8 Simple Ways to Avoid New Year’s Resolution-Induced Injury

As hangover clears on yet another festive season, I thought that I would get in early and write a blog on New Year’s resolutions. Specifically, how best reduce the risk of injury upon resuming exercise after a prolonged period of time away from exercise.

The reason behind this is very simple: Without fail, each and every mid-late January, I get an influx of people coming into the clinic with an array of injuries that include lower limb tendinopathies (achilles & gluteal), calf/hamstring strains, rotator cuff injury, lower back and neck strains, that were all sustained during an attempt to try and get “fit and healthy” for their New Year’s resolution i.e They resumed exercise after a prolonged period away from exercise.

For the most part, a majority of these injuries are due to the obvious: A rapid increase in exercise volume and intensity from previous levels of physical activity. However, a majority of these injuries could have also been prevented with an appropriate exercise plan.

So without further ado, here are my 8 pieces of friendly advice to minimize your chances of getting injured through the New Year period so that you can stick to your New Year’s resolution of getting fit and healthy, and sustaining this physical activity right through the entire year and beyond:

  1. Don’t be tempted to start that boot camp just yet. Simply start by getting off the couch and move most days per week. This sounds very basic I know, but if you haven’t regularly walked, cycled or swam for 45mins, 3-5x per week for the last few months, how on earth do you think you’ll cope with running, jumping, boxing and doing push-ups and burpees for 45mins, 5x per week?
  2. Compliment cardiovascular exercise with some simple body-weight exercises: You don’t need fancy gym equipment and extra load when you’re first starting out, but the increased nerve drive to the working muscles from 2-3 weeks of body-weight exercises such as chair squats, step ups, sidesteps, calf raises, bench/knee/toe push ups and side planks will put you in a good place to start some heavier lifting (if you want to) in late January. 2-3x strength sessions per week is all you need.
  3. Don’t shy away from strengthening exercises: Strengthening-alone has been shown in a systematic review of 26,000 participants to be far superior to stretching-alone in reducing the risk of “overuse” injuries by 50% and reduces the risk of acute injuries by 30%.1
  4. If you MUST do boot camps, or Crossfit, or F45, or other forms of high intensity interval training, do so 2x per week ONLY (non-consecutive days) for the first 2-3 weeks and increase to 3x per week (non-consecutive days) thereafter. The other 2-3 days of the week can be filled with low-moderate intensity exercise (maximum 6-7/10 rate of perceived exertion) such as walking, bike riding, swimming, pilates, yoga. The reason for this is that it takes 48 hours in trained individuals for muscles to recover from a dose of high intensity exercise,2 and 72 hours for tendons to recover from a dose of high intensity exercise, and any attempt to do back-to-back days in untrained individuals will soon result in an “overuse” injury.
  5. Don’t forget to sleep! For all your training to take hold and for your body to adapt to the exercise that you are doing, your body needs sleep. The National Sleep Foundation recommends that adults require 7-9 hours sleep per night. For more information, including how to improve the quality of your sleep, see previous blog here
  6. Use sessional RPE (sRPE) to monitor exercise loads and use it to plan and progress future exercise plans. sRPE is an evidence-based way to measure load and predict future injury and I have previously written about this; see previous blog here. To summarize, every training session you do is measurable. Simply multiply the session time (mins) by a score out of 10 (rate of perceived exertion; 0 = asleep, 10=maximal effort). And remember, “High loads are not the problem. It is how you get to these high loads that is” – Tim Gabbett. Also, don’t progress exercise loads by more than 10% per week!3
  7. Set realistic goals: If your goal is to lose 10kg in 1 month, it’s time to get a reality check. This weight loss is simply not sustainable and you will most likely get injured and end up in tears through disappointment of not achieving your goal. Be sensible; 0.5-1.0kg per week is a more realistic and sustainable way to try and lose weight.
  8. Don’t forget to factor in rest days! In similar ways that less sleep equates to higher injury rates and poor physical and mental performance, studies have shown that those people who have less than 2 rest days per week, have a 5x increased risk of overuse injury than those who have 2 or more rest days per week.4

So there you have it, my 8 big tips to safely getting started on an exercise program after a prolonged break from exercise so that you can stay on track and achieve your goals. I understand that nutrition plays a significant role in achieving your training goals, but as this is not an area of expertise of mine, I have purposely not addressed nutrition, but will gladly point anyone interested in the direction of some excellent dietitians.

In closing up, I know that I’ve given a very broad overview on how to avoid overuse injuries when embarking on an exercise program, and I completely understand that every person is different in regards to their exercise tolerance, so please remember to consult with your GP, Physical Therapist or exercise physiologist before commencing any exercise or strength training program to make sure that it is tailored to your fitness level, but importantly, it is SAFE and SUSTAINABLE for the whole of 2017 and beyond!!

#ExerciseIsMedicine.

Opinions expressed by physiogramworld contributors are their own.

Visit Mick’s website : http://www.mickhughes.physio/

References:

1.Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British journal of sports medicine. 2014 Jun;48(11):871-7. PubMed PMID: 24100287. Epub 2013/10/09. eng.

  1. Korak JA, Green JM & O’Neal EK (2015). Resistance training recovery: Considerations for single vs multi-joint movements and upper vs lower body muscles. International Journal of Exercise Science, 81 (1), 10.
  2. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? British journal of sports medicine. 2016 Mar;50(5):273-80. PubMed PMID: 26758673. Pubmed Central PMCID: PMC4789704. Epub 2016/01/14. eng.
  3. Ristolainen L, Kettunen JA, Waller B, Heinonen A, Kujala UM. Training-related risk factors in the etiology of overuse injuries in endurance sports. The Journal of sports medicine and physical fitness. 2014 Feb;54(1):78-87. PubMed PMID: 24445548. Epub 2014/01/22. eng.

Anterior Cruciate Ligament (ACL) injuries: A general overview

Anterior Cruciate Ligament (ACL) injuries: A general overview

Since I was on the topic of Anterior Cruciate Ligament(ACL) injuries in the adolescent female last week, I would like to broaden the scope and cover some more grounds on ACL injury. This time, my attention is on the rates of ACL injuries, how many people actually return back to sport after an anterior cruciate ligament reconstruction (ACLR), patello-femoral joint (PFJ) pain during rehabilitation, and some Return to sport (RTS) outcome measures that should be “non-negotiable” when deciding on return to play.

A case study performed on 242 patients – all under the age of 18 years-old – who underwent primary ACLR, found that 75 (30%) had sustained another injury to their surgical graft, or to their opposite ACL, or both within 15 years of having the primary surgery performed.1 Taking a wider look across an older age group it appears that as we get older, the success of primary ACLR is marginally better. A systematic review and meta-analysis of 1004 patients (mean age 30 years, 66% male) found that within 2 years of primary ACLR, 13.5% had failed.2 Another review found that 12% of primary ACLR will fail at least 10 years follow-up.3

Key message – Surgery is not always 100% successful. The key period of rehab is obviously the first 12 months post-operatively, but on-going regular strength and conditioning (2-3 x per week) is essential whilst the person is still playing sport.

In regards to Return to Sports (RTS), the number of people that RTS following ACLR is really surprising. One study in particular found that 81% of people will return to any sport, 65% had returned to pre-injury level of sport, and only 55% of people had returned back to competitive sport.4 In a study by the same authors, they found that less than 50% of people went back to competitive sport within 2-7 years following ACLR.5

Key message – Be realistic with your patient/athlete that there is a high chance that they won’t return to their pre-injury or competitive level of play after their ACLR. And that is totally OK. Life, work and family often take priority. Do encourage modified exercise options though, for on-going general health and well-being.

Following on from this, in regards to actual clearance from the medical team to RTS, it is very surprising to read that only 13% of 264 studies on ACLR used objective outcome measures to decide if a person was ready to r eturn to sports. Even more worrying was that 40% of the studies did not report any outcome measures, and 32% of the studies found that patients were being cleared to RTS based purely on post-operative time frames.6 With this information, it is no wonder why we have such high re-injury rates. Of course, clinical tests carried out by the treating orthopedic surgeon are of absolute importance – i.e. absence of swelling, full knee active range of motion, negative Lachman’s test and a negative pivot-shift test – but I think a marriage of both clinical tests and functional tests are essential before the athlete returns to play. I have provided a link to a paper that provides a very clear criterion-based progression from ACLR through to RTS, and I feel that we should all be using this model (or one very similar to it) with all of our ACLR patients/athletes.

Key message: Use objective measures to determine if your patient is ready to return to sports. Don’t just assume that they are ready to RTS after 12 months.

Lastly, this is one particular area that I feel very strongly about, so forgive me in advance if I get a little bit “ranty”, but PFJ pain should not be viewed as “collateral damage”  during ACLR, particularly during the first 1-2 months post-op. I’ve seen one too many patients advised to push through the pain, only for them to have a very slow recovery and poor overall outcome. In my opinion, PFJ pain is a sign that rehab has been inadequate and the vastus medialis oblique, glute medius and the hamstrings on the operated leg still need A LOT of work.

There has been some very interesting research performed on the incidence of PFJ osteoarthritis (OA) in patients who have undergone ACLR. The first study found that PFJ OA (on X-Ray) was present in 34 of 70 patients (47%) within 5-10 years following ACLR.7 What is even more concerning, another study found that PFJ OA (on MRI) was found in 19 of the 111 patients (17%) at 1-year follow-up, with men 6x more likely to have PFJ OA compared to women. These MRI findings were absent in uninjured controls.8

Key message: Neglect the PFJ at your patients peril!!

That is all for now! I hope you get something out of this summary of information. As always, please feel free to comment if you think that I have missed something, and as always, please share this post with people that you think would like to read it.

Have a great week!

References

  1. Morgan MD, Salmon LJ, Waller A, Roe JP, Pinczewski LA. Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. The American journal of sports medicine. 2016 Feb;44(2):384-92. PubMed PMID: 26759030. Epub 2016/01/14. eng.
  2. Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012 Mar 21;94(6):531-6. PubMed PMID: 22438002. Pubmed Central PMCID: PMC3298683. Epub 2012/03/23. eng.
  3. Crawford SN, Waterman BR, Lubowitz JH. Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy. 2013 Sep;29(9):1566-71. PubMed PMID: 23820260. Epub 2013/07/04. eng.
  4. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014 Nov;48(21):1543-52. PubMed PMID: 25157180. Epub 2014/08/27. eng.
  5. Ardern CL, Taylor NF, Feller JA, Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. The American journal of sports medicine. 2012 Jan;40(1):41-8. PubMed PMID: 21946441. Epub 2011/09/29. eng.
  6. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011 Dec;27(12):1697-705. PubMed PMID: 22137326. Epub 2011/12/06. eng.
  7. Culvenor AG, Lai CC, Gabbe BJ, Makdissi M, Collins NJ, Vicenzino B, et al. Patellofemoral osteoarthritis is prevalent and associated with worse symptoms and function after hamstring tendon autograft ACL reconstruction. British journal of sports medicine. 2014 Mar;48(6):435-9. PubMed PMID: 24285782. Epub 2013/11/29. eng.
  8. Culvenor AG, Collins NJ, Guermazi A, Cook JL, Vicenzino B, Khan KM, et al. Early knee osteoarthritis is evident one year following anterior cruciate ligament reconstruction: a magnetic resonance imaging evaluation. Arthritis & rheumatology (Hoboken, NJ). 2015 Apr;67(4):946-55. PubMed PMID: 25692959. Epub 2015/02/19. eng.

Opinions expressed by physiogramworld contributors are their own.

Visit Mick Hughes’ site: http://www.mickhughes.physio/

Pre-Operative Physiotherapy For ACL Reconstruction

Pre-Operative Physiotherapy For ACL Reconstruction [Physiogramworld

I had a patient present last week who hurt her knee in the first few minutes of a social game of basketball. She reported that she was trying to side-step an opponent, felt a pop in her knee and immediate pain. She collapsed to the ground, was unable to play on, and noticed her knee swell within 2 hours. She presented to me the next day, and when I heard her history – and saw the size of her knee – I feared the worst for her. I referred her to a GP who subsequently referred for MRI. MRI performed 2 days later came back positive for ACL rupture.

Prepared that it was highly likely that she had an ACL injury, I asked her to come back to me after she had her MRI and had seen the GP, to talk about what she can do whilst we were waiting for an outcome. However, she cancelled this appointment, leaving a message with reception saying that it was likely that she would have to have surgery sometime soon, and that she felt that there was “nothing that I could do for her“.

Aaaaaaaand this is where I become disappointed. Not mad. Just disappointed…

Don’t get me wrong, I’m not disappointed because I’m missing out on a patient visit and the financial gain that comes with a consult. For what it is worth, she definitely needs to see the orthopedic surgeon to discuss surgical AND conservative treatment options. In my opinion, I think that surgery for ACL injury is necessary for young active teenagers and adults if they want to play sports that involve changes of direction. What I am disappointed about is the fact that it may take 6-8 weeks (if she is lucky) to have her orthopedic consult and then have surgery, and she is going to sit around idly waiting for 6-8 weeks.

This is not helpful.

Not only will her quads function deteriorate in this period of time, so will her gluteal, hamstring and calf function. So will her proprioception and balance. Sitting around for 6-8 weeks may also lead to 1-2 kg of weight gain, maybe even more, and it is well documented that higher BMI is associated with worse outcomes in a number of conditions.

What I am more disappointed about is that there is plenty of high-quality evidence that proves pre-operative physiotherapy improves patient outcomes post-operatively in a number of different conditions. I will briefly summarize the evidence below for ACL surgery:

The most robust of the literature comes from a systematic review and meta-analysis that included 8 studies and 451 patients.1 The review concluded that pre-op physio for Anterior Cruciate Ligament Reconstruction (ACLR) for 3-14 weeks is superior to control groups at improving strength and function for ACLR patients post-operatively. The 3-week trial included in this systematic review, showed significant results in favor of pre-op physio over no physio for ROM at the 3 month post-op period, and a battery of functional and participation outcome measures at 6 and 12 months follow-up.2 To compliment this evidence, ACLR patients who had superior pre-op KOOS scores resulted in better post-op outcomes 3-6 years after ACLR.3

In regards to how long one should wait between the primary injury and surgery, there is a wide-range of time in the literature; 4 weeks – 6 months.4 The decision is never black and white, and a number of factors need to be considered. What may help the decision-making process easier for the general population, this study found that individuals who had greater than 20% quad strength differences between limbs prior to surgery, had persistent strength differences 2 years after their ACLR.5 This lead the authors to conclude that ACLR should not be performed until the quads deficit of the injured limb is no more than 20% of the uninjured limb.

So there you have it, a very strong argument to say that strengthening is not a waste of time prior to surgery.

In conclusion, based on the evidence provided above, it is clear that pre-operative exercise for as little as 3 weeks improves knee function and strength in the 12-month post-operative period. The time to which surgery is performed is a question of great debate, and based on the evidence provided above, if the patient is not a professional athlete who has to be back to sport in a timely fashion, it appears that better outcomes are seen when surgery is delayed to when quads strength is back to within 20% of the uninjured limb prior to surgery.

As for all my blogs, please feel free to comment, like and share my post. I feel that the more this information can spread far and wide, the better outcomes our ACLR patients will have not only now, but long into the future.

Have a great day!

References:

  1. Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: A systematic review. Clinical rehabilitation. 2016 Feb 15. PubMed PMID: 26879746. Epub 2016/02/18. Eng.
  2. Amaravati RS, Sekaran P. Does Preoperative Exercise Influence the Outcome of ACL Reconstruction? Arthroscopy.29(10):e182-e3.
  3. Mansson O, Kartus J, Sernert N. Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction. Scandinavian journal of medicine & science in sports. 2013 Feb;23(1):15-22. PubMed PMID: 22288718. Epub 2012/02/01. eng.
  4. Krutsch W, Zellner J, Baumann F, Pfeifer C, Nerlich M, Angele P. Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2015 Oct 16. PubMed PMID: 26475153. Epub 2015/10/18. Eng.
  5. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. British journal of sports medicine. 2009 May;43(5):371-6. PubMed PMID: 19224907. Epub 2009/02/20. eng.

Opinions expressed by physiogramworld contributors are their own.

Visit Mick Hughes’ site: http://www.mickhughes.physio/

Hamstring Injuries: A Review Of Current Literature

black injured player [physiogramworld.com]

I often tell my patients presenting with a hamstring injury, “If you’re going to hurt one thing in your body, you might as well hurt your hamstring”. I often get a bewildered look in return, but the fact is, there is such a large body of research published, and currently being published, on hamstring injuries that we can now treat and manage these injuries much better than ever before.

A major reason for this large body of research is that they are very common in sports that require high speed running and/or kicking, such as soccer and Australian Rules Football (AFL), with 80-85% of all hamstring strains occurring during high speed running.1,2 At the highest professional level, players in these sports get paid (multi) millions of dollars per season. So, in order to ensure that highly paid players are not sitting on the sidelines with a hamstring injury, a lot of research has gone into finding out how best to prevent them from occurring, and when they unfortunately do occur, how best to treat them so that the injured player can get back on the playing field as soon as possible.

Hamstring Injury [physiogramworld.com]

To give a rough idea, the average financial cost of a hamstring injury due to “lost time” in European soccer players has been estimated to be around $718K (500,000Euro).3 In AFL players here in Australia, the average financial cost of a hamstring injury due to “lost time” comes in at a very modest $40K.4 Whichever way you look at it, that’s big bucks per hamstring injury, and it’s no wonder a lot of research has gone into trying to reduce the risk of hamstring injuries from occurring in the first place.

Back in the good old days, if a player went down with a hamstring injury we blame it on the player’s older age and/or the player having a past history of hamstring injury. But we can no longer do that. Research has shown that having higher levels of eccentric strength of the hamstrings can mitigate the risk of future hamstring injury in all players, even in older players.1,5

This leads me to the most important point of this write up. The most evidence-based approach – which is a constant among all the papers being published – to reducing hamstring injuries from occurring in the first place and reducing recurrences, is performing eccentric strengthening exercises.

That’s it.

No bells.

Definitely no whistles, or injections.

Just good old fashioned hard-work!

During the 2000’s, Scandinavian researchers put a lot of time and effort into hamstring research and made some massive in-roads in reducing the incidence and recurrence of hamstring injuries. There were many studies done, but in one particular study, they discovered that if professional and amateur soccer players did a particular exercise – The Nordic Hamstring Curl – in pre-season training, and then maintained the exercise as part of their training during the competitive season, they were able to reduce new hamstring injuries by up to 60% and recurrent injuries by 86%.6 As a result, Nordic Hamstring curls were seen as the savior to all soccer and AFL clubs.

Hamstring Injuries: A Review Of Current Literature [physiogramworld.com]

Despite many studies showing the significant reduction in risk of sustaining a hamstring injury by performing the Nordic Hamstring Curl, the incidence of hamstring injuries at professional AFL level is not declining, but in fact, the incidence is actually increasing in European soccer players. In a recent paper, it was found that over a 13 year period in 36 of Europe’s best soccer teams, the annual incidence of hamstring injuries actually increased by 2% each year.3

This begs an obvious question; “With all this great research on hamstring prevention, how is it possible that hamstring incidence is still increasing?”.

From the literature it looks like there are 2 possible reasons for this, but please be aware that hamstring strains are multi-factorial and these 2 points are certainly not definitive.

The first is the speed of the game. I for one am not privy to the ins-and-out of daily professional football life, but it is widely mentioned in the media that the speed of the game for both AFL and soccer has changed dramatically in the last 5 years. As a result, players are being pushed harder than ever before in training and in competitive matches, and this high-speed running puts the hamstring muscles under a large amount of strain. New research confirms this, whereby rapid increases in the volume of high-speed running during games and training relative to what the athlete has been accustomed to over the past 2 playing seasons significantly increases the risk of future hamstring strain.7

Despite the changing speed and nature of these professional sports, the second possible reason is quite astounding. Research found that during the same time when hamstring injury rates were increasing in European soccer, only 10.7% of the surveyed clubs actually implemented the Nordic Hamstring Curl exercise program to their strength and conditioning program.8 To me, this this is unforgivable. Here, we have an evidence-based treatment and only 10.7% of clubs adopted it?!!

Now onto something that may change the way we rehabilitate hamstrings in the future…

Despite the glowing evidence for Nordic Hamstring Curls, new research has come to light that there may be an even bigger and better exercise for injury prevention and rehabilitation that players who are involved in sports that have a high incidence of hamstring strains should perform. The exercise is called the 45deg Hip Extension.9

Hamstring Injuries: A Review Of Current Literature [physiogramworld.com]

Around 80-88% of hamstring injuries occur in the long head of biceps femoris (LHBF),1,2,5 so, needless to say, it’s advantageous to make this muscle really strong, or selectively target it when it is injured. In this new study, researchers compared the recruitment pattern of the hamstring muscles during 10 typical hamstring exercises used during rehab. Although Nordics have a great evidence-base to reduce overall hamstring injuries, this research found that Nordics do not target the LHBF as well as other exercises. The one exercise that selectively recruited the LHBF the highest, was the 45deg hip extension. However, not to throw the baby out with the bath water, the research showed that the Nordic Hamstring Curl recruited the LHBF the highest out of all the 10 exercises, but it did so with also more activity within the other 2 hamstring muscles, especially the semitendinosus.

 

So there you have it, a brief run-down of the current trends in hamstring injuries in AFL and soccer and the evidence-base to reduce the risk of injury, and some promising research on how to rehabilitate hamstring injuries better. Before you all rush out and start doing Nordics and 45 Hip Extensions at training and in the gym, please consult with your physiotherapist, exercise physiologist or strength and conditioning coach prior to doing so. It is vital that programming these exercises into your current training week needs to be carefully considered so that you don’t over-train and increase the risk of hamstring injury or any other soft tissue injury for that mater.

As always please feel free to share this blog with your friends, colleagues, co-workers, team-mates and please comment below if you have any questions,.

Have a great week!

References

  1. Timmins RG, Bourne MN, Shield AJ, Williams MD, Lorenzen C, Opar DA. Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): a prospective cohort study. British journal of sports medicine. 2015 Dec 16. PubMed PMID: 26675089. Epub 2015/12/18. Eng.
  2. Bourne MN, Opar DA, Williams MD, Shield AJ. Eccentric Knee Flexor Strength and Risk of Hamstring Injuries in Rugby Union: A Prospective Study. The American journal of sports medicine. 2015 Nov;43(11):2663-70. PubMed PMID: 26337245. Epub 2015/09/05. eng.
  3. Ekstrand J, Walden M, Hagglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. British journal of sports medicine. 2016 Jun;50(12):731-7. PubMed PMID: 26746908. Epub 2016/01/10. eng.
  4. Hickey J, Shield AJ, Williams MD, Opar DA. The financial cost of hamstring strain injuries in the Australian Football League. British journal of sports medicine. 2014 Apr;48(8):729-30. PubMed PMID: 24124035. Epub 2013/10/15. eng.
  5. Opar DA, Williams MD, Timmins RG, Hickey J, Duhig SJ, Shield AJ. Eccentric hamstring strength and hamstring injury risk in Australian footballers. Medicine and science in sports and exercise. 2015 Apr;47(4):857-65. PubMed PMID: 25137368. Epub 2014/08/20. eng.
  6. Petersen J, Thorborg K, Nielsen MB, Budtz-Jorgensen E, Holmich P. Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. The American journal of sports medicine. 2011 Nov;39(11):2296-303. PubMed PMID: 21825112. Epub 2011/08/10. eng.
  7. Duhig S, Shield AJ, Opar D, Gabbett TJ, Ferguson C, Williams M. Effect of high-speed running on hamstring strain injury risk. British journal of sports medicine. 2016 June 10, 2016.
  8. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. British journal of sports medicine. 2015 Nov;49(22):1466-71. PubMed PMID: 25995308. Epub 2015/05/23. eng.
  9. Bourne MN, Williams MD, Opar DA, Al Najjar A, Kerr GK, Shield AJ. Impact of exercise selection on hamstring muscle activation. British journal of sports medicine. 2016.

Opinions expressed by physiogramworld contributors are their own.

Visit Mick Hughes’ site: http://www.mickhughes.physio/

Kinesio-Tape: You can’t band-aid a faulty training plan

The Olympic Games is the time of year where elite athletes get to become walking billboards to the masses for all kinds of products, including pseudo-science treatment modalities. Earlier this week, I gave my fairly strong opinion about “cupping”, and now I turn my attention to Kinesio-Tape (KT).

I get it that elite athletes are looking for “1’ers” over their competition to win gold, but can someone please explain what 1% the taping method in the photos above and below are adding to the athlete’s performance?? I’m sure you are all well aware what Kinesio-Tape is, but for those of you that aren’t aware, KT is a type of taping that is used by athletes/patients with the assumption that it assists in muscle activity following injury, and helps improve muscle activity for sporting performance.

AAEAAQAAAAAAAAhTAAAAJGNmMDY4Mzg5LTQ0ZjMtNDUzMC1hZjRjLWVhMDY3NzM2MmE1Mw

More eloquently, the Kinesio-Tape website says that… “The Kinesio® Taping Method is based on a simple principle that the body has built-in healing mechanisms and healthcare practitioners can help to positively influence their efficiency by removing barriers that impede them. Kinesio® Tape provides extended soft tissue manipulation to prolong the benefits of manual therapy administered in the athletic training room or physical therapy clinic. The results are increased fluid flow through an injured area, better control over muscle contractions, reduced pain, and ultimately faster healing. This effect is modulated and coordinated by the nervous system by specifically stimulating the sensory motor system”

That’s a pretty big claim…Kinesio-Tape is polarizing among my physio peers. Some use it, some think it’s rubbish. I’m more towards the rubbish side, but I will admit that I have used it in the past with some athletes as I attempted to throw everything at the athlete (including the kitchen sink) to get them on the field.

Unfortunately there is little HIGH QUALITY evidence to support its use in a number of different populations and conditions. Although not exhaustive, below is brief summary of the better quality research out there.

– Meta-analysis on Kinesio-Tape and it’s effect muscle strength: No benefit.1

– Systematic review on KT and it’s effect on improving outcomes following injury: Overall inconclusive; however positive short term effect on pain in shoulder impingement, and short term effects on pain in whiplash.2

– Systematic review on KT in treatment and prevention of sports injuries: Not superior to other forms of tape to prevent injuries, and inconclusive evidence in improving strength, ROM and proprioception.3

– Short term reduction in pain, but not function, in PFJ pain.4

– No improvement on jumping performance and balance in healthy elite athletes.5,6

– No improvement in quads strength and lower limb function in healthy adults.7

– No improvement in reducing shoulder fatigue and joint position sense in healthy adults.8

AAEAAQAAAAAAAAixAAAAJDM1NzhlZDZjLTk0MTItNDMyMy05NjVkLTA4OGYyZDMyMGZiZg

In conclusion, there is little evidence to support the use of Kinesio-Tape to improve function or sports performances, but I’m sure we’ll see plenty of it over the next week during the Olympics. Unlike some other questionable treatment modalities, Kinesio-Tape poses little to no harm; Apart from the occasional rash, and the pain felt from pulling hairs out when you rip it off.

Take home message: You can’t band-aid a faulty training plan. Nothing will ever beat an excellent strength & conditioning program, load management, mental preparation, and excellent recovery practices that include nutrition, hydration and sleep. To me, these are the 1%’ers our athletes and patients should be aiming for.

References:

  1. Csapo R, Alegre LM. Effects of Kinesio((R)) taping on skeletal muscle strength-A meta-analysis of current evidence. Journal of science and medicine in sport / Sports Medicine Australia. 2015 Jul;18(4):450-6. PubMed PMID: 25027771. Epub 2014/07/17. eng.
  1. Mostafavifar M, Wertz J, Borchers J. A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. The Physician and sportsmedicine. 2012 Nov;40(4):33-40. PubMed PMID: 23306413. Epub 2013/01/12. eng.
  2. Williams S, Whatman C, Hume PA, Sheerin K. Kinesio taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Sports medicine (Auckland, NZ). 2012 Feb 1;42(2):153-64. PubMed PMID: 22124445. Epub 2011/11/30. eng.
  3. Freedman SR, Brody LT, Rosenthal M, Wise JC. Short-term effects of patellar kinesio taping on pain and hop function in patients with patellofemoral pain syndrome. Sports health. 2014 Jul;6(4):294-300. PubMed PMID: 24982700. Pubmed Central PMCID: PMC4065564. Epub 2014/07/02. eng.
  4. Schiffer T, Mollinger A, Sperlich B, Memmert D. Kinesio taping and jump performance in elite female track and field athletes and jump performance in elite female track and field athletes. Journal of sport rehabilitation. 2015 Feb;24(1):47-50. PubMed PMID: 24959912. Epub 2014/06/25. eng.
  5. Nunes GS, de Noronha M, Cunha HS, Ruschel C, Borges NG, Jr. Effect of kinesio taping on jumping and balance in athletes: a crossover randomized controlled trial. J Strength Cond Res. 2013 Nov;27(11):3183-9. PubMed PMID: 23439339. Epub 2013/02/27. eng.
  6. Fernandes de Jesus J, de Almeida Novello A, Bezerra Nakaoka G, Curcio Dos Reis A, Fukuda TY, Fernandes Bryk F. Kinesio taping effect on quadriceps strength and lower limb function of healthy individuals: A blinded, controlled, randomized, clinical trial. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2016 Mar;18:27-31. PubMed PMID: 26708093. Epub 2015/12/29. eng.
  7. Zanca GG, Mattiello SM, Karduna AR. Kinesio taping of the deltoid does not reduce fatigue induced deficits in shoulder joint position sense. Clinical biomechanics (Bristol, Avon). 2015 Nov;30(9):903-7. PubMed PMID: 26305054. Epub 2015/08/26. eng.

Opinions expressed by physiogramworld contributors are their own.

Visit Mick Hughes’ site: http://www.mickhughes.physio/

Load Management to reduce risk of overuse or under-prepared injury in elite athletes

If you are working in the elite sporting arena with elite athletes as a Physical therapist, sports physician, doctor, athletic trainer or strength and conditioning coach, chances are that you have read something lately on Load Management or The Acute to Chronic Workload Ratio. If you haven’t, you need to continue reading this blog and start changing the way you go about training and managing your athletes. If you don’t work in the elite arena, you are excused for not hearing about it. But you still need to read this blog…

Load Management is a VERY interesting topic at the moment in sports science and sports medicine circles, and there are numerous studies published on the topic in sports such as Soccer, Aussie Rules, Rugby Union, Rugby League and Cricket.1,2,3 Regardless of the sport you’re involved in, and regardless of the level of play (i.e. professional or amateur), the principles of Load Management can and should be applied to all your athletes and patients, from the professional elite athlete to the sedentary office worker.

Load is typically broken down into two variables:

  • External load – eg. distance run, weight lifted, kms cycled/swam, repeated sprints/jumps
  • Internal load – eg. heart rate (HR), rate of perceived exertions (RPE) and/or well-being scores.

It usually takes into account, training sessions, gym sessions and games. One very simple way to measure load is by using “Sessional RPE” which is:

  • Training session time (mins) x intensity (RPE).
  • Example: 60 minute training session of 7/10 RPE = 420 units. If you had 5 training sessions in one week, you would have a weekly load of 2100 units.

From the current research, the evidence-based way to quantify “load” is by using the concept of the Acute to Chronic Workload Ratio (ACWR). It is number based, so I’ll try to keep it very simple:

  • Acute workload = sum of load across a rolling 7 day period i.e. 5 days of exercise x 420units per session = 2100 units.
  • Chronic workload = average of the acute load over a rolling 4 weeks i.e. assuming that you gradually increase your training loads per week to get fitter; week 1 (2100), week 2 (2200), week 3 (2300), week 4 (2400) = 2100+ 2200+2300+2400 /4 weeks =chronic workload of 2250 units.
  • If in week 5 you had a workload of 2500, your ACWR is 2500/2250 = 1.11

Side note – If you don’t know how many units per week you should be training,  pre-season training in rugby league players showed that players were 50-80% more likely to sustain an injury within a training load range of 3000-5000 units. Now this shouldn’t be used as a blanket “danger zone”, as each sport and each athlete will have different limits of what load they can handle. So know your athlete, and start to understand what loads they can comfortably handle.

OK, so the ACWR is all nice to know but what does all that mean? Well, researchers have found that there is a “sweet spot” to have a reduced risk of non-contact soft tissue injuries, and that “sweet spot” is a ACWR between 0.8 – 1.3. As you can see, the training plan listed above lies within the “sweet spot”.

 

loadmanagement2

As you should also be able to see is that with a ratio of 1.11 there is a bit of wriggle room for your training to be increased over the next month to get more out of your athlete. However, if you haphazardly increased the training intensity for week 5 and the load for that week was 5000 units, you would find that you would get a ACWR of 5000/2250 = 2.25 – and your athlete would be in a whole lot of trouble.

Below are some ACWR values and their chance of injury. It is interesting to note that 0.8 ACWR has a higher degree of injury risk than 0.8 – 1.3, which suggests that under-training is just as detrimental as over-training:

  • ACWR 0.8 = 5-7%
  • ACWR 0.8 – 1.3 = 5%
  • ACWR 1.3 – 1.75 = 7-10%
  • ACWR 1.75 – 2.0 = 10%
  • ACWR >2.0 = 15%-20%

So the problem for us health professionals working with patients/athletes who are training/working hard is that you don’t necessarily see an injury during a spike in training. In rugby league players, evidence tells us that the injury usually presents 7-10 days after the spike. In cricket fast bowlers injuries can present as late as 21-28 days later. As a rule, expect an injury between 1-4 weeks after your athlete/patients training has spiked compared to their chronic fitness.

So what is really valuable of being able to quantify training loads and know your patients ACWR is, we can reduce the risk of injury when unavoidable spikes occur and minimize the chance of injury. For example; extra-time in a game of soccer, or when you get called up to play an extra 2 games of social basketball in a week when you normally play 1. This is simply done by reduced training load/reduced training time/reduced intensity at training to get your training consistently back in the ACWR “sweet spot” in the subsequent 1-4 weeks.

So there you have it, ACWR in a nutshell.

In my opinion, the key messages to take home about ACWR are:

  • If unavoidable spikes in training occur, do not panic! Reduce the training loads over the next 1-4 weeks to get the ACWR back into the “sweet spot”.
  • Under-training is just as bad as over-training.
  • High loads are not the problem, it is how you get there that is.

 

References:

  1. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? British journal of sports medicine. 2016 Mar;50(5):273-80. PubMed PMID: 26758673. Pubmed Central PMCID: PMC4789704. Epub 2016/01/14. eng.
  2. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. British journal of sports medicine. 2016 Apr;50(8):471-5. PubMed PMID: 26701923. Epub 2015/12/25. eng.
  3. Hulin BT, Gabbett TJ, Lawson DW, Caputi P, Sampson JA. The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. British journal of sports medicine. 2016 Feb;50(4):231-6. PubMed PMID: 26511006. Epub 2015/10/30. eng.

Opinions expressed by physiogramworld contributors are their own.

Does Injury Rate Correlate With Team Performance?

Last week, I blogged about individual performance in team sports following anterior cruciate ligament (ACL) reconstruction and gave some examples of players career thriving after ACL reconstruction, but unfortunately for some athletes, it was the start of a decline in performance and premature end to their careers. This time however, my attention is on total team injury rates and overall team performance.

Before I get into the nitty gritty, I want to pause for a second and ask a question to those directly involved within the sporting environment as a Club Doctor, Physio, High Performance Unit (HPU) manager, Strength and Conditioning Coach, Sports Scientist, or simply a Fan of sport in general; How is your team fairing this year? Are they peaking nicely for the finals? Are they touch and go to make the finals? Or are you languishing at the bottom of the table?

Here’s another question; How’s your team injury rate been this year? Does injury rate correlate with your team’s performance? i.e Low injury rate and sitting high on the table? Or high injury and sitting low on the table?

If yes, this may not be a coincidence…

For those that enjoy watching the English Premier League (football/soccer), you would be well aware of the Cinderella story of the century, Leicester City winning this year’s premiership. For those of you that are not aware of the story, Leicester City was promoted to the Premier League from the Championship League for the 2014-15 season. At the end of that season, they barely survived relegation back to the Championship competition, and leading into the 2015-16 season were at 5000/1 odds of winning the title. However, they defied all odds and won this year’s title and bankrupted many book-makers in the process.

What was simply unbelievable about their title win, was the fact that they were the 3rd least richest club in the competition, with player transfer fees totaling just over £50m. The 2 richest clubs in the competition, Manchester City and Manchester United, who both cost in excess of £400m to put their team on the park, finished 4th and 5th overall respectively.

What is less known about Leicester City’s success are 2 other factors that are imperative to team success;

Firstly, they had the lowest injury toll all season, with only 18 injuries sustained that prevented a player from playing in a match. Manchester City on the other-hand had 69 separate injuries.

Side note: Astoundingly, as I was doing research for this blog, I came across a newspaper column describing Leicester City’s low injury toll as “lucky” and “sheer chance”. I was beside myself. Low injury rates are not “sheer-bloody-chance.” Sure, Leicester City’s scheduling was not as rough as the likes of Manchester City or Manchester United’s who also competed in the Champions League, but a low injury toll is an absolute credit to the Manager/Coach and the HPU preparing and load managing these players to perfection.

Secondly, as a result of their low injury toll, they used the least amount of players of all the clubs in the Premier League. This meant that the Manager (coach) was able to regularly pick the best starting 11 players week-in-week-out for the 38 game season.

So on the back of Leicester’s incredible result, I went looking for some more research and found a handful of studies that clearly demonstrate that lower injury rates equate to greater team success:

UEFA (soccer)- (1)

  • Lower injury burden and high match availability were associated with higher domestic league ranking and success in the UEFA or Europa league.

Australian Track and Field athletes – (2)

  • Likelihood of achieving a performance goal was increased by 7x in those that completed >80% of planned training sessions in the 6 months leading up to the event.
  • For every modified training week the chance of success reduced by 26%
  • Athletes who sustained less than 2 injuries or illnesses per training season, were 3x more likely to achieve their performance goal than those who sustained 2 or more per season.

NBA (basketball) – (3)

  • Strong correlation between player games missed and percentage of regular season games won, i.e, The less player games missed per season equates to more team wins per season.

Qatari Football (soccer) – (4)

  • Lower injury incidence strongly correlated with overall team ranking, more games won, more goals scored, greater goal difference and total points

English Rugby Union – (5)

  • Positive association between injury and team success – i.e, less injury equates to team success

So, it seems that it was simply not a coincidence that Leicester had great success this year. And it certainly wasn’t “luck” or “sheer chance” that won them the title. Of course team success is very multi-factorial, and can not be 100% contributed to low injury rates, but in my opinion it’s a bloody good place to start!

In closing up this blog, I think the important take home message for all involved within sport administration and team coaching is this:

Invest wisely in the people (experienced, evidence-based HPU) who are going to look after your primary asset – The Players.

It is clear from the above literature that lower injury rates, means that the coaching staff have a greater talent pool to choose from. As a result, there will be less team changes, more team cohesion and a better chance of winning.

Seems like a fairly simple formula for success doesn’t it?

I hope you have enjoyed this week’s blog as much I did researching it. Feel free to like and share it amongst your colleagues, and leave a comment if you have other examples of teams doing well on the back of low injury rates, or simply have other views on this topic.

Have a great week!

References:

1     Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengtsson H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. British journal of sports medicine. 2013 August 1, 2013;47(12):738-42.

2     Raysmith BP, Drew MK. Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study. Journal of Science and Medicine in Sport.

3     Podlog L, Buhler CF, Pollack H, Hopkins PN, Burgess PR. Time trends for injuries and illness, and their relation to performance in the National Basketball Association. Journal of Science and Medicine in Sport. 2015 5//;18(3):278-82.

4     Eirale C, Tol JL, Farooq A, Smiley F, Chalabi H. Low injury rate strongly correlates with team success in Qatari professional football. British journal of sports medicine. 2013 Aug;47(12):807-8. PubMed PMID: 22904292. Pubmed Central PMCID: PMC3717779. Epub 2012/08/21. eng.

5        Williams S, Trewartha G, Kemp SP, Brooks JH, Fuller CW, Taylor AE, et al. Time loss injuries compromise team success in Elite Rugby Union: a 7-year prospective study. British journal of sports medicine. 2016 Jun;50(11):651-6. PubMed PMID: 26552415. Epub 2015/11/11. eng

Opinions expressed by physiogramworld contributors are their own.

“Pokemon Go-itis”: A new injury classification?

It was only a few years ago that the world was struck down with “Nintendo Wii-itis”. Now with the world wide phenomenon Pokemon Go app growing in popularity by the day, I think it’s only a matter of time before GP clinics and physiotherapy practices around the world are going to see an influx of Pokemon Go-related soft tissue injuries. Not to mention lower limb ligament sprains and head injuries from reckless and careless walking.

I’m not sure if the app developers intention was to increase physical activity in a population of people who are notoriously sedentary (teenagers & “gamers”), but they have done just that. And if that was the case, well that’s just a stroke of genius!

injury-classification2

Regardless of the app’s original intention, what I expect to happen over the next 1-4 weeks, is see a spike of previously sedentary people, limp into their GP or Physio with complaints of hip, knee or ankle/foot pain. This is all in large to the fact that, since the app went “live” last week, there has been a spike in the amount of previously sedentary people walking and running around the streets looking for Pokemon characters than ever before.

injury-classification3

Now don’t get me wrong. I love the fact that people are out exercising!! What my concern is that, with all this extra physical activity that people are simply not accustomed to, will result in injuries.

I have written extensively in the past on Load Management, you can read it here. But because of the boom in Pokemon Go’s popularity, I think it is the perfect time to give a friendly reminder to all of you that..

If you rapidly increase your physical activity in a short period of time, it’s not a matter of IF you’ll get injured, but a matter of WHEN.

For those of you that have read the research on Load Management, it seems that sometime in the next 1-4 weeks we’ll be seeing a lot of overuse/under-prepared soft tissue injuries limp through the doors of our clinics.

For those of you that haven’t read the research on Load Management, the main principle behind it is the Acute:Chronic Workload Ratio (ACWR), and I will break it down below:

  • The Acute training load refers to the activity performed over a rolling 7 days.
  • The Chronic training load refers to the average physical activity performed over a rolling 4 weeks.
  • To get your ACWR, you divide the Acute load by the Chronic load.
  • Ideally, you get a number between 0.8-1.3 (also known as the “sweet spot”).
  • If your ACWR is above 1.5, you have a significantly increased risk of sustaining a soft tissue injury within 1-4 weeks after rapidly increasing your training, with the increase in risk rising the greater the ACWR is.injury-classification4Now let’s put the ACWR to the test with a practical example in a typical Pokemon Go user.For starters, let’s just simply use “total walking time” as our training measure, and let’s assume that the Pokemon Go users are playing the app every day this week for at least 60mins.
    • Acute load – 7x60mins = 420 units

    Now let’s assume that since the release of the game 1 week ago, they have also played the game daily for 60mins last week. Let’s also assume prior to the release of the game they did no exercise for the previous 1 month.

    • Chronic load
      • Week -1 : 420 units
      • Week -2: 0 units
      • Week -3: 0 units
      • Week -4: 0 units
    • Chronic load = 420 / 4 weeks = 105 units

    Now we divide the Acute load by the Chronic load to get our ACWR

    • ACWR = 420/105 = 4.0

    As you can see with an ACWR of 4.0, we are well and truly off the charts with our ACWR, and in a high-risk zone of soft tissue injury within the next 1-4 weeks.

    Now, we must understand that the ACWR is based on elite-level AFL, Soccer, NRL and cricket players, not sedentary Pokemon Go app users. So we do need to be careful with generalizing this research to the general public. But the basic principle of the ACWR can and should be applied to the general public when it comes to physical activity. And the basic message is:

    “Exercise too little, or exercise too much, and you’ll get injured. Just like Goldilocks would say, we just need to find the exercise load that is “just right”.

    My simple solution to this potential rise in soft tissue injuries presenting to clinics all over the world is this:

    • Limit the amount of playing time to 30mins every day, or 60mins every 2nd day. That way your body gets a dose of exercise but has a day off to recover and adapt to the new exercise stimulus. With either option, you will still meet the recommended guidelines of physical activity of 150mins of moderate exercise per week.

    In closing up today, although I don’t play this app, I absolutely love the fact that this game has encouraged a large percentage of the world’s population up from the couch and outside for some fresh air and some moderate physical activity. I think there is definitely something in this clever approach to increase physical activity in sedentary individuals that public health promotion advisors and public health researchers should be looking at in years to come to sustain this physical activity boom.

    For further reading on Load Management, please check out my blog in the link provided above. It is a summary of a weekend Load Management symposium I attended earlier on this year. Alternatively, make sure you get a hold of some research papers on this topic written by Tim Gabbett or Mick Drew.

    Have an active weekend!

    www.mickhughes.physio

    Opinions expressed by physiogramworld contributors are their own.