- Hamish's thoughts on his experiences working as a head Physio in both professional rugby and the AFL
- What to expect from Hamish at the Upper Limb Rehabilitation in Sport course in the Gold Coast
- Posterior dislocation- what are the tell tale signs?
- Where early management is different between posterior & anterior dislocations
- Common imaging findings following both posterior & anterior shoulder dislocations
- Decision making around surgical Vs non surgical management following instability episodes (see further detailed notes below)
- Differences in post surgical management for anterior and posterior repairs
- Post surgical rehabilitation
- Early exercises & targets
- Time based expectations on restoring ROM and strength
- How & when to introduce pushing, pulling and over head
- How and when to take the athlete into venerable positions (Abd/ ER
- Testing or benchmarking in readiness for a return to play
- What is often missed in shoulder rehabilitation
- Contact based conditioning
- Occupation: overhead/manual labour vs sedentary
- Sporting demands – collision sports
- Co-morbidities/physical inactivity – prolongs recovery
- Evidence based surgical indications (reduces the chance of recurrence): Male <25 y/o with traumatic MOI, requires relocation + high functional demands = EBP supports surgical repair. Generally the risk factors from the literature for recurrent instability include: young age (<40 = 13x higher; majority occurring <25), being a male, contact sport. I would also include young females in collision sports in this category. However it is a discussion and as we discussed there is evidence that people in this group can have a positive outcome without surgery.
- Hypermobility:
- I always question the patient about their episode(s) – patients can use the words dislocation and subluxation synonymously. True dislocation or instability in the absence of dislocation. I always I always question the patient around the MOI and do they have imaging evidence of the dislocation (in ED)/needed someone to relocate the shoulder… If their story is accurate for the MOI then I generally believe them when they say their shoulder dislocated. If they haven’t had true dislocation, rather instability episodes – conservative treatment. Especially if you’re dealing with someone who has more mobility than the average (>4 Beighton’s).
- Traditional classification include the TUBS (Traumatic, unilateral, Bankart, Surgery) and AMBRI (Atraumatic, Multidirectional instability, Bilateral, Recurrent, Inferior Capsular Shift), however this 2nd population doesn’t do as well with surgery as was initially intended with this classification, so conservative path is the best here. A further classification system – The Stanmore Classification (diagram below) further stratifies it into 3 groups and the relationship between trauma, structure and muscle patterning – article attached. In short, group I relates to traumatic dislocation and structural failure, group II with structural laxity that can pre-dispose them to instability with or without trauma, group III to muscle patterning issues causing instability/resting subluxation. Surgery is indicated in group I and only considered in group II with structural failure and who have failed a good rehab program.
Reference article: Jaggi & Lanbert 2010, Rehabilitation for Shoulder Instability
- Bone stress injuries
- The energy deficit athlete
- Prevention systems in endurance athletes
- Reducing the incidence of patella tendinopathy in volleyball athletes
- Groin injury prevention
- What to expect at the Athlete Groin Pain Symposium in Sydney
- Isometric hamstring strength assessment as a screening tool
- Ongoing isometric hamstring strength deficit following hamstring injury
- Who owns injury & performance?
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher. We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
This episode is brought to you by KangaTech & West Coast Health & High Performance (Perth)
Endurance sport is one of the greatest tests of mental and physical toughness. During a marathon an athlete, on average, will complete 160-200 steps per minute. Whilst running has numerous benefits for our health and wellbeing, it can be monotonous loading on the skeletal system. Bony stress injuries account for up to 20% of running related injuries per year. It is believed that one reason for this is the repetitive overloading on runners’ bones. In comparison, activities involving irregular movements seem to foster greater bone health. The ultimate goal should always be injury prevention, so, should runners incorporate directional movements into their training repertoire for bone health?
Bone is an alive, adaptable, and dynamic structure. Our bone density increases as we grow and by 30 our density is at its peak. After this age we can only maintain what we have. Bone health refers to our bones’ mineral density and quality and is the result of a plethora of factors. In otherwise healthy runners, energy availability, biomechanics, training load and recovery, all play important roles in creating good bone health. Poor bone health can increase the risk of fractures during one’s developmental years and later in life.
There are two main theories that address the way in which our bones are loaded during running. The muscle-bone unit theory refers to the pulling forces created by a muscular contraction. The other references the ground reaction forces through bone when the foot contacts the ground, producing torsional and compressive load. Both mechanisms create macro-trauma which stimulates tissue production and shapes bones geometric structure. However, like other tissues in the body, the activity needs to be progressive otherwise the bone may become accustom and stop adapting. These principles may be used to help runners who may otherwise be stunting adaptation through habitual running load.
In general runners’ bones are healthier than sedentary people. Unfortunately, runners consistently demonstrate lower bone mineral density (BMD) when compared to matched individuals who partake in high impact and irregular movement based sports. A summary of the research of athletes (aged 14-30) found soccer, basketball and volleyball players as well as gymnasts, all displayed greater BMD than those who only ran. A study of young soccer players demonstrated that female players had healthier tibiae than runners and both genders had better density at the spine, femur and calcaneus. In separate studies of track athletes and infantry recruits those who also regularly participated in basketball had up to an 82% reduction in stress fracture risk. Interestingly, in masters athletes those who participated in sprinting had greater BMD than their peers who competed in long distance running. The benefits of diverse loading in youth were also found to protect runners later in life with some up to 50% less likely to sustain a stress fracture.
What seems to be more unclear is the ideal dosage for bony loading. Bone regeneration cycles are suggested to take 3-8months. Studies of humans, mice and turkeys found significant changes after as little as 3 weeks of a jump program. Repetition amount also widely varied between studies from 30 - 350 cycles per week. A study of adolescent females found that a 9-month plyometric program improved only greater trochanter bone strength. Another found plyometric training only benefited those who participated in low osteogenic sports such as swimming. Studies on structure found that rate, magnitude and activity resulted in site specific changes, however, no optimal values for load were presented. No well-known study was found to investigate an irregular, directional and high impact, loading program for the reduction of fracture risk in endurance runners.
It is important to note there are many other factors which influence bone health that have not been explored here. The body needs a plentiful supply of vitamin D and Calcium to build strong bone. To create an optimal environment for this rest and good sleep are also essential. For distance runners who are constantly in a state of low energy availability, bone loading has been found to have little strengthening effects and can be somewhat detrimental if added in addition to their normal training.
Runners want to run. Convincing them to do otherwise continues to remain a great challenge for clinicians, however, it would seem that some variety may strengthen their bones. Youth runners should be encouraged to participate in a variety of sports. Once specialisation occurs, a runner may benefit from incorporating direction and plyometric loading into their training. Unfortunately, the optimal dosage for this is largely unknown.
References
Beck, B. R., Daly, R. M., Singh, M. A. F., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. Journal of Science and Medicine in Sport, 20(5), 438-445.
Gómez Bruton, A., Matute-Llorente, Á., González-Agüero, A., Casajus, J., & Vicente-Rodríguez, G. (2017). Plyometric exercise and bone health in children and adolescents: a systematic review.
Gómez-Cabello, A., Ara, I., González-Agüero, A., Casajús, J. A., & Vicente-Rodríguez, G. (2012). Effects of training on bone mass in older adults: a systematic review. Sports Med, 42(4), 301-325.
Hart, N. H., Nimphius, S., Rantalainen, T., Ireland, A., Siafarikas, A., & Newton, R. U. (2017). Mechanical basis of bone strength: influence of bone material, bone structure and muscle action. Journal of musculoskeletal & neuronal interactions, 17(3), 114-139.
Hong, A. R., & Kim, S. W. (2018). Effects of Resistance Exercise on Bone Health. Endocrinology and metabolism (Seoul, Korea), 33(4), 435-444. doi:10.3803/EnM.2018.33.4.435
Kato, T., Terashima, T., Yamashita, T., Hatanaka, Y., Honda, A., & Umemura, Y. (2006). Effect of low-repetition jump training on bone mineral density in young women. Journal of Applied Physiology, 100(3), 839-843.
Nattiv, A. (2000). Stress fractures and bone health in track and field athletes. J Sci Med Sport, 3(3), 268-279.
Scofield, K. L., & Hecht, S. (2012). Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep, 11(6), 328-334.
Tenforde, A. S., & Fredericson, M. (2011). Influence of sports participation on bone health in the young athlete: a review of the literature. Pm r, 3(9), 861-867.
Tenforde, A. S., Sainani, K. L., Carter Sayres, L., Milgrom, C., & Fredericson, M. (2015). Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes. Pm r, 7(2), 222-225.
Vlachopoulos, D., Barker, A. R., Ubago-Guisado, E., Williams, C. A., & Gracia-Marco, L. (2018). The effect of a high-impact jumping intervention on bone mass, bone stiffness and fitness parameters in adolescent athletes. Archives of osteoporosis, 13(1), 128-128.
Witzke, K., & Snow, C. (2000). Effects of plyometric jump training on bone mass in adolescent girls. Medicine and science in sports and exercise, 32, 1051-1057.
Wright, A. A., Taylor, J. B., Ford, K. R., Siska, L., & Smoliga, J. M. (2015). Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. British Journal of Sports Medicine, 49(23), 1517.
The dream for many sportspeople is to forge a long and successful career as a full-time professional athlete. However, only very few are lucky enough to experience this, and many more athletes across the world end up showcasing their talents as a part-time or semi-professional athlete.
Rather than having the luxury of dedicating most of their time to training and recovery, these athletes are required to work full time jobs (often labour intensive), and then attend training sessions at the end of a 10 hour work day, with training loads very similar to that of an elite athlete.
This obviously poses a massive challenge to the athlete. Having to try and fit in work, training, recovery, family time, social time and sleep all in the space of a 24 hour day.
Managing these athletes can also be a massive challenge for the sports physiotherapists helping them to rehabilitate their injuries and keeping them out on the park.
As we know, load management is an integral part of progressing through a rehabilitation plan, and also helping to reduce the risk of any niggles or injuries. Over the past few years, even with limited resources at semi professional sporting organisations, physios and S+C staff have become much better at monitoring and analysing player loads from a physical, mental and emotional perspective. However, this is where the real challenge lies in dealing with players who work physical jobs throughout the day. For example, take a player who has suffered a calf strain 10 days ago. We can’t expect a player to tell us exactly how many times he has gone up and down the ladder during his work day as an electrician, but should this be a consideration in how much running he does at training that night?
For the athlete playing at this level, at the end of the day, their paid work is a higher priority for the majority of them over their ability to play sport. This often means that rehabilitation from an injury is compromised or lengthened in time, due to the pressures of having to return to work and feed their families. Take the athlete who has had an ACL reconstruction, but also works as a carpenter. The athlete will be eager to return to full time work as soon as they get the all clear from their surgeon, but will being on their feet all day and repetitively squatting cause a knee effusion that will then hinder their ability to perform and progress their strength work?
As their sport might not be their number one priority in their lives as mentioned, training consistency can also be a challenge in dealing with players at this level. Work and family commitments can sometimes clash with training sessions, with missed training sessions affecting their training load for that week, and potentially increasing their risk of injury in the coming weeks.
The emotional toll that having to fit so much into one day can take on the athlete, is also a vital consideration as a sports physiotherapist at this level. We are in a great position as sports physiotherapists to chat to players to ask them how they are coping. Whilst strapping their ankle, we can gain a lot of information about whether or not the athlete has a rough day or period or time, and whether or not they should have a lighter night on the track to help not overload their nervous system.
Many challenges and questions have been posed above, but the number one question is what can we as sport physiotherapists do to help semi-professional athletes overcome these challenges?
In my opinion, the best thing we can do here is to educate our athletes as much as possible, and focus on the ‘big-ticket’ items to allow them to stay at their best for as long as possible.
The ‘big-ticket’ items for me are:
- Sleep – As we know, sleep has been shown to be the most important recovery technique out there for athletes. Sleep is available to both professional and semi-professional athletes, so this has to be a priority.
- Importance of communication – Empower and encourage the athletes to communicate with coaches, S+C staff and physios so we can better monitor how they are dealing with the challenges of being a semi-professional athlete.
- Training consistency – Missing a 10km training session during the week and not making up for it, can often lead to an injury down the track from my experience. It is up to the S+C coach, physio and athlete to formulate a plan as to how to best make up for this session.
I am sure for those sport physiotherapists out there who work at this level with athletes, these are common challenges for you, along with many more that I have not mentioned. Because of these challenges, I find working with these athletes highly enjoyable and rewarding, and I hope you do too!
In this 12th Episode of The Sports MAP Podcast we chat with Edel Fanning (Phd Candidate) from the Sports Surgery Clinic in Dublin about Shoulder Rehabilitation and RTP from surgery for collision based sports. In this episode we talk to:
- Findings from Edel's recent study in RTP for Shoulder injuries
- Functional testing using force plates to guide decision making
- Isokinetic Vs isometric testing for Rotator cuff strength measures
- Addressing joint position sense in shoulder rehabilitation
- Force plate functional tests Vs ASH test
- Common errors in Shoulder Rehabilitation
- Targeting specific muscle function in Shoulder Rehab
- Laterjet Vs traditional stabilization surgery
- Psychological readiness to return to play
- Edel's key career influences
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
This episode is brought to you by KangaTech & Archies Footwear
Archies are offering all listeners of our podcast a 20% discount on any order. Simply use the code Sports_MAP when ordering from www.archiesfootwear.com
In this 11th Episode of The Sports MAP Network Network we chat with previous Head Physiotherapist for the England Rugby League team Dave O'Sullivan around Syndesmosis Injury Rehabilitation & Dave's Return to Play Systems for lower limb Injury.
- Early focus area's in rehabilitation of a Syndesmosis injury
- Strength assessment & criteria
- Dynamic calf assessment
- Lunge progressions & the importance of the peroneas tertius
- Hopping progressions
- Agility /offline progressions
- Troubleshooting
- Return to running prescription
- Return to play
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
This is episode is brought to you by Archies Footwear
Archies are offering all listeners of our podcast a 20% discount on any order (big or small). Simply use the code Sports_MAP when ordering from www.archiesfootwear.com
Welcome to the 10th Episode of the Sports MAP Podcast.
In this Episode we chat to St Kilda Football Club (AFL) Physiotherapist and director of the Hip & Groin Pain Clinic Andrew Wallis on the key aspects in the assessment, diagnosis and management of Hip Dysplasia including:
- What actually is Hip Dysplasia
- How Andrew developed an interest in Hip Dysplasia
- Subjective clues in assessment and key questions to ask patients
- Key objective findings to assist in making a clear diagnosis
- The importance of differentiating FAI and Hip dysplasia
- Pain drivers in hip dysplasia
- Imaging and radiological findings
- Management options available
- Setting expectations
- Conservative management and rehabilitation guidelines
- Return to running and sport
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
This is episode is brought to you by IMeasureU and Vald Performance
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:
- Absolute training volume: no studies linking absolute training volume
- 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.
- 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
- 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.
- 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:
- General conditioning AND
- 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!):
- Push press
- Hang clean
- 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.
In this 9th Episode of the Sports MAP Podcast we chat for a second time with Rehabilitation Specialist from Ireland Enda King about ACL Rehabilitation. Enda touches on many aspects of Rehabilitation with some clinical gold around the following key aspects:
- Key targets/ criteria in early, mid & late stage rehabilitation
- Specific exercise selection
- Errors commonly in rehabilitation and exercise technique
- Isokinetic testing benchmarks
- Linear mechanics and when to commence running
- COD mechanics & how to translate to the field
- Rate of force development prescription and testing
- Key jumping tests
- Changing poor movement patterns in a previously injured athlete
- The influence of fatigue in rehabilitation
- Return to sport
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.
This is episode is brought to you by IMeasureU and Vald Performance
In this 8th Episode of the Sports MAP podcast we chat about athlete monitoring and prevention strategies for hamstring and groin injuries in sport with Martin Wollin PhD. In this episode we cover:
- Injury prevention systems- What is primary, secondary & tertiary prevention?
- Adductor strength and ADD:ABD ratio's - relevant to injuries?
- Adductor strength monitoring- key components
- Hamstring power testing as a monitoring tool to mitigate injury risk
- How to manage to an athlete with reduced hamstring strength
- Is hamstring power asymmetry important for injury risk?
- Is monitoring athletes in a team sport setting really worth it?
- Martin's key career influences
- And more
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via Twitter & Facebook.
Listen to this Podcast via your favorite platform including Apple, Spotify, Player FM & Stitcher.
This is episode is brought to you by IMeasureU and Vald Performance
Show Notes/ References
- Athlete monitoring: a complementary prevention strategy for groin and hamstring injuries in elite football (PhD Academy Award)
- Effects of match congestion on hamstring strength & lower limb flexibility
- Monitoring the effect of football match congestion on hamstring strength and lower limb flexibility: Potential for secondary injury prevention?
- The effects of football match congestion in an international tournament on hip adductor squeeze strength and pain in elite youth players
- In-season monitoring of hip and groin strength, health and function in elite youth soccer: Implementing an early detection and management strategy over two consecutive seasons
- Reliability of externally fixed dynamometry hamstring strength testing in elite youth football players