sportEX Dynamics Journal Issue 39 - January 2014

ISSUE 3 9 jan 2014 ISSn 1744-9383

promoting

best practice in

highlights

manual therapy

n latest research news

n Taping: does The science supporT The hype? n 21st centUrY anatOMY n taPing: cOntrOlling MYOfascial tensiOn n BiKe fitting: OPPOrtUnities fOr theraPists

AnA An Atomy A tomy & Soft tiSS SSue ue injury review

By Dr Simon Kaye, Sports Physician and General Practitioner

online & Mobile £14.95 For 12 Month SubScription print copy available at tiMe oF purchaSe aS one oFF £6.99 upGrade with online purchaSe

ANATOMY & SOFT TISSUE INJURY REVIEW

by Dr Simon Kay

www.sportex.net Produced by

InjuryRefresher_proofed AS.indd 1

®

Are you seeing growing numbers of people with exercise related injuries?

Help is at hand, with this informative and thorough guide to physical injuries of the joints and their surrounding tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals. n Back to basics revision of anatomy of each joint n Includes 53 anatomy animations and video clips to bring the facts to life n Covers diagnosis and treatment options with background theory

and evidence based medicine n Provides tips for examination, learning exercises and highlights key points n Gives links to further reading n Useful for practitioners and those in training

11/07/2013 10:58

contentS n Overview of diagnosis and treatment of sports injuries n Shoulder Joint and girdle n Elbow and Wrist n Ankle n Knee n Spine n Hip joint and pelvic girdle

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By Dr musc of aroun -ulna that men The shou ion two jointsto move radio The RC the head n is pulledted t. move joints rs. les the uct men g these tendo 3. move on pullin hand of five s: move is effec PM musc en as the prime introD g how vitallopment, i.e. ion, it is joint fashi rotating Rotation for ing the short joint as follow-humeral iderin t: t pulat nt: d (AC) isometricfossa, allow muscles the scapula.

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By Dr the ank (the clas surfa Navicula femu deep by lity is femu e mo ps are invol ntous es, the sub be disrupt consider from Talus - a joint on The neut of the uctionto its stabi ly. stabilisedsici s laterally l joint ligame muSclmuscle grou . s les ie. facet the neck ly and knee introDmostly due at least acute ent increas joint can ry. We will aneumora the men musc with s Calc of the patella-fe V-shaped h articulate lla Differ tring posterior injury nosu ow ment The hip, injured joint, of femoro- injuries ankle article.

2. the e inju whic pate slightly m. tibio n move flexion - hams i-membra y from of een shallthe patella ral h. The help g sem a rarel recognitio ent and the true as any kne foot in this betw r is acetabulu femo of undin some 1. Knee dinosus, the ral troug for the two main gem which surro menisci with um the femu With the back the femo a fulcrum r impin joint and ists of ischi joint severe ar joint and semi-ten s femoris le, popliteus, front entS head of cons by three with ges. as n. ice acetabula -iliac lling in chan only acts tibia, LiGamstanding, the acetabulum allow mort ists and bicepssory musc to flexio muscles The ankle ntially the sacro situation hip is to sub-tal to a cle, trave into the t s prior the to lar Femur acce esse cons mus s , Whils ting ricep s into : )knee (simi the les, the ion of the vastu efficient. in ricep and inser work joints joint tightly musc the limbs ver ks the nsion - quad lateralis, (fig.3): quad held ankle unloc s in wood the talus ent ally more no part ents knee The funct trunk on otion. Howetibia GP exte 1. the joint vastu of the pays of the it mechanic key ligam oral ligam the two medialis. also aid N Kay, 2. Knee s femoris, tenon including facet ort of is to fibula g locom -fem ent withh ts inter ing and s SIMo . s ular the supp foot durin les men and mak by artic ulate 1. Ischio moral ligam ent. that and ing and ie. rectu and vastu musc the ularly e of move

By Dr the knee femur . Man strike Note of the which artic on the tibia mius partic n of the Tibia ing, jump ter fibula heel the ankle is fixed 2. Ilio-fe femoral ligam tighten with n) medialis gastrocne ulatio e rang d to ces – the stand ion of of force at (teno ing, runn hip, to grea level the foot his legs surfa the mortice) a whol The the artic tibia is linke ligaments ) and r rigid 3. Pubo e ligaments ing us to r. e joint ruent the ing, walk on the or The funct pation n when upright on and femu powe ide a the sing The cong h form sub-talar (ACL Thes e phas flexio stand all involve le nding dissi ht s of ty, allow muscle , s all tibia g cros (whic to prov propulsiv knee depe Talus ligament ent (PCL). allow ted g facet straig (see of musc ndly fibula t of gravi t use of the extension s of the kickin r degrees the hip bear ple and two stroncruciate mass inferior complica effec running s on of this can stand the facet joint in full of grea and seco a stable iater ligam they have three Fibula 2. the e ut a t facet cruccula or lesse of time that ht. For exammit ing and is a large e purpose use the anterior eriorNavi As part the ents Pleas witho een the congruen lity. beca s. lise there be ity. g walk mation). to allow weig are unt ract joint prim trans ligam stabi stabi betw ugh durin amo will cont id bone talar le activ s are not oiliac the post nly for of body hips infor ht, ss and Altho the hip, the otion, not ly. They covered and the exce lock to of gait musc Sacr xes to avoid -weig the mmo supp more joints injurie the sub- ground. talus and cubo and ising refle multiples l ing se refer body Unco vascular 1 for tring or on around is for locom of the SI ent joint neum the to minim stand mus cle s Box e (plea sportEX the foot, uneven ments of lingreas the joint s twist lity calca le thet spinaately main whils that hamsthis articl may on ligam in te half ising, and ioning a good thehurd within ACL stop musc hiphas Calcaneu move note opria gThis shed by relies the posit the stabi rol oxim the nt anterior rough joint appr ENTS entric ssed appr t. runn throu es publi pain from the if aghpatie injury s for containedvium. The s and The PCL to cont durin of the Similarly symphysis joint addre allow ht rs vermen bone ht. r. and concare used occu sition g than ous articl lly the MovEM aNKLE Femero- ar move ankle weig howe weigafter ent femu by syno the two ntric and durin icant theitis the pubic and oppo abul to previ topic). Usua weights, ligam Ecce ing,arthr signif acet of body on the een posterior muscles of the foot oF ThE t of the truetion, plantar o 1). why gth tion and leg ACL ss jump tibia betw of huge with stren ient % men for this injury is moren. . Exce ionticula joint the shin ments the knee defic-500themiss of the along femur (see disar Move in one direc plane) (vide alar ation s. r ntothe joint bea 400 le the glide S twist flexio the trans facet t withi toultim ttal leg, ately rs musc the move and supin strain on rciSe of powe rior, Theuse the subt and on the stops the knee ents occu beca end of fermen on knee a ion (sagi a and s of trunk tibia also move is ante the joint ently G eXe at th ility of sion effect nG l at the pronation can put traum of ligam r and the thesstrans lesr from of the nin ’t inher ie. tibial dorsi-flex dimension for inver exce rni to Look and and The stabthe array mino s pane glide would ear s model musc al Lea ation hip wasn joint pronation of the foot gh to ntrically, can to and femu g the omic esthetic): omical see e extra s).

The three ver allow leads the ntricrs slow if the throu of ecce Onlin tors and pronbox and ng ecce ation. This n (kina that ritis. the anat same with howe is a due g the tibia surroundin onse to an anat ton, to s inver for video ptionlder, nsoarth o 2) cal joint oste s on pron disrushou .prime move mea contracti ectin muscles tions (vide itions article neutral and are the ght line. r. the in the in resp facet then an skele under verti conn sion Defin when the rate of to occu n of g the e,As often ated knee hum The of ever strai (see s riptio . stabl stron a ts lock the the more the in of of desc ation men very are activ ligaments control r far er point only nded ions supin 3-5 for a move the faces sure. N.B. the rim occu which the posit e trigg h not and it’s how s pres joint with jointS ular joint fully exte Knee caus within ents whic but also figure ward eversion sion ion is ately anD ro-acetab up the hip the leg down ther, ments). ment of rCISE tensions the ligam eS of thers in two al posit approxim r of inver nd , firing toge femo S t move EXE s ining is omic Bon i.e. the It ched occu tilted ent NG Try exam bone anat th thee femu that make of: The move movemenrough grou stret s pelvis ) ss The hip six joints consists ting can the two they are cal and allow movemt of the knee LEarNI of the of terac hold to take esthetic): which ttal plane. which joints ng exce men the verti riorly. when coun : foot is one (sagi hip girdle ular (FA) Move n (kina ulated foot tly, to fully the tions ut putti 30 to tilted ante twist s the tighten ch receptors . The direc of etab allow extension ion or girdle unt witho main an artic d apart sligh aspects ro-ac (SIJ) slightly off stret of rotat knee to on and into acco 2 x femo -iliac joints the n Flexi ll amount be prise e the 3-D r. sma to allow 2 x sacro symphysis ion nA appreciat joint. can occu ion is stable junct rotat re flexion 1 x pubic ar-sacral This subtalar ugh very befo altho 1 x lumb FA joint, ‘unlock’ The

this sly in Previou (issue cles. t st er arti , hip join and wri e w refresh ue 44) injury the elbo of the spin t (iss ies of ulder join 46) and title ue the ser sho cle the last in ered the le joint (issn this arti girdles. cov is the ank e give muscle re This we have 45), hav mo ue e we ociated to series e joint (issAlthough becom . and ass kne I have but difficult ds47), that han ue 49) the spine al, atic nd (iss e fou pragm a practic apy, joints re about her ch I hav ies in a it is it is mo rap this, physiot l theory, approa y, the for n rap ow ious apology the ofascia ne. People, ing my ing var no sports cture, my dici ient Review politan, mix ch. I make involves x me pun stic pat ch. It ns, acu orthodo y holi cosmo ce’ approa approa mobilisatio good old that a trul t ‘eviden ary care ssage, iatry and differen on, primlation, ma pod are so ues, h sports, essential. manipu ns techniq of whic : their each eve, roles ons, Mulliga es and different five secti is, I beli spin d into to perform their approach divide d specialise based

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is ical GP n Cerv acic n Kay, n Thor bar n Lum al two-fold: tion Duc the spine is with n Sacr ygeal. to l cord ion of n Cocc spina e roots The functction of the ned to l nerv g spina is desig positionin ical and limbs 1) Prote n of the cerv ents ical spine and allow r limbs distributio ive segm of good rmost , uppe r limbs, The cerv the skull relat oses is joint the trunk . lowe ort uppe their of phys arms and supp for purp The two sym Support pelvis use of the skull ed ing.

2) Pubic evolv on the of the ribed and of have and hear and skull locomotion lems desc the body me vision vertebrae ion. ing prob ently, funct the r allow of has becoring cervical ally differ latte Most (Atlas) bral to the anatomic vertebra relate first vertend vertebra below an the first from the seco From the rate y to lex. lop sepa fused are comp e, they deveeen anatom brae and has ectiv betw fuse are The verte gical persp which vertebrae embryolo centres The three of age. from 15 years 8 and Simo

By Dr

intro

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contents January 2014 issue 39

Editorial

publisher TOr DAvIES BSc (Hons) tor@sportex.net art editor DEBBIE ASHEr debbie@sportex.net sub editor ALISON SLEIgH Journal watch BOB BrAMAH subscriptions & advertising support@sportex.net +44 (0)845 652 1906 COMMISSIONINg EDITOrS Brad Hiskins - Australia & NZ Whitney Lowe - USA & Canada Humphrey Bacchus - UK & Europe glenn Withers - Worldwide Dr Marco Cardinale - Worldwide Dr Thien Dang Tan - USA & Canada Dr Joseph Brence, DPT, COMT, FAAOMPT, DAC TECHNICAL ADvISOrS

Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds rob granter Michael Nichol Joan Watt Dr greg Whyte

In 2006, at the sportEX and Sports Massage Association Conference, we hosted not one but two world class soft tissue practitioners. The first, Leon Chaitow, an internationally-rennowned osteopath and author of several soft tissue technique ‘bibles’ on positional release, neuromuscular and muscle energy techniques. The second, was the creator of Anatomy Trains, Tom Myers. sportEX dynamics had only been in existence for two years and little did I appreciate then, just how significant his work on fascia would turn out to be.

We had named our conference the Myofascial Matrix, eight years on and I realise how significant that was. Fascia is now undeniably all the rage and it’s almost hard to remember how amazed we were at Tom’s early discoveries outlined in both his conference presentation and his accompanying article which we published in sportEX dynamics entitled “Anatomy Trains: Early Dissective Evidence” (link to full article here http://spxj.nl/1bwOtO9).

BSc (BASraT), MSc MCSP, MSMA MSc, FA Dip, Mast STT Dip SST Dip SST BSc (BASraT) MCSP, MSMA PhD, BSc (Hons)

Now we reference this work in almost every article we publish, in this issue alone it’s referenced in four separate articles and most people working in this area will admit we’ve probably only just scratched the surface. We started training single muscles, and progressed to muscle groups, then we moved onto kinetic chains, now we’re just starting to appreciate that this could actually be one whole continuous fascial web. Just what does that mean for the future of not only our profession but our sports people?

Tor Davies, physio-turned publisher and sportEX founder

is published by Centor publishing Ltd 88 nelson road Wimbledon, sW19 1HX Tel: +44 (0)845 652 1906 fax: ax: +44 (0)845 652 1907 www.sportex.net oTHer TiTLes in THe sporTeX range

prom

ng exceotille n in

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ts

medicin sporteX medicine - ISSN e 1471-8138. Written specifically for professionals working in the field of soft-tissue injury diagnosis, treatment and rehabilitation - personal subscription £54, practice subscription £94, library subscription £175

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sportEX is printed in the UK by Cambrian Printers Ltd, award-winning colour printing specialists, independently audited to ISO 14001 and EMAS environmental standards. sportEX is printed on paper from FSC certified forests using vegetable-based inks, chemical free plates and presses running alcohol free. It is also mailed in biodegradable polybags.

ConTenTs 4 Journal watch 8 research news 9 Taping

This quarter’s latest soft tissue research The treatment of non-specific low back pain: what is the evidence for taping?

The treatment of patellofemoral pain with taping: does the science support the hype?

14 anatomy for the 21st Century 18 myofascial taping 25 bike fitting 33 sporteX news & web watch A new vision of human anatomy Controlling myofascial tension

A new opportunity for therapists

Latest news and resources from the web

To finD ouT more abouT sporTeX visiT

DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine.

Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form.

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3

online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

This was an online survey sample from 2,079 massage therapists and body workers. It looked at the reasons behind injury-forced work reduction (IFWR). The most important correlate for explaining IFWR was higher physical exhaustion. It is not just physical ‘wear and tear’, but also ‘mental fatigue’ that can lead to IFWR. Being female, having more years in practice, and having higher continuing education costs were also significant correlates of IFWR.

sportEX comment Shout it loud. Being a massage therapist is hard work. All too often

CORRELATES Of INjuRy-fORCED wORK REDuCTION fOR mASSAGE THERApISTS AND BODywORK pRACTITIONERS. Blau G, monos C, et al. International journal of Therapeutic massage and Bodywork 2013;6(3) it ends in tears (from the therapist not the patient). Some strategies are suggested such as taking sufficient time between massages and, if possible, varying your technique to replenish physical and mental energy.

Failure to take required continuing education units often due to high costs also increases risk for IFWR. A great resource to help this strategy is Rob Granter’sThe Massage Therapist’s Survival Guide (p2).

DEEp mASSAGE TO pOSTERIOR CALf muSCLES IN COmBINATION wITH NEuRAL mOBILIzATION ExERCISES AS A TREATmENT fOR HEEL pAIN: A pILOT RANDOmIzED CLINICAL TRIAL. Saban B, Deutscher D, ziv T. manual Therapy 2013;doi:10.1016/j.math.2013.08.001 Apparently Plantar Heel Pain Syndrome (PHPS) is a common foot disorder. The label can be applied to a patient with repeated clinical observations indicating heel pain during heel rise and mini-squats on the affected leg, involving activation of posterior calf muscles. Sixty-nine patients (mean age 53 years, range 25–86, 57% women), were split into a group that were given deep massage to posterior calf muscles, neural mobilisation and a self-stretch programme (n=36) and a group that received ultrasound therapy to the painful heel area with the same self-stretch exercises (n=33). They got eight treatments over a 4–6 week period. Functional status at admission and discharge from therapy was measured using the Foot & Ankle Computerised Adaptive Test. Both treatment protocols resulted in an overall short-term improvement; however, the massage group results were better.

sportEX comment Oooohhh, another syndrome! PHPS – not to be confused with PFPS or MFPS. The medical profession does like a syndrome. We found 69 of them in a quick Google search and that didn’t include the three mentioned above. You could have Ulysses Syndrome, which describes the ill effects from follow-up diagnostic tests following a false-positive screening test, or Cervical Syndrome, which means pain radiating into the shoulder from ‘supernumerary’ C7 rib pressure. However, our favourite was Chinese Restaurant Syndrome (honestly we are not making this up). It refers to a burning sensation on the skin, chest pain, flushing, headaches and sweating. A reaction to monosodium glutamate is the main suspect. What it really means is an allergy or food poisoning! PHPS sounds like a fascia problem to us. Can we leave it at that? We don’t need another syndrome. See Anatomy Trains by Tom Myers for further information.

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sportEX dynamics 2014;39(January):4-7

JOURNAL WATCH

journal watch It is worth setting out the objectives of this study before looking at what they did. The purpose was to investigate potential differences of magnitudes and durations associated with dosed myofascial release (MFR) on human fibroblast proliferation, hypertrophy, and cytokine secretions.

Bioengineered tendons (BETs) attached to nylon mesh anchors were strained uniaxially using a vacuum pressure designed to model MFR varying in magnitudes (0, 3, 6, 9, and 12% elongation) and durations (0.5 and 1–5 minutes). Conditioned media were analysed for cytokine secretion via protein microarray and the tendons were weighted and fibroblasts extracted from them and assessed for total cell protein and proliferation via double-stranded DNA quantification. Changing MFR magnitude and duration did not have an effect on total fibroblast cellular protein or DNA accumulation. However, there was a stepwise increase in BET weight with higher-magnitude MFR treatments.

Longer durations of MFR resulted in

DOSED myOfASCIAL RELEASE IN THREE-DImENSIONAL BIOENGINEERED TENDONS: EffECTS ON HumAN fIBROBLAST HypERpLASIA, HypERTROpHy, AND CyTOKINE SECRETION. Cao TV, Hicks mR, et al. journal of manipulative physiological Therapeutics 2013;36(8):513–521

progressive increase in the secretions of angiogenin, interleukin (IL)-3, IL-8, growth colony-stimulating factor, and thymus activation-regulated chemokine.

Alternatively, increasing strain magnitude induced secretions of IL-1ß, monocyte chemoattractant cytokine, and regulated and normal T cell expressed and secreted chemotactic cytokine.

sportEX comment Forget the science-speak.

This is another paper about dose.

Congratulations to the researchers for attempting to discover what exactly is happening during what clinicians describe as myofascial release.

The answer is that something is happening. At the moment that is all that can be said with confidence but that is enough to justify continuing with manual therapy at a time when, ‘hands-off’ treatment is being seriously discussed at the Chartered Society of Physiotherapy (a debate about it was held at the 2013 Congress). Here it is suggested that the change in total BET dry weight has something to do with the production of extracellular matrix protein and that different MFR parameters induce secretions of a unique subset of cytokines and growth factors that can be further enhanced by increasing the magnitude and duration of treatment. Give the scientists time and they will prove what the clinicians know. This stuff benefits patients.

R RHEumATOID ARTHRITIS IN uppER LImBS BENEfITS fROm mODERATE pRESSuRE mASSAGE THERApy. field T, Diego m, et al.

Complementary Therapies in Clinical practice 2013;19(2);101–103 Forty-two adults with rheumatoid arthritis in the upper limbs were randomly assigned to a moderate pressure or a light pressure massage therapy group. A therapist massaged the affected arm and shoulder once a week for a 4-week period and also taught the participant self-massage to be done once daily. The moderate pressure group had less pain and perceived greater grip strength following the first and last massage sessions. At one month the moderate group had less pain, greater grip strength and greater range of motion in their wrist and large upper joints (elbows and shoulders).

sportEX comment Another gem from the Touch Research Institute. If you haven’t visited their site yet check out http://www6.miami.edu/touch-research/. We are now long past the stage of saying that massage in its various forms works. It’s time to think about dosage. When? Where? And how much? Now all we have to do is sort out how we scientifically measure the difference between moderate and light pressure. www.sportEX.net

5

online

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT

DOSE-DEpENDENCy Of mASSAGE-LIKE COmpRESSIVE LOADING ON RECOVERy Of ACTIVE muSCLE pROpERTIES fOLLOwING ECCENTRIC ExERCISE: RABBIT STuDy wITH CLINICAL RELEVANCE. Haas C, Butterfield TA, et al.

British journal of Sports medicine 2013;47:83–88 Twenty-four white rabbits were surgically instrumented with bilateral peroneal nerve cuffs for stimulation of hind limb tibialis anterior muscles. The idea was that this simulated compression similar to that achieved during massage. Eight variations on the protocol used loading of between 0.25 and 0.5Hz at 5 or 10N for 15 or 30min. The bunnies were forced into a bout of eccentric exercise and then randomly assigned to a muscle-like loading (MLL) protocol following which 21 tibiotarsal joint angles pre- and post-eccentric exercise and after 4 consecutive days of MLL. The results showed that the eccentric exercise produced an average 61.8% ± 2.1 decrease in peak isometric torque output. Differences in torque recovery were found between magnitudes (5 and 10N; n=12) and frequencies (0.25 and 0.5Hz; n=12), but no difference for durations (15 and 30min) with the 0.5Hz, 10N, 15min protocol showing greatest recovery 4 days post-exercise. Histological analysis showed a difference in torn fibres between lowparameter and high-parameter MLL

sportEX comment The bottom line, or should that be the bunny line, on this study is that if one accepts that this protocol stimulates similar effects to that of massage then those effects are dose-dependent. Massage practitioners probably know this but how do they know if the tissue needs x amount of force or if they have given that much. Experience is the answer. You can’t beat having lots of patient-miles on the clock.

Ten participants (4 female, 6 male ) with triceps surae dysfunction were recruited (mean age 43 ± 7.1 years).

The intervention involved trigger point pressure release, self myofascial release and a home stretching programme.

The outcome measures were: lower extremity functional scale (LEFS), verbal numerical rating scale, myofascial trigger point (MTrP) prevalence, ankle dorsiflexion range of movement and pressure pain threshold. Measurements were taken at baseline and discharge.

There was a high prevalence of active/latent MTrPs and possible myofascial pain syndrome in all 10

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IINSTRumENT-ASSISTED CROSS fIBER mASSAGE INCREASES TISSuE pERfuSION AND ALTERS mICROVASCuLAR mORpHOLOGy IN THE VICINITy Of HEALING KNEE LIGAmENTS. Loghmani mT, warden Sj. BmC Complementary & Alternative medicine 2013;13(1):240 Bilateral knee medial collateral ligament (MCL) injuries were induced in female rats. Commencing 1 week post-injury, 1 minute of instrument-assisted cross fibre massage (IACFM) was introduced unilaterally 3 times per week for 3 weeks. The contralateral injured MCL served as an internal control. Regional tissue perfusion was assessed in vivo throughout healing using laser Doppler imaging. Regional microvascular morphology was assessed ex vivo via micro-computed tomography of vessels filled with contrast. (Thank you Roland for making the ultimate sacrifice.) IACFM had no effect on tissue perfusion when assessed immediately, or at 5, 10, 15 or 20min following intervention. But, it did at 1 day following the 4th and 9th (last) treatment sessions and at 1 week following the final treatment session (32 days post-injury). Subsequent investigation of microvascular morphology found IACFM to increase the proportion of arteriole-sized blood vessels (5.9 to <41.2µm) in the tibial third of the ligament.

sportEX comment On the plus side this paper follows on from earlier work that showed that IACFM accelerated the restoration of biomechanical properties in injured rodent knees and is suggesting a more detailed reason as to why. On the down side it starts with the statement, ‘Ligament injuries are common clinical problems for which there are few established interventions’.

Where have these researchers been living? Have they not heard of Cyriax or Maitland or Tim Watson or read the sports injury bible, Bruckner and Khan’s Clinical Sports Medicine or indeed Googled ‘ligament injury’? If you do the latter you come up with a load of physio web sites that detail lots of ‘standard’ ways to deal with them. Ultimately this is another study dealing with dosage. If we can get that right there will be positive therapeutic effects to the manual therapy intervention.

m myOfASCIAL TRIGGER pOINT THERApy fOR TRICEpS SuRAE DySfuNCTION: A CASE SERIES. Grieve R, Barnett S, et al. manual Therapy 2013;1(6):519–525 participants at baseline. Active MTrP prevalence decreased to 0%, while latent MTrPs were still present at discharge. There were positive changes in most outcome measures. At 6 weeks post-discharge there was an overall mean LEFS increase of 11 points from 61/80 at baseline to 72/80 at discharge.

sportEX comment

papers using case studies or case series as evidence. Hopefully it is because of a growing realisation that the ‘gold standard’ of randomised controlled trials does not fit into most manual therapy situations especially with real patients who cannot be denied treatment as a control. Nor can they or their therapists be fully blinded to what is going on. This study suggests that a brief

We are starting to see lots more

sportEX dynamics 2014;39(January):4-7

JOURNAL WATCH

THE ImmEDIATE EffECT Of TRICEpS SuRAE myOfASCIAL TRIGGER pOINT THERApy ON RESTRICTED ACTIVE ANKLE jOINT DORSIfLExION IN RECREATIONAL RuNNERS: A CROSSOVER RANDOmISED CONTROLLED TRIAL. Grieve R, Cranston A, et al. journal of Bodywork and movement Therapies 2013;17:453–461 Twenty-two recreational runners (11 men and 11 women; mean age 24.57 years) with a restricted active ankle joint dorsiflexion and presence of latent MTrPs were randomly allocated a week apart to both the intervention (combined pressure release and 10-second passive stretch) and the control condition. There was a clinically meaningful and statistically significant

increase in ankle ROM in the intervention compared to the control group.

sportEX comment ‘Soft Tissue Therapy Rules OK’. Although to be fair there may have been a carry-over effect in the crossover design and the combined MTrP therapy approach.

SpORTS mASSAGE wITH OzONISED OIL OR NON-OzONISED OIL: COmpARATIVE EffECTS ON RECOVERy pARAmETERS AfTER mAxImAL EffORT IN CyCLISTS. paolia A, Bianco A. physical Therapy in Sport 2013;14(4):240–245 Fifteen male cyclists (age: 27 ± 3.5 years; body weight: 77.6 ± 8.3kg; height: 178 ± 7.7cm) were subjected to a warm-up period, a maximal prefatiguing exercise phase, a recovery period and a ramp test. During the recovery period they were subjected to one of three experimental conditions: a 15min passive recovery (PR); a 15min recovery by sports massage (SM) with oil enriched with Bioperoxoil (30% ozonised sunflower seed oil with 0.5% alpha-lipoic acid) or a 15min recovery by SM with oil but without Bioperoxoil.

In PR subjects rested for ~8min in supine posture and for ~8min in prone position; during the sports massage they were treated using a ~4min sports massage routine for each leg in prone and supine. This was 2min of effleurage and 2min of petrissage applied by the same professional masseur using 40ml of oil each time. Plasma lactate was measured using capillary blood collected from the index finger. Blood samples were obtained at the ~5th (T1), ~13th (T2) and ~20th minute (T3) of the recovery period. Following recovery, athletes performed a ramp test until unable to continue. There were no significant differences in www.sportEX.net

cyclists’ heart rate patterns in the three experimental conditions.

Power output (P), Heart rate (HR), Perceived fatigue [on a visual analogue scale (VAS)] score and blood lactate clearance in response to PR were compared. After sports massage with Bioperoxoil, athletes showed a higher Pmax and a lower perceived fatigue score in the ramp test. Blood lactate decreased more at T2 (mid-time point of treatment) and T3 (final time point of treatment) than T1 (beginning of treatment) compared to SM and PR conditions.

These findings suggest that use of ozonised oil during sports massage increases blood lactate removal, improves performance and reduces the perception of fatigue in cyclists from three Wingate tests.

sportEX comment Ozone is the stuff that we are supposed to be losing and therefore the earth is frying. It’s a Greek word meaning oderant. It is an allotropic form of oxygen, which surrounds the earth at an altitude of between 50,000 and 100,000 feet. It is created in nature when ultraviolet rays cause oxygen atoms to temporarily recombine in groups of three. It is also formed by

the action of electrical discharges on oxygen, so it is often created by thunder and lightning. Medical grade ozone is produced commercially in ozone generators, which involves sending an electrical discharge through a specially-built condenser containing oxygen. It is supposed to have antimicrobial, immunostimulatory, antihypoxic, and biosynthetic effects (see Seidler et al. Ozone and Its Usage in General Medicine and Dentistry.

Prague Medical Report 2008;109:5–13).

Bioperoxoil is the stuff mixed with sunflower oil. It seems at least from this report that it aids recovery.

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ReseaRch Reviews

Functional Fascial taping: DOEs iT havE aN EffEcT ON PaiN aND fuNcTiON iN ThOsE wiTh NON-sPEcific LBP? InTroDucTIon Non-specific low back pain (NLBP) has been a heavily investigated topic, probably likely due to its prevalence as well as direct and indirect economic impacts (1,2). Recently literature indicates that the management of pain is multifactorial and a wide-range of interventions have been proposed. a recently published article investigated the use of functional fascial taping (ffT) in its management (3). ffT is a method of taping that has been proposed to have an immediate impact on reducing pain, which can increase functional movement performance.

The MeThoDs The study compared the short-term (2 week) and medium-term effect (6 and 12 weeks) of ffT on NLBP (3). The researchers of this study recruited 43 individuals with non-acute NLBP who were randomly assigned to receive either ffT or a placebo taping intervention: n ffT group: tape was applied in the direction of a skin distraction test (ie. the direction that resulted in maximal pain reduction upon trunk flexion). Three direction tapings were generally applied. n Placebo taping group: tape was applied without tension over the lower back.

Patients were asked to discontinue other treatment interventions (excluding medications), so that the tape’s effects could be analysed. The tape was to be reapplied daily by the participants as instructed by the therapist during the initial session. They were also instructed to follow back-care activities such as a simple trunk flexion exercise.

Pain intensity was measured on a visual analogue scale and disability on the Oswestry Disability index. These measures were taken at baseline, 2, 6 and 12 weeks.

BY Joseph Brence DpT, coMT, DAc

The effective treatment of non-specific low back pain (NLBP) is a tricky topic. Our research reviewer and latest sportEX commissioning editor, Joe Brence, shares his thoughts on a recent study that investigated the effects of functional fascial taping on NLBP. only describe the placebo tape as having ‘no tension’ over the back. however, inspection of figure 1 shows that the placebo tape covered a very different surface area from the ffT group, possible causing a ‘nocebo’ effect. ideally, the tape should have been applied in a direction based on skin distraction test, but without any tension. Despite the design flaws noted above, the application of this taping technique has scientific plausibility and can be performed safely in the clinic. The mechanism by which it likely works is supported by the neuromatrix model of pain and i suspect it simply provides an afferent input which reduces the brain’s perception of a threat to that region of the body. i do not believe we have enough sufficient evidence to show superiority of ffT over other methods of taping, but because it ‘makes sense’, i believe it’s worth a shot.. references 1. walker Bf, Muller R, Grant wD. Low back pain in australian adults: prevalence and associated disability. Journal of Manipulative and physiological therapies 2004;27:238–244 2. stewart wf, Ricci Ja, chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the us workforce. JaMa 2003;290:2443–2454 3. chen s, alexander R, et al. Effects of functional fascial taping on pain and function in patients with non-specific low back pain: a pilot randomized controlled trial. clinical Rehabilitation 2012;26(10):924–933.

The fInDIngs at 2 weeks, the ffT group had a greater reduction in worst pain compared to the placebo group. There were no significant differences in the average pain or disability between groups. after 2 weeks, the authors note that there were a higher proportion of participants in the ffT group who attained the minimal clinically important difference in improving worst pain and Oswestry scores.

InTerpreTATIon This study had several weaknesses. first, the daily reapplication of tape by the participant (or assistant) is problematic as ‘between-session’ changes may alter the direction of pull needed for a reduction in symptoms during trunk flexion, which should not be determined by a novice. second, the authors 8

The auThor Joseph Brence (PT, DPT, FaaoMPT, CoMT, DaC) is a Physical Therapist and fellow of the american academy of orthopedic Manual Physical Therapists, from Pittsburgh, uSa. he has just been appointed a commissioning editor for sporteX. Joseph’s primary clinical interests involve developing a better understanding of the neuromatrix and determining how it applies to physical therapy practice. he is involved in a wide range of clinical research projects investigating the mechanisms of how manual therapy may be beneficial in the treatment of pain. Joseph is also an editorial board member for the aPTa consumer-driven website, moveforwardpt.com, runs the blog www.forwardthinkingpt.com and acts as the Vice President of operations for the NXTGen Institute, which offers postdoctoral educational programs for physical therapists.

sporteX sport dynamics 2014;39(January):08

liTeraTure review

Taping To TreaT paTellofemoral pain does the science support the hype?

Patellofemoral pain is widely considered to be a condition that is multifactorial in nature and that requires a multimodal approach to its successful management. Taping is commonly used as one treatment element and there is good evidence to support its ability to modify pain and help to restore function. This article aims to provide a critical assessment of the available evidence and to help guide clinicians on the most appropriate taping intervention for individuals with PFP. Gaps in the evidence are highlighted, but potential mechanisms are discussed to ensure clinical utility.

Note from sportEX: Traditionally we publish all tape-related articles in sportEX dynamics, however, we feel because of the current popularity of this topic and its relevance for both sportEX medicine and sportEX dynamics readers, we’ve taken the decision to publish the article in both journals (the first time we’ve done this since Jan 2012). So for people with a double subscription, you’re not going mad if you think you’ve read it before, and to compensate for the double up, we’ve published 8 additional pages of clinical content in each journal (meaning an additional 16 pages for dual-subscribers).

BY SimoN Lack mSc, mcSP

aN EXPLoratioN of thE LitEraturE SurrouNdiNg taPiNg iNtErvENtioNS with ParticuLar rEfErENcE to PatELLofEmoraL PaiN Patellofemoral pain (PFP) is one of the most common musculoskeletal complaints being presented to orthopaedic, general practice (1) and sports medicine clinics (2).

Symptoms are commonly aggravated by activities of daily living, including stair ambulation, prolonged sitting

www.sportEX.net

and squatting. Although PFP is evident within a wide range of individuals, it is particularly prevalent in younger persons who are physically active (3).

There is a lack of consensus on the exact source of pain, however, patella maltracking resulting in altered loading patterns of the patellofemoral joint (PFJ) is thought to be associated with PFP (3). Proximal, distal and local factors have all been identified as potential contributors to this altered loading. The extent to which each factor relates to the symptoms felt is suspected to vary between individuals.

As a result, numerous conservative interventions such as orthoses, taping

9

(a)

(b)

(c)

Figure 1: A demonstration of the components of tailored taping to correct lateral patellar tilt (a), lateral patellar glide (b), lateral patellar spin (c), and to offload Hoffa’s fat pad (d–f).

and exercise are commonly used in rehabilitation. It is, therefore, unsurprising that a multimodal treatment approach has been shown, through systematic review, to represent the ‘gold standard’ approach to managing PFP (4). In order to tailor and improve efficacy of this multimodal approach, the value, mechanisms behind efficacy and the most effective method of application for each multimodal component need to be understood.

Patellar taping forms a core component of the current evidencebased multimodal management programme for PFP. A large variety of taping techniques are subscribed to clinically, with the tailored McConnell taping technique being one of the most widely used (5). Adhesive, rigid tape is applied to the patella in an attempt to

modify lateral glide, tilt or rotation with the primary goal to immediately reduce pain by at least 50% during relevant functional tasks (Fig. 1)(5). Additional taping techniques identified within the literature include untailored medially directed taping (6), inferiorly directed taping and kinesio taping aimed at enhancing vastii muscle activation and synergy (Fig. 2)(7).

Changes to lower limb biomechanics resulting from taping techniques directed proximal and distal to the knee have been investigated, however, the available evidence is limited both in quantity and quality.

With a growing body of evidence reporting positive outcomes following exercise-based hip and foot directed interventions (4), further studies investigating the effect of taping application to these areas are clearly warranted.

This review of the literature aims to bring together the current evidence supporting local patella taping to modify pain, muscle activity and kinematics. In addition the proximal and distal effects of taping will be discussed to provoke discussion about its use clinically, and provide the basis upon which further research could be performed.

taPiNg iNtErvENtioNS dirEctEd at thE kNEE changes in pain Figure 2: Tailored kinesio taping for an individual with patellofemoral pain, including a VMO : VL and lateral fascial offload tape

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The original taping techniques described

by McConnell (8) were designed with the primary objective of modifying pain sufficiently to enable effective exercise intervention to be performed. The

rationale for which has been supported more recently, as pain acts as a potent inhibitor of normal muscle activity around the anterior knee (9). A current systematic review entitled Taping for patellofemoral pain: A systematic review and meta-analysis to evaluate effectiveness and mechanisms (in press, BJSM) performed by our group at Queen Mary University, concluded that moderate evidence indicates tailored taping provides immediate pain relief of large effect during functional tasks. Additionally, moderate evidence indicates untailored medially directed taping results in immediate pain relief of small effect during functional tasks. Very limited evidence from one low quality study indicates kinesio taping has no effect on pain.

Due to the heterogeneity of taping interventions, data pooling was inappropriate beyond the immediate term. However, one high quality study did report greater pain reduction with McConnell taping in addition to exercise at weeks 2, 3 and 4 of intervention (10). These findings were not supported by an earlier study that reported no improvement following taping intervention plus exercise and education, or taping and education compared with education alone at 3 and 12 months (11). Furthermore, adding kinesio taping to exercise intervention did not demonstrate improvements in pain at 3 or 6 weeks (7).

Further studies, not included in the systematic review mentioned above, have since been published. Osorio et al. (12) compared the immediate sportEX dynamics 2014;39(January):9-13

liTeraTure review

(d)

(e)

(f)

A lArGE VArIETy OF TAPInG TECHnIQUES ArE SUBSCrIBED TO ClInICAlly, WITH THE TAIlOrED MCCOnnEll TAPInG TECHnIQUE BEInG OnE OF THE MOST WIDEly USED effects of kinesio and McConnell taping, and when making comparisons between the two techniques reported no significant differences, however significant differences in strength, endurance and pain responses were evident in both groups. However, when comparing kinesio taping with placebo taping, Aytar et al. (13) reported no significant difference in pain between groups. Variability in technique when applying kinesio taping and differences in the functional tasks assessed may well explain this variance in the results obtained.

changes in muscle activity Alteration in vastus medialis oblique (VMO) activation in the presence of PFP has been acknowledged as a potential mechanism through which symptoms are maintained in some individuals (14).

Furthermore, it is believed that altered activation patterns, expressed as an activation ratio of VMO relative to vastus lateralis (Vl), have the capacity to alter the loading patterns within the PFJ. Interventions, such as taping, have therefore been investigated to assess their capacity to elicit change in these activation parameters.

Within our groupâ&#x20AC;&#x2122;s systematic review presented earlier, the results indicated that moderate evidence from within three high quality (and one low quality) studies suggested that VMO onset timing was significantly www.sportEX.net

earlier following a tailored patella taping intervention. Furthermore, limited evidence indicated untailored medially directed taping resulted in a significantly lower VMO : Vl ratio during stair stepping tasks. However, no change in VMO amplitude was observed in either tailored or untailored interventions.

Kinesio taping, purported to have the capacity to alter muscle activation, has been investigated in individuals with and without PFP symptoms. In both groups no changes that are perceived to be advantageous to restoration of normal VMO muscle activity have been reported. Within pain populations, lee et al. (15) reported a reduction in VMO amplitude, and within pain-free populations, lins et al. (16) reported no changes in Vl amplitude following kinesio taping. Despite this lack of conclusive evidence for kinesio taping, the capacity for this style of taping to demonstrate any change in muscle amplitude suggests that potential benefit could be derived. Further work investigating the application technique with regards to specific muscle amplitude measure may reveal rewarding results.

changes in kinematics Kinematic variances, both associated with and leading to PFP, have been well documented within both retrospective and prospective studies (17â&#x20AC;&#x201C;19). The effects of taping on these variances

about the knee, however, have been less well reported. Evidence from one high quality study indicates greater knee flexion angles and knee extensor moments during stair ascent and descent under the taped condition (20).

With a 92.6% reduction in pain reported in the same study when individuals were taped, it is made very clear how effective pain modification can be at facilitating a change in movement patterns.

taPiNg iNtErvENtioNS dirEctEd at thE hiP With rotation, and in particular femoral internal rotation, having been highlighted as a significant indicator of PFP development among runners (19), and significantly increased in individuals with PFP during functional tasks (21), an investigation of the effects of taping at the hip is clearly warranted. Furthermore, with current literature reporting that tape applied to the knee has the capacity to alter movement patterns (as described above), the obvious progression is to test if this modality has the capacity to alter movement patterns at the hip.

Conversely, unless the hip tape is able to immediately modify pain, it is possible that alterations in lower limb movement patterns will not be modified as effectively. Kinesio taping directed at the gluteus maximus has been described within the literature to increase muscle 11

power (22). With gluteus maximus as well as gluteus medius activity having been shown to be altered in individuals with PFP (23) this may represent one potential mechanism through which its application may be effective within this population. The literature surrounding tape application to the hip is, however, sparse at best in both pain and painfree populations.

taPiNg iNtErvENtioNS dirEctEd at thE foot Influencing foot position has been of interest in those examining the PFJ because of theoretical paradigms first described in 1987 by Tiberio (24) and particularly since the addition of work

by Powers (25). Tiberio described a link between prolonged pronation, internal tibial rotation and subsequent increased internal femoral rotation to allow for knee extension to occur during the stance phase of gait (24), and Powers demonstrated how influential femoral rotation could be on the loads experienced at the retropatella (25).

To my knowledge no foot taping has been done on individuals with PFP; however, Kelly et al. (26) have published an elegant study looking at the effects of low Dye taping on gluteal, VMO and Vl muscle activity and plantar pressure during running. They reported, however, that application of augmented low Dye taping resulted in a significant delay of electromyographic activity onset for all three muscles when compared with control tape and no tape conditions.

With onset of the glutei reported to be delayed in individuals with PFP (23), an intervention that results in further delay is unlikely to be beneficial. Unfortunately, there was no attempt in this study to differentiate between foot types, which may well influence the findings.

Application of this taping approach in conjunction to a measure of foot posture may well provide interesting results in PFP populations.

coNcLuSioNS There is clearly good evidence to support the use of taping interventions in the management of PFP. In particular, clinicians should include a tailored taping approach likely to positively influence pain (large effect), VMO timing and functional capacity during 12

rehabilitative exercise. Additionally, patellar taping appears to be an effective adjunct to exercise over a 4-week period, however, longer term follow-up to evaluate efficacy is required. The evidence surrounding the use of kinesio taping is largely absent when managing PFP, and where it is present the evidence is low in quality.

Following the high profile of kinesio taping during the Olympics, the rush to ensure good quality research is out there to support its evidence-based use has clearly started and is desperately needed.

References 1. Van Middelkoop M, Van linschoten r, et al.

Knee complaints seen in general practice: active sport participants versus nonsport participants. BmC musculoskeletal Disorders 2008;9:36 2. Taunton JE, ryan MB, et al. A retrospective case-control analysis of 2002 running injuries. British Journal of Sports medicine 2002;36:95–101 3. Powers CM, Bolgla lA, et al. Patellofemoral pain: proximal, distal, and local factors, 2nd International research retreat. Journal of orthopaedic & Sports physical Therapy 2012;42:a1–54 4. Collins nJ, Bisset lM, et al. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports medicine 2012;42:31–49 5. Cowan SM, Bennell Kl, Hodges PW. Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clinical Journal of Sport medicine 2002;12:339– 347 6. Keet JH, Gray J, et al. The effect of medial patellar taping on pain, strength and neuromuscular recruitment in subjects with and without patellofemoral pain. physiotherapy 2007;93:45–52 7. Akbas E, Atay AO, yuksel I. The effects of additional kinesio taping over exercise in the treatment of patellofemoral pain syndrome. acta orthopaedica et Traumatologica Turcica 2011;45:335–341 8. McConnell J. The management of chondromalacia patellae: a long term solution. australian Journal of physiotherapy 1986;32:215–223 9. Bennell K, Hodges P, et al. The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad. Journal of orthopaedic research 2004;22:116–121 10. Whittingham M, Palmer S, MacMillan F. Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. Journal of orthopaedic & Sports physical Therapy 2004;34:504– 510

11. Clark DI, Downing n, et al. Physiotherapy for anterior knee pain: a randomised controlled trial. annals of the rheumatic Diseases 2000;59:700–704 12. Osorio JA, Vairo Gl, et al. The effects of two therapeutic patellofemoral taping techniques on strength, endurance, and pain responses. physical Therapy in Sport 2013;14:199–206 13. Aytar A, Ozunlu n, et al. Initial effects of kinesio® taping in patients with patellofemoral pain syndrome: A randomized, double-blind study. isokinetics and exercise Science 2011;19:135–142 14. Chester r, Smith TO, et al. The relative timing of VMO and Vl in the aetiology of anterior knee pain: a systematic review and meta-analysis. BmC musculoskeletal Disorders 2008;9:64 15. lee Cr, lee Dy, et al. The effects of kinesio taping on VMO and Vl EMG activities during stair ascent and descent by persons with patellofemoral pain: a preliminary study.

Journal of physical Therapy Science 2012;24 153–156 16. lins CA, neto Fl, et al. Kinesio taping® does not alter neuromuscular performance of femoral quadriceps or lower limb function in healthy subjects: randomized, blind, controlled, clinical trial. manual Therapy 2013;18:41–45 17. lankhorst nE, Bierma-Zeinstra SM, Van Middelkoop M. risk factors for patellofemoral pain syndrome: a systematic review. Journal of orthopaedic & Sports physical Therapy 2012;42:81–94 18. lankhorst nE, Bierma-Zeinstra SM, Van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports medicine 2013;47:193–206 19. noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. medicine & Science in Sports & exercise 2013;45:1120–1124 20. Salsich GB, Brechter JH, et al. The effects of patellar taping on knee kinetics, kinematics, and vastus lateralis muscle activity during stair ambulation in individuals with patellofemoral pain. Journal of orthopaedic & Sports physical Therapy 2002;32:3–10 21. Aminaka n, Pietrosimone BG, et al.

Patellofemoral pain syndrome alters neuromuscular control and kinetics during stair ambulation. Journal of electromyography and Kinesiology 2011;21:645–651 22. Mostert-Wentzel K, Swart JJ, et al.

Effect of kinesio taping on explosive muscle power of gluteus maximus of male athletes.

South african Journal of Sports medicine 2012;24:75–80 23. Barton CJ, lack S, et al. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British Journal of Sports medicine 2013;47:207–214 24. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. Journal of orthopaedic & Sports physical Therapy sportEX dynamics 2014;39(January):9-13

Literature review

1987;9:160–165 25. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective.

Journal of orthopaedic & Sports physical Therapy 2003;33:639–646

26. Kelly lA, racinais S, et al. Augmented low dye taping changes muscle activation patterns and plantar pressure during treadmill running. Journal of orthopaedic & Sports physical Therapy 2010;40:648–655.

ThE AuThoR Th Simon Lack is a PhD student at Queen Mary university London (QMuL), studying the interaction of hip and foot biomechanics (QM in the presentation and management of patellofemoral pain. he graduated from Brunel university in 2005 with a degree in Physiotherapy, and went on to study an MSc in Sports and Exercise Medicine at QMuL in 2010. Simon works as a physiotherapist in two London-based private clinics, having previously worked in New Zealand with professional golfers, local rugby and football teams.

DISCUSSIONS

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n What do you consider to be sub-groups of PFP patients, and how do you tailor your taping intervention to address this? n Which kinesio taping techniques do you use, and what do you think is the mechanism of effect? n Modification of pain appears critical to taping success; through which mechanisms do you think taping achieves this effect?

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13

A new AnAtomy for the 21st century

BY John SharkeY BSc, MSc

IntroductIon The study of anatomy begins with the joining of the largest cell, the female egg, and the smallest cell, the sperm, and the end result is an amazing human being. We stand erect on two feet with the ability to walk, run, and jump yet we also possess the dexterity to wipe a tear from a child’s face and the tactile ability to locate a small nodule within a group of muscle fibres. We are capable of complex self-reflection and we are intrigued by the world around us. It is that intrigue that led me to question the very basics of anatomy and biomechanics. During my studies and practice, I asked, “what if” and if the answer did not make complete sense I was motivated to investigate further, to find a better model. The model that I have developed is introduced here.

LaYerS Let me begin by discussing the notion of ‘layers’ in the human body.

Researchers describe multiple layers within the body (1,2) but I suggest that the human has no layers. The use of the term ‘layer’ is a language of convenience but it is also a language of reductionism. Breaking up the study of the human body into smaller more digestible parts may help the student to absorb and assimilate the information.

Figure 1: removing the skin with care – creating a new layer. (Sharkey J, 2013)

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This article aims to stimulate discussion concerning the continuity of the human form and a new vision of human anatomy. Current biomechanical explanations are challenged including the law of levers and inter-abdominal pressure, and new anatomical descriptions are put forward, such as the onemuscle ‘MyoTensegrity’ hypothesis. Understanding connectiveness of the human body can change the way a therapist provides therapeutic interventions, thus avoiding the urge to treat the symptoms and not the real source of the insult.

However, the possible downside is that it could reinforce the notion that the body is made from separate parts as opposed to an integrated whole organ system. Everything is connected to everything else. It is the anatomist who creates the layers. Figure 1 is an example of how a layer can be created.

This figure demonstrates how, following an incision, the skin can be lifted and differentiated from the superficial fascia (or subcutaneous tissue) beneath.

The language I have developed in order to discuss anatomy is holistic, based on depth. The body has depth with tissues changing in composition, arrangement and density. We palpate superficially yet we can distinguish differences at the deeper levels using our fingertips as intelligent extensions of our brains.

The study of anatomy in the current era is supported by unique modern scientific research using technologies including ultrasonography, computed tomography (CT) scans, histology, and nuclear magnetic resonance imaging (MRI) helping us to explore the world of connective tissue, hard and soft.

Imaging technology has lead to a vision of tissue stratification reflecting visual observations based on changes in

tissue density.

For example, stratification in rock formation occurs because of volcanic activity and the forming of layers on a seabed due to different types of sediment (such as mud, sand, gravel, plankton and the skeletons of seabed dwelling animals, and chemical reactions spanning millions of years).

Although changes in density do exist in the human form, the dynamic of the tissue is one that is continuous and global – changing from a sheet to an aponeurosis or to the local thickening of tendons and ligaments. It is a continuum. Touching a body is the key to most, if not all, bodywork or physical therapies. A therapist’s fingertips, elbows and thumbs trace the subtle nuances cueing an awareness of the changing contours of the underlying topography of fascia, nerves, blood vessels, muscles and lymph tissue.

The listening fingertips fall into septal spaces or bump into unexpected hills, valleys, or even mountains. Of course the skin itself is the first to be touched and its continuous, endless nature is more obvious. Contact is made through the skin, from little toe to ring of ear, from belly button to scalp, which can be traced, unbroken, continuous, unifying sportEX dynamics 2014;39(January):14-17

evidence informed prActice

and embracing.

It seems obvious, then, that the skin would play an important role in human locomotion – particularly when it is seen removed in its entirety (Fig. 2). When the skin is held and manipulated – pulled, squeezed, compressed and tugged – an incredible balance between flexibility and stability, motility and mobility can be sensed.

When we look inside our favourite anatomy textbook and admire the artist’s depiction of muscles, such as biceps brachii, tensor tympani, longus colli or the rectus capitis posticus minor, we must take a moment to ask ‘how’ did this image come into existence.

When the anatomist cuts apart the skin from the ‘underlying’ adipose tissue a ‘layer’ is created. For the first time in a lifetime, a relationship of ‘connection’ has been disrupted, disconnected, cut apart.

the one-MuScLe ‘MYotenSegrItY’ hYpotheSIS In the depths of the deep fascia, it is possible to use the fingers to provide blunt dissection and lift the ‘cling-film’ wrappings of epimysium that cover the muscle to create, yet again, a new layer. A moment ago, this layer did not exist. More careful exploration and examination of the epimysium leads to the discovery that the epimysium of one muscle is, in fact, the epimysium of another neighbouring or bordering muscle. Contraction of a muscle pulls or tugs on this fascial network resulting in tensional forces spreading along numerous vectors (3). Thus the idea of one muscle producing a specific movement becomes questionable at least (Fig. 3).

The fascia drops deeper creating rivers, brooks and streams facilitating the flow of nerves and blood vessels while providing a fluid space between fascicles. These fascial rivers, brooks and streams combine downstream eventually embracing the harder calcified, connective tissue matrix we call bone. The fascia is not separate to but continuous with the bone.

The fascia now changes in its construct becoming the outer covering of each and every bone it embraces.

Surrounding the dry banks of the bone the fascia, now called the periosteum, runs along the periphery of the bone www.sportEX.net

until once again it rises to become the ligaments, tendons and muscle gastors of a continuous, one-muscle system that is dynamically linked in such a manner that forces, generated in one part of the body, will be instantaneously translated throughout the entire body – the idea of ‘MyoTensegrity’.

Biomechanical disruption, such as a fallen right pedal arch, will have implications further upstream in the kinetic chain and down again as far as the left pedal arch. Fascia thickens along these lines of tension.

Therapists can learn to palpate the tissues to seek out these tensional pathways and provide therapeutic interventions that result in reduced pain and improved motion. As research has demonstrated, fascia is replete with proprioceptors, mechanoreceptors and nociceptors. This model provides a rationale for referred pain, ie. pain that is experienced some distance away from the source of insult.

A special relationship between the myofascial and osseous tissues results in the faster growing bones pushing out, creating compression, and the softer tissues being pulled, creating tension. Compression and tension are the two members of this MyoTensegrity structure providing each of us with ‘lift’.

This compression–tension relationship ultimately results in the iliotibial band, the posterior longitudinal ligament, the thoracolumbar fascia, plantar aponeurosis, ligament and tendon tissues. This relationship between compression and tension is ultimately a method of communication with a unique vocabulary commuted along the myokinetic chain.

Several researchers have clearly demonstrated that muscle is not isolated nor can it act independently to produce movement (4,5). At the cellular level, using fluoroscopic imaging, researchers led by pioneer Dr Guimberteau provided strong visual evidence that fascia contains a water filled vacuolar system that is capable of sliding independently of the rate of contraction of muscle (4). In turn, it is capable of facilitating and supporting capillaries throughout the fascia.

This micro-vacuolar structure seems to have an icosahedron-like (tensegrity) composition where fractal elements

Figure 3: a powerful image demonstrating the myofascial links via the epimysium. (Sharkey J, 2011)

Figure 4: a real view of muscle with its associated deep fasciae. a very different image to that seen in anatomy textbooks. (Sharkey J, 2011)

inter-relate, creating a body-wide framework or network. This structure is able to change or maintain shape and form within a fluid base allowing deformation followed by a return to its original state, while maintaining volume.

This creates a stable, yet flexible environment necessary for fascia to act as a medium for force transmission.

IMpLIcatIonS For the soft tissue therapist, health fitness expert or medical exercise specialist appreciating this ubiquitous tissue relationship as a tensegrity is a must. Functional physical activity, purposeful bodywork and massage therapy can only be truly provided when the soft tissue therapist can envisage the full-body kinetic chain ‘effect’. I promote moving away from the models of ‘treat the pain’ or ‘stretch the tension’ which are currently popular. A patient or client experiencing stiffness or tightness in their upper trapezius muscles will typically drop their ear to their shoulder in an effort to ‘stretch’ the opposite side to gain a long-term resolution, which sadly, seldom comes.

The therapist massaging the chronic upper trapezius in an effort to resolve stiffness is also on a road to nowhere.

The stiff trapezius or tight hamstrings are, for the most part, to be seen as 15

‘the symptoms’ and not the cause. We, in the soft tissue therapy and exercise science world, often accuse the medical profession of ‘treating the symptoms’ and we therefore should want to avoid the abyss of ‘stretching’ or ‘massaging’ the symptoms.

When a patient complains of a painful knee, pointing to the lateral side of their knee, does it follow that the main focus of treatment should be to the lateral aspect of the knee? Many knee pain complaints are as a consequence of fascial changes, such as migration, adhesions or muscle spasm further up or down the chain (leading to myofascial force transmissions) and it is there that most of the therapeutic intervention must be focused.

BIoMechanIcS Due to the space limitations of this article I will be brief in my effort to whet your appetite and stimulate discussion. Newtonian, Hookean and linear mechanical properties are the basis for the building of all things nonbiological as well as for all living things (including humans). However, I believe this is fundamentally flawed as we are processing human movement with maths and physics that are inherently discontinuous compared to the biology and physics of humans which is continuous and indivisible, unless we use a scalpel. Biomechanics currently ignores the tangible continuous fabric of nature’s reality.

The science of biomechanics is based on laws of rigid levers, determining the centre of gravity, two bar joints with bones touching; it is dependent on gravity and assumes a fixed fulcrum. This would require that all joints in biological organisms are hinges.

I propose that the bones that make up joints do not touch and that cartilage tissue is not a shock absorber. It is my view that the meniscus tissue could not withstand the forces generated in running or other high impact sports if bones moved closer together (as much as three to five times your body weight crashing down on your cartilage).

Scientists have pointed out that large buildings are immobile, rigidly hinged and vertically orientated structures. They are high energy consuming and depend on gravitational forces to remain orientated.

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Any bending in the structure would produce instability and possible collapse.

I ask, “Do you believe that humans are organised as machines and buildings?”

Humans are omni-directional, as are all biological organisms, in order that the tensional elements function under tension at all times regardless of the direction of applied force. The compression elements in biological structures ‘float’ in a vast ocean of tension (6). Anatomists and surgeons witness this tension as pre-stress, when incising the skin, causing it to retract from the blade. Thanks to scientists such as David Goodman Simons, co-author of the famous red books on myofascial pain, dysfunction and myofascial trigger points (7) (one of the first men in space), we know that humans can move and operate in a non-gravity environment.

Numerous studies specific to biomechanics involve the muscles exclusively with no attention or consideration given to the myofasciae (Fig. 4). Considering that the myofasciae change everything due to the fact that muscle fibres attach directly into the fascia providing a mechanism for force transmission dispersing biomechanical tensional loads to muscle tissues in multi-planar directions, without being subject to excessive shearing force.

Such research is usually conducted with a view to providing the scientific community with new findings that will shape future theoretical and experimental investigations aimed at reducing the incidence of unintentional injuries in the general and athletic populations. The mathematical equations used in biomechanics are based upon Newtonion principles, law of levers and inter-abdominal pressure. According to researcher Gracovetsky, an individual’s

inter-abdominal pressure would have to increase by 20 times more than their blood pressure, enough for them to explode, to allow a 250kg lift. Gracovetsky further states that the maximum load the erector spinae musculature could possibly support is no more than approximately 50kg (Further resources 4). One of my mentors, Dr Steve Levin, promoted his ‘biotensegrity’ model in 1995 (from which I have developed the model of myotensegrity) explaining that a 2kg fish hanging at the end of a 3m fly rod would exert a compressive load of 120kg, at least, on the lumbosacral junction (6). If the weight of the rod, torso, arms and head were included the calculated load on the spine would far exceed the critical load, resulting in fracture of the lumbar vertebrae of the average mature male. Humorously, Levin suggests this would make fly fishing an exceedingly dangerous activity.

For Newton’s first law to work, specifically with biological organisms, all forces resulting in movement must be generated external to the skin. Dr Levin says, “We cannot pull ourselves up by our own shoe laces” (personal communication, 2008). I hope you have enjoyed this short article and keep in mind that everyone is entitled to an opinion and mine may be wrong. What is your opinion? I wish you success.

SuMMarY How we view the human body, they way we think about how it moves, will shape and mould the way soft tissue therapists, approach treatments and movement options. I do not recommend we throw the baby out with the bath water but I propose the need for a new vocabulary to reflect a new understanding and a vision of living anatomy and biomechanics. references

Figure 4: a real view of muscle with its associated deep fasciae. a very different image to that seen in anatomy textbooks. (Sharkey J, 2011)

1. Stecco A, Macchi V, et al. Anatomical study of myofascial continuity in the anterior region of the upper limb. Journal of movement and Bodywork therapies 2009;13(1)53–62 2. Wendell-Smith CP. Fascia: an illustrative problem in international terminology. surgery and radiologic Anatomy 1997;5:273–277 3. Yucesoy C, Huijing PA. Substantial effects of epimuscular myofascial force transmission on muscular mechanics have major implications on spastic muscle and remedial surgery. Journal of electromyography and sportEX dynamics 2014;39(January):14-17

evidence informed prActice

n Do current biomechanical models truly explain and provide rational mathematical equations for human form and movement?

DISCUSSIONS n If the human body is a tensegrity, how can joints, levers and fulcrums exist? n Do ‘layers’ exist in the human body or is everything connected to everything else? n How does myofascial force transmission fit in to the current biomechanical models?

Kinesiology 2007;17:664–679 4. Guimberteau J, Delage J, et al. The microvacuolar system: how connective tissue sliding works. Journal of hand surgery (european volume) 2010;35(8):614–622 5. Yucesoy CA. Epimuscular myofascial force transmission implies novel principle for muscular mechanics. exercise and sport science review. 2010;38(3):128–134 6. Levin SM. The importance of soft tissues for structural support of the body. In: Dorman T (ed.) Spine: State of the Art Reviews. hanley and Belfus 1995;9(2):357–363 7. Simons DG, Travell JC. Travell and Simon’s myofascial pain and dysfunction: v.

1 & v. 2: the trigger point manual, 2nd edn. lippincott williams and wilkins 1998. isBn 0683307711 (£157.00). Buy from Amazon http://spxj.nl/17U3XeC.

continuing education Multiple choice questions This article also has an eLearning test which can be found under the eLearning section of our website.

Tests from April 2013 onwards can be done on most digital devices.

1. Login to our website, click the Online Access button in the main menu bar and the go to the eLearning section (you must be logged in).

2. Click on the quiz you wish to do. Successful completion results in a stored certificate under the My Account area of our website. This can be downloaded or printed at any time as evidence of continuing education for many national and international membership associations.

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Further reSourceS 1. Healing through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dysfunction by Starlanyl DJ, Sharkey J, Williams A. north atlantic Books 2013. ISBN 1583946098 2. Massage courses at National Training Centre: Ireland’s Leading Educator in Health Fitness & Bodywork Therapy (http://www.ntc.ie/massage-courses-uk) 3. Human anatomy dissection seminar at National Training Centre: Ireland’s Leading Educator in Health Fitness & Bodywork Therapy (http://www.ntc.ie/dissection) 4. The Spinal Engine by Gracovetsky S. Springer 2008.

ISBN 3709189519.

ThE AuThor Th John Sharkey MSc is the author of two bestselling books: his latest is Healing through trigger point therapy: A guide to fibromyalgia, myofascial pain and dysfunction dysfunction. John is a clinical anatomist (BACA), exercise physiologist (BASES) and founder of European Neuromuscular Therapy. John is a senior tutor with the university of Chester and programme leader of the Masters degree in Neuromuscular Therapy. he is a member of the editorial board of the Journal of Bodywork and Movement Therapies, and a medical team member of the olympic Council of Ireland. John also played a key part in helping to establish the Sports Massage Association. www.sportEX.net

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Myofascial Taping

Controlling myofasCial tension

BY Markus Erhard, sports sciEntist and MYofascial thErapist

Part 1: the theory MYofascial taping

Myofascial Taping is a unique, most innovative and revolutionary taping method, based on the regulation of myofascial tension to restore myofascial balance by the use of myofascial release and activation techniques.

The changes caused by Myofascial Taping mount up and provoke alterations in fascia receptor activity and, further, will cause a change in its tension and structure. This influence rids the body of restrictions and reduces pain significantly, in most cases completely, in only one therapy session, resulting in improved muscle function, movement and posture.

The techniques for using Myofascial Taping to treat non-specific low back pain (one of its most useful applications) will be described in the second part of this article.

fascia rEsEarch During recent years, various approaches to therapy have changed fundamentally. The main reasons for this are ‘new’ results from fascia research, which show that fascia plays a much more important role than previously believed. Fascia has an influence on pain (1–3), attitude (4), motion (3), force transmission (4–6), proprioception (7–9) and sports performance (10). Gradually, these results have started to change the way we diagnose, evaluate, approach and treat musculoskeletal problems.

Myofascial Taping is a new therapy that has been developed from the latest results from fascia research and works to remove tension and restrictions in the fascia allowing a return to a pain-free state and normal 18

Myofascial Taping is a unique and innovative taping therapy that has been developed by Markus Erhard. It has a revolutionary taping and therapy approach, which is totally different from kinesio taping, based on new fascia research and the myofascial connections (Anatomy Trains) to rid the body of restrictions and restore the natural myofascial balance instantly and effectively. The physiological effects are achieved by intensive myofascial release and activation; the results can be obtained in one therapy session and include improved muscle function and range of motion, enhanced sporting performance and reliable pain relief from acute and chronic myofascial pain. (sometimes enhanced) movement.

MYofascial taping controls pain The fascial network is one of our richest sensory organs. It possesses ten times more sensory receptors than muscles (8). The receptors are different types of myelinated sensory receptors – Golgi, Ruffini and Pacini endings – and many unmyelinated ‘free’ nerve endings that are found almost everywhere in fascial tissue.

Whatever else muscles do individually, they also influence functionally-integrated body-wide continuities within the fascial webbing.

These lines follow the wrap of the body’s connective tissue fabric, forming traceable lines of myofascia. These lines consist of the bundled together, inseparable nature of muscle tissue (myo-) and its accompanying web of connective tissue (fascia) (4). The mechanical fascia receptors work as proprioceptors to inform the body about position, motion and pain (11).

Every movement will change the tension in the fascial web. The fact that fascia connects all parts of the body, all muscles, all muscle bundles, all muscle fibres and organs makes it a perfect sensory reception device – monitoring even the smallest change in tension, pressure and pain.

At some points the fascia will have more tension and at others, less tension. For example, when you bend forward, your superficial back line will have more tension than in standing, and the superficial frontline will have less. All the fascial receptors of the superficial back line that measure tension will be deformed and give feedback on the amount of tension.

To perceive, control, and to alter tension and pain, the Golgi organs and the free nerve endings are especially important. The effects will be explained later for the myofascial release technique.

fascia: thE sourcE and solution of MYofascial proBlEMs Once the myofascial tension is out of balance – locally or globally – a vicious cycle of problems starts in which the fascia plays a decisive role.

Fascial tissue can change for various reasons (Table 1). Usually these changes are due to the demand and load in everyday life, our habits at work, and sports or injuries. When fascial tissue changes it has the potential to hold us in compensation due to its strong mechanical properties. It changes our posture and movement patterns. These fascia-related patterns can be ‘read’ and the tensed and sportEX dynamics 2014;39(January):18-24

EvidEncE inforMEd pracTicE

shortened muscles and lines can be traced. One can therefore develop strategies about which part of the fascial tissue has to be worked on in order to decrease and normalise mechanical tension and/or muscle tone and hence return to a healthy, efficient and pain free posture and movement.

non-spEcific low Back pain This section will explain the myofascial pain syndrome in low back pain (LBP) with injured and non-injured fascia.

LBP has become a major health problem worldwide (12). This type of back pain does not originate in the bony structures of the spine, facet joints or from alterations in the discs (13,14) but in the lumbar soft tissue or the thoracolumbar fascia, respectively (1,15). The thoracolumbar fascia is richly innervated with sensory fibres of encapsulated free nerve endings working as mechanoreceptors and nociceptors (16).

Panjabi (2) and Schleip et al. (17) explain the mechanism of LBP by ‘sub-failure injuries’: single trauma or cumulative micro-injuries that lead to nociceptive signalling.

Due to an inflammation process (micro-injury) and pain, the reflexive muscle tone will be increased, which will increase tension even more. This, in turn, can lead to re-injuring old or lead

to new micro-injuries.

Langevin et al. (18) show that the posterior layer of the thoracolumbar fascia is thickened in patients with chronic LBP. This can be explained by incomplete wound healing with the proliferation of fibres and continuous re-injury of the old and new fibres again and again.

The myofascial tension will be higher once the fascia is shortened, injured or contains scar tissue.

Therefore, the free nerve endings in the fascia are stimulated earlier and more than usual, especially during movement and when stretching occurs in the direction of the fibre as illustrated in Figure 1.

To stop the ‘dysfunctional myofascial pain loop’, fascia-specific treatment is needed. The myofascial release will be created by a mechanical shift of the fascial tissue that will result in both a mechanical and neurological decrease (tone) of the myofascial tension.

taBlE 1: paraMEtErs that changE fascia and thE MYofascial sYstEM 1. Fascia changes depending on the demand and load (20) 2. Habits (also emotional) (4) 3. Sustaining mechanical forces (21) 4. Gravity (21) 5. Injury (22) 6. Chemical substances in the body (23) 7. Direct cell signals (24)

by Franklyn-Miller et al. (6). When a straight leg raise is performed with fresh cadavers, the fascial tension of the ipsilateral lumbar fascia has 145% more tension than the hamstrings.

fascial force transmission of the superficial backline Tension and kinematic pull can be transferred to any part of the body by the myofascial web, especially along the Anatomy Trains. When the goal is to reduce tension in the low back, one must also take a look at the hamstrings, as demonstrated

Figure 1: The blue line in (A) and (B) depicts the superficial back line. (B) The fascia is relatively loose, as in standing position. Even though micro-injuries are present it is often not painful. (A) The fascia is tensioned with nociceptive signalling from the free nerve endings.

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THE FASCIA IS OFTEn THE SOURCE AnD SOLUTIOn OF MyOFASCIAL PROBLEMS MYofascial rElEasE with thE MYofascial taping MEthod Myofascial Taping aims to reduce and normalise myofascial tension and to restore myofascial balance within each single muscle (myofascial unit) and the global myofascial system. The myofascial release technique is the first step.

This is where the importance of the Anatomy Trains comes into play.

Knowledge of the basic principles of Anatomy Trains helps the therapist to understand how Myofascial Taping works.

Every part of the body is connected through fascia, but some parts are ‘more’ connected than others. These are the parts where muscles and fascia are biomechanically linked together.

These biomechanical and myofascial slings can be explained by the Anatomy Trains principal, developed by Thomas Myers, which are formed by pathways of common force transmission through myofascia. The Anatomy Trains can also be used as a map of the dominant myofascial connections. Postural compensation, strain, tension, fixation

and resilience are all distributed along these lines giving it a systemic point of view (4).

The most powerful pulls and tensions run along the Anatomy Trains. Almost all deep and superficial regular dense connective tissue (RDCT) layers are organised in series with muscle fascicles (presented as muscle compartment walls)(8). If the myofascia is overloaded, shortened, injured or scarred, the major restriction and increased tension also will be in this major fibre direction. To ‘cure’ the fascia-related problem completely, one needs to treat the fascial tissue in different ways and directions but the most intense effect will come from treatment along the line of the main fibre direction. One should start by reducing tension at the point of pain.

This is exactly the area where the fibres need to be offloaded. In LBP it would be the thoracolumbar fascia and erector spinae, although this does not necessarily mean that this is the source of the problem. If the myofascial tension has been high for a long period of time, the dysfunctions and tension could have been transferred to other connected parts that can be quite remote from the pain. The next step would be to find and treat these remote structures as well.

In LBP the hamstrings and associated fascia are often part of the structures from which LBP symptoms arise.

thE languagE of fascial rEcEptors The offloading and reduction of myofascial tension most often brings complete pain reduction immediately. The myofascial release technique not only treats fascia sensibly in a mechanical way but also addresses the receptors that are embedded in the fascial tissue in their specific language’, so that they respond immediately. It is like software programming. Once the correct code has been entered and you press the Enter key, the program is rewritten and active. In a similar way, Myofascial Taping changes myofascial tension immediately and reliably. It’s simply about shifting the tissue: by adjusting the tension on the tape, the fascia is moved in the right direction at the right places and an intense myofascial release is created. This release effect reduces the myofascial tension and pain.

The amount of tension required on the tape depends on the quality of the fascia and how much the tissue has to be moved in order to offload the fascial structures and receptors and so changing the receptor’s activity, or sensitivity, respectively, so that the release effect is created.

MYofascial rElEasE for non-injurEd fascia golgi organs Golgi organs measure and control myofascial tension in series. The highest density of Golgi organs are ‘muscular’ zones that are the stressand force conveying zones of the muscle. The fascial tissue where Golgi organs are embedded – mostly at muscle insertions and muscle tendon junctions – will be shifted by applying the tape with tension. The shift in the tissue stimulates the Golgi organs. The stimulation of the Golgi organs leads to a reduction of muscle tone that reduces the myofascial tension via a neurological pathway as illustrated in the Figure 2.

interstitial receptors Figure 2: (A) and (B) illustrate a longitudinal section of tissue showing the different fascial layers as well as muscle and bone. (A), The layers are in a normal state, without tape. (B), The MyofascialTape® is applied with stretch from left to the right, shifting all layers from left to the right. The more superficial the tissue (layer) the further it is shifted to the right. Depending on the area of the body, it moves even the deepest fascial layers as in most parts of the limbs for example.

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Eighty per cent of afferent nerve endings are free nerve endings termed ‘interstitial muscle receptors’ (interstitials), located in fascial tissues such as the endomysium or perimysium. sportEX dynamics 2014;39(January):18-24

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Figure 3: The MyofascialTape® is applied with stretch from left to the right.

Starting at the muscle insertion as depicted in Fig. 2(B), the tape is now applied with stretch to the distal part of the micro-injuries. Again the myofascial release technique is shifting all layers from left to the right.

The majority of these free nerve endings functions as mechanoreceptors, responding to mechanical tension, pressure or shear deformation.

The tissue proximal to the tape is under reduced tension and the associated receptors ‘feel’ the decreased tension, thus changing their signals and adjusting their normal activity according to the changed myofascial tension. Some have a high, some have a low threshold. Depending on the threshold and the mechanical quality of the fascia, the stretch on the tape has to be adjusted to create the right effect. In practice, the tension on the tape for a myofascial release varies between 50 and 100%. If the myofascial tension has been relatively high, the range of motion (ROM) is often restricted according to the amount of myofascial tension. Interstitial receptors (free nerve endings) acting as mechanoreceptors will be stimulated less than usual in a neutral position and they will also be stressed less and later during movement and stretching positions. This mechanism works within a split a second, as fast as the Golgi organs and interstitial receptors transmit the stimulation.

Accordingly, after applying the tape and creating a myofascial release, the restriction in ROM and pain will decrease significantly, which is the reason why Myofascial Taping is so popular in elite sports. The effect is www.sportEX.net

maintained during every movement, even preventing further injury.

MYofascial rElEasE for fascia with MicroinjuriEs The procedure and taping application for fascial structures with micro-injuries is the same as with non-injured fascia, but the tissue-shift will not only be at the point of muscle insertion affecting the Golgi organs but will also continue to the painful spot – the micro-injuries – and possibly even 2–3cm further.

Again, the tissue is shifted towards the micro-injuries, so mechanically offloading the myofascial tension from the muscle insertion (Golgi) to the injury. The torn fibres are offloaded,

like closing a gap by shifting the sides together (Fig. 3).

By mechanically offloading myofascial tension and reducing the myofascial tension via the Golgi organs (neuronal pathway), the myofascial tension will be reduced and normalised immediately. Due to the normalised tension the myofascial system works efficiently again, and the most important effects are significantly reduced pain, increased (normalised) ROM, restored muscle function with improved movement patterns, and increased maximum muscle force.

Please note that the direction of shifting of the fascia can vary. It depends on several parameters that need to be determined from specific fascia diagnostics.

Beginners should stick to one rule: never shift or pull fascia away from the pain or an injured fascial structure! If fascia is pulled away from the place where micro-injuries are present, the receptors will be stressed more and will increase nociceptive signals (eg. pain).

MYofascialtapE®: an iMportant factor The effects of Myofascial Taping can only be achieved using a tape with a very strong adhesive (as a lot of stretch is used on the tape) and a lower recoil effect (to allow fascia to be shifted in the direction it is pulled) than kinesiology tapes. Flexotape® or MyofascialTape® has been specifically developed for Myofascial Taping to give optimal myofascial release (Fig. 4).

Part 2: the PraCtiCe MYofascial taping: diagnostics and taping applications

Figure 4: Flexotape® – MyofascialTape® – is a self-adhesive and elastic tape, designed for Myofascial Taping.

Flexotape® has properties similar to kinesio tape but has a much stronger adhesive and allows fascia to be shifted in the same direction as the tape is pulled. Flexotape® is latex-free, made from 100% high quality cotton, and is water resistant.

Myofascial Taping works reliably and therefore can be used not only for treatment but also as a powerful diagnostic tool. In practice, the most meaningful parameters are pain and ROM. If someone has restricted ROM and pain, due to a high myofascial tension at a certain spot, the ROM will increase and the pain will decrease immediately after a myofascial release treatment.

Using ROM and the visual analogue scale (VAS) (where 0 = no pain and 21

MyOFASCIAL PAIn SynDROMES ARE THE RESULT OF MyOFASCIAL TEnSIOn

10 = maximum pain) to measure the effectiveness of each single tape application is effective and efficient. ROM and pain are most often interdependent, but they don’t necessarily need to be present at the same time. Hence, even if someone has no pain, Myofascial Taping will increase the ROM if the myofascial tension has been higher than normal.

gEnEral procEdurE for applYing MYofascialtapE The procedure for applying Myofascial Tape follows a certain series of steps: 1. A preliminary test of ROM and pain levels 2. Position the patient and the treatment area 3. Tape application 4. Check the tape application 5. Re-test ROM and pain levels.

Figure 5: Position the patient and the treatment area.

When using myofascial release to treat non-specific LBP, it is useful to apply the tape to two areas: the thoracolumbar fascia/erector spinae as well as the hamstrings and associated fascia – as detailed below.

MYofascial rElEasE for thE thoracoluMBar fascia/ErEctor spinaE preliminary test of roM and pain

Figure 7: Tape application. The tape is stretched and applied to the skin using the left hand to actively help move skin and fascia upwards.

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check the tape application you should be able to see a distinct difference in density of the tape with less density at the part where the tape is under tension. If the tape has not been stretched enough, no myofascial release effect will be created.

Let the patient bend over to stretch the muscle, fascia and skin of the affected structure as far as possible (as far as it is pain free) (Fig. 5).

If the patient cannot go into the stretched position without pain in standing, bring him/her into a position where his/her lumbar fascia is fairly stretched but supported, such as sitting on a chair and stretching the lumbar fascia as much as possible.

Tissue mechanics and effects The fascia is now shifted upwards in a caudal to cranial direction (along the fibre direction of the superficial back line), which facilitates the stretched position, offloads the micro-injuries mechanically and stimulates the Golgi organs to reduce muscle tension neurologically. The myofascial tension in the thoracolumbar fascia and its connected tissue is reduced, resulting in is less or no nociceptive signalling in rest as well as in motion, and increased (restored) range of motion (Fig. 8). The rest of the tape should be applied without any stretch-creating wrinkles (functional fascia lift) that would cause the Pacini receptors to increase the myofascial control or amplify it, respectively.

tape application

re-test roM and pain

Cut an i-stripe of approximately 20– 25cm. Align the tape in the direction of the erector spinae. Start 15cm below

Immediately after the tape application, re-test ROM and pain levels. re-test roM Measure how far the

test roM Measure how far the patient can bend over. test pain Assess how much pain is perceived in standing position and in stretched position (VAS).

Figure 6: Tape application. The first 5cm are used to fix the tape in place and are applied with no stretch.

the painful spot (micro-injuries) or at the posterior superior iliac spine (PSIS) if no painful spot (micro-injuries) is present. The first 5cm are used for a good fixation of the tape and are applied without any stretch. The lower hand is the fixing anchor. now shift the skin and fascia upwards by pulling the tape upwards with the upper hand and stretching the tape 100% (Fig. 6).

The left hand reinforces the upward shift by actively helping to shift the skin and fascia upwards. Hold the stretch of the tape and apply it to the skin (Fig. 7).

The stretch should end some 2–3cm higher than the painful spot. The rest of the tape should be applied without any stretch. now rub the tape to activate the acrylic adhesive for 5–10 seconds, before the patient comes back into normal position. Pay attention to the ends of the tape, not rubbing them off.

Apply the same technique to the other side of the thoracolumbar fascia and erector spinae.

position the patient and the treatment area

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Figure 8: The left picture (A) is without tape application. The right picture (B) is with tape application, shifting fascia from a caudal to cranial direction, offloading the injured facia and decreasing myofascial tension â&#x20AC;&#x201C; in rest and during movement. [Adapted from Myers (4)]

patient can bend over (stretch). re-test pain Assess how much pain is perceived in standing position and in stretched position (VAS).

MYofascial rElEasE for thE haMstrings and connEctEd fascia As described above, the hamstrings are closely connected to the lumbar fascia and release is often needed here to reduce myofascial tension that is transferred to the lumbar fascia.

Shifting the fascia at the intermuscular septum brings a great effect to the hamstrings and connected fascia with the same effects on the Golgi organs and interstitial receptors.

positioning of the patient and the treatment area As described above for myofascial release of the thoracolumbar area.

are applied without any stretch, and the lower hand is used to do this. now shift the skin and fascia upwards by pulling the tape upwards with the upper hand and stretch the tape 100% (Fig. 9). The lower hand reinforces the upward shift by actively using the hand to shift the skin and fascia upwards.

Hold the stretch on the tape and apply it to the skin. The stretch should end at the ischial tuberal area. The rest of the tape should be applied without any stretch (Fig. 10). now rub the tape to activate the acrylic adhesive for 5â&#x20AC;&#x201C;10 seconds before the patient comes back into normal position. Apply the same technique to the other side of the hamstrings.

MyOFASCIAL TAPInG COnTROLS MyOFASCIAL TEnSIOn AnD PAIn

Figure 9: Start the tape slightly caudal of the popliteal fossa.

check the tape application As described above for myofascial release of the thoracolumbar area.

re-test roM and pain tape application Measure and cut the length of the tape from popliteal fossa to the upper third of the thigh.

The start of the tape has to be aligned in the projection of the intermuscular septum of the hamstrings, beginning slightly caudal of the popliteal fossa. The first 5cm are used as a good anchor of the tape and www.sportEX.net

Immediately after the tape application, re-test ROM and pain levels, as described above for myofascial release of the thoracolumbar area.

Greater differences seen in ROM and pain from before to after tape application indicate higher levels of tension causing the problems, and larger effects of the tape.

Figure 10: Stretch and hold the tape, applying it to the skin ending at the ischio tuberal area.

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long-tErM EffEct The effects of the Myofascial Taping techniques are achieved instantly.

The longer patients wear the tape, the greater the long-term effect through lengthening of the tissue (19).

In practice, the tape is left on for 5 days on average, and then the skin should get a rest for 1 or 2 days. If this procedure is repeated for 2 to 3 times a long-term effect for many myofascial pain syndromes is created so that the patients need no further taping or other treatment.

suMMarY My Myofascial Taping method was developed only a few years ago in 2006, but is receiving more and more attention. It is one of the quickest and most reliable ways to relieve patients from acute and especially chronic myofascial pain syndromes, and it has great potential for reducing treatment and rehabilitation times as well as for saving time and money on unnecessary long treatments, surgery and suffering. Although it is totally different, many people still confuse it with kinesio taping, and as yet little scientific research has been published.

The Physio Training Academy and I have run and supervised over 100 studies and research projects that will be published soon, showing that Myofascial Taping has highly significant effects on relieving pain, increasing ROM, maximum muscle force and proprioception.

References 1. Vleeming A, et al. 2010. proceedings of the 7th interdisciplinary World congress on low Back & pelvic pain. los angeles 2010 2. Panjabi MM. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. European spine Journal 2006;15(5):668–676 3. Erhard M, Braun J. Myofascial taping – pain reduction in subacromial impingement syndrome. 2009 (unpublished) 4. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists, 2nd edn. churchill livingston 2009.

ISBn 044310283X (£37.79). Buy from Amazon http://spxj.nl/1eA7ekM 5. Hiijing PA. Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. Journal of Electromyography and Kinesiology 24

2007;17(6):708–724 6. Franklyn-Miller A, Falvey, et al. 2009.

The strain pattern of the deep fascia of the lower limb. fascia congress 2009; www.fasciacongress.org/2009 7. Stecco A, Macchi V, et al. Pectoral and femoral fasciae: common aspects and regional specializations. surgical and radiologic anatomy 2009;31:35-42 8. Van der Wal J. The architecture of the connective tissue in the musculoskeletal system: an often overlooked functional parameter as to proprioception in the locomotor apparatus. In: Hijing PA, et al. (eds) Fascia research II: Basic science and implications for conventional and complementary health care. Elsevier 2009.

ISBn 3437550225 9. Erhard M. Improved proprioception and balance by myofascial taping. 2007 (unpublished) 10. Erhard M, Bauer R. Can myofascial taping increase sprinting performance? 2011 (unpublished) 11. Schleip R. Fascial plasticity – a new neurobiological explanation: part 1. Journal of Bodywork and Movement Therapies 2003;7(1):11–19 12. Balagué F. non-specific low back pain.

The lancet 2012;379(9814):482–491 13. Jensen MC, Brant-Zawadzki Mn, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. new England Journal of Medicine 1994;331(2):69–73 14. Sheehan nJ. Magnetic resonance imaging for low back pain: indications and limitations. annals of the rheumatic diseases 2010;69(1):7–11 15. yahia LH, Pigeon P, DesRosiers EA. Viscoelastic properties of the human lumbodorsal fascia. Journal of Biomedical Engineering 1993;15, 425-429 16. Stecco C, Porzionato A, et al. Histological study of the deep fasciae of the limbs.

Journal of Bodywork and Movement Therapies 2008;12(3):225-230 17. Schleip R, Vleeming A, et al. Letter to the editor concerning “A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction” (M. Panjabi). European spine Journal 2007;16(10):1733–1735 18. Langevin HM, Stevens-Tuttle D, et al.

Ultrasound evidence of altered lumbar connective tissue structurein human subjects with chronic low back pain. BMc Musculoskeletal disorders 2009;10:151 19. Ingber D. The architecture of life. scientific american 1998;78:48–57 20. Chen CS, Mrksich M, et al. Geometric control of cell life and death. science 1997;276(5317);1425–1428 21. Iatridis J, Wu J, et al. 2003.

Subcutaneous tissue mechanical behaviour is linear and viscoelastic under uniaxial tension. connective Tissue research 2003;44(5):208–217 22. Desmoulière A, Chapponier C, Gabbiani G. 2005. Tissue repair, contraction, and the myofibroblast. Wound repair and

regeneration 13(1):7–12 23. Grinnell F, Petroll W. Cell motility and mechanics in three-dimensional collagen matrices. annual review of cell and developmental Biology 2010;26:335–361 24. Hijing PA, Langevin H. Communicating about fascia: History, pitfalls and recommendations. In: Hijing PA, et al. (eds) Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Elsevier 2009.

ISBn: 3437550225.

furthEr rEsourcEs 1. Markus Erhard’s Physio Training Academy website (www.physiotrainingacademy.com) 2. Flexotape® website (www.flexotape.com) 3. Anatomy Trains by Kinesis UK website: dedicated to providing the highest quality training and materials for manual and movement therapists (www.anatomytrains.co.uk).

ThE AuThoR Th Markus Erhard invented the Myofascial Taping method in 2006. he has a Bachelor of Arts and State Exam in Sports Science and English Language and Literature. he is the founder and director of the Physio Training Academy, which specialises in myofascial therapies, and is a cofounder of flexotape® and MyofascialTape®.

Markus and his team have run over 500 Myofascial Taping courses for physiotherapists, osteopaths, chiropractors, medical doctors, trainers, sport scientists, etc, from all over the world. Certified practitioners include therapists and medical doctors in the NhS as well as elite sports and many national teams. Markus is a member of the Anatomy Trains Development Group and now specialises in development and teaching – particularly Myofascial Taping, which has become a revolutionary method for reliable pain relief from acute and chronic myofascial pain syndromes and for enhanced sporting performance. Markus invests a lot of time in Myofascial Taping research, supervising many studies and research projects (including doing his PhD in physiotherapy).

DISCUSSIONS

n Which receptors should be influenced by the myofascial release technique (MRT) in order to normalise myofascial tension and why? n Which factors affect myofascial tension? n Why is fascia so important in myofascial pain syndromes?

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modErn-day bikEfitting can offEr proactivE thErapists nEw opportunitiEs By niCK DinsDale BsC, MsC, Msst; niCola DinsDale BsC, Msst

CyCling in the UK the growing demand in cycling UK cycling has undergone a renaissance over the last 5 years.

Cycling is a fully inclusive activity, involving all ages, abilities and disabilities – from recreational to competition, including health and rehabilitation aspects. The UK Government and various campaign groups (Health, Environmental, and Sport England) have, and continue to invigorate cycling as a viable travel option and promote its now widely recognised health and environmental benefits (Further resources 1). Referring to 2012 statistics, British Cycling’s Chief Executive, Ian Drake, stated, “Cycling in this country has never been in better health – with sustained growth” (Further resources 2). UK bike sales for 2012 grew by approximately 8% on 2011 sales and are worth an estimated £700million. Crucially, the growing popularity in cycling for recreational, health and competitive purposes has fuelled a growing demand for bikes, which in turn, has created a www.sportEX.net

With the recent successes of British Cycling and Triathlon, cycling is on the increase in the UK. However, traditional, simple bikefits have been performed by cycle mechanics primarily delivered from a mechanical perspective – with, alas, varying degrees of success. This article explores the potential role of the proactive therapist in the rapidly growing bikefit market, where correct bikefitting can result in the dual benefits of enhanced performance and reduced injury. growing number of people wanting to be properly fitted to a bicycle. As a result, therapists have an opportunity to contribute towards enhancing professional bikefitting services to meet the ever-increasing expectations of the modern-day athlete.

the many benefits of cycling The benefits of cycling are now widely recognised, with increased participation bringing broad socio-economic, health and environmental benefits to the UK. According to Dr Adrian Davis, a public health and transport expert, every £1 spent on cycling initiatives could produce a £4 saving to the NHS (Further resources 3). Regular cycling can help in the prevention and treatment of many common diseases associated with obesity and sedentary

Key Point 1 Modern-day bikefitting can offer therapists new and exciting opportunities in a rapidly growing niche market.

THE BENEFITS oF CyClING ARE NoW WIDEly RECoGNISED, WITH INCREASED pARTICIpATIoN BRINGING BRoAD SoCIoECoNomIC, HEAlTH AND ENvIRoNmENTAl BENEFITS To THE UK 25

lifestyles. According to the British medical Association, “Cycling just 20 miles a week can reduce the risk of coronary heart disease by 50%” (Further resources 4). Furthermore, cycling now has an important role to play in rehabilitation following heart surgery and joint replacement.

From an environmental perspective, greater numbers of people using bicycles instead of other modes of transport would lead to lower carbon monoxide emissions, less noise, slower depletion of fossil fuels and reduced investment in roads and railways.

According to the European Cyclists Federation’s Health and Environment policy officer Benoit Blondel (Further resources 5): “Cycling is the wonder drug of the transport world. It provides solutions to so many problems and unlike most forms of transport; it has lots of positive side effects. People riding bicycles make no noise, emit no air pollutants or greenhouse gases, and they ease traffic congestion. The real benefit is improved health, the more people cycle, the healthier they all become. This means that cyclists don’t just ease congested streets, but they ease congested health systems.”

Key Point 2 traditional bikefitting is delivered from a mechanical perspective and often fails to consider musculoskeletal deficits frequently found in cyclists.

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BiKefitting the traditional bikefit A traditional (basic) bikefit represents the necessary mechanical adjustment to the saddle and handlebars, usually delivered as a generic-fit and performed by a cycling mechanic and/or technician – with varying degrees of success. Alas, although the bike gets attention in abundance, little consideration is afforded to the musculoskeletal deficits and frailties of the rider (video 1)(1). The authors believe this mechanical approach has serious limitations, is somewhat outdated, and often fails to fulfil the modern-day athletes’ growing expectations, especially athletes in search of those elusive marginal-gains.

online

Bikefitting should be disciplinespecific Just as modern cycles are designed to be discipline-specific, riding position (bikefit) should be discipline-specific to meet the different challenges (2).

Generally speaking, the faster and more efficient the athlete wants to ride for a given discipline or a given terrain, the more crucial the correct cycle design and correct riding position becomes. Therefore, the correct combination of cycle design and riding position (marriage-of-harmony) is prerequisite to the delivery of marginal performance gains and lower incidence of overuse injury.

Although each discipline has its

if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access.

youtube video Video 1: Traditional (basic) bikefit.

Courtesy of Youtube user Masherzinc http://spxj.nl/17Xb71C sportEX dynamics 2014;39(January):25-32

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own bike set-up parameters, most disciplines (eg. road time-trialling, road cycling, cyclo-cross, sportive and mountain-biking) can be categorised into one of three riding positions (Fig. 1). Road time-trial and triathletes tend to ride in a forward, low aggressive aerodynamic position to minimise aerodynamic drag (Fig. 1, black image) (2). This position increases lumbar flexion placing increased stress on intevertebral discs – and demands high levels of spinal flexibility and pelvic, core and lumbar stability (3).

A key determinant in performance is acquiring the optimal hip angle which is fundamental to aerodynamics and power-output. At the other extreme, mountain-bikers and recreational riders tend to ride in a more upright position (vertical trunk) and sit further back towards the rear-wheel (Fig. 1, blue image). Although less aerodynamic, which is less of a priority, this position enables greater power-output, more traction and improved stability and handling characteristics. most of the other disciplines fall somewhere between (Fig. 1, red image). This intermediate position provides a balance between aerodynamics, power-output and handling (video 2). musculoskeletal screening and specific rehab and performance enhancing strategies have a crucial role in preparing the rider for specific demands (flexibility and strength) – especially time-trialists and triathletes.

Key Point 3 for optimal benefits, bikefitting should be discipline-specific, rather than generic. Consequently, the therapist has a crucial role in preparing the rider to meet the specific demands.

Dual opportunity Health-care professionals, sports scientists, coaches and athletes often view sports medicine and sports science as separate entities – a monodisciplinary approach. When bikefitting, therapists, coaches and athletes alike should pursue an integrative multidisciplinary or multifactorial approach www.sportEX.net

Figure 1: Different cycling disciplines use different riding positions. Black image, the position used by road time-trialists and triathletes; blue image, the position used by mountain-bikers and recreational cyclists; red, the position used by most other cyclists.

BIKE SET-Up IS pARAmoUNT To EFFICIENT CyClING ACTIoN AND IS A mAJoR FACToR IN BIKE-RElATED ovERUSE INJURIES and seek every opportunity to optimise the potential dual benefits of sports science and sports medicine (4).

Solutions in sport science often yield solutions in sports medicine with corresponding or associated benefits and vice versa. Refer to the practical examples of knee problems and leglength differences in the ‘Evidence base’ section.

Key Point 4 opportunities and associated dual benefits should be sought and achieved through common solutions (interventions).

Rationale Traditional bikefitting is a concept; it is part art, part experience and little science. As highlighted, traditional bikefitting is usually performed by cycle mechanics or technicians delivered from a mechanical perspective – with limited science. The authors have found that an integrative or multifactorial approach, ie. a Bikefit-package with three integrated components, to be more effective, more science driven (evidence-based) and more rewarding.

Consequently, the therapist has a major role to play: two of the three integrated components pre-Bikefit musculoskeletal Screening and personalised Rehabilitation & performance Enhancing plan are therapist-dependent while adding science to a process in need of change.

Burke and pruitt suggest that “safe, efficient, injury free cycling relies on a perfect marriage-of-harmony between man-and-machine” (5). However, a

online if you have a current subscription, login at www. sportex.net to view this video or download the mobile apps which are free to subscribers with online access. youtube video Video 2: Discipline-specific riding position (road vs triathlon). Courtesy of Daily Motion user Johncobbbikeguy http://spxj.nl/17yQkwH

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perfect marriage-of-harmony relies on rider symmetry throughout the pedal revolution. Symmetry represents a stable, level pelvis, with minimal pelvic motion throughout the frontal, transverse and sagittal planes (6).

Thus, strength and balance in the muscles situated in and around the pelvis are a pre-requisite to efficient

cycling, whether road, time-trialling or mountain-biking. Furthermore, sagittal plane deviation of the knees should be minimal (varus and valgus movement).

Excessive aberrant deviation of the knee means the knee must travel further than is necessary through each pedal revolution. This extra, but unwanted knee motion constitutes wasted energy and is potentially destructive on structures of the kineticchain. The shoe–pedal interface is the mechanical link between the leg and the cycle and consequently the point at which asymmetry arises, usually as a result of forefoot and lowerlimb misalignment (excessive foot pronation).

Key Point 5 Delivery of a perfect ‘marriage-ofharmony’ through an integrative or multifactorial approach, ie. the Bikefit-Package, is heavily dependent on the therapist.

Figure 2: Pre-Bikefit Musculoskeletal Screening and the personalised Rehabilitation & Performance Enhancing Plan (two of the three components of the Bikefit-Package) are therapist-dependent.

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Beneficiaries Cyclists of all ages and abilities can potentially benefit from preBikefit musculoskeletal Screening and the subsequent personalised Rehabilitation & performance Enhancing plan. The vast majority of cyclists have forefoot and lower-limb misalignment which can lead to overuse injury and loss of performance. older cyclists are more likely to have a history of trauma, eg. back injuries, muscle imbalance, degenerative joints, lower-limb factures, hip and knee replacements, etc. lower-limb fractures and hip replacements frequently affect leg lengths and limb alignment, which in turn, disrupt normal pedalling biomechanics.

Conversely, competitive cyclists and triathletes have the opportunity to acquire those elusive marginal-gains in performance that may mean the difference between winning or losing – or simply achieving a personal best (pB).

THE vAST mAJoRITy oF CyClISTS HAvE FoREFooT AND loWERlImB mISAlIGNmENT WHICH CAN lEAD To ovERUSE INJURy AND loSS oF pERFoRmANCE. olDER CyClISTS ARE moRE lIKEly To HAvE HISToRy oF TRAUmA sportEX dynamics 2014;39(January):25-32

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(b)

(a) Figure 3: The shoe–pedal interface is a crucial part of the bikefit process. The shoe clips into the pedal (a) through a cleat and wedge system (b).

Key Point 6 Most cyclists, regardless of age or ability would benefit from PreBikefit Musculoskeletal screening and the subsequent personalised rehabilitation plan – as part of the Bikefit process.

Modern carbon equipment exacerbates forefoot problems It’s highly likely that modern advancements in technology exacerbate forefoot problems. Carbon frames, wheels, cranks, pedals and shoes have all become significantly stronger and stiffer while the human foot remains unchanged. Jarboe and Quesda demonstrated that carbon-fibre shoes are 42% stiffer in longitudinal bending and 550% stiffer in three-point bending compared with plastic cycling shoes (7). The combination of rapid technological advancements in carbon components and ever-increasing levels of fitness enable the rider to transfer more power to the pedal, thus placing greater pressure on the structures of the foot. Increased forefoot pressures cause forefoot problems and cause the foot to collapse inwardly, which in turn increases pronation (3).

eviDenCe Base Bike set-up is paramount to efficient www.sportEX.net

cycling action and is a major factor in bike-related overuse injuries (8). The shoe–pedal interface, often referred to as the ‘cornerstone’ of effective bikefit is the mechanical link between the leg and the cycle (Fig. 3). Consequently, the shoe–pedal interface dictates how efficiently pedal forces (power) are transferred down the pedal cranks, and potentially, how efficiently deleterious forces are dissipated at source rather than ascending the kineticchain – adversely impacting on the knee, hip, pelvis, etc. (1). During one hour of cycling, a rider may average up to 5,000 pedal revolutions. The smallest amount of misalignment (creating incorrect foot positioning), whether anatomic, biomechanical or mechanically related, can lead to injury (9) and reduced performance (10). moreover, research suggests that the vast majority of cyclists have forefoot misalignment (11). Crucial to therapists, appropriate corrections at the shoe– pedal interface can offer dual benefits (ie. reduced injury and improved performance).

DURING oNE HoUR oF CyClING, A RIDER mAy AvERAGE Up To 5,000 pEDAl REvolUTIoNS. THE SmAllEST AmoUNT oF mISAlIGNmENT (CREATING INCoRRECT FooT poSITIoNING), WHETHER ANATomIC, BIomECHANICAl oR mECHANICAlly RElATED, CAN lEAD To INJURy AND REDUCED pERFoRmANCE

Knee problems Knee pain is amongst the most common overuse problem in cyclists, affecting an estimated 40 to 60% of riders – recreational and elite (12). patellofemoral joint pain (pFJ) is so common in cycling that it has been 29

labelled ‘biker’s knee’ or ‘cyclist’s knee’.

Reasons for the high incidence of pFJ include: high forces generated on joint surfaces during knee flexion (13); abnormal patella tracking caused by structural variations of the lower-limb and foot (14); incorrect foot positioning (9), which can result in abnormal wearing on the posterior surface of the patella (15), exacerbated by lack of pedal float (16); and incorrect saddle position – too low or incorrect setback (17). These incorrect saddle positions result in excessive flexion of the knee, leading to excessive pressure across the pFJ, with a more perpendicular vector force across the joint (13).

Iliotibial band (ITB) problems are common in cycling. The ITB tissue becomes irritated due to friction, typically when the knee is at approximately 30° extension. The literature suggests the main causative factors include: anatomical abnormalities of the lower-limb and foot (which cause excessive foot pronation); varus and valgus knee positions; leg-length differences; incorrect cleat positioning; incorrect saddle position; high training loads; and muscle imbalance, eg. tight

~150o ~30o

Figure 4: Saddle position should result in a knee angle of approximately 30°.

Key Point 7 the shoe–pedal interface and the lumbo/pelvic/core region arguably represent the two key areas that require most attention throughout the bikefit process.

online

if you have a current subscription, login at www.sportex.net to view this video or download the mobile apps which are free to subscribers with online access.

youtube video Video 3: Setting optimal saddle height and setback for road.

Courtesy of Youtube user Art’s Cyclery http://spxj. nl/1etmm9t 30

Figure 5: The correct knee angle can be set using a long-arm goniometer.

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EvidEncE informEd practicE

THE RApIDly GRoWING mARKET oF BIKEFITTING oFFERS NEW oppoRTUNITIES FoR THE THERApIST. A moDERN-DAy BIKEFIT SHoUlD BE DISCIplINE-SpECIFIC, SHoUlD STRIvE FoR pERFECT HARmoNy BETWEEN mAN-ANDmACHINE – WHIlE DElIvERING DUAl BENEFITS gluteus maximus and tensor fascia lata (TFl) muscle (12,13,18).

leg-length differences Cyclists should be assessed for leg-length difference (llD), especially where a history of trauma exists (lower-limb fractures and/ or hip and knee replacements) (6).

It is recommended that a battery of suitable tests be used to establish if llD exists, and thereafter, to differentiate between anatomical (actual) and functional (apparent) llD (19). Studies have demonstrated the prevalence of anatomical llD to be about 90% of the population, although the mean magnitude is small and not likely to be clinically significant (20,21).

saddle height Saddle height is arguably the most important and fundamental cyclerelated adjustment of all. A consensus within the research literature clearly demonstrates that saddle height is critical for optimal performance and injury prevention (5,12,13,17).

Although the traditional saddle height that creates 25° to 35° of knee angle is acceptable, recent studies demonstrate that a saddle height resulting in 25° to 30° of knee angle would appear to be the ideal range for cycling injury prevention and both aerobic and anaerobic performance (22–25). Thus, setting correct saddle height represents a practical example to acquire dual benefits. The knee angle can be set using a long-arm goniometer (or extendable goniometer) placed on the greater trochanter and lateral malleolus (Figs 4, 5; video 3).

PRaCtiCal oBseRvations anD Key Points Cyclists with pelvic imbalances, weak core/pelvic musculature and/or llDs www.sportEX.net

often sit twisted on the saddle as observed from behind. Riders whose knees move inwards towards the top-tube during the pedal down-stroke usually present with excessive foot pronation. If a rider’s foot rotates outwards (abducts or toe-out) during the down-stroke of intense pedal loading – excessive pronation is often the culprit. Uneven saddle wear or saddle distortion depicts abnormal loading (asymmetry) – possibly owing to unilateral foot pronation or llD. Incorrect foot position (shoe–pedal interface) and incorrect saddle height are considered to be the main contributing factors in overuse knee injury and loss in performance.

ConClUsion The rapidly growing market of bikefitting offers new opportunities for the therapist. A modern-day bikefit should be discipline-specific, should strive for perfect harmony between man-and-machine – while delivering dual benefits. This necessitates an integrated approach, inclusive of appropriate musculoskeletal screening, rehabilitation and performance enhancing strategies designed to enhance a bikefit process that is in need of change. Crucially, these proposed changes are dependent on the therapist.

References 1. Dinsdale NJ. musculoskeletal screening of competitive cyclists. the Journal of cycle coaching 2012;4:20–21 2. Bini RR, Hume pA, Croft J. Cyclists and triathletes have different body positions on the bicycle. European Journal of sports science 2012;doi:10.1080/17461391.2011.

654269 3. Hannaford Dpm, moran GT, Hlavac Dpm. video analysis and treatment of overuse knee injury in cycling: a limited clinical study. clinics in podiatric medicine and surgery 1986;3(4), 671–678 4. Whiting WC, Zernicke RF. Biomechanics

of musculoskeletal injury, pp.1–16, 2nd edn. human kinetics 2008. ISBN 0736054421 (£47.99). Buy from Amazon http://spxj.nl/1b0Exfs 5. Burke ER, pruitt Al. Body position for cycling. In: Burke ER (ed.) High-Tech cycling, pp.69–92, 2nd edn. human kinetics 2003.

ISBN 0736045074 (£16.99). Buy from Amazon http://spxj.nl/1gkUNto 6. Dinsdale NJ, Dinsdale NJ (miss). The benefits of anatomical and biomechanical screening of competitive cyclists. sportEX dynamics 2011;28:17–20 . Jarboe NE, Quesada pm. The effects of cycling shoe stiffness on forefoot pressure. foot & ankle international 2003;24(7):784–788 8. mcHardy A, pollard H, Fernandez m. Triathlon injuries: A review of the literature and discussion of potential injury mechanisms. clinical chiropractic 2006;9:129–138 9. Berry A, phillips N, Sparkes v. Effect of inversion and eversion of the foot at the Shoe/pedal interface on quadriceps muscle activity, knee angle and knee displacement in cycling. Journal of bone and Joint surgery (british volume) 2012;94-b(supp XXXvi):61 10. Dinsdale NJ, Williams AG. Can forefoot varus wedges enhance anaerobic cycling performance in untrained males with forefoot varus? Journal of sport scientific and practical aspects 2010;7(2):5–10 11. Garbalosa JC, mcClure mH, et al. The frontal plane relationship of the forefoot to the rearfoot in an asymptomatic population.

Journal of orthopaedic and sports physical therapy 1994;20:200–206 12. Wanich T, Hodgkins C, et al. Cycling injuries of the lower extremity. Journal of the american academy of orthopaedic surgeons 2007;15:748–756 13. Callaghan mJ. lower body problems and injury in cycling. Journal of bodywork and movement therapies, 2005;9:226–236 14. Ruby p, Hull ml, et al. The effect of lower-limb anatomy on knee loads during seated cycling. Journal of biomechanics 1992;17(2):1195–1207 15. Apt Jp, Smoliga Jm, et al. Relationship between cycling mechanics and core stability. Journal of strength and conditioning research 2007;21(4):1300– 1304 16. Boyd T, Neptune RR, Hull ml. pedal and knee loads using a multi-degree-of-freedom pedal platform in cycling. Journal of biomechanics 1997;30:505–511 31

17. Holmes JC, pruitt Al, Whalen NJ. lower extremity overuse in bicycling. clinics in sports medicine 1994;13(1):187–203 Farrell KC, Reisinger KD, Tillman mD. Force and repetition in cycling: possible implication for iliotibial band friction syndrome. the knee 2003;10:103–109 19. Brady RJ, Dean JB, et al. limb length inequality: clinical implications for assessment and intervention. Journal of orthopaedic and sports physical therapy 2003;33:221–234 20. Knutson GA. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. part I: anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. chiropractic and osteopathy 2005;13:11 21. Knutson GA. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. part II: the functional or unloaded leg-length asymmetry. chiropractic & osteopathy 2005;13;12 22. peveler WW, pounders J, Bishop p.

Effects of saddle height on anaerobic power production in cycling. Journal of strength & conditioning research 2007;21(4):1023–1027 23. peveler WW. Effects of saddle height on economy in cycling. Journal of strength & conditioning research 2008;22(4):1355– 1359 24. peveler WW, Green Jm. Effects of saddle height on economy and anaerobic power in well-trained cyclists. Journal of strength & conditioning research 2001;25(3):629–633 25. Bini R, Hume pA, Croft Jl. Effects of bicycle saddle height on knee injury risk and cycling performance. sports medicine 2001;41(6):463–476.

Th AuThoRS ThE The father and daughter team, Nick and Nicola Dinsdale (both graduate sports therapists), run NJD Sports Injury Clinic. The clinic is recognised for its strong ‘evidence-based’ approach to the management of musculoskeletal conditions and involvement in cycling biomechanics. Arguably, the first to coin the phrase Pre-Bikefit Musculoskeletal Screening, they are now recognised as one of the uK’s leaders in bikefitting – through their unique Bikefit-Package. Nick has worked with GB cycling teams, his unique research into the shoe–pedal interface, acknowledged by Specialized uSA, has been disseminated worldwide. Nick delivers private workshops, presents at conferences (Cycling Biomechanics) and has served on the executive committee of the Society of Sports Therapists (SST). At his first attempt, Nick won the 2013 National Standard Distance Duathlon (Age Group 55–59) Title – putting theory into practice. Nicola won the prestigious Bruce hobbs Annual Travelling Scholarship in 2010, awarded by the SST. More recently she worked at the London at the olympics and Paralympics Games and is in the final year of her MSc on sports rehabilitation. Since its conception, Nicola has further enhanced the various bikefitting protocols and strategies to address sports-specific lumbo/pelvic/ core deficits, plus many more.

DISCUSSIONS

fURtheR ResoURCes 1. The British cycling economy: ‘gross cycling product’ report by A. Grous. london School of Economics 2011 (http://spxj.nl/1dCvf9j) 2. Sport England Active People survey reveals sharp increase in cycling participation. British Cycling 2012 (http://spxj.nl/1gkW0Bf) 3. Get Britain cycling: health benefits of cycling by S. Edward. BikeRadar blog 2013 (http://spxj.nl/17ymlXn) 4. Health benefits of cycling. The Guardian 2013 (http://spxj.nl/Iirtsm) 5. The cycling ‘calculator’: valuing the health benefits of cycling by B. Blondel.

European Cyclists’ Foundation 2013 (http://spxj.nl/18JJm3y) 6. The Bikefit-package (http://spxj.nl/17ymQKR) 7. Bikefit education (www.bikefit.com/) 32

n This article presents a real-life ‘concept’ with new exciting opportunities in bikefitting – moreover, it presents a concept that can be extrapolated and applied selectively to other individualistic sports. Which sport(s) other than cycling would you like to apply the concept to, and why? n What opportunities with associated dual benefits (ie. minimise injury and enhance performance) do you envisage in your chosen sport(s) – that could be potentially achieved through common solution(s)? n How would you go about developing and implementing a plan to: a. Develop suitable sports-specific strategies, such as (i) musculoskeletal screening and (ii) Rehab & performance Enhancing Strategies? b. Thereafter, promote and deliver your unique sports-specific service?

continuing education Multiple choice questions This article also has an elearning test which can be found under the elearning section of our website.

Tests from April 2013 onwards can be done on most digital devices.

1. login to our website, click the online Access button in the main menu bar and the go to the elearning section (you must be logged in).

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frEE

with a subscription that includEs onlinE accEss to this Journal. sportEX dynamics 2014;39(January):25-32

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Do you lecTure in sporTs MeDicine or Manual Therapy and would you be interested in promoting our new student subscriptions? Your students can be in further or higher education. If so, drop us an email to marketing@sportex.net we’re looking for people To help us eXpanD our range of clienT aDvice leafleTs. These can cover the topics of rehabilitation or sports medicine issues generally and are written for members of the public. We will be publishing these in the journals as well as in our ePALs booklet. If you’re interested in contributing to these leaflets drop me an email at tor@sportex. net giving me details about your qualifications and job role and any specific areas of interest which you would like to write leaflets on.

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We’ve launched a new product, The Best of Manual Therapy, but if you have a subscription to sportEX dynamics you can already access all the articles online. However, this new product is a cherry-pick of all our best manual therapy articles, is available through our app too and looks stunning! If you’d like to access the resource it’s normally £24.95 but because you already have a subscription that covers the articles, we’re giving you a £20 discount so you can purchase it for just £4.95 to cover the costs of delivering it in mobile format.

To purchase go to this link (http://spxj.nl/BOMT_discount) and enter the redemption (http://spxj.nl/BOMT_discount code BOMTdiscount (case sensitive) to pay just £4.95 for this resource. The code is valid until the 29th February 2014.

new

DATEs FOr 2014 n n n n n n

19th March – running 2014, Kettering, Northhants (www.professionalevents.co.uk) 29th March – ACPsEM Let’s Get Physical study Day, Bristol, UK (www.physiosinsport.org) 29th april – Golf 2014, Kettering, Northants (www.professionalevents.co.uk) 10-11 May - British Fascia symposium (http://www.fasciasymposium.co.uk/) 21st or the 28th June - sports Massage Association Conference, reading area, UK (TBC) 26-27 september – Therapy Expo, Manchester UK (www.therapyexpo.co.uk)

web watch ok so you know how we trawl the research journals every quarter and come up with our top picks to save you the time in not having to do it? well we thought it would be a good idea to do the same on that even bigger resource, the web, so here is our first effort at web watch! our goal with web watch is the same as with the rest of sporteX, to find resources that help save you time, money, or allow you to do more with less! www.sportEX.net

The Massage nerD aka ryan hoyMe We’ve been a fan of the Massage Nerd for a long time and have referenced a number of his YouTube videos in past articles. He has some great resources as you can see below: n youTube channel - http://spxj.nl/1991euW - he has over 42,000 subscribers and stacks of videos n facebook page - http://spxj.nl/1hmQ4ei - he has 17,000 likes n website page - http://spxj.nl/1ad2A7s where you can access over 10,000 free massage photos (must be credited), 4,000 massage test questions and 3,500 massage videos – well worth a visit n young Thumbs Blog - http://spxj.nl/1cbPH2a - which tackles all sorts of manual therapy subjects written by some excellent contributors who write in a very ‘easy to read’ style.

33

wriTing a Blue sTreak – smart and savvy marketing for massage therapists http://writingabluestreak.com/ run by a regular blogger on the Young Thumbs blog, Allissa Haines who describes herself as ‘ridiculously in love with massage’, blogs on how to market your massage therapy business. some good free resources on the website also.

Massage learning neTwork – A networking and learning community for massage therapists https://www.massagelearning.com/ The Massage Learning Network is a community for massage therapists focused on networking and learning. It’s a place for conversation and education by practitioners, thought leaders, and educators. Learn from some of the best presenters in the profession and ask questions to solicit help from your peers. (I found this site through Allissa who contributes to the network).

we weBsiTes you MighT finD useful Migh n world w Massage conference: http://spxj.nl/1hmUWQx – loads of recorded presentations from the 2013 virtual conference (some broadcasts are free, others request payment) soft Tissue Therapy: ns http://softtissuetherapy.com.au/– http://softtissuetherapy.com.au/ great site run by one of our editorial advisors and contributors, Australian soft tissue therapist Brad Hiskins.

Well worth a visit.

faceBook pages you May wanT To like n sports Massage Association: http://spxj.nl/IkEHEL n Associated Bodywork and Massage Professionals: http://spxj.nl/1goONAf n Anatomy Trains: http://spxj.nl/180EeTU

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And don’t forget to come and find us on the social networks too!

TweeTers you MighT wanT To follow @massagetherapy: reference library of MT research and other related practice resources sporteX note: We’re a bit short on these, can you recommend me any? Tweet me @sportexjournals

e? r a h s o wanT T n our Blog features weekly blog posts covering all sorts of issues facing sports medicine professionals – sometimes these are clinical, sometimes ssues that affect us as practitioners. Come and join the discussion at http://sportex.net/blog n TwiTTer – news from around the sports medicine globe https://twitter.com/sportexjournals n linkeDin sporTeX group – articles, events, discussions and free resources http://spxj.nl/linkedinwithsportex n flickr – we publish ALL the images we create for our journals under our Flickr account – for you to use in presentations and in your clinics http://flickr.com/sportex n faceBook – we do fun stuff on here mostly but you can also find our email newsletters and other useful sports medicine information http://www.facebook.com/sportEX.net 34

If you’ve got sites or people who you follow that disseminate useful info for manual therapists, please tell us about them.

If we publish them in the journal, we’ll give you £10 store credit to use on the sportEX website.

sportEX dynamics 2014;39(January):33-34

HAve you seen

ReseaRch Reviews

d don’t ignore the imPortance of the im theraPeutic alliance thera

Work-related injuries affect almost By josePh Brence Our regular research reviewer, physical therapist Joseph Brence, 500,000 individuals annually in the dPt, Pt, t comt, t, comt dac reviews research looking into (1) whether physical therapy can help United States. Over half of these cases are related to sprains, strains and The profound effect that clinical reduce depression in people suffering work-related injuries, and (2) other musculoskeletal pathology. In interactions have on our patients is the benefits of therapeutic bond between patient and therapist. addition, musculoskeletal injuries are often downplayed by the modern the leading cause for work-related clinician. We often attribute clinical disability and lost productivity, and success and outcomes to the tools estimated direct and indirect costs we use and how they improve mobility, y most heavil range from 45 to 215 billion dollars range of movement (ROM) or strength. and are of gait cycle often the point (1). Work-related injuries can lead to But how often do we consider the of the the is on force st length placed the development of chronic pain as effects that are elicited when we simply breaking their longe demands muscle. There (11,14). This lengthening forces well as changes in societal status interact with our patients? A recent of the s most activated as the reaction anical limits failure ground tring injurie and psychological variables such as article in Physical Therapy looked at scopic via its muscle of high the mech er hams of micro a result exceed fascia (TLF) cts the depression. Research has suggested this very notion and attempted to as to wheth accumulation (11). It seems muscle force as olumbar conne erableindividuals uncertainty result of the event the the thorac that one out of every determine if the interaction between considthree functionally upper torso a is some a single rmore, example, ments occur as as a result of and the bute. For of repeated who suffer from chronic pain alsoular attach physical therapist and patient (those (10,11). Furthe typically or ic spine musc may contri result damage, and lumbar-pelv extensive suffer from depression.

Research has with chronic low back pain) is predictive state that both damage as a the muscle to ver, rable howe trings levels s in scopic hams in a vulne atic event, also suggested that elevated over outcomes (1). feasible, of micro tissue tring injurie traum ulation muscle and of hams (6). of depression are associated with an anism The authors of this study designed accum a single mech running ry leave the that 70% [H1]Inju g, and s mayon injury during increased risk for a poor response to ted during high speed levels a retrospective observational study, repor of depression (measured The researchers were able to passin sprint ptible to turning, has been ction occur physical therapy and areIt associated which was nested in a randomiseda tric Beckcontra Depression Inventory of 14 g a ball (11). enrol 235 participants, although only twisting, more susce players sliding, kickin football force eccen elite with elevated levels of pain and stretching, clinical trial investigating the outcomes or higher) to and had to such state as that they 124 met the criteria for the initial of high with contributes presence phases likely were al the rest disability. of three common interventions notspeed being treated for depression n levels of depression. Out of sthese, prese18nt (13). The maxim injurie Minatio did not completestrain most jumping e and swing injuries during throughout from for chronic low back pain (CLBP) therapeutic alliance were associated of physical follow-up data outcomes of patient-specific function ing and ered the their courseexa the stanc hamstring tring pain resultfromg (3). withresults is considtherapy.are at during of hams (general exercises, spinal manipulative with greater improvements. Among were determined were measured on a Patient Specific the study History r playersthe thigh runnin swing phase tendon units high rates posterior socce theNovember Mostcompleted therapy and motor control exercises). all the clinical outcomes measured, The enrolled participants group of only 106. high Note:speed this ratio (124le Functional Scale (PFPS) and the global A paper published in the terminal tring muscle onseta of g. The of an audib sudden of comm a hams runnin rence most the onset The emphasis of this study was therapeutic alliance was most strongly self-report questionnaireswith at treatment having depression) is quite perceived effect of treatment was edition of the Journal of Orthopaedic occur action, of 235 gradual e, dous as ibe the hazar(2) specific a more descr ed sourc to investigate the effects of the associated with disability. onset, mid-treatment, andaafter consistent with other literature which measured on a Global Perceived Effect and Sports Physical Therapy a referr However, will often stive of Players They g sensa therapeutic alliance. The researchers Overall, this study reinforces the completing 7 weeks of treatment. hastion. indicatedsugge that approximately half pain Scale (GPE). Secondary outcomes of examined the effects of physical tring tearin d hams more be participants relatesought pop or , and the defined therapeutic alliance as ‘the concept that we are physical therapists. also completed a phone interview of the physical pain and disability were measured on therapy on depressive symptoms may back-who levels tring pain only termed the L5/S1conditions sense of collaboration, warmth and We need to remember that the way 1 year after treatment onset.hams The for musculoskeletal the Visual Analogue Scale (VAS) and in individuals with work-related rior thigh ially at commtherapyespec is poste the to spine co-morbidity support between the client and we interact with our patients can have patients rated pain intensity, or onwhat a of depression.

Roland–Morris Disability Questionnaire musculoskeletal injuries. lumbarhave acan refer pain ssment, (15).of The (SIJ) therapist’. They reported that there a profound effect on their recovery. We numeric pain scale; symptoms The outcomes of this study (RMDQ) respectively. Therapeutic The authors in this prospective the asse into iliac joints on sacro e are three main components to this must keep in mind that outcomes may depression, on a Beck Depression demonstrated that depressive alliance was lastly measured (baseline cohort study recruited patients ht insig evidenc concept, as defined by Bordin (2). First, be due to more than we think.

Inventory II; pain catastrophising, on symptoms resolved in 40% of patients at the 2nd visit) on the Working who ies,met the following criteria: available a detailed current soccer. After hamstring injurbetween the ages of 18 and 65; the therapist and patient agree upon a Pain Catastrophising Scale; fear of who entered into a physical therapy Alliance Theory of Change Inventory the on in the goals. Second, the therapist and references 1 movement, on a Tampa Scale for programme following a work-related (WATOCI) (3). update injuries mechanism for ence, clinicalhad sustained a work-related, www. ides an of hamstring 1. Ferraira PH, Ferraira ML, et al. The patient agree upon the interventions.

Kinesiophobia; and pain selfaccident. This outcome is not unusual The authors found that positive musculoskeletal neck or back injury login at the cal evid le prov Munich is therapeutic alliance between clinicians cription, Third, there is an affective bond efficacy, on the Pain Self-Efficacy because of the neurological measures of therapeutic alliance injury thattic, was in the subacute This artic and prognos al anatomy, and orted by clini lly the recent nos download with nt subs orand diag and patients predicts outcome in chronic is, a curre video between therapist and patient. As Questionnaire. The 1-year follow-up have hormonal changes that we knowcribe to rs were associated with improvements on for phase of recovery (3–12 weeks h is supp d. Fina low back pain. Physical Therapy , function diagnos view thisfree to subs if you occur et towith tion, whic demonstrate of communicati a physical therapist, I believe this phone interview determined the tex.n exercise. of outcomes in all three groups of since onset); were not currently emiology are The authors 2013;93:470–478 spor ty which the epid clinical examina practice, is concept, at face value, makes sense. patients’ return-to-work status and le apps individuals with CLBP. They actually working; were receiving benefits 2. Bordin ES. The generalizability of the ove clari e mobi furtherss.reported that a reduction in psychoanalytic concept of the working and theCompensation.

But do we always consider all three level of pain. The participantsonline acce depressive symptoms was related to determined that the therapeutic from Worker’s a detailed and innovativ ented to impr capsule alliance. Psychotherapy: Theory, nce joint The variables or do our opinions and beliefs completed a course of 7 a decrease in pain and disability at the alliance predicted all of the final participants also had to have em is pres purposes. the knee experie Research, and Practice 1979;16:252–260 ding to :For those who did not get in the way? And if we become weeks of physical therapy 1-year follow-up. clinical outcomes and higher levels of clinically relevant ation syst nostic 3. Horvath AO, Greenberg LS. Development sions exten 1; Video 1)(6). animation prog classific liTe raT expan (Fig. has too operative (ie. determine what is treatment interventions, get better, it appears that combined ure rev utic and meniscus ing therape medial best for the patient versus interacting which were not restricted elevated levels of depression and Th ThE auThor iew les spann t) musc allow with their goals and beliefs), what by the researchers (but pain catastrophising before treatment Joseph Brence (DPT, C CoMT, DaC) is a physical therapist and clinical researcher from that ion (2-join n BSc, McSP is in isolat biarticular attachments lower Functio exactly happens to outcomes? This all were consistent with predicted the persistence of depressive Pittsburgh, P Pa, uSa. he is also a fellowship candidate with Sports Medicine of atlanta, e Gill s femor multiple trings are pelvis and 1a: Bicep

BY WaYn reported group are The hams knee joint with is something that definitely something clinical practice guidelines in symptoms after treatment. Depressive G Ga, uSa. Joseph’s primary clinical interests involve a better understanding of the Figure hout the frequently ll and hamstring head throug is Y hip the on of the loG muscle group sional footba needs to be reflected on. the treatment of subacute symptoms post-treatment were also neuromatrix and determining how it applies to physical therapy practice. he is currently involved affect functi le activities ver, the BF short ed tring ePideMio ted that profes them to The participants in this study musculoskeletal injuries). predicted by a lack of improvement in in a wide range of clinical research projects investigating topics such as the effects of verbalising the hams injury in . The princip flexion. Howe only involv SM been repor Injury to common therefore the extremities and knee (1). It has s femoris (BF) is were randomised to one of three I applaud the researchers a combination of depressive symptoms of pain, the effects of mobilising versus manipulating the spine on body image perception and s most and flexion sion and to be the g 12% of all injurie knee in laterally the bicep knee joint hip exten interventional groups (182 total for this decision because it and pain self-efficacy at mid-treatment. validation of an instrument which will assess medical practitioners’ understanding of pain. the BF with the s affect only the embranosus can up onally, representin tring injurie whereas crosses tly made . Additi participants included). Each participant makes the outcomes of the the semim ayer squad Clinically, Joseph treats a wide range of painful conditions in multiple settings including complex hams the tibia, ing minan of flexion affect rotate 5% 83% in knee are predo the tibial (2). A 25-pl season, result n then attended twelve sessions over an study more clinically relevant regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the blog so what does medially 10% and ated by is ST can hamstrings seaso whereas osus, respectivelyle injuries each are innerv BF short head 8-week period, at which point several and helps maintain a level of www.forwardthinkingpt.com www.forwardthinkingpt.com. this mean? d and s the tibia. The club per of fibres and semitendin hamstring musc es missed per are misse ver, the rotate portion variables were measured. Primary external validity.

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(12). This part of while trings have how rior nt, originates The ST c swing hams flexion al best player, the player’s psychological malingering or poor adherence (9). and (5). the lish all the poste popliteal ligame strong topic rele ever we feel femur taken the termin phase SM to of the tape-rel e during has attributes would combine to potentially These behaviours can, therefore, delay the stance ior tibia, vance given it the obliqu The BF also the early journals extremely the super the tibia and the curr ated articles for spo during affect his skills execution and decision physical healing such as an athlete head. fibula linking of the rare fibular le l at rtEX (the last ent SM s condy to the making leading to a poor tackling not following advice and icing the So for eus longu Additionally, the time we decision to pub medicine read popularity of attaches to peron peo (6). the BF technique contributing to potential head injury or maintaining optimal loading. did lish ers, connections ankle and foot you thin ple with a fascial the of th double this was 2 yea the same artic we’ve injury.

Conversely an over motivated and k action subscri up, we’v you’ve read to the rs ago le in both There is consistent empirical frustrated athlete (if I do more means I ption, it e in Jan you’re addition published 8 before and evidence that would suggest support will recover faster) may delay physical measures of psychological response 2012). not to al pag for this model and the premise that healing by doing too much contributing to injury that may prove beneficial es for additional pag compensate going mad doubleif es in both high levels of life stress and anxiety to further damaging tissue in a fragile when working with injured athletes for the 16 subscri double journals contribute to sport injury. Maddison healing area. (eg. Re-injury Anxiety Inventory, Sport bers). (meanin

BY Simo and Prapavessis (5) conducted a study There is a clear continuum of Injury Anxiety Scale, and Sports Injury g 16 N Lack mSc, of 470 rugby players in New Zealand psychological response to sustaining Rehabilitation Adherence Scale). mcSP aN EXP and found significant relationships a sports injury ranging from mild to Stage-based approaches such and squat of thE LoratioN between low levels of social support, severe with some authors reporting as the Grief Response Model (11) ting. Altho within ugh PFP SurrouLitEraturE a wide high level of anxiety, ineffective coping frequent clinically meaningful have been applied to describe the is evide range particularly of nt iNtErvE NdiNg taP strategies and both injury rate and psychological distress, eating emotional transition through sports prevalent individuals, who are NtioNS iNg it is in Par younger physically severity. In a study using 48 Swedish disorders, use of banned ergogenic injury recovery. This model originates ticu persons active There to Pat Lar rEfwith (3). soccer players, Ivarsson and Johnson aids and even suicidal tendencies from individuals coming to terms with ErENcE the exac is a lack of PaiN ELLofEmor consensus t sourc (6) found that over 3 months the amongst injured athletes (9,10). When a diagnosis of terminal illness and e patella aL Patellofem maltrackin of pain, howe on players injured during this period working with injured athletes there suggests the stages of denial, anger, The idea of a holistic approach to sports injury prevention and ver, loading g result the most oral pain (PFP) patte ing in reported high baseline measures of is a necessity for the practitioner to bargaining, depression are ultimately is altere joint (PFJ) rns of the recovery is nothing new. This article provides a review of the complaintscommon musc one of patellofem d life stress, anxiety and ineffective be able to distinguish between the progressed through until acceptance uloskeletal with PFP is thought to oral orthopaed being prese be assoc (3). Proxi psychology of sports injury risk, response and recovery. It is hoped nted coping strategies compared with the ‘normal’ psychosocial responses to of the injury and a readiness to factors iated mal, distal and sport ic, general pract to have all and local non-injured players. According to the sports injury (eg. yellow flags) and embrace rehabilitative support. Table

BY Dale ForsDYke Msc, MsMa, s potential been this will provoke thought and raise awareness about the psychology Symptoms medicine clinicsice (1) contributor identified evidence base, understanding the ‘severe’ responses (eg. orange flags) 1 highlights how this model can be MssT as loading. are comm (2). by activi of sports injury leading to more effective preventative strategies being The exten s to this altere only aggra ties of personogenic make-up of the athletes which would require referral to another applied to sports injury recovery with facto t d to which daily living r relate stair ambu vated adopted and more successful rehabilitation outcomes from sports you work with and being aware of the healthcare professional such as a G.P. associated thoughtswww. andsport behaviours.

InTroDucTIon , includ suspected s to the symp each lation lati , EX.ne ing prolonged external stressors they are facing on a There are many robust questionnaires There has been criticism of this t The overall incidence of sports injury As a result to vvary betw toms fel felt sitting injury. een indivi is day-to-day basis may prove beneficial that can be used as outcome model when applied to injured athletic is rising leading to the common belief interventio , numerous duals.

Case study conse ns such in reducing rate and impact of sports within sport that there two types of as ortho rvative ses, taping injury (Box 1)(7). psychologically, ready to return and of stressors includes those that athlete – those that have suffered a may contribute to an overall risk of are sport specific, injury history and serious injury and those that have not re-injury. importantly the away from sport life suffered one yet (1). One former England response To torsion, subtalar joint pronation and player were pain and effusion. As significantly increase knee valgus stressors, eg. significant change such Rugby Union player summed up his sporTs InjurY Personality History of stressors Coping resources increased femoral anteversion (4,5). pain and joint effusion cause altered loading. Potentially a mix between as relationship breakdown and moving experience as, “Players are only one As practitioners we are constantly rIsk oF sporTs InjurY Of these risk factors the player had sensory biomechanical predisposition and 23 stimulus and motor responses, home. At-risk personality variables training session away from a career challenged to manage the What if an athlete’s risk of sports injury an increased Q angle and patella alta. early management is required to environmental factors during the game include poor self-esteem, high anxiety ending injury”. This raises the issue of psychological fall-out from sustaining could be predicted by their personality the injury occurred at 70 minutes into minimise these detrimental effects. may have influenced the occurrence of levels, neuroticism, risk taking and implementing effective injury prevention sports injury. According to both theory type? It’s very much a philosophical poTenTIallY the game and at the time of injury the As the player had been immobilised the injury. sTress response hardiness. Coping resources include strategies and the need to manage and empirical evidence we should argument about how much the sTressFul player was faced with an opponent. in extension for 3 weeks he had a InjurY Cognitive Physiological/ having appropriate social support, sports injuries using best practice. assume that, to an athlete, getting physical versus psychological factors aThleTIc appraisals attention changes Both fatigue (6) and inclusion of an reduced range of movement, which Problems following Injury sleep, coping type, diet, education/ Due to the various demands on injured is a significant life event and contribute to sports injury. However, sITuaTIon opponent (7) have been shown to would need to be fully restored before the initial crucial problems facing the awareness, and relaxation skills. An practitioners it is very easy to ignore that this affects the athlete’s interlinking both theoretically and empirically there

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risk, rEsponsE and rEcovEry PSyCHOLOGy OF SPORTS INJURy

the holistic nature of sports injury prevention and rehabilitation. According to Kolt (2) sport injury rehabilitation has developed into being a multifaceted process, and means that practitioners working with injured athletes should endeavour to appreciate both the physical and psychological to be truly effective. To put this into context there is a natural assumption that physical and psychological recovery from sports injury takes place within the same time frames when they frequently do not (3). This means that athletes may well be returning to sport competition when they are physically, but not 10

does seem to be key psychological determinants that increase an athlete’s risk of sports injury. The established Williams and Anderson Model (4) suggests a number of key psychological factors contribute to athlete’s risk of injury. It is thought that an athlete’s history of stressors, personality and coping resources all come together to affect an athlete’s cognitive appraisal of a particular incident leading to adverse stress response (eg. narrowed attention focus, greater distractibility, and higher levels of muscle tension) and subsequently a sports injury (see Fig. 1). History

WE SHOULD ASSUME THAT TO AN ATHLETE GETTING INJURED IS A SIGNIFICANT LIFE EvENT

ManageMent of aCute patella disloCation A cAse study

example to illustrate the model could be a Rugby League player who has just become a first time parent and has high levels of performance anxiety. In the 75th minute of an important game when required to tackle the opponent’s

emotions, cognitions, and behaviours (8). Emotional responses are about what we feel, cognitive about how Interventions we think, and behaviour what we do.

These responses can be adaptive, Figure 1: Adapted stress and injury model [Adapted from Williams and Anderson, 1998 (4)] and facilitate recovery, or maladaptive, ultimately hindering recovery. For example it is common for an injured Box 1. pracTITIoner TIps For prevenTIng InjurY athlete to question their competency 1. Maintain open and continuous communication about sport and life stresses (I can’t do it anymore) suffer with high

bY SaM DawSon bSc, MScP2. Ask athletes to keep stress logs/diaries levels of re-injury anxiety (I won’t do 3. Be aware ofthis particularly stressful points in the seasonstudy and those not seem themselves article describes a case ofthat thedodiagnosis, this exercise as it will only make it during this period The InjuRY worse) and question their identity (if assessment and rehabilitation of a youth team 4. Raise awareness of the link between high level of stress/anxiety and injury risk Mechanism of injury I can’t train and compete what am footballer who sustained an acute patella dislocation.

5. Screen athletes for anxiety based personality traits and intervene with stress management case study a 16-yearI supposed to this do now?) which presents can techniques.the study includes all the information needed to old behaviour competitivesuch youth lead maladaptive as team male footballer who plays as a winger. effectively rehabilitate players including the mechanism during a competitive match while www.sportEX.net of injury, risk factors, a needs analysis for the sport, running the player tried to dummy in front of an opponent. the player’s leg problems identified and evidence-based management. went into a dynamic valgus position A successful, logical and evidence-based rehabilitation and simultaneously the player tried programme is presented, and objective measurement to pivot in the opposite direction. He immediately felt pain and collapsed. with an evidence base is detailed throughout. the player was removed from the field of play. subjectively the player trochlea (2). considering this, and that reported feeling a ‘pop’ as his knee fracture and loose bodies. the the risk of lateral patella dislocation is gave way and felt as if something orthopaedic consultant agreed that the at its greatest in the first 20–30°, it is came out of place and then popped AcL was stable and a lateral patella likely that the contribution of the MPFL back when he straightened his knee on dislocation had occurred. In line with is over the reported 50% static stability the floor. Objectively a haemarthrosis current hospital protocol the player was (2). As the lateral force produced was present and the player was able braced in extension for 3 weeks. was higher than 208N, which is the to flex the knee minimally, limited by reported tensile load of the MPFL (3), pain. tenderness was felt medial to the Forces and loads involved the patella did not engage the trochlea. patella and a positive apprehension test conventionally during patella dislocation, With continued knee flexion the patella was present. the working diagnosis the player has their knee in slight dislocated causing a tear to the MPFL, was lateral patella dislocation. due to flexion with dynamic valgus alignment potential damage to the VMO and the mechanism of injury, the anterior resulting in a high level eccentric chondral surfaces of the trochlea and cruciate ligament (AcL) was checked quadriceps contraction which negates patella (1). but was stable in a Lachman test. the the stabilising effect of the vastus player was booked into trauma clinic at medialis obliquus (VMO) (1). the patella a local hospital so that an X-ray could stability at this stage depends on Injury risk factors be performed to rule out osteochondral individual patellofemoral morphology Reported risk factors for first-time and the static medial stabilisers. the patella dislocation include increased medial patellofemoral ligament (MPFL) tibial tubercle to trochlea groove contributes 50% of the static patella measurement, abnormal patella stability (2). However, the fibres of VMO morphology, increased Q angle with mesh with the fibres MPFL dynamising lateral tibial tuberosity, VMO muscle the MPFL in the first 20–30° of flexion insufficiency, generalised ligament helping maintain the patella in the laxity, genu valgum, external tibial

ATHLETES MAy WELL BE RETURNING TO SPORT COMPETITION WHEN THEy ARE PHySICALLy SICALL NOT SICALLy PSyCHOLOGICALLy READy sportEX medicine 2014;59(January):10-12

cONsIdeR PAteLLOFeMORAL JOINt FORces At ALL stAGes OF ReHABILItAtION 28

sportEX medicine 2014;59(January):28-35

Table 1: ManaGeMenT Plan Problem

11

Timed goal

Measurement

Pain

1. Adequate analgesia 2. Ice 3. teNs machine

1. No day-to-day pain 3/52 2. No pain during single leg loading exercises 6/52

n Player subjective reporting (Visual Analogue scale)

Knee joint effusion

1. compression bandage 2. Isometric muscles setting 3. Progressive loading programme

action

1. Minimal activity-related effusion 3/52 2. No activity-related effusion 6/52

n Player subjective reporting n Joint circumferential measurement

Reduced range of movement

1. Range of movement exercises 2. exercise bike

1. Full extension 1/52 2. 90° flexion 4/52 3. Full AROM 6/52

n Goniometry twice weekly

Reduced confidence loading on injured limb

1. structured exercise programme with gradual increase in loading 2. Load acceptance exercises

1. symmetrical ‘normal’ gait 4/52 2. even loading on bilateral mini squat 4/52 3. control jump/hop landing with good alignment 12/52

n subjective reporting n Functional performance during exercises n Gait pattern

Poor dynamic 1. Progressive proprioceptive exercises balance and 2. Graded exercise programme stability 3. Load acceptance exercises

1. even control of bilateral mini squat 4/52 2. Good dynamic alignment single leg squat 8/52 3. seBt at pre-injury level 12/52 4. Hop test at 95% of uninjured leg 12/52

n QAsLs n seBt n Hop test: single hop, triple hop, cross over hop

Quadriceps strength

1. Progressive quadriceps loading exercises within the consideration of patellofemoral joint forces

1. static quadriceps contraction ×15 reps 1/52 2. straight leg raise ×10 reps no lag 3/52 3. single leg squat with dynamic alignment (0–1 QAsLs) 8/52 4. Hop tests with good alignment 95% of uninjured leg 12/52

n Manual resistance testing n Observation of exercise performance n QAsLs n Hop test: single hop, triple hop, cross over hop

Gluteal strength

Progressive gluteal loading exercises within the consideration of patellofemoral joint forces

1. Active hip abduction supine ×15 reps 1/52 2. side lying hip abduction ×15reps 3/52 3. single leg squat with dynamic alignment (0–1 QAsLs) 8/52 4. Hop tests with good alignment 95% of uninjured leg 12/52

n Manual resistance testing n Observation of exercise performance n QAsLs n Hop test: single hop, triple hop, cross over hop

Risk of redislocation

1. Optimal loading at appropriate time phases 2. Improve lower limb dynamic control 3. education of player of reoccurrence rates

1. No feeling of instability throughout rehabilitation 2. Negative patella apprehension test 12/52

n Palpation n Patella apprehension test n subjective reporting

AROM, active range of movement QASLS, Qualitative Analysis of Single Leg Squat SEBT, Star Excursion Balance Test www.sportEX.net

29

Here’s wHAt’s in tHe current issue n n n n n

research round up research analyses Psychology of sports injury Hamstring injuries in football Management of acute patella dislocation

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