SPNZ December 2016 bulletin by Sports & Exercise Physiotherapy NZ

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Issue 6 December 2016

Feature Fiona Mather - Head of Performance Therapies HPSNZ

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FEATURE TOPIC: Injury Prevention in High Performance Sport

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Contents FEATURE TOPIC: Education SPNZ MEMBERS PAGE See our page for committee members, links & member information

EDITORIAL By SPNZ President Hamish Ashton

MEMBERS’ BENEFITS Re-join SPNZ

FEATURE Fiona Mather—Head of Performance Therapies, HPSNZ

In this issue:

HPSNZ CORNER The Importance of Collecting Good Data in Sports Injury Prevention

CASE STUDY The Forgotten Joint

SPRINZ Symmetry in Running… What is the Literature Telling Us?

ASICS The Key to Optimising Performance Starts With Watching Your Runners Actually Run

CLINICAL SECTION- ARTICLE REVIEW Why Screening Tests to Predict Injury Do Not Work – and Probably Never Will… : a Critical Review

Categorising Sports Injuries in Epidemiological Studies: the Subsequent Injury Categorisation (SIC) Model to Address Multiple, Recurrent and Exacerbation of Injuries

RESEARCH PUBLICATIONS BJSM Volume 50, Number 24, December 2016

CLASSIFIEDS Situations Vacant

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Editorial Hamish Ashton, SPNZ President A big hi to all our members and best wishes for the Christmas period and into the New Year. As an exec our thoughts go out to those who have been affected by the latest earth quake. These events are an unfortunate but good reminder about the need to be prepared, not just with our bottles of water in our emergency kit, but the insurances that cover our work places. We hope that things soon settle down for you. Another unfortunate incident that has made the headlines in the last few weeks is that of a physiotherapist being censured for having a sexual relationship with two rugby players in the team she was contracted to. She told the Tribunal she was an inexperienced practitioner who didn't realise that the rugby players were technically her patients. This first came out in the NZ Herald at the end of November and was quickly taken up by Stuff as well. The physiotherapist was named in the Herald after being found guilty of professional misconduct. Comments and reaction to the Facebook post were interesting as well as varied, and showed the breath of understanding, or lack of it, of what it meant to be a professional, and what was acceptable as a practicing physiotherapist. Some were of the opinion that they were two adults so who cared, while others stated objection to the players remaining anonymous when the physiotherapist was named. A few even showed understanding of the concept of professional behaviour, which was pleasing to read. Three years ago, Sports Physiotherapy New Zealand released the NZ Sports Physiotherapy Code of Conduct. This, a world first, complimented the NZ Physio Board’s Aotearoa New Zealand Physiotherapy Code of Ethics and Conduct, and Physiotherapy New Zealand’s statement on Sexual Boundaries, and took physiotherapy ethics into the sporting scene. It provided clarity, especially to those working in a team environment, as to what was OK and what was not. More recently we (SPNZ) released a contract template to use with teams when working in the sporting scene. The presence of a contract helps safe guard the physiotherapist by defining duties of care, but also helps clarify who is considered under your care. Section 2 of the Sports Physiotherapy Code of Conduct states that “physiotherapists will not exploit any patient/ client whether physically, sexually, emotionally, or financially” (section 2 Part ii). It goes on to state sexual contact of any kind with athlete-patients is unacceptable. It must be realised that even if you are not seeing a particular athlete for treatment at that time, if they are part of the team you look after, then they are your patient.

So how broad does this statement go with respect to who is considered one of your athletes. This is where a contract is of value. If you are contracted to look after the Lowland Presidents team, then the members of that team are your patients. Whereas if you are contracted to look after the Tauranga Old Boys Club then any players or members of that club are potentially your patients. However, like any ethical consideration there is more grey than black and white. Do players get drafted into the Presidents team from the teams above and below. If so these will become patients as well. Some of you may state that “my behaviour with my teams is of a high standard so why should I care”. A couple of months ago you all would have received an email from the Physio Board outlining an increase in fees for our practising certificate. This is largely due to the increased number of complaints they are having to investigate, and a good number of these are of this nature. So financially this behaviour is affecting you. Also, how many of the public would be interested in whether this physiotherapist was a member of PNZ or SPNZ. All they see is the term physiotherapist. This, therefore, reflects on all our practice. So firstly, I recommend you go back and read the Board’s and our Sports Physiotherapy Code of Conduct and refresh yourself with what is and isn’t acceptable practice. Get yourself a written contact when you next work with a team to define your responsibilities and the parties involved. And finally remember we all get placed under the same physiotherapy banner, so talk to your colleagues about this and spread the word, as it is not OK. This type of conduct has no place in our profession.

Have a Merry Christmas and a Happy New Year Hamish

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Feature Fiona Mather BSc (Hons) MSc MMACP HEAD OF PERFORMANCE THERAPIES, HPSNZ

I grew up on a dairy farm in the central lowlands of Scotland, and with generations of farmers on one side and medics on the other, I convinced my father that equine physiotherapy was a viable career option. I graduated with BSc (Hons) from Glasgow Caledonian University and spent 5 years working in London teaching hospitals before embarking on an apprenticeship in equestrian physiotherapy, in the Scottish Borders. Here I learnt the value of non-verbal communication and power of observation; they cannot be understated! I had some unique experiences, treating the Queen’s Highland ponies at Balmoral was a particular highlight. Working with performance horses (eventers and racehorses) I recognised that the athlete, be it horse or human, actually had many similarities when it came to relating injuries to the demands of elite performance. With an appetite for understanding exercise physiology, I undertook a related MSc and paralleled this with completing membership of the Manipulative Association of Chartered Physiotherapists (MACP) at University College London. Please describe your current role and how you ended up there. My first exposure to elite sport was in professional rugby, where I was employed as rehabilitation physiotherapist at Glasgow Warriors. This role was a good insight into the modus operandi of team physiotherapist, reacting to injury versus the more protracted rehabilitation role which afforded a more proactive approach. Operating closely with technical coaches, strength and conditioning coaches to expedite athletes’ return to play and to help them cope with the daily demands of training and competition and ultimately return “fitter, faster and stronger” than they had been pre-injury. Prevention of recurrent injury was a key driver. As a team, we were able to understand the individual and positional risks which contributed to injuries and address these in a proactive manner. The more collaborative the approach, the better the outcome and this athlete centred integrated approach would become the mainstay of my future roles in sport. Having spent several years working with one sport, I felt it important to experience other sports and at that time was fortunate to be appointed as head of physiotherapy

in the Scottish Institute of Sport, the high performance arm of government agency, Sport Scotland. At that time (2003), the institute was a recently formed organisation developing systems and staff who could deliver integrated support to athletes in their daily training environments. Up to this point the interdisciplinary model had only been achieved in professional sport and the advent of High Performance Centres were the entry point for Olympic, Paralympic and Commonwealth sports to benefit from a similar approach. Contrary to popular belief, curling and golf are not the only sports played in Scotland – it turns out they can produce tennis players too! With 650 athletes and 26 Olympic sports/17 Commonwealth sports, the Scottish Institute was one of four “home” countries where the respective sports medicine representatives came together to discuss the unified direction and approach of delivery of sports medicine to British athletes. Around the same time the gradual recognition of the value in centralising sports, housing athletes, coaches and support staff all under one roof. Those sports which centralised early on (cycling, swimming, and rowing) continue to reap rewards across successive Olympiads. CONTINUED ON NEXT PAGE

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Feature Fiona Mather—Head of Performance Therapies, HPSNZ continued... I have been fortunate in experiencing the environments of Commonwealth and Olympic Games first hand, and acted as technical expert on the organizing committees for two home games, London 2012 and Glasgow 2014. On behalf of the British Olympic Association I was appointed as chief physiotherapist of Team GB at the Winter Olympic Games in Sochi. The health team’s role was to provide the optimal environment for athletes to perform on the world stage. Within the Olympic village set up we provide a “home from home” training environment including a physiotherapy rehabilitation unit which allows athletes access to expertise and equipment required to support their preparation and recovery. During the pinnacle events, such as Olympics and Paralympic Games, preparation and continuity is preserved whilst managing the additional pressures which inevitably occur during this most high profile of sporting events. From a performance health team perspective, it is important to consider, in advance, how the team will operate during games time in order to facilitate a very smooth (and familiar) transition for athletes coming into the Olympic environment. The preparation, recruitment and planning for these pinnacle events often occurs years in advance. What are your specific areas of interest/research? Working with elite athletes, the pressure of competition and athletes’ individual drive to expedite rehabilitation often results in them returning to the field of play before achieving adequate preparation to cope with the physical and physiological demands necessary to protect them against re-injury. We can influence and facilitate motor output through handling, appropriate cues and progress training/rehabilitation through varying plane of movement, base of support, progression of load and level of technical skill relevant to the task. Physiotherapists are expert in analysing movement, and the influence of pathology or restriction upon a desired movement outcome and we need to work collaboratively with our colleagues in strength and conditioning and in physiology to ensure that athletes continue to maintain adequate training progressions during each phase of rehabilitation. What do you think are the key elements in successfully preventing injury? The relationship between athlete, physiotherapist is based on trust

coach and and mutual

understanding which stems from the shared objective that is peak performance. The element of physical risk is ever-present and it is the role of the support team to weigh up the risks (intrinsic and extrinsic) together with the health and wellbeing of the individual and to inform the coach. The accuracy in this evaluation will facilitate appropriate decision regarding “athlete readiness” for training on any given day. Physiotherapy is internationally recognised as an essential element of the performance team and there is a growing understanding of the wider aspects of the role: injury management, injury prevention, athlete monitoring, touring and collaborating within the Inter -disciplinary team. Understanding the broader aspects of the physiotherapy role is critical in the elite environment where skilled athletes put their bodies on the line, and often walk a tight rope between achieving their best physical performance and sustaining an injury. Athletes often have an inner resilience and propensity to carry on at any cost, without becoming a “handbrake” to this approach the health team need to guide and influence appropriate levels of training progressions relevant to the individual context. Emerging evidence supports the use of regular (daily) physical benchmarks to establish athlete readiness. They can be used with healthy athletes as baseline criteria for return to sport. See BJSM Blog and embedded link to Rod Whiteley’s slide share on criteria based RTP. http://blogs.bmj.com/bjsm/2015/11/22/hamstringrehabilitation-criteria-based-progression-protocol-andclinical-predictors-for-return-to-play/ Who else is involved in the “support” team that you communicate with and how do you integrate with them to optimise injury prevention and rehabilitation? In my current role, I am privileged to be a part of the high performance system in NZ and together with an exceptional team of physiotherapists around the country, delivering within regional training centres to support New Zealanders on the world stage. Here in NZ, athletes are benefitting from the centralised approach where sport specific physiotherapists provide essential continuity, travelling with the athletes throughout the competitive season. Within the six regional hubs we work within inter -disciplinary teams with expertise from medicine, CONTINUED ON NEXT PAGE

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Feature Fiona Mather—Head of Performance Therapies, HPSNZ continued... nutrition, psychology, physiology and strength and conditioning to provide performance solutions for athletes and sports. The key areas of overlap tend to be during the phased continuum of returning athletes to performance after sustaining an injury and establishing criteria for benchmarking athlete readiness. Are you involved in performance aspects for your clients? In many cases, we have physiotherapists working fulltime, embedded within a sporting environment allowing them to interact on a daily basis with coaching staff and athletes. We have re-framed the approach from reacting to Injury to optimising athlete availability; this approach has been positively received by coaching teams as they believe this is the common thread necessary for us to work in a proactive manner and add significant value to the performance team. What are the key attributes you feel are required to work with elite level athletes? High performance is a rewarding yet challenging setting for the physiotherapist with long tours overseas, in high

pressured environments, managing highly driven individuals, the benefits of our “non-technical” skillsets become important. There is often a tension when balancing health and performance and therefore the individual who has an aptitude to build relationships, work across disciplines and avoid the pitfalls of patch protection will progress well in achieving an athlete centred performance led approach. What do you see as the major challenges for sports physiotherapy? One of the greatest challenges facing us in sports physiotherapy is our ability to understand where we can make a performance impact. There is great opportunity in reflecting on where we have come from, gathering data and sharing knowledge in a meaningful way using the common language that is numbers. Perhaps Dr Seuss explains it best; “Sometimes you will never know the value of a moment until it becomes a memory” and working in sports I’m sure there are many physiotherapists who get that!

HPSNZ Corner The Importance of Collecting Good Data in Sports Injury Prevention By Duncan Reid, Professor and Physiotherapy Advisor to HPSNZ and Fiona Mather (Head of Performance Therapies HPSNZ) In a previous paper to the sports physiotherapy group we outlined the pathway to becoming a High Performance New Zealand (HPSNZ) provider and the overall programme of work currently being put in place. (See Reid and Mather SPNZ bulletin April 2016). In this paper we would like to discuss the importance of consistent and appropriate data collection on athletes within an injury prevention framework and why this should be a model for all sports physiotherapists to follow and understand. When one embarks on a career in sports physiotherapy often the starting point is providing excellent individual care. Athletes are often looking for different and innovative approaches get them back on track and also that “miracle cure”. Those of us that have been in this world for a while soon realise there are few miracle cures and that spending lots of time at the bottom of the

cliff treating injuries becomes a little tiresome. So sooner or later you start looking at why injuries are occurring and how to reduce them. This usually fits with the coach as they are interested in having more athletes available to train more of the time and get frustrated with too much time out due to injury or illness. Athletes also don’t want to be injured and most have clear performance goals they want to achieve. In the last paper we mentioned the work of Raysmith and Drew (2016) who have demonstrated that athletes are seven times more likely to achieve performance targets if they complete greater than 80% of planned training. Therefore as a sports physiotherapist our role is to ensure that athletes are available to train and remain injury free more of the time. This may also require a change of language from injury treatment to injury management! CONTINUED ON NEXT PAGE

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Feature The Importance of Collecting Good Data in Sports Injury Prevention continued... So where does all this sit in the injury prevention cycle and what is the importance of the data. The four step sequence of injury prevention (Figure ) was developed by van Mechelen et al. (1992) to formally describe the

process of injury prevention research. This sequence of injury prevention has been the classic approach to sports injury prevention research over the past 25 years.

Figure 1 "Sequence of prevention" (from van Mechelen et al 1992)

As described by van Mechelen et al. (1992), to prevent injuries we first must understand what the extent (incidence and prevalence) of the problem is. Only then can the next questions of what causes injuries and by what mechanisms they occur, can be studied. The answers to these questions enable preventive measures to be instigated. The preventive measures must then be validated by showing a reduction in the frequency of who is at risk for injury and the type of injuries sustained (van Mechelen et al., 1992). As a physiotherapist about to undertake a sports team appointment ensuring you know the size and impact of the problem is critical before you start implementing programmes. In other words you better know what is at the top of the cliff before you start treating at the bottom of the cliff. Once you have a clear handle on part one of this model you can start to look at part two, aetiology and mechanisms. This is often where injury benchmarking comes in. This is a somewhat controversial area of the job. A recent paper by Bahr (2016) titled “Why screening tests to predict injury do not work—and probably never will…: a critical review” provided a critical commentary of this area of work.

Bahr’s suggestion that screening will not predict injury is based in current research that has used screening test to predict injury going forward rather than taking the key aspects found in the screening, then applying an intervention to those key factors and seeing if you make a difference. In other words there is no point in doing steps 1 and 2 in the above model without applying 3 and 4. In everyday practice we do a modified form of benchmarking often this is the key assessment. Perhaps we should call this filtering! Then we identify the main issues and set up a treatment. At the next visit we evaluate the effectiveness. Hence you are already doing the Van Mechelen cycle. The key thing is to record this against well validated and effective outcome measures. However as this is done on an individual basis we also need to get an overview of the whole team The figure on the next page outlines the injury profile across a team sport (see figure 2). The Y axis represents the number of days off training, the X axis the types of injury.

CONTINUED ON NEXT PAGE

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Feature The Importance of Collecting Good Data in Sports Injury Prevention continued...

The obvious thing to note is that thigh injuries are the most prevalent. The blue bar represents the number of injuries and the orange bar the days lost to training, in this case nearly 40 days per injury. Across the team for that season that equates to 280 days lost to training. Achieving predicted level of performance at a pinnacle event is significantly reduced if athletes are unable to maintain their availability to train (Raysmith and Drew, 2016). Data displayed in this manner can influence coaching and training, to manage athletes training load during key transitions throughout the Year. Longitudinal data compared year on year demonstrates athletes availability and evaluates the long term efficacy of injury prevention strategies. Having this type of data is powerful to show athletes and coaches where the efforts need to go to reduce this profile. The injuries will never be eliminated but have less of them and having plans that keep players training will see a greater impact of sports physiotherapy than just treating the hamstring! In summary have a clear model of injury prevention is key to improving performance. Collecting good data around the type, frequency and contributing factors to injury then allows a logical and targeted intervention to be put in place to see a reduction in the impact of the injury and the time lost to training. This will achieve a shared goal of more New Zealanders winning on the world stage.

References Bahr, R. (2016). Why screening tests to predict injury do not workâ&#x20AC;&#x201D;and probably never willâ&#x20AC;Ś: a critical review. British Journal of Sports Medicine. doi:10.1136/ bjsports-2016-096256 Raysmith, B and Drew, M Performance success or failure is influenced by weeks lost to injury and illness in elite Australian Track and Field athletes: a 5-year prospective study. Journal of Science and Medicine in Sport (2016), http://dx.doi.org/10.1016/j.jsams.2015.12.515 van Mechelen, W., Hlobil, H., & Kemper, H. C. G. (1992). Incidence, Severity, Aetiology and Prevention of Sports Injuries. Sports medicine, 14(2), 82-99. doi:10.2165/00007256-199214020-00002

Duncan Reid Professor and Physiotherapy Advisor to HPSNZ Fiona Mather (Head of Performance Therapies HPSNZ)

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Case Study The Forgotten Joint Subjective Examination A 34 year old man was referred by his General Practitioner with a diagnosis of knee sprain. During a rugby game (front row player) he felt his knee slowly becoming stiff. He could not record any give- way or trauma during the game. He was able to finish the game. The next day the knee felt very stiff and painful with knee flexion and extension. There was no apparent swelling. The patient had experienced one week of pain that he rated 8 on a 0 - 10 visual analogue scale of pain, where 0 means no pain and 10 means the worst possible pain. Symptoms were lateral/posterior and medial aspect of the knee during extension or flexion of the knee. No past history of similar knee problems but the patient had complained for a month about quadriceps stiffness. Activities which increased the symptoms were; initiating any movement of the knee and walking. There were no symptoms during rest and no night pain. Physical Examination Observation: Standing up from sitting was painful, fully weight bearing was painful and the patient walked with a considerable limp. Active ROM: 80/20/0 and Passive ROM: 100/10/0 with no hard end feeling. The adjunct joints like lumbar spine, hip and foot where all found to be ok. A 1 cm circumference difference of the right and left calf was present , presumably due to being right footed. Full strength against resistance for quadriceps and hamstrings muscles was found (muscle strength 5/5). The right quadriceps was significantly shorter compared to the left quadriceps. Popliteus muscle tested negative against resistance. Knee flexion against resistance and passive rocking of the fibular head were both painful over the proximal Tib-Fib joint. No ankle pain or instability. Neurological testing showed no motor or sensory loss. Ligamentous laxity tests: MCL, LCL, Lachmann, McMurray, Pivot shift and anterior drawer tests were all negative. On palpation: no swelling of the knee, no lesions or discolouring, skin temp ok. Special tests: Patella mobility: ok, proximal Tib-Fib joint was painful and mildly unstable to posterior stress. Clinical Reasoning Clinical presentation along with the examination findings points to the diagnosis of a posterior Tibio-Fibula joint sprain. Playing in the scrum being bent over and trying to drive forward requires significant loading of the lower extremity. It is assumed that the fibula and its head are helping in dissipating these extreme forces during scrummaging. Intervention The proposed treatment plan in this case was; passive mobilisation of the proximal Tib-Fib joint with instructions for a selfmobilisation technique, taping (joint compression ) and reduce weight bearing if painful. To confirm this plan of action mobilisation was trialled of the posterior Tib-Fib joint. The patient was lying supine with the right knee in 90 degrees flexion, passively mobilising the Tib-Fib joint in a P/A and longitudinal (caudal) direction. The positive response to this treatment, with increased active ROM 120/10/0, no pain on weight bearing and reduced limp, confirmed the diagnosis. The patient was instructed how to self-mobilise the joint in sitting and shown a taping technique to support and give resistance to posterior movement of the proximal Tib-Fib joint. Additionally the patient was instructed in stretching exercises for his quads and hamstrings. One week after the second visit the patient was fully weight bearing without any pain and had started light jogging Outcome Follow up phone calls after the two and three weeks found the patient still fully symptom free and he had started to train for rugby again. References Radakovich, M. & Malone, T. (1982). The superior tibiofibular joint: the forgotten joint. Journal of Orthopaedic and Sports Physiotherapy, l3(3), 129-132. Forster, B., Kelly S. & Oâ&#x20AC;&#x2122;Dowd, M. (2007). Proximal tibiofibular joint: an often forgotten cause of lateral knee pain. American Journal of Roentgenology, 188(4), 359-366. By Rene deVries

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SPRINZ Symmetry in Running… What is the Literature Telling Us? By Kelly Sheerin Approximately half of all runners will sustain an injury in a given year [1], and many of these injuries will occur on the same side of the body. As such, assessing the difference between legs is common in making clinical decisions regarding injury risk and appropriate rehabilitation. On the surface, this difference between legs, or degree of asymmetry seems fairly straightforward in the everyday clinical world. Due to practical and cost-effective reasons, these assessments around are usually subjective and observational conducted by physiotherapists or other clinicians. Despite their widespread use, the foundations of assessments of symmetry are a little less clear. Despite the number of studies examining factors associated with running injuries, little is known about why an individual gets injured on a particular side of the body. The majority of studies have compared the injured side of injured runners to an arbitrary side of healthy controls [2-4]. While this information is useful for identifying why an individual gets injured, it does not elucidate why they become injured on a particular side.

Prominent researchers have proposed an arbitrary cutoff value of 10% deviation from perfect symmetry as a criterion of asymmetry in gait [5]. This value is easy to interpret, and feasible for use in the clinic, as well as in research. As a result it has been adopted by many in a multitude of settings and applications, including for individual patients, as well as groups. A percent difference, or symmetry index, as described above, essentially describes the difference between two points with respect to an appointed reference. While these ‘difference equations’ have been used extensively throughout the literature, inconsistencies in reference selection make uniform comparisons difficult. That is, should we be comparing high with low, injured to non-injured, dominant to non-dominant? Whichever we chose could have a drastic impact on the outcome and therefore it’s interpretation. In an attempt to resolve the fundamental issues in the symmetry index, Zifchock and colleagues [6] described a symmetry angle equation. Put simply, the symmetry angle  is

a function of the ratio between two values (bilateral legs in the case of runners), and describes any deviation away from the line of perfect symmetry. On the positive side, unlike its predecessors, the symmetry angle does not suffer from reference selection, over- or artificial inflation. On the negative side, the equation is far from simple to calculate non-the-less interpret in the clinic setting. So if the research is not providing us with great evidence and guidance with regard to symmetry and asymmetry, are we best to ignore it until the windscreen becomes a little clearer? I suggest not, as there is certainly evidence to suggest that it is an important factor for some [7]. There may not be great guidance on how to interpret symmetry in runners right now, but I predict that from the large quantity of research currently underway, we will begin to develop parameter-specific criterion, with appropriate cut-offs for symmetry. However, these will vary between measures and won’t necessarily be the 10% difference that has been so commonly adopted in the past. 1.

Walter, S. D., Hart, L. E., McIntosh, J. M., & Sutton, J. R. (1989). The ontario cohort study of running-related injuries. Archives of Internal Medicine, 149, 2561–2564.

Ferber, R., Davis, I. M., Hamill, J., & Pollard, C. (2003). Prospective biomechanical investigation of iliotibial band syndrome in competitive female runners. In 50th Annual meeting of the American College of Sports Medicine, San Francisco, CA.

Hreljac, A. (2004). Impact and overuse injuries in runners. Medicine and Science in Sports and Exercise, 36, 845– 849.

Milner, C. E., Ferber, R., Pollard, C. D., Hamill, J., & Davis, I. S. (2006). Biomechanical factors associated with tibial stress fracture in female runners. Medicine and Science in Sports and Exercise, 38, 323–328.

Robinson RO, Herzog W, Nigg BM. Use of force plate form variables to quantify the effects of chiropractic manipulation on gait symmetry. J Manipulative Physiol Ther 1987;10(4):172–6.

Zifchock, R. A., Davis, I., Higginson, J., & Royer, T. (2008). The symmetry angle: A novel, robust method of quantifying asymmetry. Gait and Posture, 27, 622–627.

Zifchock RA, Davis I, Hamill J. Kinetic asymmetry in female runners with and without retrospective tibial stress fractures. J Biomech. 2006;39(15):2792-7.

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ASICS

The Key to Optimising Performance Starts With Watching Your Runners Actually Run Dr Chris Bishop PhD Head of Biomechanics – The Biomechanics Lab Post-doctoral Research Fellow, University of South Australia When we think about the needs of our running patients, I think we can sum them up simply (and in order) with three strategies and/or needs: 1. Minimise the risk of injury 2. Run further (likely through a weekly increase in volume in training program) 3. Run faster (or introduce speed work to program) Our market research indicates this is what runners feel is important in terms of optimising performance. When we search the literature to help guide us how to improve one’s performance in clinical practice, we often become stuck. It’s not that there’s a lack of literature relating to biomechanics, running economy and performance, but rather a lack of information that is relevant and translatable to the populations we see in clinic. Most running research is conducted at approximately 5 ms-1 (which equates to 18 km/h) and it would be fair to say this is not representative of most of the patients who would present to our practices. My point is that we need to understand the needs of our patients and what is likely to help them. Seminal research out of the University of Melbourne’s Lab has demonstrated the power transfer shift more proximally that occurs in fast running, and it is easy for practitioners to become obsessed with generating hip extensor strength for improved performance (i.e. hamstrings). However, a simple look across the data identifies that at recreational running speeds (i.e. < 5ms -1 ), the greatest contribution to forward momentum is through gastroc-soleus. This indicates the importance of understanding the foot and ankle in this population… and the only way we can understand its function is actually to watch our patients run!

So let’s begin… The movement of the foot and ankle underpins everything our patients do. We put all of our body mass through it every step we take – one foot in front of the other. When we walk and run, up to three times our body weight is applied through our ankle to the ground, with the same force applied directly back on the body1. This puts potentially damaging forces through our bones, ligaments and tendons, and it is our job to be able to analyse someone’s movement profile to determine if this is likely to be a problem. Research using gold standard motion capture techniques has directly informed our understanding of foot and ankle motion during gait. The kinematics (i.e. motion) of the foot during barefoot tasks have been studied in detail, giving insights into the motion at the level of the foot during walking and running2-3. Previous efforts have stemmed right from simple rigid segment models to describe idealized foot motion, through to bone pin work describing the movement of the individual bones of the foot2-5. This research has identified that motion occurs at multiple areas of the foot and that it is inappropriate to consider the foot as one segment. The current trend in the literature is to model the foot as at least three (if not four) individual segments to represent the hindfoot, midfoot, forefoot (metatarsals) and the toes. The research is conclusive that most motion at the level of the foot and ankle occurs in the sagittal plane, yet with large variability between subjects2-3. Research efforts have also given us new appreciation for the amount of motion occurring at the level of the midfoot (talonavicular and medial cuneiform-navicular joints). Overall the data in the literature demonstrates the complexity of the foot and ankle, and specifically the importance of the joints distal to the rearfoot in its overall dynamic function. Despite the detail of these studies, it is highly infrequent, in a Western society, that activities of daily living would be undertaken barefoot. Despite the barefoot debate, and the noted differences between running barefoot and shod, in reality, most people run with shoes on (of some form)6. This presents a unique set of challenges in terms of not only understanding the motion of the foot inside the shoe, but the effect that footwear design and in-shoe inserts (i.e. orthotics) have on the foot at the level of the foot-shoe interface. In CONTINUED ON NEXT PAGE

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contrast to what many footwear companies will have you believe, our understanding of in-shoe foot interaction and footwear biomechanics is extremely limited7. Understanding the true mechanisms of effect of footwear technologies has largely been restricted by both the inability of human eyes to see through the shoe upper, as well as a lack of accurate methods to analyse foot motion inside the shoe during gait. Based on current evidence demonstrating small effect, the concepts that manipulating midsole geometry (e.g. dual density) or inserting a rigid heel counter to stop the foot pronating is unsubstantiated8. Likewise, the concepts relating to increased cushioning as a result of shock attenuating systems of responsive foams to reduce loading rates of force remains questionable, especially given that there is minimal evidence to suggest high loading rates are a predictor of a lower limb injury9. This has led to the proposal of new theories, all of which focus on individual responses10-11. The take home message from the literature is that any changes as a result of shoe design features are small, and nonsystematic. Further, any changes to the foot inside the shoe as a result of footwear and/or orthotics certainly cannot be seen with the naked eye as research shows that analyzing the motion of the shoe upper is not the same as the foot inside the shoe7. Now this is certainly not me saying the footwear does not have an effect on the human body…it most certainly does. But it is important to understand that there is large variability between individuals’ response to footwear, and if anything, this supports the range of footwear present in most retail stores. The commercial reality is that all shoes, no matter their design, work for someone. This has direct implications for transforming the way we analyse gait – with less emphasis on quantifying motion control and more emphasis on how ‘comfortable’ interventions can begin to work with the foot to restore optimal function. So the question remains though – how best to replicate such detailed analytical methods in a clinical environment where we don’t have access to half a million dollars worth of motion capture equipment. Do we need to? These questions are all answered with a true understanding of the role of gait analysis in a clinical context – to provide information about movement profiles of individuals back into the clinical decision making matrix. I have spent a great deal of time advocating to other therapists the need to be able to effectively analyse gait patterns in a clinical environment. This is specifically important for running – I

just don’t understand the concept of treating running injuries without an ability to analyse running biomechanics in clinic. We walk differently to how we run1-12. How people run is arguably more variable to how people walk and this requires thorough analysis. To ensure our analysis is as accurate as possible, we must optimise setup, as well as the analytical processes we use. In terms of logistics, the most cost effective method to do this in a clinical environment is with the use of treadmills. Before we argue whether treadmills can replicate overground running, let’s first understand what a treadmill does. The motor accelerates your centre of mass (COM) instead of you having to do this overground. Also, when running indoors on a treadmill, we also don’t have the same effects of climate (i.e. heat, wind etc.) that can influence the physiological expenditure of the run. In terms of biomechanics, research has suggested small differences exist when running overground vs. on a treadmill (even though it is argued that results are generalizable13-15). I acknowledge this may be the case, yet the larger issue is the physical effort running on a treadmill vs. overground outdoors is likely to be less. In saying this, it can be controlled for with a number of setup considerations that if we get right, improve the representativeness of the gait pattern seen. Firstly, the treadmill needs to be as stiff as the ground to ensure we don’t introduce compliance into the system. Think those bouncy treadmills we have all run on – these will increase the displacement of the COM and have consequent effects on increasing joint motion16. Secondly, the treadmill motor needs to be more powerful (ideally > 2.5 HP) than the force the runner applies to it when they land to prevent belt slippage and increased braking forces. Thirdly, and most importantly, is matching physiological cost and lower limb biomechanics. Research has suggested that raising the incline of the treadmill to 1% mimics the economic cost of over-ground running, yet this will change biomechanics17. It is plausible to think that if we set someone’s analytical running speed based on their perceived level of exertion (i.e. BORG’s scale RPE) rather than speed (yes this has them run faster on a treadmill), we may get a more representative gait pattern that minimises the differences in biomechanics (and changes in biomechanics are likely to be within measurement error of 3D motion systems). Further, appropriate acclimatisation of the treadmill for up to six minutes has been shown to reduce the variability in stride-to-stride fluctuations18. And if we want to really go CONTINUED ON NEXT PAGE

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to the next level, we can place a large fan in front of the treadmill to create wind resistance. By taking a moment to think about the logistics of our analytical environment, we come out the other end with an incredibly controlled environment that has large benefits in terms of being able to describe multiple foot falls, have our patients run at any speed (training vs. tempo vs. race pace), and for as long as they want (induce fatigue). With the setup now right, we lend our attention to the analytical component of gait analysis. For years, clinicians and scientists have been fascinated by the way humans move and the analysis of gait has formed a large part of clinical practice for many practitioners. With the development of technology, we are constantly being inundated with different options to conduct this rather complex task. But do we need it? Can we analyse gait without technology? What can we see with our own two eyes and what does the addition of video feedback provide? Firstly, we need to appreciate what we can’t see with our own two eyes. Think forces, muscle activity, in-shoe foot movement when wearing shoes. We need to accept that without gold standard techniques, we can’t infer this level of detail. In saying this, it is likely that subjective feedback (i.e. self-perceived comfort, stability etc.) from our patients is going to provide a level of information that gives inferences to underlying mechanics at play. What I do see the need for though is the addition of video gait analysis (or a method to slow down and replay movements). I constantly get questioned as to what it adds to my practice and it’s a research only tool. Although I believe this is wrong, the argument that video analysis does not identify anything that a trained eye cannot is complete rubbish, and is often a sign of a practitioner who does not know when and how to utilise this technology. The human eye simply cannot see all the complex interactions of the foot and ankle during gait. It can’t break down the movement of the hindfoot, midfoot, forefoot and toes in real time, which research has indicated is required information2. It cannot play side by side movement profiles of barefoot and shod motion, or multiple shoes effect on the foot and ankle. Yet, before you even get the patient in the clinic, you must be comfortable within you own assessment protocol as to what is the purpose of gait analysis. Will it: A. Alter the treatment that the patient is given? B. Improve the outcome for the patient?

C. Simply provide a marketing avenue for the business? If it’s the latter, you are wasting your time and going about it the wrong way. Although it may look good, it takes time and considerable expertise and the appropriate utilization of gait analysis must always have the intention of improvement in technique or treatment prescription. It has to directly benefit the patient. We have to be able to report meaningful clinical outcomes, whether they be simply the visualization of applied interventions (think different shoes, taping techniques, orthotics etc.) or the success of suggested retraining protocols. It is not designed as a quantitative process in a clinical context – drawing lines to infer calcaneal eversion is incredibly inaccurate and offers little to the overall clinical management in terms that A) abnormal pronation cannot be quantified, B) pronation is not a risk factor for injury and C) interventions have a small and negligible effect on changing biomechanics. If anything, it’s a sign of being preoccupied with previous paradigms of motion control, and perhaps we need to shift our thinking towards more of qualitative point of view in terms of quality of movement occurring11. What is most important, and where the benefit of 2D analysis lies is in the quick description of gross movement changes, especially in the sagittal plane. This is assisted with one of the many pieces of software available on the market (be careful – not all are both MAC and PC compatible). Forward trunk lean, anterior pelvic tilt, knee flexion, ankle plantarflexion, arch deformation and hallux dorsiflexion can all clearly be seen, with the later outcomes giving good insight in terms of the natural mechanism of shock attenuation as well as quantification of foot strike patterns. Of course this implies that the camera is sampling at an appropriate rate (ideally > 100Hz / 100 frames per second) to be able to visualise/capture an appreciation of the movement of each joint through each phase of gait (initial contact, loading response, midstance, propulsion, swing). The addition of a second camera in the coronal plane has benefits for visualising foot progression angle and hindfoot motion, yet caution needs to be taken when inferring the magnitude of eversion (i.e. pronation) occurring as the visual appearance could be masking some influence of transverse plane foot motion (i.e. over - or under-estimating the amount of eversion really occurring). Regardless the setup, it is important that the outcomes get fed back into the clinical decision making matrix. Let me stress this…Gait analysis is not

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prospective in this environment – it does not infer why the problem is present. What it does provide in a clinical environment is a visualisation strategy to assist in making decisions on how best to reduce the load on pathological structures of the foot and ankle to restore asymptomatic function. So with this discussion, where should we be heading? If it is so important to performance optimisation, how should we be using gait analysis to analyse foot and ankle function in a clinical environment? Can we simplify our approach? To answer this, we are likely to benefit from reviewing our understanding of biomechanical theory, foot and ankle function during gait, the role of gait analysis in our assessment, and where gait analysis fits into the diagnostic matrix. To effectively analyse foot and ankle motion during running, we need to have: 1. An understanding of all the foot and ankle biomechanical theories so that we can apply the most relevant theory to the clinical presentation at hand. 2. An understanding of what clinical tests can be conducted to provide value as an input to the dynamic gait evaluation. Although static tests do not dictate dynamic function, they certainly can provide valuable insight into restrictions in range of motion that are likely to cause compensatory patterns when analysing gait.

need for a more individualized approach to the assessment of human movement of our patients. 6. An appreciation that the foot moves inside the shoe and we can’t infer in-shoe foot motion when analysing shod gait. Inferences can be made from the analysis of barefoot gait, assuming that temporal-spatial parameters do not change. 7. An understanding that the foot-shoe complex in a clinical context is a black box (a template), whereby we can add elements of design and/or technology to influence the way the foot functions and/or to modulate the load applied at the footshoe interface. 8. Force dictates motion. When we run, a force is applied to our body that causes us to move in a particular manner. In a perfect world, our muscles are strong enough to counteract this force and provide a stabilizing effect, but often this isn’t the case and we get an imbalance between the external forces acting on our body and the internal forces trying to stabilise the body. This is when we likely experience pain and injury.

3. An understanding of the differences between walking and running gait, and the appropriate facilities to describe both gait patterns. 4. An understanding that the human eye cannot observe, process and interpret all of the complex movements of the human body. We need high speed video to assist us in seeing the intricate movements of the foot and ankle that may be contributing towards someone’s pathology. 5. An appreciation that each individual is unique and requires personalised attention. Comparing a patient’s running gait profile to a theoretical or population norm has one large issue – that there is such a thing that is normal. Each person has their own unique DNA sequence, their own biological passport and therefore their own risk factors for injury. Therefore what is normal for one person is not necessarily normal for someone else. There is large variability in how individual patients move and respond to different conditions, leading to the

An appreciation that biomechanical effects can be applied without a change in visual appearance to the foot. Therefore, just because the appearance of foot motion (i.e. the kinematics of the foot) does not change with orthotics (i.e. the foot is still everted), does not mean that the orthotic is not or cannot be applying a force that is sufficient to alter the internal forces of the intrinsic muscles that are required to effectively offload the tissue. Knowledge of footwear. In light of the challenges of

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barefoot running, minimalism, maximilism and everything in between, it is up to the sports medicine professional to be equipped with the latest knowledge relating to the effect of footwear on the human body. And this knowledge is not just about joint kinematics and loading rates! Recent research data out of our lab at UniSA is starting to uncover interesting trends. Not only is comfort the most important factor in someone actually buying shoes, but it has a direct influence on performance. Look out for my colleague Joel Fuller’s work on traditional vs minimalist footwear in running; yes transitioning to minimalist shoes was associated with faster 5km time-trial times, yet he showed that an increase of body mass in those that transitioned was associated with a higher risk of injury. This gives evidence to the ‘protection-weight scale’ that has been discussed for years…the heavier a runner is, the more protection hey likely need from the shoe. So what does this all mean… The technology of gait analysis is moving rapidly, and as sports medicine professionals, we must embrace this to assist us in the diagnostic and/or assessment process. The way humans move is extremely complex. The foot and ankle, through simply being the weight-bearing joint of interest, underpins everything we do at recreational running speeds. Add to this the unique demands of individual sports, different surface terrains, variability in footwear designs and the increased in orthotic and/or bracing use, and we have a situation which requires careful thought and consideration. Clinical examination and experience are no longer sufficient to analyse the complexities of the foot and ankle during gait – static assessment does not dictate dynamic function. We need to embrace technology to better describe complex anatomical function during running. Yet we don’t necessarily need expensive motion analysis setups to analyse most runners. We now have broad applications of technology at the grasps of our finger tips, many of them free of charge and accessible right in the palms of our hands. We are slowly running out of excuses. The key to effective clinical management of the foot and ankle likely lies in taking the time to understand your patient’s biomechanical profile and the intricate interactions not just at the level of the foot, but how the foot can influence proximal mechanics. This is simply not possible without being able to analyse your patient run.

Chris Bishop content provided through the support from our SPNZ sponsor – ASICS

Dr. Chris Bishop is a Post-Doctoral Research Fellow in the Alliance for Research in Exercise, Nutrition and Activity (ARENA) at UniSA. Chris graduated with a Bachelor of Podiatry in 2007 and a Graduate Diploma in Podiatry in 2010. Chris commenced his formal research training in 2010, with his Master's Thesis developing the first biomechanical model to describe how the foot moves inside the shoe. Chris' PhD investigated the role of custom foot orthotics and athletic footwear in the management of plantar fasciopathy. Chris's current research now relates directly to foot function, athletic footwear and foot orthotic design during walking and running. Chris is an ASICS industry funded Research Fellow, allowing him to develop a custom running performance lab equipped with 3D motion capture, an instrumented treadmill, PARVO Gas Analysis, EMG, PEDAR plantar pressure and high speed videography. Through this lab, he conducts not only innovative research, but also runs the external ASICS wear-test program in Australasia. The program involves independent biomechanical analysis of footwear product, as well as comfort, performance and economic considerations. The program assists ASICS in better understanding where their footwear sits in the consumer marketplace, as well as developing new concepts for product innovation.. Outside of Chris' research role at UniSA, he runs a busy sports podiatry practice at Leading Edge Physical Therapy, as well as being the Director of The Biomechanics Lab. The Biomechanics Lab is South Australia's only private 3D Motion Analysis laboratory. With two separate labs optimised for rehabilitation and running performance, patients are provided with analytical services that were previously only available in a research environment or high level sports institutes. This level of analysis allows the translation of biomechanical data into clinical practice to improve patient outcomes.

Chris Bishop B.Pod Master of Health (Human Movement)

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Clinical Section - Article Review Why Screening Tests to Predict Injury Do Not Work – and Probably Never Will… : a Critical Review Reference Bahr, Roald (2016). Why screening tests to predict injury do not work – and probably never will…: a critical review Br J Sports Med, 0: 1-6 SUMMARY Screening is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. This enables early intervention and management in the hope of reducing future morbidity and mortality. An example of a recent screening programme is breast cancer screening with mammography. These screening programmes have distinctive outcomes. The individual either has the disease or doesn’t. However, when screening for injury risk the outcome is usually continuous. Performance tests are usually used to detect an impairment which predisposes an individual to injury and these can have varying outcomes. There is a misconception that once statistically significant associations with a screening test and increased injury risk is identified that the test will predict who is at risk of injury. This is only the first step of a validated screening programme. The next stage is to determine how well the test predicts who and who does not become injured in a new population group, different from the original test group. The final stage is then to examine the efficacy of a screening programme. This is completed using a randomized controlled trial, where the treatment group receives the combined screening and injury prevention programme. The difference between disease screening and athlete injury screening is that if a disease is detected treatment will only be provided to the individual with the disease. In athlete screening, intervention can be provided to all athletes as there is usually no risk associated with the prevention programme. However for the screening programme to be more relevant and applicable to only those at risk, the screening tests needs to be able to capture the majority of athletes with increased injury risk but also separate athletes with low risk. The optimal cut-off value for screening purposes is not always the value representing the best fit. If the intervention is costly or time-consuming a high specificity cut-off may be more appropriate. If the intervention is less costly and less time-consuming, a high sensitivity is more reasonable.

IMPLICATIONS FOR PRACTICE To date, there is no screening test available to predict sports injuries with adequate test properties and no intervention study providing evidence in support for screening for injury risk. So, should we still perform screening examinations? Screening examinations can serve several other purposes. It allows for a comprehensive assessment of the athlete’s current health status, allows review of past and current musculoskeletal history and relevant follow up, establishes a performance baseline, establishes a rapport between medical staff and athlete, reviews medication and supplementation to avoid inadvertent doping, and in some settings, satisfies medicolegal duties of care.

By Amanda O’Reilly BPhty (Otago)

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Clinical Section - Article Review Categorising Sports Injuries in Epidemiological Studies: the Subsequent Injury Categorisation (SIC) Model to Address Multiple, Recurrent and Exacerbation of Injuries Caroline F Finch,1 Jill Cook2 British Journal of Sports Medicine 2013;00:1-6. Doi:10,1136/bjsports-2012-091729 ABSTRACT Sports injuries are often recurrent and there is wide recognition that a subsequent injury can be strongly influenced by a previous injury. Correctly categorising subsequent injuries requires substantial clinical expertise and objective statistical criteria. The handling of subsequent sports injuries is a substantial challenge both in terms of injury treatment and epidemiological research to quantify them. Application of the SIC model allows for multiple different injury types and relationships within players as well as different index injuries. Sports injuries are often recurrent and there is wide recognition that a subsequent injury can be strongly influenced by a previous injury.1-5 This could be due to similar mechanisms or risk factors involved in causation or limited tissue healing from earlier injury.6-7 The aims of this paper are to present a new model for categorising ‘subsequent’ injuries in a sports injury context. The term ‘subsequent’ injury is preferred to encompass multiple and recurrent injuries as well as allowing for exacerbation of an injury. ‘Subsequent’ injuries have generally been considered from a clinical management and return-to-play perspective.1-3, 10-12 Most guidelines for properly classifying injuries have followed the suggestions of Fuller et al. 7 The SIC model takes in to account the need to include both acute and overuse injuries as conceptualised by Bahr. 8 Compared to existing sports injury definition it adopts a more statistically orientated approach towards categorising injury types. This approach is consistent with statistical modelling principles 17 and was constructed using Bayesian data analysis principles.18 The categories within the SIC model are holistic and intended to capture all types of subsequent injuries while being mutually exclusive. If an athlete sustains several injuries and these are recorded in sequence then it is possible there will be different index injuries. To allow for competing injury risks the model needs to allow different and multiple index injuries. One of the challenges with coding injury data from sequences of this type collected over a period of time is, identifying index injuries as the ‘subsequent’ injury status, always needs to be determined in relation to earlier injuries in a series. When a player sustains more than two injuries it is possible that the first injury is no longer the appropriate index injury for subsequent injuries. Preventing subsequent injury and optimising its clinical management requires a strong evidence base. There needs to be robust, high quality data from sports injury research and there is a need for a set of objective and validated subsequent injury definitions that can be appropriately applied where within-player dependencies occur and provide an inclusion of acute and overuse injuries in one sports injury model. Preventing sports injuries requires players’ ability to tolerate repeated exposures to injury risks while being active in their sport. Better identification of risk factors leading to initial injury may help identify strategies for preventing similar subsequent injuries. Subsequent injuries could also occur because injured players continue to participate in their sport with modification of their technique, physical adaptation or maladaptation, complete or incomplete recovery from injury or a combination of these factors. Thus their risk of further injury will differ from their first injury. Coding data with the SIC model provides clear definitions of recurrence, aggravation and exacerbation and would help identify if the injuries were new index injuries more so than using the Hamilton et al 4 injury classification and thus allow better injury management. The recognition and handling of subsequent sports injuries pose a substantial challenge for sports medicine practitioners. A better understanding of the nature, causes and outcomes of subsequent injuries will have major implications for sports medicine clinical practice because returning players to pre-injury function, ensuring recovery of the physical function and preventing future injuries are major goals in treatment. SUMMARY This paper presents a new model to categorise subsequent sports injuries derived from statistical considerations of dependencies between different injuries and sports medical clinical considerations. Greater capacity to classify subsequent injuries will allow improved understanding of the effect of initial injury on re-injury and injury exacerbations from both clinical management and injury prevention.

By Pip Sail Physiotherapist

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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 50, Number 24, Deember 2016 WARM UP Soft tissue injuries are still a challenge in musculoskeletal sports and exercise medicine Nikos Malliaropoulos, Mourad Ghrairi, Yacine Zerguini, Nat Padhiar http://bjsm.bmj.com/content/ EDITORIALS What does ‘preventive training’ prevent in competitive sport? Per Bo Mahler, Boris Gojanovic, François Fourchet, Finn Mahler, http://bjsm.bmj.com/content/ Fat pads adjacent to tendinopathy: more than a coincidence? Ella Rose Ward, Gustav Andersson, Ludvig J Backman, Jamie E Gaida http://bjsm.bmj.com/content/ CONSENSUS STATEMENT 2016 consensus statement of the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains Phillip A Gribble, Chris M Bleakley, Brian M Caulfield, et.al. http://bjsm.bmj.com/content/ REVIEWS Evidence review for the 2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains Phillip A Gribble, Chris M Bleakley, Brian M Caulfield, et. al. http://bjsm.bmj.com/content/ Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus Nicky van Melick, Robert E H van Cingel, Frans Brooijmans, et.al. http://bjsm.bmj.com/content/ ORIGINAL ARTICLES Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study Ryan G Timmins, Matthew N Bourne, Anthony J Shield, Morgan D Williams, Christian Lorenzen, David A Opar http://bjsm.bmj.com/content/ Effect of high-speed running on hamstring strain injury risk Steven Duhig, Anthony J Shield, David Opar, Tim J Gabbett, Cameron Ferguson, Morgan Williams http://bjsm.bmj.com/content/ Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings? Andreas Serner, Adam Weir, Johannes L Tol, et.al. http://bjsm.bmj.com/content/

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Classifieds DUNEDIN Cape Physio Physiotherapist – 2017 Cape Physio Dunedin is looking for a physiotherapist to start in 2016. As one team member in our clinic is moving to our Wellington branch we are looking for a new enthusiastic physio to join our Team We are based in the heart of North Dunedin right between Otago Uni and Otago Polytech meaning our client base is truly unique. We see a broad range of injuries across many sporting pursuits, Cape works with various codes and we help staff the Dunedin Sports Injury Clinic for special events like the Masters games and sports tournaments. While manual therapy, acupuncture and exercise based rehabilitation skills are preferred, we would also welcome a new graduate therapist who is keen to up skill and learn. All applicants must have a current APC and appropriate work visas for NZ. So if Dunedin’s rugged surf, long summer nights, or housing prices are something that interest you, there is a place at Cape for you. For further details please contact Mike on: 03 4745317 or go to www.capephysio.co.nz for more information about Cape Physio and the clinic. Please email your application, cover letter, and CV to dunedin@capephysio.co.nz. Deadline for applications close Dec 23rd 2016.

CHRISTCHURCH Body Wise Health Part/Full-time Physiotherapist – 2017 Are you ready for a change in 2017 and want to join an expanding and fun team? Body Wise Health is seeking an experienced physiotherapist to join our team. Body Wise Health is based in the new Marshlands Family Health Centre and provides physiotherapy and rehabilitation services to the medical centre, local gym and retirement village. The clinic provides a fantastic mix of health treatments including physiotherapy, Pilates, acupuncture, massage therapy and occupational health. Established 6 years ago our musculoskeletal practice is an accredited clinic which has a loyal patient and GP referral base and an excellent reputation within the community. Our clinic enjoys a strong supportive environment within the medical centre including five GPs, podiatrist, and counsellors. This year we expanded into the local gym and rest home and in 2017 there are many exciting opportunities in development at both these locations. The successful applicant will enjoy flexibility and the opportunity to work independently whilst still being part of a supportive and growing team environment. This position will be supported with regular in-service trainings, a competitive financial package including support of on-going education and conferences. The position is currently part-time with the potential to expand into full time if desired. Preferred start date is 23 rd January 2017. Check out our brand new website: http://bodywisehealth.co.nz Post-graduate qualifications are desirable but graduates with private practice experience will be considered. If you are motivated to work in a dynamic environment, then please e-mail CV to Tina McCormack at tina@bodywisehealth.co.nz or contact Tina on 021 419 744. All replies received in confidence. All applicants must have a current New Zealand APC and work visas if appropriate.

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Classifieds DUNEDIN Physio Performance Physiotherapist – 2017 Physio Performance has an exciting opportunity for the right person who is passionate about musculoskeletal and sports physiotherapy. The position is available from March 2017, though there can be some flexibility with this for the right person. Physio Performance is an established, quality based physiotherapy clinic in Dunedin. Our clientele includes a wide variety of clients from all age groups and abilities up to and including elite athletes. Physio Performance treats a diverse range of clients, including post-op orthopaedic conditions, shoulders, knees, chronic lower lumbar problems, posture related conditions and acute and chronic sporting injuries. The clinic has vast experience in real -time ultrasound imaging and functional exercise prescription. Physio Performance has two clinics - one in the exchange area of Dunedin and the other within Sky Fitness gym in central Dunedin. The opportunity to work in one or both clinics exists. Please view our website at www.physioperformance.co.nz for further information regarding the clinic. The clinic presently has five experienced physiotherapists, with the clinic director having extensive experience at various Olympic Games and World Championship level. She is presently working with a number of national sporting teams. Physio Performance is looking for someone with motivation, enthusiasm, believes in quality care and patient management and is prepared to be a team player. You will need to have excellent communication skills, be organised, professional and have NZ Physiotherapy Board Registration. Physio Performance provides a supportive environment, with great physiotherapist interaction, which is backed by great administration. If you would like to be part of our team, please email your CV and covering letter (in strict confidence) to Helen Littleworth helen@physioperformance.co.nz

MORRINSVILLE, WAIKATO Morrinsville Physiotherapy Clinic Ltd Physiotherapist – 2017 This is your opportunity to join an excellent physiotherapy team in an inspiring practice treating a wide variety of clients. Manual therapy, exercise prescription and rehabilitation are the hallmarks of our practice. Opportunity for involvement with sports teams is also available. The principal is a 6x Olympic and Commonwealth Games physiotherapist. Other staff have postgraduate qualifications. In-service training and professional support is provided regularly. We are an accredited practice and provide under -graduate and post-graduate clinical supervision for AUT students. Join our friendly, fun team in 2017 – start date negotiable. This small town has excellent facilities and is an easy commute from Hamilton. Please email your CV with a cover letter – in confidence to Gavin at: gavin@morrinsvillephysio.co.nz or contact Gavin if you have any questions regarding the position via email or phone 07 889 7474 All applicants must have a current New Zealand Annual Practicing Certificate. Check out our website: www.morrinsvillephysio.co.nz

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Classifieds TAURANGA Bureta Physio Physiotherapist Want to work alongside and be mentored by high performance and national sports team physios? Our team is growing and we need a like minded sports physiotherapist to join our team! You must be prepared to work with a sports team to be considered for this position. This is a unique and exciting opportunity to work in an established sports physiotherapy and rehabilitation clinic and the ability to learn and be exposed to the world of emerging talent and high performance sport. For over ten years, Bureta Physiotherapy has been providing the highest quality physiotherapy to a wide variety of “everyday” patients to elite athletes, with a focus on sports physiotherapy combined with overall health and wellness. Generous appointment times allow for an emphasis on manual/manipulative physiotherapy and exercise prescription encompassing full rehabilitation in the onsite rehabilitation gym or one of our partnered gyms in the community. Work alongside experienced post-graduate and Masters qualified physiotherapists, a therapeutic massage therapist, a great reception team along with close links to local sports medicine doctors and specialists. The successful applicant will receive on-going support as part of our strong mentoring program along with an allowance for CPD to assist with post graduate study/courses and conferences. Start date is negotiable, Jan/Feb 2017. We are looking for enthusiastic, hard-working physios with excellent communication skills, an interest in gym based rehab and a strong desire to learn and enhance their clinical skills. An interest in wellness, with a desire to work with teams, think outside the box, and go ‘above and beyond’ is a must to work in this dynamic and energetic young team. New graduates welcome to apply. Find out more about us here www.buretaphysio.co.nz or on our Facebook. To apply/ for more information contact jacinta@buretaphysio.co.nz or 021 623627

Preliminary announcement ...

SPNZ SYMPOSIUM 2017 Oct 14-15 2017 Key note speaker: Dr Phil Glasgow

Team GB’s Chief Physiotherapy Officer at the Rio 2016 Olympics Sports Medicine Coordinator at the Sports Institute Northern Ireland Senior Associate Editor BJSM

Further details as they become available