February 2017 bulletin by Sports & Exercise Physiotherapy NZ

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Issue 1 February 2017 FEATURE TOPIC: Surf Life Saving

Feature Mike Ellis: Keeping Our Surf Life Savers Up to Speed SPRINZ Running Cadence Membersâ&#x20AC;&#x2122; Benefits Re-join Now

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

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Contents FEATURE TOPIC: Surf Life Saving

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

EDITORIAL By SPNZ President Hamish Ashton

MEMBERS’ BENEFITS

In this issue:

Re-join SPNZ

FEATURE Mike Ellis: Keeping Our Surf Life Savers Up to Speed

SPRINZ Running Cadence… It’s Not a Cure-all, But it's a Great Place to Start

ASICS Implementation of a Footwear Program: - Why Will It Help Your Patients Run Further With Less Risk of Injury

CLINICAL SECTION- ARTICLE REVIEW Risk Factors for Medial Tibial Stress Syndrome in Physically Active Individuals Such as Runners and Military Personnel: a Systematic Review and Meta-Anaylsis

RESEARCH PUBLICATIONS BJSM Volume 51, Number 3, February 2017

CLASSIFIEDS Situations Vacant

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Editorial Hamish Ashton, SPNZ President Hi all and welcome to 2017. To all our new members, congratulations on joining SPNZ. I am sure will have something of value for you during the year, be it our courses, workshops, journals, product discounts and much, much more. To those who have re-joined welcome back. We look to providing something new and exciting to be involved with, And finally to those who have yet to pay your sub for the year, please do so as soon as possible so we can get our membership database up to date. Every two months when I sit down to write this I think to myself what has recently happened to me at work or out on the sports field. With the last two months being over the New Year period and not doing summer sport this year I don’t have much to reflect on. For a while I also thought my next few editorials would be as difficult as the team I have worked for over the last three years decided that paying for physiotherapy services was not a priority and dropped me. My wife, who is normally a sports widow, suddenly realised I would be home for weekends over the winter, bored and not knowing what to do - I have never got around to developing much in the way of hobbies due to my sporting commitments. To her relief, I think I have finally found a club to work with, and I won’t need to be travelling to Auckland every other weekend which is even better. One thing of interest to all of us, which is coming up, is the next stage in the “restructuring” of PNZ. I am down in Wellington later this month and again next month working with a diverse group of PNZ members coming up with some ideas to develop and then present back to you, the members. Whether things change or stay the same in the long run, this will be quite an event in PNZ’s history. The outcome of this will point the organisation in a new direction chosen by us, the members. I am happy to hear any feedback and comments on this process as it happens over the next year – email me at help@spnz.org.nz. A few weeks ago my family sat down to watch the Halberg Sports Awards. Every year when the nominations and finalists are announced there is always discussion on who should be included, or not. Then there is always the someone who the “experts” considered but missed out. There are a couple of points I think are overlooked in this discussion. Firstly, though they are the New Zealand sports awards, one of the main aims of them is to support the Trust, whose aims are to improve access for disabled children in sport. This should not be forgotten. Secondly, though at times someone may have missed a nomination, I can’t remember a year when any of the finalists didn’t deserve to be there. As to who wins on the night I

shouldn’t go there. I was a judge for our regional sports awards for the last six years., and though our judging process was different (and I feel better), choosing between apples and oranges is not an easy task. Going back to the Halberg Trust and its aims of inclusiveness in sport for all, takes me back to my days as a youngster, which, according to my children, was somewhere in the early 1900’s. My mother used to teach Neroli Fairhall before her injury (for you youngsters out there she was our top para-archer and competed against able bodied archers at the Commonwealth Games). I remember going to the NZ Wheelchair Games in Rolleston where Neroli used to compete in a multitude of sports. Things have changed considerably since those days, but there are still national and regional para sports days. Most of these are run by regional Parafeds. These are organisations who promote sport for the disabled at a local level, be it for fun or aiming to achieve national glory at the Paralympics. If your interest in sport doesn’t involve rugby, you may want to become involved in your local branch as something a bit different. I recently heard a talk at our local Parafed’s AGM about the experiences of some of the athletes at some of the first Commonwealth para sports events. Even with my background I was surprised to learn how long they had been running for. Though recognition and support for these athletes is now very much improved, and the TV coverage is there, I feel many still don’t consider these athletes on par with our able-bodied ones. Personally, I can’t imagine Sophie Pascoe’s training regime would be any easier than any of our able-bodied swimmers. At this year’s Halbergs there was great mention of Lisa Carrington’s two medals – the first of a NZ female athlete. How many have Sophie and Mary Fisher won over the last few years? Not until a para-athlete wins the supreme award at the Halbergs will I consider we will have as a nation truly accepted para-sport as a serious endeavour. To finish off I would like to congratulate those who went to the Paralympics and work with our disabled sports men and women – well done! Best wishes for the 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

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Feature Mike Ellis: KEEPING OUR SURF LIFE SAVERS UP TO SPEED I grew up on the West Coast of Canada to Kiwi parents and was heavily involved in school sports, as well as family pursuits of skiing and windsurfing. I completed two years of university in Victoria, BC with more interest in the arts than sciences, until I took a human physiology course which I found fascinating. Soon after, I spent a year travelling the world doing stage performance, and met an Irish physiotherapist who enthused about the profession, and encouraged me to pursue my interest when I resumed my studies. I took a human anatomy paper on return, and accepted an offer as a teaching assistant in the anatomy lab for the next two years. I switched faculties to undertake a kinesiology degree, and completed my honours thesis investigating the proprioceptive role of the ACL prior to graduation from UVic in 1997. I received my physiotherapy degree in 2000 from UBC, and worked for three years in BC and Eastern Canada in both hospital/community settings, before deciding to return to family roots in New Zealand in 2003 to pursue post-graduate work. I completed my Diploma in Musculoskeletal Physiotherapy in 2004, and late that year ruptured my ACL. While at Adidas Sports Medicine (now UniSports Sports Medicine) during post-surgical follow-up, I met Graeme White, and joined the team there for the next 4 years. It was a fantastic experience both for providing to a large and diverse elite athletic population, and for the opportunity to collaborate with therapist colleagues, sports physicians, and surgeons in management of athlete rehabilitation. During this time I also completed my clinical Masters of Health Practice at AUT. In 2010, I went through the Hand and Upper Limb coursework in Auckland, beginning part-time hand therapy work late that year. I became a fully registered hand therapist in 2013, and now practice both hand therapy and physiotherapy at Bay Hand Therapy in Tauranga.

Upon moving to the sandy Bay of Plenty in 2007, I became the key provider for Beach Volleyball NZ, working with both NZ men’s/women’s teams, as well as the German women’s team annually during their 3 month winter migration. I also started treating surf lifesaving athletes. I volunteered my services for local surf carnivals, and joined the Surf Lifesaving New Zealand high performance programme in 2011. I have travelled with the Junior Black Fins (U19) for the past three Worlds campaigns. Lifesavers are constantly honing their abilities to navigate the changing environment in which they deliver their essential services, and competition through this training has evolved into organised (primarily amateur) sport amongst clubs nationally, and between countries internationally. In a 2-year cycle, the peak competitions,

held in alternating years, are the International Surf Rescue Challenge (a series of three one-day purely beach competitions), and the Rescue World Championships (an even mix of pool and beach events). The World Championships include 41 events over four days, and 12 athletes make up a team. In contrast to most other sports, accumulation of points rather than winning the individual events is paramount. Thus, a typical team is made up of dedicated pool swimmers, “beachies”, and cross-over athletes who can perform in both environments well enough to make finals and earn the team valuable points. Events on the beach include beach and flag sprints, swimming based events, craft (surfboard and surf ski), ironman/woman (swim, ski and board), and relays. Pool events include individual and relay swim races that incorporate duck-diving obstacles CONTINUED ON NEXT PAGE

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Feature Mike Ellis: Keeping Our Surf Life Savers Up to Speed continued... (1 metre deep nets), and collecting/carrying mannequins by hand or rescue tube, as well as line throwing from the pool edge to rescue “victims”.

mannequin in one hand, which not only places all the propulsion demand on one side, but also reduces thoracic rotation and leads to sub-optimal shoulder position for the catch and initiation of pull. Ankle injuries are primarily issues with posterior impingement usually within 6 months of competition with introduction of training with very stiff racing fins. On the beach, craft specialists on board and surf-ski (kayak) deal with shoulder, low back, and knee issues. All are more prevalent in the board specialty, as the desired position to propel the board forward is kneeling with fully flexed knees in near end-range lumbar spine flexion and catching in overhead arm positions. Ironman/woman athletes have additional issues with lower limb tendinopathies and stress reactions/ fractures involving the shins/feet from high volume training on often cambered, soft-sand beaches. Entering and exiting the water at race pace is where more acute injuries are seen, especially in rougher conditions with craft involved, or on beaches with lots of pot-holes in the tidal zone. Ankle injuries are not uncommon and concussions are a risk also. Lower limb acute muscular injuries are the majority of sprinting issues. You see the whole gamut of more serious injuries with flags, as the athletes rise from prone, spin, sprint/jostle, and fling themselves to pull a remaining flag from the ground.

In my role, I see the athletes typically twice a year for three-day training camps, and annually for competition where we are together for 1-2 weeks. Unlike the NZ Open squad, who have little turnover from one campaign to the next, the Junior team has almost all new faces every two years. I therefore try to get full medical screenings in the first camp - to have each athlete’s medical, injury, and training load history, as well as to build a rapport with each athlete. Some team members have had little or no previous physiotherapy contact, and getting some level of comfort with the physiotherapist makes it much easier for the athlete to be forthcoming about injuries, and have confidence in coming for any treatment necessary when in competition. The most common injuries in swimming as it relates to surf lifesaving are shoulder and ankle related. There are typical swimmer’s shoulder issues of periarticular muscle imbalances/joint hypermobility in combination with high volume overhead loading with potentially poor technique. This is compounded in many events by carrying a

There are a number of important factors in maintaining a healthy squad over the two-year build-up to Worlds. A good understanding of the biomechanics of each discipline within the sport gives direction to early screening, to ensure appropriate mobility and strength in regions of the body that are key for optimal performance/at most risk to injury. On our team, each athlete completes a standard medical screening questionnaire at the first camp. This is useful for obtaining injury history (a strong predictor for future injury especially if insufficient rehabilitation), and for elucidating any ongoing issues at that time. The athletes also give their medical/physio point of contact in their region so I can touch base regarding updates/ collaboration on rehabilitation from injury if appropriate. Concussion baselines (ie. SCAT3) and Movement Competency Screening (Matt Kritz-developed) are measured, and the swimmers complete a modified swimming MSK screen as well. I have followed with interest the research and conference presentations of Craig Purdam and Jill CONTINUED ON NEXT PAGE

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Feature Mike Ellis: Keeping Our Surf Life Savers Up to Speed continued... Cook regarding tendon pathology/rehabilitation over the past 10 years, in particular their ideas on load progression in return to sport. The recent work by Tim Gabbett and Peter Blanch to quantify injury risk by assessing acute/chronic training workloads (2015/2016 articles accessible in BJSM) builds on these ideas. Their concepts give an understandable framework for collaboration with the coaches to maintain a healthy athlete despite training load variation/build-up, as well as to ensure the injured athlete’s successful progressive return to required training loads. With the Junior Black Fins, implementing these ideas also reduces injury risk with the build-up of sport-specific training loads (i.e. swimmers using mannequins and race fins) typically focussed on only in the last few months prior to competition. Working with a youth team has its unique challenges. Frequently the athletes’ knowledge of nutrition, supplement safety, strategies for getting adequate sleep, international travel, and even appropriate warm-up/ recovery (around sessions and in competition) is limited. Our management team present on these topics during training camps to ensure these aren’t factors affecting tolerance to training loads. In the last lead-up to the big competitions, itineraries, training sessions and race plans are reviewed daily to prepare for the unfamiliar and reduce stress that may negatively impact performance or increase injury risk. During competition, recovery strategies are key to perform through multiple heats/finals for different events on a given day, as well as to back up performance over multiple consecutive days. The athletes spend a lot of time on the table: pre-racing, after post-race warmdowns +/- ice baths, and for many in the evenings also. Given the heat in enclosed pools, as well as on the beach, and the length of competition days (often 10-12 hours), appropriate hydration and scheduled nutrition is paramount.

To work with elite athletes of any age, you need patience. If they don’t have previous experience dealing with injury, most athletes are very reluctant to follow relative rest instruction, often to their detriment. Noting early outcome measures that improve with rest over a relatively short period of time can often convince them of their early recovery progress despite “not doing anything”. If you have a working knowledge of the sport of the athlete(s) you are treating, can take the time to explain

your diagnosis, prognosis and management plan in meaningful terms; focus on what needs to happen to train adequately and compete optimally without dwelling on restrictions; potentially validate their feelings at being injured (if early in prolonged recovery); and can actually trial possible beneficial hands-on techniques +/- external support (ie. strapping/bracing) in the clinic/training environment to confirm good function with acceptable symptoms when nearing return to sport, you’ll have their trust and often good word-of-mouth that positively influences interaction with other team members going forward.

The ongoing challenge for sports physiotherapy in New Zealand continues to be remuneration for time contributed to teams. There has been a precedent set in the majority of sports team roles, that physiotherapy services are provided for nothing, with the team contributing at most strapping supplies and kit. For new graduates desiring side-line management experience and an opportunity to use this as a stepping stone to other roles, the trade-off is likely worth it. For therapists with more clinical experience, who may have their own businesses, extended time away comes with significant financial cost. I enjoy the sport, time spent with these appreciative athlete, change in scene, the varying roles in addition to physiotherapy provision, and the relatively short time away from family enough to make this sacrifice worthwhile for me. I am fortunate that my partner sees things the same way. There are many very capable people in our organisation for whom this commitment is not fiscally viable, and until there is a shift in how physiotherapy contribution is valued (as is certainly my experience with club involvement in Canada), their collective experience will go to waste.

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SPRINZ

Running Cadence… It’s Not a Cure-all, But it's a Great Place to Start

By Kelly Sheerin Running related injuries are some of the most prevalent that Physiotherapists treat, but they can also be equal parts challenging and frustrating, with an astonishingly high recurrence rate. Abnormal biomechanics have long been proposed as a potential risk factor for running-related injuries, and over this time many interventions have been aimed at modifying these biomechanical risk factors through such approaches as the varied use of orthotics, shoes, the absences of shoes, strengthening or various combinations of all of these. I have previously written on gait retraining [see issue 4 - August 2016], which is a complex area, especially for those that don’t work in this space all the time. As Physiotherapists we are traditionally really good at assessing movement patterns, and can often spot runners with poor technique a mile off. However, when it comes to what to change, and how to go about it, it can get difficult pretty quickly, and that’s even before you begin trying to explain to you runner that they should have their foot here, their knee there and their eyes looking in a different direction.

That brings us to running cadence… Before I race head-on into this topic, it’s worth pausing on the definition of cadence, which quite simply is ‘steps per minute’, or how many times your feet hit the ground in one minute (think left and right). Cadence, along with stride length, are the fundamental parameters that define running pace. In running these two factors are inversely related, that is, for a given pace if you increase your stride length, you will automatically decrease your cadence. It is this relationship that we’re able to take advantage of from an injury prevention and rehabilitation perspective. A longer stride length, particularly excessive reaching out or opening up too far in front (overstriding), is associated with increased braking and vertical loading forces on the lower extremities, which in turn have been linked with a number of common running injuries. A study by Heiderscheit et al. [1] found that increasing cadence resulted in decreased heel strike distance (the anterior component of stride length), decreased peak vertical ground reaction force and decreased peak hip adduction, hip and knee flexion angles, as well as an increase in knee flexion angle at initial contact. All of these changes are in the opposite direction of the abnormal mechanics associated with PFPS [2], ITBFS [3] and tibial stress fractures [4]. One of the easiest ways to facilitate a change in cadence is to have your patients listen to a digital metronome when running (there are plenty of apps out there), and try to match their cadence to the beat. For those that would rather listen to something a little more exciting than a constant beep, there are also plenty of pre-existing music playlists set to specific beats that you can bop along to instead. Many sources suggest 180 steps per minute as being a good rule of thumb for ‘optimal cadence’… However, in reality optimal running cadence will vary from runner to runner, and importantly from pace to pace even for the same runner, so the template stamp approach of 180 is best avoided. Recent research from Hafer et al. [5] again reported positive biomechanical changes as a result of an increase in cadence over a 6-week intervention period. However, some of the more interesting findings of this CONTINUED ON NEXT PAGE

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SPRINZ Running Cadence… It’s Not a Cure-all, But it's a Great Place to Start continued...

By Kelly Sheerin research were that runners could achieve these biomechanical changes by increasing their default cadence by as little as 10%. Additionally, they were able to facilitate these changes by using a metronome, or music if they preferred, and the increased cadence didn’t result in any decreases in running efficiency (a common worry for runners). Of course, like any changes to technique, it’s not all roses and sunshine… When trying to increase cadence, some runners report that they feel like they’re ‘cutting their strides short’ to accommodate the new rhythm, or they feel really uncomfortable and unable to maintain the higher cadence at higher pace. You need to reinforce with these runners that changing technique will likely take some time to feel natural (weeks in many cases), and you may need to work closer with them on how to how to maintain a reasonable stride length by improving their propulsion rather than stretching further out in front. Key points:  Increased stride length is a common factor related to many common overuse running injuries.  Increasing cadence is one potentially easy method of reducing stride length and eliminating abnormal biomechanics in runners.  There is no magic cadence figure, but positive changes can be achieved by increasing natural cadence by as little as 10%.  Music set to a pre-defined tempo can be used in favour of a digital metronome if preferred.  Like any change to technique, for some runners it can take some time to feel natural. References 1.

Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan M. Effects of step rate manipulation on joint mechanics during running. Medicine & Science in Sports & Exercise. 2011;43:296–302.

2. Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands. Clinical Biomechanics. 2008;23:203–11. 3. Noehren B, Davis I, Hamill J. Prospective study of the biomechanical factors associated with iliotibial band syndrome. Clinical Biomechanics. 2007;22:951–6.

Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners. Journal of Biomechanics. 2008;41:1160–5.

Hafer JF, Brown AM, deMille P, Hillstrom HJ, Garber CE. The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of Sports Sciences. 2014;33:724–31.

About the author: Kelly Sheerin Kelly is a registered Physiotherapist and Biomechanist who leads the AUT Millennium Sports Performance Clinics. He has a clinical interest and expertise in running injuries and biomechanics. Kelly has a Masters degree in musculoskeletal physiotherapy, including research in 3D running biomechanics. He is currently completing his PhD in the area of real-time feedback in runners at risk of tibial stress fracture. If you have questions on running biomechanics or the treatment of specific running injuries, feel free to e-mail me. About the Sports Performance Clinics The Sports Performance Clinics, based at AUT Millennium, have world class facilities teamed with a highly skilled and knowledgeable team, to provide the best sports science support, irrespective of your requirements whether it be rehabilitating from injury, improving your strength and power, honing your cardiovascular fitness, or acclimatising to heat. The services on offer are grounded in research, and underpinned by the principles of AUT’s Sports Performance Research Institute New Zealand (SPRINZ). The overall paradigm is that all of the athletes and clients seen at the SPC can potentially be research subjects through various on-going studies. Thus, our research is facilitated through the services we provide, and the services are in turn improved through research. Further information on the Sports Performance Clinics can be found here.

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ASICS Implementation of a Footwear Program - Why Will It Help Your Patients Run Further With Less Risk of Injury In a job where my role is stay up-to-date with the current trends and innovation concepts in athletic footwear, it is certainly interesting to take a step back and reflect on how footwear has got to wear it is and review what it actually does for our patients. If you pull back the layers on the marketing hype of individual companies and assess the product for what it is, I think what you find is another resource that can be used to manage load in our patients.

 Re: the bending stiffness of the 1st MTP. Our lab at UniSA has long shown that the addition of a midsole creates a functional restriction to MTP dorsiflexion (i.e. functional hallux limitus) which is influenced by the position and depth of flex grooves placed in the forefoot. This has potential implications for power absorption at the MTP as well altered leverage effect of ankle torque during the push-off phase of stance.

Load monitoring and management is certainly the buzz concept in running at the moment. A lot of this work has been pioneered by Tim Gabbett and specifically the concept of acute vs chronic training load. Although demonstrated largely in rugby and tennis population, the concept relates to the importance of preparation and conditioning to assist in future counts of load (and hopefully prevent injury). Preparation and conditioning can be influenced by numerous factors (i.e. strength, physiology, biomechanics etc.), yet recent research out of Europe by Laurent Malisoux’s groups has certainly proposed that multiple shoe use can lead to a variation in the load applied to the musculoskeletal system.

The conclusion is then that shoes can alter the kinematic patterns of the foot and ankle, just in different ways than previously thought.

So in light of Malisoux’s findings and the benefits of multiple shoe choice, and before we discuss how to implement a footwear program, let’s take the time for a second to review what footwear actually does. Based on the research, I feel footwear can do five things to the human body: 1. Alter the kinematics of the human body This is a contentious issue as there is a depth of information that relates to shoes not influencing foot motion. This is true to a degree, yet the statement is a product of biomechanical analyses traditionally focussing on the hindfoot as the only region where the shoe acts on the foot. The foot is a multisegment structure, and certainly the latest research coming out of the footwear labs in Australia points to significant effects of footwear on the joints distal to the hindfoot. With respect to the kinematic effect of footwear, I want to make two distinct points based on some recent distal foot data collected:  Re: the arch of the foot - Dr Luke Kelly’s work out of the University of Queensland is pioneering the way we look at the function of the medial longitudinal arch. They have shown that shoes can actually increase the stiffness of the medial longitudinal arch.

2. Alter the forces acting on the human body (which in turn influence the work done by different joints) When we talk forces and shoes, a lot of emphasis has been placed on the vertical GRF and specifically loading rates of this force. Although loading rates are sensitive to alterations in foot strike (i.e. removal of the 1st impact peak in forefoot strikers), there remains minimal to no evidence in the literature that loading rates are related to injury or are influenced by cushioning technologies in footwear. What I feel is forgotten when discussing forces though is that the GRF is a 3D vector that moves through the foot during stance. The position of the origin of the GRF vector is called the centre of pressure (COP), and for me, the medial displacement of the COP in foot is a measure of medial column loading. Recent data out of our lab at UniSA shoes that manipulating the torsional stiffness of a shoe with something like a trustic in the midsole has the capacity to reduce medial displacement of the COP by approximately 10 mm. This is obviously a substantial magnitude and can be used to offload anatomical structures of the foot. This data supports the shift we made in our lab some 5-10 years ago away from changes in hindfoot kinematics to a model centred on manipulating shoe and joint stiffness to optimise the dynamic function of the foot. 3. Influence the physiological performance of running

cost

AND

Name a runner who does not want to run using less energy, allowing them to run further and faster than CONTINUED ON NEXT PAGE

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ASICS Implementation of a Footwear Program continued... ever before. Well a really nice systematic review from Joel Fuller suggested that simply transitioning to light-weight footwear (< 220g for approx.US sized 9 male) resulted in instance benefits in running economy. Now YES this conclusion needs to be interpreted in light of the size of someone’s foot (which we don’t have the data on yet), but it does provide a crude threshold for targeting shoe mass. This concept of lighter mass being more economical is supported by some of Joel’s experimental data in that running in a lighter trainer (compared to traditional running shoe) is associated with improvement in running economy, yet the difference were only seen when above 15km/h. Although the data also supports that people can run quicker in lighter shoes over a 5km time-trial (approx. 2% improvement in time), the take home message is likely to be that any benefit of light-weight footwear is likely only seen at faster running speeds. This is an important concept to grasp in terms of translating the information to patients (especially in light of point 4 below). 4. Provide protection to the body during running Ever since the barefoot movement in 2010, the question of whether shoes provide protection has been brought into question given the right-sided debate surrounding the benefits of running barefoot. In my mind it cannot be questioned that the addition of a shoe (and therefore a layer between the foot and external environment) provides protection to the sole of the foot. This is supported by individuals selfreporting that they are more comfortable when running in shoes. What we have seen as a ‘middleground’ is the development of ‘minimalist’ footwear. Firstly I want to crush this new minimalist movement on its head and say it’s nothing new – minimalist shoes are simply racing flats, and have been used by high end runners for years. Yet, I want to share some really recent data published by my colleague Joel Fuller (ex-UniSA and now at Macquarie Uni in Sydney) who has shown that body weight is a factor to consider in the purchase of footwear. Not only should runners limit weekly training volume in minimalist shoes, heavier runners (i.e. > 71.4 kg) were at greater risk of injury when running in minimalist shoes. This supports the concept of a protection-weight scale in that a shoe with more ‘protection’ is likely going to weigh more. In light of the discussion of mass and economy (physiological cost) above, a decision needs to be made…lighter shoes for physiological cost benefit or heavier shoes

for injury prevention? That’s a balancing act if I have ever seen one! 5. Influence comfort Finally (but definitely not least) is comfort. In the absence of strong evidence that modern running shoe features reduce injury rates, Benno Nigg and his team at University of Calgary have proposed that the shoes that an individual is most comfortable in are not only the best shoes for them, but can likely improve performance and reduce sports related injury. Although comfort has been long known to be an important factor in selling footwear as improved comfort is associated with increased likelihood of purchase, categorising it has been hard. Most people are able to sense whether the shoes they are trying on are comfortable or not, yet discomfort is more easily defined as it is more strongly influenced by physical factors such as ‘lack of cushioning’, ‘tightness’ or ‘numbness’. Our data from the ASICS wear test program in Australasia identifies differences in comfort based on the self-assessment of shoes in terms of domains such as cushioning, stability, fit, depth and flexibility. This flies in the face of the traditional segmentation of athletic footwear, with less emphasis on motion control and gait analysis towards a model of consumer-input and subject-specific feedback. Watch this space for some really neat data. Let’s think about the above content. If we have defined benefits of footwear that are specific to different models and/or components of shoe design, does it not make sense to implement a program of wearing different footwear that is prescribed for different purposes, that in turn will provide a different stimulus, that is thought to be protective of injury? It makes sense to me. So we have developed the case for the effect of footwear and associated need of a footwear program. Let’s conclude by talking about implementation. It’s one thing to have a great idea, yet too often we see the ideas not implemented. There should be no barrier. It should not be difficult to implement a footwear program in practice. This is how I do it with my patients in four simple steps: Step One – Understand an individual’s training program and running requirements Load comes in a variety of forms. It is important we consider both internal (heart rate, rating of perceived CONTINUED ON NEXT PAGE

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ASICS Implementation of a Footwear Program continued... exertion) and external loads (such as volume, duration and intensity). Specifically relating to the latter, it is vitally important that we understand a runners total mileage per week, the surfaces they run on, the intensity they run at and the footwear they currently use. We then need to understand there running goals in terms of any increase in training volume that is going to occur over time (i.e. are they preparing for a race), and how quickly they want to achieve these goals.



The runner themselves needs to track mileage run in each shoe, as well as any injuries or aches and pain developed along the way. Once we have hit 600-800kms in the shoe (likely less for performance trainers or racing flats), its time to replace those shoes. I find in my runners they respond to the comfort stimulus a lot better than trying to establish an explicit number – once the shoes are not as comfortable as they once were, they return for an assessment and discussion of new footwear.



The health care professional needs to ensure that not only is there an adequate training base in the program, but to ensure the footwear is matched to any changes prescribed. Further, the health care professional must continue to monitor the selftracking of the runner to ensure any clinically important changes in load can be identified before they present as problems in the clinic.

Step Two – Program development This step has two stages: 1. Know your product – if you don’t…go and educate yourself. To successfully develop a footwear program, you need to know your product. Know your footwear product (racing, traditional, trail, track etc.) and how it differs from brand to brand. Specifically, understand the science of the material properties of the different design components of the shoe and relate that back to how the footwear can influence the human body during running. 2. Review the program from Step One and subcategorise the different components of training they do. Based on the knowledge of footwear product you have, you can then match the right product to the type of training conducted. Recommendations can then be provided in where and when a runner should use a particular pair of shoes and when they should not.

So there I have it. I’m a big fan of utilising footwear as a positive training stimulus, with the anecdotal benefits clear over a long period of time. Funny enough, we are starting to see the literature support these trends we see.

By Dr Chris Bishop PhD Director of Biomechanics - The Biomechanics Lab Post-doctoral research fellow - UniSA

Step Three – Implement the footwear program This is the hard part. You’re asking the runner to go buy a second pair of shoes (maybe three), spend another $200. There will be a question of why? There will be other barriers. But you need to address all of these barriers before they arise and educate the runner on the benefits of the program upfront. Once the runner appreciates the injury prevention strategy being put in place (and we know runners are obsessive and want to run pain free), they will quickly redirect their spending priorities away from a social night out towards another pair of shoes. Implementation will also be easier if you have a very good relationship with you retail store – educate them on what you are trying to do, provide a referral to the runner to take in with them and be contactable if any issues arise. Step Four – Review the program It is vitally important that both you and the runner review the program. The review responsibilities can be split and consist of:

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

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Clinical Section - Article Review Risk Risk

Factors for Medial Tibial Stress Syndrome in Physically Active Individuals Such as Runners and Military Personnel: a Systematic Review and Meta-Anaylsis

Hamstra-Wright KL, Huxel KC and Bay 0 British Journal of Sports Medicine 2014;0:1-9. doi 10.1136/bjsports-2014-093462 Abstract: Medial tibial stress syndrome (MTSS) is a common injury in runners and military personnel. There is a lack of agreement on the aetiological factors contributing to MTSS making treatment challenging and highlighting the importance of preventive efforts. Understanding the risk factors for MTSS is critical for developing preventive measures. The purpose of this systematic review and meta-analysis was to assess what factors put physically active individuals at risk to develop MTSS. Selected electronic databases were searched. Studies were included if they contained original research that investigated risk factors associated with MTSS, compared physically active individuals with MTSS and physically active individuals without MTSS, were in English language and were full papers in peer-reviewed journals. Data on research design, study duration, participant selection, population, groups, MTSS diagnosis, investigated risk factors and risk factor definitions were extracted. The methodological quality of the studies was assessed. When the means and SDs of a particular risk factor were reported three or more times, that risk factor was included in the meta-analysis. There were 21 studies included in the systematic review and nine risk factors qualified for inclusion in the meta-analysis. Increased BMI, navicular drop, ankle plantarflexion range of motion and hip external rotation ROM were risk factors for MTSS. Dorsiflexion and quadriceps-angle were clearly not risk factors for MTSS. There is a need for high-quality, prospective studies using consistent methodology evaluating MTSS risk factors. Our findings suggest that interventions focussed on addressing BMI, navicular drop, ankle plantarflexion ROM and hip external rotation ROM may be a good starting point for preventing and treating MTSS in physically active individuals such as runners and military personnel. This paper outlined a systematic review of literature to try and elucidate the risk factors for medial tibial stress syndrome. They did not clearly state how they were defining medial tibial stress syndrome and their search criteria used the following terms: medial tibial stress syndrome, mtss, medial tibial stress, shin splint and shin pain. Using a methodological quality tool, they selected 21 papers to be included in their metaanalysis. Studies included were original research looking at comparison of physically active individuals.

categories: arch height or angle, Bone Mass Index (BMI), bone parameters, calcaneus and rearfoot position and displacement, calf girth, demographics, flexibility/ROM, foot posture index, forefoot position, gait variables, leg angle and tibia angle, medical history and symptoms, Ober’s test, strength, structure/alignment, and training variables/fitness level. When the means and SD’s of a particular risk factor were reported three or more times, that risk factor was included in the metaanalysis.

Medial tibial stress syndrome is common amongst runners and the authors found incidence rates of between 13.6% and 20%. It is also common in military personnel with rates of between 7.2% to 35%. Generally though there is a lack of agreement on the cause and risk factors for MTSS which makes subsequent treatment difficult at times. Knowing what the risk factors are is also important in trying to prevent the issue occurring in the first case.

The 21 papers consisted of cross-sectional, casecontrol and prospective cohort studies, the participants across the 21 papers were; recreational athletes, runners, military personnel and high school or college athletes. Both males and females were represented.

One of the reasons behind the systematic review was: “Studying the potential risk factors in a systematic fashion can reduce bias and increase confidence through the analysis of pooled data”. The data from the 21 studies was analysed and the reviewers categorised common variables into risk factor

Risk factors that were reported on three or more times in the above studies were included in the meta-analysis. These were: BMI, navicular drop, ankle plantarflexion/ dorsiflexion/inversion/eversion ROM, hip external/ internal range of motion, Q-angle. Over 100 more risk factors were mentioned in the studies, but data was not sufficient to include in this review.

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Risk Factor

Pooled No. of Subjects

Comments

Body Mass Index

451 (187 MTSS, 264 Controls)

In two of five data sets, greater BMI increased the risk for MTSS, BMI was generally greater in the other studies.

Navicular Drop

564 (198 MYSS, 366 controls)

Three data sets reported navicular drop to be a risk factor, generally greater in other sets.

Ankle Plantarflexion

237 (71 MTSS, 166 Controls)

Four data sets found this a risk factor.

Hip External Rotation ROM

279 (117 MTSS, 162 Controls)

3 studies mean values were greater in MTSS in all, but not significant in 2. Measured in sitting or supine.

Ankle Dorsiflexion

481(173 MTSS, 308 controls)

6 data sets were used, none of the results supported ankle DF as a risk factor for MTSS.

Q-angle

346 (132 MTSS, 214 controls)

3 Studies included, none supported Q-angle as a risk factor

Hip Internal Rotation ROM

279 (117 MTSS, 162 controls)

3 data sets were included, conflicting results in studies, concluded more study with similar methodology needed.

Ankle eversion ROM

281(108 MTSS, 173 controls)

Five studies looked at, only one found increased eversion to be a risk factor. More work needed.

Ankle inversion ROM

249 (89 MTSS, 160 controls)

Five studies - neither passive or active ROM or testing position reported consistently, confliction results amongst studies – more work needed.

□ Possibly Not a risk factor □ Not a Risk Factor □ Risk Factor

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Clinical Section - Article Review Risk Factors for Medial Tibial Stress Syndrome in Physically Active Individuals Such as Runners and Military Personnel: a Systematic Review and Meta-Anaylsis continued... In their discussion the authors noted that BMI in athletic/ physically active populations was not a direct measure of body fat. Rather an increased mass relative to height, the increased mass could be due to either lean or fat mass. They hypothesise that the explanation for BMI as a risk factor is around the response of bone to loading. When loads exceed the bone’s microdamage threshold, injury can occur. They suggest that those with a higher BMI may need a longer adaptation period than those with a lower BMI, which seems sensible. In the case of navicular drop, the authors have discussed the relationship in running between navicular range/arch height and tibial rotation, they concluded that “perhaps individuals with an increased navicular drop (lower arch height) are at risk for MTSS because they do not then have as much tibial internal rotation, which may be an important factor in absorbing impact forces.” They suggest foot and ankle exercises to increase the rigidity or the arch may help with prevention. There are a number of suggestions as to why increased plantarflexion may be a risk factor in MTSS, including a greater likelihood of individuals landing on their forefoot when running, increasing strain on the posteromedial tibia or that increased navicular drop and plantarflexion are related. They postulate that eccentric exercises for the tibialis anterior to control end range plantarflexion may be an important consideration for the prevention and treatment of MTSS.

Dorsiflexion and Q-angle most clearly do not appear to be risk factors for MTSS, but more studies are needed to assess hip internal rotation and ankle inversion/ eversion as risk factors for MTSS. This was an interesting review of data, but more up to date information regarding MTSS is probably out there now, most of the data for this study was gathered prior to 2012. There have been more recent reviews looking at chronic versus acute loading and some work done on stride length in regards to running and injuries, which seems promising. As with everything, it is important to remember that it is probably not one risk factor, but usually a combination of factors that play a role in injury. It was interesting to note the lack of data on factors such as training variables and shoes which are often subjects that come up when discussing the aetiology of MTSS, perhaps these factors are not as important as thought, or maybe the data and good quality studies are lacking. It would be good to see more studies into those factors, especially around the barefoot running movement. This is a subject which repeatedly comes up with clients and there seems to be a lack of independent research into it (let me know if you have some). In the meantime, looking at the known risk factors of higher BMI, navicular drop, ankle plantarflexion and hip external rotation are good places to start in screening and advising on training and in treatment programmes. Good luck with all those MTSS clients.

The mechanisms behind why hip ROM may be related to tibial injury are unknown.

By Karen Carmichael BSc, BPhty, M(SportsPhysio)

New Zealand Post-Operative Rotator Cuff Rehabilitation Survey

Below is a link to the “New Zealand Post-Operative Rotator Cuff Rehabilitation Survey”. The researchers are interested in current physio practice following a rotator cuff repair in New Zealand. International studies have examined rotator cuff rehabilitation in other countries, and they are interested in what is currently happening in New Zealand. This survey will take about 15 minutes to complete and is entirely anonymous. Click on the link for more information or to start the survey. https://www.surveymonkey.com/r/nzrotatorcuff

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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 51, Number 3, February 2017 EDITORIALS Debunking early single sport specialisation and reshaping the youth sport experience: an NBA perspective John P DiFiori, Joel S Brenner, et.al. http://bjsm.bmj.com/content/ Youth sports injury prevention: keep calm and play on Cynthia R LaBella, Gregory D Myer http://bjsm.bmj.com/content/ Cognitive rest following concussions: rethinking ‘cognitive rest’ Mark E Halstead, Brenda Eagan Brown, Karen McAvoy http://bjsm.bmj.com/content/ Preparticipation physical examination: Is it time to stop doing the sports physical? Michele LaBotz, David T Bernhardt http://bjsm.bmj.com/content/

REVIEWS Are all sport activities equal? A systematic review of how youth psychosocial experiences vary across differing sport activities M Blair Evans, Veronica Allan, Karl Erickson, Luc J Martin, Ross Budziszewski, Jean Côté http://bjsm.bmj.com/content/ Recurrence and return to play after shoulder instability events in young and adolescent athletes: a systematic review and meta-analysis Jason L Zaremski, Juan Galloza, Fernando Sepulveda, Terrie Vasilopoulos, William Micheo, Daniel C Herman http://bjsm.bmj.com/content/

ORIGINAL ARTICLES Nine-year study of US high school soccer injuries: data from a national sports injury surveillance programme Morteza Khodaee, Dustin W Currie, Irfan M Asif, R Dawn Comstock http://bjsm.bmj.com/content/ Subjective well-being and training load predict in-season injury and illness risk in female youth soccer players Andrew Watson, Stacey Brickson, Alison Brooks, Warren Dunn http://bjsm.bmj.com/content/

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Classifieds Vestibular Rehabilitation Training NZ Anne Burston MHealSc (Rehab) MPNZ & Carole Rogers MPNZ Vestibular Rehabilitation– an Advanced Course  Intensive 2-day workshop for physiotherapists who have completed the 2-day introductory course and have 1 year’s clinical experience in vestibular rehab.  Course content includes: review of anatomy & physiology, BPPV affecting anterior and horizontal canals, Persistent Postural & Perceptual Dizziness (PPPD), Cervicogenic Dizziness, Vestibular Migraine, TBI & Concussion and video practical’s looking at nystagmus. Date: 20 & 21st May 2017 Vestibular Rehabilitation - An Introductory Course  2 Days for Physiotherapists with no experience in vestibular rehab.  Anatomy & Physiology, BPPV, vestibular loss and central pathologies/ concussion. Date: 17 & 18th June 2017 Both courses involve lectures and practical - assessment and treatment techniques Venue

16 Kent Terrace, Wellington

Cost for each course $550 per person Early Bird $500 per person (before 15th March & 15th April respectively) Spaces are limited to 18 people for each course For further information, queries and registration contact Anne kapitidizzinessandbalance@gmail.com Tutors - Professional Bio Specialising in Vestibular Rehabilitation clinically since 2000 and teaching Vestibular Rehabilitation since 2006. Both have presented at and attended numerous conferences nationally and internationally & Anne is involved in research and has an article published in Journal of Clinical Neuroscience.

Looking for a great job in Christchurch? We’re looking for the right person to join our physiotherapy team. Is that you?

This is the perfect full time position for someone keen on both acute injury management and seeing the job through with great follow up rehabilitation. With our main clinic based onsite at a busy rugby club this role provides an opportunity to work closely with sports teams - especially rugby; so a keen interest in sports injury management is vital. However, with our diverse client base this job also offers a great range of experience from treating children through to the elderly. Regular in-service training and mentoring for new graduates or those returning to the work force will be provided along with ongoing support from the experienced principal and senior staff members. Part times hours will be considered for the right applicant.

If this sounds like you please apply in confidence with your CV and covering letter to Megan at chchpark.physio@xtra.co.nz or call 027 4397353.

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Classifieds ASHBURTON PhysioSteps Staff Physiotherapist – Full Time PhysioSteps is growing and we want you to join us! If you are looking to work in a positive environment, and have a passion for musculoskeletal and sports physiotherapy, then you are the perfect fit for our team. PhysioSteps is a modern practice in Ashburton and we pride ourselves on high quality service, using hands-on treatment techniques and exercise prescription to help patients back to their best. We are a fully electronic practice, with a great team and ACC accreditation and a EPN contract. Ashburton is in the heart of the Canterbury plains, 1 hour from Christchurch and half an hour to Mt Hutt Ski field, lake hood and numerous other outdoor activities. Mid-Canterbury is a very sports-orientated region and you will see a wide variety of sporting and general musculoskeletal injuries and have your pick of sports teams to work with if wanted. A willingness to learn and build your career are must-haves, as well as a can-do positive attitude and good people skills. What we offer:  A supportive professional environment  Regular mentoring for new graduates and fortnightly in-services  Opportunity for career advancement  A competitive remuneration package, including a competitive base salary + bonus’  A $500 CPD fund  The opportunity to work with experienced physiotherapists and see a varied and motivated caseload This is a full time position, 40 hours/week, starting in end of March 2017. Start date and times negotiable. If you are interested in this job, please send your CV and cover letter to Shaun at sclark@physiosteps.co.nz. For more information visit our website www.physiosteps.co.nz

MOUNT MAUNGANUI Part-time Physiotherapist Part-time physiotherapist wanted for our clinic in the heart of sunny Mount Maunganui. We are a modern, fully electronic practice with three locations in. We pride ourselves on high quality service, using hands-on treatment techniques and exercise prescription to help patients back to their best Due to an upcoming maternity leave and service expansion we are looking for a physiotherapist for 15-20 hours with view to full-time for the right candidate. Experience in Pilates and acupuncture preferred but new grads are encouraged to apply. If you are a confident clinician with great communication skills, and enjoy being part of an easy-going team, please apply in confidence with your CV and covering letter to Chris Butler chris@mountphysio.co.nz or 07 575 4080. For more information please visit our website at www.mountphysio.co.nz or alternatively call the clinic on 07 5754080 for further information.

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Classifieds NORTH SHORE Forrest Hill Physiotherapy Full or part-time physiotherapist required Full or part-time positions are available with Forrest Hill Physiotherapy from early 2017. Our musculoskeletal practice is a certified community based clinic, with representative team and high performance sport links amongst the six post-graduate qualified physiotherapists. Established over 25 years ago, the clinic has a loyal patient and GP referral base and an excellent reputation within the community. Our clinic has a strong manual therapy and exercise rehabilitation focus, facilitated by a fully equipped Clinical Pilates studio, rehab gym and Real Time Ultrasound Imaging service. In addition to fortnightly in-service education, the successful applicant will work alongside clinical Pilates instructors, a continence physiotherapist and massage therapists. All staff are supported by a skilled and experienced administration team and practice manager. A competitive financial package is offered including support of on-going education, conferences, courses and work in special interest areas, e.g. sports teams. Post-graduate qualifications are desirable but PGD students with private practice experience will be considered. If you fit these criteria and are motivated to learn and work in a dynamic post-graduate environment, then please e-mail CV to Chris McCullough at chris.mccullough@xtra.co.nz. All replies received in the strictest confidence.

NZ OLYMPIC HEALTH TEAM – EXPRESSION OF INTEREST OPEN Expressions of Interest are now open for Health Team positions for New Zealand Olympic Committee teams in 2017 and 2018. We are seeking applications from medical professionals (sports physicians and doctors, physiotherapists, massage therapists, and administrators) for the following teams; Bahamas 2017 – Commonwealth Youth Games (doctor and physiotherapist(s)) Taipei 2017 – World University Games (doctor and physiotherapist(s)) – (University and Tertiary Sport New Zealand, UTSNZ managed team) PyeongChang 2018 – Winter Olympic Games (physiotherapist(s)) Gold Coast 2018 – Commonwealth Games (doctors, physiotherapists, massage therapists, and health team administrator) Buenos Aires 2018 – Youth Summer Olympic Games (doctor, and physiotherapist(s)) Position descriptions for all positions can be found by clicking here. To compete an “Expression of Interest” please complete the questionnaire by following this link. Appointment Timeline EOI Open

Thursday 2 February 2017

EOI Close

5pm, Thursday 23 February 2017

Short listing and Medical Experience & Reference Checking

27 February – 3 March

Interviews (if required)

Week 6 March

Please contact Dr Bruce Hamilton, NZOC / HPSNZ Medical Lead if you wish to discuss or require further information on the Doctor Job Description or application process: email: bruce.hamilton@hpsnz.org.nz Phone: 021 271 1320