Case Study: working through the pain with Nick Atkins

Nicks 30/30 challenge

A bit of an unusual blog from us, but I hope its as popular as our previous ones due to the message it contains. A very good friend of mine is undergoing a year-long series challenges to help raise money for a cause very close to his heart.

Below is a summary of the 30 challenges that Nick Atkins is doing, having turned 30 this year.

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Nick Atkins 30 / 30 challenges

I’m sure a lot of people will question the management of some of his injuries I’m detailing here because I’ll admit its not how I would typically manage these problems, so let me explain quickly why rest is not an option here:

Nick, along with his sister Jen & brother Jon, very sadly lost their mum, Judith Atkins, to pancreatic cancer in 2013. Pancreatic cancer has the lowest survival rate of any cancer. Doctors believe there is a period of remission around 5 years that if reached, the risk of the cancer returning is negligible. Judith was a few months short of this milestone before the pancreatic cancer aggressively returned. While we are generally winning the fight against cancer, pancreatic cancer remains the outlier and part of Nicks aim is to not only raise money for research, but also awareness. (Nicks justgiving page here). For this reason, he is displaying an incredible amount of grit and determination to complete these challenges, despite his body saying otherwise.

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Nick, certified drinking athlete. Pre-challenge training

A quick background into Nick, he is what his friendship circle would describe as a “drinking athlete” and certainly not a runner. So while some endurance junkies out there may do physical challenges like these regularly, Nicks starting position was certainly not one built on endurance.

Nicks injuries to date:

 

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Disclaimer – I have permission from Nick to share these details regarding his injuries.

 

The nature of Nicks challenges meant the timeframes were dictated by inflexible dates, making it very hard to periodize any training. So load management became critical, forecasting time periods where we could off-load but maintain a crucial level of fitness.

The first problematic injury(ies) was the bilateral plantafascia pain with right sided calcaneal fat pad irritation. This was the first time we had to make decisions about the program. Previous aches and pains in the lower limbs and back were manageable and its not in Nicks nature to complain. But this pain in his foot was affecting ADL’s as well as training. Typically inflammatory in nature and progressively increasing pain, it took him to the point where he couldn’t weight bear through his heel – but was still completing physical challenges.

Controlling the controllables:

Dropping or moving a challenge was not an option, so we had to sacrifice road running training and hockey for a period of two weeks. Nick maintained fitness via swimming and cycling (a lot) in the mean time we addressed some biomechanical issues in the foot. I say this very tentatively, because in fact it was a lack of biomechanical issues that we had to address. Nick was prescribed some permanent orthotics when he was about 16 for “collapsed arches” – in fact these orthotics were probably causing more problems than solving. Nick had good active control of the medial and longitudinal arches in both feet, so no evidence of a collapsed arch. These orthotics were encouraging him to laterally weight bear via some high density medial posting of the calcaneus & preventing any medial rocking after heel-strike. We removed these, added some gel heel cushions to his work shoes to help offload the fat pad and temporarily reduced running training, which seemed to resolve the pain after two weeks. Instead, nick ramped up the swimming and cycling as part of his triathlon training.

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Nature of the beast:

There have been times recently however where we can’t modify load. Nick is currently running with right sided Achilles pain and in the last week has developed sharp pain in his left groin which is present following a rest at the end of a long run. This presented us with a problem; a month of 10k’s, with half marathons immanent and full marathons on the near horizon. Nick can’t afford to rest.

Typical management of tendon problems would be modifying load along with addressing strength. There was a dramatic difference with single leg heel raise between left & right. Temptation would be to add some exercises here to address this, but we need to acknowledge the accumulative load and consider if there would be any benefit. We decided that the back to back events could in themselves serve to maintain fitness, so we could drop a training session during the week.

The other consideration is where & when Nick is getting the pain. The Achilles pain is only present with compression, so with full plantaflexion – recreated both actively and passively, which makes me suspect a retrocalcaneal bursa involvement. We know that tendons don’t like compression but the absence of any Haglunds deformity and with adequate, well fitting running shoes there is reason to think the tendon may not be a source of symptoms. (See my previous tendon blog here with references).

The pain has stayed at the same level for over 4 weeks now, so we have identified an upcoming gap in events as a window to unload and reassess. In the mean time we can achieve short term relief with soft tissue massage to the gastrocs and some tib-fib, talocrural and subtalar mobilisations.

The groin on the other hand presents like a classic tendinopathy and we were able to exclude any pubic synthesis involvement via a series of tests. This injury was a lot more acute in nature compared to the Achilles. We tried some isometric adduction through different ranges of hip flexion and achieved some short term reductions in pain. Once again, we had to sacrifice some hockey training to try and reduce load and cutting actions in the groin, but in place of this we added isometric groin squeezes into Nicks program.

What’s next?

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Nick & his wife Cat, who has done every challenge with him so far & ironically is conducting her PhD in tendon pathology.

At the time of writing, I have my fingers crossed as Nick is running a “True Grit” obstacle course with his dedicated wife, Cat, who has done every challenge with him so far! (Except the 100 different beers in a year).

With some half marathons and marathons coming up, along with long distance treks I’m anticipating an update to this blog in the summer. Like I said, the plan now is to highlight a window of relative rest where we’ll do some detailed analysis of the right leg in particular. Overall though, I’m incredibly impressed that someone with no endurance running experience has had so little problems. It wont be typical management that’s for sure – while there are long term goals to be met, performance is not the main driver. I’m used to managing similar problems with a view of being pain free, able to perform at high level and minimising the risk of re-injury. So some of this management may not appease the purists, I understand.

For Nick, however,  there are no specific performance targets to be met, it is just essential that he finishes. He’ll do that without my help because of the level of determination he has, but my job is to try and keep a lid on the severity of injury (he insists 90 days without a hot drink is harder than any marathon or combination of marathons).

But the description of Nicks injuries & management are secondary to the fact that hopefully I’ve helped promote Nicks challenges and ultimately an awareness of Pancreatic Cancer. For that reason, if you’ve read this far please help share Nicks challenge.

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Nick & his mum, Judith.

https://www.justgiving.com/nicks3030challenge/

On behalf of Nick, yours in sport

Sam

ps – the 30th challenge is yet to be decided, Nick wants to make it something special so please send us your suggestions!!

 

Motor learning theories – why should progression stop at physical?

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As a younger physiotherapist, I don’t think I ever consciously paid attention to the psychological aspect or power of my job. By that I mean, I didn’t read any research around it – it all seemed a bit wishy-washy and non-tangible. But quickly you realise that a verbal cue that just clicks with one patient turns into a complex dance choreography with another.. “No, I just wanted you to bend you knee.. why are you doing the worm?”

I’ve talked before about the clinical reasoning behind exercise progression and regression and in doing so, I skimmed the surface of the addition of intrinsic & extrinsic stimuli.  So now I want to build on the concepts of motor learning to underpin that exercise progression.

My inspiration for this blog came from a couple of podcasts by the PT Inquest gang, Erik Meira (@erikmeira) & JW Matheson (@EIPConsult). Well actually, first I bought a chinchilla, then I wrote this blog. If that doesn’t make sense, don’t worry. It doesn’t. But listen here (PTInquest).

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The gents speak in detail on two particular podcasts about non-linear pedagogy and how this teaching concept & theory of motor learning ties in with implicit learning. I will break down the idea and definitions shortly, but the reason I wanted to blog about this rather than just direct listeners to the podcast, is I feel the motor learning concepts need to be progressed just as much as the physical demands of an exercise are considered.

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What are we talking about?

Ok so breaking down some of the terms. Because from first hand experience, these terms can be confusing. Cap in hand moment but, I Published a model to explain exercise progression (here). You will see I have described implicit & explicit learning – where in fact I mean intrinsic and extrinsic. Very different things, here’s why:

Intrinsic exercises – relies on internal feedback mechanisms, such as capsuloligamentous structures – Pancian & Ruffini receptors within joint capsules providing proprioceptive feedback that the athlete is acutely tuned into. A good example is a single leg stand where the athlete is consciously thinking about balance, aware of every movement in the foot & knee, the upper body and arm position etc – those exercises where nothing else in the room matters apart from the mark on the floor you are concentrating on to keep your balance.

The opposite to this are Extrinsic exercises – these revolve around the athlete and their environment. A snowboarder reacting to a sheet of ice after carving through powder, or a downhill biker absorbing the changes in terrain – their thought process is very external. Its about the factors they can’t control. At no point (or at least for an extremely limited time) are they consciously aware of their scapular position or degree of knee valgus, for example.

Explicit teaching – This is probably something that is easy for us to relate to. It’s a teaching technique that most of us are comfortable with because we can achieve quicker short term goals. “I want you to put your feet shoulder width apart” or “keep your knees in line with your second toe during the squat” – very clear instructions that require the athlete internalise their thoughts, suddenly their actions become intrinsic. But we get quick results in line with our (not necessarily their) goals.

Implicit teaching – this is a bit more tricky. It is giving the athlete non-directive instructions with the aim of externalising their thoughts. “When you jump onto that box, I want you to land as quietly as you can” or as the PT Inquest lads say “Land like batman” (in the batman voice). If you are encouraging effective change of direction, Conor always says “Push the ground away with your foot.” We are still giving instructions, but the athlete is thinking about external environment; noise, surface contact etc.

And this is where non-linear pedagogy comes in. Creating learning environments for athletes to explore movement variability. After all, that perfect text-book single leg squat we spent weeks mastering isn’t going to look so perfect on a skier trying to regain their balance. Chang Yi Lee et al (2014) use the example or learning a tennis stroke – comparing linear pedagogy of prescriptive, repetitive drills versus non-linear pedagogy of more open instructions like “make the ball arc like a rainbow.”

Think shoe lace tying - easier to learn with the rabbit going round the tree etc
Think shoe lace tying – easier to learn with the rabbit going round the tree etc

 

How does this fit into progression?

The ideal scenario is for the athlete to have as little reliance on us as therapists or coaches as possible. We wont be following them around the track, or on the pitch reminding them of their pelvic tilt.

I think the concepts of non-linear pedagogy are brilliant to explore with coaching. Working with young athletes for example that are still developing their motor control and have some fantastic imaginations to tap into.

However with a rehabilitative role, I think we need to be more inclusive of all concepts. Learning of a new task is initially rapid but without the addition of further stimuli it can quickly plateau (Gentile 1998). A rehab program should always be low risk, high demand (Mendiguchia & Brughelli 2011).Consider the pathophysiology and the structures injured. No injuries happen in isolation, if muscle is injured we will have some neural limitations also. The presence of swelling and inflammation decreases cell metabolism along with a decrease in the presence of oxygen; so we can assume that proprioception is reduced and risk of secondary injury is high.

Therefore, following injury, it is always a good concept to assume that skill level has regressed to novice, regardless of the level of athlete pre-injury.

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“So whats the knee brace for?”                                             “Well you only had your surgery 2 weeks ago – just being safe”

What if we were to encourage intrinsic, explicit, linear pedagogy exercises in the early stages? We don’t need to be adding external stimuli at this stage. It’s important to internalise in order to rehabilitate proprioception. You can’t safely expect someone to externalise while proprioceptively deficient – as soon as someone can weight bear, we don’t start throwing them a tennis ball whilst stood on a Bosu (I hope!)

As the injury improves and skill levels progress, it is then important to move our instructions towards non-linear pedagogy methods, encouraging extrinsic thinking via implicit instructions. By end stage rehab, our instructions should be “start – stop” and hopefully not much more.

Just as we would progress the demand of physical activity following injury, we should really progress the cognitive demand also – but we need to start from a safe, effective position in acute stages.

Yours in sport,

Sam

Massage: A case for the defence

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Just because we can’t prove what something does, doesn’t mean it doesn’t do anything.

The older I get, the more I read, the less I know. I know that for a fact. But recently I’ve started re-reading around the topic of massage and its place in sport and recovery. And with my critical head on, the one thing that I can consistently critique is the literature. The methodology, the participant population, but not necessarily “Massage” itself.

A good starting point for this defence would be to read the antithesis for this blog, a great blog by @AdamMeakins (There is no skill in manual therapy). Adam makes a valid point that there is not a strong background of evidence to support massage. Agreed. And its worth pointing out that a large, very large, part of my practice is exercise based rehab – I’m a strong believer of “move well, move often”. However, massage is a very well used tool in my pocket of possible treatments, so I’m going to fight for the underdog.

Below is a summary of terms / applications commonly used with recognised massage techniques (not an exclusive list).

Table 1: A summary of western massage techniques (Weerapong et al)

Technique Definition Suggested Application Proposed clinical effects
Effleurage Gliding movement over the skin in a continuous movement Beginning & end of a session Stimulates the parasympathetic nervous system, promotes relaxation and enhances venous return.
Pretissage Lifting, wringing, squeezing and kneading of soft tissue. Following effleurage Mobilise deep muscle and subcutaneous tissue. Increases local circulation and enhances venous return
Friction An accurate penetration of pressure applied with the fingertips Used for specific purposes, such as reducing muscle spasm or breaking down adhesions. Break down adhesions from old injuries
Tapotement Various parts of the hand striking the tissues in a rhythmical but rapid rate Before and during competition Stimulation of tissues either by direct mechanical force or by the reflex action

 

The problem with Evidence Based Practice:

I think that all medical professions are dependent on research to ensure our practice evolves for the better. But I think sometimes we overlook the importance of anecdotal evidence. It must be considered that not all aspects of sporting competition depend on physical attributes, the mind and perceived benefits of treatment play an important role. The majority of people that go back for massages are because it made them feel better. Maybe not during, but after. A prime example, my wife never says “Can you give me an exercise program for my neck & shoulders please?” But I know that anecdotal evidence on its own doesn’t wash.

So here is where I think the literature lets massage down. The effectiveness of massage will vary depending on duration, method and depth of pressure (Drust et al) however none of these variables have been standardized making comparisons between studies very difficult (Mancinelli et al).

Jönhagen et al investigated the effects of sports massage on recovery following eccentric exercise. 16 “recreational athletes” (I have issues with this terminology for a start) were asked to complete 300 maximal eccentric contractions of their quadriceps using a Kin-Com dynamometer. Subjects received a pretissage massage once a day for 3 days before re-testing single leg long jumps to analyse “functional recovery”. SHOCK – The study found no improvement in function following massage.

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@ConorMcGoldrick has been quiet on blog front, but promises he is still working hard in the gym. Trying a new technique of 300 eccentric max contractions

 

  • Firstly, it may not be possible for one to truly maximally contract for such a high number of repetitions, therefore cannot be considered functional for an athlete; professional or recreational.
  • Secondly, name a sport that requires 300 maximal eccentric contractions in succession. Even an eccentric dominant sport like basketball would be interspersed with periods of rest and I don’t imagine basketball players would define those eccentric actions as maximal.
  • Thirdly, pretissage is a deep and firm technique, the use of which immediately following 300 eccentric contractions and continued for 3 days is more than likely going to cause mild muscle trauma. Not exactly a therapeutic choice for a tissue with acutely induced micro-trauma.

In another study investigating fatigue, Zainuddin et al studied the effects of massage on the upper limb following 60 maximal eccentric contractions of the elbow flexors of a single arm in 10 healthy subjects (5:5 M:F). The results indicated no significant change between the two arms in isometric & isokinetic strength and torque, but it did find reductions in muscle soreness and swelling. The lack of significance in the results may be due to measurements, including maximal strength, being taken before, immediately and 30 minutes after, and at 1, 2, 3, 4, 7, 10 & 14 days after, which may have been too many re-assessments of maximal strength following eccentric activity. Also, the 10 minute massage protocol consisted of 3 minutes frictions to the major muscles in the upper limb. As explained earlier, frictions are designed to promote inflammation, not to promote recovery!

The point of these studies was to investigate the use of massage in recovery from sport. Eliciting DOMs in untrained subjects and concluding that they still hadn’t returned to baseline in 3 days is not representative of the demands you will be faced with in sport. For the most part, the athletes are familiar with the exercise, so apart from pre-season or the introduction of a new exercise technique, DOMS is relatively rare throughout a season.

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No blog on massage would be complete without mentioning Lactic Acid

Fatigue is believed to be determined by the accumulation of lactate in exercising muscle (Monedero & Donne). However, the notion that lactic acid (consisting of lactate ions and H+) is detrimental to muscle function is derived from early findings on amphibian muscles, in which acidosis is more pronounced than mammalian musculature. These early studies were conducted at 10-20°C, when they were repeated at 25-30°C the effects of acidosis were abolished (Cairns). Studies on human skeletal muscles have shown a positive correlation between increased lactic acid and muscle fatigue, but what is usually overlooked is that there is also a relationship between fatigue and a decrease in ATP, increases in inorganic phosphate and increased ADP, as well as decreased nitrous oxide and reactive oxidative species (Franklin et al) – so why do we bang on about lactate clearance all the time?!

There is now a belief that lactic acid may have ergogenic effects on performance. It is well known that acidosis stimulates the Bohr effect, whereby H+ causes the release of oxygen from haemoglobin, which stimulates increased ventilation, enhanced blood flow, and an increased cardiovascular drive. (Cairns). Despite this recent shift in opinion, many studies still believe lactate to be detrimental to performance, and investigations continue into the most efficient method of lactate removal.

Monedero & Donne investigated different recovery strategies after maximal exercise using 18 trained cyclists. It was concluded that a combined treatment of massage and active recovery was significant in aiding future performance compared to passive recovery, active recovery or massage alone. Despite quoting in the introduction that “the role of lactate in fatigue is questionable”, the removal of lactate forms the bulk of the conclusion as to why massage alone was not a viable treatment for recovery.

 

Judging a fish by its ability to climb trees:

I mentioned earlier that I have reservations over the term “recreational athletes” – its unclear if this is an accepted scholarly word for “weekend warrior” or if its 3-times-a-week gym goers at the local spa and health club. Even so, the use of these participant populations to make assumptions on elite sport should be taken with caution. So should the use of athletes asked to perform unfamiliar tasks. Robertson et al used cycling to exhaust 9 male subjects and found no significant effect with blood lactate clearance following 20 minutes massage. However participants were from field based backgrounds such as football, rugby and hockey.

A study by Mancinelli et al investigated the effects of massage on DOMS using female athletes. 24 volleyball and basketball players underwent a vigorous strength and conditioning training session to elicit DOMS. The study found that the massage group (n=12) had significant increases in vertical jump scores (P=0.003) and decreased levels of perceived soreness (P=0.001), while the control group significantly increased their shuttle run times (P=0.004). The study that used functional tests appropriate to the subjects sport found favourable results for massage.

More recently, in a series of studies Delextrat et al (and again here) compared the benefits of massage alone and in combination with other recovery modalities (stretching; cold water immersion) using basketball players. Again using measure specific to the sport. While I question the conclusions about different reactions between sexes (9:8 M:F), there was significant improvements in interventions compared to control groups, supporting the use of massage as a recovery modality.

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So what do we think massage might do but we can’t prove?

“Massage therapy modulates the autonomic nervous system” – Franklin et al

The good thing about the Franklin paper is that it looks at potential systemic effects of massage, in particular the vascular endothelial function of the upper limb following lower limb massage – and they found a single treatment of massage had an immediate (90mins) parasympathetic nervous system response, characterised by reduced heart rate and reduced systolic blood pressure.

We think that massage, administered appropriately with appropriate techniques to suit the situation, may:

  • Decrease pain (Mancinelli et al; Delextrat et al)
  • Reduce swelling (Weerapong et al)
  • Improve mood state (Hemmings et al; Robertson et al)
  • Increase range of movement (Rushton et al)

I would question the last point – for how long does this influence last? Do we actually increase length? Or do we restore it following a loss of range (injury / pain / change in tone following exercise)? I don’t think even regular massage is enough to encourage creep deformation on tissues, but I’m more open to a change in tone to achieve an optimal length / range.

 

Conclusion:

Therapists working within a sports setting often have to adapt the duration of a massage depending on the number of athletes that require treatment, the number of clinicians available, the seniority of players (!) Clinical based MSK therapists may also be restricted by time constraints. There is also a dearth of techniques and combinations with other modalities to chose from. Two therapists performing the same technique will apply different pressures for different durations in slightly different directions possibly over different tissues. I can see this being an argument against, but its for this reason that its very difficult to measure and quantify effectiveness. To create a sturdy study design, you end up being far removed from how clinical practice actually operates. My point is, although it is important I don’t think you can base an opinion of an intervention soley on published literature.

A lot of the literature with non-significant findings will question the use of massage in clinical application, but I can’t think of any occasions where the intervention has caused a detrimental effect! This leads me back to my first sentence.

Just because we can’t prove what something does, doesn’t mean it doesn’t do anything.

Remember that the field I practice in means I’m exposed to athletes for long periods of time through the day and through the week. As a proportion of that day, massage does not make up a large percentage of treatment time. Gym based, movement optimisation does. So I’m not saying we should all go and massage every athlete and patient that requests it. Like everything I think there are certain individuals that benefit from certain techniques and methods. Given time restraints in an outpatients clinic, it may not feature at all as part of my treatment. But regardless of the size this cog plays in the treatment machine, I believe its a valuable one.

Little-cogs Yours in sport

Sam

Pitch-side management in sport: a POV from a bucket & sponge man

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Although it only forms a small percentage of our working week, the thing most people associate with physio’s working in sport is the match day, and the infamous bucket and sponge! When we watch the TV at the weekends, this is the closest we ever get to seeing a physiotherapist working in professional sport. We don’t see all the early morning meetings, assessments, rehab programs, maintenance treatments etc.

I have to admit, rightly or wrongly, it is the least enjoyable bit of my job. I can’t remember the last time I enjoyed watching a game of sport whilst I was working. Wincing at every tackle, losing track of the score back in my rugby days because I’m too busy counting the players get up from a ruck and constantly running through scenarios and management in my head. However, it is the money end of the job. The games are all about why we do what we do.

I feel bad for physiotherapists trying to break into sport, I’ve been there and done it, working evenings and weekends covering training matches and weekend games and essentially not doing very many of the skills I’ve been taught at University or on the courses I’ve dished out money for. Essentially, you are a first aider. I try and make our part time work at the club as attractive as possible in other ways, with CPD, shadowing, training clinics etc because I know its not the glamour and jazz that people think when working for a pro club.

Like it or lump it, its a huge part of the job. So, what do we do when we run on mid game? Like all aspects of our job, there should be an element of clinical reasoning behind what we do. What are we actually asking? And why do we ask it?

For the sake of keeping the blog concise and not too heavy reading, I’m going to talk about your more routine injuries, which can sometimes create harder decisions. For the management of cardiac, spinal, airway stuff make sure you go onto a proper trauma course to get your qualifications!

 

Stop ball watching

The first habit I had to break when I got into sport was to leave the armchair fan mindset at home. I started off in rugby before moving to football and was lucky to have a brilliant mentor from the start, Clare Deary, who quickly taught me to look away from the ball. Instead your watching the knees and ankles of the forwards in a line out, or checking the prop gets up after the scrum has collapsed. One of the Maddox questions we ask when we check for head injury is “what is the score?” or “who scored last” – in my early days I was asking this without knowing the answer, so if they spoke coherently that was good enough for me.

It is a little bit easier in football because there are typically only two people involved in the tackle, but still don’t get caught up in the game. It important to watch the movement of players, those with known previous injuries or knocks sustained earlier in the game. Are they worsening or improving?

The run on

Ever consciously changed your walk or run because you think people are watching you and all of a sudden you lose all motor patterns and co-ordination? Well when the game stops for an injury, everyone is watching you. If the player is rolling around on the floor screaming in pain, you already know they are conscious and their airways are well maintained, so don’t worry about your 100m sprint time for these cases. Save that for the motionless players.

Approaching the player

The location of the injury will obviously affect your approach, head or spinal injuries aside, I always approach the feet first so the player can see me and I can continuously assess their level of pain, respiratory rate, shock etc. As well as asking “where does it hurt” always make sure you double check other structures, don’t be lured by the pain. Someone landing on their shoulder could always have a neck or head injury.

“You are not trying to diagnose the problem there and then”

When questioning the player, remember its not a consultation in the clinic. You are trying to determine “is it safe for the player to continue” and “will a labouring player cost the team tactically”. If they are missing tackles that they would usually make, or misplacing passes that they normally wouldn’t you firstly run the risk of putting them into scenarios that could cause another injury as well as potentially costing the team.

BHAFC pitchside

Try to determine the irritability of the pain early on. Has it changed since the game stopped to the point of you arriving at the player? If its worsened, despite not moving, that would suggest a rapid inflammatory problem. In which case you really want to be removing the player from the field of play to reduce the risk of secondary injury. If the pain has settled or gone in the time its taken you to consciously jog perfectly across the pitch without falling over, you can probably proceed with some more vigorous testing.

Providing you’ve excluded any fractures, check what the athlete can do with the injured structures ACTIVELY before you do any passive movements. If they are reluctant or guarded with any movements thats enough of an indication for me not to do any passive movements. Why force them through a range that they consciously don’t want to go through?

Walking the green mile

So you’ve establish that they are alive, there are no fractures, they can actively and passively cope with movement, by this point the referee is probably in your ear to make a call quickly. In football, if you have entered the field of play, the player is expected to leave before kindly being invited back on by the ref. This is a good time to continue your assessment as you the leave pitch.

Can the player get themselves up from the floor unaided? Can they weight bear? Can they walk? Does walking ease the pain or make it worse? If they can walk off, assess their ability to jump / hop / run / jog on the sideline.

By this point, you have to go with your gut instinct. If any of the assessment so far has thrown you into doubt, you probably have a good reason to remove that player from the pitch. Consider the structures involved, the presence of any swelling, the compensatory movement patterns that you may have noticed leaving the pitch. I usually ask myself what I would prefer to manage out of two scenarios:

1) Substituting a player that reports to clinic the next day with no signs or symptoms of injury, but is a little p*ssed off because you wouldn’t let them play (or a peeved coach because you’ve taken their best player off the pitch).

2) Allowing a player to go back on that has given you doubts and they break down in their next sprint / action on the pitch. They walk into clinic the next day and you have to tell them they are out for 6-8 weeks.. Your coach is definitely going to be more peeved today than they would have been pitch side, I can assure you.

Vincent Kompany

This isn’t to say you remove every player from the pitch that has an injury. The mechanism of injury will have a big say in determining your thought process. For example you may be more lenient with an impact injury that is smarting a bit compared to a non-contact mechanism of injury.

Key Points:

So, chances are this has made things a lot less clear about pitch side assessment.. Unfortunately there is no algorithm to determine whether a player should continue or come off. Every individual player is different and every injury is just as individual.

  • Is it safe for the player to continue – consider secondary injuries caused by swelling / decreased proprioception, as well as the initial insult worsening.
  • Will a hampered player on the pitch cost the team tactically.
  • Whats the worst that could happen if you remove them from the pitch. This can be made easier if you are working with younger ages that perhaps have a rolling sub system, giving you more time to assess. Also, consider the implication of the game / event. A once in a lifetime shot an olympic medal may be worth the risk of a secondary injury. A community level tournament in kids rugby might make you a bit more conservative.
  • This is only discussing minor knocks and strains. If you are working pitch side and haven’t done or updated your trauma course, make sure you do! Don’t put others health at risk at the same time as your professional credentials. (lubas medical / AREA or RFU are good courses to check out)

I’d be really keen to hear peoples thoughts and experiences with this topic, I’m sure there will be some disagreement with my thinking and methods. Or perhaps people have seen some incidents of players returning to the field when they shouldn’t (I’m thinking the FIFA world cup 2014 with numerous head injuries, but concussion is a separate blog altogether I think).

 

BHAFC

 

As always, Yours in Sport

 

Sam

Exercise Progression & Rehab Programs

A year or so ago, I put on a CPD evening for our part time staff at the football club discussing exercises and the clinical reasoning behind developing a program (needless to say I got talking about the use of clams for a quite a while – clam blog). In this presentation, I started drawing my reasoning process onto powerpoint using some coloured blocks to help visualise the theory that I was trying to describe.

The theoretical model was recently published in Physical Therapy in Sport and I thought I would use this blog to try and discuss it in a less formal way than the writing style allowed in publication.

 

The model (here) is designed to be fluid and adapted to any individual by any level of clinician. Let me quickly introduce the components:

Model
A theoretical model to describe progressions and regressions for exercise rehabilitation (Blanchard & Glasgow 2014)

 

  • The triangular blocks (1) represent the fundamental exercise, the core ingredient that will remain throughout the progression. The arrows running up the side of the triangles represent an ongoing progression throughout the rehab process such as speed, duration, repetition etc. So basically, something that can’t be affected by the stimuli that are added or removed. If you add an unstable surface to an exercise, you can still progress by increasing the duration.
  • The coloured blocks represent a stimulus that will help the exercise progress. This can be one of two things;
  1. Internal – something that the patient has to focus on intrinsically. A decreased base of support for example, where the patient must focus on the balance element of an exercise.
  2. External – the addition of something to the exercise that takes the patients focus away from the movement or action they are performing – adding a ball to a running drill, or a verbal command that initiates a change in direction.

The blocks are interchangeable and can be added / removed at the clinicians discretion.

  • Adding a new block, which will progress the exercise, is accompanied by a regression of the “gradient” on the blue triangle. Creating a step-like progression across the model. As you progress with an internal or external stimulus, its important to bring the difficulty levels back down, so reducing repetitions or speed or duration. This allows the pateints to adjust to the new stimuli without fear of re-injury or task failure. When teaching a child to ride a bike with stabilisers, you don’t take them off and ask them to cycle at the same speed you did with them on. For that reason, you wouldn’t get someone going from 30 reps of a hamstring bridge straight into 30 reps on a single leg bridge as a progression. You would decrease base support and reduce reps to allow adaptation.
  • Adding a “block” doesn’t mean you have to add something to the exercise. The block represents a step up in their progression. So progressing from two legs to single legs is technically “taking away base of support” but is an addition to the ongoing progression.

 

Lets use an example, recently I started designing a program for a teenage footballer with a proximal adductor strain. New to professional football with no history of conditioning.

In the sub-acute stage, once intial pain had settled, we began looking at his movement patterns and stability and noticed a huge imbalance with his left sided control through sagittal and transverse planes compared to his right. He is left footed, so his plant leg (right) is used to supporting his body weight.

His body awareness and “physical literacy” was so poor we had to regress him right back to basics. The following represents a small proportion of a larger exercise program. I’m not usually an advocate of planks in a multidirectional sport like football, but in this case, his single plane control was so poor that I swallowed my pride and began with basic planks.

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When I say basic, we reverted to short lever planks with the knees on the floor – this was the only was we could get him to control the relationship between his trunk and pelvis. Looking at the model, this short lever plank would be the singular blue triangle at the start (1). We built up the duration of the hold from 30 seconds to 90 seconds over time. This would be the arrow running up the gradient of the triangle.

 

The addition of the first block (2) was to increase the length of the lever so that he now has to hold a traditional plank. In doing so, we dropped from 90s hold back down to 30 seconds and over time, built up to 90s. (These are just arbitrary times, based on no real evidence).

 

The next block we added was a rotational element (3), but to ensure the progression wasn’t too sharp, I removed the long lever and returned to a short lever position. I then asked the player to move a light 1.25kg weight from his left side, with his right hand and place it on his right side. Then with his left hand etc etc. The purpose of this was to introduce a transverse task to a sagittal plane activity – as the arm moves from the ground and across the body, the player has to control the rotation through his trunk and avoid rotation at the pelvis. Instead of duration, we built up repetitions over time.

 

Now that we were confident he could hold a plank, and control rotation in a short lever plank, we could combine the two blocks as the next progression. Now in a long lever plank with a rotational element.

 

The next progression was to add an unstable surface (4). To do this, the player performed a plank with his thighs on a gym ball. This in itself was quite easy so we instantly added a rotational component with an unstable surface, gym ball pelvic rotations (see video here). So now on the model, we have the basic “plank” triangle at the top, a block underneath to symbolise the long lever, another block to symbolise rotational control and a third block to symbolise an unstable surface.

 

“The length of time required by an individual to master a task has

been described as a linear function that begins quite rapidly with

the introduction of a new task and then plateaus or slows over time

as practice continues (Gentile, 1998).”

 

 

This is a very simplistic example of how the model works, but hopefully it demonstrates the fluidity that is intended with it and how the blocks are interchangeable and can work independently or as part of a more complex progression. Every program you write will be individual and the progressions will be different, therefor every model will look different. Some will continue longer than others, some may be shorter than the one I’ve described here. Some will end up with taller columns due to the number of progressions. The width of one column compared to its neighbour may be different size due to the length of time it takes for the patient to master. And so on and so on. If I continued, hopefully I could have ended up with the player doing this:

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But whats the use of that defending a counter attack?

 

Like many conversations I begin or poor jokes I tell, this may be one of those things that only makes sense in my head, but I would love to hear if it makes sense to others – if you think it works and examples of doing so.

 

Yours in Sport

 

Sam

 

 

Case study: “Bulls Eye Lesion”

Every now and then in clinic you come across an injury that doesn’t quite fit “the norm” in terms of its recovery and management. I know every injury should be considered unique and every individual managed differently, but I thought I would share the management of this particular injury as it did prove tricky, we did fail a couple of times but eventually we got it just right.

 

Background:

This case study revolves around an 18 year old central midfielder, skeletally mature (no increase in height throughout the year / evident secondary sexual features) with a regular playing and training history prior to this injury. The presentation started in the autumn, after a complete pre-season and a good few weeks of competitive season underway. The player was in & out of training with a niggling groin / quad but with nothing substantial showing in assessment (the benefit of hindsight would be a very good money earner for any clinician that could harness it and set up a course!)

Towards the end of an under 21 game, the player was visibly struggling with pain at the top of his thigh, unable to sprint or strike a ball but 3 subs had been made, so he was inevitably staying on the pitch. At the end of the game, there was pain on palpation of the proximal rectus femoris and sartorious region. At this stage, there was nothing more to assess – there was no point, we would only aggravate something without actually learning too much more.  He presented the next morning with visible swelling in a small pocket of proximal thigh, palpable crepitus and pain with straight leg raise at 20 degrees.

 

Review of anatomy

The rectus femoris is a long fusiform muscle with TWO proximal attachments. The Direct Head attaches to the AIIS and Indirect Head attaches to the superior ace tabular ridge and the joint capsule. It has a long musculotendinous junction, as such can execute high velocity shortening as well as coping with significant length changes – remember it is a two joint muscle crossing both the hip and knee, with an action like kicking it must cope with hip extension coupled with knee extension during the pull-back of the kick, so both ends of the muscle are undergoing an eccentric load (Figure 1). The muscle structure itself is made up of mostly type II fibres so this high eccentric load makes the muscle quite prone to injury (Mendiguchia et al 2013 source).

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Figure 1: Demonstrating the demands on rectus femoris during a kick

 

“Bulls eye lesion”

The term “Bulls eye lesion” was coined by Hughes (1995 source) following the presentation of injury on MRI (Figure 2). The high signal signs around the tear of proximal injuries. Occasionally this causes a pseudocyst, thought to be the serous fluid in the haematoma.

Image
Figure 2: MRI scans highlighting a “Bulls-eye lesion” presentation

Predisposing factors to a proximal tear include fatigue, insufficient warm up and previous injury. From this case, we know that the pain started at the end of the game with the player in a fatigued state, and there was a history of niggling pain on and off for a couple of weeks.

 

Management:

The initial management of this injury was relatively routine, revolving around the POLICE guidelines (see Cryotherapy Blog). By day 2/3 we were addressing pelvic control exercises & posterior chain assessments. By day 5 we could achieve pain free stretching of the hip flexors and were using “Compex” to achieve isometric contractions of the quad while the player did upper body exercises.  After day 7 we were able to begin loading through a pain free range, working on co-contractions and concentric contractions of the quad.

To Speed up, you must be able to slow down – Bill Knowles

In the early-mid stages of rehab, we began working on movement patterns but at a painfully slow speed. Using the Bill Knowles mantra above, we progressed though different ranges of box step ups at slow pace to elicit a co-contraction of quads, hamstring and glutes (Figure 3). We slowly lowered the player through a Bulgarian split squat (Figure 4) to work on stability through range and we did some bridging variations (anti-rotational core) to encourage isometric control of the pelvis (Figure 5 – excuse the size 11 shoes taking up most of the picture!!).

Figure 6: a) Low box step up with knee drive
Figure 3: a) Low box step up with knee drive

 

 

Figure 6: b) medium box step up
Figure 3: b) medium box step up
Figure 6: c) High box step up
Figure 3: c) High box step up

 

 

 

 

 

 

 

 

 

 

 

Figure4: Bulgarian split squat (a & b) with progressive knee drive added later (c)
Figure4: Bulgarian split squat (a & b) with progressive knee drive added later (c)

 

 

 

Figure 5: Single leg bridge (a) with ipsilateral arm fall out (b) and contralateral arm fall out (c)
Figure 5: Single leg bridge (a) with ipsilateral arm fall out (b) and contralateral arm fall out (c)

 

By adding speed to the high box step up, we were able to switch the demand of the quadriceps to an eccentric action as the hip extends from a flexed position and the pelvis rapidly comes forward. We felt confident adding this eccentric component after we had cleared the player at a decent weight using the cable machine and a jacket to work though some deceleration work on the hip and knee (Figure 6).

 

Figure 6: Cable decelerations. a) start position b) end position with 3 sec hold. c to e) Dead slow step backs with weighted cable pulling posteriorly

 

The Bulgarian split squat was advanced by adding a knee drive at the top the squat, taking the back leg from a position of full hip extension through into hip flexion, a rapid concentric action. Following the model of exercise progression and regression (source) we added weight, removed the concentric component and decreased the speed again before building back up in a now weighted position.

The later stage of rehabilitation saw the player undertake more field based conditioning, working under fatigue whilst completing technical drills and building up his range of passing and shooting, all the while maintaining his gym program to supplement his rehab. This late stage rehab combined the expertise of the physiotherapy department, working alongside the strength and conditioning coach to discuss reps and sets of all drills and help periodise the weeks for the player and design the field based conditioning sessions; the sports science department was able to use GPS for all outdoor drills to help monitor load and provide up to date feedback on key information, in this case monitoring the accelerations and decelerations for the player in a fatigued state.

It was important that the stress elicited in this late stage was in line with the rest of the squad mid-competition. Rob Swire and Stijn Vandenbroucke (source) explain the importance of rehab being harder than the team training. This is because we have control over rehab, but no control of training so we must be confident that player won’t break down again in training!

The player returned just under 8 weeks later. He continued his gym program for another 4 weeks after his return to training and (touch wood) has had no recurrence of this injury since.

 

Conclusion

Knowing what I know now, I would be more cautious of this nondescript pain around the proximal thigh. The indirect head runs quite deep and typically presents as a gradual onset. The niggle the player was displaying a few weeks before was probably a worsening of this small tear, that when fatigued and put under a double eccentric load such as kicking or sprinting, was bound to “give” at some point.

I’m sure that reading this back, it seems pretty obvious that there was something wrong with the player initially. Again, another lesson learnt from this relates to the players age. He had not had a soft tissue injury prior to this, so his subjective history was vague and typically teenager-ish. Its important to remember that young players and professionals don’t necessarily understand their own body. If they play things down, its important that we as clinicians double check everything before we clear them and not just rely on their feedback alone.

 

I hope you find my reflections useful

 

Yours in sport

 

Sam

Don’t clam up over lower limb exercises

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I regularly find myself debating this exercise with students, new staff, and part-time staff all from different clinical backgrounds and I always find myself asking them – “Why is that patient doing clams?”

For those unsure of the terminology, the “Clam” exercise is designed to activate the external rotators of the hip, performed in side lying with limited pelvic / lumbar rotation.

Firstly I’d like to make it clear that this exercise does have a place in some rehab plans and I am not adverse to including it as part of a program where necessary – but I strongly disagree with it being a mainstay in rehabilitation plans. Purely going from anecdotal evidence, people seem to use clams as a way of increasing endurance of the glutes, particularly glute med. Often prescribing high sets and reps to target the endurance component of the muscles. Previous literature has suggested that Maximum Voluntary Contraction (MVC) of greater the 50% is required to produce any strength gains in an individual muscle (Atha 1981). Figure 1 below demonstrates the EMG activation of glute med during 2 clam exercises, at 30 and 60 degrees hip flexion. Its clear from this study that the activation of glute med is below the required level to achieve any strength gains.

Glute med (if it ever did work in isolation, which I don’t think it does) would concentrically abduct the hip, isometrically stabilise the pelvis and lower limb, and eccentrically control adduction and internal rotation. The best types of activity to stimulate these actions are going to be weight bearing exercises (Figure 1); (Krause et al 2009).

There is evidence to suggest that the posterior portion of glute med is deactivated with any degree of hip flexion, with the bias for primary movement coming from gluteus maximus (Delp et al 1999). This said, Di Stefano et al’s (2009) study produced similar glute med activation at 30 and 60 degrees hip flexion. Either way, my argument is the same – clams probably aren’t working the structures you intend to target.

Reference: DiStefano 2009 here

Clinical Reasoning

My question to clinicians who regularly use clams is always “why?”. What is the purpose of this exercise? At the moment, I work with an elite athletic population. How often in their training and/or competition do they have to externally rotate a flexed hip in an open chain from a side lying position? Never. Even in standing, I can only think of them opening up their hip to control a ball in mid-air but then they are mainly using hip flexors to activate that movement – something we strictly instruct them not to do with a clam. So now that we can’t think of a transferable example for this exercise, I would ask “why are we doing high reps and sets of an exercise we don’t need to do?”

Problem solving

We have already said that the best exercises for glute med activation are weight bearing exercises and the reason for that is exactly the reason why we shouldn’t try and isolate glute med… in weight bearing, it will work as one part of a complex and brilliant kinetic chain. This was highlighted in a very interesting study recently by Kendall et al (2013) who used a nerve block on the superior gluteal nerve and then performed the Trendelmberg test. Even with a neural block to the gluteal muscles, patients maintained pelvic alignment through the step test, highlighting that in isolation, the glutes alone do not support the pelvis.

One of my preferred, early stage exercises to improve hip control / stability is a single leg isometric movement (figure 2).

Figure 2: Single leg isometric glutes
Figure 2: Single leg isometric flutes (brilliantly demonstrated by @riarottner)

The patient is instructed to rest the contralateral leg against the wall for balance only. All of the body weight should be through the standing leg. Explain to the patient that their foot is superglued to the floor, but you want them to rotate their thigh out (encourage external rotation). There should be no movement from the upper body, bum should be “tucked in” with text book posture and they should hold this contraction for 10s, repeat 10 times. I promise, it will burn your glutes towards the end. Try this yourself and pay particular attention to what else happens further down the chain. You’ll see activation of the VMO and the medial arch will raise as tibialis posterior activates too. A brilliant example of the kinetic chain in action.

“Providing the patient is able to single leg balance, any exercise targeting hip control should be done unilaterally”

Now, there are examples in the patient populations where this is not an appropriate exercise. For example, early stage ACL injuries due to the torsion this creates through the femur and tibia. Instead I would adapt the exercise to something that we were all taught very early on in our physiotherapy degree – a simple small box step, placing one foot from the floor onto a step and back onto the floor – where the standing leg is the working leg. If you are strict enough with posture and lumbo-pelvic control, this is great early stage exercise for the glutes and easily progressed into a full step up, step downs, lateral steps, greater step heights etc. (For exercise progression, please see my shameless plug for my recent Model of Exercise Progression). Kendalls (2013) paper that we mentioned earlier, supports this simple trendelmberg exercise for patients with marked hip abductor weakness. Krause et al (2009) found an increased activation of glute med with single leg exercises compared to double leg stance, so providing the patient is able to single leg balance, any exercise targeting hip control should be done unilaterally.

For the non-weight bearing patients there is reasoning to perform these open chain exercises. While we have said we may not be increasing strength, we know that there is some activation occurring within the glutes so we limit an atrophy and maintain neuromuscular activation while the patient is NWB. Refer back to figure 1- the top exercise for glute med EMG is straight leg hip abduction so even with these NWB patients there are more appropriate alternatives to the clam.

Conclusion

Two of the core elements of physiotherapy is the ability to clinically reason and to provide effective exercise prescription. I would encourage people who regularly use any exercise, not just clams, as part of their mainstay exercise protocol to consider exactly why they are using them. I personally don’t think there are many examples where the clam is an appropriate exercise for sports medicine populations. The exception being NWB patients who are unable to control long lever exercises like single leg hip abduction. Therefore, there is an argument that the clam may quickly become an extinct creature.

 

Yours in sport

Sam