October 2014 bulletin by Sports & Exercise Physiotherapy NZ

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BULLETIN Issue 5 October 2014

FEATURE TOPIC: Specialised Lower Limb Physiotherapy SPNZ MEMBERS PAGE

See our page for committee members, links & member information EDITORIAL

By SPNZ President Hamish Ashton MEMBERâ&#x20AC;&#x2122; BENEFITS

IT Benefits FEATURE

In this issue:

Geoff Potts - Physiotherapist: Specialised Lower Limb Physiotherapy SPECIAL REPORT

Youth Olympic Games PLANET OF THE APPS

Muscle System Pro II CASE STUDY

Lost in the Knee SPRINZ

So is He Ready to Play? The Science of Return to Play Status ASICS

ASICS Report - Footwear and Knee Osteoarthritis CLINICAL SECTION- ARTICLE REVIEW

Rehabilitation After Hip Femoroacetabular Impingement Arthroscopy CONTINUING EDUCATION

SPRINZ Strength & Conditioning Conference 2014 Local course and APA CPD Event Finder RESEARCH PUBLICATIONS JOSPT Volume 44, Number 10, October 2014

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

Hamish Ashton

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ASICS EDUCATION FUND A reminder to graduate members that this $1000 fund is available twice a year with application deadlines being 31 March 2015. Through this fund, SPNZ remains committed to assisting physiotherapists in their endeavours to fulfil ongoing education in the fields of sports and orthopaedic physiotherapy. An application form can be downloaded on the SPNZ website

sportsphysiotherapy.org.nz.

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Editorial Hamish Ashton, SPNZ President There are a couple of points that have come to mind from events recently that I feel are worth thinking about. The first is our worth as a Sports Physiotherapist. In the last bulletin I mentioned that we should have a contract even when we are not getting paid for a team position. This is something I haven’t personally done in the past but on reflection I can see their worth. They should outline what services we are providing to the group, team or club, as well as what they can expect from us and what we expect from them. I would also recommend that if the services are being provided for free that the actual cost be put in the document so they are aware of the value they are getting. Further to this we are currently involved in trying to put together a selection of contracts for our members that they could use when dealing with positions. If anyone out there has a contract that they are willing to share please send it through to me (help@spnz.org.nz). Take all the personal stuff out. These are meant as a starting point and we as SPNZ don’t guarantee their legality. If we are being paid, what is our worth from either a financial point of view or a professional development point of view? As many will know I am getting a little bit more silver on top which I assure myself is due to all the wisdom I now have. I have worked with a number of teams internationally over the years and though it would be great to do some more I am mostly content in what I have achieved. I also have post graduate qualifications in physiotherapy and sports science. What I feel I have to offer a team professionally is a dedicated and professional service at a high level. I have recently been involved in negotiations with a team from a well-established code and the management were keen to have me on board. I therefore sat down and decided my worth from a financial point of view taking into account time off work and time involved on training nights and weekend games.

Needless to say the financial committee felt it was too much and offered me less. What should we do in this situation? I said, no thanks. They might find someone else for the job and pay them less than what I asked but will they provide the same service as I could, and if they can does that mean they are selling themselves short? Now if I was a young physiotherapist wanting to make it in the big time I may have taken the job for nothing as this may have led to further opportunities for me. Doing this may help me in the short term but is it the right thing for our profession? If the sport was a minor sport how would this change things? Minor sports struggle to find the money for necessities let alone medical or physiotherapy support. Should their athletes miss out on this support because the sport lacks funding? A few days after this I was talking to a colleague who works with a number of teams. He had an arrangement to look after the players in the teams. Over the season not many sought treatment despite the arrangement. What’s more he had the impression that they thought it was his privilege to work with them and not their privilege having his expertise. I don’t know if there was a contract here but one would have outlined to the team management the service and value the physiotherapist was delivering as well as outlining what was expected in return from the players. In conclusion, if you are working with a team get a contract with them and in it outline what service they are getting and what you expect in return. If you are getting paid something, or even nothing, think of the value of the service you are providing and what you get in return, be it in the short or longer term. Ultimately, is your time and commitment worthwhile? Hamish

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Members’ Benefits

There are many benefits to be obtained from being an SPNZ member. For a full list of Members’ Benefits visit http://sportsphysiotherapy.org.nz/benefits/ In each Bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.

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We have recently added a Twitter account to our list of ways of keeping contacted with the world. Follow us and join in the conversations. Follow links through to interesting articles and hear titbits from conferences as they happen.

Podcasts - SPNZ Members Section

In the Members Resources Section of the website there are links to some free podcasts. These are a great way to listen to world renowned experts from your home in your own time and credit some CPD at the same time.

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Feature Geoff Potts - Physiotherapist: Specialised Lower Limb Physiotherapy MHSc., Post Grad Sports Physiotherapy, Post Grad Western Acupuncture. KneeCare provider

My name is Geoff Potts. I’m a clinician based in Takapuna Auckland. I started my physiotherapy degree at AUT in 1996 as an adult student after spending several years working and living in Australia. I’d always had an interest in exercise and human physiology, but back then the tipping point for me was that exercise science degrees didn’t seem to offer a clear career pathway and so I migrated towards physiotherapy as I thought it offered a defined job in the future. Little did I know!

My first clinical position was a great example of a supportive and caring environment that had a great culture. My boss at the time was instrumental in moulding my work ethic and ideas for the future. I didn’t earn fantastic money at the time, but I had a fantastic education and experience. It’s always something I struggle with now, with some of our new grads who particularly seem to prioritise or value remuneration rates over clinical support and education in the first couple years of work. Without doubt you need to be paid appropriately, not underpaid, but I would always advocate finding a good supportive environment where you can be challenged and grow clinically, and not just be number driven. I totally shudder when someone applies for a job with us now and they’ve been isolated or not supported for the first part of their career. My sports physiotherapy experience started when I worked at a local Auckland rugby club providing typical training and game day injury cover. It’s funny now, but I started out with a fresh sports doctor who has gone on to head the NZRFU. The work was great fun, and the experiences and friendships that you develop in those environments last for a lifetime. I now actively encourage our students who work with us to similarly work with sports teams. We currently provide physiotherapy services to a couple of North Shore club rugby sides: Takapuna, and Northcote. They are managed by senior physiotherapists and we place students with a qualified physiotherapist to help and learn with a team. It’s a perfect way to learn and gain experience while being supported, and it also works as a long-term job application. It’s not accidental that many of those students are offered clinical positions when they graduate. From local rugby I went on to work with the NZRFU as the NZ Sevens Rugby physiotherapist. This meant being away for the majority of the year either in training camps or traveling on the World Series circuit. Back then I was single and without kids so it was great fun. The experience and responsibility certainly made me tune in clinically. I needed to make concise and ac-

curate decisions or predictions about recovery, return to play, training etc. It was soon after starting this fulltime job that I started my Masters degree, and I think this was the next important turning point in my career to date. I certainly wouldn’t change anything about the sports physiotherapy roles I had. Most of the time I loved the work; sometimes I didn’t enjoy the travel, the conditions, the pay, the time away, the politics, the players’ demands. I certainly don’t want it to seem like I didn’t like the time or enjoy myself. Like anything there is always good and bad, and in my experience there was certainly more good. I was privileged to be part of some really great teams. Please describe your current role and how you ended up there. Currently, I work in my main Shore Physio clinic, which is in Takapuna, Auckland a couple of days per week. The other days are made up of research, clinical observation and mentoring for our managers and staff. We’ve currently got five clinics across the North Shore. The main focus of my clinical work, development, and research has now turned to our KneeCare services, where qualified providers offer specialised lower limb services through our five Shore Physio sites. It’s interesting that the development of this service literally stems back to years ago when I was working in the Sevens and a particular player who’s an All Black now had a knee injury and I felt there were real deficiencies in our evidence based practice, and the ability for our medical team at the time to offer advice about his long term options and prognosis. What are your specific areas of interest/research? I’m really passionate about improving the quality of physiotherapy services with specific reference to lower limb injuries. I’m a real advocate of the recent promotion to recognising specialised physiotherapists, and I completely believe that we can’t be good at everything, and specialisation as a pathway can only be good for our industry. Some might find it a little distasteful to

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Feature Geoff Potts: Physiotherapist: Specialised Lower Limb Physiotherapy continued... start with but change is often challenging. I have actively been involved in research through AUT with Duncan Reid and Peter McNair who were originally my supervisors for my Masters research where we completed an EMG study investigating the commonly used Alfredson’s protocol for Achilles tendinopathy. We’ve also recently published a study looking at the referral patterns and attitudes of GPs, and orthopaedic surgeons towards the physiotherapeutic management of hip and knee OA. A key member of our KneeCare group and one of my clinical managers, Brydie Harris, recently finished her Masters investigating the cardiovascular capacity of patients with hip and knee OA. They demonstrated significant reductions in VO2 capacity and activity levels compared to matched subjects. The relevance from a sports physiotherapy perspective is that many of these subjects we see in our OA research are the weekend warriors and athletes of years ago. They’ll typically describe their first knee tidy up 20 years ago, or their ACL reconstruction 10 years ago, and they’re now considering a total knee or hip joint replacement, or they’re struggling with pain not knowing what to do, or where to go for help. We are also working with a couple of physiotherapy professors from University of Melbourne, Kim Bennell and Rana Hineman looking at patients’ exercise adherence with some novel smart phone applications, which is quite interesting. It fits nicely with our lower limb bias and especially with ACL rehabilitation, which can be quite prolonged. What are the types of injuries you commonly see? We see the full spectrum of conditions, from acute sports to end stage palliative reconstructions. If I had to put my finger on something though I mostly see achilles tendon problems and knee injuries now. What do you think are the key elements in successfully preventing injury? I believe to produce a truly effective preventative programme like some of the ACL prevention protocols we use, you really need the subject and their family to buy into the plan. You certainly don’t get change instantly and ongoing support is important to ensure you make real morphological and neuromuscular change. It reminds me of a webinar I recently participated in from the excellent Physio Scholar group. We were discussing the effectiveness of current ACL rehabilitation, and highlighting the persistent observation that despite what we think is effective rehabilitation, subjects still years later have persistent quadriceps muscle changes. I personally like incorporating evidence based practice wherever possible so often use Adams et al 2012, and studies from Frobell in our clinical practice to rationalise what we do and its effectiveness. I also place a massive emphasis on mastering normal exercise principles as without having a sound grounding we really couldn’t provide

well developed and reasoned exercise rehabilitation to pathological groups. This is where as an industry we have been talking for years about the encroachment of other non-medical trained providers into the rehab space, yet we might be guilty sometimes of not keeping up. I suppose in summary a key element to success is sometimes the knowledge base of the practitioner. 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? You need to engage with all the key stakeholders to ensure everyone is heard and included. With the example of ACL preventative programmes we engage with the parents, coaching staff, teachers, literally anyone who will offer the subject support and have a positive role during the process set out. Are you involved in performance aspects for your clients? Yes, at the end stage of rehab or return to sport we often integrate and help coordinate periodised training protocols with athletes and their trainers. It’s a really important aspect of our work now, and it’s a cornerstone of integrated care for patients. What are the key attributes you feel are required to work with elite level athletes? I always see it as this very careful balance between confidence and competence. Athletes generally have seen lots of different medical providers throughout their careers, and will sometimes search out those who will give them the answers they want. I’m thinking about some specific examples just recently with the upcoming Auckland marathon. If you are competent and can offer an honest, caring, integrated, and most importantly effective approach to their injury or problem they’ll certainly have confidence in your abilities and advice. Sorry, that probably sounds a bit cheesy. What do you see as the major challenges for sports physiotherapy? I always felt that validity and efficacy in physiotherapy generally had been an issue, but we are now seeing some great research coming through that reinforces our position as important and effective health providers. At our recent national conference we had great support from Karim Khan where he highlighted that we should spread the word more. It may not be a direct challenge, but there is an opportunity to advance sports physiotherapy awareness and efficacy with research. It could be as simple as practitioners contributing with case series, or going the full distance with university based research. I’m a firm believer in the value and importance of ongoing learning, and giving back to the industry, as this will certainly help secure sports physiotherapy in the future. As an unashamed personal plug that’s partially why we’ve developed KneeCare.

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Special Report Youth Olympic Games By Brett Warman, Physiotherapist In August 2014 I was lucky to attend the 2nd Youth Olympic Games in Nanjing, China. I was one of three members of the medical team, the other two being Dr Jake Pearson, and physiotherapist Jess Meyer. We had 51 athletes (aged 14-18 years old) and about 30 support staff to look after. The Chinese built an amazing village consisting of six tower blocks and an eight storey food-hall!! As the village was to be used as high end apartments at the completion of the games, they were designed around apartment living. This meant no common areas and no medical room in the New Zealand area. Hence, our two bedroom apartment also became the medical room. Luckily, the Chinese supplied minimal furnishings, so the table and two chairs in the living area easily allowed room for our three treatment tables and boxes of medical stock. This common living only became a problem when the doc needed to have a private consultation and had to turn our bedroom into a makeshift office. China is an amazing place, but supplies its fair share of challenges. We had planned to buy a couple of wheelie bins for cold immersion when we arrived in China. Everything is made in China so it should have been no problem getting access to this type of thing. However, even with the help of our wonderful Chinese helpers, it quickly became apparent that it isn’t as easy as a trip to Bunnings. After some sign language, a lot of Google images and a bit of charades, we managed to find some very deep but small paddling pools, called tiny tots. Turned out they were perfect for what we needed: easy to move about, could fit on our little deck, didn’t take much water to fill, so little ice required to get them good and cold. Apart from the odd basketballer, our athletes could fit in them, sometimes in pairs. Lesson two: acupuncture needles originated in China but don’t try to find any; it’s impossible. Long story short, we traded with the Aussies - way easier than trying to access them through the Chinese. Once set up in our cosy little medical come living quarters, the work could begin. Either by good luck or good management, we only had two serious injuries: one of our wrestlers injured an AC joint in his final wrestle, so although painful it didn’t affect his games, and one of our hockey players sustained a sprained ankle and missed the last two games. Most of our physiotherapy work comprised of minor injury management, maintenance and massage. We didn’t have

a massage therapist with us, but doc was more than happy to get his hands dirty when necessary. We were also kept busy by the support staff in any down time between athletes. Nothing like a bit of free advice!! The doc was kept busy with quite a few respiratory ailments, possibly a commentary on the air quality, and the usual stomach upsets from the change in food. Speaking of food, it was interesting for the first few days, but three weeks of stir fry three times a day becomes a little tedious. With only three members of the medical team, it was not practical for us to attend all sporting events. But we got out whenever we could to give medical assistance and to show our support. We spoke with all the coaches with regards to their sports needs and expectations regarding medical cover at the venues. From this we identified hockey and wrestling as the sports most likely to require our services at the venue. The other sports utilised us based in the village. Working with 14-18 year olds presented some challenges; education around what the medical team did being one. Some athletes came from sports where medical support was routine, but for many of the athletes, especially those from the more minor sports, it was a new experience to have medical support so accessible. We found many athletes needed to be educated on things like letting the medical team know if they had a niggly injury or were feeling unwell, rather than keeping it to themselves. The athletes also needed a little encouragement around their time management skills, being too late or missing physiotherapy appointments or failing to book an appointment and then just showing up, or showing up at 10:30 at night for a nonurgent problem, were all issues that the athletes were educated in. Overall, the Nanjing Youth Olympic Games was a fantastic experience, and a successful one. The team came home with two gold, one silver and three bronze. As a medical team, working with adolescents in a foreign country, it presented its share of challenges, but it was those challenges that made the trip such a rewarding one. The next Youth Olympics is in Argentina in four years’ time - if you get the opportunity to go, jump at it.

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Special Report Youth Olympic Games continued...

The NZ medical room in Nanjing

One of our basketballers in the tiny tots cold baths

NZ weight-lifter Cameron McTaggart competing

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Planet of the Apps Your monthly App review by Justin Lopes - Back To Your Feet Physiotherapy, SPNZ executive member. Hi, Last bulletin I reviewed a great free App, Ubersense. For this edition I am reviewing a paid App - Muscle System Pro II which was designed in conjunction with Stanford University School of Medicine. Anytime an App asks for your hard earned dollar it needs to deliver as there is so much competition from cheap or free Apps. Be aware that some free apps are designed to get information on you and your contacts or personal information. Beware the free lunch! That said, there are lots of great free Apps out there, and I would love to hear your feedback and, if you have any specific apps you would like me to review, please send me the details at info@backtoyourfeet.health.nz . hAPPy APPing!!

App: Muscle System Pro II By 3D4Medical.com, LLC Again this App has been around for a little while but I use it most days in the clinic to help educate patients on their anatomy or to test my own anatomy shortfallsâ&#x20AC;Ś Requires: IOS 7.0 or later IOS8 compatibility has been added. What it is used for: Self Education for clinicians and great for educating clients Where to find it: Download from Apple store, https://itunes.apple.com/nz/app/muscle-system-pro-iii/id364596328? mt=8 or just search for it in the App store! Category:

Medical

Released 2013 Updated: 20 September 2014 Version:

3.8

Size:

828 MB

Seller:

3D4Medical.com

Rated:

4+ in Apple store

Compatibility: Requires iOS 7.0 or later. Compatible with iPad. IPhone and Mac OS Android or Apple or both: Apple - works best on an iPad due to larger screen, but the iphone version is great as it is more portable and only $3.99 Features: Great anatomical 3D modeling of muscle system Pros: Loads quickly, and is quite intuitive as you are able to rotate the model . You are able to view, zoom & rotate parts of the muscle system as well as watch animations, reveal layers, create notes, and share screenshots. There are drop in pins that you can drop in to the relevant muscle which gives you a information box on the muscle, where you can add a note, explore media on the muscle and have public notes. You can annotate on the muscles and save your notes for later. There is a quiz section which will test your anatomy expertise which is great for learning. Cons: To take it to another level it would be great if the movements of the muscles were animated when you clicked on the muscle. Overall Rating: 4/5 Link for app review You can buy the App in a bundle with 3 other APPs by 3D4Medical.com for $30.99 at https://itunes.apple.com/ nz/app-bundle/3d4medicals-body-systems-for/id917661035?mt=8 YouTube link: www.youtube.com/watch?v=GonAO2ffbXA For further discussion on this App check the SPNZ LinkedIn forum page Click here

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Planet of the Apps

Screenshots from Muscle System Pro II

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Case Study Lost in the Knee A 76 year old female retired nurse presented three days after twisting her R knee getting out of car. She did not fall. She had a past history of bilateral TKR’s in 1997. She also fractured her L femur 2007 which required multiple operations. It was finally plated with the plates still being in situ. Prior to this event she was mobile, and walking without support. She stated her knee moved greater than 90 degrees flexion. Her health was affected by high BP which she had previously been hospitalised for earlier in the year. She was on medication for this. She also took diazepam at nights. On presentation she complained of pain in the medial knee. She felt it was hot red and very tender and larger than normal. She had trouble walking, getting up from toilet and if she twisted her knee. She was needing a stick for support. Initially she rested it and the pain settled after a few days to near normal, but then for no obvious reason it reoccurred. On assessment her knee was limited to F 65 – normally>90. There was no pain on resisted movements. It was very tender over the medial knee – joint line and surrounding soft tissues. There was noticeable “laxity” with valgus /varus stressing, but also with the other knee. Working diagnosis Pinched soft tissues medial knee, which were settling but then she returned to activity too quickly so it was aggravated. Plan Rest a bit longer to allow to settle. Grade A ROM exercises, and static quads to maintain muscle function. She was seen next three days later and at this stage her movement had improved (F 105). However over that time she had experienced pain all over the place including her lateral knee, calf, and lateral thigh. She put this down to side effects of her medication (Google is wonderful helping patients to come up with all sorts of ideas). With the pain moving I started thinking of a loose body, but where could it come from as the joint was artificial? We decided to get the GP to review her medications and in the meantime push the strengthening to gain better support of the joint. If it didn’t settle further we would get an orthopaedic review of the prosthesis in case it was loose (being 15 years old). Four days later when I saw her again there was much less pain, and it was the best it had been since she first twisted it. Her ROM was good and there was minimal tenderness. She then saw her GP and had her medications checked. I then saw her after a further five days. She came in in pain again, this time more laterally. Flexion was reduced to 80. Xrays were done showing nothing of concern. Treatment over the next few sessions was mainly to the soft tissues around the knee to especially medially (the pain was now back to just the original region over the medial knee). My thought process being there was still irritation to the soft tissues surrounding the joint – my original working diagnosis. Over the next few sessions the pain settled slowly and the movement improved. There was then an increase of pain – again for no obvious reason. She saw her specialist who was happy with the prosthesis, but thought there was likely a synovitis going on. He decided to do an arthroscopic clean out to free up the soft tissues. I next heard that during the arthroscopy it was noted that there was a piece of prosthesis broken, and it was lodged in the joint space. She is now awaiting a revision of the joint. Discussion My initial thoughts were similar to the surgeon’s initial conclusion that there was a synovitis present, however when the pain started coming and going and moving around the symptoms suggested a loose body. This didn’t make sense as it was an artificial joint and nothing was obvious on the xray. However the final outcome was both synovitis and loose body. Not everything has only one cause. She is much more comfortable with the loose bit having been removed, but still limited functionally until she has the joint revised. By Hamish Ashton, MHSc

What was your original impression of what was going on? What was the process to final diagnosis? In hind sight is there anything you would do differently? Do you have any clinical tips on this injury? For answers to these and further discussion check the SPNZ LinkedIn forum page Click here

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SPRINZ

So is He Ready to Play? The Science of Return to Play Status. By Kelly Sheerin and Scott Brown It’s the inevitable question from coaches that will send a shiver down the spine of most sports physiotherapists: “Is he ready to play? We really need him on the team this weekend”. Determining return-to-sport status for our players irrespective of the sport is an age-old problem, and even though we’re always looking for evidence to support our rehabilitation choices, this aspect of our practice seems to be more of an art, than a science… Well until now that is. To gain better insight into tracking rehabilitation progress, and to ensure that star players are spending less time on the bench, objective athletic assessments are becoming more common in the modern sporting environment to help medical professionals with making the right call on how athletes progress through their rehabilitation, and ultimately when to step foot back on the field. In New Zealand the development of these services is being lead by clinicians and researchers at AUT Millennium’s Strength and Conditioning Clinic. By combining strength and force data gathered via isokinetic dynamometry and through a high tech force instrumented treadmill, assessing injury and re-injury risk has become a little more sensitive and reliable. To date, the main focus has been on moderate to serious knee injuries, and posterior chain muscle injuries. Using the isokinetic dynamometer, concentric and eccentric hip and knee torque (strength), as well as angle of peak torque, can be measured under controlled speed and range of motion conditions. This is combined with sprinting contact time, flight time, as well as vertical and horizontal force measures for each limb. All of this information gives a fantastic objective picture of the athlete, potentially uncovering insufficiencies or asymmetries which would otherwise remain undetected. While it is ultimately desirable to have individual baseline figures to compare with post-injury assessment data, if this is not available, it is still possible to make comparisons with the athlete’s non-injured leg, as well as with the Clinic’s own database of athletes.

CASE STUDY Recently the medical staff from a professional rugby league team sought the advice of Clinic staff to assess one of their players who had suffered several serious injuries (ACL and patellar tendon ruptures) to same knee in a relatively short period of time. He was referred to the Clinic at the stage when the medical staff were confident to clear him to play based on their standard criteria. Not wanting to risk the player further, the question was asked “Is he ready to play?” After undergoing hip and knee isokinetics, as well as sprint kinetic testing, it was discovered that he still fell substantially outside of the Clinic’s criteria for a safe return to play. The injured leg was still 34% weaker during knee extension, and 22% weaker during hip extension than the non-injured leg. Similar deficits in peak sprinting force were also measured, with the injured leg producing 31% less propulsive force and 9% less vertical force that the non-injured side. Based on these results, a collective decision was made that he should undergo an additional 10-week rehabilitation period, with further assessment before a receiving a clearance to play. With a shift in focus to lower extremity eccentric training, not only was an increase in strength seen in both legs, but more importantly, the asymmetry between legs reduced to level that would be considered normal for a rugby league player of his level (<10% for isokinetic strength and vertical force and <20% horizontal force during maximal sprint). This case provides a prime example of the difficulties that face medical staff working with athletes, and highlights the fact that even those with a great deal of experience can still struggle to detect deficiencies that could potentially lead to ongoing injury problems. The services outlined above are available to both athletes and private clients. For more information on the services of offer at AUT Millennium’s Strength and Conditioning Clinic check out their website: www.autmillennium.org.nz/theclinics/

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SPRINZ So is He Ready to Play? The Science of Return to Play Status continued…

Kelly Sheerin Kelly is a registered Physiotherapist and Biomechanist who has a Masters degree in 3D gait mechanics, and is currently working towards his PhD. He has a unique mix of injury and biomechanics knowledge that enables him to take proven research and put it into practice to enhance the prevention and rehabilitation of running related injuries. Kelly is also a Lecturer at AUT’s School of Sport and Recreation where he teaches courses in human anatomy, human movement and body composition analysis. Scott Brown Scott has served as a head strength and conditioning coach for a NCAA Division 1 men’s tennis team in the US while obtaining his Masters degree in biomechanics. His Masters thesis focused on lower-extremity asymmetries in elite female footballers as potential risk factors for ACL injury. Scott is currently working towards his PhD to better understand how asymmetry and abnormal movement patterns contribute to hamstring injuries in rugby. He also puts his knowledge and experience to use as a key provider in the Strength and Conditioning Clinic.

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ASICS ASICS Report Footwear and Knee Osteoarthritis Hello again readers, hopefully you’re managing to stay warm this winter wherever you are. As the weather starts to get colder, this is often the time when we see a bit of a spike in people complaining of joint pain. And for those of us dealing with the lower limb, the major offender is usually the knee. So given we might be hearing from a few more people complaining of knee joint pain in these winter months, what better time than now to devote an issue of Forerunner to talk a little more about knee osteoarthritis, and in particular, the role of footwear in helping to manage symptoms. The focus of this article will be on the most common form of knee osteoarthritis – disease affecting the medial (inside) aspect of the joint. So firstly, is knee osteoarthritis a very big problem? In fact, knee osteoarthritis is a major public health problem that affects around two million Australians. People with the disease suffer from knee pain and physical dysfunction that dramatically impacts their quality of life. Unfortunately there is no cure, and given the condition tends to worsen over time, non-drug treatments that reduce symptoms and assist with patient self-management over the long-term are needed. And luckily for us, it turns out one such option – the humble shoe – has been quietly gaining support as a promising low cost and widely available management strategy with real potential to improve knee joint symptoms. How do shoes influence knee osteoarthritis then? Research has shown that greater forces (also termed loading) across the knee joint contribute to osteoarthritisrelated pain1 and increase the chance of the condition getting worse2. In particular, in people with medial knee osteoarthritis, the force pushing up from the ground tends to pass medial to the knee joint causing the medial compartment to compress and thereby increasing load in the region. But it just so happens that the type of shoe a person wears can directly influence these knee joint loads, depending on the specific design features of the shoe. In fact, not wearing a shoe at all also affects knee loads – we’ve known for a little while that walking barefoot can significantly reduce knee load, although barefoot is unlikely to be safe or practical for most of the people we’re seeing. In a similar vein, more recent research has reported both a reduction in knee joint load and pain whilst wearing very thin, light and flexible shoes3. Once again though, these shoes may not be for everyone, and in some instances, they may contribute to other problems.

Which leads us to the important question - which shoes are best able to reduce knee joint loading during walking? In fact, this question isn’t as simple as it sounds, and it turns out that our knowledge of which shoes or shoe features are good for knee osteoarthritis still needs a bit of work. So instead, let’s start with what we know about which shoes and shoe features are not good for knee osteoarthritis – some of the results may be a little surprising… and controversial. 1. High heels – ok, so this one probably isn’t so surprising. Amongst the many side effects of high heels, research has quite clearly shown that shoes with raised heels of just under 4cm (the height of some running shoes and many dress shoes) can increase knee load by as much as 14% 4, while a 6cm heel can increase load by a whopping 23% 5! Narrow heels are also not the best choice for knees, with a heel width of 1.2cm reported to increase knee load by up to 18%6. It’s also important to remember that shoes with raised heels may increase the risk of falling in older adults7, so it’s clear then that high heels aren’t the best option. 2. Stability shoes and arch supports – this is the controversial one. Although these shoes may be beneficial for a number of other musculoskeletal conditions, new research suggests that stability shoes (sometimes termed motion control shoes) may actually increase medial knee joint forces. In fact, these recent studies have shown that stability shoes, and in particular, those with a dual density midsole where the medial aspect is harder than the lateral aspect, increase medial knee load by an average of 1215% compared to shoes that lack these features 8,9. The addition of an arch support may also exacerbate this, with research reporting a more modest 6% increase in medial knee load10. Remember, these loads directly increase knee pain and disease progression in people with medial knee osteoarthritis, so it appears that stability shoes may be detrimental to people with the condition. This is an important point - we’ve just completed some research showing that not only do most people with knee osteoarthritis think that stability shoes are best choice for managing their knee osteoarthritis symptoms, more significantly, they were also the shoe style most commonly recommended by their health practitioner and/or footwear retailer for their knee pain. Some clinical guidelines also still recommend these shoes as part of the management strategy for people with knee osteoarthritis. Again though, I want to stress that these findings are specific to people with medial knee osteoarthritis, and stability shoes may well help people with other lower limb injuries.

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ASICS ASICS Report continued... 3. Your patient/client’s own shoes (probably) – perhaps most surprisingly, two studies have found that their research volunteer’s own self-chosen walking shoes can also increase knee load3,8. In these studies, the participants were asked to bring along their own conventional walking shoes, which the researchers reported as ranging from loafers to traditional sneakers, but did not include high-heeled shoes, boots, high tops or dress shoes (which we already know aren’t particularly knee-friendly). When the volunteers walked in their own walking shoes the loading in their knee joint was found to increase by 12% when compared to walking barefoot. 4. Clogs – just in case any you come in contact with anyone who is partial to wearing clogs, they’re going to increase knee joint load by up to 15%9. So let’s return now to our original question: which shoes are best for knee osteoarthritis? Taking the finding that stability shoes with a higher medial midsole density increase medial knee loads, it follows that making the lateral midsole denser could decrease medial loads, doesn’t it? Thankfully, the answer is yes. In a pilot study sponsored by ASICS, we gave 22 people with knee osteoarthritis a modified shoe to wear for a minimum of 4 hours daily for 8 weeks. The shoe had a variable-density midsole that was harder laterally and contained a full length lateral wedge fixed to the sockliner. When wearing the modified shoe, we found that knee load reduced by 8-9%, knee pain on walking reduced by 50%, and physical function improved by 22%. Our knee osteoarthritis patients also seemed to like the shoe, with 79% rating their pain as better and 73% rating their function as better. For those interested in the biomechanics behind (or more

correctly—under) the shoe, we found that the change in knee load wasn’t related to alterations in the knee adduction angle or the magnitude of the ground reaction force (GRF), rather, it was due to a decrease in the mediolateral distance of the GRF lever arm from the knee joint axis, and a corresponding lateral shift in the centre of pressure (COP)11,12. Or more simply, the increased lateral density and full length lateral wedge in the modified shoe realigned the ground reaction force (that normally passes on the inside of the knee joint in people with knee osteoarthritis) more towards the centre of the knee, thereby relieving the increased medial compartmental loading. We’re now well in to the next phase of our research, in which we’re randomly allocating 164 people with knee osteoarthritis to wear either the modified “intervention” shoe, or an identical looking unmodified “control” shoe, for six months. Neither the people wearing the shoe, nor the researchers measuring the outcomes, will know which shoe the person is wearing until after the study. And I’m please to report that as of the start of July, we just tested our 100th knee osteoarthritis patient…so watch this space for any updates regarding the study findings. So to summarise, the best footwear options for people with medial knee osteoarthritis appear to be either a very light, thin and flexible shoe for those without any contraindications, or a shoe with a laterally dense midsole and a full length lateral wedge. At the moment, there are a couple of footwear manufacturers making such a shoe internationally, including ASICS’ Gel Melbourne OA – born out of some of this pilot research.

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ASICS ASICS Report continued... And to finish, what about the weather influencing knee symptoms mentioned at the start of this article? Well believe it or not, these complaints may actually be true. Research has shown that changes in outside temperature and barometric pressure directly influence pain severity in people with knee osteoarthritis13. Unsurprisingly, as the thermometer drops, both the quality and quantity of physical activity performed by people with knee osteoarthritis also drops with it14 (hopefully that research didn’t get too many tax payer dollars!). So as always, let’s make sure we en-

courage those with the condition to keep active in these colder months – after all, exercise is a major recommendation in every international osteoarthritis clinical guidelines… but just make sure they’re doing it in the right shoes!

References

8. Shakoor N, Lidtke RH, Sengupta M et al. Effects of specialized footwear on joint loads in osteoarthritis of the knee. Arthritis Care & Research 2008; 59(9):1214-1220.

1. Amin S, Luepongsak N, McGibbon CA et al. Knee adduction moment and development of chronic knee pain in elders. Arthritis Care & Research 2004; 51 (3):371-376. 2. Miyazaki T, Wada M, Kawahara H et al. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of the Rheumatic Diseases 2002; 61(7):617-622. 3. Shakoor N, Lidtke RH, Wimmer MA et al. Improvement in knee loading after use of specialized footwear for knee osteoarthritis: Results of a six-month pilot investigation. Arthritis & Rheumatism 2013; 65(5):12821289. 4. Kerrigan DC, Johansson JL, Bryant MG et al. Moderate-heeled shoes and knee joint torques relevant to the development and progression of knee osteoarthritis. Archives of Physical Medicine and Rehabilitation 2005; 86(5):871-875. 5. Kerrigan DC, Todd MK, Riley PO. Knee osteoarthritis and highheeled shoes. The Lancet 1998; 351 (9113):1399-1401. 6. Kerrigan DC, Lelas JL, Karvosky ME. Women’s shoes and knee osteoarthritis. The Lancet 2001; 357 (9262):1097-1098. 7. Koepsell TD, Wolf ME, Buchner DM et al. Footwear style and risk of falls in older adults. Journal of the American Geriatrics Society 2004; 52(9):1495-1501.

KADE PATERSON Sports Podiatrist – Lakeside Sports Medicine Centre Post-doctoral Research Fellow – Centre for Health, Exercise and Sports Medicine, University of Melbourne

9. Shakoor N, Sengupta M, Foucher KC et al. Effects of common footwear on joint loading in osteoarthritis of the knee. Arthritis Care & Research 2010; 62(7):917-923. 10. Franz JR, Dicharry J, Riley PO et al. The influence of arch supports on knee torques relevant to knee osteoarthritis. Medicine & Science in Sports & Exercise 2008; 40 (5):913-917 910.1249/ SS.1240b1013e3181659c3181681. 11. Kean CO, Bennell KL, Wrigley TV et al. Modified walking shoes for knee osteoarthritis: Mechanisms for reductions in the knee adduction moment. Journal of Biomechanics 2013; 46(12):2060- 2066. 12. Bennell KL, Kean CO, Wrigley TV et al. Effects of a modified shoe on knee load in people with and those without knee osteoarthritis. Arthritis & Rheumatism 2013; 65(3):701-709. 13. McAlindon T, Formica M, Schmid CH et al. Changes in Barometric Pressure and Ambient Temperature Influence Osteoarthritis Pain. The American Journal of Medicine 2007; 120(5):429-434. 14. Robbins SM, Jones GR, Birmingham TB et al. Quantity and Quality of Physical Activity Are Influenced by Outdoor Temperature in People with Knee Osteoarthritis. Physiotherapy Canada 2013;Osteoarthritis. Physiotherapy Canada 2013; 65(3):248-254.

FORERUNNER AUGUST 2014

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Clinical Section - Article Review Rehabilitation After Hip Femoroacetabular Impingement Arthroscopy Clinical sports Medicine 30 (2011) 463-482 Mark Ryan MS, ATC, CSCS Michael Wahoft, PT SCS Hip arthroscopic techniques to repair labral tears and address femoroacetablar impingement syndrome (FIS) continue to evolve. Hip arthoscopic procedures are used to correct bony geometry and provide an intact labral complex and ligamentous structure for improved hip congruency. Post â&#x20AC;&#x201C;operative rehabilitation must protect the healing tissues, minimise pain and inflammation, allow for early range of movement (ROM), reduce muscle inhibition, restore neuromuscular control and proprioception, normalise gait and improve strength. For the athlete, power, speed and agility are recommended for optimal return to competition and for all patients, overall longevity and patient satisfaction. ARTICLE REVIEW Principles of Hip Arthroscopy Rehabilitation 1.

Rehabilitation is an individual and evaluation based program addressing the findings of the surgeon, the procedure and the patients individual characteristics

Circumduction is critical for early mobility and reduction in scar tissue

Rehabilitation is functional and sports specific

The 4 phases of rehabilitation include: 1.

Maximum protection and mobility

Controlled stability

Strengthening

Return to sport

Fig. 1. The 4 phases of rehabilitation as shown in a motor control dia-

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Clinical Section - Article Review Rehabilitation After Hip Femoroacetabular Impingement Arthroscopy continued... Rehabilitation is individualised with specific timelines for weight bearing and Range of Movement (ROM) restrictions (imposed by the specific procedures performed). Compliance by the patient and guidance from the therapist is critical to allow for soft tissue healing. Programs are similar for all patients in early and mid phases. Advancement to the next phases allows for difference in age, genetics, nutrition, concomitant injury, symptom onset, goals and sports specific demands. Rehabilitation programs have restrictions and precautions in place as per the surgical procedures performed. See Table 1 & 2 in article

Pain and inflammation can be controlled with ice, compression, and lymphatic massage. Myofascial release, deep tissue massage and active resistance techniques can be used as the swelling decreases. Mobility within restrictions can be with CPM, cycle, aquatic therapy and passive ROM with emphasis on circumduction. It is critical to re-establish dynamic hip joint mobility congruency. Exercises are selected for muscular strength, work rate, power or endurance. The goals of the exercises selected include preventing muscle inhibition, regaining neuromuscular control and proprioception, or increasing strength, power and/or endurance. It is critical the exercises selected are based on performance while maintaining surgical precautions and consideration of joint reaction forces. Depending on the goals and the phase of rehabilitation, isometric, isotonic, slow and/or fast dynamic and functional exercises may be selected. Weaning off crutches depends on the patientâ&#x20AC;&#x2122;s tolerance to gradually increase weight bearing and proper firing patterns of gluteal muscles without a Trendelenburg gait pattern. Gluteus Medius muscle is a key stabiliser of the hip during gait and requires progressive strengthening within the restrictions of surgical precautions. Assessment of the Lumbar-pelvic-hip complex and lower limb kinetic chain helps address muscle imbalance. Manual mobilisation of the spine and Sacro-Iliac joint and soft tissue work may be necessary at this phase to facilitate normal mechanics. Improvement of neuromuscular control is critical for balance and proprioception. Endurance exercise emphasising gluteus maximus and medius and core exercises are performed as weight bearing increases to facilitate a normal gait pattern. Cardio-vascular fitness can start in phase 1 after day 7 Upper extremity strengthening regimes can return to normal in phase 2 and core conditioning can be advanced also in phase 2 See Table 3 in article Sports progressions are performed within pain free ROM and duration and intensity controlled by soreness in the joint and muscles. As confidence, strength, and endurance builds, faster movements of increased volume can be instigated. The volume and intensities need to be controlled and rest should be mandatory. Recovery sessions can include balance, co-ordination and continuing mobility exercises. A balance between cardio-vascular, strength, core, rest and sports specific should be planned and developed. Sports progressions are critical aspects of phases 3 and 4. Neuromuscular control (phase2) and endurance strength (phase 3) is emphasised incorporating power agility and pace training into the strengthening programme with shorter rest periods. As the patient demonstrates the ability to perform single leg strengthening with adequate endurance, good form, power and agility, movements can be added including lateral and diagonal activities. Phase 3 culminates in passing of a sports test.

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Clinical Section - Article Review Rehabilitation After Hip Femoroacetabular Impingement Arthroscopy continued...

See Table 6 in article Once completed the athlete enters phase 4 and transition in to full training with a dedicated return to sport plan. Advanced power, plyometrics, and conditioning training and performance should transition smoothly if the hipspecific treatment, cardio-vascular fitness, conditioning and sports progression were used. See Table 7 in article CONCLUSION Rehabilitation after FAI arthroscopy is individual. Adhering to restrictions and following the performance criteria through each subsequent phase will allow patients to return to sport without complications and with positive outcomes. See references in article By Pip Sail Dip Sports Med., BSc, Cert acupuncture (PANZ)

Continuing Education

For current SPNZ members only: Go to the Eventbrite site SPRINZ Conference 2014 Eventbrite Registration and "Join a Group". Select SPNZ and enter in the promo code "SPNZ

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Continuing Education Upcoming courses and conferences in New Zealand and overseas in 2014. For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/

LOCAL COURSES & CONFERENCES When?

What?

Where?

1 November 2014

Canterbury Branch Shoulder Symposium

Christchurch

2 November 2014

Mulligan Concepts Part A

Dunedin

2 November 2014

StabilityPlus - Foam Roller Workshop

Auckland

14-16 November 2014

2014 SESNZ - SMNZ Shared Conference

Wellington

15-16 November 2014

Kinesio Taping Course - KT 1 & 2

Whangarei

22-23 November 2014

Kinesio Taping Course - KT 1 & 2

Hamilton

29 November 2014

Flawless Motion Shoulder Course

Auckland

29-30 November 2014

Kinesio Taping Course - KT 3

Christchurch

6 December 2014

Flawless Motion Shoulder Course

Auckland

APA CPD EVENT FINDER SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and conferences at APA member rates. This includes all webinars and podcasts (no travel required!). To see a full list visit the APA and SPA Events Calendar

APA SPA COURSES & CONFERENCES When?

What?

Where?

8-9 November 2014

The Sporting Shoulder

Rozewell, NSW

8-9 November 2014

Sports Level 1

Bentley, WA

21-23 November 2014 Sports Level 2

St Lucia, QLD

21-23 November 2014 Sports Level 2

Camberwell , VIC

22-23 November 2014 The Sporting Hip

Silverwater, NSW

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Research Publications JOSPT www.jospt.org JOSPT ACCESS All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the “Forgotten your password” link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.

Volume 44, Number 10, October 2014 EDITORIAL Always on the Run On the Run: A Runner's Perspective On the Run: A Coach's Perspective On the Run: A Physician's Perspective CLINICAL COMMENTARY Management and Prevention of Bone Stress Injuries in Long-Distance Runners The Re-emergence of the Minimal Running Shoe Lower-Limb Muscular Strategies for Increasing Running Speed Heat Stress and Thermal Strain Challenges in Running MUSCULOSKELETAL IMAGING Tibial Cyst Formation Following Anterior Cruciate Ligament Reconstruction Symptomatic Ganglion Cyst in a Patient With Knee Pain PERSPECTIVES FOR PATIENTS Running: How to Safely Increase Your Mileage RESEARCH REPORT What Do Recreational Runners Think About Risk Factors for Running Injuries? A Descriptive Study of Their Beliefs and Opinions Excessive Progression in Weekly Running Distance and Risk of Running-Related Injuries: An Association Which Varies According to Type of Injury Hip Muscle Loads During Running at Various Step Rates Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running Summer Training Factors and Risk of Musculoskeletal Injury Among High School Cross-country Runners Injury Reduction Effectiveness of Prescribing Running Shoes on the Basis of Foot Arch Height: Summary of Military Investigations