continued... was weakness on resisted right hip abduction and lateral rotation. On testing of M’s trunk endurance she was unable to hold a prone plank position with good form for longer than 30 seconds, both right and left side plank endurance was limited to 20 seconds with poor control.

Left ankle testing revealed adequate range of motion and strength.

My clinical impression was of right ITBS caused by a combination of intrinsic musculoskeletal factors: right hip abductor weakness and reduced trunk control/ stability and training errors: road surface and camber, rapid increase in running volume, and an inadequate bike set up.

The fact that M was still able to run for 45 min and symptoms at rest were minimal indicated a good prognosis. The challenge to her recovery and performance on race day was that M’s race was only 4 weeks away and that she was still building her running.

I was hopeful that M would be able to participate on the event although it was discussed that her running performance was likely to be affected. Further, she needed to prepare for the possibility of walking sections or part of the run. Full recovery was expected at 6 weeks but the main goal was to prevent the injury from reoccurring during the build up for the Ironman race.

Goals and Key Treatment elements The initial goal of treatment was to settle any active inflammation by icing regularly the lateral aspect of the knee (10 minutes 2 to 3 times a day and after activity) and taking nonsteroidal anti-inflammatory medication.

However, the symptoms seemed to be more mechanical than inflammatory and treatment focused quickly on addressing the following: -Activity modification; goal: to reduce symptoms. Advice to run on flat, soft surfaces and only if pain-free. In order to maintain running fitness I recommended that M walked or aqua jogged for the remaining or the running time of her training plan as long as the activities remained pain-free.

-Running biomechanics; goal: to increase running economy. Education to increase awareness of running form particularly when fatigued. Emphasis was placed on lumbopelvic control, correct lower limb alignment and advice to maintain a higher cadence. Cues such as “running tall and light” and increase the step rate by 10% were provided.

- Hands on treatment; goal: to reduce symptoms, ITB tension and myofascial restrictions. Soft tissue massage of the right quads, ITB and gluteal muscles was performed 1 a week on each of the 3 appointments. M was encouraged to foam roll regularly around these areas SPNZ Bulletin December 2015 Issue

and self-trigger point any tender spots everyday.

- Home exercise programme; goal: to address hip abductor weakness, lumbopelvic control and improve muscle flexibility. Progressive strengthening: side lying hip abduction and hip lateral rotators (clams) with increasing theraband resistance 3x12, prone and side bridges 3x30 sec gradually increasing as able up to 3x1 min, once a day. Quadriceps, gluts and ITB stretches 3x30 sec 2 a day or after activity.

- Bike set up; goal: correct bike mechanics. Advice to lower the seat height and visit the bike fitter for a follow up.

- Gradual increase in running volume; aim: to achieve estimated half marathon running time pain-free. Advice to increase running volume by modifying time and frequency avoiding intensity and hill training.

M responded favourably to the treatment plan and on follow up a week later she had been able to do 3 runs on alternative days one of them for 1 h 40 min with only slight pain afterwards. Although this was very encouraging I suspected that she had increased her running distance too rapidly. The strengthening exercises were progressed by performing the resisted hip abductions standing and adding single leg glut bridges.

On the third and last appointment before travelling overseas for the race as I feared some of the symptoms had returned. I suspected that M running volume was too high for her current capacity. On initial treatment success M reported that she had also reduced the frequency of the home exercise programme. This session focused on emphasizing the advice provided for M to manage her injury while overseas.

M managed to successfully race and complete the 70.3 distance, it was a difficult race because of circumstances outside her control (her bike and triathlon gear was lost by the airline and she had to buy and borrow equipment in order to race). However, on return she continue applying the treatment principles and she was able to complete the Taupo Ironman in good time and injury free.

Key Case Point Although ITBS is a relatively common running injury in this instance a successful intervention depended on a good understanding of the technical aspects of triathlon and how each discipline influences the other. A knowledge of both running and cycling biomechanics was necessary to effectively address any deficiencies in equipment and training errors. It is always a challenge for the clinician to balance the need to rest an injury caused by overuse whilst minimising deconditioning of CONTINUED ON NEXT PAGE

PAGE 13

Case Study Triathlete Trouble continued... the cardiovascular and musculoskeletal systems. Although triathlon offers the possibility of cross-training balancing high training volumes and fatigue, particularly in the long distance triathlons, is crucial for optimum performance.

Discussion The ITB originates in the facial components of the gluteus maximus, gluteus medius, and tensor fasciae latae muscles. The ITB is attached distally to the supracondyle tubercle of the femur and the lateral intramuscular septum. In addition it has fibers that attach to the patella Due to these attachments, increased hip adduction is likely to lead to increased tension on the ITB. Running on a cambered surface would accentuate hip adduction on the lowered limb at foot strike. It has been reported (2) that female recreational runners who developed ITBS exhibited greater hip adduction and peak knee internal rotation moments.

Proximally, the ITB acts as a lateral hip stabilizer resisting hip adduction. Another study (2) found that runners who presented with ITBS exhibited weaker hip abductors on the injured side compared to the uninjured side and uninjured controls. Since the study participants were already injured at the time of the measurement, the authors admitted that it was unclear whether the weakness was the cause or result of the ITBS. However, the ITBS symptoms were resolved in 90% of the subjects following a six week program of hip abductor strengthening.

The cycle-run transition (T2) is a period of particular risk for knee injury (4). The change from concentric to eccentric muscular contractions, and from the unloaded cycling phase to the loaded phase of running is extremely delicate. Further, the longer the biking leg the more time is needed to regain the neuromuscular and

elastic efficiency of an economical running style. In addition, muscle fatigue jeopardizes the ability to effectively dissipate the load forces and an increased hip adduction and knee internal rotation pattern during foot contact, when maximal deceleration absorbs ground reaction forces, leads to a raised valgus vector at the knee increasing the tension on the ITB. It has been shown (5) that increasing the runner’s preferred step rate reduces the impact load on the body. This is due to less vertical center of mass velocity at landing and subsequent less energy absorption (negative work) required. The study found that during 5% and 10% above preferred step rate less mechanical energy was absorbed at the knee. When step rate was increased to 10% above preferred, peak hip adduction angle as well as peak hip adduction and internal rotation moments were significantly decreased.

Conclusion and Reflective Statements M’s injury was the result of a complex interaction of running and cycling biomechanics aggravated by a high training volume that stressed her musculoskeletal system to the point of injury. From this case I learnt that in triathlon injury treatment and prevention needs to focus on learning the correct technique of each discipline and ensuring the suitability of the equipment, particularly in regards to the bike biomechanics. An insight into the sport, the athlete’s experience and physiological capacity is needed to make judgements about the suitability of the training programme and in order to make appropriate adjustments or modifications.

Ultimately, gaining the patient’s trust is a crucial components of an effective treatment, particularly when some of the clinician’s advice might conflict with the patient’s expectations.

By Lidia Escrig

References: 1.

Tuite MJ. Imaging of triathlon injuries. Radiol Clin N Am 48 (2010) 1125-1135; doi:10.1016/j.rcl.2010.07.008 2.

Noehren B, Davis I, Hamill J. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon) 2007; 22:951–956.

3.

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Clin J Sport Med. 2000; 10(3):169-75

4.

Migliorini S. Risk factors and injury mecahnism in triathlon. J. Hum. Sport Exerc. 2011; 6(2):309-314

5.

Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. Effects of Step Rate Manipulation on Joint Mechanics during Running. Med Sci Sports Exerc. 2011; 43(2): 296–302; doi: 10.1249/ MSS.0b013e3181ebedf4

Lidia Belles Escrig works as a head clinician for PHYSIOSOUTH, qualified in Spain in 1996 and gained registration in the UK in 2000. Lidia moved with her partner to NZ in 2004 and has been working in private practice since. Lidia is a keen triathlete and has competed across all distances since 2000. She has twice represented NZ on her age group. Currently Lidia is the main physiotherapy provider for Canterbury basketball academy and has been the RAMS physiotherapist since their revival season in 2014.

SPNZ Bulletin December 2015 Issue

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SMA Conference Grant 2015 ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE

By Adam Letts, Physiotherapist Learnings from the 2015 ASICS Sports Medicine Australia Conference t was a real privilege to attend the 2015 ASICS SMA conference in the tranquil setting of Sanctuary Cove, Gold Coast, from the 20th to 24th October 2015.

As well as enjoying the superb weather the Gold Coast had on offer, it was a pleasure to listen to the wide range of high calibre clinical and research presentations.

I found the conference engaging and challenging with many things to take back to my clinical practice and will share my highlights in this report.

I attended two full day pre conference workshops prior to the official opening of the SMA conference.

The first was the ASICS Running Symposium held in conjunction with the Australasian Academy of Podiatric Sports Medicine (AAPSM).

Professor Joseph Hamill from the University of Massachusetts presented on how in the modern era, lower extremity biomechanics is now providing a rationale for footwear design. He also discussed his recent research based around the “eversion buffer” concept. He feels that athletes that work closer to the maximum point of eversion for longer therefore spending more time in their “eversion buffer” are more susceptible to lower extremity injury.

Dr Joel Fuller presented on the short and long term effects of minimalist shoes on running economy and performance. Overall he found that there was a significant increase in running economy when training in minimalist shoes. He felt this was due to decreased ankle dorsiflexion at foot contact to the ground causing forefoot strike and therefore an increased strike rate. He also thought long term training in minimalist shoes could cause an increased elasticity in the Achilles tendon due to forefoot running, which would benefit performance.

However when looking at injury risk he found there was a progressively rapid injury rate with long term training (over 12 weeks) in minimalist shoes. This relationship became even more significant when factoring in the athlete’s body weight.

The final speaker at the running symposium was Dr Kade Patterson who discussed the influence of high versus low support footwear on patellofemoral joint related biomechanics during running. He found that footwear with medium to high heel heights increased PFJ forces compared to low support footwear or barefoot. He also found that there was a significant reduction in Achilles tendon forces in high support

SPNZ Bulletin December 2015 Issue

footwear compared to low support footwear and barefoot. This has clinical implications when trying to reduce load effects across the PFJ and Achilles tendon.

Overall I found this symposium refreshing and it was good to collaborate with my Podiatry colleagues.

The second pre conference workshop I attended was the Onfield Emergency Management workshop in conjunction with Sports Doctors Australia. This workshop was presented by Emergency Department doctors and Sports doctors currently working with elite sports teams. Skills covered in this workshop included basic life support including DEFIB training, advanced life support, spinal immobilisation and removal from the field and how to deal with medical emergencies such as choking, shock, anaphylaxis, seizure, tension pneumothorax and acute severe asthma. We also discussed the key points of Crisis Resource Management and how important it is to be prepared, know your environment and what resources you have on offer before working at a sporting event.

This was followed by a practical simulated learning session that was nerve wracking at the time but stimulated you to make quick decisions and good clinical judgments. I found this to be an extremely beneficial workshop that was pertinent to my role as a sports physiotherapist for a team.

The SMA conference was officially opened by Dr Peter Brukner, providing everyone with an insight of the lessons he has learnt over the past 30 years in sports medicine. His engaging and humorous presentation highlighted his genuine love of sport and how we need to occasionally reflect on why we have chosen a profession working with athletes. He touched on the satisfaction he gets in playing a small part in helping an athlete or team achieve their goals.

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SMA Conference Grant 2015 ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE continued...

By Adam Letts, Physiotherapist A highlight of the conference was the hamstring symposium.

Nicol Van Dyk, Physiotherapist from Aspetar Sports Medicine Hospital in Qatar presented his work on hamstring assessment and rehabilitation in football players. His model is based on daily assessment including total palpation length of soreness, hamstring length, functional tests such as double & single leg squat and inner & outer range strength tests measured by a handheld dynamometer.

They have found they have had good results from a 3 stage rehabilitation protocol that is more criteria based rather than time based. An athlete cannot move onto the next stage of rehabilitation until they have passed certain criteria.

Stage 3 is focused mainly on onfield sport specific rehab to evaluate readiness to return to sport.

There were also some excellent presentations from a group of researchers from the University of Queensland.

Dr Matthew Bourne looked at the influence of low eccentric hamstring strength as a predictor of hamstring injury using a novel piece of equipment called the Nordboard. The Nordboard measures maximal force output during a Nordic drop exercise, which is indicative of maximal eccentric hamstring strength. He found that low eccentric hamstring strength was associated with a higher risk of hamstring injury in AFL, A-League Soccer and Australian Cricket. However rather than eccentric hamstring strength, a lower limb imbalance greater than 15% was associated with an increased risk of hamstring injury in rugby union players. This risk was heightened if they had suffered a previous hamstring injury.

Dr Ryan Timmins presented his study on biceps femoris long head fascicle length and the risk of hamstring injury. He showed that a decreased muscle fascicle length was a predictor of increased hamstring injury risk. However he also showed that it was possible to increase fascicle length with only 2 weeks of eccentric hamstring strengthening. The Nordic drop exercise was shown to be the best exercise for increasing fascicle length. However, the 45 degree prone hip extension was shown to be the best exercise to activate biceps femoris long head.

Dr David Opar looked at AFL players that have returned to play following a hamstring injury. He found that they had decreased eccentric hamstring strength on their

SPNZ Bulletin December 2015 Issue

injured limb compared to their uninjured limb up to 10 months post hamstring injury. He felt this was due to persistent inhibition due to shorter fascicle lengths over a period of time causing eccentric weakness particularly at longer hamstring lengths.

Finally Dr Steven Duhig showed that high speed running was the primary mechanism to hamstring injury in AFL players. Even though this was not surprising he also found using GPS data that hamstring injury was more likely to occur in spikes of high running load and that the greater high speed running in a given week increased the hamstring injury risk.

Overall the clinical implications to minimising hamstring injury risk would be to increase eccentric hamstring strength, increase biceps femoris long head fascicle length and gradually increase in high speed running load avoiding high speed running spikes.

Another highlight of the conference was the Tendon symposium presented by Jill Cook and her fellow researchers from Monash University in Melbourne. I had heard Jill talk once before at the SPNZ conference in Tauranga and was looking forward to hearing her up to date knowledge on the management of tendon pain.

Jill emphasised the importance of concentrating on return to function when dealing with tendinopathy.

Improvement in function will always improve pain. Jill talked about the need to progressively increase the capacity of the tendon to tolerate load.

This led into the work done by Ebonie Rio on isometric exercise to induce analgesia and reduce inhibition in tendinopathy. She found that a single bout of isometric contractions reduced tendon pain immediately for at least 45 minutes and also increased maximal voluntary isometric contraction. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms.

Dr Sean Docking presented his work on the science and art of imaging in tendinopathy and it’s role in diagnosis and injury prevention. He discussed the thicker the tendon, the more disorganisation in the tendon. Symptomatic tendons have developed more fibular structure around a disorganised tendon. The pathological tendon has a limited capacity to return to a normal structural tendon at this stage. He used the analogy of “Think about the doughnut, not the hole”. In

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SMA Conference Grant 2015 ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE continued...

By Adam Letts, Physiotherapist other words in a degenerative tendon aim to progressively build load, improving fibular structure around the disorganised area.

Other keynote speakers that presented were: Mr Alex Kountaris, who is currently the lead physiotherapist for the Australian Men’s Cricket team, discussed load management and in particular how it relates to lumbar stress fractures. He talked about monitoring players response to load by using various methods such as regular strength and flexibility tests, RPE and GPS data to measure training intensity and wellness information measuring players sleep quality, soreness, fatigue and stress levels. It is then important to act on markers that indicate players are not coping and readjust the training plan accordingly. The ultimate outcome is to strike a workload balance and minimise workload spikes that may result in injury such as lumbar stress fractures.

Professor Jens Bangsbo presented the effect of speed endurance training on muscle adaptations, performance and health. His study showed that using the 10-20-30 training concept, moderately trained runners were able to increase running economy and increase short and long term performance despite a 50% reduction in their total training. The 10-20-30 training concept is quite simple and consists of three to four blocks of five consecutive one minute intervals divided into 30, 20 and 10 seconds of running at a low, moderate and then near maximal intensity. Another great benefit the runners experienced was a significant decrease in blood pressure and total cholesterol.

Ms. Susan Mayes who has been the principal physiotherapist of the Australian ballet presented an interesting talk on posterior impingement syndrome of the ankle. Posterior impingement pain is usually caused by soft tissue impingement and periosteal reaction and is quite commonly in combination with FHL tenosynovitis. The main focus of rehabilitation is improving gastrocnemius strength and control so not to overload FHL and soleus. The best exercise is single leg calf raises with the knee stable in extension. There should be an emphasis on good ankle alignment and gastrocnemius staying active throughout the full range of movement.

This is a brief insight into the key findings I gained from the SMA conference. Overall I found attending the SMA conference a rewarding experience and was encouraged with the multidisciplinary approach and SPNZ Bulletin December 2015 Issue

willingness to share knowledge across disciplines. I returned from the conference inspired and motivated to apply some of my new learnings into clinical practice. I would like to thank SPNZ and ASICS for the opportunity to attend the conference with the SMA conference grant. I would also like to thank Chris Horrocks from ASICS for being the ultimate host.

Adam Letts Physiotherapist adam.letts@highlanders.net.nz

Adam was the inaugural winner of our new Asics sponsored grant to attend the Asics SMA Conference. The grant covers accommodation and conference fees and will be available every two years to one of our members as part of our new deal with Asics.

Asics Sports Medicine Australia Conferences focus on current research and practice in areas relating to the promotion of, and safe participation in, all kinds of sport, exercise and physical activity.

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SPRINZ

Faster and Fitter for Summer!

By Travis McMaster PhD – Strength & Conditioning Clinic Coordinator The Strength & Conditioning Clinic (SCC) as part of the Performance Clinics at AUT Millennium provides world-class strength and conditioning assessment, programming and training services to all types of athletes.

The SCC has a range of state-of-the-art equipment designed to measure and train various elements of strength, power, speed, balance and coordination. Strength and conditioning is vital to the junior, elite and recreational athletes physical development.

Sport, movement and individual specific physical conditioning can lead to a faster, stronger, powerful and more efficient athlete.

The SC clinics cutting edge technology available to measure your physical performance includes a Biodex balance system, a HumacNorm isokinetic dynamometer, Exerbotic strength machines, a Keiser power rack, a Fitness Technology power cage and magnetic braking system, a non-motorised Woodway force treadmill, Gymaware rotary encoders, Push wireless accelerometers, Stalker radar, Swift Performance timing lights and a number of uni and tri-axial force plates (AMTI, BMS, Bertec and Pasco).

Our team of highly qualified professionals are certified strength and conditioning specialists with a vast amount of experience and expertise. If you’re looking to get stronger, faster or fitter for the summer, please visit our website to enquire about the services we offer. http://www.autmillennium.org.nz/health-and-fitness/clinics/scc/1134-2 Dr Travis McMaster Travis has a PhD in Strength and Conditioning from AUT University, and a MSc in Sports Science from Edith Cowan University. Dr McMaster is a Certified Strength and Conditioning Specialist (CSCS) through the US-National Strength and Conditioning Association and a Tactical Strength and Conditioning Specialist through the Australian Strength and Conditioning Association. He has tested and trained a range of athletes including: provincial, professional and national and wheelchair rugby players, Paralympic snowboarders, national ice hockey players, two Canadian junior moguls champions, three freestyle ski world champions and New Zealand defence force operatives. He has a number of applied research interests including: athlete profiling, sports technology, periodised training design, and neuromuscular and morphological training adaptations. Travis has a number of peer-reviewed publications in sports science and strength and conditioning and is a reviewer for several related journals. He continues to work as a strength and conditioning coach, lecturer and applied researcher through his work at AUT Millennium.

SPNZ Bulletin December 2015 Issue

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ASICS

ASICS Report CSI Episode 21 - What is the Truth About Widths?

I thought for this issue of the FORERUNNER it was a good time for us to find the truth on the issue of widths and dispel some of the untruths that goes in footwear development by giving information that you can take forward to weed out the genuine width varieties from the mythical sorts!

For one I have to call foul of some who say they have a width story when really all they are doing is adding volume to a shoe and not really giving WIDTH to a shoe.

So the naming of a shoe that it is a wider width is really misleading in many cases.

To understand what is happening you first have to understand that the biggest cost in footwear development for any company is the moulds or toolings as we call them that are made for a particular shoe. That is toolings or moulds for the midsoles, outsoles, and even things like TRUSSTICS and GEL to name a few other mould issues, adds to the high cost in the manufacture of a shoe.

You do these moulds for every size of a shoe. Although what happens to help with the costing of a shoe is that the men’s and women’s shoes share the toolings. What changes is the ‘lasted upper’. The upper last is the shape that the shoe takes around the plastic mould of a foot.

The upper is stretched over this mould and gives the final shape of the upper.

Now this is where the lasted upper becomes more important in the scheme of things when talking about ‘widths’.

As mentioned previously the biggest cost for a shoe’s development is the tooling and this is even more when you go from compression moulded toolings to injections toolings.

There is another issue when talking about these two types of manufacture in relation to the number of shoes that get made.

But that is for another day!

For now let’s come to agree that the toolings no matter what type they are expensive in the overall costing of the shoe.

So what we all try to do in footwear development is limit the number of toolings that are being produced so it keeps the cost of the shoe down in the end.

Therefore what happens in a lot of cases is that when a shoe is made the tooling is ‘shared’ not only for the two genders but also with different widths.

In some widths this is fine because there is enough tolerance in the midsoles to allow for a slightly wider upper to be put on the same tooling. But the problem occurs when you go too far with the requirements to reach the wider 4E or in women’s the very narrow width of 2A. An all too common procedure is to accommodate the wider 4E width foot is to put a higher volume lasted upper still on that same tooling. Unfortunately this is when it should not be called a ‘width’ anymore as the volume in the toe box or vamp

SPNZ Bulletin December 2015 Issue

has come from giving depth and not width.

We tested this when looking at this issue more than 10 years ago and we found when you put these commonly called 4E width shoes on a true 4E foot that the material would bunch when the shoe dorsiflexes as there was no real correlation between the foot and the shoe shape.

So we questioned this process of manufacture and thus proceeded to study the 4E foot. We had a small team from our last building team travel the world and even here in Australia they came and measured the 4E foot globally. They found in general that the depth is in some cases less for the 4E foot compared to say the 2E foot shape as there was a spread of the metatarsals and the assumption was that we needed to make a new tooling to accommodate this foot shape when manufacturing shoes.

From that day forward we made the decision that if we were to make a 4E width shoe it MUST have new toolings produced to then truly be called a 4E ‘width’.

That means that when you see a 4E width shoe from ASICS in our range that a whole new set of toolings have been produced to make this happen. This adds to overall cost of the shoe of course.

Oh! You are wondering about the 2A for women. Yes, we must build new toolings for any shoe we build in 2A also as trying to use the same toolings from the bigger widths makes for ‘crinkling’ of the midsole when the upper is glued to it. This means there are often defectives and in general a very ugly look to the shoe.

Often, we get called to do different widths in Australian only developed shoes, such as cross trainers or football boots but as you can see to open the moulds for extra widths we need a lot of production forecast to make this happen.

Unfortunately for Australia our numbers do not allow us to open up a whole new set of moulds across all the sizes for some shoes because the market volume here is quite small in the big scheme of things based on what numbers are done globally.

That is why you will see width offerings in our iconic running models as the volume allows us to open the moulds.

So there is the truth about widths and yes, please, do a strong forensics examination of the next shoe you get told has width offerings! Use this power you now have in your hands for good!

Mark Doherty General Manager Product ASICS OCeania Pty Ltd.

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Clinical Section - Article Review Concentric Exercises for the Treatment of Tendinopathy Christian Couppe, PT, PhD1-4; Rene B Svensson, PhD1-3; Karin Gravare Silbernagel, PT, ATC, PhD5; Henning Langberg, PT, PhD, DSc6; S. Peter Magnusson, PT, DSc1-4 Journal of Orthopaedic and Sports Physical Therapy, 2015, Volume: 45 Issue: 11 Pages: 853-863 doi:10.2519/ jospt.2015.5910

Abstract Synopsis Tendinopathy is a very common disorder in both recreational and elite athletes. Exercise, in particular isolated eccentric, has become a popular treatment regime.

There is no convincing clinical evidence to suggest that isolated eccentric loading exercise improve clinical outcomes more than other loading therapies.

Future studies should control for load magnitude, speed of movement, and recovery period between exercise sessions and evaluate exercises to think beyond isolated eccentric exercises regarding rehabilitation of individuals with tendinopathies.

The exact mechanism of tendinopathy is unknown. It is the commonly accepted term for the clinical condition in and around overloaded tendons46 of slow, insidious onset characterised by pain during activity, localised tenderness in palpation, local swelling of the tendon and impaired performance. 45,60 Available interventions for tendinopathy is extensive46 however various lading interventions have predominated in the treatment of tendinopathies.64 These paradigms seem to yield positive clinical, 2,61,88 structural,50 and biomechanical outcomes.49 Stanish et al90 describes an eccentric component rapidly followed by a concentric component. An external load is added for progression as symptoms abated.90 A decade later it was suggested that isolated eccentric contraction alone provided good clinical outcomes for tendinopathy4 and is currently regarded as the treatment of choice.

More recently loading-based exercises such as isolated concentric training, 61 heavy slow resistance training9,49 and concentric/eccentric progressing to eccentric training88,89 have emerged.

Exercise in general can affect skeletal muscle38 and tendon.48 In tendon there is an increase in blood flow and collagen synthesis54,55 and long term effects lead to tissue hypertrophy and altered material properties. 12,85,98 The magnitude and type of adaptation likely depend on the exercise regime.

Tendon is responsive to loading42,66,96 and will respond more strongly to greater loads,56,101 however here is likely an optimum beyond which load becomes detrimental.41,68 Speed may also be important for tendon adaptation6,41,51,56 and it appears that dynamic load is superior to static load.30,41,97 It is unknown if tendons cells experience fatigue from repeated load.

Most exercise protocols for tendinopathy management are performed without recovery periods 4,67,89 but there is a lack of research addressing the effect of recovery and how it effects tendon adaptation.

Although isolated eccentric loading regimes for tendinopathy has been accepted as the treatment of choice, 92 the mechanisms behind this remain unclear.

SPNZ Bulletin December 2015 Issue

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Clinical Section - Article Review Concentric Exercises for the Treatment of Tendinopathy continued...

There are a number of mechanisms that could theoretically differentiate the effect of eccentric from concentric exercise on tendon but there is no evidence that these play a role or are beneficial. The evidence from animal and human studies that suggest a lack of differential effect of eccentric versus concentric.

Eccentric loading regimes for Achilles tendinopathy can provide clinical improvements including reduction in pain and improved function.15,47,88,92 In addition MRI and ultrasound studies show altered structural features after isolated eccentric loading.28,70,71,86 Isolated eccentric loading appears to influence biochemical and biomechanical parameters and improve clinical outcomes. Several studies have compared isolated eccentric loading with body weight, to other types of non-loading therapies.16,76,83,102 Collectively these show positive clinical benefits from eccentric loading but they are unable to show whether the actual muscle contraction mode affect the outcome.

The literature confers that there is some clinical improvement with loading eccentric or concentric but it cannot delineate from that of load magnitude, number of reps and sets, contraction speed and recovery time between sessions.

Similar to Achilles it has been suggested the eccentric loading regimes for patella tendinopathy may provide clinical improvement.8,13,39,78

Collectively studies show that eccentric loading may provide clinical benefits in patella

tendinopathy treatment, but, as for Achilles, whether the direction of the muscle contraction plays a role in the outcome or clinical benefits compared with magnitude of loading is unclear. Isolated heavy eccentric training low reps, high load compared with isolated heavy eccentric squat on a decline with large reps at lower load both improved pain and function.

Summary Clinical Implications and Future Direction Etiology of tendinopathy is incomplete. There are several treatment options though it appears that loading regimes have good clinical results.

There is little evidence for isolating the eccentric component of a loading-based regime, Mechanisms that are likely to influence tendon adaptations appear to be related mainly to tendon load, strain, magnitude, and duration.

There is a paucity of clinical trials directly comparing different exercise regimes and dosages but the available evidence provides little support for isolated eccentric exercises. The focus on eccentric exercise has overshadowed other aspects of tendinopathy rehabilitation, particularly, heavy load and low speed which has some support scientifically and clinically.

References Full list of references available on request.

By Pip Sail Physiotherapist

SPNZ Bulletin December 2015 Issue

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Research Publications 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.

Volume 45, Number 12, December 2015

CASE REPORT Soft Tissue Mobilization to Resolve Chronic Pain and Dysfunction Associated With Postoperative Abdominal and Pelvic Adhesions: A Case Report RESEARCH REPORT The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial Association Between Anatomical Characteristics, Knee Laxity, Muscle Strength, and Peak Knee Valgus During Vertical Drop-Jump Landings Quadriceps Strength, Muscle Activation Failure, and Patient-Reported Function at the Time of Return to Activity in Patients Following Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study Validity and Reliability of the Dutch Version of the International Hip Outcome Tool (iHOT-12NL) in Patients With Disorders of the Hip Electrically Elicited Muscle Torque: Comparison Between 2500-Hz Burst-Modulated Alternating Current and Monophasic Pulsed Current Effects of Neuromuscular Fatigue on Quadriceps Strength and Activation and Knee Biomechanics in Individuals Post—Anterior Cruciate Ligament Reconstruction and Healthy Adults

SPNZ Bulletin December 2015 Issue

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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 49, Number 24, December 2015 REVIEWS A qualitative review of sports concussion education: prime time for evidence-based knowledge translation Martin Mrazik, Christopher R Dennison, Brian L Brooks, Keith Owen Yeates, Shelina Babul, Dhiren Naidu http://bjsm.bmj.com/content/ Exercise for osteoarthritis of the knee: a Cochrane systematic review Marlene Fransen, Sara McConnell, Alison R Harmer, Martin Van der Esch, Milena Simic, Kim L Bennell http://bjsm.bmj.com/content/ Kinesio taping in musculoskeletal pain and disability that lasts for more than 4 weeks: is it time to peel off the tape and throw it out with the sweat? A systematic review with meta-analysis focused on pain and also methods of tape application Edwin Choon Wyn Lim, Mathew Guo Xiang Tay http://bjsm.bmj.com/content/ Exercise-associated DNA methylation change in skeletal muscle and the importance of imprinted genes: a bioinformatics meta-analysis William M Brown http://bjsm.bmj.com/content/ ORIGINAL ARTICLES MRI does not add value over and above patient history and clinical examination in predicting time to return to sport after acute hamstring injuries: a prospective cohort of 180 male athletes Arnlaug Wangensteen, Emad Almusa, Sirine Boukarroum, Abdulaziz Farooq, Bruce Hamilton, Rodney Whiteley, Roald Bahr, Johannes L Tol http://bjsm.bmj.com/content/ PEDRO SYSTEMATIC REVIEW UPDATE Exercise for the management of depression (PEDro synthesis) Nolwenn Poquet, Christopher G Maher http://bjsm.bmj.com/content/ MOBILE APP USER GUIDES Track My Health: a mobile application that allows patients to monitor their health Patrick S Tucker, Aaron T Scanlan, Vincent J Dalbo http://bjsm.bmj.com/content/ Effortless activity tracking with Google Fit Paolo MenaspĂ http://bjsm.bmj.com/content/

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Classifieds DUNEDIN Sportsmed Mosgiel Physiotherapy Physiotherapist Sportsmed Mosgiel Physiotherapy requires a permanent part time working towards full time physiotherapist to start in February 2016.

Sportsmed Mosgiel is a musculoskeletal physiotherapy clinic situated beside the Olympic Gym in Mosgiel. There is an emphasis on manual/manipulative and rehabilitative physiotherapy with appointment times of 30-45 minutes duration to ensure quality treatment.

The ideal applicant should have sound musculoskeletal skills, a great work ethic and hold a current annual practising certificate. Remuneration is excellent, ongoing education is encouraged and regular in-services are held in a relaxed and friendly setting.

The applicant should have an interest in sport and dealing with athletes although a wide variety of patients are seen.

New graduates are welcome to apply.

Please forward CV and cover letter in strict confidence to: Adam Letts Sportsmed Mosgiel Physiotherapy Olympic Gym, 9b Gladstone Road Mosgiel 9024 Email: adam.letts@gmail.com

Season’s Season’s Greetings fromGreetings everyone at SportsFrom Physiotherapy everyNew Zealand one at Sports

SPNZ Bulletin December 2015 Issue