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Emidio Pacecca, Performance and Rehab manager at New England Patriots was recently on the How I Rehab Podcast with Sports MAP founder Nick Kane.

Emidio gave listeners amazing insights into the high demands on NFL athletes. Some great takeaways are below.

Key Stats:

  • 30% of achilles ruptures in the NFL and NBA don’t return to professional sport.
  • 43% of patella tendon ruptures fail to return to the highest level.

 

High Speed Running:

NFL athletes can be conditioned to running >90% max velocity up to a 100 times per week. Additionally, exposure can be 4-5 days per week at speeds >95% max velocity. Highlights what can be possible when athletes have been exposed to these numbers for many years in college football and/or athletics.

 

Chronic Loads:

Must maintain chronic exposure to their key lifts throughout off-season periods. This typically involves low level isometrics, heavy strength work and ballistic exercises.

 

Must Have Exercises:

For injury prevention and performance, his four most important exercises are:

  1. Squat
  2. Nordic
  3. Calf based exercise (seated or standing)
  4. Copenhagen

 

Tendon Protocol:

5 x 45” long time under tension for pain management. Coupled with 5 x 3 heavy slow eccentrics.

Additionally, using Scot Morrison’s proposed cluster sets of 3-8” holds with a total time under tension of 1-2 minutes cumulatively (link of article below)

Use these cluster sets interspersed within heavy strength days and on alternate days to the longer 45” isometrics for pain.

 

Strength:

Goal is sled push x2 bodyweight for 15 yards for x10 reps

Limited research in groups >100kg for calf strength so must be cautious when applying group wide strength goals as x3 bodyweight standing calf is very different for a 60kg athlete (180kg) vs a 150kg NFL player (450kg)

A 5% loss of strength for an offensive lineman who weighs 150kg is very significant. Asymmetries with certain players or positions can be incredibly detrimental.

 

Strength Endurance:

Stair climbing at 80 beats per minute working up to 180 bpm. Building toward x10 sets of stadium climbs (380 steps).

 

Communication:

If you’re struggling to build trust, leverage players that you have had good outcomes with to act as mediators. Encourage these athletes to recount their personal successes and talk to other athletes to build buy-in and trust in large programs.

 

General Advice:

Speak to colleagues from different sports about their injury management techniques. Can easily be a victim of doing what everyone else around you are doing if you only speak to your colleagues that work in that sport.

View now on the Sports MAP YouTube channel

Listen to the full How I Rehab Podcast episode

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.

The Flexor Hallucis Longus (FHL) has long been considered a site of potential overuse injury, especially in dancing cohorts (De-la-Cruz-Torres et al., 2020; Newman et al., 2021; Wentzell, 2018). What appears to be less widely discussed is the implications of the FHL in the management of acute ankle inversion injuries, which are far more common in most sporting populations (Van den Bekerom et al., 2013). This blog aims to highlight the importance of the FHL in such injuries, especially in cohorts where ankle inversion injuries are common, but overuse FHL injuries are rare, such as court sports and field sports.

Anatomy of the FHL

The FHL originates on the posterior aspect of the distal two thirds of the fibula and interosseous membrane. The muscle courses inferomedially and its tendon runs through the posteromedial compartment of the ankle with the tibialis posterior (TP) and flexor digitorum longus (FDL), colloquially known together as Tom, Dick and Harry. It’s important to note that the FHL tendon sits more laterally and deep to its “Tom and Dick” counterparts, coursing directly between the medial and lateral processes of the posterior talus (Figure 1 & 2). The tendon sheath of the FHL creates a fibro-osseous tunnel securing it in its groove.

The tendon continues beneath the sustentaculum tali of the calcaneus to the plantar aspect of the foot. Beneath the 1st cuneiform, the FHL crosses dorsally and medially to the FDL at a fibrous intersection known as the “Knot of Henry”. The FHL tendon continues along the medial, plantar foot, between the sesamoid bones of the 1st toe and inserts at the distal phalanx of the 1st toe.

(Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018).

Figure 1 - Reproduced from Sharp et al., 2020. The FHL sits between the posteromedial and posterolateral process of the talus.

Figure 2 - Reproduced from Major et al., 2020. Axial MRI slice showing the FHL in its fibro-osseous tunnel (green arrow) communicating much more closely with the ankle joint than the FDL (blue arrow) and tibialis posterior (red arrow).

Function of the FHL and Role in Athletic Performance

The FHL is a multi-joint muscle, spanning and acting upon the joints of the ankle and medial column of the foot all the way to the 1st interphalangeal (IP) joint. It serves as the primary flexor of the IP and metatarsophalangeal (MTP) joints of the 1st toe and has secondary roles as an ankle plantar flexor, rear foot invertor and medial longitudinal arch stabiliser (Murdoch et al., 2021; Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018).

In athletic movements, such as high-speed running, changing direction and jumping, the forefoot is often the only ground contact point for the body. It is imperative that the 1st toe can resist extension and provide a rigid base to transfer the forces produced by the powerful muscles of the hip, knee and ankle into the ground (Goldmann et al., 2013; Yuasa et al., 2018). It is also understood that, to transfer this force effectively, the foot must be held in supination and the medial longitudinal arch actively stiffened to act as a stable base (McKeon et al., 2015). The importance of the FHL to athletic performance appears to be supported by small cohort studies correlating its function with change of direction speed (Yuasa et al., 2018), horizontal jump distance (Goldmann et al., 2013), and ground reaction force absorption in landing (Oku et al., 2021).

Due to its position, wrapped behind the posteromedial ankle, the FHL requires adequate mobility to avoid acting as a tether restricting ankle dorsiflexion (Michelson et al., 2021). Restricted ankle dorsiflexion is a commonly reported, ongoing, impairment following ankle inversion injury (Van den Bekerom et al., 2013), and it appears that the FHL has the potential to be a contributor.

Aetiology of FHL Injuries Secondary to Ankle Inversion Injuries

The most common mechanism of ankle injury is forced ankle plantar flexion and inversion, which distracts the anterolateral aspect of the joint, commonly injuring anterolateral structures like the anterior talofibular ligament (ATFL) (Van den Bekerom et al., 2013). On the other side of the joint, the structures in the posteromedial aspect of the joint are compressed (Van den Bekerom et al., 2013), commonly including the FHL tendon within its fibro-osseous tunnel (Sharpe et al., 2020). The FHL tendon can also be implicated secondary to ankle injuries as the proximity of its synovial sheath to the ankle joint (directly communicating in approximately 20% of individuals) can allow ankle effusion to leak into it, acting as a pseudo-tenosynovitis (Major et al., 2020).

Assessment

Assessment of the FHL should be a staple component of the assessment of the injured ankle. FHL pain may be suspected if posteromedial ankle pain is reported, especially with activities involving ankle plantar flexion such as toe-off in gait or the top of a calf raise (Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018). The FHL can be directly palpated in its talar groove (Sharpe et al., 2020), instructing the patient to wiggle the 1st toe whilst palpating can help confirm the accuracy of palpation. The FHL is also stressed with the posteromedial impingement stress test (Figure 3), resisted 1st toe flexion, resisted ankle inversion and a full range calf raise (Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018). Pain in the posteromedial ankle with these tests should increase suspicion that the FHL is a source of symptoms. 

Figure 3 - The posteromedial stress test involves passively moving the ankle in to end range plantar flexion and inversion then applying an overpressure at the posteromedial heel.

Along with assessing whether the FHL may be a source of symptoms, it is important to ascertain whether the function of the FHL has been impaired, which may have implications for returning to performance (Goldmann et al., 2013; Oku et al., 2021; Yuasa et al., 2018). The most commonly described test for assessing FHL flexibility involves assessing maximal 1st MTP extension range with the ankle held in dorsiflexion and the 1st metatarsal head stabilised (Michelson et al., 2021;Sharpe et al., 2020). This can be compared to 1st MTP extension range in ankle plantar flexion (FHL off stretch). Another, potentially more functional, test that could flag whether FHL flexibility is limiting ankle dorsiflexion is to compare the ankle dorsiflexion lunge test with and without a small wedge under the first toe. If the range decreases with the wedge, it could be hypothesised that FHL flexibility is the limiting factor and worth addressing.

As a secondary ankle plantar flexor and inverter, impaired FHL function may contribute to deficits in strength testing of these movements. To get a clearer understanding of FHL muscle function, 1st toe flexion strength must be assessed, as the FHL is the primary driver of this movement (Murdoch et al., 2021; Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018). In athletic tasks, active 1st toe flexion is most often required in 1st MTP extension (Goldmann et al., 2013; Yuasa et al., 2018), so testing in this position may be advised. This theory appears to be supported by a recent, small, cohort study that showed 1st toe flexion strength in 45 degrees of extension was correlated with change of direction performance but flexion strength in flexion was not (Yuasa et al., 2018). 

Figure 4 demonstrates a possible set-up to take this measurement (depending on equipment available). The hip, knee and ankle are standardised to 90 degrees, the pad of the 1st toe is centred on the dynamometer which is fixed by the wall and the floor. Although the degree of 1st toe extension would vary from patient to patient in this position, the goal is to standardise the position for reliable re-testing of the patient. Small cohorts of healthy participants in their 20’s have shown an average 1st toe flexion strength of ~20% of body weight (Mickle et al., 2016; Spink et al., 2010). No evidence exists for an “ideal” strength level for athletes, but a common target is >30% of bodyweight and >90% limb symmetry.

Figure 4 - Position for dynamometry assessment of 1st toe flexion strength in extension. The toe is centred on the pad of the dynamometer which is fixed in place by the wall and floor. The hip, knee, and ankle are in 90 degrees of flexion.

Rehabilitation

The implications of the FHL for ankle inversion injury rehabilitation will depend on the results of the objective and subjective examination. Factors include; the severity of the ankle injury, whether or not the FHL is a likely source of symptoms, FHL flexibility restriction, strength deficits of the FHL and strength deficits of other muscles of the foot and ankle. Figure 5 is a simplified model of the decision-making process regarding the FHL after ankle inversion injury.

Figure 5 - Flowchart to guide decision making around the FHL following ankle inversion injury based on assessment findings.

The proposed management of the symptomatic FHL tendon has been outlined in several papers, with limited evidence, primarily considering dancing cohorts. The conservative management includes non-steroidal anti-inflammatory medications (NSAIDs), ice, non-provocative loading of the FHL (such as mid-range isometric toe flexion in ankle neutral), strengthening of the kinetic chain (especially the hip), and external support for protection (may include weight bearing aids, arch support, toe spacers, limiting end range 1st toe extension, and/or limiting end range ankle plantar flexion) (Newman et al., 2021; Sharpe et al., 2020; Wentzell, 2018). If conservative management fails to get symptoms under control, medical intervention may be necessary, anecdotally, this is not commonly required following ankle inversion injury.

Beyond managing the painful FHL, rehabilitation must consider any functional impairments of the FHL (evidence is lacking for the rehabilitation of FHL function so the following recommendations are based on clinical opinion).  If the FHL appears to be limiting dorsiflexion range of motion, then targeted FHL mobility exercises may be of benefit (examples in the video below). Passive treatment modalities targeting the FHL muscle such as massage or dry needling may also be considered. 

If the FHL is found to be weak, that weakness must be considered within the context of the whole assessment. For example, if 1st toe flexion shows a 50% deficit from expected values, but so too does ankle plantar flexion, ankle inversion and ankle eversion, exercising each muscle group in isolation would be inefficient. In this case, more benefit would be gained by focussing on functional plantar flexion exercises that load the triceps surae, foot intrinsic muscles, flexor compartment muscles and peroneals to a high degree simultaneously. These exercises may include calf raise variations and toe walking variations with cueing encouraging:

  • Pressure through the 1st and 5th toe - driving through the forefoot.
  • Driving the heel up in a straight line.
  • A stable, upright stance.
  • Slow, controlled, deliberate, movement quality.

Conversely, if 1st toe flexion shows a 50% deficit from expected values but the other muscle groups do not, more targeted FHL loading may be advisable. Examples of these exercises are provided in the video below, they include similar functional exercises with greater constraints to encourage active 1st toe flexion. Isolation 1st toe flexion exercises (video) are another option in this scenario but may not be necessary with appropriate loading of more functional variations. Isolation 1st toe flexion exercises may be more appropriate in severe ankle injuries when the early stages of rehabilitation involve a period of modified weight bearing status. 

To summarise, the FHL is not to be forgotten in the management of ankle inversion injuries in any sport due to its anatomical proximity to the ankle joint and function in athletic movements. A structured and thorough physical examination will help determine whether the FHL is a source of symptoms following ankle inversion injury and whether the function of the FHL has been impaired. The results of the examination can be used to guide rehabilitation and ensure that a forgotten FHL is not the source of ongoing functional impairments and, consequently, performance deficits.

References

De-la-Cruz-Torres, B., Barrera-García-Martín, I., De la Cueva-Reguera, M., Bravo-Aguilar, M., Blanco-Morales, M., Navarro-Flores, E., Romero-Morales, C., & Abuín-Porras, V. (2020). Does Function Determine the Structure? Changes in Flexor Hallucis Longus Muscle and the Associated Performance Related to Dance Modality: A Cross-Sectional Study. Medicina (Kaunas, Lithuania), 56(4), 186. https://doi.org/10.3390/medicina56040186

Goldmann, J.-P., Sanno, M., Willwacher, S., Heinrich, K., & Brüggemann, G.-P. (2013). The potential of toe flexor muscles to enhance performance. J Sports Sci, 31(4), 424-433. doi:10.1080/02640414.2012.736627

Major, N. M., Anderson, M. W., Helms, C. A., Kaplan, P. A., & Dussault, R. (2020). Musculoskeletal MRI (Third edition.. ed.): Philadelphia, Pennsylvania : Elsevier.

McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2015). The foot core system: a new paradigm for understanding intrinsic foot muscle function. British journal of sports medicine, 49(5), 290. https://doi.org/10.1136/bjsports-2013-092690

Michelson, J., O’Keefe, J., & Bougioukas, L. (2021). Increased flexor hallucis longus tension decreases ankle dorsiflexion. Foot and ankle surgery, 27(5), 550-554. doi:10.1016/j.fas.2020.07.007

Mickle, K., Angin, S., Crofts, G., & Nester, C. (2016). Effects of Age on Strength and Morphology of Toe Flexor Muscles. The Journal of Orthopaedic and Sports Physical Therapy, 46(12), 1065-1070.

Murdock, C. J., Munjal, A., & Agyeman, K. (2021). Anatomy, Bony Pelvis and Lower Limb, Calf Flexor Hallucis Longus Muscle. In StatPearls. StatPearls Publishing.

Newman, D. P., Holkup, K. C., Jacobs, A. N., & Gallo, A. C. (2021). Recalcitrant Flexor Hallucis Longus Dysfunction: A Case Study Demonstrating the Successful Application of an Adaptable Rehabilitation Program With a Two-Year Follow-Up. Cureus, 13(4), e14326. https://doi.org/10.7759/cureus.14326

Oku, K., Kimura, D., Ito, T., Matsugi, A., Sugioka, T., Kobayashi, Y., Satake, H., & Kumai, T. (2021). Effect of Increased Flexor Hallucis Longus Muscle Activity on Ground Reaction Force during Landing. Life (Basel, Switzerland), 11(7), 630. https://doi.org/10.3390/life11070630

Sharpe, B. D., Steginsky, B. D., Suhling, M., & Vora, A. (2020). Posterior Ankle Impingement and Flexor Hallucis Longus Pathology. Clin Sports Med, 39(4), 911-930. doi:10.1016/j.csm.2020.06.001

Spink, M., Fotoohabadi, M., & Menz, H. (2010). Foot and Ankle Strength Assessment Using Hand-Held Dynamometry: Reliability and Age-Related Differences. Gerontology (Basel), 56(6), 525-532.

Van den Bekerom, M., Kerkhoffs, G., McCollum, G., Calder, J., & Van Dijk, C. (2013). Management of acute lateral ankle ligament injury in the athlete. Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA, 21(6), 1390-1395.

Wentzell M. (2018). Conservative management of a chronic recurrent flexor hallucis longus stenosing tenosynovitis in a pre-professional ballet dancer: a case report. The Journal of the Canadian Chiropractic Association, 62(2), 111–116.

Yuasa, Y., Kurihara, T., & Isaka, T. (2018). Relationship Between Toe Muscular Strength and the Ability to Change Direction in Athletes. Journal of human kinetics, 64, 47–55. https://doi.org/10.1515/hukin-2017-0183

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.

T-Junction injuries of the distal biceps femoris – a more severe variant of hamstring strain injury

Although there are signs of a drop in the number recurrences of hamstring strain injuries (HSIs) in sport[1], it has been long evident both epidemiologically and experientially that these are amongst the most challenging in sport. In fact, since re-injuries have been reported to occur in up to 63% of HSIs[2], it is obvious that it is this recurrence risk underpins the high rates of HSI in sport. If these recurrences could be reduced, it would have an exponential effect on reducing the burden of this injury. What’s more, as these reinjuries typically present having worsened radiologically, they have a significant effect on a club’s injury burden [3].

An important development thus, has been the evolution in imaging classifications that have allowed for bespoke diagnosis, management and rehabilitation. These are particularly important in professional sport where rapid access to MRI common, to meet the pressurized demands of competition and contracts. The widespread adoption of classification systems such as the British Athletics Muscle Injury Classification (BAMIC)[4] mean that modern sports medicine now gives consideration to anatomical location in addition to grading, and can modify expectations accordingly. Although the research so far has been mixed [5, 6], some studies have demonstrated prolonged time to return to play and increased recurrence risk following intramuscular tendon injury in athletes [7-10].

This development has now widely expanded the considerations for clinicians in rehabilitation. Macdonald, McAleer [11] have described a tailored exercise progression with consideration of load, speed and contraction type dependant on BAMIC classification, while Askling, Tengvar [12] has discussed the variation in outcome following stretch and sprint type HSI. Hence, it’s now clear that all HSIs should not be thought to be the same, and they should not be homogenised from a prognostic or management perspective. In order to best mitigate against recurrence, it is necessary to understand the characteristics of each sub-type.

The most frequently injured of the hamstring muscles is the biceps femoris (BF) in running sports [13-15]. While these typically occur at the proximal musculotendinous junction (MTJ), a single retrospective analysis by a Super 15 rugby union team noted higher incidence of distal injuries than had otherwise been previously been reported [14]. Huygaerts, Cos [16] have extensively reviewed the anatomical and morphological features of BF that may predispose it to greater injury risk. As it’s name suggests, BF has two heads – the biarticular long head (LH) forming a conjoint tendon with semitendinosus proximally, and a second monoarticular short head (SH) which functions primarily as a knee flexor. These heads are innervated separately by the common peroneal and tibial nerves respectively.

Importantly, Entwisle, Ling [13] has recently descripted the distal MTJ ‘T-Junction’ of the biceps femoris, formed by a complex confluence of the epimyseal surface of the LH and SH in the distal posterior thigh (Image 1). Injuries to this location have been suggested to be a more severe variant of HSI that should, like intramuscular tendon injuries, be treated as a distinct clinical entity [13, 17].

Figure 1: Reproduced from Entwisle, Ling [13]. A schematic demonstrating the sequential axial anatomy of the T junction of the biceps femoris distal musculotendinous junction (MTJ). Proximally, the anterolateral epimyseal surface of the long head (L) condenses to form the proximal portion of the distal MTJ and appears L-, C-, or U-shaped. In the midportion, the opposing epimyseal condensations as the anterolateral aspect of the long head and posterolateral aspect of the short head (S, small arrow) form the DMTJ that appears as a T-shaped structure. Distally, the posterolateral epimyseal condensation of the short head forms the DMTJ and appears as a shallow convex structure.

The greatest insight into these injuries is derived from a retrospective analysis of 1850 MRIs in a predominantly professional cohort of athletes at Olympic Park in Australia following acute HSI. The authors detected 106 injuries involving the T Junction of the distal MTJ of the BH. While injuries to the LH component in isolation occurred in 50% of cases, injuries to the SH alone were infrequent. Critically, the recurrence rates, reported at 53.8% HSI (68% of grade 2s, 71% of grade 3s), are towards the very higher end of what has been reported for any sub-type of HSI. These findings were almost identical to those of Kayani, Ayuob [17], who found recurrences in 55% of conservatively managed high grade injuries.

Figure 2: Reproduced from Kayani, Ayuob [17]. Axial section T2-weighted MRI slices showing grade 3 injury to the distal musculotendinous T junction of the biceps femoris with surrounding peritendinous oedema.

While it is clear that these are a distinct clinical entity, and are more likely to recur, developing an optimal management strategy to achieve best outcomes remains a challenge. Kayani, Ayuob [17] reported good outcomes (function, satisfaction and recurrences) following surgical repairs of 34 professional athletes after Grade 3 T Junction injuries (involving either the MTJ or intramuscular tendon) and described a four stage rehabilitation strategy. The next stage however, in the same way that principles for management for other locations in the musculotendinous unit have been established, is to establish why these are injuries are recurring, and subsequently, how this should influence rehabilitation and the return to play process [11]. There must be anatomical or physiological reasons that injuries to the T Junction are recalcitrant, and have poorer outcomes than neighbouring muscles and locations, and ultimately it is these factors that should influence management.

Presently, however, there is a vacuum of information to guide us. Firstly, no characteristic mechanism of injury has been described that is associated with T Junction strain. While semimembranosus and proximal free tendon injuries have been shown to occur during overstretch, there is no distinct pattern of T Junction injury. Table 1 outlines the mechanisms of injury of a small subset of athletes who incurred a T Junction injury, but this is by no means an exhaustive analysis of the biomechanical factors involved. Some muscle injury classification systems have been proposed that include the mechanism of injury[18], and these would add value in this case in rising suspicion of such an injury that can only be determined using imaging. With further longitudinal analysis to better understand injury mechanism, preventative strategies – via exercise selection and skill execution – could be designed and trialled.

In addition, no study has described the clinical characteristics of such injuries. There are no proven pathognomic signs that should alert the clinician to the suspected presence of an injury in this location, other than palpation around the distal MTJ. So far, as these injuries can only be identified using MRI and thus, they are most frequently detected in elite sports people. In fact, it is suspected that in many cases these are never identified. This may result in frequent recurrences of BF strains over prolonged periods of time in sub-elite athlete athletes. It has been reported that these injuries become ‘relatively symptom free’ 3-4 weeks following injury, which may lull clinicians into under-estimating the prognosis of such an injury and progressing too rapidly through the return to play process

Table 1: Brief description of mechanism of T-Junction injuries observed in 10 cases in a cohort of rugby union players

This early resolution of symptoms may cause the frequency of early recurrences that has been described for this sub-type, with 76% of recurrences occurring within the first 3 months [13]. Incomplete aponeurotic healing remains at 6 weeks following injury [19], so perhaps one principle of management would be a more cautious approach with consideration of the stages of healing.

Periodisation of rehabilitation should give consideration to three keystones – (1) anatomical diagnosis, (2) functional diagnosis or limitations and (3) the demands of ‘return to sport’. Given the nature of the anatomical diagnosis in this case, and the risk of early recurrence, it is proposed that a gentler cadence through the process is best. As with the recommendations for intramuscular tendon injury [11], sprinting activities and exercises involving maximal length, high force and rate of loading should be programmed in a manner that respect immature histological healing at the location of injury.

Consideration should also be given to the distinct characteristics of the distal BF that could be implicated in the poor recovery from injuries in this location as identification of these directs the strength training interventions[20]. The proximal and middle regions of the BFlh have larger pennation angles and greater fascicle lengths than the distal portion [16]. Although this has not prevented the proximal hamstring from being more frequently injured, perhaps the shorter fascicle lengths of the distal hamstring are implicated in poor recovery when injury does occur. Similarly, the distribution of fibre types is not uniform throughout the muscle, with a greater proportion of type 2 muscle fibres existing proximally. This could impact upon the type of training that is deemed optimal for this region.

The duel innervation of the BF is consistently suggested as a potential reason for the high proportion of injuries to this muscle. Given T-junction injuries occur at the confluence of the two heads, it is logical that an asynchrony in co-ordination of the heads could contribute. However, how this can be quantified, and resolved, is unclear and it is only speculative as to what approach could be taken. Macdonald, McAleer [11] suggest isometric exercises as a tool to overcome the neuromuscular inhibition that exists during eccentric exercise following injury[21], and a similar approach may yield benefit in injuries at this confluence.

Recent research has demonstrated the differences in inter-muscular activation during various exercises [20], and has allowed for increasing specificity in rehabilitation. The ‘Nordic hamstring exercise’ and ‘single-leg hip extension’ elicit high activity in the biceps femoris muscle, and thus exercises with these characteristics should be considered important for eliciting an adaptation, while also treated with caution given they are likely to stress this area. Subsequently, Hegyi, Csala [22] has expanded upon this, by demonstrating region specific differences within individual muscles (Figure 3). The eccentric component of the straight knee bridge, upright hip extension conic-pulley and slide leg curl may be most appropriate if attempting to elicit a location specific response in this region, with contraction type adapted dependant on whether the goal is to overcome inhibition (isometric), develop fascicle length or local strength and hypertrophy (eccentric), or simply to induce healing through mechanotherapy. However, again, it is not known whether these injuries occur due to compensation for proximal dysfunction – at which point offloading distally would be the targeted outcome. In the absence of this information, a balanced programme is advised, giving cognisance to inter-muscular and proximal-distal biases, across multiple contraction types.

Figure 3: Reproduced from Hegyi, Csala [22]. Mean and standard deviation of the normalized activity level (%MVIC, maximal voluntary isometric contraction) in the proximal, middle, and distal regions of each muscle during the eccentric phase of each exercise. GM, good morning; RDL, unilateral Romanian deadlift; CP, cable pendulum; BB, bent‐knee bridge; 45HE, 45 degree hip extension; PLC, prone leg curl; SLC, slide leg curl; UHC, upright hip extension conic‐pulley; SB, straight‐knee bridge

In addition, the same group were able to demonstrate highest EMG activity of the distal BF during late swing phase of fast running [23]. This should influence running rehabilitation progression, and suggests that exercises targeting front-side mechanics and over-stride tolerance or reduction could be advocated.

Given that early recurrence is a key feature is this injury, the pace of progression is critical. If attempting to offload the distal BF, exercises that preferentially activate the medial hamstring or proximal BF may be indicated. In addition, initially restricting range of motion and rate of force development, as well as muscle length across the two involved joints are characteristics of exercise selections that can be manipulated and progressed, while still giving consideration to prioritising the adaptations that might be necessary to prevent recurrence (Table 4).

Figure 4: Proposed conceptual progressive loading model specific to a hamstring strain injury

In conclusion, it’s clear that an even more complete approach to rehabilitation is required following T-Junction than for a typical HSI, giving consideration to the structural diagnosis and characteristics of the distal BF. At present however, it remains unclear which anatomical and morphological traits have the greatest influence on injury risk, nor which approaches will generate the most specific and appropriate adaptation. In addition, strategies that help with the identification of these injuries and raise suspicion amongst clinicians would likely improve management of this complex variant of HSI.

References:

  1. Ekstrand, J., et al., Injury rates decreased in men's professional football: an 18-year prospective cohort study of almost 12 000 injuries sustained during 1.8 million hours of play. Br J Sports Med, 2021.
  2. de Visser, H.M., et al., Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med, 2012. 46(2): p. 124-30.
  3. Koulouris, G., et al., Magnetic resonance imaging parameters for assessing risk of recurrent hamstring injuries in elite athletes. Am J Sports Med, 2007. 35(9): p. 1500-6.
  4. Pollock, N., et al., British athletics muscle injury classification: a new grading system. Br J Sports Med, 2014. 48(18): p. 1347-51.
  5. van der Made, A.D., et al., Intramuscular tendon involvement on MRI has limited value for predicting time to return to play following acute hamstring injury. 2018(1473-0480 (Electronic)).
  6. van der Made, A.D., et al., Intramuscular tendon injury is not associated with an increased hamstring reinjury rate within 12 months after return to play. 2018(1473-0480 (Electronic)).
  7. Pollock, N., et al., Time to return to full training is delayed and recurrence rate is higher in intratendinous ('c') acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification. Br J Sports Med, 2016. 50(5): p. 305-10.
  8. Eggleston, L., M. McMeniman, and C. Engstrom, High-grade intramuscular tendon disruption in acute hamstring injury and return to play in Australian Football players. Scand J Med Sci Sports, 2020.
  9. Comin, J., et al., Return to competitive play after hamstring injuries involving disruption of the central tendon. Am J Sports Med, 2013. 41(1): p. 111-5.
  10. Vermeulen, R., et al., Complete resolution of a hamstring intramuscular tendon injury on MRI is not necessary for a clinically successful return to play. Br J Sports Med, 2020.
  11. Macdonald, B., et al., Hamstring rehabilitation in elite track and field athletes: applying the British Athletics Muscle Injury Classification in clinical practice. Br J Sports Med, 2019. 53(23): p. 1464-1473.
  12. Askling, C.M., et al., Proximal hamstring strains of stretching type in different sports: injury situations, clinical and magnetic resonance imaging characteristics, and return to sport. Am J Sports Med, 2008. 36(9): p. 1799-804.
  13. Entwisle, T., et al., Distal Musculotendinous T Junction Injuries of the Biceps Femoris: An MRI Case Review. Orthop J Sports Med, 2017. 5(7): p. 2325967117714998.
  14. Kenneally-Dabrowski, C., et al., A retrospective analysis of hamstring injuries in elite rugby athletes: More severe injuries are likely to occur at the distal myofascial junction. Phys Ther Sport, 2019. 38: p. 192-198.
  15. Askling, C.M., et al., Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med, 2007. 35(2): p. 197-206.
  16. Huygaerts, S., et al., Does Muscle-Tendon Unit Structure Predispose to Hamstring Strain Injury During Running? A Critical Review. Sports Med, 2021. 51(2): p. 215-224.
  17. Kayani, B., et al., Surgical Repair of Distal Musculotendinous T Junction Injuries of the Biceps Femoris. Am J Sports Med, 2020. 48(10): p. 2456-2464.
  18. Valle, X., et al., The MLG-R muscle injury classification for hamstrings. Examples and guidelines for its use. Apunts. Medicina de l'Esport, 2019. 54(202): p. 73-79.
  19. Jaspers, R.T., et al., Healing of the aponeurosis during recovery from aponeurotomy: Morphological and histological adaptation and related changes in mechanical properties. Journal of Orthopaedic Research, 2005. 23(2): p. 266-273.
  20. Bourne, M.N., et al., An Evidence-Based Framework for Strengthening Exercises to Prevent Hamstring Injury. Sports Med, 2018. 48(2): p. 251-267.
  21. Fyfe, J.J., et al., The role of neuromuscular inhibition in hamstring strain injury recurrence. J Electromyogr Kinesiol, 2013. 23(3): p. 523-30.
  22. Hegyi, A., et al., High-density electromyography activity in various hamstring exercises. Scand J Med Sci Sports, 2019. 29(1): p. 34-43.
  23. Hegyi, A., et al., Individual Region- and Muscle-specific Hamstring Activity at Different Running Speeds. Med Sci Sports Exerc, 2019. 51(11): p. 2274-2285.

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.

Orthopaedic Surgeon from OrthoSport Victoria Dr. Brian Devitt explains when, why and how for considerations of hamstring surgery.

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

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Despite the large amount of knowledge we now have regarding injury prevention of athletes, the shear amount of non-contact injuries that occur each year can be alarming. The balancing act between allowing an athlete to perform at an elite level and keeping them in a rehabilitation program for an extra couple of days can be a decision that keeps the medical team up at night. There are many factors which can contribute to a decision such as this and being pain free is not always a necessity. It has been found that an athlete’s performance will increase with volume and intensity increases, however, with these factors also comes the increased risk of injury. It has been found that an athlete is seventy times more likely to suffer injury if they exceed their individual weekly training threshold. The following article looks to answer some questions in how the medical team may deal with the manipulation and interpretation of an athlete’s load during the during pre, inter and post season.

Pre-season training for elite clubs, is the strength and conditioning programs designed to prepare athletes for an entire competitive season and not just an individual event. For amateur clubs the pre-season may be used for maintenance of fitness in the post season. The development of a well-planned pre-season training program can lead to a decrease in injury risk, increase in mental strength and condition the body for the cues and contacts of a game. The old adage of “train smarter not harder” has changed with the recent evidence produced by Tim Gabbett and Peter Blanch, with the new spin stating: “Train Smarter, Train Hard”.

The premise being that completing short hard training sessions is more beneficial to athletes than those of a longer duration which has the potential to increase injury risk. Training hard with a vehicle like High Speed Running helps to protect physical qualities of an athlete. However, a well-planned pre-season can only be as well planned as the measurement of the athletes load during that pre-season.

Measuring Loads

There are a number of different ways that load can be measured both subjectively and objectively and all with their own pros and cons.

One such way of measuring an athletes training load is through the use of the Acute: Chronic Workload Ratio. The chronic workload is measured over a four week rolling average, while an acute workload can be anything from one training session to one week, depending on the fatigue level of the athlete. The ratio known as the “sweet spot” is between 0.8 and 1.3, this is further supported by the rule of “10% volume increase” which would produce a 1.1. The “Danger Zone” in the Acute: Chronic Ratio is any workload exceeding 1.5, however, there is increased risk for any ratio above a 1.

Another way of measuring athlete load is through Rate of Perceived Exhaustion (RPE) times the duration of the session (minutes). Using this measurement tool allows for not only physical load to be recognized but the mental load being placed on an athlete. If a programmed session is expected to rate a 7 on the RPE scale but the athlete scores the session as 12 then there may be something else worth exploring within the athletes life.
It is suggested that you have 7 days to manage an injury risk for a non-contact presentation. If an athlete is seen to be in the danger zone for too long a period the use of more recovery sessions or complete rest may be required to decrease the physical and mental stressors affecting the athlete. The load variables that have potential to affect the load felt by the athlete are sport specific and can be both intrinsic and extrinsic in nature.

Contributors to Load

There are a large number of factors which can contribute to load accumulation in an athlete and how that load accumulation is attenuated by the tissues of the body. Past injuries are one of the biggest contributors to future injury whether within the same region of tissues or in a separate region as a result of detraining. What was originally an ankle injury which saw an athlete reduce training load for two weeks, can easily lead a vortex of injury in other regions due to deconditioning associated with the reduced game readiness.

Additionally, the bio-mechanics of an athlete cannot be directly correlated to an injury which has not occurred yet – in other words, you cannot predict a specific injury based on bio-mechanical factors that you may visualize. Yes, those bio-mechanical factors can be seen as risk factor for injury but not specifically tied to an individual athlete and the injury they may incur.

Moment in time injuries (ankle sprains/ACLs) and contact injuries of varying degrees will lead to weakness within those tissues and an increase of further injury in the future. This may be a result of “overloaded” tissues relative to their current ability to handle loads – therefore the question is posed again, is it an Overuse Injury, Overload Injury or Training Error which should be the primary umbrella term used to describe these conditions.

The rehabilitation process which has been used to see the athlete return to sport is also important in the contribution to athlete load.

Did the athlete stop all physical activity over the time of injury?
Did the athlete return to training before returning to sport?
Was the athlete returned to their pre-injury chronic load before returning to game play?
Was the athlete 100% ready to return?
If not is the club, player and practitioner willing to take that risk?

There are many more questions that need to be asked and many more which we have not covered here. These decisions are commonly made under pressure to get the player back to field as soon as possible.

Managing Load

So far we have seen what may contribute to an athlete’s load as well as how we can best measure that load in both a subjective and objective format. But how good is that information if we do not have an effective way of managing those risk factors, acute physical load spikes and psychological stressors?

Load should be considered a vehicle, an objective and subjective matter that can drive an athlete towards injury or away from injury. At the end of the day your main destination is “game day performance” or “season performance”, how you reach that destination can be done via a number of routes and selecting the best one is what must be decided upon by the medical staff, athlete and the organization.

When looking to manage load, an athlete’s activity levels should be modified but never ceased. This is to limit detraining, maintain aerobic and anaerobic fitness and continue a base level of their chronic work load. The use of increased aerobic fitness and lower limb strength has been found to reduce an athletes risk of injury. For a long term injury which requires an extensive rehabilitation program it is suggested that workload is increased by 10% per week until the patient reaches their pre-injury chronic workload and are suitable to return to full training.

In conclusion, the monitoring of an athletes load with both subjective and objective measures is essential in the preparation for the competitive season. The development of a well-structured pre-season training plan can bullet proof an athlete not only for a single event but an entire season if completed successfully. A detailed medical history, injury history and lifestyle awareness is important for understanding of how an athlete should prepare for the sporting tasks required of them; from an easy recovery run to a worst case scenario within a single game. It is important to note that an athlete should not stop activity altogether but modify their activities in a way which is most appropriate for their injury.

References

Blanch, P., & Gabbett, T. (2016). Has The Athlete Trained Enough to Return to Play Safely? The Acute: Chronic Workload Ratio Permits Clinicians to Quantify a Players Risk of Subsequent Injury. British Journal of Sports Medicine.

Gabett, T., Hulin, B., Blanch, P., & Whiteley. (2016). High Training Workloads Alone Do Not Cause Sports Injuries: How You Get There Is The Real Issue. British Journal of Sports Medicine.

Halson, S. (2014). Monitoring Training Load To Understand Fatigue In Athletes. SPorts Medicine, 139 - 147.

Saw, A., Main, L., & Gastin, P. (2015). Monitoring The Athlete Training Response: Subjective Self-Reported Measures Trump Commonly Used Objective Measures: A Systematic Review. British Journal Of Sports Medicine, 281 -291.

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.

For a long time now, I have stood with my feet precariously placed on two icebergs that sometimes slowly drift apart and sometimes drift back together again (obviously increasing and decreasing my sensation of precariousness). The first iceberg is where I started as a clinician, with both my feet solidly planted in the belief that all my patients got better from my superior diagnostic skills and almost magical treatment abilities. Later in my career, I made a rather silly step and tentatively lifted one of my feet and placed it on to the solid and friendly looking iceberg next to me, the one of clinical research. Almost immediately the gap between the two started to widen.

In 2001, I was reading an article in New Scientist (Watts 2001) (all of us cool/nerdy sciencey guys were) and it started, ‘Do you want to start a new therapy?,’ which of course heightened my interest as perhaps ‘Blanch therapy’ could be the new musculoskeletal cure-all. The article then went on to outline the placebo effect in, at the time, quite uncomfortable depth. Over time, I read more and more about this area and came to the conclusion that people get better, and they don’t always get better for the reasons we think they get better. That often we in musculoskeletal medicine often fall into the logical error known as “post hoc ergo propter hoc” or for those of you whose Latin is a little rusty, “after this, therefore because (or on account) of this” (Damer 2009). We have a theory, we treat a patient, the patient gets better, and therefore our theory is correct. This may seem a minor point as long as you think that the only responsibility you have is trying to get people better. However, our responsibilities, when placed in the privileged position of someone paying you to make them better then extend to asking: why do people get better?

For a while, this realisation had an epic global warming effect, with my two icebergs floating apart quite dramatically, to the point I felt like I was going to either split in two or fall off both into the cold water of uncertainty. I have come to accept that the relationship, rapport and empathy I develop with patients are extraordinarily important to the outcome of the treatment. My beliefs and their beliefs and what I can get them to believe will ultimately shape the therapeutic experience. This is not from any ‘hug a tree’ and ‘save a whale’ spirituality, but that is what the evidence shows us. I think that this is outlined extremely well in the books of Dylan Evans (Evans 2003) and Daniel Moerman (Moerman 2002). We are psycho-social biological beings and to believe therapeutic interventions only have a biological effect is ridiculous. This should not be interpreted as all our techniques and tools used in the treatment of patients are all due to the placebo effect. On the contrary, if you believe this and approach your treatments without belief, conviction and enthusiasm, it is likely you will get poor outcomes due to the nocebo response. We must accept that the psycho-social aspect of a therapeutic encounter can enhance, in fact create (placebo) or negate (nocebo) the biological effect.

Whilst this brought my feet back closer together, it raises a rather tantalising question and perhaps the point of this blog, ‘Why do we believe, why do we have the placebo effect?’ I think there has been a bit of work recently that gives us a strong evolutionary biological argument on the nature of why humans believe and it has something to do with our genes.

Lorimer thought this would be a good spot to end this post because he has been advised by those in the know (ie Heidi) that we are close to the maximum recommended length of a blog post. So, the rest of what I have to say in this diatribe will be in the next post. Stay tuned…..

References

  • Watts, G. (2001). The power of nothing New Scientist (2292)
  • Damer, T. E. (2009). Attacking faulty reasoning : a practical guide to fallacy-free arguments. Australia; Belmont, CA, Wadsworth/CengageLaerning.
  • Evans, D. (2003). Placebo : the belief effect. London, HarperCollins.
  • Moerman, D. E. (2002).Meaning, medicine, and the “placebo effect”.Cambridge ; New York, Cambridge University Press.
  • Moerman DE, & Jonas WB (2002).Deconstructing the placebo effect and finding the meaning response.Annals of internal medicine, 136 (6), 471-6 PMID: 11900500

Firstly, thanks to the SportsMap for asking me to wrote this blog. I hope as least a couple of you out there can take a thing or two from it!

I first enrolled in Physiotherapy with the aim of working in elite sport. Thankfully, due to a combination of having clear goals, working hard and a fair bit of luck, I have managed to work full time in professional sport since 2010. I am often asked by other Physios about how to get a foot in the door in this area. The reality is that with more students enrolling in Physiotherapy courses than ever before, the competition for jobs is only going to get worse. I by no means have all the answers, but these are a few tips that might help you get an opportunity, and then hopefully allow you to make it a success.

I love working in elite sport. However, it can involve long hours, pressure situations, weekend work, dealing with an array of personalities, constant turnover of staff (including perhaps yourself), public criticism, politics and more. In my view all these potentially negatives are far outweighed by the positives, but prior to embarking on this path make sure you understand all that it involves.

HERE ARE MY 16 KEY’s BE SUCCESSFUL WORKING IN ELITE SPORT:

  1. You need to immerse yourself in the job and be always evolving. In this age of social media there is no excuse for not keeping abreast of the latest in sports science and medicine. From the time you begin university start to attend conferences and courses, & use social media to follow prominent people, journals and other resources that will add to your knowledge.
  2. Attempt to get experience working in sport as early as possible. I do not agree with the theory that one should work in a hospital first to ‘round out’ their education. Working in a hospital and sport are miles apart. Attempt to get work in a private practice, with good mentors that will take time to educate you and also have links to sporting clubs or organizations.
  3. Do not be afraid to network. Be prepared to write emails and call people that you think may be able to give you an opportunity. Showing a willingness to learn and work hard is important early in your career.
  4. The well known book ‘legacy’ states that ‘better people makes better all blacks.’ The same thing could easily be applied to Physio’s. If I am looking to hire someone, it is the impression I get of them as a character that counts for the most.
  5. Be familiar with the load requirements of the sport, and ensure when rehabilitating a player that you have them prepared to meet these demands.
  6. Coaches, players and other staff will often ask why you have a certain opinion, or how you came to a particular decision. Be able to justify how you go about things.
  7. Do not be a know it all. The best Physio’s I have come across are humble, always learning and realize that they do not have all the answers. Be prepared to listen, evolve, seek assistance and do not be offended when someone else challenges your view points.
  8. Being ‘just’ a physio is not enough. You should have at least a moderate understanding of other areas such as strength and conditioning & nutrition. This will help you be a better Physio and should allow you to build better relationships with staff in these areas… As long as you don’t tell them how to do their job!
  9. Each player is different. Work closely with other relevant staff such as the doctor and S & C to provide players with an individual physical preparation program that aims to maximize performance and reduce the risk of injury.
  10. When a player is injured focus on what they CAN do, as opposed to what they can’t. Be creative and always work around the injury. Use the rehab time as an opportunity to not only address the specific injury, but also to work in conjunction with the S & C staff to improve the overall physical characteristics of the athlete.
  11. Plan well and have key objective markers from early rehab all the way up until clearing a player to return to competition.
  12. Have a plan, but also be flexible and ready to adapt and deal with challenges and obstacles along the way.
  13. Ensure the athlete receives the same message from all support staff. Don’t be the guy that undermines the rest of the group and tells the player that you would be approaching things differently or that your colleague is wrong. Debate amongst staff is healthy, but this needs to be done in the correct manner.
  14. Be organized, document well and prioritize things that you think will best impact performance.
  15. Enjoy your job. Bring positivity to the group and don’t take yourself too seriously. Maintain high standards and keep professional relationships with players but don’t be afraid to have a laugh when the time is right.
  16. Maintain a healthy work / life balance. Work hard but also put aside time to relax and pursue interests away from the job. This will help you be more productive when at work and also minimize the risk of burn out.

As a young teenager, I was always with my older brother Ben. He was almost three years my senior and was a very promising young Australian Rules Football Player. He played in the elite underage competition that sees more young athletes drafted into the professional ranks (AFL) than any other in the country. For my brother, it was his big year to showcase his talents in hope of getting drafted.

Ben was training harder than ever to make his dream become a reality. It was then that I recall him starting to complain of sore shins.

I attended the local Physiotherapist with Ben who was eager to have his shin pain fixed. After a brief look, the physiotherapist told Ben he had "shin splints." The physio applied some ultrasound and told him to ice, stretch his calves & reduce his training sessions.

Ben reduced his training yet continued to play games whilst seeing the Physiotherapist weekly as recommended for ultrasound and soft tissue massage. Three weeks later, Ben become increasing concerned. His pain had worsened and his performance was suffering.

Ben eventually opted for a second opinion where it was revealed he had a bilateral medial tibia stress fracture. He missed the next ten weeks of the season leaving him only six games to prove his worth at a higher level. He was devastated.

What is the point of this story?

  • What if our local physiotherapist was more thorough in his early management and loading protocols?
  • What if our physiotherapist picked up a low-grade stress reaction in the first week and opted for three weeks strict rest?

As Physiotherapists managing athletes (elite or amateur), early accurate diagnosis and current evidence based management is paramount. The athletes career, dreams, goals and aspirations may depend on it.

Don't be the Physiotherapist that misses the fracture, misdiagnoses or mismanages. Your professional integrity rests on it! Invest in your career; invest in your learning, invest with Sportsmedicinephysiotherapy.com

100% attendees said they would highly recommend this course to their friends and colleagues.

The first of our Advanced Lower Limb Rehabilitation in Sport course was recently held in Perth, Western Australia with a huge success.

Experienced Sports Physiotherapists Anthony Hogan, Greg Mullings & Emidio Pacecca delivered a thorough evidence based and practical two day course at the home of Rugby WA. Excellent feedback by received by all thirty plus attendees which, included representatives from the West Coast Eagles, Fremante Dockers, Essendon Bombers (AFL), Western Force, Brisbane Broncos (Rugby), and the Western Warriors (Cricket WA).

Anthony Hogan delivered a full day on Groin Injury Rehabilitation. I will provide a brief summary of Anthony’s model here.

Session one from Anthony included a summary of the recent World Groin Injury Conference held at the Aspetar Sports Medicine Centre in Qatar. Anthony then gave a detailed look at patho-anatomy and the clinical entities of groin pain. This went much more than general anatomy. We explored the rectus abdominas- adductor longus (RA-AL) aponeurosis, nerve innervation and tracks, inguinal canal & superficial inguinal ring just to name a few.

This lead Anthony to describe his own Groin Rehab Model in which is used to guide his assessment & clinical decision-making.

There are four key entities in which Anthony broke down in a simple and easy to follow method.
1) Hip (joint) related
2) Hip Flexor Related

3) Abdominal/ Inguinal Related
4) Pubic Related

4a) Adductor related
i. Enthesis
ii. Pubic Plate/ RA-AL aponeurosis

4b) Rectus related
i. Enthesis

ii. RA tendon- Ligament
iii. Distal rectus Sheath

4c) Symphyseal related
i. Isolated
ii. Rectus- Symphyseal
iii. Adductor Symphyseal

Anthony focused on assessment in session two. Key points to come from his assessment included:

1) Establish likelihood of hip joint as a source of pain

2) Establish likelihood of hip flexor as a source of groin pain

3) Establish likelihood of inguinal as source of groin pain

4) If squeeze at 0, 45 & 90 are pain free but complain for pain on ADL= unlikely to be pubic related

If these three entities have been ruled out, the clinician must decipher the source of the pubic related groin pain. This differential, in Anthony’s model, can be explored by a number of groin pain provocation tests. This is a systematic approach in which can also provide insight into impairments. These impairments often fall in to one of the following categories.

1) Increased muscle tone

2) Decreased muscle performance

3) ROM impairments

4) Stability impairments

Session 3 three took place in the treatment rooms on the plinths. Anthony took participants through a measured & professional approach to accurate palpation of the pubic and adductor region. This followed with the opportunity to practice the pain provocation tests from the assessment module under Anthony’s supervision. Participants found this very helpful in order consolidate what they had learned from the morning sessions.

Session three concluded with an open discussion on three different case studies and the role of imaging in athletic groin pain. This was great time to explore how imaging does not always match the clinical presentation and a look at when & why we would use imaging in athletic groin pain.

Session four was solely dedicated to rehabilitation from groin pain, which was broken into six different phases with practical demonstrations of exercises and programs for each stage provided:

1) No Running

2) Straight Line Running

3) Multi Directional Running

4) Controlled Running

5) Uncontrolled Running

6) Return to Play

Anthony explored and discussed the following therapy options including when and when not to utilize as well as positives and negatives of each:

- NSAIDS
- Electrotherapy
- ICE
- Nutrition
- Dry Needling
- Manual therapy
- Injections- CSI, PRP, prolotherapy

Throughout the rehabilitation of groin pain, it is imperative to have key re assessment tests in order to monitor the athlete’s response to loading. Anthony advocates the use of the following tests:

1) Squeeze test to Pain or percentage of max

2) Pubic stress test (in modified Thomas test position) OR the side bridge

3) Hip muscle tone (Bent knee fall out)

The day was a comprehensive look at the ever-challenging facet of groin pain, rehabilitation and return to play. Anthony explores the intricate details required when dealing with complex longstanding groin pain making him the premier clinician of this topic in Australia. Don’t miss out on the next opportunity to learn from Anthony Hogan. See our event page for upcoming courses.

Thankfully the day concluded with a couple of relaxed beers and wine for the attendees and presenters to network and just enjoy each other’s company.

Nick Kane