Outcome measures: An observation and a reflection

Sports science and strength & conditioning practice is built on a foundation of identifying a problem, testing the problem, applying an intervention and then re-testing to ensure progression. Athletes will buy into fitness testing, injury prevention and subsequent high performance behaviours if they are given the impression that their coach and medical team know what they are doing and things are done with a purpose (Kristiansen and Larsson, 2017). This begs the question whether coaches can justify and clinically reason their battery of performance tests.

When applying a performance measure, understanding of the underlying kinematics is essential to understand the validity of the test to the desired outcome. The OptoJumptm is a valid tool in assessing a reactive strength via  drop jump (Healy et al., 2016) however what components of the jump is the coach wishing to address? The validity of the tool is the not the same as the validity of the test. For example, reactive strength index (RSI) can be influenced by a reduced contact time (stretch shortening cycle via the musculotendinous unit) or via total jump height (power output throughout the lower limb and nervous system) or a combination of both (Healy et al., 2017). Understanding these mechanisms may influence the instructional bias of technique given by the coach in order to test what is desired.

With complexities over a test like an RSI to something seemingly obvious like a jump, testing for broader components of fitness and multiple movement patterns is much more difficult.

The Yo-Yo intermittent recovery test (IRT) is reported to be a valid measure of fitness and correlates to match performance in football (Krustrup et al., 2003). However, this is an example of a fitness capacity test and in fact correlates to fitness capacity in a match scenario. In field based team sports, there are a large number of variables and complex interactions that all contribute towards “performance” as an outcome (Currell and Jeukendrup, 2008). Krustrup’s conclusion was based on correlated Yo-Yo IRT results to high speed running in a game (>15km.h-1) with a strong correlation (r=0.58). Overlooking the methodological accuracy of this (pre-GPS, using VHS locomotive assessment retrospectively), the correlation is between two differing metrics. Where the high speed running was recorded over 90 minutes of varying intensities and periods of effort (12 players across 18 different games), the Yo-Yo IRT covered 1.7km in a mean time of 14.7mins with incremental increases in pace dictated externally. For a test to be considered a valid indicator of performance, it should meet the same metabolic demands as the sporting activity (Currell and Jeukendrup, 2008). The Krustrup paper does not make this comparison, instead analysing physiological markers from rest to exhaustion during the Yo-Yo IRT, not exhaustion markers in comparison to game data.

Perhaps semantics, but in fact there should be differential terminology to distinguish “fitness performance” from “athletic” or “sporting performance.” It should be considered that sporting performance is influenced by a large number of uncontrollable and non-modifiable factors that would make any comparison of validity and reliability to outcome measures unfair. Essentially, recreating a competitive environment is near impossible. This raises the question whether we are exercising just to improve test scores or, closing the loop and relating exercises to performance? Does raising the envelope of one, consequently improve the other? Something that we should not only be asking ourselves, but a question we could come to expect from coaches and athletes a like.

Oriam

Does the research answer this?

It has been suggested that stronger athletes produce faster sprint time, quicker change of direction speeds and higher vertical jump scores when compared to weaker athletes of the same sport (Thomas et al., 2016). Squat jump (r = -0.70 to -0.71) and counter movement jump (r = -0.60 to -0.71) demonstrate strong correlations to change of direction speed (Thomas et al., 2016). Peak force during isometric mid thigh pull was significantly correlated to 5m sprint time (p <0.05) however this correlation was only moderate (r = -0.49). But again, does this correlation transfer into performance if the testing protocol doesn’t accurately mirror sporting performance?

Sprint times over 40m have been shown to decrease following an acute bout of heavy loaded squats, hypothesised to be due to post activation potentiation (Mcbride et al., 2005). Higher squat strength scores also correlate with sprint times over 0-30m (r= 0.94, p=0.001) and jump height (r = 0.78, p=0.02) (Wisløff et al., 2004). Importantly, we know sprint performance tests have demonstrated construct validity to the physiological requirements of a competitive field based game (soccer) (Rampinini et al., 2007), which is ultimately what we are aiming to do; relating performance testing to physiological and metabolic markers from a given sport.

The addition of a jump squat exercise into a training program may help improve 1RM squat and 1RM power cleans (Hoffman et al., 2005). So perhaps yes, there is a perpetuating loop between exercise, tests and performance but the link between them all may not be tangible or direct.

But how do we translate all of these statistics and data sets this to a non-scientific population, as a lot of our athletes are? I’ve developed the following analogy to try and help with this.

 

Solar system analogy:

If we consider that “athletic performance” is the main focus of any intervention, much like the sun at the centre of the solar system. This is the bright light that everything revolves around; media, finance, fan base and support and so on. It could be argued that any intervention we have as coaches will never truly replicate “athletic performance” but should be influenced by it. This influence works both ways, positively and negatively. For example, if we maximally test an athlete before a competition, this will likely have a negative impact on “athletic performance”. Conversely, if we were able to collect data that informed a training program to improve athletic performance, despite not actually replicating “athletic performance” it would (hopefully) have a positive impact. For example, a football game is determined by so many uncontrollable variables that can not be replicated in a gym, but we might identify that a player needs to improve their 5m sprint time which in turn, will benefit performance.

Figure 1 solar system
Figure 1: An analogy depicting the relationship between “athletic performance” and controlled interventions / measures. The skill of the coach is identifying which outcome measure or intervention is going to have the greatest influence on athletic performance.

Let’s consider our potential interventions to be orbiting the sun (Figure 1). There is an interaction between the planets and the sun via gravity but they do not have a direct overlap, where the planets do not collide with the sun just as an outcome measure does not truly match sporting performance. We know that larger planets have a greater influence, so as coaches, we are trying to affect the level of positive interaction with “athletic performance”, the gravitational interaction. By influencing links between exercise intervention and outcome measures, we can affect the size of these planets. In turn, this will have a greater interaction with the centre of our solar system, “athletic performance” (Figure 2). Much like the universe, there will be many different solar systems just as there are different sporting codes and contexts, so the skill lies in identifying the most influential planets in your solar system.

figure 2 solar system
Figure 2: The impact of enhancing an intervention or measure on sporting performance, in this case there has been a greater focus and development of the blue “planet” which has changed the interaction with the “athletic performance”

 

A clinical reflection:

For long term injuries, I utilise a continuum to guide return to play (train / play / perform), often these stages are guided by outcome measures linked to goals and aims for stages of rehab. Typically these tests are scheduled in advanced and often follow a planned “de-loading” micro-cycle. This helps with continuity and, as much as you can in sport, standardisation of the test.

A recent case study found me questioning my judgement and to a degree, wondering if my intrigue and curiosity about my rehab plan drove me to test out of sync with the schedule, instead of doing the test for the athletes benefit.

Following a good period of return to train, the proposed testing date previously scheduled clashed with a squad training session. Observational assessment suggested the athlete was coping well with the demands of training and it seemed counter-intuitive to pull them out of training to undertake some tests. A few weeks later, a gap in the daily schedule presented an opportunity to re-test. The test scores were down compared to the previous month, most likely because the athlete had trained in the morning and trained the 4 out of the last 5 days in some capacity. In previous tests, the athlete had come off of a de-load week and tested the day after a day off.

The result:

The athlete began to question their ability and availability to train. They were visibly knocked in their confidence given a drop in scores, despite me being able to rationalise why this could be. Having had the opportunity to feed my own interest and try to prove to myself that a rehab program had worked, the outcome was much worse. I threatened the confidence of a long term injury returning to training, potentially adding doubt and hesitation to their game and I did not get the results I was expecting.

On reflection, given their time out through the season so far, I should have stuck to protocol and tested on the scheduled day (one training session was not going to increase their chances of availability).. or, not tested at all. Instead, i shoe-horned some testing into an already busy schedule. What did I expect given the current level of fatigue?!

Image result for reflection

Previous results had reached a satisfactory level to return to train and I was now chasing the final few percentages available. To give them confidence? Probably not, as they were training and enjoying the return to train. So perhaps it was just to give myself confidence. An interesting lesson learnt, mostly about myself.

 

Yours in sport,

Sam

Viewing balance exercises with eyes closed

For a long time, I have questioned prescribing balance exercises with eyes closed to athletes in sport. Regular readers of the blog will know that I continuously explore the clinical reasoning behind treatments and interventions but have a particular interest in exercise prescription. I have to admit that single leg balance with eyes closed is an example of exercise prescription that just doesn’t make sense to me, how many athletes close their eyes to perform a sport related task? I’m regularly seeing discussions online about “what is functional?” and most of the debates are based around semantics without much weight behind them but provide a good opportunity for people to have a little disagreement about something. To avoid getting into a debate about “functional” I thought it best to better understand the concepts and demands behind “balance” to see if I can answer the “why” behind balance exercise progressions.

SLB
Now stay like that for 1 minute or until another player throws a ball at your face
One argument for closing eyes during balance exercises is to remove the visual stimulus and encourage the athlete to challenge vestibular and proprioceptive senses. Remove one thing and make others compensate for this deficit. In a study of track athletes, sway velocity (cm/s) increased two-fold when athletes closed their eyes during a static balance test (here) but the only significant finding in the study was the difference in centre of pressure displacement (cm) between non-dominant and dominant limb across the medial-lateral plane. So, no difference between male and female athletes and no difference between “eyes open” and “eyes closed”.

So how does this explain the increase in sway velocity? The sway velocity is the area covered in both the anterior-posterior and medial-lateral planes of the centre of pressure per second, indicating speed of correction. The fact that the displacement between “eyes open” and “eyes closed” was not meaningful suggests that the demand on the fine motor correction increases. A decent argument to include “eyes closed” in a balance program, if that is the aim.

Static balance in dynamic sports

Compared to dynamic balance tests, static tests do not allow re-positioning of the centre of mass within the base of support, so the athlete becomes more reliant on smaller corrections. Different sporting populations have demonstrated varying abilities in static and dynamic balance skills, with gymnasts outperforming in static balance but soccer players demonstrating better dynamic balance (here).

This may seem obvious given the control on the balance beam vs changing direction to avoid an opponent. But actually, perhaps where the argument becomes more broad and complex.

As with any exercise selection, it needs to be appropriate to the aims of the rehabilitation program and the demands of the sport, taking into consideration open and closed skills and linking these to fixed gaze drills vs dynamic gaze drills.

Have we gazed over “skill”?

In a given skill, experts can recognise which cues are relevant and avoid information overload (Martell & Vickers 2004). Below is a slide from my presentation “3 sets of when?” It explains the concept that following any injury, the athletes ability to perform a given skill returns (temporarily) to novice level.

skill level injury

Take a skill like walking. Immediately after an ankle sprain, your ability to perform that skill at an expert level is decreased. A skill that has taken years to perfect, to become automatic, now becomes a task which requires concentration. Thankfully, the return to expert level doesnt take years (hopefully!) and this is where our exercise selection becomes crucial to optimally load and sufficiently challenge. We can’t presume that the pre-injury skill level is the same post-injury. We should also consider experience of the balance task specifically. I can think of experiences where athletes are standing on one leg on a Bosu throwing a reaction ball at a 45 degree trampoline. “Oh you’re no good at that are you… we need to address your balance”

I’ve digressed slightly from single leg balance with eyes closed… and actually I still haven’t discussed “gaze control”.

off on a tangent

Gaze control links specifically to experience of a task. Comparing those skilled at orienteering to non-skilled (here) demonstrated an increased ability of the orienteering folk (what do you call people that go/do orienteering?!) to employ a wide focus of attention and to shift efficiently within a peripheral field. The test very cleverly measured gaze control to flashing images with varying degrees of relevant and irrelevant information. What is interesting from this study was that the control group where physically active and proficient in other sports, but the “skill” advantage lay with the orienteering-iers. [shrugs and thinks “sounds right”].

I did not know that about balance!…

Elite athletes have heightened spatial awareness and processing capabilities vs their non-elite counterparts, where gaze control is cool and calm, with long duration of fixation of specific locations. This results in better body positioning end efficient limb actions (here). What better example than ballet. When comparing professional dancers to controls walking along a thin taped line, it was observed that experienced dancers focus far into space, delivering effortless and accurate movements where as controls looked down and focused on the line, moving with greater speed and less control (here). Dancers shift their neural control from somatosensory inputs and to an increased use of visual feedback, via peripheral fields and focused gaze control. Interestingly, sub-maximal exercise has been shown to increase visual attentional performance (posh words for reaction time) and a decreased time need to zoom focus of attention (here). This is useful for prescription considerations.

This efficiency has been demonstrated in other studies also, where the addition of a 4-week balance training program to Physical Education classes in school resulted in increased CMJ, Squat Jump and Leg Extension Strength (here). A time period that can’t be associated with physiological adaptations to muscles (regardless of time, they did balance exercises!) and even when a balance training program has been compared to a plyometric strength program (here). It is thought that improved centre of pressure is linked to spinal and supraspinal adaptations, due to high inter-muscular activation and co-ordination.

My question for any budding researchers out there… if there is a spinal level involvement here, can we utilise the contralateral limb at the very early stages of injury to improve balance on the injured side?

Finally, I get to my argument… balance is the output. Balance and proprioception are different entities, as are gaze strategies and balance. But they may all be interlinked via “skill.”

In researching this blog, I’ve certainly become more accepting of “eyes closed” as an addition to balance programs. But also think I’ve gained more clarity on appropriate prescriptions and the suitable progressions for individuals.

Perhaps “eyes closed” is not a progression, but a starting point!

Immediately post injury, we are looking to internalise feedback (intrinsic) and focus on local, fine movements. There are plenty of regressions within “eyes closed” balance that we can make the athlete safe from secondary injury. Graded progressions from static to dynamic, trying to keep the demands appropriate to the skill required to return the athlete to “expert”.

From here, our progressions should not be the removal of a visual stimulus, but instead optimising and enhancing gaze control:

  • Focus on a stationary target –> moving target
  • Head still –> head moving (repeat stationary and moving target progressions within this)
  • Static balance –> dynamic balance (repeat progressions above)

Essentially, we progress through from intrinsic cues to extrinsic cues, where gradually the athlete is thinking less and less about the mechanics of balance and more about skill execution and performance. We know that gaze control components improve with sub-maximal exercise, so our ordering of our program can reflect this. It is commonplace for balance exercises to be at the beginning of the program, but if balance is our primary aim for rehabilitation, perhaps it should be later in the schedule.

I don’t think this is too dissimilar to how most people prescribe exercises, but for me at least it has given me a better thought process into the “why” which ultimately should make rehabilitation programming more effective and efficient and therefore more elite.

Yours in sport,

Sam

Compex doesn’t have to be complex

compex

I should probably start by acknowledging that there are other muscle stimulation devices available… but I’m not employed by Compex, I just have some very good experiences using their product. This blog was borne out of frustration of seeing Compex machines gathering dust in treatment rooms or being used ineffectively as passive, plinth based modalities. I think a lot of people are missing the trick, you need movement!

While I am an advocate of its use clinically, I  want to disclose that using a Compex will not make a bad exercise good. It is a bolt-on to a rehab program and is something that can make a good exercise great. That is key. The clinical reasoning, exercise selection and placement of the stimulation all underpins an effective application, so before rolling it out to all athletes or patients make sure you can reason why it has a place in your practice.

Its all about progress

Like with any intervention, the clinical reasoning behind the application of muscle stimulation can influence its use at different stages of injury and rehabilitation. In the acute stages, it is believed that muscle stimulation may modulate pain. For an interesting read on the use of electricity and pain throughout the centuries, click here. However, as we understand more about optimal loading and mechanotherapy, we probably need to limit the time an athlete sits on the plinth watching the latest Mannequin Challenge on their smart phone while their quad twitches. It is worth considering that a Compex placed on a dead body would still cause it to twitch. The key is to get them moving and use the Compex to either facilitate movement or provide an external load. Interesting that we can use the same machine and the same settings to either regress or progress an exercise… the key is in the exercise selection.

Consider the tissues

Muscle injury: It should be pretty obvious that placing a muscle stimulation device, designed to promote contraction of muscle, on a contractile tissue with a tear or micro-damage could have negative consequences. For a second, lets forget the Compex. Respect the pathology and consider if you really need to lengthen or contract that muscle to load it. Is there a way you can work that tissue as a synergist perhaps? If the hamstring was injured in the sagital plane, can we move through coronal (frontal) planes and still load the hamstring? This could possibly be a slight progression on an isometric exercise and shouldn’t change the length of the muscle that may cause pain or further damage. Certainly more beneficial than sitting on the treatment bed though. So now consider how muscle stim may benefit this stage of injury. It could possibly help with any inhibition due to swelling or pain, perhaps be used to add an increased load to unaffected tissues that you may not be able to load otherwise.

As the healing progresses and the level of activity increases, it is quite common that we see some deficits in muscle function, especially after a long acute phase (if that isn’t a paradox?! Think post surgery or fixation). A good example is post ankle reconstruction, where you have worked on regaining plantar / dorsi flexion but when you ask the athlete to do a heel raise, it’s quite an effort. It may be appropriate to use the Compex here as a little crutch to facilitate movement and contraction. But the key thing here is it is not our cadaver that we causing a contraction in, the athlete is consciously initiating the movement. (Previous blog on internal and external cues here).

csjjpmaw8aefyb4
Now promise me if the Compex hurts, you will turn it down. OK?
Progressions by all definition, progress. So after working through isometric and concentric exercises, the program may require some eccentric load. This is worth trying yourself before asking a patient to do it, because a very simple exercise like a TRX squat that may have been cleared earlier in the program can dramatically increase in work with the addition of Compex. Consider a quad injury. The Compex has two phases of a cycle, a fasciculation phase that causes visible twitch and a long contraction phase (depending on the setting, the length and intensity of the contraction change). After one or two cycles for familiarisation, instruct the athlete to work against the contraction – so when the Compex wants to promote knee extension via a quad contraction, sit back and encourage knee flexion. Try this yourself for 6-8 reps and feel the fatigue induced, it usually surprises people. Again, make sure you can reason WHY you are doing this. This is usually a good bridge for someone who needs to step up their program but maybe can’t tolerate external load (confounding injuries, instability of joints, lack of technique etc etc.)

Joint Injuries: In comparison to a muscle injury, your application of Compex may be more aggressive. Because you are unlikely to affect a non-contractile tissue with the stimulation, you may use the eccentric reasoning to help reduce atrophy rates following a intracapsular injury like an ACL. Ensure you know the available range first of course.

With these injuries, the external stimulation may help with inhibition, improve proprioception lost by the ligament or capsule or it may provide stability to the joint by increasing the available contraction. Again, there will be a time and a place and it requires the clinician to reason through the application, but this may be a great addition to a program that is becoming stale.

Tendon injuries: The use of the Compex to enhance an isometric contraction or to create an eccentric contraction may be a great addition for an in-season tendinopathy as a way of managing load. The timed contraction allows clinicians to monitor Time Under Tension (TUT) which is essential for tendon management. If considering a High-Medium-Low frequency through the week, a pain free exercise that is used on a Medium day can become a High load exercise with the addition of an externally generated contraction. But consider the two things that aggravate a tendon, compression and shear. Appropriate exercise selection and range is going to be crucial, that being said, it may be that the addition of stimulation to the quads actually reduces shear through the patella tendon by changing the fulcrum of the patella (no research to back this up, just my musings).

musing
I really like Geckos. I found this Gecko a musing
Conclusion:

I think there are many options out there to enhance rehabilitation by considering the diversity of muscle stimulation. But I want to repeat for the hundredth time, it is the exercise selection that is key. The addition of a Compex will only amplify that choice.  For the patient, it adds a bit of variety to a rehabilitation program and for the clinician it is another tool to help with optimal loading of a healing tissue or structure. I am a big fan of weight training (don’t let my chicken legs fool you) but there are injuries or athletes that for one reason or another are unable to tolerate weights. This is one tool in a very large and overused metaphorical tool-box that may bridge that gap between body weight exercises and weighted exercises. I also believe there is great benefit when complimenting this with Blood-Flow Restriction Exercise or Occlusion training… but that’s another blog.

As always, thoughts and opinions are welcome.

 

Yours in sport,

Sam

Case Study: Myositis Ossificans – Deadlegs aren’t just for the playground

Whether you call them a “dead leg” or a “Charlie horse” or a “cork thigh” chances are we have all had one. Mostly from the playground days where the bigger kids want to take pleasure in seeing you limp for 5 minutes. However when they happen in sport, with fully grown athletes running at full pace, a collision to the thigh can result in an injury much more serious than the one we associate with from childhood.

The reason I wanted to write this blog was that I worry  that thigh contusions are underplayed in the treatment room, potentially because we associate them with those school sports injuries that can be “run off”. This is a case study that I became involved with after initial management of the “dead leg” failed, and to this day is one I reflect on about how important initial management can be in saving severe stress in the long run. This is a case of a “routine” dead leg that is commonly seen in contact sports that resulted in 9-months of rehab to manage a secondary case of myositis ossificans.

What are we dealing with?

There are two types of “dead legs”

  1. Intramuscular: blunt force trauma to the muscle that results in a haematoma, in this scenario the epimysium remains in tact and the bleeding is contained within the muscle compartment.
  2. Intermuscular: the epimysium surrounding the muscle is broken along with the damage to the muscle tissue, the resulting haematoma spreads outside of the damaged muscle.

The intermuscular hematoma by far looks the worst, it’s the one where the whole thigh goes black and blue and looks pretty nasty. However, clinically these ones tend to heal quicker and they look a lot worse than they feel. The problem with the intramuscular haematoma is that because it is contained, the pressure can build up and become more painful. It is generally more debilitating as a result, with larger loss of range and more pain. It also doesn’t provide that visible diagnosis as very often you just get a small sign of bruise on the skin from the impact – this is where it can get dangerous as we like to be able to see injuries (hmmm something about invisible injuries and under diagnosis.. concussion?). We have discussed acute management before (here) but with dead legs, it is always worth monitoring for a few days and hoping that the leg goes black and blue.

fig2

In the first few days, range is a good indicator. On day 1 after the injury, if they are unable to achieve >90 degrees knee flexion, the prognosis is generally longer. For a bad intramuscular contusion, you could be looking around 6 weeks. This is where the coaches tell you it’s just a dead leg and they’ve had worse. But, it is structural damage to the tissue resulting in bleeding and should be given the same respect you would give to a tear. (Muscle injury classification via the Munich Consensus here).

Myositis Ossificans (MO):

MO is the formation of heterotrophic bone within the muscle following trauma (here) essentially following failed healing the body begins to lay down bone in an attempt to add stability and structure.

Case study:

The following case study is an example of an academy player, where an initial intramuscular trauma to the muscle was accelerated back to activity resulting in a 17cm tear of vastus lateralis (VL), consequently being diagnosed with MO that was estimated to be 3cm thick and of equal length to the tear.

Timeline:

  • Day 0 – initial impact to right VL via collision in training, had to be removed.
  • Day 1 – “able to squat and lunge but pain on a stretch”. Player expressed determination to train and so was allowed to.
  • Day 2-3 – continued training
  • Day 5 – Removed from training with “cramp / DOMS” in right leg.
  • Day 8 – Sudden loss of power with running and kicking, removed from training.
  • Day 30 – returned to training
  • Day 31 – played in a competitive game but substituted by manager after 25 minutes due to inability to run. Assessed by doctor and head physio. Visible contained swelling in VL, palpable solid mass, loss of range and pain on contraction of quads. MRI scan demonstrates a 17cm longitudinal tear of VL. Suspicion of MO so sent for ultra sound scan which was confirmed, absent from full team training for 9 months.

Intramuscular haematoma
Contained haematoma within the vastus lateralis muscle after 30 days of continued training post-initial injury
Management:

Surgical excision of MO is only really reserved for persistent cases that don’t respond to conservative treatment (here). A collective decision was made that we should try to reduce any form of load that may stimulate further bone growth. As a result, the player was removed from all activity of the lower limbs, no soft tissue therapy to the quads and at this stage no stretching of the affected tissues.

It is neither healthy nor beneficial (or fun!) to completely rest when you are used to training 6 days a week. Credit should go to Will Abbott (@WillAbbott_) for his contribution to the maintenance of the athletic profile for this player. A periodised program was designed to maintain metabolic and cardiovascular systems, strengthen the upper body and completely unload the lower body.

Screen Shot 2016-06-19 at 9.02.28 AM
A periodised model to demonstrate maintenance of unaffected systems with complete lower body unload (designed by Will Abbott)
The program included swimming, with multiple floats between the legs to reduce the temptation to kick. All gym based activities were performed seated or with legs supported when lying to reduce axial load through the legs during upper body lifts. Upper body metabolic sessions were implemented via high intensity interval training, with small rest periods to help maintain specific anaerobic demands relating to the sport. This was done using medicine balls, ropes, boxing pads.. anything to reduce the monotony of daily upper body training.

Each month was broken down further (as shown below), with follow-up ultra sound scans every 4 weeks. After the first 4 weeks, we observed a 2.5cm reduction in length which consolidated our thought process to continue de-loading. With limited exercise potential and treatment for the leg, we ran half days and 5 day weeks to help maintain a positive psychological presence.

Screen Shot 2016-06-19 at 9.02.58 AM

This was an opportunity to increase muscle mass in the upper body, an opportunity that would not have been possible during season if the player continued to play and train. This allowed a clear progressive pathway for increased lean mass with the following phases:

Hypertrophy –> Max strength –> Strength / power conversion –> Power

While the conditioning phases were as followed:

Aerobic base –> Max aerobic –> Supra max aerobic

There was a decrease in calcicific mass every month, although the rate of this varied each time. By the end of month-4, the mass had completely reabsorbed which meant the reintroduction of load to the lower libs.  By this point, the end of the season was 6 weeks away and therefore no realistic opportunity to play again this season, so the decision was made to start physical preparation for the following season.

Screen Shot 2016-06-19 at 9.03.30 AM
An example of the lower body periodisation
The lower body gym program was tailored as followed:

Strength endurance* –> Strength –> Max strength –> Strength & power complex training

(* This was probably more “re-introduction to the gym” rather than true strength-endurance. But this phase would have served as a gentle hypertrophy phase given the 4 months of atrophy)

Before undergoing a linear outdoor session progressing from general preparation to sport specific drills with Tom Barnden (@barnden_tom). The player completed a full pre-season and no recurrent symptoms to date.

Conclusion:

Hopefully the lengthy timeline of this case study demonstrates the importance of giving each individual injury the respect it deserves. While I hope the management is interesting, the key discussion point is how do we approach “dead legs”? Should there be better education to athletes and coaches about the magnitude of injury? Essentially given the tissue damage, are they a tear? If an A4 piece of paper represented a muscle, and we tear down the middle (strain) or poke a hole through the centre of the page (blunt force trauma), that page is still affected and unable to serve as an A4 piece of paper. Why does the mechanism of damage change the management of injury? Given any loss of range or function following a blunt force trauma, always consider the magnitude of potential damage; monitor swelling, bruising and pain and have adequate timelines in the back of your mind – don’t rush to a diagnosis / prognosis on day 1. There will be times where there is impact and initial pain but full range and full strength – this is where our pitch-side assessment and reasoning comes in (here).

Yours in sport,

Sam

Laboring through a Labral Tear

One skill when working in sport is learning to compromise between your clinical brain (the one that tells you that pathology and injury needs to be managed a certain way) and your performance brain (which tells you that your job is to get athletes back over the “white line” in order to do their job). In an ideal world, we try and appease both of these brains where tissues heal well and performance is optimised with the lowest risk of re-injury. But there are some pathologies that cause these two brains to clash. Ones that can be “managed” until the off season where proper interventions can take place. One such injury that I’ve been trying to learn more about is the mid-season hip labral tear.

labral-tear-img

The purpose of these blogs is to encourage me to read more around certain topics, so in order to help with this I have to say thanks to a few people that have provided me with papers and words of wisdom (Erik Meira, Nigel Tilley & Joe Collins). And thanks to whoever invented Twitter because I probably wouldn’t have this access to knowledge otherwise.

The Problem..

Typically, hip instability injuries are seen in sports with high repetitions of rotational and axial load – football, gymnastics, hockey, tennis, martial arts.. and so on. The hip is widely accepted as being one of the most structurally stable joints in the body, with a deep acetabular socket lined by the labrum, which creates negative pressure within the joint to increase congruency of the femoral head. But what happens when this environment is disrupted? A recent review by Kalisvaart & Safran (here) explain that it takes 60% less force to distract the femoral head from the acetabulum in presence of a labral tear. (This review is great for explaining multiple causes of hip instability, not just labral tears, and also assessment techniques.)

Typically, a lack of stability is replaced by rigidity, where the surrounding soft tissues try to compensate for this increased translation (Shu & safran 2011 here and Boykin et al 2011 here). On assessment of an ongoing labral tear, its quite common to find increased tone or reduced range around adductors and hip flexors. Iliopsoas in particular plays a role to help increase congruency in the hip. (For tips on how to release iliopsoas, please tweet @Adammeakins) – one key thing when managing this condition is not to confuse high tone / over activity with being “too strong”. Chances are its the opposite, it more likely indicates a lack of control. Its not uncommon to see adductor tendinopathies secondary to labral tears as the the load around the joint increases – especially in sports like ice hockey where there is high eccentric load on the adductors (Delmore et al 2014 here).

The Intervention..

So, you’ve diagnosed the tear (clinically and / or radiographically) but other than being irritable, it isn’t affecting the athlete. (Note, not all tears can be managed conservatively, due to pain & some require mid-season surgical intervention – Philippon et al 2010 here). The key premise to your ongoing rehab should be to make the hip joint as robust as possible. Remember, “Stability – not rigidity”. Whats the difference? Can the athlete control the hip or pelvis while performing another task? Or do they lock into a position and rely on passive structures like ligaments and joints.

Consider the demands of the sport. Don’t just fall into the trap of working through what I’d call the “action man ranges” – true anatomical flexion, extension, abduction and adduction. Watch training and competitions of nearly all sports and you’ll rarely see these truly sagittal or coronal movements. They tend to be combinations accompanied by transverse movements of the body in relation to the limb. Make sure this is replicated in your rehab.

Using the three examples above, consider the role of the hip musculature throughout these movements. We don’t always have to replicate abduction in an open chain movement, sometimes its necessary for it to be closed chain and for the body to move relative to the limb. Note how none of these tasks fit the “action man ranges” but all involve some degree of traverse rotation, combined flexion and abduction or extension and adduction etc etc.

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No I can’t bench press, but my squats are awful.
Delmore et al (here) and Serner et al 2013 (here) describe some excellent exercise interventions for the adductors here. These include some good low-load isometrics for those early stage reactive tendons – with isometrics appearing to down-regulate pain associated with this acute pathology (Koltyn et al 2007 here; Rio et al 2015 here to name just two resources) . Moving forward through rehab, I’ve discussed exercise progression at length before (here), I’m not dismissing exercises that involve pure flexion, extension etc but as part of a progression, its important to combine these movements. For example, start with a single leg dead lift – can the athlete control their trunk through hip flexion and through extension back to neutral? No? Then here’s a range to work on, using regressions to help improve technique and control. Yes? Then add a rotational component at different ranges of flexion – rotation away from the standing leg will increase the demand on the adductors to control the pelvis in outer ranges. The leg itself hasn’t abducted, but relative to the trunk it is hip abduction.

Remember the bigger picture

Its important not to just focus on the affected structures. For those interested in groin pain, a summary of the 1st world conference on groin pain is here – one key message from that conference was that anatomical attachments are not as discrete as text books make them. Consider what else contributes to the hip and pelvis control. We have mentioned iliopsoas control, but also rectus abdominus. Its not just a beach muscle. Eccentric sit ups can help improve control of the hip flexors, along with some lower load exercises like dead bug regressions – a little imagination or some quick youtube research can turn this one concept into hundreds of different exercises.

We have addressed the issue of controlling abduction through range with the adductors, but also remember to maintain that abduction-adduction ratio with some external rotator & abductor muscle exercises (queue Clam rant here – clams to me are like psoas release to Meakins). Possibly the best piece of advice I was given when doing this research was from Joe Collins, who told me to consider hip joint pathologies like you would a rotator cuff injury in the shoulder. Don’t neglect those smaller, intrinsic muscles around the hip. The exercise below is an anti-rotation exercise working through ranges of hip abduction-adduction.

The athlete is tasked to resist the rotation of the femur into external rotation while slowly moving through hip abduction and back to adduction. (This example is done with a shorter lever to improve control and the bench provides feedback to keep the hips in neutral or extension, rather than the favored flexion). Anti-rotation exercises can also be incorporated into trunk / core control exercises (for any instagrammers – follow ETPI who post some great videos and snaps of golfers working on rotational control). Progress from anti-rotation into control through rotation. Some examples here:

anti-rotation plank with sagittal control

Anti-rotation plank with traverse control. Encourage the athlete to keep the pelvis still when moving the upper limb.

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Single leg bridge with arm fall outs. Can be regressed to a normal bridge if the athlete lacks lumbo-pelvic control.

Side plank with arm tucks – an example of controlled trunk rotation while isolating the lower body to stay stable. Can be combined with the adductor bridge mentioned in Serners paper to increase load through proximal adductors.

 

These are just some ideas of how to manage a labral tear mid-season; working on rotational control, analgesia via isometrics, improving congruency in the hip joint and overall hip stability via strengthening – Stability, not rigidity! The exercises mentioned here are by no means an exclusive list and I love learning about new drills and ideas, so please share any that you find useful.

 

Your in Sport,

Sam

Rehabbing teenagers can be awkward! – sensorimotor function during adolescence

There is a bit of a buzz phrase in rehab about “individualising programs” and while it is something we wholeheartedly agree with, it is a phrase that is very easy to say and yet very difficult to implement. Especially when you work with a population where said individual changes rapidly through time, like a teenager! It is a common sight on a training pitch to see a star player in their age group suddenly tripping over cones or developing a heavy touch where there was previously effortless control. Side effects of the adolescent growth spurt, where the brain is now controlling a much longer lever. It’s like giving a champion gardener a new set of garden sheers when for the past year they have used little hand-held scissors and asking to them maintain their award-winning standards. (My garden embarrassingly needs some attention and it’s affecting my analogies).

Master-Gardener-Pruner-Secateurs-Shears-Garden-Hand-plants-Shears-trim-cutter-easy-carry-Garden-Tool
The control and precision between these two instruments is influenced by the lever length of the handles…
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…Similar to a rapidly growing femur and tibia which is still being operated by muscles that have length and strength suitable for shorter levers.

 

 

 

 

 

 

 

 

Alongside the performance related issues, there is suggestion that this period of growth may coincide with increased risk of injury (Caine et al 2008). We believe that bone grows quicker than soft tissue, so we are asking a neuromuscular system to control a new, longer lever using prior proprioceptive wiring. Imagine our gardener again, for a long time he has been able to keep his pair of scissors close and controlled, now with his extra long shears the load is further away from his body, his back and shoulders are starting to ache. Not sure what I mean? With one hand hold a pencil to the tip of your nose. Now, with one hand hold a broom handle to your nose. The longer lever is harder to control. **I promise it gets a bit more sciencey than gardening and broom handles. **

Managing these growth spurts is something we have talked about before and recently contributed to a BJSM podcast on the topic (Part 1 & Part 2) and a complimentary BJSM blog about “biobanding” during periods of growth and development (here). This particular blog was inspired by a recent (2015) systematic review looking into exactly which sensorimotor mechanisms are mature or immature at the time of adolescence by Catherine Quatman-Yates and colleagues over in Cincinnati (here). The following is a combination of their summary and our examples of how these findings can influence our rehab programs.

Tailoring the program:

We have so many options for exercise programs, that’s what makes the task of designing them so fun. It challenges our creativity. When working with a teenager with sensorimotor function deficits, let’s call them “Motor Morons” for short, we don’t have to totally re-think our exercise list, just perhaps the way we deliver them. We previously spoke about motor control and motor learning (here) and how our instructions can progress just as our exercises do, but the following relates to children and adolescents in particular.

Consider the stimuli.

Children aged between 14-16 have well-developed visual perception of static objects however their perception of moving objects and visual cues for postural control continue to mature through adolescence. When very young children learn new skills such as standing and walking, they become heavily reliant on visual cues. Quatman-Yates et al suggest that puberty and growth spurts (think gardener with new shears) brings new postural challenges that causes adolescents to regress proprioceptive feedback and increase reliance on visual cues again. From a rehab perspective, we need to consider this as part of our balance and proprioception program. How many of us default to a single leg stand and throwing a tennis ball back & forth from therapist to athlete? For our Motor Moron, this may not be an optimal form of treatment in early stages, where it is commonly used, however it may incredibly beneficial to that athlete in the later stages or as part of ongoing rehab as we try to develop that dynamic perception.

Consider the amount of stimuli involved in an exercise versus what your goal of that exercise is

We should also consider the amount of stimuli we add to an exercise. Postural stability in children is believed to be affected by multiple sensory cues. If we consider that children are more dependent on visual cues than adults are, perhaps our delivery of external stimuli should be tailored also. With a multi directional running drill for example, there is sometimes an element where the athlete is given a decision making task (a red cone in one direction and a yellow cone in another) and they have to react quickly to instructions from the therapist or coach. Rather than shouting instructions like “red cone”, “yellow cone” etc, hold up the coloured cone for the corresponding drill. This way we are utilising this developed visual perception, minimising the number of stimuli and also encouraging the athlete to get their head up and look around rather than looking at their feet.

When to include unilateral exercises:

Within adult populations, it is often considered gold standard to make exercises unilateral as soon as tolerable. If they can deep squat pain free and fully weight bear through the affected side, progress them to pistol squats ASAP, or single leg knee drives. However, young children (pre-pubescent) may struggle with this for a couple of reasons.

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Difficult enough even for an adult to perform, but uncoupling the actions of the each leg & fine muscle movements to maintain balance are extra challenging for children

Firstly, we need to consider postural adjustments. Where as adults and young adults can adjust their balance with smooth control and multiple, small oscillations, children rely on larger ballistic adjustments. There is also reduced anterior-posterior control in younger athletes which suggests reduced intrinsic ankle control. Put this alongside immature structures and (if working a physio, most probably) an injury then single leg exercise become a progression that may be further down the line than an adult counterpart with the same injury. Instead, consider semi-stable exercises. Support the contralateral leg with a football or a bosu ball – something that is difficult to fixate through but provides enough stability to support the standing leg.

Secondly, we understand that coupled movements are mastered earlier in adolescence, around 12-15 years old but uncoupled movement patterns take longer to develop, 15-18 years old (Largo et al). A good example is watching a young child reach for a full cup of water at the dinner table. It is much easier and more natural for them to reach with both hands than it is with one, as coupled movements are unintended. Rarely do you see a child taking a drink with one hand filling their fork with the other – yet this is something commonly seen with adults as they are able to uncouple and segmentalise. Another example is watching a child dynamically turn, watch how the head, trunk and limbs all turn as a “block”, it is not until further down the line where dynamic movements become more fluid. The argument here is that surely running is an uncoupled movement? Or kicking a football, swinging a tennis racket, pirouetting in ballet – they are all uncoupled, segmental movement patterns that we expect kids to do, and in all they cope with. Correct, but it is usually in rehab programs for kids that we begin to introduce unfamiliar tasks and exercises that they may not have encountered before. Also, we should respect the impact of the injury on proprioception and control. So these are all considerations for starting points in exercise & if a regression is ever required.

For this reason, it is important that exercises are monitored and reviewed regularly. There is no need to hold an athlete back because of their age and making assumptions on motor function because of their age. If they can cope, then progress them. But be mindful of “over-control” where speed and variability of movement are sacrificed in place of accuracy and control (Quatman-Yates et al 2015).

Become a Motor Moron hunter

It is worth spending some time watching training, watching warm ups, watching gym sessions and talking with coaches and S&C’s trying to identify a Motor Moron as soon as possible. It’s important to minimise the chances of an immature sensorimotor mechanism ever meeting a growth spurt. It is when these two things combine that we see kids doing immaculate Mr Bean impressions and therefore increase their risk of injury.Safari-kids

Regularly re-assess your exercise programs. If things arent quite progressing as quickly as they should, it may not be failed healing of an injury, but it may be that we are providing the sensorimotor mechanism with too much information!

 

Yours in sport,

Sam

 

“The Young Athlete” conference 9-10th Oct, Brighton. Here

Hamstring Injury – What are we missing? by Jonny King

We are delighted to introduce a guest blog from Jonny King (@Jonny_King_PT), a sports physiotherapist based at Aspetar, Qatar. Jonny has experience working in professional football in the UK with both Norwich City FC and AFC Bournemouth before he made the big move East to Doha. A prevalent voice on twitter and definetely worth a follow, he provkes some intriguing questions regarding our current understanding of hamstring injuries. We hope you enjoy… P&P

 

Hamstring strain injury (HSI) continues to present as a huge challenge for those of us working within the sport and exercise medicine field – whether that be in a research or clinical setting. Disappointing figures have recently shown that despite an increasing body of publications over recent years and a perceived improvement in understanding of underlying causes, the epidemiology for HSI in elite sport has not changed over the past 10 years (Ekstrand, Hagglund & Walden, 2009) A worrying reality.

Some will argue that WE HAVE improved our understanding and management of hamstring injuries but the evidence base is not being applied effectively into clinical practice. (Bahr, Thornborg, EKstrand, 2015). Others will state that our ability to influence epidemiological data at elite level, has been affected by the evolution of sporting competition including increased physical application. Take professional football for example, both sprint distance (35%) and high intensity running distance (30%) have significantly increased over the past 7 years, alongside a reduction in recovery times as a result of increased fixture congestion (Barnes et al, 2014) These can all be seen as restraints to our drive for better data around HSI.

These are all factors we should appreciate, however are we missing something else?

In brief, we know those at highest risk are those with history of previous strain, weak eccentric strength and those in a fatigued state (Opar, Williams and Shield, 2012). Flexibility, neuromuscular inhibition, biomechanics and H:Q ratios have all been flirted with, but with no real hard conclusion as to their influence on HSI. Identifying those at risk is relatively straight forward these days, given increased accessibility to advanced monitoring technology, helping to identify fatigue or strength reduction. We can thank systems such as GPS and The Nordboard for this. These are for sure all very important considerations as we take a multifactorial approach to injury management and prevention. But, Is there anything else we need to consider?

One area that I feel needs further investigation with regards to HSI is the psychological harmony of the athlete. It may be difficult to account for the primary injury, but are negative beliefs, anxiety and apprehension contributing factors to high rates of re-injury?

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More brain training before RTP?

Cognitive functioning and therapy has been discussed at length in the treatment and management of many other musculoskeletal conditions, notably chronic LBP (O’Sullivan 2012) and ACL Reconstruction , with methods such as CBT proving an effective intervention in many cases. I wonder therefore if this needs more consideration when it comes to hamstring injury treatment? Poor psychological readiness has been associated with hamstring strain re-injury (Glazer, 2009) and this would also provide a feasible explanation as to why completion of Carl Askling’s H-Test appears a strong indicator for RTP. Maybe it’s something we are missing, or not considering enough? By more thorough monitoring of anxiety and apprehension can we mitigate ‘previous HSI’ as a risk factor? Food for thought..

What about fatigue and eccentric weakness?

  • We know HSI is more likely to occur towards end of 1st half & throughout the 2nd half (Ekstrand 2011) and that optimal time for full physiological recovery is 72 hours (Dellal et al 2013).

We also know..

  • The widely documented success of the Nordic Curl programme and other eccentric lengthening programmes in reducing HSI in some populations (Arnason, 2008 and Askling 2013).

Throughout the competitive season, the clinical challenge is to address both fatigue and eccentric strength, because for me, the 2 are counterintuitive to one another. You cannot perform regular, effective eccentric strength training without inducing fatigue, therefore it becomes very difficult to address both variables during a season of heavy fixture congestion.

I do wonder if we spend too much time in-season, prescribing injury prevention programmes and exercises. I feel there is a strong argument that we are only exposing our athletes to a greater risk of injury by adding to the overall accumulative training load and fatigue.

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Are we doing too much?

Why are we not reducing hamstring strain injuries?

Are we trying too hard in search for that holy grail of HSI prevention? Do we just need to ease off these guys?

Ultimately, and realistically I think there has to be a fine balance between the 2 . Windows of opportunity, such as the international breaks and pre-season, should be fully utilized for specific strength training and the remainder of the season used to ensure players have adequate time to recover and prepare physiologically for upcoming competition.

 

No answers here, just some food for thought. Enjoy your sport =)

 

Jonny