- Developments in ACL surgical considerations
- Anatomical risk factors
- Bone bruising in ACL injuries & implications
- Chondral defects of the knee & management strategies
- Surgery Vs non operative management for ACL injuries
- Surgery for degenerative meniscus pathology
- Adolescents & ACL surgery
- Female sports and ACL rupture rates
- Physiotherapy & Rehabilitation considerations with post knee surgery
- PCL surgery
- Posterior lateral corner injuries of the knee
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.
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
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.
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)
- 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)
- 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.
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
- Joint effusion
- Loose bodies
- Ulnar neuritis
- Thickening of triceps tendon
- Thickening of ulnar collateral ligament
Posterior medial impingement or Valgus instability.
- More seen in elbow flexion
- 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
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
- Subluxation: get them to grip then supinate and pronate
- Differs significantly depending on diagnosis (Campbell 2013)
- Consider grip & wrist postures
- 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
- 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.
● 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.
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
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
Jurdan is a world leading expert in the space of hamstring and quadriceps injury prevention and rehabilitation. Jurdan is the current director of Zentrum Sport & consults for some of the best European Soccer Clubs. In this episode Jurdan talks to:
- Key components of this approach to hamstring rehabilitation
- Common errors seen in hamstring rehabilitation
- Power Force Velocity Profiling in hamstring rehabilitation
- Jurdan's greatest professional influences
- What to expect from our Masterclass events with Jurdan in Melbourne and Sydney
This episode is brought to you by IMeasureU
We hope you enjoy this episode of the Sports MAP Podcast. If you do, please let us know by leaving a review and sharing via twitter & Facebook.
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.
- 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.