USEMS e-Mag (E7)

USEMS

S E V E N T H E D I T I O N - R E C R E AT I O N A L R U N N E R S

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Pre-participation Cardiac Screening of Athletes

Relative energy deficiency in sport (RED-S)

Patellofemoral pain in runners

contents FEATURED

POSTERS

INTERVIEWS

04 Pre-participation

07 BASEM annual

16 MSc Student Perspective

09 Relative energy

15 SEM: In and out of

12 Achilles Tendinopathy:

21 Isokinetic Football

Cardiac Screening of Athletes deficiency in sport (RED-S) an evidence based approach

conference

by Kelly Newton

Spotlight

Medicine Conference

18 Patellofemoral pain in runners

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2 USEMS / SEPT 2019

EDITORS’ NOTE

It wasn’t until the start of my intercalated degree that I really understood the impact that sports and exercise medicine could have in running. Having the opportunity to work with Dr Izzy Moore at Cardiff Metropolitan University opened my eyes to a whole new area of medicine. The role that interventions, such as gait retraining, can have with regards to running related injury and performance captured my interest and is becoming a useful tool for healthcare professionals involved in the care of runners.

We would like to say a massive thank you to the previous editors (Dr Sean Carmody, Dr Fadi Hassan and Dr Steffan Griffin) for consistently producing high quality and engaging content in the first six editions. We look forward to overseeing the USEMS e-magazines next step.

Finally, I am extremely thankful for Dr Izzy Moore’s support with regards to the creation of the edition. Izzy is the current Programme Director of the Sports & Exercise Medicine Masters Programme at Cardiff Metropolitan University as has helped many past and present SEM professionals achieve their aims in the speciality.

With the growing popularity of running and increasing participation in events such as parkrun and many half marathons around the country, running is an activity with a great following. As healthcare professionals, we all strive for an increasingly healthy population and running as a form of physical activity can help achieve improved health outcomes. Yet, running has been associated with high injury rates, especially for those recently taking up the recreation. Therefore, we are delighted to dedicate the 7th edition of the USEMs eMagazine to running medicine and present some of the medical considerations that may accompany running, both as a recreational and sporting activity.

We all look forward to hearing your thoughts on the latest edition.

Dr Daniel Phillips (Co-Editor) Dr Edward Smith (Co-Editor) Dr Fadi Hassan (Co-Editor)

I am delighted to have Eddie involved with the current edition as a member of the USEMS committee. This year has been another year of continued success with the creation of an elective award and a Swiss exchange for healthcare students. We believe these opportunities will not only help to improve access for students in the global speciality that is sports & exercise medicine it will also help to give healthcare students the support needed to aid their knowledge and understanding in the speciality.

Dr Izzy Moore (7th Edition, Guest Editor)

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Pre-participation Cardiac Screening of Athletes Dr Catherine Sedgwick, Honorary Research Fellow Cardiology Clinical and Academic Group St Georges, University of London Dr Sabiha Gati, Consultant Cardiologist and CMR Specialist Department of Cardiology / Cardiac MRI Lister Hospital, East and North Hertfordshire Twitter @s_gati Correspondence email address: sabiha.gati@nhs.net

The benefits of regular exercise on the cardiovascular system are well reported. For example, exercise reduces obesity and its associated diabetes, in addition to producing a favourable blood pressure response and lipid profile with a 33% reduction in all-cause mortality (1). However, occasionally a seemingly healthy young athlete will die unexpectedly while participating in a sporting event. The issue of whether or not to screen young people for inherited or congenital cardiac diseases before they participate in their chosen sport is important, considering that 1 in 300 young athletes harbours a cardiac condition predisposing them to sudden cardiac death (SCD) (2). The unpredictable nature of such a potentially tragic event compels us to consider screening young people using a medical interview, non-invasive cardiac testing such as an electrocardiogram (ECG) and further cardiac investigations such as exercise testing and cardiac MRI in those identified to be most at risk.

The incidence of sudden cardiac death in athletes is 1 in 50,000 (2), with a mean age of 23 and a male:female ratio of 9:1 (3). Of these deaths, 90% occur during or immediately after cardiovascular exercise and can be difficult to predict, and 80% of these deaths occur in asymptomatic individuals (4). In those athletes who do experience symptoms, the most common clinical manifestations include chest pain, dyspnea, palpitations, exertional dizziness, syncope and epilepsy. Sometimes there is a family history of epilepsy or a hereditary cardiac disorder or there may be a history of unexplained death that may have been attributed to drowning or a road traffic collision.

Triggers for SCD during exercise include dehydration, electrolyte imbalances, adrenergic surges and acid-base disturbances. However, research suggests that 50-60% of cases of SCD are caused by structural heart disease, with Hypertrophic Cardiomyopathy (HCM) and 3

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) being the most common culprits, accounting for 40% of deaths in young athletes (5). In older athletes, the most common cause is Coronary Artery Disease (CAD) (6). However, it is not always possible to identify a cause of death in this cohort so, in 42% of cases, a diagnosis of Sudden Arrhythmic Death Syndrome (SADS) was declared (7). The majority of these individuals die from electrical abnormalities and possibly congenital accessory pathways.

diagnosed 22 athletes with HCM, of which 3% were identified from their family history, 9% from their heart murmur and 73% from their ECG.

Screening models There are two main screening models, the American Heart Association (AHA) and the European Society of Cardiology (ESC). Both models aim to identify the highest number of athletes at risk, using the most practical and cost effective methods.

The American Heart Association model The AHA model involves a health questionnaire to identify a family history of cardiovascular disease as well as symptoms such as chest pain, palpitations, syncope and disproportionate shortness of breath. A physical examination is used to identify hypertension, murmurs and features of Marfan Syndrome. Unfortunately this model lacks sensitivity because 80% of affected athletes are asymptomatic (4).

To screen or not to screen?

The European Society of Cardiology model

We know that pre-participation screening works in reducing the risk of SCD in young athletes. A longitudinal study by Corrado et al showed a reduction in the rate of SCD from 3.6 to 0.4 per 100,000 over a 25 year screening programme (2). Although there is no mandatory cardiac screening programme in the UK, it is offered through charities like Cardiac Risk in the Young.

The ESC model also employs a health questionnaire and physical examination, but in addition utilises a 12-lead ECG, which enables the physician to identify electrical abnormalities including Long QT syndrome, Brugada Syndrome and Wolff Parkinson White Syndrome in otherwise asymptomatic individuals. The importance of an ECG is illustrated by a large study of nearly 34,000 individuals by Corrado et al (8). This study

Unfortunately, a single ECG is rarely enough to capture every affected individual so serial ECGs over several years would be preferable. In a study by Malhotra et al of over 11,000 adolescent footballers who underwent screening with a health questionnaire, ECG and echocardiogram, 42 were identified to have a serious heart condition, yet 40 of these individuals remain alive today (9). However, eight young athletes from the 4

original cohort died from a cardiomyopathy but only two had been identified as being at risk during the initial screening and five of the six died of a cardiomyopathy six years later.

adaptation to exercise. We must also remember that early cardiopulmonary resuscitation (CPR) and AEDs save lives in sport.

The young athletes participating in these highly visible sporting events are at risk of losing their life or numerous years of their lives, so it would seem appropriate to try to mitigate against that public and personal loss with a non-invasive screening programme.

Once identified, there are acceptable interventions to prevent fatalities such as lifestyle changes, medications and even implantable cardioverter defibrillators (ICDs) in suitable individuals.

References 1.

Nocon M, Hiemann T, Muller-Riemenschneider F et al.

Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2008;15(3):239-46.

2.

Corrado D, Basso C, Pavei A et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296(13):1593-1601.

3.

Harmon KG, Drezner JA, Wilson MG et al. Incidence of sudden cardiac death in athletes: a state-of-the-art review. Heart 2014 Aug;100(16):1227-34.

It is important to remember that SCD in athletes is uncommon and, when identified, these cardiac disorders are rare and have a diverse pathology. Screening programmes incur a cost and there is a significant risk of false positives, ranging from 10% to an unacceptably high 17% (10). There is also a concern regarding false negatives. Cardiovascular diseases that would not be detected via a pre-participation screening programme include: anomalous coronary arteries, premature atherosclerotic coronary disease, incomplete expressions of cardiomyopathies and ion channel diseases. Additionally, acquired conditions such as commotio cordis, myocarditis and electrolyte disorders can be detected. For such individuals we need to consider a good emergency response plan and the availability of automated external defibrillators (AEDs).

4.

De Noronha SV, Sharma S, Papadakis M et al. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart. 2009;95(17):1409-14.

5.

Maron BJ, Doerer JJ, Haas TS et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119(8):1085-92.

6.

Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol. 1986 Jan;7(1):204-14.

7.

Finocchiaro G, Papadakis M, Robertus JL et al. Etiology of sudden death in sports: insights from a United Kingdom regional registry. J Am Coll Cardiol. 67 (2016), pp.2108-2115.

8.

Corrado D, Basso C, Schiavon M et al. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med, 339 (1998), pp. 364-369.

9.

Malhotra A, Dhutia H, Finocchiaro G et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med 2018; 379:524-534.

10.

Baggish AL, Hutter AM Jr, Wang F et al. Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study. Ann Intern Med. 2010;152(5):269-275.

Conclusion Although SCD in young athletes is rare, we know that exercise is a trigger in predisposed athletes. The diagnosis of cardiac pathology is challenging in some young athletic individuals but pre-participation screening with an ECG has been shown to identify cardiovascular disease and prevent cases of SCD. Cardiac screening should be voluntary and performed by physicians who are highly skilled in this area and who are able to differentiate between pathology and cardiovascular 5

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Relative energy deficiency in sport (RED-S) Dr Nicky Keay BA, MA (Cantab), MB, BChir, MRCP Twitter @nickyKfitness Medical doctor with clinical and research experience in sports endocrinology Under performing, tired, recurrent illness and/or injury?

Lack of support networks? No, I am not just talking about junior doctors. This can be the scenario for athletes of any level and any age, both male and female.

weight are not limited to effects on the reproductive axis and bone health.

Relative energy deficiency in sport (RED-S) is relatively new on the scene, being first described in a consensus statement from the International Olympic Committee (IOC) published in the British Journal of Sports Medicine (BJSM) in 2014. RED-S has evolved from the female athlete triad, which as originally described, included disordered eating/eating disorder, amenorrhoea and low bone mineral density (BMD). This female athlete triad has itself evolved into a clinical spectrum, rather than a rigid structure. However, as the name suggests, this syndrome is limited to female athletes. Nevertheless it became clear that male athletes are also at risk of restrictive nutrition practices to reduce body weight in order to confer an aesthetic or performance advantage.

Moreover the consequences of maintaining a low body

De Souza et al BJSM 2014

Low energy availability is the underlying factor that results in the adverse health and performance consequences outlined in the RED-S model. Energy availability is calculated by taking nutritional energy intake and subtracting from this energy expenditure from exercise training. The residual should be 45 Kcal/Kg of fat free mass in order to maintain baseline biological processes, equivalent to resting metabolic rate. If energy availability falls below this level, then the body 8

effectively goes into energy saving mode. Metabolic stress signals, together with external psychological stressors feed into the neuroendocrine gatekeeper: the hypothalamus. This results in down regulation of the hypothalamic-pituitary (H-P) axis and hence all the endocrine feedback loops. Apart from the positive feedback that occurs to induce ovulation, all the feedback loops in the endocrine system are negative, to maintain homeostasis. For example, considering a fully functioning H-P-thyroid axis, if there is a high circulating level of peripheral hormones T4, then this provides feedback to the hypothalamus to induce reduction of TRH and hence TSH release, so that less T4 is released from the thyroid gland. The result is return of peripheral circulating levels of T4 to normal range. Conversely low levels of T4 feedback to the H-P to increase release of TRH and TSH in order to restore T4 levels. However, in the case of RED-S these endocrine feedback loops are dysfunctional: despite low circulating levels of T4 and sex steroids, this does produce a response from the H-P. The only hormone axis up regulated is the adrenal axis with increased cortisol production, which in turn amplifies the disruption of the other axes.

How can you tell if an athlete has low EA and therefore at risk of developing negative clinical sequalae of RED-S on health and performance? Although it is possible to measure EA in research settings, this is laborious and prone to inaccuracies assessing energy intake and expenditure. This process also requires measurement of fat free mass from DXA scan. Taking a detailed clinical history is the key to making any diagnosis. RED-S is no different. Getting a feel for training load and nutrition is important. In the case of female athletes the overt clinical sign of RED-S is menstrual disruption.

However, bear in mind that RED-S is a diagnosis of exclusion. For example, in the case of female athletes, any woman of reproductive age, however much exercise she is doing, should have regular menstrual cycles. So before making a diagnosis of functional hypothalamic amenorrhoea, other causes of amenorrhea should be excluded. In a similar way, other causes of fatigue, underperformance and recurrent injury should be considered before making a definitive diagnosis of RED-S. For example endocrine conditions per se,

Figure from BJSM blog 2018

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infection, systemic inflammatory/autoimmune and metabolic conditions. Even then, once medical conditions have been excluded, how to distinguish between the functional states of low EA, over training or inadequate recovery?

consequences of RED-S are also outlined. Even if the athlete feels that performance is not affected, nevertheless full potential may not be attained unless adequate EA is restored.

Health and therefore performance depends on getting the right balance and timing of the 3 fundamentals of exercise, nutrition and recovery. Non-integrated periodisation of the elements of training and recovery tend to be towards the non-functional overreaching/ overtraining grouping, whereas imbalance in training load and nutrition indicates more of a RED-S picture.

These patterns of imbalance can be intentional, in the case of attaining a low body weight to confer a performance or aesthetic advantage. Inadvertent low EA can also occur when an increase in training load is not matched with increased nutritional intake.

Diagrams from IOC published in BJSM illustrating potential health and performance effects of RED-S

In summary, low EA can occur in male and female athletes of any age. This situation may arise intentionally in striving to attain low body weight, or inadvertently with increased training loads. The clinical outcomes, as outlined in the RED-S model, can include far-reaching health and performance consequences.

Therefore early identification of athletes at risk is essential to safeguard their health. In order to achieve this goal, an educational RED-S website is being developed to raise awareness, amongst athletes and dancers, their coaches/teachers, parents/teammates and all healthcare professionals.

References Illustration from BJSM blog 2018

2018 UPDATE: Relative Energy Deficiency in Sport (RED-S) Dr N. Keay BJSM blog 2018

Why is it important to identify athletes at risk of RED-S? Prompt intervention can prevent development of health and performance consequences. The most established, quantifiable adverse effect of RED-S is on bone health.

This is due to suboptimal levels of sex steroids and other hormones such as T4 and IGF-1. In the long term the clinical outcome of impaired bone health is an increased risk of bone stress injuries. There is potentially a negative impact on others systems as seen in the diagrams from the IOC. Athletic performance

Part 2: Health, Hormones and Human Performance take centre stage Dr N. Keay BJSM blog 2018 The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S) BJSM IOC consensus statement 2014 IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update BJSM IOC consensus statement 2018

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Achilles Tendinopathy: an evidence based approach Fadi Hassan BSc (Hons) MBBS Birmingham based junior doctor with interest in Sports and Exercise Medicine @DrFadiHassan Definition and presentation

runners, compared to age-matched controls. Around 6-18% of all injuries in recreational runners are Achilles related.6-9

Achiles Tendinopathy (AT) is a clinical condition characterised by pain, swelling and functional impairment.1 It is often the result of repeated strain until the tendon is unable to withstand further loading due to damage to the tendon collagen cross-links, showing a tendinosis and inflammatory histological picture.2

Aetiology AT can be secondary to seronegative arthropathies, cholesterol deposits, diabetes mellitus and use of fluoroquinolones.5-7,10

The process can often start before the onset of symptoms, which can result in advanced pathology at presentation. The chronic and limiting nature of the condition can impact on patient’s physical and emotional wellbeing.3,4 Hence, the need for a robust rehabilitation plan.

Risk factors can be intrinsic and extrinsic. Intrinsic risk factors include overuse, over-pronated foot, tibia vara, cavus foot or underdeveloped hamstring. Extrinsic factors include inadequate footwear, training technique or surface.7,11,12

Epidemiology

Conservative Management

AT can occur in men and women of all age groups, however, the literature suggests that it is more prevalent in middle aged men between 35 and 45 years.5,6

Loading Exercise is the cornerstone of AT management and it is the one treatment that has a strong evidence base.7,8

Furthermore, the prevalence of the condition is higher in sports involving running or jumping, as studies suggested there is a 10-fold increase in AT injuries in

The 12-weeks Alfredson protocol of eccentric loading has been reported in the majority of studies available. It 11

involves 180 heel drops per day as 3x15 repetitions twice daily with variations of knees bent/straight.13 This was found to be effective in short and long term, as demonstrated in a 5 year follow-up study.14,15 This would involve progression with weighted backpacks to work the tendon with heavier load.

Orthoses, soft tissue therapy and taping can provide short-term relief and correct some biomechanical deficit.20,21 However, there is a lack of supporting evidence in the literature. Other modalities such as topical GTN, bracing/splinting, low-level laser therapy and acupuncture have featured in the literature, however, there remains a lack of strong supporting evidence.

Injectable treatments High-volume injections (HVI) involves injecting a large volume of saline with/without a small amount of corticosteroid. This has been shown to be effective in improving pain and function in short and long-term.22,23 HVI with corticosteroid has been shown to be more effective.

Figure 1. Demonstration of the eccentric heel-drop. (Image by: runningwritings.com)

This heavy approach can be irritating in the early inflammatory phase. Hence, an isometric approach is preferred at the early stage to allow loading and slowly progressing to heavier concentric-eccentric approach. A study showed benefit with the use of a pain-monitoring model, which allows progressive rehabilitation, continued activity and a more tailored tendon-loading.16 There is a lack of studies assessing other loading programmes, especially in different subgroups, however, a recent study showed no difference between the Alfredson’s protocol and a do-as-tolerated protocol, suggesting a more lenient approach can yield clinical benefit and could as a result improve adherence.17 Conservative adjuncts Extracorporeal shockwave therapy (ESWT) has been shown to offer short-term benefit in terms of symptomatic relief, allowing rehabilitation to continue and not substitute it.18,19 However, the cost of it can make it difficult in certain settings.

Figure 3. Transverse needle placement under US guidance delivering HVI 23

Corticosteroid injections alone and at higher volumes are usually avoided but have a use in providing short-term symptomatic relief. The use is controversial due to the long-term negative effects and risk of tendon rupture.24,25 Other injectable treatments such as prolotherapy, Platelet-rich plasma, sclerosing polidocanol and autologous components have no evidence to support their use in AT.

Figure 2. Demonstration of ESWT delivery

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Surgical treatment

References

Surgery is often used after exhausting the conservative approach.2,7 It is reserved for refractory chronic cases that fail a robust rehabilitation programmes. 4 Debridement of the tendon and paratendon stripping may be carried out to excise fibrotic tissue and stimulate the healing process. Minimally invasive procedures are usually preferred to open surgery.

1. van Dijk CN vSM, Wiegerinck JI, Karlsson J, Maffulli N. Terminology for Achilles tendon related disorders. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19:835–41.

2. Kader D, Saxena A, Movin T, et al Achilles tendinopathy: some aspects of basic science and clinical management British Journal of Sports Medicine 2002;36:239-249.

3. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long-term prognosis of patients with Achilles tendinopathy - An observational 8-year follow-up study. American Journal of Sports Medicine. 2000;28(5):634-42.

4. Paavola M KP, Jarvinen TA, et al. Achilles tendinopathy. J Bone Surg Am. 2002;35:3-6.

5. Kingma JJ dKR, Wittink H M. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. British journal of sports medicine. 2001;41(6):e3.

6. Cook JL KK, Purdam C. Achilles tendinopathy. Manual therapy. 2002;7:121-30.

However, it is usually avoided in chronic cases due to poor post-operative results and the high rate of re-operation.26

7. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev 2001:CD000232.

8. Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scand J Med Sci Sports 2005;15:252–9.

9. Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998;30:1183–90.

Challenges and gaps in evidence

10.van der Linden, P D et al. “Achilles tendinitis associated with fluoroquinolones.” British journal of clinical pharmacology vol. 48,3 (1999): 433-7. doi:10.1046/j.1365-2125.1999.00016.x

It is important to address patient expectations and focus on patient education in early stages to improve adherence and patient awareness, which could potentially improve long-term outcomes.

11.Ames PR LU, Denaro V, et al. Achilles tendon problems: not just an orthopaedic issue.

Disability and rehabilitation. 2008;30(20-22):1646-50.

12.Munteanu SE BC. Lower limb biomechanics during running in individuals with Achilles tendinopathy: a systematic review. J foot Ank Res 2011;4:15.

13.Alfredson H CJ. A treatment algorithm for managing Achilles tendinopathy: new treatment options. British journal of sports medicine. 2007;41:211-6.

Furthermore, translation of evidence can be difficult for adjuncts. Most modalities reported lack high quality literature, hence, making it difficult to draw meaningful conclusion regarding efficacy. Furthermore, most of the evidence available does not factor subgroups such as elderly vs young, athletes vs sedentary, male vs females as direct comparison, hence, limiting the potential of targeted treatments for certain subgroups. These are areas future evidence could address.

14.de Vos RJ, Weir A, Visser RJ, de Winter T, Tol JL. The additional value of a night splint to eccentric exercises in chronic midportion Achilles tendinopathy: a randomised controlled trial. British journal of sports medicine. 2007;41(7):e5.

15.an der Plas A, de Jonge S, de Vos RJ, van der Heide HJL, Verhaar JAN, Weir A, et al. A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. British journal of sports medicine. 2012;46(3):214-8.

16.Silbernagel KG, Thomee R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The American journal of sports medicine.

2007;35(6):897-906.

17.Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy. 2014;44(2):59-67.

18.Rompe JD, Furia J, Maffulli N. Eccentric loading versus eccentric loading plus shock-wave treatment for midportion achilles tendinopathy: a randomized controlled trial. The American journal of sports medicine. 2009;37(3):463-70.

Conclusion

19.Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. The American journal of sports medicine. 2007;35(3):374-83.

AT is a chronic condition leading to pain and functional impairment. It can have physical and psychological impact on patients due to the chronic limiting nature of the condition. Addressing this condition requires a multidisciplinary approach with loading being at the core of the management plan. High quality studies assessing different loading programmes and efficacy of adjuncts are needed, especially in subgroups to enhance the evidence base and improve patient experience.

20.Shannon E Munteanu LAS, Daniel R Bonanno, Karl B Landorf, Tania Pizzari, Jill L Cook, Hylton B Menz. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. British journal of sports medicine. 2014;0:1-7.

21.Norregaard J, Larsen CC, Bieler T, Langberg H. Eccentric exercise in treatment of Achilles tendinopathy. Scandinavian journal of medicine & science in sports. 2007;17(2):133-8.

22.Boesen AP, Langberg H, Hansen R, et al 19 High-volume injection with and without corticosteroid in chronic midportion achilles tendinopathy – a randomised double blinded prospective study British Journal of Sports Medicine 2018;52:A7 23.Peter Resteghini & Justin Yeoh (2012) High-volume injection in the management of recalcitrant mid-body Achilles tendinopathy: a prospective case series assessing the influence of neovascularity and outcome, International Musculoskeletal Medicine, 34:3, 92-100.

24.Mahler F FD. Partial and complete ruptures of the Achilles tendon and local corticosteroid injections. British journal of sports medicine. 1992;26:7–14 25.Chechick A AY, Israeli A, Horoszowski H Recurrent rupture of the achilles tendon induced by corticosteroid injection. British journal of sports medicine. 1982;16:89–90 26.Maffulli N, Binfield PM, Moore D, et al. Surgical decom- pression of chronic central core lesions of the Achilles tendon. Am J Sports Med. 1999;27:747–752.

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USEMS

Sports and exercise Medicine: In and out of Spotlight

Twitter @sheffsem Book Now! Visit https://tinyurl.com/y2ar4z7y 14

USEMS Interview – MSc Student Perspective Kelly Newton

Why did you choose to do a MSc in Sport and Exercise Medicine, and why Cardiff Met?

complete which I did not feel suited my learning style or career plan.

I wanted to complete a masters in sport and exercise medicine to improve my clinical practice in my current role as a physiotherapist in a professional ballet company. Within the company, the medical provision is physiotherapy lead, therefore it was important for me to complete a course focussed on sport and exercise medicine rather than just physiotherapy which would therefore increase my breadth of knowledge and understanding. Additionally, undertaking a MSc in this field is necessary for career progression, and would equip me to take on more senior roles. The structure and delivery of the course also meant that it was achievable to complete whilst working, as I only required leave for the four intensive residential blocks and one exam block and the rest could be completed in my own time. This also meant that I could complete the course full-time in just eighteen months, whilst other distance learning or part time masters took three to five years to

What have you learnt from the course?

I feel that the course has strengthened my existing skills as a physiotherapist as well as provided me with a broad understanding of alternative disciplines of sport and exercise medicine, for example it has introduced me to sports imagery, exercise nutrition and everything in between. The course has also provided me with the skills to critically appraise research and identify the current best evidence to inform my decision making in practice as well as giving me a solid understanding regarding the research process and how to undertake a research project. There was a real variety of sports covered, from diving medicine to Paralympic sport, all of which have provided insight and increased depth of knowledge that is invaluable and can be transferred to numerous areas.

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What aspects have you enjoyed most about the course and why?

How have you found balancing your clinical day job and a masters course?

One of the elements I enjoyed most about the course was learning from a whole host of guest and in-house lecturers that are specialists within their fields. The variety in teaching styles and experiences made it interesting and engaging as well as presenting numerous opportunities to network with skilled clinicians in a plethora of different environments. This was particularly beneficial when presenting opportunities for diverse placements that wouldn’t normally be accessible, for example I spent a fascinating day in a heat chamber at the Institute of Naval Medicine observing a heat illness clinic with Dr Dan Roiz de Sa. The course explores every aspect within sport and exercise medicine, from the basics of performance analysis to cardiac rehabilitation, and the practical elements are enjoyable, enabling you to put into practice the learnings.

Completing this MSc on a full-time basis has been challenging alongside my full-time role with Birmingham Royal Ballet, which involves extensive travel around the UK and internationally. It has required me to be exceptionally organised and plan my time efficiently, which has included using every opportunity of quiet time, such as appraising papers for assignments whilst travelling on planes and coaches for tours. However, the structure of Cardiff Met’s MSc allowing for completion in 18 months enabled me to maintain focus for that time period, as personally, keeping motivation and momentum for much longer on a part-time or distance learning basis would have been more difficult and less achievable. Additionally, my team at Birmingham Royal Ballet have been exceptionally supportive, giving me the time required to complete my assignments, residential blocks and placements, as well as constantly offering encouragement, understanding and the ability to directly apply my learnings to clinical practice. Both of my bosses also had masters degrees in sport and exercise medicine so could appreciate first-hand the benefits that undertaking the course would provide. I feel when taking on a full-time MSc in addition to a full-time job, it is important to acknowledge the organisational effort it will take, the fact you will need to prioritise studying for a short period and that you are in environment that is committed to professional development, providing the opportunity to flourish.

How have you used knowledge and skills development on the course in your clinical practice?

The depth and breadth of knowledge I have gained from this course has not only enabled me to add to discussion and support decision making pathways for the elite dancers in our company but provided me with the understanding to question or provide counterarguments for alternative management strategies following injury. The course has also enhanced my practice and encouraged me to think outside the box, for example I ran a “Greatest Showman” themed exercise class for the dancers after being inspired by a practical teaching session about making strength and conditioning fun and engaging for children. Ultimately, the course has improved my confidence and made me feel more prepared and qualified to provide medical support for elite performers in a sport and exercise medicine environment.

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Patellofemoral pain in runners 1Willy, 1 School

2 Cardiff

R. W., & 2Moore, I. S.

of Physical Therapy and Rehabilitation Science, University of Montana, USA School of Sport and Health Sciences, Cardiff Metropolitan University, UK

What is patellofemoral pain?

Promisingly, these risk factors are modifiable which means that they can be addressed with education on proper training practices and adequate conditioning exercises.

Patellofemoral pain is characterised by pain under or around the knee cap during activities ranging from prolonged sitting to running. While patellofemoral pain is experienced by athletes of all sports, it represents about 25% of all knee injuries sustained by runners and is the most common running-related injury.1 This injury tends to affect females at nearly twice the rate of males2, and affects between 8-37% of individuals in the military.3, 4

Although commonly thought, there is no compelling evidence that an individual’s structural characteristics, such as height, knock-kneed posture, or flat feet, increase risk of patellofemoral pain.7, 8 While a person’s structure or posture is not related to patellofemoral pain, certain movement patterns can be a risk factor. For instance, there is evidence that athletes whose knees tend to drift toward midline during running appear to be at greater risk for the development of patellofemoral pain.9 Still, the greatest risk factor for the development of patellofemoral pain is a previous history of the patellofemoral pain.8 This finding suggests that individuals who have experienced patellofemoral pain in the past have unresolved factors, such as continued risky training practices or unresolved movement patterns, that continue to place them at risk.

Patellofemoral pain is most often associated with a gradual onset. It can affect any individual regardless of activity level, but most often occurs in individuals who repetitively load their knees, such as runners. Increases in training loads that outpace the knee’s ability to adapt, such as a rapid increase in running or jumping volume, appear to be an important risk factor for the development of patellofemoral pain.5, 6 In particular, weakness of the quadriceps musculature prior to beginning a training program is associated with a greater risk of developing patellofemoral pain.7 17

Injury presentation: Signs, symptoms and how is patellofemoral pain diagnosed?

To assist with a gradual return to running, gait retraining may be indicated in some runners with patellofemoral pain. Runners who may benefit the most from gait retraining are those who tend to take large steps, known as overstriding, or those whose knees drift toward midline during running. For instance, taking a 5-10% shorter step length during running reducing loads under the knee cap by 15-20%.16 Even just a 3% reduction in step length has been shown to reduce patellofemoral pain.17 A shorter step length is easily adapted by most runners by increasing their step rate, i.e., cadence, while maintaining the same running speed. A metronome can be used during treadmill running,17 with many commercially available running watches able to provide real-time feedback on running cadence and are an invaluable tool to retrain a runner’s gait.18 Providing visual and verbal feedback on knee alignment during running has also been shown to reduce patellofemoral pain in female runners.19, 20 To provide visual feedback on knee alignment during runners, clinicians commonly use a full-length mirror placed in front of a treadmill.

Finally, changing from a rearfoot strike to a forefoot strike pattern also reduces loads under the kneecap by about 13% but may place the runner at greater risk of an overuse injury to the Achilles tendon.16 Runners with patellofemoral pain who think they may benefit from retraining their running pattern should only do so under the guidance of a trained physiotherapist so that other injuries are not developed.

Patellofemoral pain is most often diagnosed by a combination of patient history and symptom reproduction during resisted knee extension, deep squatting, step descent or complaints of pain with prolonged sitting.10 Clinical examination techniques in which the clinician may compress the knee cap against the underlying femur bone are commonly used to assist with the diagnosis of patellofemoral pain. However, these tests have not been shown to be a valid means to diagnose an individual with patellofemoral pain.10 Similarly, imaging procedures such as X-rays or magnetic resonance imaging (MRI), are also not a valid means of diagnosing patellofemoral pain and is not appropriate in the patient with patellofemoral pain unless a serious medical diagnosis, such as malignancy, is suspected.

Treatment Patellofemoral pain does not appear to resolve on its own, particularly in adolescent athletes. Over 50% of adolescent athletes with patellofemoral pain will continue to report persistent knee pain two years later.11, 12 Furthermore, greater than 50% of individuals will continue to experience patellofemoral pain years after the initial diagnosis.8 Patellofemoral pain, as such, will not go away with rest and it is not an injury that will go away as an athlete matures.

Summary

Exercise therapy is the current best practice for the treatment of individuals with patellofemoral pain.13 Combined quadriceps and hip strengthening should be a cornerstone of rehabilitation for patellofemoral pain,14 supplemented with patient education on the nature of the condition and best training practices.15 In order to be effective, quadriceps and hip strengthening requires multiple exercise sets using added resistance, via weight machines or weights, interspersed with appropriate rest intervals.

Patellofemoral pain is one of the most common injuries experienced by runners and is a gradual onset injury.

While the etiology of patellofemoral pain is poorly understood, it is generally thought to result when an athlete experiences a rapid increase in knee joint loads.

Patellofemoral pain is most often noticed during activities that result in high loads under the kneecap, such as running and jumping. This injury does not often resolve on its own. Exercise therapy, coupled with patient education, is the current standard of care for 18

9.

Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. Med Sci Sports Exerc. 2013;45(6):1120-4.

patellofemoral pain. Some runners with specific running mechanics may benefit from changes to their running mechanics to assist with a return to running.

10.

Cook C, Hegedus E, Hawkins R, Scovell F, Wyland D. Diagnostic accuracy and association to disability of clinical test findings associated with patellofemoral pain syndrome. Physiother Can. 2010;62(1):17-24.

11.

Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. Am J Sports Med. 2016;44(5):1165-71.

Dr Richard Willy is an Assistant Professor at the University of Montana’s School of Physical Therapy & Rehabilitation Science. His research focuses on the treatment of abnormal gait mechanics of individuals who are at high risk for the development of knee osteoarthritis as well as gait modifications for runners with patellofemoral pain and tibial stress fractures. He is well published in the field of running medicine, using both his biomechanical and clinical knowledge to progress our understanding of how to rehabilitate runners.

12.

Rathleff CR, Olesen JL, Roos EM, Rasmussen S, Rathleff MS. Half of 12-15-year-olds with knee pain still have pain after one year. Dan Med J. 2013;60(11):A4725.

13.

Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. British Journal of Sports Medicine.

2009;43(3):163-8.

14.

Lack S, Barton C, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med. 2015;49(21):1365-76.

Dr Izzy Moore is a Lecturer in Sport and Exercise Medicine at Cardiff Metropolitan University. She specialises in lower limb biomechanics and injury epidemiology, with a particular expertise in running-related rehabilitation and rugby injury risk.

Over the past six years she has worked with the Welsh Rugby Union, England & Wales Cricket Board and Sport Wales to develop injury prevention and management strategies, receiving national and international research awards for human movement and sports medicine.

15.

Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The 'Best Practice Guide to Conservative Management of Patellofemoral Pain': incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med. 2015;49(14):923-34.

16.

Willson JD, Ratcliff OM, Meardon SA, Willy RW. Influence of step length and landing pattern on patellofemoral joint kinetics during running.

Scand J Med Sci Sports. 2015;25(6):736-43.

17.

Diss CE, Doyle S, Moore IS, Mellalieu SD, Bruton AM. Examining the effects of combined gait retraining and video self-modeling on habitual runners experiencing knee pain. Transl Sports Med. 2018;1:273-82.

Twitter @IzzyMoorePhD

References

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Willy RW, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson J. In-field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture. Scand J Med Sci Sports.

2016;26(2):197-205.

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Taunton JE. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine. 2002;36(2):95-101.

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Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal of Sports Medicine. 2010;45(9):691-6.

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Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010;20(5):725-30.

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Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech 2012;27(10):1045-51.

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Wills AK, Ramasamy A, Ewins DJ, Etherington J. The incidence and occupational outcome of overuse anterior knee pain during army recruit training. J R Army Med Corps. 2004;150(4):264-9.

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Van Tiggelen D, Witvrouw E, Coorevits P, Croisier JL, Roget P. Analysis of isokinetic parameters in the development of anterior knee pain syndrome: A prospective study in a military setting. Isokinetics and Exercise Science. 2004;12(4):223-8.

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Willy RW, Meira EP. Current Concepts in Biomechanical Interventions for Patellofemoral Pain. Int J Sports Phys Ther.

2016;11(6):877-90.

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Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res. 2005(436):100-10.

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Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012;42(2):81-94.

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Lankhorst NE, van Middelkoop M, Crossley KM, Bierma-Zeinstra SM, Oei EH, Vicenzino B, et al. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2016;50(14):881-6.

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