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How I Rehab
How I Rehab
#31 How I Rehab in the NFL with Emidio Pacecca
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In this episode of the How I Rehab podcast by Sports MAP we chat with Performance and Rehab manager at New England Patriots, Emidio Pacecca.

Emidio has extensive experience working in elite sporting environments including the Carlton Blues in the AFL, the Australian Institute of Sport (AIS) and Western Force Rugby Union team.

In this episode we cover a range of topics including:

  • Emidio’s experience and journey to get to the NFL
  • Expectations and responsibilities within an NFL team
  • Early strategies around Achilles tendon injuries within the NFL
  • Loading protocols
  • Isometric loading expectations
  • High speed running dosage and hamstring loading
  • Strength training expectations across different sports
  • Quantifying strength levels

Listen to this Podcast via your favourite platform including AppleSpotifyPlayer FM & Stitcher. 

You can also VIEW this Podcast on the Sports MAP YouTube channel.

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook

How I Rehab
How I Rehab
#30 Isolated lateral collateral ligament ruptures with Matt Konopinski
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In this 30th episode of the Sports MAP Podcast we chat with co-founder and Head Physiotherapist for Rehab 4 Performance in Liverpool, Matt Konopinski. Matt is a highly decorated specialist sports physiotherapist practicing in the UK.

Matt has over 15 years of experience working at the highest level of professional football. He has worked as the Head Physiotherapist for Liverpool, Rangers and Barnsley FC. Additionally, Matt has spent time as Men’s team Physiotherapist at the FA, England’s football governing body. He specialises in lower limb rehabilitation and optimising performance through biomechanics.

In this episode we cover a range of topics including:

  • Matt's background in elite men's football, Liverpool FC
  • Matt's interest and experience in knee injury rehabilitation
  • Importance of recognition and optimal management of LCL injuries
  • Mechanism of the injury
  • LCL injuries in conjunction with additional knee injuries
  • Assessment and diagnosis stategies
  • Imaging
  • Surgical vs non-surgical
  • Bracing processes
  • Key strengthening
  • Return to run
  • Return to kicking progressions

Listen to this Podcast via your favourite platform including AppleSpotifyPlayer FM & Stitcher. 

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook

How I Rehab
How I Rehab
#29 Calf strains & injury management in female football with Jaclyn Benz
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In this 29th episode of the Sports MAP Podcast we chat with Lead Physiotherapist of the Matildas, Australian Womens Football Team, Jaclyn Benz. Jaclyn has immense experience working at all levels of womens football. Her experience extends well beyond Women's Football after spending timeworking as a Locum at the Australian Institute of Sport and Hunter Sports Academy.

In this episode we cover a range of topics including:

  • Jaclyn's background and pathway to her current position
  • Her day-to-day experience of the recent World Cup
  • Training and prep for the World Cup campaign
  • Individualising injury prevention programs
  • Injury differences between womens and mens sport
  • Challenges and opportunities within womens elite football
  • Management of Sam Kerr's calf injury
  • Pressures and celebrations throughout the World Cup campaign

Listen to this Podcast via your favourite platform including AppleSpotifyPlayer FM & Stitcher. 

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook

As you know, you should begin high-quality rehabilitation immediately after an injury. Everyone with an acute knee injury (e.g. ACL rupture, MCL injury, meniscal tear…) experiences early loss in muscle mass and muscle strength. So the first phase is crucial!
Overuse injuries also require adequate load management to reduce pain and increase load capacity.  

Can we reduce these losses and restore them more early with Blood Flow Restriction Training (BFRT)? Can we reduce pain with BFRT?

credits to The BFR Pros

Yes you heard that right! Blood Flow Restriction Training is able to increase muscle mass and strength with much less weights or NO weights at all. Which is absolutely important to maintain and improve post knee injury to restore daily functioning and participation to sports!

Experts Agree on the Recommendation to Use BFR in ACL Rehab

(Practice guideline Kotsifaki et al., 2023)

Based on the scientific evidence, high intensity strength training is necessary to get these improvements. But all of you know that training with heavy loads is far from possible after an acute knee injury. We need to protect tissue healing and respect the reduced load capacity of the knee! Especially when there are weight bearing restrictions given by the surgeon because of for example a meniscal repair.
So we have no other choice than applying low intensity training in these cases. But almost always muscles aren’t getting into fatigue and thus you aren’t experiencing the feeling of the pump, because of the very high amount of repetitions needed. The pump is actually very important to achieve because we then know that mechanisms are taking place and we are reducing the loss or even gaining muscle mass and strength.  

Typically with overuse injuries, patients or athletes experience pain and are unable to tolerate the loading that occurs during training or high intensity strength exercises. Current research is suggesting that BFRT could reduce knee pain (e.g. anterior knee pain, patella femoral pain, patellar tendinopathy). This isn’t the only advantage of BFRT. Imagine your patient or athlete is already able to experience the physiological benefits associated with training at a higher intensity, meaning they are already building muscle mass and strength, or at least maintaining them without performing high intensity strength training.

Researchers found that BFRT can improve cross-sectional area and stiffness of the patellar tendon in healthy individuals. This is interesting to consider regarding the rehab of patellar tendinopathies, but should be further investigated!

BFR is no Magic! It's Pure Exercise Physiology
#CHASETHEPUMP

Besides that, BFR could:

  • Reduce loss in bone mineral density and bone mass
  • Possibly reduce swelling
  • Possibly resolve activation problems
  • Maintain or improve aerobic capacity, muscle mass and muscle strength with Aerobic BFRT
  • Improve physical functioning and quality of life
  • Be used safe in adolescents

LL-BFR Outperforms LL Training without BFR

 

How should BFRT be applied?

Step 1: is there an indication?

Who is likely an appropriate BFR training candidate? The evidence strongly supports BFR’s use in those patients with either a loading problem or a pain problem.

There is no discussion that there is an indication after for example ACLR or other serious knee injuries. Because load capacity is suppressed and pain is a major factor influencing the knee function.

 Step 2: is it safe?

The evidence does not support the assertion that BFR creates blood clots! It seems to reduce the possibility of a blood clot.
BFR is safe if the following requirements are met:

  • Medical screening passed
    • Rule out absolute contra-indications
    • Take into account relative contra-indications
    • Blood pressure assessment
    • Consult with doctor or expert (when in doubt)
  • Applied by an experienced and trained therapist
  • Correct protocols and techniques applied
  • Use of objective LOP (limb occlusion pressure) assessment and pneumatic cuffs or validated automatic devices
    • DON’T USE STRAPS
    • DON’T USE PRESSURE BASED ON LEG CIRCUMFERENCE SOLELY
      • Choose your cuffs wisely!

Stop Guessing! Start Assessing!

Step 3: write a BFR training program!

Writing a BFR training program includes taking into account medical screening and patient characteristics. Determining the training pressure based on a LOP assessment and prescribing based on the pressure/load continuum are crucial! When necessary, implement strategies to reduce perceptual demands to maintain long-term compliance. Last but not least, think about The Pillars of BFR Training throughout your training and within each session. Use them as a progressive framework/ continuum to applying BFRT from very easy to harder and select the right exercises.

Pillar 1: cell swelling/ passive BFR

Goals of Pillar 1:

  • Short familiarization period
  • Reduction in atrophy and muscle strength loss

Pillar 2: cardiovascular training

Goals of Pillar 2:

  • Increase in muscle mass and strength
  • Maintenance or improvement of aerobic capacity
  • Pain relief
  • Bridge towards pillar 3

Pillar 3: resistance training

Goals of Pillar 3:

  • Pursue the same benefits as with traditional high load strength training without all the external mechanical stress
  • Attenuate atrophy
  • Increase muscle hypertrophy
  • Increase muscle strength and endurance
  • Resolve activation problems
  • Pain relief
  • Facilitate bone metabolism

Pillar 4: performance training

Not often used in knee rehab

Individuals can skip pillar 1 and/or 2 if your evaluation suggests that they are able to tolerate the stress of later pillars.

BFR Training as a Bridge Towards High Load Training

BFRT is already being used all over the world to accelerate fatigue and rehab. Not only with elite athletes, but also with the recreational athlete and non-sporter with knee injuries. Doctors and surgeons are already referring to the use of BFR in their patients rehab! Don’t stay behind. It’s not IF, it’s WHEN!

Are you a doctor or a patient and do you want to find a BFR certified physio? LOOK AT www.bfrproviders.com

Find your BFR specialist

BFR COMPLEMENTS BUT DOES NOT REPLACE TRADITIONAL REHAB

Mathias Thoelen
The BFR Pros

If you have any questions, Mathias Thoelen and The BFR Pros are ready for you!

#CHASETHEPUMP!
The BFR Pros are a team of clinicians, coaches and athletes who have combined forces to bring you the real science and tools behind Blood Flow Restriction.

References:

Abe, T., Kearns, C. F., & Sato, Y. (2006). Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. Journal of applied physiology, 100(5), 1460-1466.

Abe, T., Fujita, S., Nakajima, T., Sakamaki, M., Ozaki, H., Ogasawara, R., ... & Ishii, N. (2010). Effects of low-intensity cycle training with restricted leg blood flow on thigh muscle volume and VO2max in young men. Journal of sports science & medicine, 9(3), 452.

Bond, C. W., Hackney, K. J., Brown, S. L., & Noonan, B. C. (2019). Blood flow restriction resistance exercise as a rehabilitation modality following orthopaedic surgery: a review of venous thromboembolism risk. journal of orthopaedic & sports physical therapy, 49(1), 17-27.

Centner, C., Jerger, S., Lauber, B., Seynnes, O. R., Friedrich, T., Lolli, D., ... & König, D. (2022). Low-load blood flow restriction and high-load resistance training induce comparable changes in patellar tendon properties.

Constantinou, A., Mamais, I., Papathanasiou, G., Lamnisos, D., & Stasinopoulos, D. (2022). Comparing hip and knee focused exercises versus hip and knee focused exercises with the use of blood flow restriction training in adults with patellofemoral pain. European Journal of physical and rehabilitation Medicine, 58(2), 225.

Cuddeford, T., & Brumitt, J. (2020). In‐season rehabilitation program using blood flow restriction therapy for two decathletes with patellar tendinopathy: A case report. International journal of sports physical therapy, 15(6), 1184.

Formiga, M. F., Fay, R., Hutchinson, S., Locandro, N., Ceballos, A., Lesh, A., ... & Cahalin, L. P. (2020). EFFECT OF AEROBIC EXERCISE TRAINING WITH AND WITHOUT BLOOD FLOW RESTRICTION ON AEROBIC CAPACITY IN HEALTHY YOUNG ADULTS: A SYSTEMATIC REVIEW WITH META-ANALYSIS. International Journal of Sports Physical Therapy, 15(2).

Giles, L., Webster, K. E., McClelland, J., & Cook, J. L. (2017). Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. British journal of sports medicine, 51(23), 1688-1694.

Hughes, L., Grant, I., & Patterson, S. D. (2021). Aerobic exercise with blood flow restriction causes local and systemic hypoalgesia and increases circulating opioid and endocannabinoid levels. Journal of Applied Physiology, 131(5), 1460-1468.

Hughes, L., Paton, B., Haddad, F., Rosenblatt, B., Gissane, C., & Patterson, S. D. (2018). Comparison of the acute perceptual and blood pressure response to heavy load and light load blood flow restriction resistance exercise in anterior cruciate ligament reconstruction patients and non-injured populations. Physical Therapy in Sport, 33, 54-61.

Hughes, L., & Patterson, S. D. (2020). The effect of blood flow restriction exercise on exercise-induced hypoalgesia and endogenous opioid and endocannabinoid mechanisms of pain modulation. Journal of Applied Physiology, 128(4), 914-924.

Hughes, L., Patterson, S. D., Haddad, F., Rosenblatt, B., Gissane, C., McCarthy, D., ... & Paton, B. (2019a). Examination of the comfort and pain experienced with blood flow restriction training during post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service trial. Physical Therapy in Sport, 39, 90-98.

Hughes, L., Rosenblatt, B., Haddad, F., Gissane, C., McCarthy, D., Clarke, T., ... & Patterson, S. D. (2019b). Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: a UK National Health Service Randomised Controlled Trial. Sports Medicine, 49(11), 1787-1805.

Hughes, L., Rosenblatt, B., Paton, B., & Patterson, S. D. (2018). Blood flow restriction training in rehabilitation following anterior cruciate ligament reconstructive surgery: A review. Techniques in Orthopaedics, 33(2), 106-113.

Jack, R. A., Lambert, B. S., Hedt, C. A., Delgado, D., Goble, H., & McCulloch, P. C. (2022). Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction. Sports Health, 19417381221101006.

Korakakis, V., Whiteley, R., & Epameinontidis, K. (2018). Blood flow restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Physical Therapy in Sport, 32, 235-243.

Kotsifaki, R., Korakakis, V., King, E., Barbosa, O., Maree, D., Pantouveris, M., ... & Whiteley, R. (2023). Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 57(9), 500-514

Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., ... & Loenneke, J. (2019). Blood flow restriction exercise: considerations of methodology, application, and safety. Frontiers in physiology, 10, 533.

Prue, J., Roman, D. P., Giampetruzzi, N. G., Fredericks, A., Lolic, A., Crepeau, A., ... & Weaver, A. P. (2022). Side effects and patient tolerance with the use of blood flow restriction training after ACL reconstruction in adolescents: a pilot study. International Journal of Sports Physical Therapy, 17(3), 347.

Rolnick, N., Kimbrell, K., Cerqueira, M. S., Weatherford, B., & Brandner, C. (2021). Perceived Barriers to Blood Flow Restriction Training. Frontiers in Rehabilitation Sciences, 14.

Skovlund, S. V., Aagaard, P., Larsen, P., Svensson, R. B., Kjaer, M., Magnusson, S. P., & Couppé, C. (2020). The effect of low‐load resistance training with blood flow restriction on chronic patellar tendinopathy—A case series. Translational Sports Medicine, 3(4), 342-352.

Wernbom, M., & Aagaard, P. (2020). Muscle fibre activation and fatigue with low‐load blood flow restricted resistance exercise—An integrative physiology review. Acta Physiologica, 228(1), e13302.

For contact sport athletes, a common injury which is prevalent is an injury to the Medial Collateral Ligament (MCL) of the knee. As a diagnostic and rehabilitation professional, it is important to understand the mechanics of the anatomy of the MCL in order to accurately diagnose the injury and the recondition an athlete back to their full performance capacity. The purpose of this blog will be to outline the epidemiology of isolated high grade MCL injuries; differential diagnosis and the rehabilitation process from Protection to Return to Performance utilising a systems based approach that can be applied to multiple knee pathologies.

Anatomy & Function of the MCL

Crucially it is important to understand that the MCL is composed of two distinct bands that allow it to perform its anatomical role. These are known as the Superficial MCL (sMCL) and the Deep MCL (dMCL). The superficial and deep ligaments each have a unique function, making the MCL the primary responder to valgus stress and a secondary restraint to rotational forces. The sMCL, specifically the proximal division, resists valgus forces through all degrees of knee flexion. The distal division of the sMCL helps stabilize external rotation of the knee at 30-degree flexion. The dMCL helps stabilize internal rotation of the knee from full extension through 90-degree flexion (Juneja et al 2022).

The sMCL has its proximal insertion at the medial epicondyle of the femur where it blends into the semimembranosus tendon. The distal attachment is at the posteromedial surface of the tibia. The dMCL is composed of 2 ligaments: meniscofemoral and meniscotibial. The meniscofemoral has its proximal insertion at the femur just distal to that of the sMCL; it attaches to the medial meniscus. The meniscotibial ligament is thicker and shorter. It travels from the medial meniscus to the distal edge of the articular cartilage of the medial tibial plateau (Juneja et al 2022).

Anatomy of the sMCL & dMCL
Figure 1: Anatomy of the sMCL & dMCL

Mechanisms of Injury: Contact vs Non Contact

When placed in a situation that an athlete has suffered an acute injury and pain to the medial aspect of their knee, it is important to decipher whether the primary mechanism of injury (MOI) is either contact or non contact. For isolated MCL injuries, ~80-90% of them come from a contact MOI whereby a Valgus stress occurs. In field / court based contact sports, due to the position of the knee and the force vectors, a combined flexion/valgus/external rotation injury is usually the end result. The vast majority of MCL injuries are from a direct blow to the outer aspect of the lower thigh or upper leg (Phisitkul et al 2006). The exception to this is in winter sport athletes such as skiiers who have high rotation loads when cutting and turning. In light of this, if an athlete is subject to a non contact MOI and presents with MCL laxity, a suspicion must be present for a concurrent ACL injury regardless of clinical testing results for the ACL itself.

 

Immediate Assessment & Management

When determining the grading of an isolated MCL injury, there is a wide variety of presentations that a clinician can be faced with. Particularly important is the athletes natural level of laxity and thus stress test comparisons with the non injured limb is critical to providing an accurate assessment. Gradings for an injury to the MCL can be defined as the following:

Grade 1 - Pain on stress testing at 0 & / or 30 degrees with nil significant laxity in comparison to the contralateral limb

Grade 2 - Pain on stress testing 0 & / or 30 degrees with comparable laxity in comparison to the contralateral and a presence of a ligamentous end feel

Grade 3 - Pain or no pain on stress testing 0 & / or 30 degrees with significant laxity in comparison to the contralateral and no end feel.

Palpation is an important tool in conjunction with radiographic imaging in determining whether the injury has been sustained to either of the: Femoral component; mid belly MCL or Tibial component of the ligament. Prognosis can differ with slower recoveries indicated for injuries to the tibial insertion of the MCL due to it's thinner anatomical insertion

Cadaveric model of the anatomy of the sMCL
Figure 2: Cadaveric model of the anatomy of the sMCL

As this blog is dedicated towards a high grade injury, when a grade 2 and above injury is suspected, the clinician should place the athlete in a hinged knee brace restricting the athlete from end ranges of extension and flexion that place higher strain on the MCL (Vosoughi et al 2021). Conjecture exists surrounding the natural history and recommendations for bracing, there are no set rules on how long an athlete should be braced for and a principle that I like to live by is that an athlete will remain braced until the ligament stabilises. An example 6 week bracing progression is listed below

Weeks 1 & 2: 30 - 60 degrees
Week 3: 20 - 70 degrees
Week 4: 10 - 80 degrees
Week 5: 0 - 90 degrees
Week 6: 0 - 120 degrees
Week 7: Brace off

Importantly, a clinician should not regularly assess healing of the MCL as this may disrupt fibres that are attempting to scar and realign. Personally I re-assess the MCL at the week 4 mark after initial collagen has had time to be laid and then at 2 week intervals until it has stiffened up to the comparable marker of the contralateral limb.

*A clinical observation I have made is that assessment at 0 degrees of extension stabilises and reduces in irritability far faster than at 30 degrees of flexion.

 

Radiography: What value can it add?

Radiographic Stress X Ray Assessment of the MCL
Figure 3: Radiographic Stress X Ray Assessment of the MCL

As mentioned above, radiography can assist with a clinical diagnoses in many ways:

  1. In the presence of non contact injury confirm Dx for concomitant pathology

  2. Confirm clinical grading of MCL injury

  3. Confirm location of MCL injury

Different methods of radiographical assessment exist, namely through the form of valgus stress x rays or MRI. I havn't come across a scenario where valgus stress x rays are practical so in that space MRI imaging should be ordered.

MRI imaging of a High Grade Injury to the Tibial Portion of the sMCL
Figure 4: MRI imaging of a High Grade Injury to the Tibial Portion of the sMCL

Rehabilitation Planning:

Importantly, part of my process for any long term rehabilitation planning is to map out the projected journey from start to finish and break it down into our 5 phases of rehabilitation that we utilise at Athletes Authority.

The 5 stages of Athletic Rehabilitation at Athletes Authority
Figure 5: The 5 stages of Athletic Rehabilitation at Athletes Authority

By detailing the rehabilitation plan it allows myself as the clinician to be targeted and objective my staged progression as well as giving the athlete context to each mini progression and goal that we tick off along the way. Below is an example of a full detailed rehabilitation plan for a high grade isolated MCL injury.

Example G3 MCL Rehabilitation Plan
Figure 6: Example G3 MCL Rehabilitation Plan

Important key themes within the progression of the rehabilitation plan include the restoration of physiology in the Protection phase. Development of base strength capacity in the Load Introduction phase. Restoration of plyometric capacity, particularly within the frontal plane in the Strength Accumulation phase; in tandem with return to run. Late stage return to contact and skill demands in the Training Integration & Return to Performance phase.

Following on from this macro rehabilitation plan, I then look to design integrated training weeks with the athlete in the form of a micro weekly rehabilitation plan. This allows for appropriate measures of load monitoring and session timing when designing a program that encompasses for local tissue restoration; full body strength capacity & cardiovascular reconditioning.

Example Weekly Micro Planning Sheet
Figure 7: Example Weekly Micro Planning Sheet

Whilst giving complete insight into an athletes full journey is impractical deliver on a blog, below I will outline some key training program progressions that could be utilised in different phases of the rehab journey.

Protection Phase:

Protection Phase
Figure 8: Protection Phase

Within the protection phase, our primary focus is to facilitate an environment that allows the MCL to gain strong foundations of anatomical healing and scar formation. First and foremost ensuring that the hinged ROM brace provided to the athlete is fitted correctly and that compliance is maintained to wearing the brace is priority number 1. I have experienced scenarios in the past whereby I felt my rehabilitation planning and implementation was incredibly spot on however once we got to clinical re-assessment date it came to my surprise that there was still significant laxity in the ligament. Upon further questioning I would then discover compliance with the brace had deteriorated because the athlete felt it was impacting their ability to perform their rehabilitation. Ironically, this desire to improve their rehab became their downfall. An important lesson for me to learn and a reminder that in rehabilitation, the basic principles of tissue healing come before those of strength & conditioning restoration.

With this in mind, second order principles are the following:

  1. Reduction of pain & swelling

  2. Re-activation of Quadriceps

  3. Maintenance of Hamstring, Calf & Foot strength

  4. Development of single leg stance and lateral hip rotation control

  5. Energy Expenditure

 

Reduction of pain & swelling:

Despite a lack of concrete evidence existing for the efficacy of cryotherapy against reduction in localised inflammation post injury, there remains a strong level of evidence for the use of cryotherapy in the improvement of function post severe trauma to the knee (Dambros et al 2012). My preference in clinic is to utilise Game ready protocols of 30 minute sessions whenever the athlete is in the facility, before and after they perform their rehabilitation. Analgesic effects provided from cryotherapy can reduce arthrogenic muscle inhibition (Rice et al 2009) as well as providing improvements in joint range of motion (Dambros et al 2012, Rice et al 2009). For maintenance at home, I would provide a compression sleeve for the athlete to wear in conjunction with regular icing whenever they are sedentary at home.

Amongst passive protocols, it is important for an athlete to maintain an active approach to this process. Utilisation of the skeletal muscle pump in the lower limbs can be an effective way of clearing fluid, particularly as in the instance of a high grade injury and that the MCL is an extracapsular structure, swelling may pool well below the knee into the calf and ankle.

Simple protocols such as ankle pumps can be scaled effectively to an athlete wearing a brace, can be done anywhere and place no undesired load onto the healing MCL.

Video 1: Ankle Pump Example (No Brace Worn)

Re-activation of Quadriceps:

Acute trauma and associated joint swelling are key contributors to arthrogenic muscle inhibition of the quadriceps. AMI is caused by a change in the discharge of articular sensory receptors whilst the importance of the quadriceps to overall knee function surrounds the relationship between skeletal muscle and their role in providing shock absorption towards articular joints (Suzuki et al 2022).

Key principles are to develop quadriceps strength within the allowances that the hinged ROM brace provides to the athlete. A high variability in athlete function can exist within this population and it is important to achieve a stimulus that is great enough to overcome aforementioned AMI and redevelop quadriceps capacity. Having a continuum of early stage exercise progressions is critical in being able to apply the appropriate progressions towards the athlete in front of you. Below are some examples of protection phase quadricep focused options that you may utilise with an athlete.

Protection Phase Quadricep Based Exercise Options
Figure 9: Protection Phase Quadricep Based Exercise Options

Below are three examples of early stage protection phase quadricep exercises. I normally combine all of these with NMES and BFR for increased neural drive and metabolic stress production.

Video 2: Inner Range Quadriceps Contraction (pictured with no brace)
Video 3: Banded TKE to A Frame (Pictured with no brace)
Video 4: Swiss Ball Leg Extension Isometric Push

Maintenance of Hamstring, Calf & Foot Strength:

Whilst quadriceps are the key priority in the early stages of rehabilitation, the importance of the hamstrings, calves and feet are paramount in ensuring optimal functional rehabilitation once an athlete enters a more integrated pattern of movement demands. As discussed in a previous blog (https://www.sportsrehab.physio/post/failure-of-hamstring-graft-aclr-part-1-the-role-of-eccentric-strength); the hamstrings play an intricate role in the protection of knee health, whilst the calf and feet are gaining increased attention due to it's role in force production, absorption & neuromuscular control when running (Bohm et al 2021).

A consideration for the rehabilitation professional when it comes to hamstring exercise prescription is the interrelationship between the MCL and the insertion of the distal hamstrings at the pes anserinus (Vosoughi et al 2021). During knee joint flexion, the semimembranosus muscle contracts and tightens the posteromedial knee capsule and the POL. It also pulls the medial meniscus posteriorly and prevents the anterior subluxation of the tibia. Another important role of the semimembranosus muscle is internal rotation of the tibia (Vosoughi et al 2021). Matching this with literature suggesting that exercises such as lying leg curls may preferentially activate the medial hamstrings in comparison to the lateral hamstrings (Bourne et al 2017) the rehabilitation professional should monitor with caution patient responses to traditional concentric based hamstring exercises.

Posteriomedial Corner Anatomy
Figure 10: Posteriomedial Corner Anatomy

With this anatomical consideration in mind, my hamstring based progressions typically are centred around the projected load that I believe will be placed on the posteriomedial corner (PMC) of the knee. Below is an example exercise progression based around this concept with some notes on progression of exercise options. It is important to note that progressive overload should be kept front and centre in mind as the athlete recovers and we can utilise increased loading and volumes in conjunction with more challenging exercise progressions

Protection Phase Hamstring Exercise Progressions
Figure 11: Protection Phase Hamstring Exercise Progressions

When evaluating options for the foot and calf, my focus is on increasing the force production of the Gastrocnemius and Soleus musculature whilst improving the proprioceptive capacity of the foot intrinsics, extrinsics and ankle stabilisers. As stated above, options should be scaled to the athletes level of competency and function whilst what also should be kept in mind is that they will be bound to the ROM restrictions of a brace so expectations should be that particularly for calf based options that the soleus will end up with greater loading than the gastrocnemius in this phase of rehab.

Below are some examples of accessory foot and calf options that I typically prescribe:

Accessory Foot & Calf Exercise Options
Figure 12: Accessory Foot & Calf Exercise Options
Video 5: Seated Arch Doming

Development of Single Leg Stance & Lateral Hip Control

An area I wouldn't place a large deal of emphasis on early however is pivotal during the back end of protection and during the load introduction phase. Primary reasoning for me behind not placing it as a priority (at least in functional positions) early in rehab is due to the fact that the athlete will be stuck in a position of mini knee flexion and thus prolonged time loading in single leg stance may lead to overload of the patellofemoral joint. Nevertheless an example stream that may assist in the development of the lateral hip has been placed below for consideration.

Example Accessory Lateral Hip Options
Figure 13: Example Accessory Lateral Hip Options

Energy Expenditure:

One of the biggest issues that athletes face when they are compromised of their usual training routine is that metabolically they face an imbalance of calorie in and calorie out energy expenditure. Whilst the purpose of this blog is not to discuss the ins and outs of energy intake requirements during rehabilitation (which is generally higher to support tissue healing) and that certain supplementation may assist in recovery (I'll leave this to my Dietitian friends), when an athlete suddenly loses their greatest contribution of energy output in their team training it can be useful to substitute this with off leg conditioning options.

Something I find important to stress is that particularly in the early stages of rehabilitation when an athlete is completely leg compromised when it comes to cardio training options, we shouldn't expect much development when it comes to higher end aerobic adaptation due to the inability for the athlete to reach Vo2 Max when it comes to upper body only cardiovascular training. In this light I like to keep Intervals short, Intensities high and recovery low.

A sample session I like to utilise is very simply a 20/10 Tabata interval session x 8-10 reps x 2-4 sets at the end of an athletes strength training session. Similarly, placing time caps on an athletes strength component of their sessions can increase overall metabolic output through decreasing rest periods between sets.

 

Load Introduction Phase:

Load Intro Phase Mapping
Figure 14: Load Intro Phase Mapping

With solid foundations laid in the Protection Phase, my key foci in the Load Introduction Phase are namely to increase the intensity of the strength training that has been established in the protection phase; increase ROM allowances and transition the athlete towards more functional, unilateral training and most importantly; introduce plyometric and modified surface running demand.

When it comes to progressing an athlete in quad dominant lifting exercises, my preference is to transition athletes from Bilateral --> Unilateral Oriented --> Unilateral progressions. Namely due to the demands that unilateral closed chain training places on valgus control on the knee. Hypothesising decreased proprioceptive control during the initial stages post healing, it makes sense to me to develop proficiency with an increased base of support prior to moving on to true unilateral streams.

As the athlete shifts into more functional lifting, combination cueing can be utilised such as medially banding split squats to further constrain the athlete and force greater deep gluteal external rotation and abduction activation to prevent valgus force on the knee.

MCL Quad Dominant Progressions
Figure 15: MCL Quad Dominant Progressions

Developing a Performance Profile

Once an athlete has full terminal extension, nil effusion, a solid end feel on clinical testing and 80% quadricep, hamstring and calf strength capacity; this is enough for me to commence low amplitude plyometrics.

Assessment procedures I utilise are via the VALD Performance Dynamo for quadricep testing, VALD Performance Nordbord & Forcedecks for Hamstring testing as seen in a seperate blog (https://www.sportsrehab.physio/post/assessment-of-hamstring-strength-post-aclr) and a combination of VALD Performance ForceFrame & ForceDecks for maximal straight knee and bent knee calf torque. These maximal torque tests are performed in conjunction with capacity based endurance testing of single leg squats, single leg foot elevated hip bridges and single leg straight knee & seated calf raises.

When creating a velocity profile for the athlete, I believe it is important to get an idea on how an athlete produces force both bilaterally and unilaterally as well as in horizontal and vertical vectors. This is largely centred around the altering contribution of the hip, knee and ankle in the propulsion and landing phases of both horizontal and vertical jump tasks (Kotsifaki et al 2021; Kotsifaki et al 2022).

A full list of assessments that I utilise to begin my performance profiling in the load introduction phase is displayed below:

Load Intro MCL Performance Profile Testing
Figure 16: Load Intro MCL Performance Profile Testing

Redeveloping Plyometric Capacity:

As an introduction to low amplitude plyometrics, similarly to my strength progressions I progress the athletes from Bilateral --> Unilateral Oriented --> Unilateral Tasks. I find Pogo jumps to be incredibly versatile in this space and an excellent precursor to shifting athletes towards more specific skipping based drills which are effective in promoting the 'bounce' component of the Max Velocity phase that we want to see in an athletes running.

Below are some examples of progressions from bilateral to unilateral low amplitude plyometrics:

Video 6: Low Amplitude Pogo Jumps
Video 7: Low Amplitude Ankle Skips
Video 8: Single Leg Pogo Hop

One important bug bear of mine to note is that when I see athletes performing pogo variations, a common error I see is far too much knee flexion when the athlete hits the ground. This is not only inefficient in the sense of increasing ground contact time and shifting energy up the kinetic chain, it can also lead to overload of the PFJt. When prescribing pogo jumps, the objective is to gain maximal output from the calf-achilles complex and thus cueing strong active dorsiflexion when in the air, plantarflexion to hit the ground hard and maintain stiff knees is critical.

In addition to low amplitude plyos, I believe in the Load Introduction Phase we can also expose the athlete to a good base of eccentric absorption type plyometric progressions to assist in increasing the athletes eccentric rate of force development (RFD) in their quadriceps. Tall to Short and Altitude Landing variations are my preferred go to in this space, however I find that we as professionals typically under load these exercises. My objective is to progress athletes towards loading these with dumbbells and eventually a heavy trap bar in hand

Video 9: Tall to Short - Single Leg
Video 10: Tall to Short - Loaded
Video 11: Tall to Short - Single Leg Loaded

Restoration of Gait Mechanics:

When it comes to restoring an athletes gait mechanics prior to returning to run, I follow a very simple model of stepped progression. This is based around certain positions of athletic movement and then broken into different stages of complexity and intensity.

The athletic positions I place emphasis on are the:

  1. Acceleration Position

  2. Max Velocity Position

  3. Frontal Plane / Lateral Position

Position Based Reconditioning
Figure 17: Position Based Reconditioning

Selection of emphasis for these particular positions to train varies pending the injury in question. For an MCL I will place greater scrutiny on the Frontal / Lateral plane position and then look to identify which out of Acceleration & Max Velocity positions that the athlete is at their weakest.

Once a position has been selected then the next stage in the development of drills is to identify at what stage of complexity and intensity the athlete can comfortably manage. For me I break this down into 4 stages:

  1. Positional Sense Drills

  2. Walking Drills

  3. Low Amplitude Drills

  4. High Amplitude Drills

Competency / Tolerance Continuum
Figure 18: Competency / Tolerance Continuum

Below are some examples of some drills that I may utilise in the Load Introduction Phase with an athlete:

Video 12: Walking Frontal Plane Option - mBand Push to Base
Video 13: Walking Acceleration Option - Sled March

Role of Alter G Running:

I believe where available, anti gravity treadmill running can have a significant role to play both physically and psychologically in the transition from gym based rehabilitation to field based running. In contrast to more longer term rehabilitation such as ACL rehab, in the context of MCL reconditioning I am happy to start at a relatively higher % of body mass (%BM) and to allow the athlete to self select a comfortably jogging speed. Normally I would implement these sessions in the week after the athlete has had their brace removed and prior to them returning to running on the field. I like to see the athlete tick off 3 sessions with a ramped increase in %BM whilst leaving the other parameters consistent. A sample week of sessions could look like the following:

Session 1 --> 5 x 1 min Jog / 1 min Walk @ 80%BM
Session 2 --> 5 x 1 min Jog / 1 min Walk @ 90%BM
Session 3 --> 5 x 1 min Jog / 1 min Walk @ 100%BM

 
 

Integration Of ESD? Development of Aerobic Capacity

Whilst the focus in the Protection Phase when it came to cardiovascular training was largely centred around energy expenditure, development of Aerobic Capacity in the Load Introduction phase will create a framework for on legs conditioning when the athlete returns to running whilst also assisting to break up the monotony that strength training can sometimes give. Prior to an athlete achieving a great enough level of knee flexion that can facilitate Watt Bike conditioning, I will steer towards the ski erg and cue the athlete for a more hinge dominant pulling pattern rather than a squat based pulling pattern. Additional cues for the athlete during these sessions is to focus on consistency of stroke rate and breathing rather than aiming to pull as hard and fast as they can. A sample session which I might prescribe on the ski erg is the following:

Ski Erg Session Sample - 5 x 5 mins @ 75%RPE / 1 min Passive Recovery (PR)

Once an athlete is able to perform Watt Bike based conditioning I will get a measurement of the athletes Maximal Minute Power (MMP) so that I can utilise accurate intensity targets. A sample Watt Bike session is as follows

Watt Bike Session Sample - 5 x 4 mins @ 70% MMP / 2 mins @ 55% MMP

When it comes to weekly prescription, you really need to get a gauge of your athlete as to how much they can commit to their reconditioning program, particularly in amateur and semi professional settings. In these instances I'll aim for ~1-2 sessions per week whilst for the professional athlete I'd aim for ~2-3 sessions per week.

An example Load Introduction Microcycle could look like the following:

Figure 19: Load Introduction Phase Microcycle Plan

Within the above plan we allow for the following sessions

  1. 3 x High Day Strength Sessions

  2. 3 x Alter G Sessions

  3. 0-4 x Low Day Rehab Sessions

  4. 1-2 x Off Feet Conditioning Sessions

Weekly planning in my opinion has to be completely individualised, as for many factors certain athletes may be able to dedicate and tolerate more or less than others. In light of this there are no rules in this space and session prioritisation has the utmost importance attached to it in environments where athletes can perform limited sessions

 

Strength Accumulation Phase:

The primary focus that I want to place emphasis on in the Strength Accumulation phase is the athletes return to running as this certainly a cap in the sports rehabilitation field that I feel is present, particularly in the private sector.

In the context of an MCL injury, the demands of running will increase quickly and I'll aim to develop the following in order:

Target 1 - Volume Tolerance
Target 2 - Speed + Planned COD
Target 3 - Unplanned COD (+ Consolidation of the above)

Usually I will aim for ~2 sessions per week and a rough starting point I like to shoot for is 1000m volume for the athletes first running session and then bumping this up to ~40-50% match volume in session two.

In the initial return to run (RTR) week, the volume that the athlete achieves will not produce any great metabolic or speed producing effects, thus the rehab professional should ensure that the athletes technical drilling is performed exceptionally well to ensure that they gain the most out of each session. In terms of linear based running drills these can be broken down into the following focus

  1. Cycle - Developing the cyclical action of the lower limbs

  2. Switch - Developing the ability to switch limbs in the air

  3. Bounce - Promoting a strong yielding capacity of the lower limbs to 'bounce' off the ground.

An example of technical drills in each stream are included below:

Video 14: Cycle - Wall Drill
Video 14: Switch - A-Skip
Video 15: Bounce - Ankle Dribble

Looking at Speed Development in a short time frame, my experience has yielded greatest results when utilising a 'Short to Long' approach starting at higher running intensities rather than the reverse gradually developing the athletes running speed. This approach places a heavy emphasis on an athletes acceleration mechanics & capacity which is a heavily relied upon trait in field sports whilst also reducing the risk of over exposure to high speed run metres HSRm as it limits the athlete from opening up and moving faster than they should.

Resisted accelerations through the form of banded and sled runs can assist the athlete in being exposed to a strong forward lean position whilst also providing a constraint to increase force production.

Video 16: Band Resisted Acceleration Run

As the athlete begins to open up to higher speeds, from both a technical and speed management perspective I like to implement 'Wicket' style drills for the promotion of strong front side mechanics as well as ensuring athletes do not move too quickly or over stride, this allows the rehabilitation professional to create as much of. a 'vacuum' environment as possible.

Video 17: Wicket Drill

Speed & Agility Progression

When approaching speed progression in rehabilitation via a short to long approach, the objective is to allow the athlete to reach 100% max velocity over a short distance and gradually build their exposure at 100% max velocity over time. In light of this, there may be many 'sub-levels' within the initial stages of speed exposure in order to build an athlete to 100% of their max velocity. A sample speed progression could look like the following:

Stage 1 - 40m Efforts (10m Build - 20m Hold - 10m Decel) [Build from 80-100% MSS}
Stage 2 - 50m Efforts (10m Build - 30m Hold - 10m Decel) [Build from 90-100% MSS}
Stage 3 - 60m Efforts (20m Build - 20m Build - 20m Hold) @ 95%, 100%, 100% MSS

When looking to recondition an athletes change of direction capacity, consideration needs to be made towards the following variables:

  1. Tissue implicated by injury

  2. Sub-Capacities of COD

  3. Degree of COD

  4. Planned vs Unplanned

I personally really like to hone my focus on developing the sub-capacities of change of direction prior to implementing a COD task on the athlete. When looking at this I break down a single COD moment into involvement an acceleration moment, a deceleration moment, pre-cut strategy, cutting moment and finally a re-acceleration.

Change of Direction Moment Breakdown
Figure 21 - Change of Direction Moment Breakdown

With this in mind, being aware that we have already dedicated a stream to developing acceleration and speed; my primary key focus is to develop an athletes ability to decelerate prior to asking them to cut. To develop deceleration I'll combine both over exertion type drills such as loaded deceleration lunges to develop the athletes ability to eccentrically control their COM via their quads with drills such as planned decel stop runs to instil the behaviour of dropping their COM and shortening their stride prior to stopping (and eventually cutting).

Once I'm confident in my athletes ability to linearly decelerate, then I'll aim to introduce some planned swerving tasks to improve their ability to control rotation at the hips and torso whilst introducing light planned sagittal to frontal cuts in the form of box based drills

Video 18: Box Drill 5x5m Facing Up

The advantage of a sagittal to frontal plane transition is that it forces the athlete in question to develop push off power from their outside leg, which is a precursor to being able to produce an effective sidestep cutting strategy. Common errors I see in 45 and 60 degree cuts is athletes attempting to swerve and using a crossover step strategy to complete the cut. Whilst this is effective from a safety perspective, I don't personally believe it is practical to expect this to carry over to their return to match play.

Progressing past box drills, this is where my focus will shift to the prescription of <90 degree cuts, with the aim of carrying over the body positioning, lateral pushing power and deceleration strategy into these more dynamic and faster paced cuts. Example drills that you can utilise are 'Z' runs and 'Y' drills.

Video 19: Z Drill
Video 20: Y Drill

The primary difference between a cut that is <90 degrees in comparison to a cut that is >90 degrees is in the selection of the cut foot. In <90 degree cuts the most effective cut strategy is to load the outside leg through a sidestep type strategy, whilst for those >90 degree the body position strategy should shift to the athletes bodyweight onto their inside leg to project towards the intended direction of cut. An example of a >90 degree cut drill is displayed below:

Video 21: M Drill

Adding elements of reactivity to both styles of cutting tasks can increase the complexity of the drill. If i'm structuring a session there are three ways I look to prescribe COD drills.

  1. Planned COD (Max Quality)

  2. Planned COD (Metabolic Focus)

  3. Reactive COD (Max Quality)

 

Plyometric Focus

When it comes to progressing plyometrics from low amplitude and eccentric absorption progressions, focus shifts towards increasing the amplitude of jumps and hops, decreasing ground contact times and integration of lateral and rotational plyometrics.

Simple vector plyometrics are best utilised for improving rate of force development whilst more complex variations such as lateral and rotational options are best for exposing the athlete to increased proprioceptive demands.

Video 22: Box Jump (Concentric Development)
Video 23: Hop - Lateral mHDL Inside Edge (Jump Integration)
Video 24: Hop - Horizontal DC mHDL (Continuous Jumps)

The use of a double contact between a continuous jump / hop can be a useful stepping stone in order to dissipate the pressure that comes from each land and allow the athlete to re-organise themselves prior to the next hop.

Importantly, as running demands begin to increase; adequately prescribing more intensive plyos is critical in active load management for the athlete. I typically try to leave one session per week dedicated to intensive plyometrics (Jump Integration & beyond).

 

Performance Profiling

In addition to the aforementioned profiling battery listed above in the load introduction phase. Emphasis shifts towards measures of reactive strength index and thus the main additions into my testing battery include:

  1. Triple Hop

  2. Triple Crossover Hop

  3. Timed 40/30 Lateral Hop

  4. Drop Jump

  5. Single Leg Drop Jump

When it comes to benchmarking for these tests, a reasonable starting place is to aim for 90% limb symmetry index on all single leg tests whilst I additionally set the following targets:

Single Leg Hop:
Males >80% the athletes height
Females >70% the athletes height

Timed 40/30
Males >50 hops in 30 seconds
Females >45 hops in 30 seconds

Drop Jump RSI
Males > 2.5
Females >2

Single Leg Drop Jump RSI
Males >1.5
Females >1.25

 

Training Integration & Return to Performance Phase:

Figure 22: Training Integration & Return to Performance Mapping

Once an athlete reaches the training integration phase, majority of the cogs should be in place when it comes to their physical preparation training in the gym and on the field. In this stage of rehabilitation, the focus and key communication with coaching staff should be around an athletes return to skill exposure, contact and transitioning back to match play.

Figure 23: Return to Contact Guidelines

When it comes to return to contact for athletes, the design of specific drills needs to be individual to an athletes sport in order to yield the greatest gains from a physical and psychological perspective. With this considered, I like to break my drill design down by intensity and position that the athlete is going to be in and then design different categories based upon the athletes sport. Above is an example of a 6 stage return to contact continuum that can be integrated in an athletes session.

 

Role of PROMs

An under utilised component of assessment in athlete recovery is the utilisation of PROMs throughout a rehab journey. When it comes to knee rehabilitation, I believe a simple IKDC is easy to use and will give the practitioner an insight into the athletes knee health during ADLs

 

Conclusion:

The utilisation of a systems based approach allows a practitioner to be objective, stepped and planned with each stage of an athletes recovery. High grade MCL tears can represent a difficult rehabilitation in the amateur and semi professional space as there are many boxes that need to be ticked both clinically and athletically to ensure an athlete experiences a successful return to performance. Consideration of the mechanism of injury, and the anatomy of the MCL is important to early stage programming, whilst knowledge of integrated athlete programming can help to ensure optimal physical preparation. The above journey is a very non exhaustive list of options in regards to training drills, athlete planning and performance profiling, each athlete must be treated as an individual however I hope there are some takeaways that can be implemented in daily practice. At the very least I hope this blog has gotten you thinking about how your planning process works in the rehabilitation of sporting injuries.

Justin Richardson

www.sportsrehab.physio
www.athletesauthority.com.au

 


References:

Phisitkul, P., James, S. L., Wolf, B. R., & Amendola, A. (2006). MCL injuries of the knee: current concepts review. The Iowa orthopaedic journal, 26, 77–90.

Vosoughi, F., Rezaei Dogahe, R., Nuri, A., Ayati Firoozabadi, M., & Mortazavi, J. (2021). Medial Collateral Ligament Injury of the Knee: A Review on Current Concept and Management. The archives of bone and joint surgery, 9(3), 255–262. https://doi.org/10.22038/abjs.2021.48458.2401

Dambros, C., Martimbianco, A. L., Polachini, L. O., Lahoz, G. L., Chamlian, T. R., & Cohen, M. (2012). Effectiveness of cryotherapy after anterior cruciate ligament reconstruction. Acta ortopedica brasileira, 20(5), 285–290. https://doi.org/10.1590/S1413-78522012000500008

Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010 Dec;40(3):250-66. doi: 10.1016/j.semarthrit.2009.10.001. Epub 2009 Dec 2. PMID: 19954822.

Sebastian Bohm, Falk Mersmann, Alessandro Santuz, Arno Schroll, Adamantios Arampatzis (2021) Muscle-specific economy of force generation and efficiency of work production during human running eLife 10:e67182 https://doi.org/10.7554/eLife.67182

Kotsifaki A, Van Rossom S, Whiteley R, et al
Single leg vertical jump performance identifies knee function deficits at return to sport after ACL reconstruction in male athletes
British Journal of Sports Medicine 2022;56:490-498.

Kotsifaki, A., Korakakis, V., Graham-Smith, P., Sideris, V., & Whiteley, R. (2021). Vertical and Horizontal Hop Performance: Contributions of the Hip, Knee, and Ankle. Sports health, 13(2), 128–135. https://doi.org/10.1177/1941738120976363

Juneja, P., & Hubbard, J. B. (2022). Anatomy, Bony Pelvis and Lower Limb, Knee Medial Collateral Ligament. In StatPearls. StatPearls Publishing.

Endurance sport is one of the greatest tests of mental and physical toughness. During a marathon an athlete, on average, will complete 160-200 steps per minute. Whilst running has numerous benefits for our health and wellbeing, it can be monotonous loading on the skeletal system. Bony stress injuries account for up to 20% of running related injuries per year. It is believed that one reason for this is the repetitive overloading on runners’ bones. In comparison, activities involving irregular movements seem to foster greater bone health. The ultimate goal should always be injury prevention, so, should runners incorporate directional movements into their training repertoire for bone health?

Bone is an alive, adaptable, and dynamic structure. Our bone density increases as we grow and by 30 our density is at its peak. After this age we can only maintain what we have. Bone health refers to our bones’ mineral density and quality and is the result of a plethora of factors. In otherwise healthy runners, energy availability, biomechanics, training load and recovery, all play important roles in creating good bone health. Poor bone health can increase the risk of fractures during one’s developmental years and later in life.

There are two main theories that address the way in which our bones are loaded during running. The muscle-bone unit theory refers to the pulling forces created by a muscular contraction. The other references the ground reaction forces through bone when the foot contacts the ground, producing torsional and compressive load. Both mechanisms create macro-trauma which stimulates tissue production and shapes bones geometric structure. However, like other tissues in the body, the activity needs to be progressive otherwise the bone may become accustom and stop adapting. These principles may be used to help runners who may otherwise be stunting adaptation through habitual running load.

In general runners’ bones are healthier than sedentary people. Unfortunately, runners consistently demonstrate lower bone mineral density (BMD) when compared to matched individuals who partake in high impact and irregular movement based sports. A summary of the research of athletes (aged 14-30) found soccer, basketball and volleyball players as well as gymnasts, all displayed greater BMD than those who only ran. A study of young soccer players demonstrated that female players had healthier tibiae than runners and both genders had better density at the spine, femur and calcaneus. In separate studies of track athletes and infantry recruits those who also regularly participated in basketball had up to an 82% reduction in stress fracture risk. Interestingly, in masters athletes those who participated in sprinting had greater BMD than their peers who competed in long distance running. The benefits of diverse loading in youth were also found to protect runners later in life with some up to 50% less likely to sustain a stress fracture.

What seems to be more unclear is the ideal dosage for bony loading. Bone regeneration cycles are suggested to take 3-8months. Studies of humans, mice and turkeys found significant changes after as little as 3 weeks of a jump program. Repetition amount also widely varied between studies from 30 - 350 cycles per week. A study of adolescent females found that a 9-month plyometric program improved only greater trochanter bone strength. Another found plyometric training only benefited those who participated in low osteogenic sports such as swimming. Studies on structure found that rate, magnitude and activity resulted in site specific changes, however, no optimal values for load were presented. No well-known study was found to investigate an irregular, directional and high impact, loading program for the reduction of fracture risk in endurance runners.

It is important to note there are many other factors which influence bone health that have not been explored here. The body needs a plentiful supply of vitamin D and Calcium to build strong bone. To create an optimal environment for this rest and good sleep are also essential. For distance runners who are constantly in a state of low energy availability, bone loading has been found to have little strengthening effects and can be somewhat detrimental if added in addition to their normal training.

Runners want to run. Convincing them to do otherwise continues to remain a great challenge for clinicians, however, it would seem that some variety may strengthen their bones. Youth runners should be encouraged to participate in a variety of sports. Once specialisation occurs, a runner may benefit from incorporating direction and plyometric loading into their training. Unfortunately, the optimal dosage for this is largely unknown.

References

Beck, B. R., Daly, R. M., Singh, M. A. F., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. Journal of Science and Medicine in Sport, 20(5), 438-445.
Gómez Bruton, A., Matute-Llorente, Á., González-Agüero, A., Casajus, J., & Vicente-Rodríguez, G. (2017). Plyometric exercise and bone health in children and adolescents: a systematic review.
Gómez-Cabello, A., Ara, I., González-Agüero, A., Casajús, J. A., & Vicente-Rodríguez, G. (2012). Effects of training on bone mass in older adults: a systematic review. Sports Med, 42(4), 301-325.
Hart, N. H., Nimphius, S., Rantalainen, T., Ireland, A., Siafarikas, A., & Newton, R. U. (2017). Mechanical basis of bone strength: influence of bone material, bone structure and muscle action. Journal of musculoskeletal & neuronal interactions, 17(3), 114-139.
Hong, A. R., & Kim, S. W. (2018). Effects of Resistance Exercise on Bone Health. Endocrinology and metabolism (Seoul, Korea), 33(4), 435-444. doi:10.3803/EnM.2018.33.4.435
Kato, T., Terashima, T., Yamashita, T., Hatanaka, Y., Honda, A., & Umemura, Y. (2006). Effect of low-repetition jump training on bone mineral density in young women. Journal of Applied Physiology, 100(3), 839-843.
Nattiv, A. (2000). Stress fractures and bone health in track and field athletes. J Sci Med Sport, 3(3), 268-279.
Scofield, K. L., & Hecht, S. (2012). Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep, 11(6), 328-334.
Tenforde, A. S., & Fredericson, M. (2011). Influence of sports participation on bone health in the young athlete: a review of the literature. Pm r, 3(9), 861-867.
Tenforde, A. S., Sainani, K. L., Carter Sayres, L., Milgrom, C., & Fredericson, M. (2015). Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes. Pm r, 7(2), 222-225.
Vlachopoulos, D., Barker, A. R., Ubago-Guisado, E., Williams, C. A., & Gracia-Marco, L. (2018). The effect of a high-impact jumping intervention on bone mass, bone stiffness and fitness parameters in adolescent athletes. Archives of osteoporosis, 13(1), 128-128.
Witzke, K., & Snow, C. (2000). Effects of plyometric jump training on bone mass in adolescent girls. Medicine and science in sports and exercise, 32, 1051-1057.
Wright, A. A., Taylor, J. B., Ford, K. R., Siska, L., & Smoliga, J. M. (2015). Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. British Journal of Sports Medicine, 49(23), 1517.

The dream for many sportspeople is to forge a long and successful career as a full-time professional athlete. However, only very few are lucky enough to experience this, and many more athletes across the world end up showcasing their talents as a part-time or semi-professional athlete.

Rather than having the luxury of dedicating most of their time to training and recovery, these athletes are required to work full time jobs (often labour intensive), and then attend training sessions at the end of a 10 hour work day, with training loads very similar to that of an elite athlete.

This obviously poses a massive challenge to the athlete. Having to try and fit in work, training, recovery, family time, social time and sleep all in the space of a 24 hour day.

Managing these athletes can also be a massive challenge for the sports physiotherapists helping them to rehabilitate their injuries and keeping them out on the park.

As we know, load management is an integral part of progressing through a rehabilitation plan, and also helping to reduce the risk of any niggles or injuries. Over the past few years, even with limited resources at semi professional sporting organisations, physios and S+C staff have become much better at monitoring and analysing player loads from a physical, mental and emotional perspective. However, this is where the real challenge lies in dealing with players who work physical jobs throughout the day. For example, take a player who has suffered a calf strain 10 days ago. We can’t expect a player to tell us exactly how many times he has gone up and down the ladder during his work day as an electrician, but should this be a consideration in how much running he does at training that night?

For the athlete playing at this level, at the end of the day, their paid work is a higher priority for the majority of them over their ability to play sport. This often means that rehabilitation from an injury is compromised or lengthened in time, due to the pressures of having to return to work and feed their families. Take the athlete who has had an ACL reconstruction, but also works as a carpenter. The athlete will be eager to return to full time work as soon as they get the all clear from their surgeon, but will being on their feet all day and repetitively squatting cause a knee effusion that will then hinder their ability to perform and progress their strength work?

As their sport might not be their number one priority in their lives as mentioned, training consistency can also be a challenge in dealing with players at this level. Work and family commitments can sometimes clash with training sessions, with missed training sessions affecting their training load for that week, and potentially increasing their risk of injury in the coming weeks.

The emotional toll that having to fit so much into one day can take on the athlete, is also a vital consideration as a sports physiotherapist at this level. We are in a great position as sports physiotherapists to chat to players to ask them how they are coping. Whilst strapping their ankle, we can gain a lot of information about whether or not the athlete has a rough day or period or time, and whether or not they should have a lighter night on the track to help not overload their nervous system.

Many challenges and questions have been posed above, but the number one question is what can we as sport physiotherapists do to help semi-professional athletes overcome these challenges?

In my opinion, the best thing we can do here is to educate our athletes as much as possible, and focus on the ‘big-ticket’ items to allow them to stay at their best for as long as possible.

The ‘big-ticket’ items for me are:

  • Sleep – As we know, sleep has been shown to be the most important recovery technique out there for athletes. Sleep is available to both professional and semi-professional athletes, so this has to be a priority.
  • Importance of communication – Empower and encourage the athletes to communicate with coaches, S+C staff and physios so we can better monitor how they are dealing with the challenges of being a semi-professional athlete.
  • Training consistency – Missing a 10km training session during the week and not making up for it, can often lead to an injury down the track from my experience. It is up to the S+C coach, physio and athlete to formulate a plan as to how to best make up for this session.

I am sure for those sport physiotherapists out there who work at this level with athletes, these are common challenges for you, along with many more that I have not mentioned. Because of these challenges, I find working with these athletes highly enjoyable and rewarding, and I hope you do too!

A big thank you to attendee Luke Nelson for doing a fantastic job in providing this educational summary of our recent course, The Advanced Upper Limb Rehab in Sport.

With a fair share of conferences covering injuries of the lower limb, the SportsMAP Advanced Upper Limb Rehab in Sport event provided a content rich weekend for those wishing to upskill in the management of shoulder, elbow and wrist injuries. Featuring some of the top clinicians in their field, the event did not fail to deliver, with the typical SportsMAP format of combining theory and practical sessions. This blog will present some of the key topics discussed throughout the weekend, and is by no means all the content covered over the 2 days!

Kicking the event off on Day 1 was Andrew McGough, Head Physiotherapist Diving Australia, with “The Sporting Shoulder”.

One of the recurring themes throughout the weekend was the importance of assessing the kinetic chain in athletes with injuries to the upper extremity: for a number of athletic actions (ie. throwing, hitting) the generation of force begins from the ground up. Neglecting to address issues further down the body may be the difference between failure and success in rehabilitating the athlete. Andrew used the case example of a 29 year old Strongman competitor with shoulder pain, who displayed poor trunk control.

“It must be realized that throwing is a whole body activity”

Andrew stressed the importance of both discussing with the athlete and then examining what they CAN and CAN’T do with their presenting complaint. “What can you do? Do that, What can’t you do? Modify that”

Examination of the throwing athlete

Physical examination of the athlete with shoulder pain should be comprehensive to address all potential contributions. This incorporates a full assessment of the kinetic chain. Andrew discussed some of the key tests that should form part of the examination

When assessing flexibility, some tests that should be performed include:

  • Shoulder IR/ER range: total range 180 degrees
  • Lat dorsi/pec minor length
  • Thoracic extension/rotation range
  • Cervical ROM
  • Combined elevation test: should be able to get above ears
  • Knee to wall test
  • Hamstring/hip flexor/glut length
  • Active straight leg raise
  • Hip IR range (especially on lead leg)

Neuromuscular tests

  • Rubber duck test: get the athlete to close their eyes, squeeze a squeaky rubber duck and get them to touch it
  • Closed kinetic chain test
  • Upper limb Y balance test
  • Single leg squat (especially ability to load into trail leg)

Strength testing

  • Single arm wall push up
  • Side plank hold L vs R
  • Glut bridge single leg
  • Front plank hold
  • Int/ext rot in neutral: performed in standing, 3:2 ratio
  • Resisted ext and int rotation: can test at different ranges of external/internal rotation
  • Testing push and pulls at different positions and ranges

Following assessment, Andrew then discussed the possible intervention and rehab options that are available.

Session 2 saw Kylie Holt, Senior Sports Physio Swimming Australia, present on her area of expertise: the swimmer’s shoulder. Swimmers shoulder is a highly prevalent condition, occurring in 70% of swimmers and with no decrease in incidence in the last 36 years.

Kylie firstly clarified some of the potential contributors to the “swimmer’s shoulder”, with a number of often cited causes shown to be lacking in evidence, or with evidence to the contrary:

  1. Absolute training volume: no studies linking absolute training volume
  2. Limitation of ranges specific to swimming (internal rotation >40deg), external rotation (>93, <100): no difference in range with those with pain in Swimming Australia 70 swimmers Holt et al 2017. Not predictive of pain. Those with less humeral torsion were the higher level performers. Relatively ante torted bilaterally, not greatly different from the general population but different from throwing population.
  3. Scapular dyskinesis: MacLaine 2018. Is important to assess. No necessarily strength related. Is dyskinesia secondary to pain?? Scapular upward rotation/ position is highly variable, don’t bother measuring just YES/NO
  4. Strength imbalance: Boettcher et al 2019 in press: average ratio 3:2 Int/Ext, those with pain often maintain ratio but decrease strength in both. NOT predictive of pain. Using manual muscle testing to assess tendon health & monitoring.
  5. Insufficient glenohumeral stability/laxity: vast majority of swimmers have laxity, but not classified as instability. They are just mobile. +ve sulcus sign in 82 of 84 (98%) shoulders examined. We want shoulder movement overhead, stop cueing down and back with shoulders.

Kylie then discussed her yet to be published research of the MRI imaging findings in 60 elite swimmers versus 22 aged matched controls.

Summary of the key findings from this study:

  • Tendinopathy is highly prevalent & major findings in swimmers
  • Anterior (subscap) and superior (supraspinatus) cuff affected equally: subscapularis (29.2% grade 3) and supraspinatus (30% grade 2) tendinopathic changes, with only 30% showing “normal” tendons in these regions
  • Biceps sheath effusion, labral pathology & lesser tubercle oedema not uncommon. 100% of all swimmers have swelling in the long head of biceps, leading to believe that this finding is “normal” in swimmers
  • AC joint pathology common
  • Subacromial bursa possibly less affected than thought: all subacromial bursa examined were within normal limits
  • Early phases of stroke most pain provoking
  • Single greatest predictor of tendinopathy in swimmers is years in squad training (especially for subscap tendinopathy).

Findings from this study are not consistent with an external impingement model: In the catch position the subscap is impinging with labrum, and the Supraspinatus is NOT in contact with the acromion. Subacromial external impingement probably less a factor than what previously thought, time for a new model?

"Swimmers Shoulder" Tendinopathy- Anterior superior internal impingement (ASII) and Posterior superior internal impingement (PSII)

  • Normal physiological internal contact in high degrees of elevation and internal rotation
  • Elite training volume potential to drive pathological response
  • Tendinopathy caused by mixed loading ie tensile, compressive & intra-substance shear
  • This ASII and PSII explains pathoanatomical findings ie subscapularis, biceps, supraspinatus & intra-articular changes

Things to keep in mind for management of the “Swimmers shoulder”:

  • Tendinosis is highly prevalent in swimmers
  • Changes in load therefore likely to be an issue (ACWR rather than absolute)
  • In many situations not a case of "here now- gone tomorrow"
  • Monitor and strengthen the muscle/tendon unit
  • Scapular upward rotation likely to be important
  • Avoid hyper elevated position where possible (ie. kickboard kicking, chin-ups)
  • Are bursal injections as necessary as once thought?

Keeping with the SportMAP mix of theory and practical, it was time to get moving with a breakout into practical workshops.

First up Bruce Rawson, Head Physiotherapist Australian Baseball, took attendees through a throwing rehab workshop. Attendees were fortunate to have former Major League Baseball player, Brad Harman assist in this workshop, giving his unique experience of playing in the majors.

Again reiterating what was taught in the earlier theory, attendees were reminded that throwing is

  • Whole body activity
  • Complex skill

Therefore, when presented with an injury in the throwing athlete, important to address the 2 above factors.

Fundamentals are important in throwing, and one must not overlook the grip in throwers: if this is not right, then everything else can follow. The correct grip on a ball is 2 fingers on top thumb UNDERNEATH. A common error seen in throwers is the thumb coming up near the index finger, which tends to create a sideways movement when throwing. It is also important to have a gap between the ball and hands

 

Other key aspects of throwing techniques examined in this workshop were:

  • Have the body is squared up side on to target
  • Step towards the target not off to the side.
  • Ensure that the arm does not winding back before lifting the front leg: they should be simultaneous to help with energy storage.
  • Follow through with the thumb down and across the body NOT just across the body

The second workshop with Andrew McGough saw attendees split into small groups and get creative with finding suitable rehabilitative exercises for 2 cases of an injured athlete. What was interesting to observe in this workshop was that pretty much all groups came up with different exercises, which demonstrates the multitude of rehabilitative options we have for the injured athlete.

Day 2

The second day started with Bruce Rawson discussing rehabilitation of the shoulder and elbow in the throwing athlete. In late stage rehab & conditioning it’s important to consider both:

  1. General conditioning AND
  2. Throwing specific conditioning

Bruce then discussed some of the key exercises which should be part of a throwers rehabilitation program:

Power (again remember that throwing is from the ground up!):

  1. Push press
  2. Hang clean
  3. Olympic lifts

Throwing creates 1-1.5x bodyweight distraction force through the shoulder, therefore the value of exercises like heavy carries and deadlifts can not be underestimated.

To address trunk rotation some potential exercises that can be used include:

  • Medicine ball throw: under arm, over arm focusing more on push
  • Tornado ball twist: standing or sitting on floor
  • Swinging ball on rope above head

To progress a throwing athlete through throwing progressions, simply increase resistance by increasing distance. Athletes need to “earn the right” To throw hard and often.

Focusing on the injured shoulder is not enough, you must assess the whole chain

Don’t forget the kinetic chain of developing force in the throwing athlete: Each body segment starts accelerating when the previous reaches its peak. Those injured will often have incorrect timing in linking these segments.

Ask the athlete when does their shoulder hurt?

  • Before release/cocking phase/acceleration: result = reduced velocity of throw. Check ER ROM
  • Release after the throw (velocity ok). Check IR ROM, strength (posterior cuff & capsule)

Bruce then discussed injuries to the elbow in the throwing athlete.

For suspicion of UCL injury at the elbow, it’s important to determine if the ligament is torn or not:tears don’t tend to heal often need surgery.

What protects the UCL? biceps and forearm flexors. Will often see tenderness in distal biceps and forearm as a sign of overload at the elbow.

When assessing the UCL, the standard tests don’t stress the UCL highly enough in throwers, so Bruce uses a “bounce test” in the cocking position. Look for pain reproduction in this position.

Additionally, another test that can be used is getting them in the cocking position and then flexing and extending the elbow, again looking for pain reproduction.

This session then lead into another practical workshop with both Bruce and Andrew demonstrating some of the key exercises that can be used for the throwing athlete.

Next up Phil Cossens, Senior Sports Physio Rowing Australia, explored the unusual wrist & elbow presentations in the athlete.

Posterolateral instability of the elbow

  • Can be traumatic and acute or develop over a period of time
  • Posterior subluxation of the radial head
  • Rotation of ulna/olecranon in fossa
  • Severe cases can click
  • Mild cases associated with other conditions

Clinical assessment should include:

Table top test

  • Palpate and feel for radial head moving posterior
  • Positive test is reproduction of their symptoms

Posterolateral rotatory instability test (pivot shift of elbow)

Flex and extend the elbow, feel for movement or reproduction of symptoms.

Osteochondritis dissecans of the capitellum

  • Be aware of niggling soreness
  • This is a diagnosis that should not be missed
  • MRI is essential
  • Clicking & locking indicates a worse prognosis
  • Weight bearing (ie gymnastics) or throwing
  • Palpating capitellar WB surface: flex the elbow (to expose the weight bearing aspect of joint) and you can palpate it
  • May have small loss of flexion
  • Palpating for swelling in Elbow joint: elbow extended, palpate in olecranon fossa
  • Management: conservative management does work, but expect 6-12months

Hyperextension induced posterior impingement

May involve:

  • Joint effusion
  • Calcification/osteophytes
  • Loose bodies
  • Ulnar neuritis
  • Thickening of triceps tendon
  • Thickening of ulnar collateral ligament

(Tyrdal 1999)

Posterior medial impingement or Valgus instability.

  • More seen in elbow flexion

TFCC

  • Ulnar sided pain with WB and/or traction forces
  • Significant injury=instability
  • Those with instability will often have a more supinated position of hand on radius and ulna. Distal Ulna may be more prominent
  • Pronation of hand may relieve symptoms

Prognosis

There is a continuum from missing 1 week to career ending instability

Overload injuries do well with conservative management if caught early enough

Significant TFC tears require arthroscopic surgery

Extensor carpi ulnaris injury

  • Common in racquet sports

Differentials

  • Tenosynovitis
  • Tendinopathy
  • Subluxation: get them to grip then supinate and pronate
  • Rupture

Management

  • Differs significantly depending on diagnosis (Campbell 2013)
  • Consider grip & wrist postures

Intersection syndrome

  • More commonly seen in rowers
  • Test resisted extension and Finkelstein's test - these tests should be negative before resuming rowing
  • More common on inside arm for rowers

Management

  • Address technique: excess wrist extension, ulnar deviation & grip
  • External factors: rough waters, change grip
  • Hard to row through
  • Splint, anti inflams, corticosteroids, surgery (Hoy et al 2019)

Attendees then broke into more workshops firstly with Kylie demonstrating assessment of the swimmer, then Craig with rehabilitation of the wrist and elbow.

Some of Kylie’s key tips to assessment of the swimmers shoulder include:

  • Scapula assessment: Observe both at rest with arms by side and overhead in streamline position. Not necessarily looking at symmetry of movement, more just that they move

  • (Abduction and internal rotation): elbow in armpit, lift elbows up, want to see >140 degrees
  • Resisted catch position: look for pain provocation
  • Supine internal rotation: 45-60deg
  • Supine external rotation: 90+. But greater than 105 is a red flag. You can compensate much easier for a loss of internal rotation vs external rotation

Combined elevation test: hands together, ideal range is humerus 10 degrees above parallel.

This assessment then followed by some good manual therapy techniques to use on the swimmer:

  • Prone lat release: arms above head in catch position

Seated lat release: towel around back to grasp lats, then get them to raise arms above head

● Thoracic mobilization

Shifting our attention down to the wrist and elbow, Craig then discussed assessment and rehabilitation of the wrist and elbow.

Some of his go to tests for the elbow include:

Forearm Flexor range test:

● Have 3rd finger facing directly down
● Then slide up the wall as high as you can until the heel of your hand comes off.
● Ensure they don’t rotate the hand to cheat
● Can either measure angle of arm or tape under their fingers

Forearm/shoulder dissociation test:

● Check internal and external rotation holding a dowel with elbow extended: can they disassociate their elbow and shoulder movement.
● They can have their opposite finger on their elbow crease to ensure they are just using more forearm

In regards to rehabilitation for elbow issues, Craig uses pronation & supination exercises a lot: Supinator is an important stabilizer of the elbow.

The anconeus should also not be neglected: Important in supporting the radial lateral component. To palpate this muscle, extend the elbow. Feel the muscle bulk just lateral to the olecranon

UCL thumb injury:
● If they have a high degree of laxity surgery rather than splint
● Usually injured with hyperextension and abduction
● Taping for UCL injuries: Standard Taping is good for abduction but often doesn’t stop extension at thumb. Craig uses a tape underneath in addition to the standard tape.

Extensor tendinopathy
● Craig will often do hands on work on flexor/pronators as tightness in this group can bring the radial head more anterior and potentially increase tendon compression
● Again look for dissociation of forearm & shoulder
● Strengthen supination and pronation as they are important stabilizers.
● Weight bearing exercises are really important as they can often be done pain free and therefore allows the patient to be able to use the arm.

The final sessions of the weekend featured Head Physio from the Melbourne Storm, Meirion Jones, who delved into the management of the “Contact shoulder”.

Some of the key takeaways from these final sessions include:
● Isolated strength: Get volume into cuff with time under tension: 12-15 reps, slow
● Pulling technique: ensure that the shoulder does not dump anteriorly, and allow the scapula to fully retract at the bottom
● Concentric RFD- plyo press, medicine ball throw
● Eccentric RFD- drop and stick
● Reactive RFD- countermovement plyo press
● Proprioceptive rich: isometrics in outer ranges, KB get ups, arm bar trunk rotations, wall walks

Just like we learnt earlier in the weekend with throwing, technique for tackling is also just as important. Early in the rehab, non contact tackling technique drills can be performed, with progression to contact drills when within 15% strength of other side has been achieved.

So as you can see there was a LOT of content covered in the weekend, with this blog the tip of the iceberg. I’d like to thank SportsMAP and the speakers for making this such a great event, and I look forward to attending future events in 2020!

 

Many thanks to Luke Nelson from Health and High Performance for his contribution with this blog and allowing us to share it our platform.

Free access to Jarrod Wade's presentation on Rehabilitation for Match Demands

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Bruce Hood (Hood 2009) in his book “Supersense: why we believe in the unbelievable” makes a couple of quite pertinent points. He outlines a simple experiment he uses in his presentations where he presents to the audience ‘the pen’ (he admits to stretching the truth here) that Albert Einstein used. The object causes a sense of awe with people wanting to touch it. Immediately after, he offers up an old cardigan which he asks if people would like to try on (maybe that was Albert’s as well). After he has a few takers, he lets it be known that it used to belong to an infamous serial killer -whereupon all of the takers tend to withdraw. As a group, we tend to apply an irrational, supernatural spirituality to objects. This is displayed economically by a painting, supposedly by a grand master being worth millions one day, and nothing the next when described as a fake. Now before all you extremely analytical people jump up and say “I would wear the cardigan” or “I think both paintings are of equal value” this supersense actually extends to the essence of what forms human relationships.

Hood (Hood 2009) further points out that whilst humans do have the capability to make judgements and to reason, there are parts of what make us human and makes our society function that rely on things that go beyond the boundaries of rational analysis. The unconditional love of a mother, the warm feeling you get when you see old friends (in fact having old friends) or being attached to an heirloom from a dead parent, are all examples of emotional based responses that we just accept as ‘normal’. Now again there maybe a few (hopefully only a few) that are still saying, “I feel indifferent about my mother/kids”, “Old friends, what have they done for me lately!” and “I only like new shiny stuff”. If this is the case, it is you that is in the extreme minority. It is argued that it is these traits that have allowed humans to be evolutionarily successful. As individuals in the grand scope of evolutionary time, we are not a particularly hardy example of a species. However as a group that can divide the labour, provide protection and co-operate towards a common goal, we become far more viable. This requires that we form social bonds and these bonds require us to have something more than cold hard reason. We need to believe in something special about the people around us. Our ancestors who were able to create these bonds would have been more successful (finding food, protecting children) and these traits would have entered and then dominated the genetic pool.

In describing the vagaries of evolution theory, in particular evolution of the human cortex, Granger and Lynch in their book “Big brain” point out that we often fall into an evolutionary fallacy (Granger 2008). We often believe we humans are carefully planned, rather than Mother Nature throwing a dice with the DNA and seeing what comes up. Granger and Lynch point out there is no specific reason for why we have 5 fingers (4 or 6 may have been equally as good), but it was a piece of genetic code that was shared about (eventually) amongst a great number of species that worked and didn’t seem to need changing. As a trait becomes more engrained in the success of a species (and then subsequent off-shoots) the less likely there continues to be variations in the code of that trait. Also, it is not only attributes that may bestow some sort of evolutionary advantage, but also those that don’t create too much disadvantage, that can be passed on. Over time these successful (or not too damaging) adaptations form modular patterns within the genetic code that tie together numerous traits and show very little variation. The characteristics of mammals of a spinal cord, head , tail, four limbs, two eyes, two ears and highly similar circulatory, digestive, reproductive and nervous systems, is quite consistent. Furthermore, many of these traits were perfected well before mammals and are borrowed from further back along the evolutionary chain.

Returning to the brain, one of the arguments regarding the evolution of brain size is that increases in brain size are as a result of need, due to changes in behaviour. As our behaviour became more sophisticated, the brain grew to cope with it. Granger and Lynch (Granger 2008) point out that this is somewhat Lamarckian (inheritance of acquired characteristics) and perhaps falling into the above fallacy that our characteristics were carefully planned. They argue that increases in brain size are largely accidental and it is then the behaviour of the species that has to adapt to the rather high biological cost of having a bigger brain. In their words, “Brains are expensive”. Brain cells use up about twice as much energy as the other cells in the body. Bigger brains require longer gestation periods and necessitate longer development to maturity. For humans to survive the genetic code that gave us our big brains had to also encode behaviours that allowed us to pay the cost.

Let’s get back to me on my icebergs and my shivering interpretation of all this. I would argue that for humans to pay the cost of the big brain, the behaviours required would be to create social units that allowed for greater protection and food gathering capabilities. As mentioned earlier, these social units require more than blind brain power to be effective. Whether we call it the “supersense” as described by Hood (Hood 2009) or another name, there appears to be an irrationality and a need to believe, integral in the formation of human emotional bonds. It is within these very traits that the origin of the placebo effect lies. It then may seem attractive to look at the placebo effect as an evolutionary redundancy (did no harm so no need to get rid of it). I think this is a little myopic. We modern humans have been around for about 200,000 years and have been getting sick and injured for most of that time. For a lot of that time, we have had all sorts of healers, shaman and medicine men to help us on our way. However, it is probably only the last seventy years or so (since the advent of evidence-based medicine) that we have any sort of proof that any of the interventions, libations and chants offered up to us has had any effect (helpful or deleterious) (Goldacre 2008).

So, now as I stand somewhat more comfortably than I have for years, with my two icebergs merging into one (those adductors were getting a little stretched). I think we believe because it is far more evolutionary viable to believe than to not believe.

I hope there are no polar bears around here.

References

  • Goldacre, B. (2008). Bad science. London, Fourth Estate.
  • Granger, G. L. a. R. (2008). Big Brain: The origins and future of human intelligence New York, Palgrave MacMillan.
  • Hood, B. M. (2009). Supersense : why we believe in the unbelievable. New York, HarperOne.
How I Rehab
How I Rehab
#17 Traumatic Shoulder Instability with Hamish Macauley
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In this 17th Episode of The Sports MAP Podcast we chat with Hamish Macauley and discuss some key topics with respect to traumatic shoulder instability.
  • Hamish's thoughts on his experiences working as a head Physio in both professional rugby and the AFL
  • What to expect from Hamish at the Upper Limb Rehabilitation in Sport course in the Gold Coast
  • Posterior dislocation- what are the tell tale signs?
  • Where early management is different between posterior & anterior dislocations
  • Common imaging findings following both posterior & anterior shoulder dislocations
  • Decision making around surgical Vs non surgical management following instability episodes (see further detailed notes below)
  • Differences in post surgical management for anterior and posterior repairs
  • Post surgical rehabilitation
    • Early exercises & targets
    • Time based expectations on restoring ROM and strength
    • How & when to introduce pushing, pulling and over head
    • How and when to take the athlete into venerable positions (Abd/ ER
  • Testing or benchmarking in readiness for a return to play
  • What is often missed in shoulder rehabilitation
  • Contact based conditioning
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher. We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook. This episode is brought to you by KangaTech & West Coast Health & High Performance (Perth)   Information below on is hyper mobility and key factors that needs to be considered for a surgical decision from Hamish Factors to consider:
  1. Occupation: overhead/manual labour vs sedentary
  2. Sporting demands – collision sports
  3. Co-morbidities/physical inactivity – prolongs recovery
  4. Evidence based surgical indications (reduces the chance of recurrence): Male <25 y/o with traumatic MOI, requires relocation + high functional demands = EBP supports surgical repair. Generally the risk factors from the literature for recurrent instability include: young age (<40 = 13x higher; majority occurring <25), being a male, contact sport. I would also include young females in collision sports in this category. However it is a discussion and as we discussed there is evidence that people in this group can have a positive outcome without surgery.
  5. Hypermobility:
    1. I always question the patient about their episode(s) – patients can use the words dislocation and subluxation synonymously. True dislocation or instability in the absence of dislocation. I always I always question the patient around the MOI and do they have imaging evidence of the dislocation (in ED)/needed someone to relocate the shoulder… If their story is accurate for the MOI then I generally believe them when they say their shoulder dislocated. If they haven’t had true dislocation, rather instability episodes – conservative treatment. Especially if you’re dealing with someone who has more mobility than the average (>4 Beighton’s).
    2. Traditional classification include the TUBS (Traumatic, unilateral, Bankart, Surgery) and AMBRI (Atraumatic, Multidirectional instability, Bilateral, Recurrent, Inferior Capsular Shift), however this 2nd population doesn’t do as well with surgery as was initially intended with this classification, so conservative path is the best here. A further classification system – The Stanmore Classification (diagram below) further stratifies it into 3 groups and the relationship between trauma, structure and muscle patterning – article attached. In short, group I relates to traumatic dislocation and structural failure, group II with structural laxity that can pre-dispose them to instability with or without trauma, group III to muscle patterning issues causing instability/resting subluxation. Surgery is indicated in group I and only considered in group II with structural failure and who have failed a good rehab program.
Reference article: Jaggi & Lanbert 2010, Rehabilitation for Shoulder Instability
How I Rehab
How I Rehab
#16 Prevention Systems with Paula Charlton PhD
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In this 16th Episode of The Sports MAP Podcast we chat with Paula Charlton (PhD) we discuss her current work with Triathlon Australia and delve in to your expert knowledge on injury prevention systems in sports. We discuss at the length:
  • Bone stress injuries
  • The energy deficit athlete
  • Prevention systems in endurance athletes
  • Reducing the incidence of patella tendinopathy in volleyball athletes
  • Groin injury prevention
  • What to expect at the Athlete Groin Pain Symposium in Sydney
  • Isometric hamstring strength assessment as a screening tool
  • Ongoing isometric hamstring strength deficit following hamstring injury
  • Who owns injury & performance?

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher. We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

This episode is brought to you by KangaTech & West Coast Health & High Performance (Perth)

How I Rehab
How I Rehab
#12 Return to Play for Shoulder Injuries in Collision Based Sports with Edel Fanning
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In this 12th Episode of The Sports MAP Podcast we chat with Edel Fanning (Phd Candidate) from the Sports Surgery Clinic in Dublin about Shoulder Rehabilitation and RTP from surgery for collision based sports. In this episode we talk to:

  • Findings from Edel's recent study in RTP for Shoulder injuries
  • Functional testing using force plates to guide decision making
  • Isokinetic Vs isometric testing for Rotator cuff strength measures
  • Addressing joint position sense in shoulder rehabilitation
  • Force plate functional tests Vs ASH test
  • Common errors in Shoulder Rehabilitation
  • Targeting specific muscle function in Shoulder Rehab
  • Laterjet Vs traditional stabilization surgery
  • Psychological readiness to return to play
  • Edel's key career influences

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

This episode is brought to you by KangaTech & Archies Footwear

Archies are offering all listeners of our podcast a 20% discount on any order. Simply use the code Sports_MAP when ordering from www.archiesfootwear.com

How I Rehab
How I Rehab
#11 Syndesmosis Rehabilitation & Return to Play Systems - Dave O'Sullivan
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In this 11th Episode of The Sports MAP Network Network we chat with previous Head Physiotherapist for the England Rugby League team Dave O'Sullivan around Syndesmosis Injury Rehabilitation & Dave's Return to Play Systems for lower limb Injury.

  • Early focus area's in rehabilitation of a Syndesmosis injury
  • Strength assessment & criteria
  • Dynamic calf assessment
  • Lunge progressions & the importance of the peroneas tertius
  • Hopping progressions
  • Agility /offline progressions
  • Troubleshooting
  • Return to running prescription
  • Return to play

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

This is episode is brought to you by Archies Footwear

Archies are offering all listeners of our podcast a 20% discount on any order (big or small). Simply use the code Sports_MAP when ordering from www.archiesfootwear.com

How I Rehab
How I Rehab
#10 Hip Dysplasia with Andrew Wallis
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Welcome to the 10th Episode of the Sports MAP Podcast.

In this Episode we chat to St Kilda Football Club (AFL) Physiotherapist and director of the Hip & Groin Pain Clinic Andrew Wallis on the key aspects in the assessment, diagnosis and management of Hip Dysplasia including:

  • What actually is Hip Dysplasia
  • How Andrew developed an interest in Hip Dysplasia
  • Subjective clues in assessment and key questions to ask patients
  • Key objective findings to assist in making a clear diagnosis
  • The importance of differentiating FAI and Hip dysplasia
  • Pain drivers in hip dysplasia
  • Imaging and radiological findings
  • Management options available
  • Setting expectations
  • Conservative management and rehabilitation guidelines
  • Return to running and sport

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

This is episode is brought to you by IMeasureU and Vald Performance

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#9 ACL Rehabilitation with Enda King
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In this 9th Episode of the Sports MAP Podcast we chat for a second time with Rehabilitation Specialist from Ireland Enda King about ACL Rehabilitation. Enda touches on many aspects of Rehabilitation with some clinical gold around the following key aspects:

  • Key targets/ criteria in early, mid & late stage rehabilitation
  • Specific exercise selection
  • Errors commonly in rehabilitation and exercise technique
  • Isokinetic testing benchmarks
  • Linear mechanics and when to commence running
  • COD mechanics & how to translate to the field
  • Rate of force development prescription and testing
  • Key jumping tests
  • Changing poor movement patterns in a previously injured athlete
  • The influence of fatigue in rehabilitation
  • Return to sport

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

This is episode is brought to you by IMeasureU and Vald Performance

How I Rehab
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#8 Athlete Monitoring & Injury Prevention with Martin Wollin
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In this 8th Episode of the Sports MAP podcast we chat about athlete monitoring and prevention strategies for hamstring and groin injuries in sport with Martin Wollin PhD. In this episode we cover:

  • Injury prevention systems- What is primary, secondary & tertiary prevention?
  • Adductor strength and ADD:ABD ratio's - relevant to injuries?
  • Adductor strength monitoring- key components
  • Hamstring power testing as a monitoring tool to mitigate injury risk
  • How to manage to an athlete with reduced hamstring strength
  • Is hamstring power asymmetry important for injury risk?
  • Is monitoring athletes in a team sport setting really worth it?
  • Martin's key career influences
  • And more

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

This is episode is brought to you by IMeasureU and Vald Performance

Show Notes/ References

 

How I Rehab
How I Rehab
#7 Athletic Groin Pain Rehabilitation with Enda King



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In this Episode #7 of the Sports MAP Podcast we chat with Enda King around his approach to the Rehabilitation of Complex Athletic Groin Pain using a case example.

  • Determining if this athlete is suitable for Rehabilitation
  • Assessment protocols
  • Addressing & identifying movement based impairments
  • Assessment of speed & power in Athletic Groin Pain
  • Imaging & the significance of bone marrow edema
  • Diagnosis and the entity based approach
  • Rehabilitation strength measures
  • Return to running & change of direction
  • Return to Sport
  • Key influences in Enda' career
  • And more

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

This is episode is brought to you by IMeasureU and Vald Performance

Show Notes/ References

Athletic Groin Pain Part 1

Athletic Groin Pain Part 2

Clinical & Biomechanical outcomes of Rehabilitation targeting intersegmental control

Enda King Groin Rehabilitation Video Series

 

How I Rehab
How I Rehab
#6 Calf Injuries with Shane Kelly (British Olympics)



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Shane Kelly is the Head Physiotherapist of the British Athletic Team

In this episode of the Sports Map Podcast, Shane is presented with a case study of an acute calf strain injury and talks us through his process of rehabilitation back to competition levels. Shane touches on the following area's:

  • Acute Calf Injury assessment
  • Imaging for calf injuries
  • Prognostic factors
  • Adjuncts for early rehabilitation
  • Early loading & building calf capacity
  • Foot intrinsic training
  • Key criteria in calf rehabilitation
  • Return to Run criteria
  • Early running prescription
  • Training periodization & speed progressions
  • Re training acceleration mechanics
  • Monitoring response to loads
  • Thoughts on ACWR
  • Multidisciplinary team involvement for RTS
  • Key influences
  • And more

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

This is episode is brought to you by IMeasureU

Article

British Athletic Muscle Injury Classification

How I Rehab
How I Rehab
#5 Metatarsal Fractures & Tendon Pain with Scott Epsley from Philadelphia 76 ers (NBA)
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Scott Epsley is the Director of Physiotherapy & clinical diagnostics at the Philadelphia 76er's in the NBA.

In this episode we chat about:

  • Scott's journey from Australia to working in the NBA
  • The pro's & cons of working in the NBA
  • The Rehabilitation system and structure at the 76er's
  • Rehabilitation of 5th metatarsal fractures/ stress fractures
  • Using ultrasound to improve diagnostics
  • Ultrasound guided dry needling
  • Technology advances used in rehabilitation*
  • Some interesting early work tendon stiffness in tendinopathy

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.

This is episode is brought to you by IMeasureU

* Side note: In this episode Scott mentions the use of IMU in his practice. This comment was not related in any way to the sponsorship and were completely unsolicited as part of the podcast.
How I Rehab
How I Rehab
#2 Hamstring Rehabilitation with Jurdan Mendiguchia



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Jurdan is a world leading expert in the space of hamstring and quadriceps injury prevention and rehabilitation. Jurdan is the current director of Zentrum Sport & consults for some of the best European Soccer Clubs. In this episode Jurdan talks to:

  • Key components of this approach to hamstring rehabilitation
  • Common errors seen in hamstring rehabilitation
  • Power Force Velocity Profiling in hamstring rehabilitation
  • Jurdan's greatest professional influences
  • What to expect from our Masterclass events with Jurdan in Melbourne and Sydney

This episode is brought to you by IMeasureU

We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via twitter & Facebook.

Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.