You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Student interested in Sports and Exercise Medicine? Can you afford not to attend #USEMS16?!

27 Aug, 16 | by BJSM

By Tej Pandya

undergrad students

Manchester Sports and Exercise Medicine Society are proud to host the Undergraduate Sports and Exercise Medicine Society’s (USEMS) 2016 annual conference. The day will be a mix of talks and interactive workshops; from concussion & career progression to hands-on ultrasound scanning. You will also hear from professionals working in high-performance roles of all sorts (think Team Sky, Liverpool FC & England Rugby+++)! Not only that – USEMS conferences famously provide a fantastic opportunity to network among both peers & professionals in a friendly environment – so what’s there to lose?

In a world filled with expensive conferences, how many are specifically tailored at undergraduates and cost less than a tenner?

There will also be a ticket competition on the USEMS Facebook group on the 1st of September, so keep your eyes peeled – you might just get lucky!

In the meantime, early-bird tickets only £8!

Hope to see you all there & please help spread the word! #USEMS16

Tickets are available from:

http://tinyurl.com/z4q6r8q

Tej Pandya is an intercalating medical student at the University of Manchester and currently President of the Manchester Sports and Exercise Medicine Society (@semsocuk). All enquiries can be directed to semsocuk@gmail.com

Clinical Reasoning in Exercise and Performance Rehab: 24/25 Sept and 15/16 Oct 2016

25 Aug, 16 | by BJSM

NRC2016 flier (3)

To register and for more information: http://www.physiosinsport.org/courses.html

Training modifications for Achilles pain in runners: #AchillesAl case study part 2

22 Aug, 16 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Tom Goom @TomGoom, Sports Physiotherapist at the Physio Rooms and the creator of Running Physio; lead on Running Repairs Course  http://www.running-physio.com/running-repairs-course/

Welcome to part 2 in this ACPSEM series about Achilles tendinopathy, starring #AchillesAl as a fictional case study. Part 1 covered training error and the development of symptoms. Thank you everyone who tweeted about the blog after. I’ve summarised your thoughts on Al’s training error using Storify below:

Here’s our twitter discussion from Part 1:

 

Part 1 concluded that too much high intensity training and a rapid introduction of treadmill running was likely to have overloaded Al’s Achilles and led to pain. The blog closed with a couple of questions from Al that we’re hoping to answer in this blog…

“What training should I do now then?”

“How could I modify it to help my Achilles?”

Once again we invite you to share your views about Al’s care using the hashtag #AchillesAl with @physiosinsport and @BJSM_BMJ.

Before we answer Al’s questions let’s explore some of the principles involved in the decision making process.

Risk vs reward

When we’re working with a patient to help them find the right level of training there isn’t just one right answer. It’s more about examining the options available and considering the risk (of injury or aggravating symptoms) versus the reward (optimising performance and achieving the patient’s goals).

The aim is to strike a balance and reduce risk as much as possible while maintaining performance. Stopping running altogether may not be the lowest risk option. Al will lose fitness and tendons don’t respond favourably to being unloaded plus it’s common for people to develop an injury after returning from a rest from sport. It’s also likely that optimal training doesn’t just mean as much as possible! As training load increases above a point, there are diminishing returns and ‘overtraining’ is known to impair performance.

In reality then a graph of injury risk, performance and training load may look a little like this;

A key factor in risk versus reward and determining the right training level is the patient’s goal and the timescale involved. Al’s goal is a sub 3:30 marathon in 5 months time. This means we have time to achieve Al’s goal and improve his performance – we are not under pressure to take risks and can be a little more cautious with Al’s return to running. If, however, Al was competing in the Olympics in a couple of weeks time and he’d trained for 4 years to get there we might be more inclined to take risks for performance gains. Our approach might then centre around doing everything we can to reduce symptoms to allow Al to compete. Goal and timescale can make a big difference!

Determining load tolerance

Before we can advise Al we need to find out his load tolerance i.e. how much running he can currently manage (if any). Subjective questioning appears to be the best way to determine this as there are few objective tests that can reliably tell you how much running someone can manage. So we might ask Al, “how far can you run without pain?” It’s likely we’ll need to explore Al’s answers with him to get as much information as possible on what running conditions are most comfortable (distance, speed, surface, time of day etc) and how his Achilles responds to it both during and for around 48 hours after.

Our conversation with Al goes like this:

PT “How far can you run without pain?”

Al “It hurts a little almost immediately but then settles fairly quickly and I can keep going”

PT “It sounds like it warms up as you get going, that’s fairly typical of tendons. How far can you run until it starts to get sore again?”

Al “It’s pretty comfortable until around 8 miles then gets quite sore.”

PT “Where would you score that pain out of 10?”

Al “It’s around 3 or 4 at that point.”

PT “How does it react after the run and for the next couple of days”

Al “If I stop at 8 miles it settles quite quickly, and is usually fairly comfortable again within half an hour or so. If I keep going though it’ll ache after and be stiff the next day, especially in the morning. Then going up and down stairs first thing is uncomfortable.”

PT “Does speed make a difference? What pace have you been doing these runs at?”

Al “If I go faster it definitely hurts sooner, then it’ll stay sore for a couple of days. I’ve done most of these runs at around 8:30 to 9 mins per mile.”

PT “Ok, so would it be fair to say then that you can run about 8 miles at around 8:30 to 9 mins per mile and get some mild pain but it’ll settle quickly and be comfortable the next day?”

Al “Yes, that’s about it!”

With that conversation in mind, how might you modify Al’s training regime? What else might you want to know? What objective tests might you examine? How important are they in this decision? Share your ideas on #AchillesAl.

Training modification options

In tendon rehab we want to monitor how symptoms respond to load both during activity and after. Various studies have used a similar approach with this;

Pain should be minimal during activity (e.g. VAS 0 – 3 out of 10) and settle quickly with no reaction the following day.

Silbernagel et al. (2007) was a key paper in continuing sport with Achilles pain. They allowed athletes with Achilles tendinopathy to continue sport with symptoms up to 5 out of 10, providing there was no lasting reaction into the next day. Those that continued sport actually had better outcomes in some tests than those in the active rest group.

Our chat with Al has given us some really useful information. Running approximately 8 miles at a slow pace appears to fit within acceptable limits for pain – he has some mild discomfort during but it settles quickly and doesn’t lead to a reaction the following day. Our aim then for all Al’s training sessions is for them to sit within similar limits. Ideally we can find a way to make them pain free but we’re loading sensitive tissue so some pain is expected.

Options, options, options!…

One exciting thing with working with runners is you have lots of options of things you can modify to make running more comfortable and reduce load on injured tissue. Rather than rest altogether modify and move!…

Distance – as discussed above if we keep the running distance below the level that causes lasting irritation we can help reduce symptoms. In time we can gradually increase distance again to work towards Al’s goal.

Pace/ intensity – Al’s symptoms began largely due to high intensity training. Faster sessions aggravate his symptoms so at present we’ll stick with slower workouts but aim to reintroduce them when Al’s pain is less irritable and he’s developed more load tolerance.

Frequency – reducing training frequency to allow a rest day between each run can be very helpful. Research suggests tendons may take 24-36 hours to recover from exercise. Magnusson’s work (as pointed out on Twitter by top Sports Therapist Ian Brown) indicates that it takes roughly this long for tendon synthesis to exceed tendon degradation;

Source: Magnusson et al. (2010) via Researchgate

Surface – the obvious example in Al’s case is treadmill compared to road running. As previously mentioned, Rich Willy’s recent work shows greater peak Achilles load on the treadmill so it would make sense to reduce Al’s treadmill running or remove it for the time being. This also reduces the risk of dying of boredom which can be a concern with prolonged treadmill running!

Time of day – early morning stiffness is a recognised feature of tendinopathy and some runners report their pain is worse with early morning runs. Switching to training later in the day may be more comfortable for Al, at least in the short term.

Cross-training – Al has a gym membership (it’s where he’s been doing his treadmill running) and has found his Achilles is pretty comfortable on the bike or swimming in the pool. We could replace some of Al’s runs with cross-training and try and achieve similar training goals. For example replace a long, slow run with a long slow swim, or swap an interval session on the track for an interval session on the bike. If we choose to restrict Al’s high intensity runs for the moment it would be good from a performance point of view to replace them with high intensity cross-training; a good way to achieve the balance of risk versus reward.

Recovery – optimising recovery is an important strategy, especially in high volume or high intensity training programmes. This can involve lifestyle change to improve sleep and stress (which we’ll touch on in more detail in later in this series). How and when we use rest/ active recovery is important. In Al’s case we could put a rest day prior to his longest run (so he isn’t fatigued when doing it) and one afterwards (to give him a chance to recover).

What else might you change? How might footwear influence symptoms? It’d be great to hear people’s views on this, especially from podiatrists! Get involved in the discussion on#AchillesAl.

We have lots of options here and it’s important we aren’t too prescriptive. We can discuss the pros and cons of the options available with Al and decide a plan together. We’ll also be mindful that it will change as treatment progresses. Here is what we decided for the next 2-3 weeks;

In a nutshell we have 3 runs, each separated by a rest day and all of them at a slow pace and below 8 miles in distance (where symptoms worsened). The high-intensity run is replaced by a cross-training interval session on the bike, with a rest day after for recovery. We’ve removed treadmill running (which Al is pleased about as he never really enjoyed it!). This will take us to around 4 months until the marathon when we’re hoping Al can slip into a 16 week training programme, that starts at around 20 miles per week.

Thoughts from the MDT

Exercise Physiologist John Feeney from Pure Sports Performance joins us again to add his take on Al’s training…

“It’s important to identify the physiological mechanisms and effects of de-training and then try to mitigate those effects without aggravating the underlying injury. Initially, I would plan for a short term loss of training stimulus (<4 weeks) but also prepare a contingency plan in case Al’s injury becomes increasingly chronic and long-term (> 4 weeks). The strategy should focus on each key physiological area (maximal aerobic capacity, the sustainable percentage of VO2 max Al can utilise and running economy) and then introduce a training intervention to help mitigate the de-training effect on each of these areas. In the short term, we are likely to see a reduction in VO2 max due to decreased cardiac stroke volume and a rapid reduction in the level of chemical activity in the mitochondria which means Al may also become less efficient at utilising his fat stores thereby placing greater reliance on muscle glycogen. There will also be an increase in blood lactate levels which may result in Al becoming becoming less tolerant when exercising at increased intensities.

If the injury persists, longer term de-training effects become more specific to the trained skeletal muscle and so consideration should be given to introducing alternative sport specific exercises that involve the same muscle groups but without placing excessive stress and load on the injury. Exercises such as cross training using an elliptical trainer have been shown to maintain maximal aerobic capacity in the short-term (Joubert, Oden & Etes, 2011). Other sport specific exercises like deep water running are also likely to have a similar ‘maintenance’ effect provided the session frequency, relative intensity and duration are similar to Al’s pre-injury training plan. Non-sport specific exercises such as arm-cranking could be helpful in the short-term if Al needed to further reduce the load on his injury. An interesting study by Pogliaghi et al. (2006) found similar gains in VO2 max between an arm cranking group and a cycling group. Although this study was aimed at an older population, the results indicate that both forms of aerobic training (using different muscle masses – i.e. arms v legs), produced similar improvements in maximal and sub-maximal exercise capacity.”

Planning for the future

We’ve agreed a plan with Al for the next few weeks but it isn’t set in stone. We’ll need to see how he responds to training and adapt it accordingly. We’ll also need to gradually re-introduce the high intensity running and return to his goal weekly training volume of approximately 40 miles per week. There’s no recipe for this but it’s usually sensible to change one thing at a time (e.g. Volume or intensity) and monitor symptom response.

Going forward, one strategy we could use that could both improve performance and reduce injury risk is to ask Al to record the RPE (Rate of Perceived Exertion) for each session. Dantas et al. (2015) found RPE correlated well with blood lactate levels in desired training zones in runners and so can be a useful way to determine the right training intensity. Effort is rated out of 10 where 0 is no effort and 10 is maximal. Roughly 2 to 4 on this scale corresponds to low intensity training (e.g. Long slow run). Approximately 4 to 7 would be moderate intensity (e.g. Tempo runs) and above 7 would be high intensity (e.g. Interval training).

Tim Gabbett’s excellent recent work combines RPE with training volume to give a measure of overall training load, referred to as Arbitrary Units (AU). For each session you multiply training volume (in minutes) by the athlete’s RPE score to provide the total AU e.g. 50 minute run at RPE of 4 = 200 AU.

If we think back to part 1, one of the issues we had was that training volume itself didn’t change a great deal so training error might not have been obvious. If we’d had RPE for each session we might have been able to spot a trend more clearly.

In runners we often use the fabled ‘10% rule‘ suggesting weekly training volume (e.g. Miles per week) shouldn’t increase by more than 10% per week. There isn’t a great deal of evidence to support this in runners but Tim Gabbett’s work did find an increase in injury risk (in rugby league) when Arbitrary Units increased by more than 10% per week;

We could ask Al to get into the habbit of recording RPE during training and calculating total weekly training load in Arbitrary Units. Monitoring this and adapting as necessary could help Al improve his performance and reduce injury risk. Win, win!

Al is happy with the training plan but a little apprehensive about returning to training. He has a few questions about how the tendon will cope;

“Will continuing to run damage my tendon?”

“Is it likely to lead to a rupture?”

What do you think? How would you address these concerns? We’d love to hear your views, share them on #AchillesAl and we’ll include the highlights, plus our answers to these questions, in part 3…

 

Behind the front page/special features: Comments by film maker Donal O’Neill ‘Cereal Killers’, ‘Run on Fat’ and ‘The Big Fat Fix’

20 Aug, 16 | by BJSM

Nutrition – a BJSM blog series

BJSM Editor’s Alert & Recommendation: Do not read this if you know everything you want to know about healthy eating already .

By Donal O’Neill

New Year’s Eve 2011 was the first time I stepped off a plane in Cape Town, South Africa. With the usual carry on plus duffel in the hold combo. I looked like any other holiday maker to this spectacular destination. The laptop in my bag carried two years of research into a topic of no interest to pretty much anyone but myself – or so I thought. Bleary eyed after the overnight flight, I walked out into blazing sunshine and an even brighter African adventure.

The fact that I am still here is down to some remarkable good fortune, two very special people and a niche little movie that almost didn’t happen.

The good fortune?

NoaxesThat all started at a braai (the local term for barbeque) one evening where the topic of my research was pushed center stage courtesy of special person #1. That he wasn’t even there to kick it all off himself didn’t matter a jot. Prof Tim Noakes MD, who is just about as famous in South Africa as any of their elite athletes, had issued his first public comment on the revival of that bad boy of macronutrients – FAT.

In a moment of inspiration, I penned a note to the great man asking if he would like to participate in a documentary on the topic. Our initial exchange gave birth to my first documentary – Cereal Killers. The movie charted my own experiment with a sugar and wheat free, high natural fat diet for 28 days under the watchful medical eye of Noakes. The context was simple. My fit, former elite sportsman father had suffered a very unexpected heart attack in 2010, and I just thought to myself “How the hell did that happen… and am I next?”

As I was leaving his office after our first animated discussion, Noakes said something profound with that wicked signature smile of his.

“Let’s cause some trouble.”

So we did.

The epochal scene in Cereal Killers is of course Noakes tearing out the carb loading chapter of his endurance tome, Lore of Running. When he did so, it sparked the old athlete in me and I knew there was much, much more to this low carbohydrate story.

By the time Cereal Killers released in 2013, John Yudkin’s anti sugar epic “Pure, White and Deadly” was back in print (we had to make do with a bootlegged PDF copy for research) and the topic was at least raising eyebrows. A good sign!

The good fortune never left us really. An editing delay had opened a window of opportunity to include the brilliant Dr Peter Brukner and his low carb, World Cup winning Aussie cricketers in the movie. When World Ironman Champion (AG) Sami Inkinen saw that, he contacted me out of the blue to say he too excelled on a low carb diet. Working with the ketogenic diet pioneer Prof Stephen Phinney, he was metaphorically ripping out that chapter in Lore of Running every time he swam, biked or ran.

Run on Fat

Sami would star in our second movie – Run on Fat – and Steve Phinney crackled with wisdom, enthusiasm and knowledge throughout. The athletes were emerging – albeit slowly – as advocates of lower carb diets for myriad reasons including faster recovery, lowered inflammation and improved endurance performance.

Phinney also dropped a bombshell. When he had met Ancel Keys in the 1980s at the University of Minnesota, Keys had reached in to his briefcase and produced a paper he could not get published. That paper, which allegedly showed that high cholesterol was not as strongly associated with premature death as he originally thought, would have gone some way to amending his own – and possibly everyone else’s – position on cholesterol. “Keys was furious.” said Phinney.

When we wrapped Run on Fat, I wanted to know more about Keys, the legacy he had left and the direction he may have taken with that unpublished paper.

The answers lay in Pioppi (pop 190), a tiny Italian village two hours south of Naples which is the UNESCO protected home of the Mediterranean Diet. Keys, the most powerful voice in the history of nutrition, had lived here for 30 years. His work in Pioppi ultimately laid the foundation for the introduction of modern low fat food policies in the 1970s, but he seemingly died an angry man. Keys’s influence had waned and he was unable to find a scientific journal to publish his updated position on cholesterol. “It was too late. The juggernaut was unstoppable.” said Phinney.

British Cardiologist Dr Aseem Malhotra joined me to explore why that happened. What we found amongst these wonderful people in a magical environment, was remarkable. “We have a treasure” said Stefano Pisani, the local Mayor.  He speaks the truth. That journey is our new movie – The Big Fat Fix.

big fat fix poster movie

Men’s Health have called it “the final word in the fight against dietary misinformation.” I hope they’re right.

The adventure continues at www.thebigfatfix.com. I encourage you to check it out –

PS  Special person #2 is my wife Louise. Because every film maker needs a happy ending too.

*****************************************

Donal O’Neill is a former international athlete and film maker.

#RSNlive16: Rugby Science Network 2016 Conference (September 13th and 14th, 2016)

19 Aug, 16 | by BJSM

Tackling. Concussion. Doping. Rugby is a sport which has had to confront some big topics in the public domain over the past few years, and has persistently shown significant commitment to ensuring the welfare of its participants, be it through research, education, or otherwise.

RSN live picture

As a collision sport, injuries are unavoidable – and so there has been much in the form of injury research in the game, with the RFU in England, the NZRU in New Zealand and the SARU in South Africa in particular, providing examples of high quality surveillance research over the past few years. World Rugby, the governing body, deserve much credit for clear and effective leadership – and have been at the forefront of ensuring player welfare through taking account of this research and enforcing rule changes, most notable when it comes to dangerous tackles and the scrum.

With its inclusion in the Olympics however, and with more lucrative prizes, nations and teams have been searching for the marginal gains of sporting performance, which as a result has provided a great bulk of research, some of which has been published in the BJSM.

As such, rugby medicine has a high quality and diverse range of research topics – the vast majority of which are applicable to both team, and individual sports – and may be of interest to the majority of the BJSM readership. Interested in knowing more?

The University of Bath, who have been at the forefront of rugby medicine through their work with the RFU, have organised a two-day conference, on September 13th & 14th, at which much of this research will be presented. Topics include: injury prevention; dietary supplementation; skill development; long-term player welfare; and concussion – which will be brought to life by a fantastic array of speakers including Prof Ross Tucker, Prof Graeme Close, and Dr Martin Hagglund amongst others.

Whilst tickets are available online, if you can’t make it in person, they will be live-streaming the talks for free via their website, with even an opportunity to join in the conversation through the usual social media channels via #RSNlive16. BJSM+ will be tweeting from the event and helping to widen the conversation – we look forward to engaging with the SEM community on a wide range of issues.

Can’t wait? Here are some seminal #RugbyMedicine papers to whet your appetite:

We look forward to your contribution to #RSNlive2016

Expedition Medicine: The Grubby Twin of Sports and Exercise Medicine?

16 Aug, 16 | by BJSM

By Dr Nick Knight

Sports and Exercise Medicine (SEM) is a specialty with clear direction. It creates SEM doctors to manage the medical care of injury and illness in sport and to provide large scale application in improving the health of the general public through exercise advice and prescription1. As broad as this ‘broad church’ speciality is, some of its key functions are sports team care, musculoskeletal medicine, exercise medicine and, away from the sports arena, workplace wellness1.

nick scuba

Dr. Nick Knight scuba diving

But did the SEM Faculty realise that it has a twin?

Expedition medicine, I would argue stands in the shadow of its bigger brother, SEM. After all, expedition medicine has a reputation as dirty, roguish and with an unpredictable wild look in its eye. It is quite simply not everyone’s cup of tea and a fringe aspect of medicine that many dismiss.

Now as a doctor in the early stages of my career I find this puzzling. Maybe it is my simple mind but does SEM and expedition medicine not both share remarkable similarities? Both are largely aimed a treating a driven population looking to achieve a physical and mental goal and thereby also motivated to recover, are they not? Consider the types of medical issues that arise in SEM as well, such as musculoskeletal medicine and GP-type issues (especially gastrointestinal2). This almost mirrors the medical profile within expedition medicine (although foot care and dermatological issues will feature more heavily)2. Now explain to me why a sports medical team would be vastly different from an expedition medical team?

As I reflect on the case of our twins, it is clear that expedition medicine can learn a lot from SEM. SEM is established, well researched and focused on maintaining and optimising the melting pot of physiological, biochemical, and psychological processes with our athlete population. Let us too not forget to mention SEM’s focus on optimising training and competitive environments. These are all aspects an expeditioner needs. Indeed I believe that anyone undertaking expeditions deserves the title of athlete. Their physical and mental challenge is just as omnipotent – just dressed up differently.

Dr Nick Knight_Nepal Trek

Dr Nick Knight Nepal Trek

So can SEM learn from expedition medicine?

I am sure many purists may click onto the next BJSM link at this point. If you are reading on then you have let me explain how SEM’s grubby little twin has lessons for its bigger brother. Now as I ponder over my tea and mind-map I realise just how difficult it is to separate SEM and expedition medicine. There is however one key factor which stands out to me. It is this factor that, in turn demonstrates the learning potential.

‘Variables’

Expedition medicine possesses a melting pot of variables that simply cannot be uncontrolled. On an expedition an ‘expedition athlete’ has no rules to govern the environment around them, unlike in established sports. As such the medical impact on the expedition athlete can be magnified, while the expedition medic too is required to react to events or injuries that cannot be rehearsed.

Expedition medicine offers the SEM community a window to a world where there is far less control of the athlete, of the medical resources, of the environment, and of the timeline from injury to care and extraction from the field of play. These skills have the capacity to build further flexibility, adaptability and reactivity into the SEM medic; a robustness that comes from practicing what is essentially SEM in an environment where there is no comfort, no control, little resource and where patients are stretched often beyond the safe limits of their physiology and psychology. There are no rules.

Now while I appreciate that may sound intangible and romantic for some, the take-away message is this: SEM and expedition medicine share the same goals of promoting, protecting, enabling and optimising an athlete’s health and their performance. So why don’t we start by extending a simple handshake and introducing SEM to its emerging twin brother and start paving the way for some collaborative ‘Performance Medicine’?

**********************

Dr Nick Knight, GPST1, London

References

1 The Faculty of Sports and Exercise Medicine Website

http://www.fsem.ac.uk/about-us.aspx

2 World Extreme Medicine Conference 2015: The Ultra-endurance athlete symposium

Physiotherapy and treating golfers: practical tips and experience based principles

12 Aug, 16 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Nigel Tilley @nigel_tilley

Physiotherapist on European Tour/ETPI; Team GB Golf Physio Rio 2016; European Ryder cup team physio 2016

Identifying the cause of an injury is often key to the effective assessment and management of a condition/problem.  All too often practitioners jump to the ‘hands-on’ objective assessment & identification of structural issues.

Take time to stand back and speak to the player in detail to get an insight into their history and what has led them to arriving in front of you.  Always remember though that first and foremost you are treating the person not the injury.  As a general rule most problems we see on tour can relate to a few simple issues and is likely to be similar with most club/amateur golfers you will see in your day to day practice.  Think about these things and use these questions to help you identify the problem:

kettle ball golf1) VOLUME – Have they hit more balls recently, been practicing more, playing more?  Have they been practicing a certain shot? Have they had a change in their routine? Have they started a new exercise programme or increased their workload suddenly? Have they been hitting off hard mats or suddenly gone from doing nothing for a month to hitting 300 balls a day for a week?

2) TECHNIQUE –  Have they changed anything in their technique recently? Grip, Swing biomechanics, equipment, footwear?  Have they been pulling a cart or carrying a bag when they may normally have used a buggy.

3) ACUTE TRAUMA – have they hit a shot from thick rough, caught a tree root, forced a shot too hard, lifted something (heavy bags and equipment in/out of house and car)

4) A combination of any or all of the above.  Such as a player who has recently changed shafts in their woods and made some swing changes due to poor form. But the poor form and desire to practice and ‘imbed the new swing’ changes means instead of hitting 50-100 practice balls a day they are now hitting 300 a day (a 300% increase) on tissues that are potentially not used to tolerating those loads in that intensity.

Of course there are many other potential triggers and causes of injury in golfers, but more often than not the presenting player will usually identify a specific trigger to the start of their symptoms.  The solution often lies with the cause.  Whilst we may direct acute treatment plans to the structures we believe are involved, the key to success is identifying the cause.  More often than not education is vital to enable the player to both resolve their problem and prevent its return.  We work hard on encouraging players to use practice and training logs (practice time, balls hit, number of swings, effort used, practice putting and chipping times etc) to ensure they don’t have volume and training spikes (and troughs!!). Educating players on periods of high vulnerability and injury risk, such as when they are making technique or equipment changes and to take care that they are not linked with large spikes in practice volume is hugely important.

There are 3 key areas you can get patients to work on to reduce injury potential and benefit their game.

Develop/maintain mobility in 3 key areas

The Thoracic spine

Golf requires a lot of rotation.  The thoracic spine provides a lot of this rotation.  If it is stiff the rotation (or rotational forces) end up going elsewhere. Often this means the Lumbar spine (which is not designed well to do this) and can lead to injury or technique faults.

The hips

Having good range of internal and external rotation in the hips is important to facilitate a full and efficient swing through correct loading and weight transference through the feet and up the chain during the golf swing.  Limitations in hip rotation have been shown to be linked with increased low back pain in golfers.

The shoulders

Golf is an asymmetrical sport requiring different movements and actions from the lead and non-lead upper and lower limbs.  A right handed golfer will require greater range of external rotation of the right shoulder than the left and subsequently more adduction of the left than the right during the swing.  Having a good range of movement in both shoulders helps both technique and reducing excess forces to other areas of the body during the swing.

Develop stability and control through range

Flexibility is obviously important in golfers but it is equally as important to be able to safely control that movement through the range and as part of the kinetic chain.  Having a stable base from which to create and transmit forces from the ground up through the kinetic chain to the hands is vital for efficient and maximal power creation & use.  Being able to control and brake the forces involved in the golf swing is as important as being able to create them.

Understand a players physical capabilities and limitations

It is important for both you and the patient to have an understanding of the golf swing and what is required of the body to perform the golf swing.  A player can either build a golf swing around what their body can do OR can look to change their physical limitations or improve their capabilities to fit the swing they want.  Developing a good relationship with a PGA teaching professional will help you both to understand & identify swing faults & link this to your physical assessment & subsequently with your treatment & management.

The underlying aim of what we do with players in rehabilitation and conditioning work, is ‘to make them strong, make them robust and make them stable’.  Evidence really is pointing towards the use of strength and conditioning programmes and making people strong as the key tool in both injury prevention & performance enhancement.  A large amount of the injuries we see in golf are tendinopathies.  The immediate requirement of a player presenting to you the day before he plays an important game with an acute tendinopathy is to make sure they play if that’s what they want.  Our acute management of that issue may include strappings, tapings, soft tissue techniques etc etc.  But fundamental to the long term management of this is identifying the cause, ensuring the right education is given to the player and most important of all that an appropriate and structured loading programme is used for the tendon/tissues as the foundation of their management plan.

resistence training golf

Players need to develop an underlying stable athletic foundation and to develop tissue resilience that can tolerate the forces being placed upon them.  The use of strength and conditioning as part of professional golfers training is well and truly engrained and is becoming more widely used and accepted amongst amateur golfers.  The golf swing requires a large mix of explosive power, strength, stability, flexibility, and athleticism.  The modern day professional golfer really is now seen as an athlete. Their training reflects this.  We should be encouraging all golfers we see from beginners to elite to develop that mindset and look to improve their general athleticism.   As physiotherapists we are ideally placed to deal with the complex acute and chronic injuries, rehabilitation and strength and conditioning & performance needs of golfers.

References

CABRI, J., SOUSA, J.P., KOTS,M. and BARREIROS, J. (2009) Golf-related injuries: a systematic review. European Journal of Sports Science, 9(6), 353-366

EVANS, K., REFSHAUGE, K.M., ADAMS, R. and ALIPRANDI, L. (2005). Predictors of low back pain in young elite golfers: a preliminary study. Physical Therapy in Sport, 6, 122-130

FRADKIN, A.J., SHERMAN, C.A. AND FINCH, C.F. (2004). Improving golf performance with a warm up conditioning programme. British Journal of Sports Medicine, 38, 762-765

GLUCK, G.S., BENDO, J.A. and SPIVAK, J.M. (2008). The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention. The Spine Journal, 8, 778-788

GOSHEGER, G., LIEM, D. and LUDWIG, K. (2003). Injuries and overuse syndromes in golf. American Journal of Sports Medicine, 31(3), 438-443

HOSEA, T.M., GATT, C.J. and CALLI N.A. (1990). Biomechanical analysis of the golfer’s back. In COCHRAN, A.J. (Editor) Science and Golf I: Proceedings of the World Scientific Congress of Golf. London: E&FN Spon, 43-48

HOSEA, T.M. and GATT, C.J. (1996). Back pain in golf. Clinical Sports Medicine, 15, 37-53

LAURENSEN, J.B., BERTELSEN, D.M. AND ANDERSON, L.B. (2014). The effectiveness of exercise interventions to prevent sports injrueis: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48 (11), 871-7

LINDSAY, D.M, and HORTON, J.F. (2002). Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Sciences, 20, 599-605

LINDSAY, D.M, and HORTON, J.F. (2006). Trunk rotation strength and endurance in healthy normals and elite male golfers with and without low back pain. North American Journal of Sports Physical Therapy, 1(2), 80-89

MCHARDY, A., POLLARD, H. and LUO, K. (2006). Golf injuries. Sports Medicine, 36(2), 171-187

METZ, J.P. (1999). Managing golf injuries: technique and equipment changes to aid treatment. Physician and Sports Medicine, 27, 41-58

Myotendinous injuries call for proposals – NBA and GE Healthcare Orthopedics and Sports Medicine Collaboration

11 Aug, 16 | by BJSM

NBA call for proposals

In June 2015, the NBA and GE Healthcare launched the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration, a strategic partnership aimed at engaging leading clinical researchers who have demonstrated excellence in orthopedics, sports medicine, radiology, and related disciplines. The NBA, GE Healthcare, and additional partners will provide funding for research that supports the mission of the collaboration.

The mission is to address high-priority clinical questions regarding the prevention, diagnosis, and treatment of acute and overuse injuries among NBA athletes, and to apply such findings to basketball players and the general population.

A series of Calls for Proposals (CFP) will be consecutively released by the NBA & GE Healthcare Orthopedics and Sports Medicine Collaboration, with each CFP strategically focused on a class of acute or overuse injuries affecting NBA athletes. The first CFP was released in 2015 and focused on the natural history, diagnosis, treatment, and prevention of tendinopathy. To learn more about the Tendinopathy CFP and awardees, and to register for notifications of upcoming CFP releases, please visit the NBA & GEHC collaboration CFP website.

MYOTENDINOUS INJURIES CALL FOR PROPOSALS

Myotendinous injuries are common issues in competitive athletes and can impair performance, limit playing time, and disrupt a career. Such injuries are often referred to as “muscle strains, tears, ruptures, or pulls.” Prevention programs for some specific myotendinous injuries have been described for varying levels of play; however, there is little evidence supporting many of these strategies. When an acute muscle injury occurs, the best techniques for clinical assessment, choice and timing of imaging modalities, treatment, and return-to-play strategies are unclear.

Questions to be addressed in this CFP:

  • How can the impact of acute myotendinous injuries on athletic participation be reduced?
  • What is the efficacy of prevention programs?
  • What specific prevention, assessment, and treatment techniques are needed for different injury sites (e.g. hamstring vs. gastrocnemius/soleus)?
  • What is the correlation between imaging and clinical assessment?
  • Which interventions are effective for treatment?
  • What are the risk factors associated with an initial injury?
  • What are the risk factors for re-injury?

To read about specific areas of research interest please go to the NBA & GEHC collaboration website.

AWARD MECHANISMS AND AMOUNTS

This CFP will award a total of $1,500,000 over a three-year period to support preclinical and clinical research addressing important unanswered questions regarding myotendinous injury diagnosis, treatment, and prevention in elite basketball athletes. The maximum amount for an individual grant is $300,000 including direct and indirect costs for the entire project period. More focused, impactful projects requiring less support are encouraged.

DEADLINE

Completed applications and proposals must be received no later than 5:00 pm EDT on September 8, 2016.

Scientific peer review and programmatic review is intended to be complete in November of 2016.

This CFP with complete instructions and forms for applying are available at the NBA & GEHC collaboration Myotendinous Injury CFP website (https://gex.brightidea.com/MyotendinousCFP2016).

All roads lead to Rome – Running a marathon on ACL injured knees

9 Aug, 16 | by BJSM

By Catherine Lester

I ran my first marathon in Rome in April, albeit slowly. I had never run further than 10km as of December last year.  My dad asked me if I was sure I should be running – in 2008 I injured my left anterior cruciate ligament (ACL), medial collateral ligament (MCL) and both menisci skiing and in 2012 I ruptured my right ACL.  Both have subsequently been reconstructed and rehabilitated.  My left knee has had a lateral meniscal debridement and a failed medial meniscal repair followed by a meniscectomy.

all roads lead to rome - picture

Me on left in the front with my significantly faster friends before the start of Rome Marathon, April 2016

What are the risks associated with the repetitive load of marathon training in a previously injured knee? Wearing my ‘SEM Clinician’ rather than my ‘athlete’ hat, what do we tell our patients? 

The May BJSM featured the old knee in the young athlete and particularly focused on pivoting sports.(1)  Whilst perhaps not relevant to marathon running, their recommendations were to allow the patient to be the boss of their decisions, to embrace shared decision making in deciding on return to play and to present risk and information that is relevant to the athlete.(1)

Recreational running is on the increase.  Spend a day either spectating or working medical support at the London marathon and you will quickly learn that not all marathon runners are equal.  Running a marathon attracts avid charity fundraisers, people coerced by friendly ‘peer pressure’ and in some instances it has become a sporting event ‘everyone’ would like to do at least once.  Runners come in all shapes and forms and the average age is getting older.(2)  Because of this variable body shape and increasing age it is easy and almost logical to expect to see an increased incidence of osteoarthritis (OA) secondary to the repetitive joint load involved in training and completing a marathon.

If you sustain an ACL injury you will have a greater chance of developing OA down the line.(3)  It is a well-known complication with a prevalence of 10-90% at 10-20 years following an injury.(4)  But what are the risks of OA in a previously injured knee when running a marathon?

A recent systematic review by van Meer et al.(3) looked at both tibiofemoral and patellofemoral OA after ACL injury. Their review concluded the medial meniscal injury/meniscectomy is a positive predictor for tibiofemoral OA and OA of the knee joint where the compartment was unspecified.  The same cannot be said for lateral meniscal injury/surgery where there is conflicting evidence. In addition, there was conflicting evidence on the development of osteoarthritis in an ACL reconstructed knee versus a conservatively managed cruciate ligament.(3)

The knee is the most injured structure during distance running accounting for up to 42%(5) of running injuries.  Traditionally this has been iliotibial band and patellofemoral joint injuries however meniscal injuries are starting to be more common.(2)  Previous injury and running mileage over 40 miles or more per week have been proven to be significant risk factors for developing a running injury,(2) but this mileage does not necessarily cause OA.  It is important to note that other research suggests that 40 years of running 20-40 kilometres weekly does not lead to OA in individuals without previous injury(6). Leech et al. wrote an editorial citing ten papers and concluded that overall there is insufficient evidence that recreational running contributes to the development of OA.(7)

A literature search revealed an article entitled ‘To run or not to run: A post-meniscectomy qualitative risk analysis model for osteoarthritis when considering a return to recreational running’.(8)  The author summarised the predictors for OA into a table and while meniscus surgery and injury were included so were age, female gender, body mass index and pre-existing radiographic or arthroscopic evidence of OA.(8)

They concluded their paper with two phrases which could be adopted into one’s clinical practice that symptomatic OA in a patient following meniscal surgery ‘is a probability and not a certainty’ and ‘runners are a self-selecting group’, in other words generally those who experience significant symptoms choose not to partake in long-distance running.(8)

In summary, the risks of developing osteoarthritis of the knee are complex and often multi-factorial.  I am at risk and am likely going to develop OA, certainly radiographic even if not symptomatic, particularly in my left knee, but did running Rome marathon increase this risk significantly?  I think it is unlikely, as there is insufficient and conflicting evidence to support this.  This experience will further reinforce my current clinical practice; that ‘never’ is very rarely an answer.  As Sport and Exercise Medicine clinicians I feel we need to be educating patients in order for them to make their own risk assessments and I believe that often the gained benefits of taking part in physical activity of any nature outweigh the risks in most scenarios.

********************************

Catherine Lester is a speciality registrar in SEM currently based in Cambridge. She works with Bedford Rugby club and the GB and England women’s hockey teams under the CMO.

Farrah Jawad is a SEM registrar in London and co-ordinates the BJSM Trainee Perspective blog.

References

  1. Ardern CL, Khan KM. The old knee in the young athlete: knowns and unknowns in the return to play conversation. Br J Sports Med. 2016;50(9):505-6.
  2. Fields KB. Running injuries – changing trends and demographics. Curr Sports Med Rep. 2011;10(5):299-303.
  3. van Meer BL, Meuffels DE, van Eijsden WA, Verhaar JA, Bierma-Zeinstra SM, Reijman M. Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review. Br J Sports Med. 2015;49(15):975-83.
  4. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-69.
  5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95-101.
  6. Konradsen L, Hansen EM, Søndergaard L. Long distance running and osteoarthrosis. Am J Sports Med. 1990;18(4):379-81.
  7. Leech RD, Edwards KL, Batt ME. Does running protect against knee osteoarthritis? Or promote it? Assessing the current evidence. Br J Sports Med. 2015;49(21):1355-6.
  8. Baumgarten B. To run or not to run: a post-meniscectomy qualitative risk analysis model for osteoarthritis when considering a return to recreational running. J Man Manip Ther. 2007;15(1):E1-E15.

Employment opportunity: Clinical Research Scientist (4 positions) – Aspetar Orthopaedic Sports Medicine Hospital

6 Aug, 16 | by James Smallbone, Publishing Assistant

ASPETAR_logo

 

Aspetar is the first specialised Orthopaedic and Sports Medicine Hospital in the Gulf region. It provides the highest possible medical treatment for sports-related injuries in a state-of- the-art facility, staffed by some of the world’s leading sports medicine practitioners and researchers. Through the delivery of excellence in sports medicine, physiotherapy, sports science, orthopaedic surgery and rehabilitation, Aspetar services the needs of football and Sports Clubs and Federations throughout the state of Qatar, and regularly services international athletes and professional sportspeople.

Aspetar strives to meet the highest international standards obtainable in its treatment of musculo-skeletal injuries and combines best-practices with the latest technology to guide athletes from diagnosis through rehabilitation and recovery. Our teams of dedicated researchers and physicians couple leading methodologies with state-of- the-art technology to provide athletes with total health, physical management and performance strategies.

In 2009, Aspetar was accredited as a “FIFA Medical Centre of Excellence” by F-MARC and in 2014 an “IOC Research Centre for Prevention of Injury and Protection of Athlete Health”. A core research objective of Aspetar is to produce clinically relevant research that focuses on the aetiology, diagnosis, prognosis and treatment of sports injuries; thereby assisting athletes in their endeavour to reach their full potential.

Accordingly, Aspetar is seeking to employ 4 Clinical Research Scientists. The purpose of a Clinical Research Scientist is to produce internationally recognised peer reviewed research by planning, executing and delivering clinical research projects in coordination with Aspetar clinicians; whilst simultaneously providing high-level care for athletes rehabilitating from injury. The primary research focus of the Clinical Research Scientist will be in one (or more) of the following topics; anterior cruciate ligamentous injury, muscle injury, groin pain/injury, foot and ankle injury and return to play.

Whilst reporting directly to the Director of Research, the Clinical Research Scientists will split their time between the Aspetar Research Department and other Aspetar clinical departments where relevant (physiotherapy, sports medicine, exercise science and/or surgery), where they would assist in providing clinical services to injured athletes directly within the research topic they are assigned to. Accordingly, the Research Scientist’s clinical time will be spent under the direction of the supervising clinical lead of the respective clinical department where applicable.

Key responsibilities:

  • To produce internationally recognised peer reviewed research by planning, executing and delivering clinical research projects in one (or more) of the following topics; anterior cruciate ligamentous injury, muscle injury, groin pain/injury, foot and ankle injury and return to play.
  • Act independently to plan, implement, evaluate, treat and progress patient care to maximise rehabilitation potential.
  • Independently manage a caseload of athletes and non-athletes effectively and efficiently; and advance treatment progression of patients independently.
  • Support, apply and develop the existing clinical sports medicine research programmes at Aspetar.
  • Provide operational leadership to research activities that participate to develop recognition of Aspetar as a ‘global leader in sports medicine and exercise science by 2020’.
  • Contribute to evidence based practice in the department at a proficient level and provide significant input into development of assessment and treatment protocols.
  • Independent charting using SOAP format.
  • Take decisions regarding discharge planning of patients independently or with Senior Physiotherapist(s) as deemed appropriate.
  • Fulfil all administrative and organisational duties related to the clinical research topic including defining study design, obtaining ethics clearance, recruiting participants, assuring data collection and analysis (statistical analysis).
  • Prepare articles for international peer-reviewed journals.
  • Co-supervise PhD student or post doc fellow candidates with partner universities (if appropriately qualified).
  • Collaborate with and act as a conduit between other clinical leadership roles to develop research programs that links and builds upon clinical requirements and activities within the Clubs/Federations. These include, but are not limited to: Research, Exercise and Sport Science and National Sports Medicine Programme staff, and other relevant Aspire Academy, Qatar Olympic Committee, Club or Federation staff as required.

Necessary requirements:

  • Excellent knowledge of the aetiology, diagnosis, prognosis and treatment of sports injuries in one (or more) of the following topics; anterior cruciate ligamentous injury, muscle injury, groin pain/injury, foot and ankle injury and return to play.
  • ≥ 3 years of experience in either sports physiotherapy, sports medicine, surgery, exercise science or podiatry
  • Bachelor degree in physiotherapy, medicine or equivalent clinical sports medicine area. Candidates educated to higher degree level (PhD or equivalent degree) will be prioritised.
  • Demonstrated ability to manage orthopaedic and sports medicine caseloads independently and proficiently
  • Proven personal communication (oral / written) skills to write scientific papers, deliver lectures or seminars and to represent Aspetar and its research activities in international scientific meetings.
  • Proven organisational skills and the ability to work well under pressure, while adhering to tight timelines.
  • Proficient in computer skills, especially MS excel / Word / Powerpoint and scientific software such as SPSS or SigmaPlot, Spike 2, etc.
  • Patient, meticulous, confident and motivated.
  • Ability to work well independently as well as part of a multi-disciplinary team of clinical and applied research scientists.
  • English and/or Arabic speaker.

Closing date: 31 st August 2016

For more information on this position, please email Director of Research, Prof. Mathew Wilson (Mathew.wilson@aspetar.com) or Assistant Director of Rehabilitation, Dr. Rodney Whiteley (rodney.whiteley@aspetar.com).

 

ASPETAR_logo

BJSM blog homepage

BJSM

A peer review journal for health professionals and researchers in sport and exercise medicine. Visit site



Creative Comms logo

Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine