ISSUE 2 0 April 2009
promoting
best practice in
highlights
sports care n Craniosacral therapy: its role in sport n Sports medicine, rehabilitation and the law n Hydrotherapy in sport n Podiatry and its role in sports medicine n Chiropractic and sport
n Hamstring muscle injuries
Sports Healthcare Life Size Models Anatomical Models
The most realistic selection of life size anatomical models ever. Complete with ligament attachments.
Knee, Shoulder, Foot and Ankle. Only £19.99 each
Special Edition Anti Burst 65cm Ball for Maximum Performance. Ribbed design for extra grip and stability.
BU
E E R
NE
YO
Silver Physique GymBall 65cm
F
NE
O GET
Only £9.99 BUY ONE GET ONE FREE
E E R
NE
YO
BU
F
NE
O GET
2009-2010 Catalogue, order online
w w w. p hy s i q u e . c o . u k Hot and Cold Packs
Reusable Hot or Cold Packs. Simply place in microwave for a hot pack or in the freezer for a cold pack. (Free item = Red Square Hot/Cold Pack)
Only £2.19 BUY ONE GET ONE FREE
Prices exclude VAT and delivery Offers valid until end of May 2009 or until stocks last.
Special Offer
or call 0870 6070 381
contents April 2009 Issue 20 Publisher Tor Davies BSc (Hons) tor@sportex.net Editor Bob Bramah MSMA, MCSP bob@sportex.net Art editor DEBBIE Asher debbie@sportex.net Advertising manager Paul Harris paul@sportex.net +44 (0)845 652 1906 Subscriptions Sandra Greatorex subs@sportex.net +44 (0)845 652 1906 Technical advisors
Bert Appleton MSMA Steve Aspinall BSc (BASRaT), MSc Paula Clayton MSMA, MCSP Steven Cluney MSMA Dr Marco PhD, MSc, BSc Cardinale Dave Clark MSc, BSc (Med Hons), BPE Stuart Hinds Dip SST Brad Hiskins BSc, Dip SST Ian Jeffrey BA (Hons), MSc, PGCE, CSCS Michael Nichol BSc (BASRaT) Joan Watt MCSP, MSMA Dr Greg Whyte PhD, BSc (Hons)
is published by Centor Publishing Ltd 88 Nelson Road Wimbledon, SW19 1HX
Welcome Welcome to the Spring edition of sportEX dynamics. In this edition we take a look at some therapies that may help with the preparation of athletes for sporting performance. Our more forward thinking professional teams are already beginning to embrace the idea that the old ‘bucket and sponge’ man who combined a rudimentary knowledge of injury management with the role of fitness trainer, kit man, cleaner and bus driver, are long gone. In this we are a long way behind some of our continental neighbours. The article on chiropractic in particular hints at the work being done by Italian football giants AC Milan. They focus not simply on the day to day preparation of their current squad but are actively involved in longer term research projects to ensure that they remain at the top of the sports science league. The proof of what they achieve is demonstrated by David Beckham. In a couple of months they reduced his body fat percentage from 13 to 8%. They improved his overall fitness and level of play to such an extent that he was recalled to the national team. A multidisciplinary approach is very much the way forward but it needs to filter down the pyramid from the elite to the grass route level. When we think of health professionals and sport we tend to focus on physio and sports therapists but there are many other disciplines out there and they all have something to offer.
Bob Bramah, MSMA, MCSP bob@sportex.net
Tel: +44 (0)845 652 1906 Fax: +44 (0)845 652 1907 www.sportex.net other Titles in the SportEX range sportEX medicine - ISSN 1471-8138. Written specifically for professionals working in the field of soft-tissue injury and rehabilitation - personal annual subscription £35, practice subscription £99 sportEX health formerly known as healthEX specialist - ISSN 1471-8154. For people working in the physical activity health promotion sector, health and fitness industry as well as in primary care and occupational health annual subscription £35 for individuals, £60 for departments
Contents 4 Journal watch 7 Craniosacral therapy 11 Foot care for sport
A look at some of the latest research
and its role in sport
A look at how podiatrists can play an important part in the prevention and management of lower limb problems
14 Litigation in sport 17 Chiropractic and sports 19 Hydrotherapy 21 Hamstring muscle injuries
How the practice and conduct of sports medics is under rising scrutiny The value of chiropractic clinicians and their holistic approach within sport The case for using hydrotherapy in sport
A look at this common injury and why they reoccur so frequently
DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.
www.sportEX.net
3
online
CLICK ON RESEARCH TITLES TO GO TO ABSTRACT
DECLINING INCIDENCE OF CATASTROPHIC CERVICAL SPINE INJURIES IN FRENCH RUGBY. Bohu Y, Julia M, Bagate C, et al. American Journal of Sports Medicine 2009;37:319–323 This epidemiology study looked at players with cervical spine injuries causing neurological disorder classified from the American Spinal Cord Injury Association (ASIA) scale, grade A to D (Box 1), between the 1996–97 and the 2005– 06 seasons. Circumstances of the injuries and of the clinical outcome were collected by interview. There were 37 cases. The incidence of the cervical spine injuries decreased during this period. The rates of injury were 2.1 per 100,000 players per year during the 1996–97 season and 1.4 per 100,000 players per year during the 2005–06 season. The scrum was a major cause of injury, accounting for 51.3% (19/37) of injuries. The forwards represented 89.2% (33/37) of the injured players. The hookers were involved in 37.8% (14/37) of cases. The measures of prevention with the modification of the rules of scrum and the creation of a medical certificate required for players to play in the front row must have been successful.
sportEX comment The decreased injury rate seems to be linked to the decreasing incidence of injuries in the scrum. It shows that the preventive measures, particularly rule changes, are working. It is a good model for other sports to follow: identify a cause and do something about it. It has not changed the nature of the game or participation numbers.
Box 1. The American Spinal Cord Injury Association (ASIA) defined an international classification based on neurological levels, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, i.e. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7) and hip flexion (L2). Traumatic spinal cord injury is classified into five types: A: “complete” spinal cord injury, where no motor or sensory function is preserved in the sacral segments S4–S5. Since the S4–S5 segment is the lower segment, absence of motor and sensory function indicates “complete” spinal cord injury. B: “incomplete” spinal cord injury, in which sensory but not motor function is preserved below the neurological level and includes the sacral segments S4–S5. This is typically a transient phase. If the patient recovers any motor function below the neurological level, the patient essentially becomes motor-incomplete, ie. ASIA C or D. C: “incomplete” spinal cord injury, in which motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3. D: “incomplete” spinal cord injury, in which motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more. E: “normal”, ie. motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficit with completely normal motor and sensory scores.
THE USE AND ABUSE OF PAINKILLERS IN INTERNATIONAL SOCCER. Tscholl P, Feddermann N, Junge A, Dvorak J. American Journal of Sports Medicine 2009;37:260–265 Team physicians reported 10,456 uses of medication 72 hours before each match in 2,488 soccer players participating in six international soccer tournaments. Results: The use of a total of 6,577 medical substances was reported, leading to an average intake of 0.63 substances per player per match (under-17s, 0.51; under-20s, 0.51; women, 1.0). Non-steroidal anti-inflammatory drugs were the most commonly prescribed type of medication in
4
all tournaments. Women’s soccer had the highest percentage of players using non-steroidal anti-inflammatory drugs per match (under-17s, 17.3%; under-20s, 21.4%; women, 30.7%). Relatively few players were taking b2-agonists for the treatment of asthma (under-17s, 1.3%; under20s, 1.3%; women, 4.3%).
sportEX comment These findings highlight the apparent excessive medication use in international top-level women’s and men’s youth soccer nearly to the same extent as in men’s soccer. Is it all necessary? Continued abuse of medication may negatively influence not only the quality of the game but also the health status of the players.
sportEX dynamics 2009;20(Apr):4-6
Journal watch
Journal Watch SELF-REPORTED ANABOLIC-ANDROGENIC STEROIDS USE AND MUSCULOSKELETAL INJURIES: FINDINGS FROM. Horn S, Gregory P, Guskiewicz KM. American Journal of Physical Medicine and Rehabilitation 2009;88:192– 200 The relationship between musculoskeletal injuries and anabolic-androgenic steroids is not well understood. The purpose of this study was to investigate the association between self-reported anabolic-androgenic steroids use and the prevalence of musculoskeletal injuries in a unique group of retired professional football players. A general health questionnaire was completed by 2,552 retired professional football players between 2001 and 2003. Results of self-reported musculoskeletal injuries were compared with the use of anabolic-androgenic steroids. Results: 9.1% reported using anabolic-androgenic steroids during their professional career. A total of 16.3% of all offensive line and 14.8% of all defensive line players reported using anabolicandrogenic steroids. (These are the big guys on the team.) Self-reported anabolic-androgenic steroids use was associated significantly with the following self-reported, medically diagnosed joint and cartilaginous injuries in comparison with the non-anabolic-androgenic steroids users: disc herniations, knee ligamentous/meniscal injury, elbow injuries, neck stinger/burner, spine injury, and foot/toe/ankle injuries. There was no association between anabolic-androgenic steroids use and reported muscle/tendon injuries.
sportEX comment US professional sport seems to have lagged behind the rest of the world when it comes to recognising performance-enhancing drug use, but it has had a wake-up call in recent months. The star baseball player Alex Rodriguez has admitted steroid abuse, and Balco, the San Francisco drug laboratory, has been exposed as a supplier of growth hormone to a number of leading athletes. This report demonstrates not only considerable drug abuse in the National Football League but that an association may exist between anabolic-androgenic steroids use and the prevalence of reported musculoskeletal injury, particularly ligamentous/joint-related injuries.
DOES THE USE OF ORTHOSES IMPROVE SELF-REPORTED PAIN AND FUNCTION MEASURES IN PATIENTS WITH PLANTAR FASCIITIS? A METAANALYSIS. Lee SY, McKeon P, Hertel J. Physical Therapy in Sport 2009;10:12–18 The major databases MEDLINE, SPORTDiscus and CINAHL were searched from their inception until December 2007 using the terms “foot”, “plantar fascia”, “arch”, “orthotic”, “orthoses” and “plantar fasciitis”. Original research studies that met the following criteria were included: (i) randomised controlled trials or prospective cohort designs; (ii) patients were suffering from plantar fasciitis at the time of recruitment; (iii) the study evaluated the efficacy of foot orthoses with self-reported pain and/or function; (iv) means, standard deviations and sample size of each group were reported. The meta-analysis results showed significant reductions in pain after orthotic intervention.
sportEX comment This does what it says on the tin. The use of foot orthoses in patients with plantar fasciitis appears to be associated with reduced pain and increased function.
ELECTROMYOGRAPHY AND KINEMATICS OF THE TRUNK DURING ROWING IN ELITE FEMALE ROWERS. Pollock CL, Jenkyn TR, Jones IC, et al. Medicine and Science in Sports and Exercise 2009;41:628–636 Nine rowing Canada national team candidates performed a 2000m race simulation. Electromyographical (EMG) activity of spinal and pelvic extensor and flexor muscles and kinematic data of the pelvis and the spine were collected and analysed during the period of peak force production. Pelvic and spinal extensor muscles demonstrated similarities in the timing of muscle activity with minimal co-activation of flexors and extensors. Minimal excursion of spinal segments occurred during the stroke, with most of the extension occurring at the pelvis. Flexor activity occurred towards late drive, suggesting that trunk extension is slowed by increasing activity of the flexor muscles. Of the spinal segments, L3–S1 showed the most movement
sportEX comment This has implications for muscle balance training. In particular, the greater movement recorded at the lower spinal and sacral segments may make the area more susceptible to soft-tissue injury, which could potentially be prevented with focused attention.
www.sportEX.net
5
Journal watch
EFFECTS OF LEFT- OR RIGHT-HAND PREFERENCE ON THE SUCCESS OF BOXERS IN TURKEY. Gursoy R. British Journal of Sports Medicine 2008;42:142–144 The study was based on a sample of 22 active, semi-professional or amateur male boxers who had been actively boxing for 4–15 years (mean 9.87 years), were aged 17–46 years (mean 32.25 years) and weighed 65–101 kg (mean 81.06 kg). They were divided into groups depending on their prominent hand. The status of left- or right-handedness was determined using the Oldfield (Edinburgh Handedness Inventory) Index. This asks the prevalence of how often each hand is used in writing, throwing, using scissors, using a knife (without a fork), using a spoon, using a computer mouse and striking a match. The boxers were then categorised into two groups (win and defeat). The left-handed boxers had been involved in 75–800 fights (mean 120.6 fights), with 5–79 fights lost (mean 19.32 fights). The right-handed boxers had been involved in 50–820 fights (mean 127.8 fights), with 23–78 fights lost (mean 42.25 fights). Left-handed boxers were found to be more successful than right-handed boxers.
sportEX comment The authors concluded that left-handed people should never be forced to “convert” to right-handedness. Instead, they should be supported both verbally and in terms of their equipment, and they should be motivated, because the data obtained proved that lefthandedness means success, especially in boxing. This is fair enough, except that it does not state whether the boxers are fighting similar-handed opponents, which may make a difference. CRICKET BALL INJURY: A CAUSE OF SYMPTOMATIC MUSCLE HERNIA OF THE LEG. Gupta RK, Singh D, Kansay R, Singh H. British Journal of Sports Medicine 2008;42:1002– 1003 A 26-year-old male professional cricketer was injured by the direct hit of a high-speed cricket ball while trying to stop the ball with his leg. He was treated with application of ice, analgesics, rest and a compression bandage for the first 24 hours, followed by analgesics and then a compression bandage. The symptoms of acute injury were over in 3–4 weeks. In the subsequent matches he reported acute pain in the leg after 2–3 hours of activity, which prevented further participation in the game. Over the next 2 years the patient was treated by different sports physicians and orthopaedic surgeons. He had numerous investigations, including plain radiography, a bone scan, coloured Doppler and magnetic resonance imaging (MRI) of the lumbar spine, none of which identified a problem. His symptoms worsened and he started getting an unbearable pain in the leg after walking for 400–500 m. Eventually he was seen by the authors, who noted a subtle swelling on resisted dorsiflexion and suspected a muscle hernia. Surgery discovered a deep facial defect, which was treated by fasciotomy, and the player made a full recovery. Unfortunately, so much time had elapsed that his professional career was over.
sportEX comment Another case study. Such studies tend to be discounted as being at the bottom of the evidence pecking order, but they are excellent sources of information for practitioners, especially with rare cases. Fascial problems are often overlooked by clinicians, who focus on larger structures visible on the various scans. Soft-tissue therapists, however, know better. Speak up! The delay in diagnosis cost this player his livelihood.
6
MASSAGE AFTER EXERCISE-RESPONSES OF IMMUNOLOGIC AND ENDOCRINE MARKERS: A RANDOMIZED SINGLE-BLIND PLACEBO-CONTROLLED STUDY. Arroyo-Morales M, Olea N, Ruiz C, et al. Journal of Strength and Conditioning Research 2009 (to be published) The aim of this study was to determine the effect of massage on endocrine and immune functions of healthy active volunteers after intense exercise. After repeated Wingate cycle tests, the effects of whole-body massage and placebo on salivary cortisol, immunoglobulin A (IgA) and total protein levels were compared using a betweengroup design. Sixty healthy active subjects (23 women, 37 men) underwent two exercise protocol sessions at least 2 weeks apart and at the same time of day. The first session familiarised participants with the protocol. In the second session, after a baseline measurement, subjects performed a standardised warm-up followed by three 30-second Wingate tests. After active recovery, subjects were randomly allocated to massage (40-minute myofascial induction) or placebo (40-minute sham electrotherapy) group. Saliva samples were taken before and after the exercise protocols and after recovery. In both groups, the exercise protocol induced a significant increase in cortisol, decrease in salivary IgA (sIgA), and increase in total proteins in saliva. Generalised estimating equations showed a significant effect of massage on sIgA rate, a tendency towards significant effect on salivary total protein levels, and no effect on salivary flow rate or salivary cortisol. The sIgA secretion rate was higher after the recovery intervention than at baseline among women in the massage group but similar to baseline levels among women in the placebo group.
sportEX comment The evidence base for the efficacy of massage grows and grows. This article shows that massage may favour recovery from the transient immunosuppression state. It is of particular value between high-intensity training sessions or competitions on the same day.
sportEX dynamics 2009;20(Apr):4-6
craniosacral therapy sports medicine
Craniosacral therapy:
its role in sport? By Penny Nisbet, MCSP RCST
INTRODUCTION Flexibility, muscular strength and smooth coordinated movement are recognised important factors in optimum sporting performance. One only has to glance at familiar images of athletes in action to observe movement that is powerful, graceful and apparently effortless. This is undoubtedly achieved by dedicated practice and effort by the individual. However, it is not difficult to notice when reading sporting news reports that some talented athletes who have competed consistently at a very high level are frustratingly injury-prone and are forced to spend months or even years of a potential peak performance period in their lives recovering from injury or repair surgery. Another picture can be imagined of a group of athletes possessing similar sporting ability and determination to succeed, and undergoing the same conditioning programme but achieving very dissimilar results, which cannot be attributed to any particular factor. In spite of diligent investment of time and effort by many experts, and not least by the individual, it may have to be accepted that no further improvement is possible. A therapeutic modality that helps the body to find its own resources in order to achieve a better balance and level of health would seem a welcome option. This is the potential in craniosacral therapy, which can be undertaken as a possible means to prevent injury, achieve optimum performance level and recover from the effects of injury.
WHAT IS CRANIOSACRAL THERAPY? Craniosacral therapy is a gentle hands-on therapy that assists the body’s natural ability to repair itself. It is a therapy that is becoming increasingly popular, perhaps due to the effectiveness of its gentle approach. Craniosacral therapy has www.sportEX.net
Craniosacral therapy is a therapeutic modality that helps the body use its own resources to achieve a better balance and level of health. It is a possible means to prevent injury, achieve optimum performance level and recover from the effects of injury. been developed from discoveries made by osteopaths about the body’s subtle physiology in the USA around 100 years ago. These findings show that all cells in the body express a rhythmic movement – usually referred to as “craniosacral motion” – that is fundamental to life. In the core of the body, the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord and provides protective cushioning and nutrition for the nervous tissue expresses the rhythmical craniosacral motion in an ebb and flow type of movement, which could be compared to a tide or current in the sea. Bones, organs and other structures possess their own characteristic patterns of movement. This movement is very subtle but a trained therapist is able to recognise it. These discoveries were developed and have been refined into a unique style of “listening” to the body via the trained therapist’s hands. This process of listening to the body also facilitates the body’s healing resources.
craniosacral therapy is A gentle hands-on therapy that assists the body’s natural ability to repair itself 7
experienced after around five to ten sessions. Craniosacral therapy is regarded as one of the safest therapies available. It is non-invasive and works on a subtle level, facilitating the body’s natural ability to heal.
HOW CRANIOSACRAL THERAPY WORKS
A registered craniosacral therapist is a graduate of a training course accredited by the Craniosacral Association of the UK and has to undertake continuing professional development. Chartered physiotherapists are able to practise craniosacral therapy as part of their scope of practice as long as they have achieved a measured level competence as a result of training by an accredited college or training organisation. It should be understood that the approaches used by a craniosacral therapist may vary according to where and how they have been trained. The author is registered with the Craniosacral Association of the UK (www. craniosacral.co.uk), which requires its members to adhere to a strict code of ethics and practice and to undertake a programme of continuing professional development.
WHAT HAPPENS DURING A TREATMENT SESSION? A craniosacral therapist is trained to “listen” to what is going on in the body using very light manual contact. The therapist uses this contact to identify and assist the release of pain and tension in the body. It may take a few sessions to get used to the process, so it is often beneficial to consider having a series of treatments in order to discover the benefits and effects of craniosacral therapy. The client may feel a deep sense of relaxation during the therapy session, and there can be an awareness of heat, tingling, pulsations or other sensations. A craniosacral therapy session is very much led by the client: the client’s body sets the pace of work during a session, so the experience is comfortable. The client feels in control and is able to integrate the changes that occur. Therapy sessions typically last between 45 and 90 minutes, depending on the practitioner and the nature of the visit. The number of sessions varies according to the condition being treated. Often, many benefits are
craniosacral therapy is becoming increasingly popular, perhaps due to the effectiveness of its gentle approach 8
The body’s tissues contract in response to physical strains or emotional stress. Sometimes these physical or emotional shocks can be very severe and the body is unable to resolve the effects of the contraction. Tensions remaining in the body restrict its function, which can lead to the development of problems over the years. The effects of such contractions include back pain, migraine, digestive disorders and emotional disorders such as anxiety and depression. Such contractions in the body could also be contributors to troublesome sports injuries. These restrictions show up as differences in the way craniosacral motion is expressed in the body. These differences can be felt by the therapist and used to identify where there is congestion or restriction in the body. The therapist’s hands are used to amplify the pattern of movement that the body is expressing. This provides an opportunity for the body to “let go” of its restriction and thus find a better way of functioning. The body has to use energy to hold the contraction in the body. When the body has let go of the contraction or restriction, this energy is set free and therefore there is often an increase in available energy in the body as an outcome of this therapy. There can also be an increase in emotional or mental ease. Craniosacral therapy is also highly effective as a general therapy to help people gain a feeling of wellbeing and also to regain a feeling of balance.
TREATMENT OF TRIGGER POINTS Many writers have produced works on trigger points. These points are blamed for a range of musculoskeletal dysfunction. Simons et al., writing on the phenomenon of trigger points, describe trigger points and how they were caused (1). They also discuss seemingly intractable pain, which is often characteristically worsened by exercise but could be relieved or removed with simple treatment methods. A reference appears to myofascial release, which is given a “cranial” link by the authors. Their observation in this reference is that trigger points not treated directly by cranial techniques would remain untreated. However, with my understanding of the effects of craniosacral treatment, all trigger-point symptoms are likely to be addressed at some point, although some may be more deep-seated than others and therefore treated at different times during a series of treatment sessions. Leon Chaitow has written widely concerning this subject and strives to compare different methods of treatment (2). His description – and my experience – of using positional release techniques (3) can be likened to the process of fascial unwinding, a useful technique used in craniosacral therapy. Positional release techniques are a group of manual treatment methods that can help to relieve painful, traumatised or inflamed soft tissue. Essentially, an affected area is placed in its most eased, pain-free position. This provides an opportunity for the release of spasm or increased tone, thus resolving the musculoskeletal dysfunction (3). This method of treatment is also referred to sportEX dynamics 2009;20(Apr):7-10
craniosacral therapy sports medicine as an “unlatching” principle. In order to unlatch a gate, the gate often has to be moved into a tighter closed position first, thus releasing the latch. Ed Wilson conducts a 2-day course during which he explores trigger-point treatment methods (4). Wilson teaches that extremely light touch techniques can be very beneficial in relieving pain and tension in local very tender spots. It was this discovery that led me on the path towards training in craniosacral therapy. However, the approach can be timeconsuming: it can take time to identify the presence of trigger points, and when these are resolved, more trigger points – known as latent trigger points – often become active. As I have discovered repeatedly, both clinically and as a result of my training, deeper, hidden dysfunctions may cause symptoms to recur.
RELEVANCE OF CRANIOSACRAL THERAPY TO SPORT Balance and optimum function are important factors in sports performance, which necessitates dedicated and persistent training and practice of technique. Therefore, the achievement of the body in finding a greater balance overall is bound to benefit the body not least in potentially helping to reduce stresses within the body and subsequently releasing the energy required to overcome those stresses for all aspects of performance of sport or other activity. Traditionally, the athlete seeks to overcome restriction in range of movement and imbalance in function by sheer willpower and effort. However, the body could be holding significant restriction, such as the effects of past accidents or stresses to the body that are not visible or evident during a conventional recall of personal medical history or in particular as a result of objective physical examination and that cannot spontaneously or by self-effort let go of this restriction. This is just the situation that many physiotherapists encounter in a physiotherapy department when some gains have been made, but options for treatment have been exhausted resulting in a reduced outcome and possible fairly rapid return to physiotherapy when symptoms recur. (A similar situation can arise in sport when an individual is unable to return to their sport for many months because of an apparent inability to return to full fitness in spite of diligent training. Worse than this, an attempt may be made to return to full fitness but result in re-injury.) It can be discouraging for both the physiotherapist and the individual with the injury to have to say that no more can be done during that programme of physiotherapy. Many people use craniosacral therapy as a preventive therapy in order to maintain a good level of bodily health. If you are participating regularly in sporting activities, this is when craniosacral therapy can be very useful – perhaps to reduce factors leading to injury as a result of increased balance in the body.
HOW DO WE KNOW THAT CRANIOSACRAL THERAPY WORKS? No guarantees can be given concerning whether craniosacral therapy will work for a particular client, but a craniosacral therapist can explain what to expect and what results have been achieved with clients in the past. Elderly people are often precluded from other treatments because of their age, vulnerability or state of health, but for craniosacral therapy there is no prerequisite condition of age, fitness or strength. Many elderly people discover that craniosacral therapy relieves the common symptoms of old age such as aches and pains, headaches, and back, sleep and digestion problems. These are often the problems that prevent
Box 1: Conditions that can be helped by craniosacral therapy n Allergies
n Arthritis
n Asthma
n Autism
n Back pain
n Birth trauma
n Bone and joint disorders
n Breathing disorders
n Bronchitis
n Cerebral palsy
n Chronic fatigue
n Colic
n Depression
n Digestive problems
n Drug withdrawal
n Dyslexia
n Emotional problems
n Exhaustion
n Frozen shoulder
n Headaches and migraines
n Hormonal imbalances
n Hyperactivity
n Impotence
n Infertility
n Insomnia
n Learning difficulties
n Myalgic encephalomyelitis (ME)
n Menstrual pain
n Muscular aches and sprains
n Nervous disorders
n Post-dental trauma
n Rheumatism
n Sciatica
n Sinusitis
n Spinal curvatures
n Stress-related conditions
n Stroke
n Trigeminal neuralgia
n Temporomandibular joint (TMJ)/ jaw disorders
n Visual disturbances
CONDITIONS THAT CAN BE HELPED BY CRANIOSACRAL THERAPY Box 1 lists many of the conditions that can be helped by craniosacral therapy. It should be noted that although many of the conditions do not fall into the usual categories of sports illness or injury, all of them can affect sportspeople and therefore influence performance.
www.sportEX.net
9
continued participation in sport and exercise programmes by people as they age. In addition, although not strictly used within the sports or performance arena, craniosacral therapy is particularly well known for its benefits in babies and children.
CASE STUDY Lucy, a 40-year-old professional woman, attended my physiotherapy clinic, having recently sustained a Colles fracture of the wrist. The plaster had been removed a few weeks previously. She was suffering pain, loss of function and reduced range of movement in her wrist and hand, and she was unable to continue her work as an experienced therapist. Subjective assessment indicated that Lucy had a history of multiple horse-riding accidents since early childhood. Questions concerning Lucy’s past medical history included exploration of any recollection of heavy falls or injuries in the past. I included my awareness of this information in my planned programme of treatment, and the outcomes of treatment appeared to benefit from this inclusion, rather than a programme focusing entirely on the limb part that had suffered the most recent injury. Physiotherapy treatment approaches were selected to address apparent soft-tissue and postural adaptations to past injury, and to encourage mobilisation of the affected wrist. Progress, however, was extremely slow. In spite of diligent physiotherapy and good patient cooperation, it was 3 months before a phased return to work was possible for Lucy. Six months after the wrist fracture, I conducted a craniosacral assessment with Lucy before a planned series of craniosacral therapy treatment sessions. The subjective gathering of information in a craniosacral therapy assessment tends to be more detailed than that in a conventional physiotherapy subjective assessment: I found out that she was born 6 weeks’ premature, experienced family breakdown at a young age and underwent major orthodontics designed to correct a bite pattern. She regularly experienced severe and persistent temporomandibular joint (TMJ) pain accompanied by a painful neck, with muscle spasms occurring when she sneezed. Some months after starting craniosacral therapy, Lucy reported a general improvement in her wrist, accompanied by improvements in her knees, ankles and hips and an increased sense of wellbeing.
ISBN 0683083635 2. Chaitow L, Delany JW. Clinical application of neuromuscular techniques, Vol. 1. Churchill Livingstone 2000. ISBN 0443062706. 3. Chaitow L. Positional release techniques, 2nd edn. Churchill Livingstone 2000. ISBN 0443070814 4. Wilson E. Integrated soft touch techniques: trigger points, pain and muscle tone – a two day course in needle-free intervention in somatic pain syndromes 5. Speece CA, Crow WT. Ligamentous articular strain: osteopathic manipulative techniques for the body. Eastland Press 2001. ISBN 0939616319.
FURTHER READING Kern M. Wisdom in the body: the craniosacral approach to essential health. Thorsons 2001. ISBN 0722537085.
The Author Penny Nisbet, MCSP RCST, is a chartered physiotherapist and registered craniosacral therapist. She has wide experience in physiotherapy practice spanning many years, having first qualified as a physiotherapist in 1969. She works part time in the NHS in a GP’s practice and is currently developing a private practice based at her own home in Symington, South Lanarkshire. She recently completed a 2-year diploma in craniosacral therapy at the College of Cranio-Sacral Therapy (CCST) headed by Thomas Attlee (www.ccst.co.uk), attending monthly training weekends, completing regular assignments and passing final examinations that consisted of practical and written elements. She is particularly interested in the integration of craniosacral therapy within physiotherapy.
Professional Liability Insurance for Sports Massage Practitioners
CONCLUSION In this article I have aimed to show some of the relationships between physiotherapy and craniosacral therapy, how craniosacral therapy can treat a range of conditions, and how craniosacral therapy can be relevant to sports and performance activities. There is a special-interest group of physiotherapists known as the Craniosacral Association of Chartered Physiotherapists – more information about this group can be found on the Chartered Society of Physiotherapy’s website (www.csp.org.uk). However, many other craniosacral therapists come from other occupational backgrounds. References 1. Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Williams & Wilkins 1998. 10
Competitive Rates, Wide Cover and Many Options from the Professional Liability
Insurance Specialists
LFC GRAYBROOK LIMITED Tel: 01245 321185 Fax 01245 322240 graybrook@lfcinsurance.co.uk LFC Graybrook Ltd is an appointed representative of LFC Insurance Brokers Ltd who are authorised and regulated by the Financial Services Authority. Registered no. 301666
sportEX dynamics 2009;20(Apr):7-10
podiatry sports medicine
Foot care for sport
By Alison Barlow, MSc(Med)
INTRODUCTION Every sportsperson knows how important their feet are to them, especially when they give problems, but do they really know how looking after their feet can prevent those problems in the first place? Podiatrists (chiropodists) are autonomous healthcare professionals who aim to improve the mobility, independence and quality of life for their patients. They assess, diagnose and treat people with problems of the feet, ankles and lower limbs. All podiatrists now have to be registered with the Health Professions Council (HPC). The training consists of 3 years of study, leading to an honours degree covering all aspects of podiatry. Although some students will do a piece of work in a specialist area at undergraduate level, specialisation usually occurs at postgraduate level, as with all medical subjects.
FOOTWEAR The foot is a complex structure that adapts to stress and strain admirably. It is only when these pressures become abnormal that structures such as skin, muscle or tendon react. The type of injury varies depending on the sport. A major factor in injury prevention is to ensure that the correct footwear is worn at all times. Sports shoes www.sportEX.net
Podiatrists are healthcare professions specialising in the problems of the foot and lower limb. This article looks at the important part a podiatrist can play in the assessment of the foot and lower limb, the prevention and management of foot and lower-limb problems, and how podiatrists can help to keep sportspeople in top condition. will protect, be durable and have the correct amount of flexibility. This varies according to the use. Flexibility increases in running shoes and decreases in cross-trainers to provide support for sideways movement. I have seen injured players who always wear the correct footwear for training and competition but who forget to do so when going for a quick run or a game of football in the park – with disastrous results. Footwear worn by athletes is often occlusive. This prevention of air circulation can give rise to skin conditions such as peeling and tender skin. Sometimes the type of glue used to bond the shoe surfaces together can cause a similar reaction. Often a simple solution is a change of footwear.
A major factor in injury prevention is to ensure that the correct footwear is worn at all times
Preseason advice Preseason assessment can be particularly valuable, as it can pick up any existing or potential problems and give an opportunity to offer advice. It can also create opportunities for case profiles, which may in future provide evidence for management of similar cases and information for audit. Prevention advice and action can be very effective, provided it is supported by facts and the athlete feels and is fully involved. In its simplest form, such advice stresses the importance of hygiene, thereby helping to prevent fungal infection, and cutting the nails little and often, thereby preventing problems from the sides and corners of the nails rather than cutting the nails too short. Advising on the different types of sock material can prevent rashes; wearing socks inside-out if the seams are too thick can make the feet more comfortable. Wearing flip-flops in shower rooms can help to prevent the spread of fungal and viral infections, while the use of paper towels avoids the re-infection associated with shared towels. 11
Biomechanical assessment involves assessing the architectural merit of the foot. The joints are examined for their potential range of movement, with one foot being compared with the other. Past injuries are important, as are current problems, but equally important are athletes without symptoms at the time. Detailed training schedules need to be taken into account so that type and length of training may be given consideration. Usual footwear and training footwear should be available for examination. The athlete will normally be examined on both a weight and a non-weight basis in order to compare areas such as arch profile. Gait analysis may well be considered necessary, in which the athlete is asked to walk with or without footwear to monitor the angle of the femur, patella and tibia and the angle the foot takes in motion. Routine clinical treatment from a podiatrist helps to keep discomfort under control. General clinical work in the athlete is better done from a minimal and frequent scenario, which is a different concept from a normal clinic. The athlete needs to be able to continue with their sport, and it is essential that skin and nail are not left in a pre-vulnerable state where any further trauma caused may create problems and the healing
process may take longer.
NAILS Nails naturally vary in shape and thickness, and this shape and thickness may change due to trauma either from a one-off event or from multiple minor trauma against the shoes. It is not unusual to find a corn under the nail, either at the corner or in the middle, caused by the snug fit of some sports shoes. Nails are also prone to press into the sides, causing ingrowing toenails, and may separate from the nail bed due to trauma. Once the nail has separated from the nail bed, it is much more vulnerable to bacterial and fungal infection such as Candida infection, which can give rise to inflammation surrounding the nail known as paronychia. (See Box 1 for an explanation of some clinical
Box 1: Clinical terms Corns (helomas) and calluses are both formed from frictional and direct pressure. Both are found on the dorsal (upper) and plantar (underneath) parts of the feet. A corn has a nucleus or hard centre, which is an indication of more severe pressure, whereas a callus does not. n Blisters are caused by friction. They may occur anywhere on the foot. The depth of the blister is dependent on the severity of the friction. They may be filled with clear fluid or blood. n Athlete’s foot is caused by a fungal infection. It may affect the skin or nails. The skin may be treated by over-the-counter preparations. If the nails are affected, prescription-only medicines are considered to be more effective. The skin may take various appearances, such as white and moist between the toes, blisters in the arch area, and flaky dryness around the heels. The nails are usually thickened, discoloured and crumbly. n Verrucae (warts) are viral infections that are normally not harmful and will disappear with no treatment. The skin striations (lines) will not continue through a verruca. They tend to bleed easily, and sometimes dried blood within the verruca may look like a thorn. They can be painful on sideways pressure (pinching). n Paronychia is inflammation of the skin surrounding the nail, which may look red and swollen and be painful. terms.) The podiatrist can keep the nails cut and reduced to a reasonable thickness, which will help to prevent problems. Paronychia can often be treated with an over-the-counter (OTC) preparation such as Canesten. Bacterial infection, which is very often caused by the edge of a nail piercing the skin, is usually cleared up by removing the offending piece of nail, using saline (salt) footbaths and simple dressing. Antibiotics are required very rarely. Blisters under the nail are common. They are usually filled with blood but can also contain pus. The crucial management of these is to release the pressure by piecing through the nail, often using a fine drill. The blood will then be released and the pain resolved almost immediately. Then all that is usually required is a saline footbath and a simple dressing of gauze.
SKIN Skin is subject to pressure-related lesions such as hard skin and corns. The most usual place for these is underneath the hallux (big toe) and the fifth (small) toe, both on the top of and in between the toes. This can be due to snug-fitting sports shoes, the shape of the toe area in the shoe, and shoe 12
sportEX dynamics 2009;20(Apr):11-13
podiatry sports medicine stitching in these areas. Lightweight football boots can create excessive skin in direct relation to the position of the studs. Podiatry management of these is to remove the excess skin frequently, which will reduce the pressure on the area. Skin is subject to a bacterial infection, albeit a different type of infection to that of nails. The most common type of bacterial infection is one that can mimic the fungal infection athlete’s foot between the toes. The same type of bacteria can be seen on the sole of the foot, this time appearing like white macerated pitted areas. Athlete’s foot is prevalent among people using communal showers, showing itself as itchy red areas between the toes, blisters that itch intensely as they form in the arch area, or a dryness that is slightly inflamed on the underside of the foot. Verrucas, a viral infection, are not uncommon among athletes. Diagnosis is essential in order to ensure correct management.
OTHER CONDITIONS Other conditions seen by podiatrists involved in sport include pain and injuries in the soft tissues and bone. These vary from common toe injuries caused by trauma, which require no treatment, to metatarsalgia, heel pain, ankle sprain, shin splints and other problems associated with leglength discrepancies. They may be unilateral (one-sided). Many require a biomechanical assessment, perhaps gait analysis, shoe advice and perhaps orthoses therapy. Metatarsalgia is a general name given to pain over the metatarsal head area. This is more commonly found in athletes who need to jump off the ground in their activity, landing on a hard surface. Pain under the first metatarsal head (base of the big toe), where the small sesamoid bones are (sesamoiditis), is more common in cyclists and other athletes who have a high arch profile, thereby increasing the pressure on the first metatarsal head area. Plantar fascia is the big band of tissue that goes underneath the foot. It is quite commonly inflamed and can be extremely painful, especially in the heel area. It is particularly painful after rest, such as first thing in the morning, but it can also be painful after exercise. The www.sportEX.net
pain is usually brought about when the band is stretched and pulls, giving little micro-tears/bleeds at the insertion in the heel. Runners and cricket players are particularly vulnerable to plantar fasciitis, which can also be referred to as enthesopathy and calcaleal spur. The area underneath and at the back of the heel is prone to bursitis formation. A bursa is a deep sac of fluid (as in tennis elbow) caused by a shearing type of force. This can cause the heel to be inflamed and painful and is usually seen in walkers. Achilles tendon problems at the back of the heel are seen frequently and usually mean that the foot is functioning in such a way that puts stress on the tendon. It is seen in many different types of sport and usually requires orthoses therapy. Ankle sprain, shin splints and knee pain can also be found to be biomechanically related and be aided in recovery by orthoses.
ORTHOSES Orthoses can be a particularly useful adjunct to therapy, providing they are the correct type for the condition, made of the correct material and form part of the multidisciplinary therapy, and the athlete is involved in the decisionmaking process. Experience has taught me that, although these points seem obvious, this simple process does not always happen. An orthosis is often an insole, but it may also be a piece of material that may be functional (changes function of the foot) or may be palliative (provides comfort). Materials range from spongetype materials, some of which are highly technical such as those that spring back to their original shape, to firmer materials available in different densities (softness) and that can be moulded. An orthosis can be described as simple (not moulded), off-the-shelf (ready-made) or moulded. Ready-made orthoses usually have a moulded arch. Many of these can be adjusted on a grinding machine or with a heat gun, and material may be added. Moulded orthoses require a plaster of Paris cast of the foot. The foot may be cast either in an impression box or with plaster of Paris bandage. The former method is very often the choice of the podiatrist. The type of footwear is a major consideration in recommending the
Assessment preseason can be particularly valuable type of orthosis. There are also cost differences between the devices, with moulded orthoses being the most expensive at ÂŁ300 and above. Simple devices can be highly effective. A piece of technical foam/sponge may be all that is required under a blistered first metatarsal head in a close-fitting sports boot or in bursitis in the heel. A lateral (outside) posting to a heel can reduce inflammation on a tendo achilles, but it is likely that sesamoiditis, plantar fasciitis and shin splints will need a moulded device.
CONCLUSION The multidisciplinary approach to athletes is the way forward. It is one in which podiatry should play its part, either as a member of the medical team or on a consultancy basis. The holistic approach of core stability, massage, stretching, emollient therapy and management of foot problems will enable the athlete to achieve their goal.
THE AUTHOR Alison Barlow has a fellowship in podiatric medicine and general practice and is director of prosthetics and orthotics and podiatry at the University of Salford. She has a wealth of clinical experience, especially in dermatological areas, where she continues to act as podiatrist to a Premier League football club, attending twice a week for both clinical and orthoses sessions. She is also consultant to DEBRA (epidermolysis bullosa charity), an external advisor and examiner for other universities, and a member of the Faculty of Education at the Society of Chiropodists and Podiatrists. Previously she was programme leader for both the undergraduate and postgraduate podiatry programmes.
13
Sports medicine, injuries, rehabilitation and the law By Mark James
INTRODUCTION Litigation arising from sports injuries has seen a dramatic increase over the past 25 years. From a position where injury was considered to be an acceptable hazard of sports participation, many athletes now search actively for someone to blame and, eventually, someone to sue. Injured sports participants have successfully sued other players, their opponent’s employer, the referee, and the owner of the sports facility where the injury occurred. Actions against a sport’s national governing body and international federation have been allowed but have rarely succeeded (1). Although there is no definitive explanation for this phenomenon, a number of factors appear to influence an injured player’s decision to commence legal proceedings. These include the rise in people’s awareness of their legal rights, the encouragement by claims agents to sue when injured, the greater ease of access to legal advice following the introduction of contingency fee arrangements (commonly referred to as “no win, no fee” agreements), and a lack of adequate insurance on the part of the injured player. With the ever-increasing numbers of medical staff treating and advising sports participants, it is a natural extension of both medical and sports law to encompass the liability of sports and exercise medical practitioners. This article highlights the legal flashpoints at which sports medics may attract legal liability, how and why the law applies to these situations, and how to avoid being on the wrong end of a legal action.
The use of litigation in sport is increasing. The conduct of a sports medic will be judged by the standards of the reasonable practitioner in their particular specialty. Because the vast majority of practitioners act within their spheres of competence, the number of cases involving sports medicine practitioners is extremely small. This does not mean that there is any room for complacency.
THE LEGAL FLASHPOINTS There are four main flashpoints when the conduct of a sports medic might be subject to the scrutiny of the law: n “First contact”, ie. the initial treatment or first-aid administered to a player at the time of injury. n Quality of the design and appropriateness of the implementation of return-to-fitness regimes that aid the rehabilitation process.
Everyone associated with a sportsperson’s health and fitness should be aware of the law 14
n Potential, from a practical perspective, for a conflict of interest that can arise following the referral of an injured sportsperson by their club to a specific medical specialist. n When acting as an expert witness and giving evidence at trial on the competence of another person’s practice. Each of these scenarios could occur at either the professional or the amateur level of sport, but it is at the elite or professional level where the compensation awarded has become so high that it can affect a sports medic’s insurance position. In the recent case of Collett v Smith and Middlesbrough Football and Athletics Company (1986) Ltd (2), the claimant had suffered a career-ending injury as a result of a negligent tackle performed by an opponent footballer. He was aged 19 at the time of the tackle and had recently been offered a professional contract by, and was playing for, Manchester United Football Club. He was awarded almost £4 million in lost earnings on the basis that he would have had a successful career playing professional football in the Championship and Premier Leagues for the next 11 years. With sums such as these being awarded by the courts, it is essential that everyone associated with a sportsperson’s health and fitness is aware of how and why the law might apply to their professional practice.
FIRST CONTACT – TREATING THE INITIAL INJURY The law applicable to all medical practitioners, regardless of their specialty, is that found in the seminal cases of Bolam and Bolitho (3): that your conduct will be judged by the standards of the reasonable practitioner in your particular sportEX dynamics 2009;20(Apr):14-16
law sports medicine
field. When determining whether a particular specialist practitioner has breached that standard, the court must determine whether the practitioner has acted in accordance with a recognised body of medical opinion. It is not enough to establish that others would have acted as the practitioner did; the practitioner must be able to demonstrate that their choice of procedure was logically sustainable. From a practical perspective, this means that if a procedure that is other than the norm is being considered, then there must be a reason for choosing the non-standard approach. The main issue that arises at the first contact stage concerns the number and variety of medical practitioners, and other people fulfilling quasi-medical roles, who may be present at the scene and to provide advice and treatment to the injured sportsperson. The question that the court will ask, if the player claims that the medical practitioner caused or exacerbated their injury, is whether the medic was qualified to carry out the examination or administer the treatment that caused the harm. If the medic is not appropriately qualified, then it is extremely difficult for them to prove that they have acted reasonably in performing the treatment on the injured player. If they are appropriately qualified, and they have followed standard practice for their profession regarding the procedures performed, then no liability will attach to the medical practitioner’s conduct. If the person is administering genuine first aid, then the law expects the first-aider only to avoid making the patient’s condition worse.
The sports medic should always ensure that the advice that they are giving is accurate and truthful medical practitioner to give the player a clean bill of health so that the player can return to action as quickly as possible. Similarly, the player may wish to return to action sooner than they ought to in order to retain their place in the starting line-up or so that they can compete in a prestigious or lucrative event. An added complicating factor is that, in many professional team sports, the players are contractually obliged to either use the club’s medical teams or to disclose the reports of their own medical team should this be different. The sports medic should, of course, always ensure that the advice that they are giving is accurate and truthful, whether this relates to the design of a return-to-fitness programme or a diagnosis of an athlete’s fitness. Any rehabilitation programme should be appropriate to the specific injury, sport and athlete, and its design should be within the experience and expertise of the sports medic overseeing its implementation. When the time comes for a determination of a player’s fitness to play, if the player is still not fit to play, then they should be told that. If the sportsperson chooses to ignore that advice, then the risk is on them, not the medic. Any diagnosis should be disclosed to the sportsperson rather than the club, although
REHABILITATION PROGRAMMES Exactly the same legal issues arise in the context of the design and implementation of rehabilitation programmes: as long as the conduct of the medical practitioner is in accordance with a recognised body of opinion in their particular specialism, then no liability will attach to their conduct. The practical difficulty that can arise here concerns the potential conflicts of interest faced by the sports medic. The club may apply pressure to the www.sportEX.net
15
where professional athletes are concerned, it is likely that disclosure will be made to both at the same time because of the athlete’s and the medic’s contractual obligations.
SPECIALIST REFERRALS A similar conflict of interest can be seen to arise when an injured player is referred for treatment to a specialist or consultant. In the case of West Bromwich Albion Football Club v El-Safty (4), the football club was trying to claim that the consultant orthopaedic surgeon El-Safty, to whom the club’s physiotherapist had referred an injured employeeplayer, owed them a duty of care not to cause him injury. As a result of El-Safty’s (admittedly) negligent conduct, the player was unable to resume his career and the club sought compensation equivalent to the player’s value on the transfer market (approximately £1 million). The court held that, despite the fact that the club’s own physiotherapist had made the referral, and despite the club’s interest in the procedures being carried out on the player in a non-negligent manner, and despite the fact that the club was paying the player’s health insurance premiums, the only duty owed by the consultant was to the player, not to the employing club. Although El-Safty was still liable to the player for the injuries caused to him and for the accompanying loss of earnings, he was not liable for any further losses sustained by the club in having to replace its injured employee.
EXPERT WITNESSES The final occasion on which a sports medic may come into contact with the law is when called on to act as an expert witness. This will usually be to comment on the conduct of a fellow medical practitioner. It is always of the utmost importance that, if asked to act as an expert witness, you provide an opinion that is within your sphere of expertise and that your expertise is relevant to the case before the court. A salutary lesson can be learned from the case of Blackburn Rovers Football Club v Avon Insurance plc (5). Blackburn sought to claim a sum of £4 million plus interest from its insurance company following a career-ending training accident involving its Swedish international player Martin Dahlin. After falling awkwardly, Dahlin was found to be suffering from degenerative disc order, a condition that restricted his movement and his ability to play professional football. The club’s insurance policy would pay out only for injuries suffered during training or play and not for those that were caused by preexisting conditions or by general degeneration, ie. wear and tear. The trial centred on the issue of
16
whether the degenerative disc disorder was caused by a single traumatic event – the training ground incident – or was normal wear and tear on the body of a 29-year-old professional footballer. At trial, Avon Insurance called a Mr Webb, a consultant spinal surgeon, to give evidence on the company’s behalf. Blackburn called a Mr King, a consultant in orthopaedic and trauma surgery and knee specialist. Although clearly capable of offering an opinion on the case, the evidence of Blackburn’s expert witness was significantly less cogent than that of the spinal injury specialist, a fact exacerbated by Mr King’s demurral to the opinion of Mr Webb on several occasions. When such a significant amount of money is at stake, as in this case, it is obviously important to use a specialist in the field and to accept the brief of being an expert witness only if you can properly regard yourself as expert.
CONCLUSION Despite the increase in sports-related litigation and the ongoing debate about a compensation culture, the number of cases involving sports medicine practitioners is extremely small. The simple reason for this is that the vast majority of practitioners do act within their spheres of competence and do not do anything that could be considered to be out of step with the body of opinion that holds sway in their own specialism. This does not mean that there is any room for complacency. As can be seen from the examples above, as soon as a practitioner starts to act outside of their area of specialism, they run the risk of being held to have breached the duty that they owe to their patient. The courts have not extended liability unnecessarily or in a way that is out of line with other areas of medical law – but in a field of specialism that is growing, the scope for litigation to test its boundaries is always present. References 1. Gardiner S, James M, O’Leary J et al. Sports law. Cavendish Publishing 2006. ISBN 1859418945 2. Collett v Smith and Middlesbrough Football and Athletics Company (1986) Ltd [2008] EWHC 1962 (QB) 3. Bolam v Friern Hospital Management Company 1957 1 WLR 582; Bolitho v City and Hackney Health Authority 1998 AC 232. (See also Steele J. Tort law: text, cases and materials. Oxford University Press 2007. ISBN 0199248858 4. West Bromwich Albion Football Club v El-Safty 2006 EWCA Civ 1299. (See also Lewis A, Taylor J. Sport: law and practice. Tottel Publishing 2008. ISBN 9781847660664) 5. Blackburn Rovers Football Club v Avon Insurance plc 2006 EWHC 840 (QB).
THE AUTHOR Mark James is a reader in law at the Salford Law School, University of Salford. He has taught, researched and written about sports law, in particular as it relates to sports injuries, for many years. He is co-author of the third edition of Sports Law (Routledge Cavendish 2006) and the author of Palgrave Law Masters: Sports Law (Palgrave Macmillan 2009). He has co-organised a series of seminars on the law relating to sports and exercise medical practitioners with medical and legal training services and presented papers on this topic for them, for the Manchester Sports Medicine Clinic and for the Rugby Football League.
sportEX dynamics 2009;20(Apr):14-16
A case for hydrotherapy in sport This article presents the case for using hydrotherapy in sport in three different dimensions: treatment of sport injuries, maintenance of fitness during rehabilitation from injury, and prevention of sport injuries. By Alison Skinner, MCSP
INTRODUCTION The use of exercise in water as a treatment modality is available to everyone with access to a pool. In addition to public facilities provided by local councils, an increasing number of private health clubs and the major fitness chains have pools or large hot tubs. The properties of water – pressure, buoyancy, turbulence and warmth – can be used to create rehabilitation programmes to suit any stage of healing, but particularly the early stage. Activities can be functional, be sports-specific and, if the facility allows, include the use of sporting equipment.
TREATMENT OF SPORT INJURIES Following injury, treatment can begin in the pool earlier than on land as a result of the warmth of the water and the weight relief from the effect of buoyancy, which produce relief of pain and reduction of muscle spasm and thereby facilitate: n movement; n strengthening; n coordination; n functional recovery. According to Mano et al., sympathetic nervous system activity is reduced in water; the deeper the water, the greater the effect. The relaxation gained will help to reduce muscle tone (1).
Hydrostatic pressure The hydrostatic pressure of the water 18
produces a redistribution of interstitial fluid (2). This is equivalent to a double layer of Tubigrip on the lower leg. The hydrostatic pressure, which becomes greater as the depth of the water increases, therefore reduces swelling and effusion. This reduction of swelling is particularly effective for lower limb injuries, as there is increased lymphatic and venous return (3).
Buoyancy and turbulence Two physical properties of water, buoyancy and turbulence, can be used to strengthen muscles by finely graded and progressive exercise, ie. from buoyancy-assisted exercise, to buoyancy counterbalance and finally buoyancyresisted exercise. Turbulence may be used to increase resistance and develop function or to re-educate balance. Exercises can be applied in functional patterns using the Bad Ragaz ring method, in which resistance is provided by turbulence and controlled by the athlete. This treatment method is based on three-dimensional diagonal movement patterns very similar to those of proprioceptive neuromuscular facilitation (PNF). It has the advantage of using the athlete’s perception of effort and discomfort to progress the exercise within their own control. Mobility of joints is facilitated by activities where buoyancy is counterbalanced and the joints are relieved from stress and weightbearing. This enables synovial sweep, which allows synovial fluid to be moved
over articular surfaces in order to restore nutrition to articular cartilage and promote healing. The exercises may be applied in a cyclical orientation, which ensures the compression and relaxation, both of which are needed to restore the normal structure of the articular cartilage. The weight relief of immersion facilitates gait re-education. The depth of the water is critical. For example, if the water is at C7 level for the athlete, then just 8% of their body weight is transmitted to the lower limbs (4).
Proprioception A number of athletic injuries require re-education of proprioception. The viscosity of the water may be utilised to facilitate proprioception by enabling slower three-dimensional movement enhanced by the creation of turbulence and support for balance. Athletes therefore have the time to perform movements in a balanced position, which facilitates accuracy and control. Activities such as standing on one leg while performing kicking movements with the other leg – important for a footballer, for example – can be started in the pool earlier than on land (5).
Functional rehabilitation Functional rehabilitation aims to ensure
Injury treatment can begin in the pool earlier than on land sportEX dynamics 2009;20(Apr):18-19
hydrotherapy sports medicine
The viscosity of the water provides much added resistance when compared with the same movement in the air that athletes return to sport as quickly and as safely as possible. To achieve this, the programme must include sports-specific activities using sporting equipment. The equipment, such as a racquet, has a large surface area and the water provides increased resistance and develops endurance. The viscosity of the water provides much added resistance when compared with the same movement in the air. In this example, the athlete swings the racquet through the water using a similar stroke to that used in the sport. This improves the neuromuscular facilitation, particularly of the upper limb, and the stability of the lower limb (6).
MAINTENANCE OF FITNESS DURING REHABILITATION FROM INJURY Athletes are often concerned that during injury their fitness will decrease and it will take a long time to return to active sport. This part of training should include cardiovascular conditioning as well as maintaining flexibility, strength and coordination of uninjured areas. Exercise in deep water results in weight relief for the lower limbs while providing an environment that increases the muscle strength of the whole body. Therefore, athletes may have an intensive and possibly competitive workout without stressing the injured area.
Deep-water running Deep-water running (DWR) is a form of aquatic exercise simulating running. Participants wear buoyancy jackets or a form of floatation and keep the body upright using arms and legs as in running. Three or four 45-minute sessions, three to four times per week, will increase fitness. The injured limb is exercised in a pain-free, safe environment that cannot be simulated on land. British marathon runner Sarah Rowell cites personal experience of the benefit gained from DWR while recovering from a fractured metatarsal, Mary Decker practised DWR for 3 weeks after injury and then did 3 days’ training on land before breaking the world 2000-m record (7).
Circuit training
jumps, trunk rotation with bats held in both hands, running against a Theraband, running on the spot with high leg-lifts, push-ups on a pool bar, pushing a float down into the water, and touching opposite knee and elbow. These exercises may be customised for the athlete to include the skills required in their sport. Competitive acumen is maintained by recording the time taken for each task or the number of repetitions performed.
PREVENTION OF SPORT INJURIES Once the injured athlete has recovered, an important aim is to protect the athlete from stress and to prevent further injury. The athlete’s fitness programme should include flexibility and myofascial stretching exercises. Stretching exercises are performed slowly to the point of discomfort, held at the limit determined by the athlete, and then followed by relaxation and further stretching into more range. Ideally these exercises are performed with buoyancy assisting into the new range. This helps to reduce recurrent injuries related to overuse and stress. Such a programme interspersed with land training is also useful as part of pre-season training. Other aspects of prevention include circuit training (see above).
CONCLUSION Hydrotherapy can provide an adjunct or alternative to land-based rehabilitation programmes. In the early stages of rehabilitation, buoyancy can be utilised to assist in weight relief. At later stages it is used to provide resistance to movement. Water
provides an excellent medium in which to perform cardiovascular conditioning and to maintain flexibility, strength and coordination of uninjured areas. References 1. Mano T, Satoshi I, Yamazaki Y, Saito M. Sympathetic nervous adjustments in man to simulated weightlessness induced by water immersion. 1985 2. Hall J, Bisson D, O’Hare P. The physiology of immersion. Physiotherapy 1990;76:517– 521 3. Genuairio SE, Vegso JJ. The use of a swimming pool on the rehabilitation and reconditioning of athletic injuries. Contemporary Orthopaedics 1990;20:381–387 4. Harrison R, Bulstrode S. Percentage weight bearing during partial immersion in the hydrotherapy pool. Physiotherapy Practice 1987;3:60–63 5. Tierney T. In: Ruoti RG, Morris DM, Cole AJ (eds) Aquatic Rehabilitation. Lippincott 1997. ISBN 0397551525 6. Tierney T. In: Ruoti RG, Morris DM, Cole AJ (eds) Aquatic Rehabilitation. Lippincott 1997. ISBN 0397551525 7. Rowell S. Deep water running. Coaching Focus 1992;19 A version of this article was first published in Aqualines 2007;19(2). Reprinted with permission of the Aquatic Therapy Association of Chartered Physiotherapists (ATACP).
Exercise in deep water results in weight relief for the lower limbs while providing an environment that increases the muscle strength of the whole body
THE AUTHOR Alison Skinner trained as a physiotherapist in Glasgow. She gained the hydrotherapy certificate and the teaching diploma of the Chartered Society of Physiotherapists (CSP) at the Middlesex Hospital School of Physiotherapy, where she subsequently taught for many years. Recently she has been leader of the physiotherapy skills course for physiotherapists who qualified outside the UK at University College London. She is an external examiner for the Bath hydrotherapy course, an international lecturer in the Halliwick concept, and co-author of Duffield’s Exercises in Water and Tidy’s Physiotherapy. She has lectured and delivered courses in hydrotherapy both in the UK and abroad. She has been instrumental in moving the ATACP foundation course towards CSP endorsement and has served as ATACP treasurer for many years. She was awarded a fellowship of the CSP for services to physiotherapy, particularly hydrotherapy.
Circuits in the pool can include star www.sportEX.net
19
chiropractic sports medicine by dr Edward Rothman
INTRODUCTION Chiropractic is one of the largest independent health professions; however, there is often confusion about its place in healthcare, the amount of research that is generated at its educational institutions, and the diversity of the therapy and care offered by its registered clinicians.
WHAT IS CHIROPRACTIC? Although chiropractic has earned an international reputation because of practitioner skills in spinal and extremity manipulation, clinicians are also skilled in diagnosis and radiology and practise a wide range of therapeutic interventions that address muscles, tendons, ligaments and nerves. Exercise as treatment and physical rehabilitation has a long history in chiropractic. The prescription and use of therapeutic exercise, as part of the profession, can be dated to the profession’s formative years in the early 1900s. Large physical rehabilitation facilities were part of chiropractic clinics and several institutions as far back as the 1920s. The interest in rehabilitation methods, exercise as treatment and the care of injured athletes continues to grow within the profession. The chiropractic approach uses a biopsychosocial model of examination and care. It is holistic and includes nutrition counselling, reassurance, lifestyle changes, positive attitude resulting in speedier recovery, and the restoration of function through active care and participation of the patient in recovery. Chiropractors are trained to recognise deeper emotional and psychological problems and the need to refer for psychological care when indicated.
CHIROPRACTIC AND SPORTS Chiropractic has a long history of caring for athletes from recreational sports through to participants at the Olympic Games. Several countries at the Beijing Games, including the USA, Brazil, Hungary and the Philippines, included chiropractors as part of their medical teams. Many UK-based football and rugby clubs, including Chelsea, Portsmouth, Middlesbrough and Wasps, have chiropractors working with their athletes. Chiropractors will also be caring for athletes at the 2009 World Games in Kaohsiung, Taiwan. The Federation Internationale de Chiropractic du Sport (FICS) is the governing body for international sports chiropractic and comprises members of national chiropractic sports councils from around the world. FICS is also affiliated with several international sports organisations. FICS goals include the promotion of excellence in postgraduate education, the facilitation and promotion of research in sports, and ensuring that the highest levels of professionalism and clinical acumen are practised by chiropractic clinicians.
PRACTICAL RESEARCH Football is a major international sport with huge financial interests; however, very little is spent on research into improving players’ performance, health and wellbeing. The Anglo-European College of Chiropractic (AECC) in Bournemouth recently announced that it has signed a formal agreement with football club AC Milan’s assessment and treatment centre, MilanLab. Their training methods are innovative and appear to be achieving significant outcomes. AECC and MilanLab will focus on several primary objectives that include joint supervision of postgraduate and www.sportEX.net
Chiropractic and sports Chiropractic clinicians offer a wide range of holistic therapeutic interventions of value to sports. A partnership between a leading UK chiropractic educational institution and a major European football club will increase the therapy research base and provide practical applications. postdoctoral research involving current Milan players, teaching and staff exchanges, and organisation of joint sports conferences. AECC is also working towards developing similar collaborative programmes with progressive football clubs in the UK. AECC principal, Kenneth Vall, noted: “We want to develop the evidence base through collaborative research, which will underpin our own ambition for our current development of a centre for excellence for the assessment and treatment of athletes at our clinic on campus in Bournemouth.” AECC is an associate college of Bournemouth University. It currently delivers a full-time undergraduate master’s programme in chiropractic, co-delivers a bachelor’s degree in exercise science with the School of Health and Social Care at the university, and has a substantial portfolio of postgraduate offerings, including a new MSc in sports and rehabilitation and a series of master’s degrees in diagnostic ultrasonography.
CONCLUSION The science involved in sports and exercise training, performance, injury prevention and treatment is growing at a fast pace. It is essential that the lessons learned through research can be applied practically and at ground level for the benefit of the players and participants, whether professional, amateur or recreational. The interdisciplinary nature of the subject involves the integration and application of principles drawn from functional anatomy and biomechanics, physiology, nutrition, psychology, neurology, orthopaedics and general health, all of which are components of chiropractic therapy. The partnership between AECC and AC Milan will significantly increase the research base and its practical application.Details of the courses offered by AECC can be found at www.aecc.ac.uk. The Author Dr Edward Rothman is director of clinic at the Anglo European College of Chiropractic (AECC). He is also the former programme leader of the BSc in exercise science at Bournemouth University and the current pathway leader of the MSc in sports and rehabilitation. He has twenty years of practice experience in the United States, working with athletes in a variety of disciplines including runners, cyclists, martial artists and ballet dancers. He moved to the UK in 2000 to join the faculty at AECC. He is a member of the British Association of Sports and Exercise Science and the International Academy of Dance Medicine.
17
Hamstring muscle injuries
By Lee Herrington, PhD MCSP CSCS
What causes hamstring injuries? There are a number of predisposing factors pertaining to hamstring muscle injuries which a clinician and a sports performer must be aware of, these include; the particular anatomy of the hamstring muscle group, muscle flexibility, muscle strength imbalances, lumbo-pelvic status and running mechanics.
Anatomy The hamstrings are a group of three muscles (Biceps Femoris, Semitendinosus, Semimembranosus) these muscles are bi-articular in that they cross two joints; the hip and the knee. This means their action involves controlling motion at two joint simultaneously, to further complicate this Biceps Femoris also has dual innervation which means it is supplied by two nerves further complicating its action and control of this muscle.
It is very rare that a weekend of sport goes by without a player at a top sporting club or athlete injuring their hamstring muscle. It is by far the most common muscle injury with injury rates as high as 10-15%. Perhaps even more significant than this is that the reoccurrence rate for another hamstring injury is anywhere between 12-34% for those sports people who have suffered an initial hamstring injury. The question which needs answering then must be what causes hamstring injuries? And equally what is going wrong with the rehabilitation of these injuries so as to not prevent their reoccurrence?
Muscle flexibility Despite the considerable hype around this issue, there is little strong or convincing research evidence to support either the use of stretching exercises for the hamstrings to prevent injuries or lack flexibility increasing the risk of injury. This might in part be due to the fact that the majority of hamstring muscle injuries occur during rapid changes in type of contraction i.e. eccentric to concentric or velocity of the limb during the cross-over from swing to stance phase for instance, at this point the hamstring muscles are nowhere near their full range of movement. It could also be the case that athletes who regularly statically stretch their hamstring muscles are at increased risk of injury. Static stretching has been shown to acutely decrease the performance of muscle and increase resting tone in the muscle. Furthermore, inappropriate stretching, for instance involving excessive lumbar flexion could irritate and damage elements of the lumbar spine and nervous system, which as mentioned later could increase the predisposition to injury. It has also been
there is little strong or convincing research evidence to support the use of stretching exercises for the hamstrings to prevent injuries 20
the author’s experience that those athletes who stretch excessive and often have exceptional ranget of movement compared to their team mates are often the ones who most frequently suffer muscle injury.
Muscle strength imbalances Unbalanced quadriceps action due to excessive muscle hypertrophy of the quadriceps (as opposed to weakness of the hamstrings) has been cited as a potential cause of hamstring muscle injuries. The excessive development of quadriceps strength in certain sports, particularly those incorporating heavy squatting exercises, or short burst sprints for example, may fail to address hamstring strength development increasing the load produced by the quadriceps the hamstrings must overcome to decelerate the limb. A second muscle imbalance which also needs considering in relation to hamstring muscle injuries is that of hamstring activity to Gluteal muscle activity during hip extension. Previous research has shown the hamstring muscles to produce slightly less than 50% of the force during hip extension with Gluteal muscles (principally Gluteus Maximus) producing the rest. If the Gluteal muscles are deficient either in turns of their recruitment or strength than the relative load will be increased on the hamstring muscles.
Lumbo-pelvic status Two potential areas related to the lumbo-pelvic function can have a direct bearing on hamstring injuries the first is sportEX dynamics 2009;20(Apr):20-22
sports medicine HAMSTRING INJURIES pre-existing lumbar spine pathology’ the second stability and control of the lumbo-pelvic region. Pre-existing lumbar spine pathology: these problems can affect the hamstring muscles in two ways to predispose them to injury. First are mechanical based problems, if the inter-segmental motion of the lumbar spine is abnormal this will place increased load on other segments of the kinetic chain. For example, if a lumbar segment is hypomobile (stiff) due to pre-existing pathology, this will shift relative movement onto another area of less resistance to movement. If the lumbar spine cannot fully extend the hip would be required to extend further at the end of the stance phase, increased hamstring muscle activity would be required to achieve this, and the increased use of the hamstrings could cause premature fatigue in the muscle increasing the risk of injury. Alternatively, the increased tone in the muscle from it being over-active may increase the resistance to it being lengthened during the swing phase of gait again increasing the potential for injury. The second mechanism by which pre-existing lumbar spine pathology could influence the predisposition to hamstring injury is through a neurological mechanism, here the efferent (motor) nerve communication with the muscle is affected, this can either be in the form of decreased activity; inhibition of the muscle making it weaker, or increased activity raising its tone (effects of which are discussed above). There are two modes by which preexisting lumbar spine pathology could efferent nerve activity. The first is through direct referral; many structures in the lumbar spine are capable of referring pain to the posterior thigh and so changing efferent nerve activity to the region. The second is through the impingement (putting direct pressure on) the sciatic nerve which supplies the hamstring muscles this alters neural mobility and reduces the nerves ability to communicated effectively with its target tissue (the hamstrings), the poor communication leading to poor control and the potential for injury. Motion control of the lumbo-pelvic region: Most coaches and athletes are familiar with the term “core stability” were the deep abdominal muscles (principally Transversus Abdominis), segmental spinal muscles (principally Multifidus) and the Gluteal muscles provide stability to the lumbo-pelvic region and the dampening of been linked to many different musculoskeletal injuries. With regard to hamstring injuries, failure to fully recruit the gluteal muscles during hip extension will increase the load on the hamstrings, the implications of which where discussed earlier.
Running mechanics The key area in running mechanics which has been linked to hamstring injuries is over-striding. The placement of the foot relative to the body’s centre of mass will affect the force the hamstring muscle will have to generate; ideally the foot
www.sportEX.net
should be placed as close as possible to the body’s line of gravity. The further the foot is placed in front of the body’s centre of mass the greater the load placed on the hamstring to brake the knee extension in swing phase and the greater length of the hamstrings at the start of the stance phase (so called increased clawing). Excessive “clawing” will lead to early hamstring fatigue leading to increased potential for injury.
What factors are related to the reoccurrence of the injury? To answer this question an understanding of the factors causing the injury is needed, hopefully these have been clearly detailed above. The cause of reoccurrence has often been fairly reported to be due to a failure in rehabilitation of the injury and this cannot be disputed. Too often the patient only receives local treatment in the form of massage and electrotherapeutic modalities to the hamstring muscle. In planning a rehabilitation programme for the hamstring injured patient an assessment needs to be undertaken of all those factors which could have caused the injury and then the correction of any faults found needs to be undertaken and accounted for in the treatment plan.
Key elements in multi-factorial assessment n Assessment of lumbar spine posture and movement: Two key points here first is to establish the presence of any inter-segmental hypomobility and hypermobility within the spine. The second is to establish any deficits in lumbo-pelvic motion control that is the activity of the deep core muscles. n Assessment of neural mobility: mobility of the neural system needs assessing and its role in presenting pathology differentiated through the use of the straight leg raise (Leseages) test and slump tests. n Assessment of muscle strength and activation imbalances: The ratio of strength of the quadriceps to hamstrings needs defining ideally being at least 60:40. This ratio is for concentric strength; more significant would be eccentric hamstring to concentric quadriceps strength. The ability to activate the gluteus maximus and its active participation in hip extension activities should also be investigated.
In order to treat hamstring injuries and prevent their reoccurrence it is crucial that the cause of the injury itself is clearly understood. The injury is often caused by a multitude of interrelating factors all of which will need addressing if a complete recovery and a minimised risk of re-injury are to take place. At the core of this is a thorough assessment of all the underlying predisposing factors which may cause the injury and prevent optimal recovery.
21
Figure 1: The slump test The slump test involves the use of neck position to detect the role of neural tissue in the restriction of knee extension. The subject is asked to “slump”; flex the lumbar and thoracic spines and fully dorsi-flex the foot. Then in either a position of neck extension or flexion the subject is asked to extend the knee and the angle achieved is noted. When undertaking the slump test, if there is a significant difference in knee extension range between the neck in a flexed compared to an extended position (as shown) the test is said to be positive and it is likely that the neural structures are involved in the restriction of range of movement.
Click the button for a YouTube video Figure 2: Assessment of extension disassociation between movements of the hip and lumbar spine This test assesses the ability of the hip to move into extension in isolation from the lumbar spine. The subject is asked to lift their thigh off the bed aiming to achieve 20-30° of hip extension. The picture on the left shows a subject performing the test correctly on the right the subject fails the test. Note the anterior pelvic rotation and lumbar extension of the subject on the right, indicating poor dissociation of hip extension from lumbar extension.
Click the button for a YouTube video Figure 3: Assessment of control of lumbo-pelvic motion using leg slide exercise This test assesses the ability to maintain a stable pelvis and lumbar spine whilst the leg is moving from the bed to 90° hip flexion and back. The subject is asked to draw in the lower abdominal muscles and hold that contraction while flexing the hip to 90° and returning it to the bed. The test is failed if the pelvis moves, indicating an inability to control the pelvis and spine under limb loading conditions. Figure 4: Assessment of preferential recruitment of gluteal muscle during hip extension During active hip extension the gluteal muscle should show equitable activity in terms of strength of contraction and timing of contraction to the hamstring muscles. Whilst palpating gluteus maximus and the hamstring muscles the subject is asked to actively extend the hip. Failure is indicated by an inability to recruit the gluteal muscles or a poor level of contraction compared to that of the hamstrings. THE AUTHOR Lee is a chartered physiotherapist and certified strength and conditioning specialist and a senior lecturer in sports rehabilitation at the University of Salford. Lee has worked with elite sports people for the last seventeen years including time with the Great Britain Rugby League and Wigan Warriors Rugby League Club. He currently with the Great Britain Women’s Basketball team. Lee also has worked as a consultant for a number of professional football clubs and individual elite level sports people from a multitude of sports including archery, athletics, swimming, triathlon, sailing, boxing and martial arts.
www.sportEX.net 22
sportEX health 2009;20(Apr):00-00 22
40 what’s in the latest issue of
?
n Chronic compartment syndrome - by Dr Nat Padhiar, FCPODS n Arterial compression syndromes at the shoulder - Part 2: Diagnostic arm manoeuvres - by Claire Stapleton, MSCP n Grow your own knee cartilage - by Oliver Schindler, MD MFSEM(UK) n Femero-acetabular impingement syndrome - by David Binningsley, MCSP
plus online n Animation on autologous chondrocyte implantation n Animation on the anatomy of the hip joint and hip ROM movie showing bony articulations of the joint n Chondroplasty procedure video n Movies showing exercises for femoro-acetabular impingement n Videos of diagnostic arm manoevres referenced in the shoulder arterial compression syndrome article n Selection of YouTube videos on managing chronic compartment syndrome
ADDITIONS
to SUBSCRIBE call +44 (0)845 652 1906
or visit our website www.sportex.net
Get social with Come and join the sportEX community catch up with the latest news
http://sportextor.wordpress.com
www.flickr.com/sportex
39 39 online
Ref: 2
become a fan! www.facebook.com/pages/sportEX/53569242960
Knee articular cartilage repair and athletes
Click on the images below to see the videos
on
on: 2line Ref
Autologous chondrocyte transplantation (note: animation only covers first generation procedure)
Cartilage repair - (note: animation only covers first generation procedure)
Microfracture drilling procedure for isolated chondral defect (microfracture drilling)
OAtS cartilage repair surgery (OAtS)
The Rol PReven e of exeRcise Tion of in hamsTR The ing inj
Click on the pict ures
or links to see the interactive
extras
tel +44(0)845 652 1906 email: subs@sportex.net web: www.sportex.net
see videos
www.youtube.com/isportex
1) Nordic hamstring
uRy
2) Anima tion review hamstring ing anatomy
exercise
3) Anima ted patient lea hamstring flet
http://www.slideshare.net/sportEX tel +44(0) 84
5 652 19 06 email : subs@s po
rtex.net
Unfortunate ly to leave for our animator had Africa for before this two weeks sequence animations of was com pletely finished. By mid-Feb we something considerab will have so come ly improve back soo d n!
web: ww w.sporte
x.net
www.twitter.com/sportextor