sportEX Medicine Journal Issue 64 - April 2015

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ISSUE 64 Apr 2015 ISSN 1471-8138


excellence in



n ReseaRch Reviews n Fai: diagnosis and tReatment

medicine n achilles tendinopathy n gait RetRaining in oa oF the knee

n tendinopathy loading pRogRammes

contents April 2015 Issue 64 Publisher/editor Tor Davies Art editor DEBBIE Asher Sub-editor alison sleigh Journal watch bob braMah Subscriptions & Advertising +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, D PT, COMT, FAAOMPT, DAC Technical advisors

Steve Aspinall Bob Bramah Paula Clayton Stuart Hinds Rob Granter Michael Nichol Joan Watt Prof Greg Whyte



apr 2015

With the publication of this issue comes the launch of our brand new website which we hope you will love! It’s been built from scratch to suit exactly the needs of you, our readers. The goal is that it will be come a fully flexible learning community developed on a foundation of great quality ‘translational’, practical, hands-on content. We can now work with University courses, education providers, corporate businesses, event organisers and professional associations around the world to publish custom branded websites and mobile apps using the content hosted on our platform. And the content doesn’t have to originate from sportEX either if you have some of your own, or if you want to supplement your own with some of ours. Over the comming months we will be working with one of each of the above groups as case studies to demonstrate exactly what this means in practical terms. Basically we can build a content portal for your members, a resource portal for your students, some education resources for users of your products or an online community for anyone running events. If you’re interested in any of these opportunities get in contact. In the meantime, enjoy the new site :) Tor Davies, physio-turned publisher and sportEX founder

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4 Journal watch 8 R esearch reviews

The latest key research from this quarter Management of post-surgery lumbar pain and is exercise or advice better for WAD?

emeroacetabular 10 Fimpingement iagnosing Achilles 19 Dtendinopathy

Assessment and management

‘A how to’ guide

Contents 25 Gait retraining for OA of the knee 28 Tendinopathy loading programmes 33 The new sportEX website Walking ‘properly’ reduces pain

Are your tendinopathy management protocols up-to-date?

An overview of the launch of the new sportEX website and our goals and aspirations

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. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.




ACCESSORy SOLEuS muSCLE IN AN ATHLETE. pRESENTATION Of A CASE ANd A LITERATuRE REvIEw. Rubio fJ, franco L, montero mJ, ugarte p, valero A. Apunts. medicina de l’Esport. 2015;doi:10.1016/j.apunts.2015.01.004 This study examines the incidence of people having an accessory soleus muscle. According to autopsy studies it was found in between 0.5 to 6.0% of the population. Typically in the live population it presents as a soft mass in the posteromedial distal third of the leg, which increases in size with physical activity, especially plantar flexion. It is accompanied by pain with exercise in

Nine medical databases were searched in May 2014 for treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n >10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Seventy-two relevant studies were included for quality analysis. Four studies were high

67% of reported cases. The treatment of choice is conservative, but when it causes compartment syndrome, fasciotomy should be performed. If a patient has symptoms of claudication or nerve compression, a complete excision of the muscle is required.

sportEX comment You spend years studying

anatomy and then along comes someone who says, “Yeah but”. It’s why working with the human body is so fascinating. Given the incidence of people presenting with pain it is interesting to speculate on how many of these were missed in the past before ultrasound scanning was available.

STudy quALITy ON GROIN INJuRy mANAGEmENT REmAINS LOw: A SySTEmATIC REvIEw ON TREATmENT Of GROIN pAIN IN ATHLETES. Serner A, van Eijck CH, Beumer BR, Hölmich p, et al. British Journal of Sports medicine 2015;doi:10.1136/bjsports-2014-094256 quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman’s hernia, surgery results in better treatment

success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success but not between study quality and publication year.

sportEX comment If reviewers can make decisions about the quality of studies why, oh why, can’t the editors of peer-reviewed publications do so and stop publishing them. Just say No.

THE EffECTIvENESS Of EyE-CLOSuRE IN REpEATEd INTERvIEwS. vredeveldt A, Baddeley Ad, Hitch GJ. Legal and Criminological psychology 2014;19(2):282–295 This was an experiment in recall for witnesses to a crime but it should apply to any event you need to recall. The participants were shown a video and asked to recall what they had seen a few minutes later with their eyes open and then with them closed. A week later they were again asked to recall the event firstly without being given reminder cues and then with a cue. Immediately after the video, eye-closure had no significant effect on recall performance. However, eye-closure during the 4

second session increased the amount of correct visual information reported by 36.7% in free recall and by 35.3% in cued recall, without harming the accuracy of what was recalled. Eyeclosure also facilitated the recall of new, previously unreported visual information.

sportEX comment This one is for anyone taking exams and struggling to recall the anatomy lecture from 2 years ago (or anything else for that matter).

Close your eyes and visualise. Note to examiners. Your students are not asleep they are trying to remember the answers. For the record the scientists believe the eye closing helps to remove distractions to the thought process. They also found that if the person trying to remember had a rapport with the person doing the interview the eyes-closed recall was enhanced. This is believed to have something to do with being willing to close your eyes if you feel safe with another person in the room. sportEX medicine 2015;64(April):4-7


Journal watch THE BASES, pRINCIpLES, ANd mETHOdS Of dECISION-mAKING: A REvIEw Of LITERATuRE. Shahsavarani Am, Abadi EAm. International Journal of medical Reviews 2015;2(5):214–225 The aim of this paper is to present an integrated concept of decisionmaking. It was a literature search of the usual medial databases plus Google Scholar and a few we don’t usually come across in this publication such as Proquest, Ebsco, Springer, IEEE, Kolwer, and IranDoc using variations on the words ‘decision’, ‘making’, ‘optimisation’ ‘reduction’ and a few others . The result was that they came up with 9 definitions of decision-making in 3 classes, 4 involved factors, 5 types of decision-making, processes and steps of decision-making, 11 techniques of individual and participatory decisionmaking, 3 groupings of steps of decision-making, 5 related theories and 7 related constructs. In general the influencing factors on decision-making are: 1. Rational factors. Quantitative factors such as price, time, predictions, etc. 2. Psychological factors. Such as personality of the decider, her/ his capabilities, experiences, perceptions, values, goals, and roles are important factors in decision-

making. 3. Social factors. Others’ agreement, especially those who influence decider, is a matter of importance. Considering these issues reduces others’ resistance against the decision. 4. Cultural factors. Surrounding environment has varied layers which are called culture of the region, culture of the country, and culture of the universe. Also, the culture of the decider’s organisation should be also considered. These cultures influence individual/organisation decisions in the form of socially accepted values, trends, and common values.

sportEX comment If you are reading this you are in the decision-making business. It is something you do with every clinical encounter you have so anything that can help the process should be welcomed. There is of course a ‘but’! The aim of this paper was to obtain an integrated concept of decision-making but it seems that it

only succeeded in pointing out the complexities of the process. It has a section called ‘Decision-making in therapeutic environments’ in which it supports the use of clinical decisionsupport system software to aid doctors, and other healthcare staff in determining diagnosis according to patients’ data. It justifies this as a method to reduce the need to consult with professionals, and therefore reduce consulting rates and costs of treatment. This is very dangerous road to go down. It looks good to accountants but it reduces healthcare to a tick-box exercise.

INCLuSION Of TRIGGER pOINT dRy NEEdLING IN A muLTImOdAL pHySICAL THERApy pROGRAm fOR pOSTOpERATIvE SHOuLdER pAIN: A RANdOmISEd CLINICAL TRIAL. Arias-Buría JL, valero-Alcaide R, Cleland JA, Salom-moreno J, et al. Journal of manipulative & physiological Therapeutics 2015; doi:10.1016/j.jmpt.2014.11.007 Twenty patients (5 M, 15 F; age, 58 ± 12 years) with postoperative shoulder pain after either open reduction and internal fixation with proximal humeral internal locking system plate or rotator cuff tear repair were randomly divided into two groups: a physiotherapy group (n = 10) who received physical therapy interventions and a physical therapy plus trigger point dry needling (TrPt) group (n = 10) who received the same

intervention plus a single session of TrPt therapy targeted at active TrPs. The Constant–Murley score was used to determine pain, activities of daily living, range of motion, and strength, which was captured at baseline and 1 week after by an assessor blinded to group assignment. The results were that subjects receiving the trigger point therapy plus physical therapy exhibited greater improvement in the Constant–Murley total score and also

activities of daily living and strength subscales than those receiving physical therapy alone. Both groups experienced similar improvements in pain and range of motion

sportEX comment This is a double plus. Physical therapy works alone and with the addition of a few needles. Good result.




THERApEuTIC EffECT Of ExTRACORpOREAL SHOCK wAvE COmBINEd wITH ORTHOpAEdIC INSOLE ON pLANTAR fASCIITIS. yan w, Sun S, Li x. Zhong Nan da xue xue Bao yi xue Ban. 2014;39(12):1326–1330 One hundred and fifty-three people with plantar fasciitis were randomly divided into a combined group (n = 51), an extracorporeal shock wave (ECSW) group (n = 53) and an orthopaedic insole group (n = 49). Visual analogue scale (VAS) pain scores, continued walking time and thickness of the plantar fascia were obtained before and after the treatment at 2 weeks, 1 month and 3 months. The VAS scores in all three groups were reduced after the treatment. The score in the extracorporeal shock wave group was greater than that in the orthopaedic group after the treatment at 2 weeks. The score in the combined group was smaller than that in the orthopaedic group after the treatment at 2 weeks and 3 months. The VAS scores in the orthopaedic group and the combined group were smaller than those in the ECSW group

after the treatment at 1 month and 3 months The continued walking time and thickness of the plantar fascia was improved after all the treatment The cure rate and total effective rate in the combination group were obviously greater than those in the two other groups. The cure rate in the orthopaedic group was greater than that in the ECSW group

sportEX comment It’s International month here at sportEX Towers. We have studies from journals we don’t usually follow. The reason for this is that therapists in India, China and Japan are producing good quality research on subjects ignored by the mainstream Western academic media and proving that simple techniques can have dramatic results. As to this one, sorry but if you want to read the full paper you will

B BROKEN HEART SyNdROmE: A TypICAL CASE. Therkleson T, Stronach S. Journal of Holistic Nursing 2015:pii:0898010115569883 This is a case of a lady diagnosed with ‘Broken Heart Syndrome’ who was treated with, amongst other things, massage with oils and a relaxing footbath once a week for 4 weeks which proved to be effective.

sportEX comment Ok be honest. When you read ‘Broken Heart Syndrome’ (BHS) what were you thinking? Was it a positive thought? BHS was first reported in Japan in 1991 and is a medical condition triggered by extreme physical or emotional stressors that is found to mainly affect postmenopausal women. It was originally called ‘Takotsubo cardiomyopathy’ due to the presentation of cardiac changes, with weakened heart muscle in the left ventricle causing transient ballooning in the apex of the left ventricle. It has been acknowledged by the American College of


Cardiology and the American Heart Association as a unique form of reversible cardiomyopathy. Generally, the symptoms are chest pain and tightness accompanied by shortness of breath. Typical management is the same as for a heart attack until symptoms settle. It is suggested that it is activated by neurogenic stunning of the myocardium. ECG and cardiac markers show minimal change and there is no myocardial arterial blockage but a definitive diagnosis is obtained from an echocardiograph. So now you know that your team members distraught at losing the cup final on a penalty shootout have a genuine medical condition.

have to be able to read Chinese as there is only a translated summary available but this confirms earlier work including a meta analysis [Gerdesmeyer, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis results of a confirmatory randomised placebocontrolled multicenter study. The American Journal of Sports Medicine 2008;36(11):2100–2109] which states that extracorporeal shock is great for plantar fasciitis. If you are not familiar with ECSW or extracorporeal shock wave lithotripsy to use its full title it is usually used for battering kidney or gall stones into submission. You can buy a generator for between £7–12,000. S SENSORy NERvE fIBRES CONTAINING CALCITONIN GENE-RELATEd pEpTIdE IN GASTROCNEmIuS, LATISSImuS dORSI ANd ERECTOR SpINAE muSCLES ANd THORACOLumBAR fASCIA IN mICE. Barry Cm, THORACOL Kestell G, Haberberger Rv, Gibbins IL. Neuroscience 2015;doi:10.1016/j.neuroscience.2015.01.062 This study used multiple labelling immunofluorescence and retrograde axonal tracing to identify dorsal root ganglion cells associated with muscle, and to characterise the distribution and density of their nerve fibres in mouse gastrocnemius and back muscles and the thoracolumbar fascia. Most nerve fibres in these tissues contained calcitonin gene-related peptide and two major subpopulations of neurons were found: those containing calcitonin gene-related peptide and substance P, and those containing calcitonin gene-related peptide but not substance P. Innervation density was three times higher in the thoracolumbar fascia than in muscles of the back.

sportEX comment So what? Well what this does show is that in mice at least there are more nerve fibres that can cause pain in the thoracolumbar fascia than the underlying muscle. If this transfers to humans it’s a good clinical reason for doing fascial techniques on pain sufferers.

sportEX medicine 2015;64(April):4-7


pROTECTING THE HEALTH Of THE @HLETE: HOw ONLINE TECHNOLOGy mAy AId OuR COmmON GOAL TO pREvENT INJuRy ANd ILLNESS IN SpORT. verhagen E, Bolling C. British Journal of Sports medicine 2015;doi:10.1136/ bjsports-2014-094322 This report is based on the authors keynote presentation at the IOC World Conference on Injury and Illness Prevention in Sport (Monaco, 12 April 2014). It outlines the use of eHealth in research, implementation and practice, and provides an overview of possibilities and opportunities that existing and emerging eHealth solutions provide for sports and exercise medicine and physiotherapy. Contemporary online platforms enable self-monitoring and provide tailored feedback to the different stakeholders who play a role in the health and care of athletes. Innovations such as digital monitoring, mobile applications and connected hardware provide the critical tools to solve current enigmas in sports medicine research, and to streamline and facilitate

injury prevention, management and rehabilitation. eHealth is not an emerging future of sports medicine – the technology to move our field forward in terms of research and practice is already available. The paper highlights numerous other studies where eHealth has been used. Examples include, online surveys, using text message to monitor injury rehab, the interaction possibilities of social media, social marketing to spread messages of improvement of healthy and safe sports behaviour or raise awareness of issues. The viral (or vile) Ice Bucket Challenge is used as an example. Mobile phones as data gathering devices are highlighted, eg. tracking via GPS, heart rate monitors, accelerometer, pedometers and of course the massive variety of ‘Apps’

T EffECT Of TwO mOBILIZATION TECHNIquES THE ON dORSIfLExION IN pEOpLE wITH CHRONIC ANKLE INSTABILITy. marrón-Gómez d, Rodríguez-fernández AL, martín-urrialde J. physical Therapy in Sport 2015;16(1)10–15 The aim of this study was to compare two manual therapy techniques for the improvement of ankle dorsiflexion in people with chronic ankle instability (CAI) over 48h. Fiftytwo participants, (31 M, 21 F; age 15–36 years) with CAI were randomised to a mobilisation with movement group using a belt, a talocrural manipulation group or a placebo group, which involved holding onto the leg and foot in the same manner as the mobilisation with movement group but without actually doing very much. Weight-bearing ankle dorsiflexion was measured with a weight-bearing lunge obtained before and immediately after intervention, and 10min, 24h and 48h post-intervention. There was a significant increase in ankle dorsiflexion in both treatment groups compared to placebo but no differences between both active treatment groups.

sportEX comment There are some nice stats in this paper. Ankle sprains are the most common injury incurred during sports activities and it is estimated that between 20% and 40% of ankle sprains will result in chronic ankle instability, with up to 70% reported in specific sports such as basketball. Nice also to know that manual therapy techniques work.

for injury prevention and treatment.

sportEX comment If the use of ‘@hlete’ rather than ‘athlete’ puts you off the ‘e’world then look away now. Whether we like it or not, eHealth has entered our life. Ninety percent of the world’s population has a mobile phone and there are 1.2 billion active Facebook users and 255 million on Twitter. We have ‘mHealth’, which is ‘eHealth’ delivered via a portable (mobile) devices. A word of caution, however. None of this stuff is regulated. The fancy ‘App’ could be valuable or dangerous. Maybe it is time the professional medical bodies like the BMA, CSP or BASRAT started endorsing or even producing a few.

L LIfE-THREATENING EvENTS duRING ENduRANCE SpORTS: IS HEAT STROKE mORE pREvALENT THAN ARRHyTHmIC dEATH? yankelson L, Sadeh B, Gershowitz L, werthein J, et al Journal of the American College of Cardiology 2014;64(5):463-469 This retrospective study examined all the long distance popular races that took place in Tel Aviv from March 2007 to November 2013. The number of athletes at risk was known. The number of athletes developing serious sport-related events and requiring hospitalisation was known. Life-threatening events were those requiring mechanical ventilation and hospitalisation in intensive care units. Overall, 137,580 runners participated in long distance races during the study period. There were only 2 serious cardiac events (1 myocardial infarction and 1 hypotensive supraventricular tachyarrhythmia), neither of which were fatal or life threatening. In contrast, there were 21 serious cases of heatstroke, including 2 that were fatal and 12 that were life threatening. One of the heatstroke fatalities presented with cardiac arrest without previous warning.

sportEX comment As we enter the mass participation marathon season it is worth taking heed of this study. For every serious cardiac adverse event, there were 10 serious events related to heatstroke. We do like the idea that if you are lucky enough to have your cardiac event at a sporting event with high level medical services on hand a ‘myocardial infarction’ is not life threatening.


Brought to you By

Nxt Gen Institute of Physical Therapy

our regular research reviewer, physical therapist Joseph Brence, reviews research looking into the benefits of exercise and advice for pain (i) following lumbar surgery, and (ii) with chronic whiplash-associated disorder.

post-surgery Lumbar pain BY Joseph Brence DpT, coMT, DAc Lumbar discectomies for radicular symptoms are quite prevalent in the united States. Despite this, one out of every four individuals undergoing these procedures continues to have persistent pain and disability (1,2). Although many patients receive education from their physicians prior to surgery, research does not support that this influences postoperative pain or disability (3). A recent article published in Spine may change the way we approach pre-operative education and may improve patient’s perception of surgery and reduce long-term postoperative costs (4).

The sTuDY the researchers in this multicentre, randomised controlled trial, investigated the potential outcomes of providing pain neuroscience education to patients undergoing lumbar surgery for radicular pain. Sixty-seven patients, scheduled for surgery, were randomly assigned to receive one of two pre-operative approaches:

control group this group had the usual surgeon-led

pre-operative education, focusing on procedures and anatomical description of the surgery.

function, pain knowledge, satisfaction with surgery and healthcare expenses.

experimental group

At 1 year, there were no statistical differences between the two groups in regards to back pain, leg pain, fearavoidance, pain catastrophisation and function. the experimental (pain education) group, however, rated surgery significantly more satisfactory on several levels and spent 45% less of medical tests and treatment, despite having similar pain and disability. the one-time Pt session resulted in savings of more than $2000 per patient.

this group had the usual surgeonled pre-operative education plus one physical therapist (Pt) session (30 minutes) teaching the patients about the neurobiology of pain, accompanied by a $5 neuroscience education booklet. Material covered in this session included: 1. the decision to have the surgery 2. the nervous system’s physiology and pathways 3. Peripheral nerve sensitisation 4. Surgical experiences and environmental issues effects on nerve sensitivity 5. Calming the nervous system 6. recovery after lumbar surgery 7. Scientific evidence for the neuroscience education booklet content 8. An opportunity to reflect and write questions to ask the surgeon prior to surgery. Following the education, all of the patients underwent surgery and then outcome measures were collected 1, 3, 6 and 12 months after surgery and consisted of surveys regarding low back pain, leg pain, fear-avoidance, pain catastrophisation,

THE AUTHOR JOsEpH BREncE DpT, cOMT, DAc J Joseph Brence (DpT, (D cOMT, DAc) is a physical therapist and clinical researcher from p pittsburgh, pA, UsA. He is also a fellowship candidate with sports Medicine of Atlanta, GA, UsA. sA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and s determining how it applies to physical therapy practice. He is currently involved in a wide range of clinical research projects investigating topics such as the effects of verbalising of pain, the effects of mobilising v. manipulating the spine on body image perception and validation of an instrument which will assess medical practitioners’ understanding of pain. clinically, Joseph treats a wide range of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and chronic fatigue syndrome. Joseph also runs the blog


The resulTs

so whAT Does This MeAn? Pts are very well equipped in strategies to help you better understand and manage pain. growing research, such as this, is indicating education, focusing on the re-conceptualisation of pain, can lead to improved function, and less care-seeking due to the pain. It appears that pain is a normal experience following lumbar surgery, but as little as one session with a Pt can ultimately result in lower healthcare expenditure costs. References 1. Loupasis gA, Stamos K, et al. Seven- to 20-year outcome of lumbar discectomy. Spine 1999;24:2313–2317 2. yorimitsu E, Chiba K, et al. Long-term outcomes of standard discectomy for lumbar disc herniation: a follow-up study of more than 10 year. Spine 2001;26:652–657 3. Johansson K, Nuutila, et al. Preoperative education for orthopaedic patients: systematic review. Journal of Advanced Nursing 2005;50:212–223 4. Louw A, Diener I, et al. Preoperative pain neuroscience education for lumbar radiculopathy. Spine 2014:39;1449–1457.

sportEX medicine 2015;64(April):08-09

reSeArch review

Is exercI exercIse better than advI advIce for W Wad ad? Whiplash-associated disorder (WAD) is a complex, multifaceted disorder that is often the result of the 300,000 plus road traffic accidents that occur in England per year (1). Evidence has suggested that 50% of individuals who acquire WAD do not recover within the first 3 months (1) and that upwards of 30% of individuals with WAD report the development of moderate to severe pain and disability, up to 6-months following the onset (2). A recent article in The Lancet set out to investigate if a comprehensive exercise program is more effective than advice, for the treatment of individuals diagnosed with chronic WAD (3). this article followed 172 participants, between the ages of 18 to 65, who had a diagnosis of chronic grade 1 or 2 WAD (>3 months and <12 months). they were allocated into one of two treatment groups, to receive either a comprehensive exercise program (20 sessions) or advice (1 session and telephone support). Each participant, regardless of group, was also given a patient educational booklet, that provided information about WAD, advice regarding the management of symptoms, and a simple exercise programme to help reduce pain. here is a detailed analysis of what each of these groups received: Group 1: comprehensive exercise programme n Participants received 20 individually tailored and supervised exercise sessions lasting one hour each over 12-weeks (2×week for 8 weeks; 1×week for 4 weeks). n For the first 4 weeks, the participants performed specific cervical spine exercises (such as craniocervical flexion training, neck extensor training, scapular training, posture re-education, and sensorimotor exercises). n Manual therapy techniques (non-

thrust) could be used by the clinician within the first week. n In weeks four through six, the participants transitioned from a focus on specific neck motor exercises to integration of this control in entire body exercises. n By week 7, individually designed, graded activity programmes were completed to help participants progressively achieve their goals. n In addition, aerobic activities were prescribed from week 1 to 12 in a submaximum way. Group 2: Advice n Participants received a 30-minute consultation with a physiotherapist during which they read the educational booklet, practiced the exercises, and had any additional questions or concerns clarified. n Participants were advised to implement the advice and do the exercises at their own discretion. n the participants could contact the physiotherapist by telephone on two occasions, if needed, for further verbal clarification. the researchers performed follow-up assessments on the participants at 14 weeks, 6 months and 12 months. During this time they compared baseline readings on the following scales to assess outcomes: 1. primary outcome measure Average pain intensity during the preceding week (before the outcome assessment was measured) 2. secondary outcome measures a. Average pain intensity over the past 24 hours b. Self-rated recovery c. Disability measured on the neck disability index d. Disability on the Whiplash Disability Questionnaire. After careful analysis, the researchers found that simple advice

was just as effective as a 12-week comprehensive exercise programme. this finding refutes some previously held beliefs about the treatment of WAD, supporting some more recent findings about the diagnosis (4,5,6) the findings of this study further support the complex, multifaceted nature of painful conditions and the notion that simply understanding pain, may be beneficial in recovery. Because central sensitivity is suspected to be a tenant of chronic WAD, it may be more beneficial to approach treatment with interventions which devalue the threat and hypersensitivity of the nervous system, prior to performing exercise interventions. overall this was a tightly controlled, well-performed study that gives us more effective approaches to treatment for this complex disorder. References 1. Crouch r, Whitewick r ,et al. Whiplash associated disorder: incidence and natural history over the first month for patients presenting to a uK emergency department. emergency Medicine Journal 2006;23:114–118 2. Jull gA, Sterling M, , et al. toward lessening the rate of transition of acute whiplash to a chronic disorder. Spine 2011;36:173–174 3. Michaleff ZA, Maher Cg, et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (ProMISE): a pragmatic randomised controlled trial. The Lancet 2014;384:133–141 4. Lamb SE, gates S, et al. Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. The Lancet 2013;381:546–556 5. Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD): a randomised group study. Physiotherapy Theory and Practice 2001;17:229–238 6. Jull g, Kenardy J, hendrikz J, et al. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain 2013;154:1798–806.


Femoroacetabular impingement MechanisMs, diagnosis and treatMent options using postural restorationÂŽ: part 1 Upon completion of this series, the reader will have a greater understanding of the biomechanics of lumbo-pelvic-femoral dysfunction as it relates to femoroacetabular impingement (FAI) as understood by the Postural Restoration InstituteÂŽ (PRI). Restoration of pelvic-femoral alignment and recruitment patterns of specific rotational muscles within the lumbo-pelvicfemoral complex will be discussed. Treatment techniques to recruit, retrain and restore ideal lumbo-pelvic-femoral position will be discussed. The reader will be able to apply PRI clinical assessment and management skills when treating diagnoses such as FAI. by JaSon maSek ma, Pt atC CSCS PrC

Symmetry and aSymmetry in the human body A common misconception is that the human body is symmetrical. It is symmetrical about the midline of the body for many structures such as eyes, ears, and limbs. In spite of this outward noticeable symmetry, there is an inherent internal organ asymmetry with regards to the left and right side of the body. For example, the heart is on the left side, the right lung has more lobes than the left, and the liver lies on the right side of the body. Furthermore, our respiratory and cardiovascular systems are designed asymmetrically. The right hemi-diaphragm, being larger and more domed than the left, provides greater force development and therefore greater transdiaphragmatic pressure. In regards to the heart function, the left side of the heart pumps blood under high pressure to the whole body, whereas the right side pumps blood at a lower pressure to the lungs. 10

Nevertheless, there is an opinion that symmetry generates the basis on which asymmetry can be developed, influenced, and exercised. Recognising the structural and functional asymmetries of the human body for what they are, not for what they should be, proposes an overwhelming desire on the part of many to obtain symmetry. Symmetry is established once there is a balancing mechanism for identifying different movement patterns between the left and right side of the body. Anatomical asymmetry cannot be eliminated, but functional asymmetry can be consistently monitored, assessed and influenced in order to reduce negative consequences. These asymmetries lead humans to function very differently in regards to the left and right sides of their bodies. Asymmetries may not always be disadvantageous or detrimental to function. In fact they can allow individuals to adapt to various task constraints. Through favouring sportEX medicine 2015;64(April):10-18

evidence inFormed practice

one side over the other, functional asymmetries can be amplified through time even though anatomical asymmetries are an inherent design of the human body. These side-toside differences may act as functional mechanisms for adaptation to various constraints to optimise function. Patterns evolve and exist in all of us to some degree. A movement or recruitment pattern develops as one trains or habitually repeats the same action to contribute to a desirable and/or undesirable activity. Identifying movement patterns that one wants to change and factors that are interfering with the movement one wants to achieve, will allow one to learn new movement patterns that are more productive for the individual. Repetitive sequential action of muscles, bones and joints, therefore, contributes to differences or similarities in the development of asymmetrical human behaviour.

PoStural reStoration® Postural Restoration® as described by the Postural Restoration Institute® (PRI), is a form of treatment based on objective anatomical asymmetry and correlated predictable asymmetrical patterns of behaviour. Application of the treatment requires ongoing assessment of common postural patterns found within the human body. It is understood that all humans have anatomical asymmetry which influences the way human body functions. These asymmetries can predispose our body to fall into neuromuscular patterns that may have an undesirable influence on muscle function and structural alignment. Postural Restoration® techniques assist in the treatment of undesirable asymmetry, restoring proper joint position, and retraining proper muscular activity in triplanar movement patterns. This approach has shown to be successful in the management of individuals with anterior knee pain (1,2), asthma (3), trochanteric bursitis (4), low back pain (5,6) and thoracic outlet syndrome (7).

PelviC aSymmetry Pelvic asymmetry is common among symptomatic and asymptomatic individuals (8,9). Pelvic asymmetry

refers to asymmetric pelvic alignment with respect to the frontal or sagittal planes (10). Pelvic asymmetry in the sagittal plane refers to mal-alignments between the left and right innominate bones (11). Thus, clinical assessment of innominate position and motion is later made by describing motion or position of one side in relation to the other. This mal-alignment could either be unilateral anterior or posterior rotation of one innominate bone or bilateral movement of the innominate bones (12). Furthermore, pelvic asymmetry has been thought to alter body mechanics, affect the length of muscles that originate on the pelvis, and result increased strain on bony and soft tissues possible producing asymmetrical adaptations (12).

FemoroaCetabular imPingement Femoroacetabular impingement (FAI) is a recently understood hip condition in which there is abnormal mechanical contact (impingement) between the ‘ball’ and ’socket’ of the hip (13–15). The femoroacetabular joint is the medical term for the hip joint. The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thigh bone). Impingement is a term to describe the catching, pinching, and/or abnormal rubbing of the femoral head ball with the acetabulum socket leading to loss of motion within the femoroacetabular joint. Furthermore, this impingement can occur from changes in the shape of the acetabulum socket or the femoral head ball. There are three types of FAI: pincer, cam and mixed impingement. FAI due to ‘overcoverage’ of the acetabulum is referred to as pincer impingement. Pincer impingement occurs because extra bone extends out over the normal rim of the acetabulum. FAI due to ‘lack of femoral head roundness’ is referred to as cam impingement. In cam impingement the femoral head is

The ABSeNce OF A lIveR ON The leFT SIDe OF The BODy cReATeS A SITUATION WheRe The leFT heMI-DIAPhRAgM IS NOT Well POSITIONeD AND cReATeS AN ASyMMeTRIcAl PUll ON The RIBS not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum. Mixed impingement suggests that both the pincer and cam types are present. The significance of FAI has been discussed at both the scholarly and the clinical level (16–24). FAI has recently been considered to be one of the causes of osteoarthritis (OA) of the hip (2,13,25–27). OA is perhaps best understood as resulting from excessive mechanical stress applied to the joint surface. This cumulative excessive stress results from biomechanical alterations and conditions such as post-traumatic joint incongruity, joint instability, mal-alignment and altered joint loading. In recent years, hip arthroscopy has become an increasing popular method for the surgical treatment of FAI because of favourable outcomes (28).

aSymmetry ContributionS to Fai Postural Restoration® recognises a common pattern of asymmetry that may contribute to a multitude of musculoskeletal conditions including FAI. FAI is an increasingly accepted cause of hip pain in young active adults. While the exact cause of hip impingement is not well understood, concomitant hip pain is often seen in individuals who have hip impingement. Because FAI is a dynamic process, mechanical hip pain has remained a diagnostic hurdle for most healthcare


professionals on the basis of clinical evaluation. Despite an emergence of advanced diagnostics and surgical intervention techniques there remains a lack of information focused on specific rehabilitation in regards to FAI. The high incidence of this condition necessitates a specialised treatment and rehabilitation programme in order to address the specific needs and challenges associated with FAI. It is the intent of the forthcoming articles to provide the reader with a better appreciation and understanding of the mechanisms of hip impingement, diagnosis and treatment/management options as it relates to dysfunctional asymmetry and the use of Postural Restoration® techniques. It is important to detect predisposing factors in individuals presenting with FAI and labral tears; these factors can include anatomical asymmetry and asymmetrical patterns of muscle pull that develop due to postural habits, repetitive movements and side dominance. Pelvic asymmetry alters the body mechanics, puts various body segments under strain, and therefore contributes to musculoskeletal pain (29). Pelvic asymmetry appears frequently as a consequence of mechanical loading of the pelvis. compensation for pelvic asymmetry occurs in the musculoskeletal system altering the mechanics of the lumbo-pelvic-femoral complex. This is reflected by altered movement patterns in the upright standing position, and therefore a recognised functional alteration adapts the locomotor system to the transmission of these asymmetrical mechanical loads (29). Furthermore, it

Figure 1: Hruska’s left anterior interior chain (left AIC) pattern of the pelvis. (J. Masek, 2014)


(a) left acetabular-femoral internal rotation (left aF ir)

(b) left femoral-acetabular internal rotation (left Fa ir)

(c) left acetabular-femoral external rotation (left aF er)

(d) left femoral-acetabular external rotation (left Fa er)

Figure 2: Left acetabular-femoral and femoral-acetabular mechanics. (J. Masek 2014)

is valuable to consider other etiological factors when evaluating the lumbopelvic-femoral complex for alterations. The position of the pelvis is affected by factors such as acetabular orientation, soft-tissue flexibility, muscular imbalances and respiratory dysfunction and all must be considered together when evaluating pelvic findings.

PatternS oF PelviC aSymmetry Janda (30) has described a predictable pattern of muscular imbalance in the pelvis, known as the lower crossed syndrome. he suggests that tight hip flexors and lumbar erector spinae and weak gluteal and abdominal musculature characterise the lower crossed syndrome. The subsequent imbalance leads to an anterior pelvic tilt, increased hip flexion, and hyperlordosis of the lumbar spine. hip flexor tightness may lead to increased weight-bearing load upon the anterior acetabulum and labrum predisposing it to injury. Similarly, hruska has described a predictable underlying postural pattern of asymmetry known as the left anterior interior chain (left AIc) pattern (Fig. 1). hruska’s left AIc pattern

calls attention to the tendency for the anterior tilt and forward rotation of the left hemi-pelvis. The position of the pelvis orients the pelvic girdle to the right causing a shift in one’s centre of gravity to the right resulting in compensatory activity throughout the frontal and transverse planes of the thorax and consequently the upper extremities. The typical left AIc pattern involves a pattern of pelvic, spinal and diaphragmatic orientation towards the right with compensation, usually occurring above the diaphragm (at about T8/T9), from the neuromuscular system to rotate the spine back to the left. Upon frontal plane observation, the thorax and lumbar spine will be side-bent right with the right shoulder appearing to be lower than the left (31–34). Specific movement patterns have a significant effect on the relative strength and consequently the length of the musculature involved in all three planes. Although muscles are often prime movers in a single plane, they must actually be considered as having an effect on movement in all three planes – sagittal, frontal and transverse. Assessing the frontal and sportEX medicine 2015;64(April):10-18

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transverse planes when it comes to addressing postural asymmetry is often overlooked. Janda’s approach to addressing patterns of muscular imbalance within the sagittal plane is rather straightforward. hruska’s approach addresses muscular imbalances with a tri-planar viewpoint in order to manage muscular patterns of asymmetry and also incorporates the respiratory system’s influence on muscular imbalance.

anatomiCal and reSPiratory inFluenCeS oF the leFt aiC Pattern It is beyond the scope of this article to address in depth all aspects of the left AIc pattern and its influence on the management of FAI. Therefore, this article will focus on providing an understanding of how respiratory and lumbo-pelvic-femoral function accompanies FAI. Moreover, the reader will have a more complete understanding of anatomical considerations in regards to altered pelvic mechanics and respiratory function as it relates to FAI.

bones. The right and left innominate bones articulate anteriorly to form the symphysis pubis joint and posteriorly to form the sacroiliac joints. The femurs articulate with the acetabulum of the innominates to form the hip and/or FA joint. Femoral-acetabular (FA) motion refers to the femur moving within the acetabulum. Acetabular-femoral (AF) motion refers to the acetabulum moving on the femur. Movement of the femur relative to the acetabulum does not produce pure arthokinematic motion, rather, combinations of movements (36). The habitual patterns of motion for the non-weight-bearing lower extremity are a combination of flexion with abduction and external rotation (eR), and extension with adduction and internal rotation (IR) (37). Arthrokinematics of both motions are impure swings (37). however, acetabular-femoral internal rotation (AF IR) and femoral-acetabular internal rotation (FA IR) usually includes a combination of extension, internal rotation and adduction (Figs 2,3).

The major function of the pelvic girdle is to transmit forces and weight of the trunk and upper extremities to the lower extremities and to distribute ground reaction forces. The pelvic girdle forms the base of the trunk, supporting the superincumbent body structures and linking the vertebral column to the lower extremities (38). In bilateral asymmetrical stance, muscle activity will be required to either control osseous instability or to return the FA joint (hip) to a symmetrical state. Shifting ones weight over the right hip results in relative adduction and internal rotation of the right hip (right AF IR) (Fig. 4) and abduction and external rotation of the left hip (left AF eR). To return the pelvic girdle to a neutral state, an active contraction of the right hip abductors (right AF eR) and/or left hip adductors (AF IR) is required (Fig. 5) (39).

(a) right acetabular-femoral internal rotation (right aF ir)

(b) right femoral-acetabular internal rotation (right Fa ir)

(c) right acetabular-femoral external rotation (right aF er)

(d) right femoral-acetabular external rotation (right Fa er)

the thoraCiC and PelviC diaPhragmS The thoracic and pelvic diaphragms interconnect your ribcage, spine, and pelvis. Because of these relationships

anatomy The complex anatomy and biomechanics of the lumbo-pelvicfemoral complex have made it challenging to propose specific diagnostic and treatments for FAI. The muscle attachments about the lumbopelvic-femoral complex provide this area with significant power accelerating and pivoting as rapid contractile forces are applied. The pelvic girdle is a complex group of skeletal (bone) and soft-tissue (muscles and ligaments) structures that transmit power and weight of the torso and upper body to the lower extremities for ambulation and performance (35). In order to comprehend the biomechanics of the pelvis, which is the foundation of the spine, the pelvis must be defined in relationship to the bones contained within it and those affecting it. The pelvic girdle is formed by six joints: two femoroacetabular (FA) joints (hip joints), two sacroiliac joints, the lumbosacral junction (l5–S1), and the symphysis pubis joint. The pelvis is formed with the sacrum wedged between the right and left innominate

Figure 3: Right acetabular-femoral and femoral-acetabular mechanics. (J. Masek, 2014)


Figure 4: Shifting one’s weight over the right hip results in relative adduction and internal rotation of the right hemipelvis (right AF IR), and abduction and external rotation of the left hemi-pelvis (left AF ER). (J. Masek, 2014)

Figure 5: Shifting one’s weight over the left hip results in relative adduction and internal rotation of the left hemi-pelvis (left AF IR), and abduction and external rotation of the right hemi-pelvis (right AF ER). (J. Masek, 2014)

the diaphragms are significantly influenced by posture and continuously influenced by respiratory function. The pelvic girdle is important in regards to respiratory function because of its relationship to the pelvic diaphragm (Fig. 6). Altered mechanical function of the pelvic girdle can influence the functional capacity of the muscles of the pelvic diaphragm, as does the thoracic spine; whereas rib mechanical function influences the functional capacity of the thoracic diaphragm. When linked to the thoracic diaphragm, the pelvic diaphragm acts as a powerful stabiliser of lumbosacral, sacroiliac, pubic symphysis and FA joints allowing for higher efficiency of lower extremity use. lumbar and pelvic stability is dependent upon optimal coordination between the thoracic diaphragm, the 14

pelvic diaphragm and the abdominal musculature. The pelvis and its direct attachment to the spine is the determining factor for the shape of the two diaphragms, and must be supported by the muscles that attach to the ribcage and the pelvis. As the thoracic diaphragm pulls air into the lungs upon inhalation, it pushes down on the viscera, which in turn, press down on the pelvic diaphragm to move it downward. On exhalation, the thoracic diaphragm and pelvic diaphragm both elevate. When upper respiratory activity (scalene, sternocleidomastoid, pectoralis minor) is the predominate pattern of respiration, the pelvic diaphragm becomes less efficient during reciprocal phases of respiration. This lack of coordinated reciprocal movement between the two diaphragms tends to exacerbate respiratory dysfunction and lumbo-pelvic-femoral mechanical derangement. Proper function between the two diaphragms is fundamental for proper core stabilisation. Kolar has previously described how proper core stabilisation is achieved by the simultaneous activity of the thoracic diaphragm’s two functions of respiration and stabilisation (40–42). The position of the chest and pelvis affect the synchronised activity of both the thoracic and pelvic diaphragms. The area of attachment (apposition) between the diaphragm and the ribcage is referred to as the zone of apposition (ZOA) which is of great importance for proper diaphragm function (40,42,43). An elevated chest position reduces the ZOA between the diaphragm and the lower ribcage, and impairs the contraction of the costal part of the diaphragm (Fig. 7). The ZOA is controlled by the abdominal muscles and affects both the thoracic and pelvic diaphragms’ length–tension relationships. The efficiency of both diaphragms largely depends upon the diaphragm’s position and anatomical relationship with the lower ribcage and the pelvic girdle. In other words, not only can changing the position of the pelvis affect ribcage position, but changing ribcage position can affect pelvic position. The combination of an elevated chest with an anteriorly tilted pelvis is a common posture that severely

compromises the ability to achieve proper stabilisation. Ideally the diaphragm and pelvic floor should be parallel and/or horizontally to each other for maximal position and function (Fig. 8). The role of the abdominal musculature is to oppose the action of the thoracic diaphragm by way of eccentrically contracting. This opposing action of the abdominal musculature is imperative in controlling the length– tension relationship of both sides of the diaphragm muscles. All skeletal muscles, including the diaphragm, have a length– tension relationship where decreased length (contraction) decreases the force of the contraction. The opposing forces created by the abdominal muscles in their eccentric contraction maintain a normal range of ZOA so that the needed force generated by the thoracic diaphragm is not lost.

the leFt aiC The left AIc pattern describes a polyarticular chain of muscles that is anterior to the spine and interior in the body. There are two anterior interior polyarticular muscular chains in the body that have a significant influence on respiration, rotation of the trunk, ribcage, spine and lower extremities. These two tracts of muscles, one on the left and one on the right, are interior to the thoraco-abdominalpelvic cavity and are composed of the diaphragm, psoas, iliacus, tensor fasciae latae, biceps femoris and vastus lateralis muscles (Fig. 9). This chain of muscles provides the support and anchor for abdominal counterforce, trunk rotation and flexion movement. These muscles are all interrelated; thereby changes in one of them will affect the others (32–34).

Zone of apposition The thought is that this chain of muscles becomes imbalanced because of several factors such as asymmetrical position of organs, asymmetrical forces exerted by the diaphragm and cerebral hemisphere dominance (31–34). This pattern is thought to be established in both right- and left-handed individuals. The absence of a liver on the left side of the body creates a situation where the left hemi-diaphragm is not well positioned and therefore sportEX medicine 2015;64(April):10-18

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the area of the diaphragm known as the ZOA becomes decreased (43). consequently, the left lower ribs become more elevated and/ or externally rotated relative to the right side and the left abdominals may become lengthened relative to the right side. The ZOA is the area of the chest wall where the abdominal contents abut the lower ribcage. The influence of the asymmetrical pull of the hemi-diaphragms on the ribs is due in part to the asymmetrical distal diaphragm attachment sites; asymmetrical domes of the hemidiaphragms and asymmetrical forces are produced resisting the descent of the diaphragm upon inhalation. The distal attachment sites are known as the crura (singular, crus). The right diaphragm’s crus is broader and longer and arises from the anterolateral aspect of the first three lumbar vertebral bodies (l1–l3), whereas the left hemi-diaphragm’s crus corresponds to the upper two vertebral bodies (l1– l2). The left and right crura converge to form the central tendons of the

diaphragm. The right hemi-diaphragm dome is much larger and more dome-shaped than the left. The right diaphragm has the liver directly under it, giving it more of a dome-shape and providing a better fulcrum by resisting downward displacement on which the diaphragm acts to raise the lower ribs upon inhalation and therefore provides a more optimal ZOA. The left hemi-diaphragm is smaller and flatter than the right, due to development, location and lack of a central fulcrum. It has little oppositional resistant force upon inhalation and most often leads to a less than optimal ZOA, and consequently an elevated lower ribcage and/or rib flare.


Pelvic position The greater pull of the left hemidiaphragm due to decreased oppositional demands, when compared to the right, is thought to contribute to an asymmetrical lumbo-pelvic-femoral position. This position contributes to an anterior pelvic tilt and forward pelvic rotation on the left side. Accompanying

} Figure 6: Relationship of thoracic diaphragm and pelvic diaphragm in regards to respiratory function. (Copyright: Postural Restoration Institute, 2014. Image used with permission.)

Figure 7: Forward tilt of pelvis and elevated lower ribcage and sub-optimal zone of apposition (ZOA). (Copyright: Postural Restoration Institute, 2014. Image used with permission.)

Figure 8: Neutral position of pelvis and depressed lower ribcage with optimal ZOA. (Copyright: Postural Restoration Institute, 2014. Image used with permission.)

left anterior interior chain (left aiC)

Figure 9: Left anterior interior chain (left AIC). (Copyright: Postural Restoration Institute, 2014. Image used with permission.)


positional issues would include rotation of the lumbar vertebrae and the sacrum to the right. The right hip when operating in a closed chain would therefore be in adduction and orientated in internal rotation. The left hip would also compensate for this right spine and sacrum orientation by abducting and externally rotating the lower left extremity to realign the foot in the sagittal plane. This is complimented by a left anteriorly tilted pelvis (sagittal plane) and forwardly rotated pelvis (transverse plane). An individual with a left AIc pattern will demonstrate an anterior tilt and forward rotation of the left hemi-pelvis. Due to this position, the individual will usually demonstrate weakness and lengthening of specific muscles in all three planes. Muscles that provide movement and control of the lumbopelvic-femoral complex have the ability to perform in more than one plane. Symmetry is restored when recruitment of specific muscles are engaged between the left and right side of the body. Individuals with a left AIc pattern who are positioned in a state of right AF IR and left AF eR will most likely demonstrate the following myokinematic relationships: the left hemi-pelvis is positioned in a state of flexion, abduction and external rotation; the right hemi-pelvis is positioned in a state of extension, adduction and internal rotation (Fig. 10). All efforts to restore proper acetabular femoral position in all three planes are desired (Fig. 11). Furthermore, it necessitates

Figure 10: Clockwise rotation of the acetabulum on the femur results in the acetabulum internally rotating on the fixed right femur causing right acetabulum femoral internal rotation ‘right AF IR’ and concomitant left acetabulum external rotation ‘left AF ER’ of the acetabulum externally rotating on the fixed left femur. (J. Masek, 2014)


correction of femoral acetabular compensatory activity once proper acetabular femoral position is obtained (32–34). The pelvic position with this left AIc pattern is thought to result in part from the asymmetrical pull on the spine by the diaphragm and also from the weaker left abdominals which would result in a an anterior tilt and forward rotation of the left innominate relative to the right and sacral orientation to the right (44). If the femur stays neutral in the acetabulum when the pelvis goes anterior and forward it would appear to be oriented inward with toes pointing inward to the midline. This position often results in compensatory left hip external rotation to reorient the foot on the ground and the femur back into the sagittal plane (32–34).

length–tension and positional influences Prolonged postural adaptations can result in muscle length changes. The time muscle spends in the shortened range and the amount the muscle is contracted in the shortened range determines whether it becomes shortened. conversely the rationale for lengthening a muscle is the amount of tension placed on the muscle over a prolonged period. Sustained postures, particularly postures that are maintained in faulty alignments can induce changes in the muscle’s length. These adaptations in the muscle length may not only contribute

Figure 11: Anticlockwise rotation of the acetabulum on the femur results in the acetabulum internally rotating on the fixed left femur causing left acetabulum femoral internal rotation ‘left AF IR’ and concomitant right acetabulum external rotation ‘right AF ER’ of the acetabulum externally rotating on the fixed right femur. (J. Masek, 2014)

to being responsible for the faulty posture but also may contribute to altered length–tension properties and subsequent force couple action of muscles. Musculature may be unable to develop the required tension if it is mal-positioned or if non-desirable symmetry exists. Therefore the use of other muscles with similar actions to control the action otherwise carried out by the prime mover needs to occur. This in turn may lead to abnormal movement patterns (45). Balance between musculature across the left and right side of the lumbopelvic-femoral complex is essential in the development and maintenance of correct postural alignment and consequently avoids the development of a faulty posture (Table 1).

aF/Fa mechanics The inability to rotate an acetabulum on a non-moving femur or the inability to rotate a femur on a non-moving acetabulum can result in compensatory shearing forces throughout the pubis symphysis, sacroiliac joints and the lumbosacral junction. It would be beneficial to establish stability throughout these structures before addressing the compensatory shear issues. compensatory rotational control, throughout the body’s transverse plane of movement, secondary to decreased rotational control throughout the AF/FA joints, places additional compression and shearing forces on these same joints. Rotary movements of the femur depend largely on the acetabular position, compression of the femur in the acetabulum from muscle activity during open kinetic chain activities, and from bearing weight during closed chain kinetic activities (45). Anterior rotation of the two hemi-pelvises on the femur places the femurs in a passively internally rotated position in relationship to the pelvis. Anterior rotation of one hemipelvis places one’s centre of gravity on the contralateral lower extremity. On the side that the hemi-pelvis is rotated anteriorly and forwardly, there is probable accompanying internal rotation weakness. This occurs as a result of the passive internal orientation of the femur or as a sportEX medicine 2015;64(April):10-18

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result of compensatory activity of the external rotators to orientate the femur towards midline if the hemi-pelvis does not extend or posteriorly rotate. The lower extremity on the contralateral side of the posteriorly rotated pelvis would most likely demonstrate external rotation weakness secondary to the orientation of the pelvis on the femur, for the aforementioned reason. examination of one’s posture may reveal an increased lumbar lordosis or pelvic obliquity that may account for

hip impingement (46,47). Therefore, if the pelvis is more anteriorly rotated, the greater the risk for impingement (46). Acetabular movement on the femur (AF) and femoral movement on the acetabulum (FA) occurs with rotation in all three planes of sagittal, transverse and frontal direction. At heel strike the acetabulum adducts on the femur and then abducts from midstance until terminal swing. At foot stance the femur externally rotates on the acetabulum and then internally

rotates during midstance. Regardless of the phase, the inability to decrease the forces of the femur on the acetabulum or the acetabulum on the femur because of improper pelvic orientation or asymmetry leads to possible hip impingement and/or labral tearing. This lack of congruent rotation and stability of AF/FA movement secondary to asynchronous AF activity and dyssynchronous FA activity can lead to undesirable force-coupling and contact during adduction and internal rotation

table 1: PoSitional and ComPenSatory inFluenCeS oF the leFt aiC Pattern on muSCulature oF the lumbo-PelviC-Femoral ComPlex (J. maSek, 2014) Plane


effect on left lumbopelvic-femoral complex

effect on right lumbo-pelvic-femoral complex



Shortened and strong secondary to flexion of the left hemi-pelvis (Positional)

lengthened and weak secondary to extension of the right hemi-pelvis (Positional)

Tensor fasciae latae

Shortened and strong secondary to flexion of the left hemi-pelvis (Positional)

lengthened and/or normal length secondary to extension of the right hemi-pelvis (Positional)


lengthened and weak secondary to flexion of the left hemi-pelvis (Positional)

Shortened and strong secondary to extension of the right hemi-pelvis (Positional)

gluteus maximus

lengthened and weak secondary to flexion of the left hemi-pelvis (Positional)

Shortened and strong secondary to extension of the right hemi-pelvis (Positional)

Posterior gluteus medius

Shortened and strong secondary to abduction (compensatory)

lengthened and weak secondary adduction (Positional)

Anterior gluteus medius

Shortened and strong secondary to abduction (Positional)

lengthened and weak secondary adduction (Positional)

Adductor magnus and longus

lengthened and weak secondary to abduction (compensatory)

Shortened and strong secondary to adduction (Positional)

Ischiocondylar adductor magnus

lengthened and weak secondary to abduction (compensatory)

Shortened and strong secondary to adduction (Positional)


Shortened and strong secondary external rotation (compensatory)

lengthened and weak secondary internal rotation moment (Positional)

Tensor fasciae latae

Shortened and strong secondary external rotation (compensatory)

Shortened and/or normal length and strength secondary to internal rotation (Positional)

gluteus maximus

Shortened and strong secondary external rotation (compensatory)

lengthened and weak secondary internal rotation (Positional)

Anterior gluteus medius

lengthened and weak secondary external rotation (compensatory)

Shortened and/or normal length and strength secondary to internal rotation (Positional)

Posterior gluteus medius

Shortened and strong secondary to external rotation (compensatory)

lengthened and weak secondary internal rotation (Positional)

Adductor magnus and longus

lengthened and weak secondary to external rotation (compensatory)

Shortened and strong secondary to external rotation (compensatory)

Ischiocondylar adductor magnus

lengthened and weak secondary to external rotation (compensatory)

Shortened and strong secondary to internal rotation (Positional)


Shortened and strong secondary to external rotation (compensatory)

lengthened and weak secondary internal rotation (Positional)

Obturator internus

Shortened and strong secondary to external rotation (compensatory)

lengthened and weak secondary internal rotation (Positional)




and abduction and external rotation, regardless if the lower limb is loaded or unloaded (34). Although surgical options have developed considerably to reduce or prevent further joint degeneration, restore structural anatomic abnormalities and eliminate biomechanical factors (14,48–50), there is still a lack of information regarding the underlying FAI pathomechanics. It is theorised that correcting the underlying mechanical pathology in FAI will help delay the progression of hip arthritis (51). Although pathomechanics appear to account for FAI symptoms and provide insight into the development of diverse therapeutic approaches for FAI, there is an absence of biomechanically based treatments with proven effects on both structure and pain. Furthermore, there is limited theoretical information that has been applied in a manner that provides understanding or offers a foundation for clinical decision making regarding the biomechanics that may have caused the hip pathology.

key PointS n the human body has a noticeable outward appearance of symmetry, with eyes, ears and limbs being symmetrical around the midline. n internally, the organs are inherently asymmetrically arranged. n Postural restoration techniques assist in the treatment of undesirable asymmetry, restoring proper joint position and muscle activity. n Pelvic asymmetry is common among symptomatic and asymptomatic individuals. n Pelvic asymmetry has been thought to alter body mechanics, affect the length of muscles that originate on the pelvis, and result increased strain on bony and soft tissues possible producing asymmetrical adaptations. n there are three types of Fai: pincer, cam and mixed impingement. n hruska’s postural pattern of asymmetry, the left anterior interior chain (aiC) pattern, is characterised by the tendency for the anterior tilt and forward rotation of the left hemi-pelvis. n the pelvis and the ribcage are linked through the pelvic and thoracic diaphragms. n respiratory and lumbo-pelvic-femoral function can have an effect on Fai.

Summary Postural Restoration® recognises a common pattern of asymmetry that may contribute to a multitude of musculoskeletal conditions including FAI. This article has described the different types of FAI and the influence that respiration can have on the pelvic girdle through two part of the diaphragm. In part two of this series I will propose biomechanical mechanisms and rationale for both cam and pincer types of FAI as it relates to Postural Restoration®.

online References Owing to space limitations in the print version, the references that accompany this article are available at the following link and are also appended to the end of the article in the web and mobile versions. click here to access the references

Further reSourCeS 1. hruska clinic website ( 2.Postural Restoration Institute website ( 18

THE AUTHOR JASON MASEK MA, PT ATC CSCS PRC Jason completed his degree in Physical Therapy from Des Moines UniversityOsteopathic Medical Center in Des Moines, Iowa, USA. He received his athletic training experience from the University of Nebraska-Lincoln and the University of Minnesota. Jason currently practices at the Hruska Clinic™ Restorative Physical Therapy Services in Lincoln, Nebraska, USA. Jason has developed a strong background in sports medicine and athletic injuries with an emphasis in manual physical therapy. He is a member of the National Athletic Trainers Association, the National Strength & Conditioning Association. Jason has earned the designation of Postural Restoration Certified (PRC) as a result of advanced training, extraordinary interest and devotion to the science of postural adaptation, asymmetrical patterns and the influence of polyarticular chains of muscles on the human body as defined by the Postural Restoration Institute® in Lincoln, Nebraska, USA.


n how are respiration and the lumbopelvic complex linked? n Name and describe the three types of femoroacetabular impingement. n What is the left anterior interior chain pattern and how is it linked to FAI?

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Femoroacetabular impingement References 1. Schneider F, Labs K, Wagoner S. Chronic patellofemoral pain syndrome: alternatives for cases of therapy resistance. Knee Surgery, Sports Traumatology, Arthroscopy 2001;9:290–295 2. Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clinical Orthopaedics and Related Research 2004;429:170–177 3. Coughlin KJ, Hruska R, Masek J. Cough-variant asthma: responsive to integrative management and Postural Restoration. Explore 2005;1:377–379 4. Boyle K, Jansa S, Lauseng C. Management of a woman diagnosed with trochanteric bursitis with the use of a Protonics® neuromuscular system. Journal on the Section of Women’s Health 2003;27:12–16 5. Boyle K. Conservative management for patients with low back pain: a case series. Journal of Orthopaedic & Sports Physical Therapy 2008;38: A67 6. Robey JH, Boyle KL. The role of prism glass and postural restoration in managing a collegiate baseball player with bilateral sacroiliac joint dysfunction: a case report. The International Journal of Sports Physical Therapy 2013;8(5):716–728 7. Robey JH, Boyle KL. Bilateral functional thoracic outlet syndrome in a collegiate football player. North American Journal of Sports Physical Therapy 2009;4(4):170–181 8. Krawiec CJ, Denegar CR, et al. Static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes. Manual Therapy 2003;8(4):207–213 9. Levangie PK. The association between static pelvic asymmetry and low back pain. Spine 1999;24:1234–1242 10. Dubousset J. Pelvic obliquity: a review. Orthopedics 1991;14:479–481 11. Egan DA, Cole J, Twomey L. The standing forward flexion test: an inaccurate determinant of sacroiliac joint dysfunction. Physiotherapy 1996;82:236–242 12. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. Physical Therapy 1988;68:1359–1363 13. Anderson SE, Klaus SA, Moritz T. Femoroacetabular impingement: evidence of an established hip abnormality. Radiology 2010;257(1):8–13 14. Bedi A, Kelly BT. Femoroacetabular impingement. Journal of Bone & Joint Surgery (Am) 2013;95(1):82–92 15. Berkes MB, Cross MB, et al. Traumatic posterior hip instability and femoroacetabular impingement in athletes. The American Journal of Orthopedics. 2012;41(4):166–171 16. Blecher CB, Ly, JQ. Femoroacetabular impingement. AMSUS Military Medicine Radiology Corner 2008;173(4):xxvi–xxvii ( 17. Byrd JWT, Jones KS. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clinical Orthopaedics and Related Research 2009;467:739–746 18. Byrd JWT. Femoroacetabular impingement in athletes, part II: treatment and outcomes. Sports

BY Jason Masek MA, PT ATC CSCS PRC Health 2010;2:403–409 19. Ejnisman L, Philippon MJ, Lertwanich P. Femoroacetabular impingement: the femoral side. Clinical Sports Medicine 2011;30:369–377 20. Emara K, Samir W, et al. Conservative treatment for mild femoroacetabular impingement. Journal of Orthopaedic Surgery 2011;19(1):41–45 21. Hack K, Di Primio G, et al. Prevalence of camtype femoroacetabular impingement morphology in asymptomatic volunteers. Journal of Bone & Joint Surgery (Am) 2010;92:2436–2444 22. Kaplan KM, Shah MR, Youm T. Femoroacetabular impingement--diagnosis and treatment. Bulletin of the NYU Hospital for Joint Diseases 2010;68(2):70–75 23. Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Medicine 2008;10:863–878 24. Lee JT, Fiechti JF. Femoroacetabular impingement in a soccer player. International Journal of Athletic Therapy & Training 2012;17(6):40–43 25. Ganz R, Parvizi J, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research 2003;(417):112–120 26. Giori NJ, Trousdale RT. Acetabular retroversion is associated with osteoarthritis of the hip. Clinical Orthopaedics and Related Research 2003;(417):263–269 27. Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. Journal of Bone & Joint Surgery (Am) 1999;81(12):1747–1770 28. Klingenstein GG, Zbeda RM, et al. Prevalence and preoperative demographic and radiographic predictors of bilateral femoroacetabular impingement. American Journal of Sports Medicine 2013;41(4):762–768 29. Gnat R, Saulicz MB, Kłaptocz P. Does pelvic asymmetry always mean pathology? Analysis of mechanical factors leading to the asymmetry. Journal of Human Kinetics 2009;21:23–32 30. Janda, V. Evaluation of muscular imbalance. In: Liebenson C (ed.) Rehabilitation of the spine: a practitioner’s manual, pp. 97–112. Lippincott Williams & Wilkins 1996. ISBN 978-0781729970 (£81.18). Buy from Amazon 31. Boyle K. Conservative management for patients with sacroiliac joint dysfunction. In: Norasteh AA (ed.) Low back pain, pp293–332. InTech 2012. ISBN: 978-95351-0599-2 ( 32. Hruska RJ. Myokinematic Restoration. An integrated approach to treatment of lower half musculoskeletal dysfunction. Postural Restoration Institute Course Manual 2014 33. Hruska RJ. Advanced Integration. Postural Restoration Institute Course Manual 2014 34. Hruska RJ. Impingement and instability. Postural Restoration Institute Course Manual 2014 35. Sonzogni JJ, Gross ML. Biomechanics and softtissue insults; Hip and pelvic injuries in the young - Part I. Emergency Medicine 1993;74–94

36. Reimann R, Sodia F, Klug E. Die umstrittene Rotationswirkung ausgewahlter Muskeln im Huftgelenk. Annals of Anatomy 1996;178:353– 359 37. Lee D. The pelvic girdle: an approach to the examination and treatment of the lumbo-pelvic-hip region (3rd edn). Churchill Livingstone 2004. ISBN 978-0443073731 (£27.16). Buy from Amazon 38. Alderink GJ. The sacroiliac joint: review of anatomy, mechanics and function. Journal of Orthopaedic & Sports Physical Therapy 1991;13:71–84 39. Norkin CC, Levangie PK. Joint structure and function: a comprehensive analysis (5th edn). F. A. Davis 2011. ISBN 978-0803623620 (Print £51.43, Kindle £48.86). Buy from Amazon 40. De Troyer A, Estenne M. Functional anatomy of the respiratory muscles. Clinics in Chest Medicine 1988;9(2):175–193 41. Kolar P, Sulc J, et al. Postural function of the diaphragm in persons with and without chronic low back pain. Journal of Orthopaedic & Sports Physical Therapy 2012;42(4):352–362 42. Mead J. Functional significance of the area of apposition of diaphragm to rib cage. American Review of Respiratory Disease 1979;11:3 43. Reid WD, Dechman G. Considerations when testing and training the respiratory muscles. Physical Therapy 1995;75(11):971–982 44. Cibulka MT. Sacroiliac joint dysfunction as a reason for the development of acetabular retroversion: a new theory. Physiotherapy Theory and Practice. 2014;30(4):249–253 45. Hruska RJ. Pelvic stability influences lower extremity kinematics. Biomechanics 1997;(5)6:23–29 46. Ito K, Minka L, et al. Femoroacetabular impingement and the cam-effect. Journal of Bone & Joint Surgery (Br) 2001;83B:171–176 47. Reynolds D, Lucas J, Klaue. Retroversion of the acetabulum: a cause of hip pain. Journal of Bone & Joint Surgery (Br) 1999;81B:281–288 48. Lavigne M, Parvizi J, et al. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clinical Orthopaedics and Related Research 2004;418:61–66 49. Leunig M, Robertson WJ, Ganz R. femoroacetabular impingement: diagnosis and management, including open surgical technique. Operative Techniques in Sports Medicine 2007;15(4):178–188 50. Matsuda DK, Hanami D. Hip arthroscopy for challenging deformities: posterior cam decompression. Arthroscopy Techniques 2013;2(1):45–49 51. Brandt KD, Dieppe P, Radin EL. Etiopathogenesis of osteoarthritis. Rheumatic Disease Clinics of North America 2008;34:531–559.

eviDence informeD practice

Diagnosing achilles tenDinopathy

e D i u g ’ o t a ‘how

BY Dr Sarah Morton MBBS anD Dr DYlan MorriSSeY PhD

introDuction Tendinopathy is a very common condition, seen regularly by sports physicians, physiotherapists, general practitioners and others. Indeed overuse injuries are estimated to be implicated in between 30–50% of all sporting injuries (1). It can be extremely debilitating so requires quick recognition to enable you to help your patient and to ensure you commence the appropriate management. Of the tendinopathies, Achilles tendinopathy is likely to be the most common to present and therefore the aim of this article is to help with this diagnostic process and how to differentiate it from other pathologies. The lifetime cumulative incidence is estimated at 5.9% in sedentary individuals and 50% in elite endurance athletes (2). We recognise that a lot of different opinions revolve around tendinopathies, from the aetiology (degeneration versus inflammation) to when to image or not (3,4). However, this ‘how to’ guide is based on both the evidence and rich clinical experience. Our key message throughout, therefore, remains always treat the patient, rather than primarily the investigations, but do include diverse forms of information where possible.

This article aims to act as a ‘how to’ guide for diagnosing Achilles tendinopathy. We describe the differential diagnoses and look carefully at the history taking, examination methods and imaging techniques that we find useful in diagnosing Achilles tendinopathy. We emphasise the use of imaging only when necessary and that abnormal imaging does not necessarily translate to symptoms. Throughout the article our key method remains to always treat the patient and not the results of the investigations. hiStorY taking Achilles tendinopathy is likely to have an insidious onset over time and so patients are unlikely to present immediately (5). Debate continues about the exact pathology. In recent years the continuum of tendinopathy had been (mostly) accepted with three stages recognised: reactive tendinopathy, tendon disrepair and degenerative tendinopathy (3). However, recent work suggests that chronic tendinopathy may in fact be an active process of ongoing tendon degeneration with an inflammatory response underlying this (4). More research will likely build on both of these models in the future, and they are something to consider when managing your patient. What is agreed upon is that Achilles tendinopathy is more commonly mid-tendon Achilles tendinopathy, although insertional Achilles tendinopathy is not uncommon. As the literature (and our clinical experience) suggests, these two main types of Achilles tendinopathy require different management. Therefore, it is always crucial to determine the

site of the pain: if the patient points at their calcaneus, insertional must be considered before midsubstance Achilles tendinopathy. If the patient points more generally at their Achilles tendon, or indeed rubs their hand along the length of their tendon when asked where the pain is, this will point you more towards midsubstance Achilles tendinopathy. Differentials for heel pain are numerous but other common local things to consider are: Achilles tendon rupture, Achilles partial tear, Achilles intratendinous tear (described below), fascia crura tear (described

Our key MessAge THrOugHOuT, THerefOre, reMAIns ALWAys TreAT THe pATIenT, rATHer THAn prIMArILy THe InvesTIgATIOns, buT DO IncLuDe DIverse fOrMs Of InfOrMATIOn WHere pOssIbLe 19

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Youtube Video 1: ‘David beckham injury – Achilles tendon – 14 March 2010’. (


below), posterior impingement of the ankle, long flexor tendinopathy, plantaris tendinopathy, sinus tarsi syndrome, retrocalcaneal bursitis and many other but less common things such a referred pain (6). The type of pain a patient presents with is also very important for guiding your diagnostic process. It should be noted that different tendon problems have different pain mechanisms and there are likely to be interactions between pain beliefs, central sensitisation, neuropathic and localised pain (7). Therefore it is crucial to listen to what your patient says; what doctors are taught in the first year of medical school still applies – you ask an open question, shut up and actively listen. patients with Achilles tendinopathy will typically describe more of a dull throbbing pain throughout their tendon, that often worsens with activity and improves with rest (5). It is often associated with stiffness in the morning, with a patient describing the need to warm their tendon up (5). Indeed the vIsA-A questionnaire, a validated questionnaire used in assessing the severity of the Achilles tendinopathy, uses the time the stiffness lasts in the morning as one of its grading questions (8). Interestingly another question on the vIsA-A questionnaire is to describe the pain when walking downstairs, which may be helpful in clarifying your patient’s description (8). In contrast, Achilles tendon rupture or tear is characterised by a very sharp, sudden onset pain, which some patients describe as being shot in the back of the leg (5). normally it will stop the patient continuing their activity immediately; David beckham in March 2010 is a classic example of this (video 1). Interestingly, although normally asymptomatic, full tendon ruptures do normally occur on a background of tendon pathology. partial tears tend to be a more pin-point sharp pain with a memory of the event occurring. These, unlike tendon ruptures, often have preceding tendinopathy pain and can co-exist. Intratendinous tears have been recently described in the literature and some patients with small tears appear to be able to train but not reach maximal loading; these tears will

also tend to occur in active individuals performing at high levels of sport (9). patients will also describe an area of maximum pin-point pain (9). Another recently described pathology is that of a fascia cruris tear; again this presents with sudden onset pain more medially or laterally to the tendon (10). both fascia cruris tears and intratendinous tears also often co-exist with Achilles tendinopathy. It is recognised that different tendons have different pain mechanisms, which is yet another reason why it is important to take time to get an accurate description of the pain (7). Our suggestion is, therefore, to establish the type of pain, and if in any doubt, organise suitable imaging. The likelihood is you won’t need the imaging to do more than confirm your clinical suspicions, because if you have really listened – and examined accordingly – you will have got the answers. Although Achilles tendinopathy is more common in active individuals, for example male distance runners are recognised to have a lifetime risk of 52%, it is by no means exclusive to active people, as mentioned above (2,11). Therefore, although it is important to establish the amount and type of physical activity and/or exercise your patient undertakes, if they do not partake in anything you should not immediately exclude the diagnosis (12). In fact, as many as half of all patients are not sportingly active, hence why tendinopathy is a major public health issue. Also, beware of asking patients only about their exercise. for example, a builder might reply that he does not do any exercise when in fact he spends all day every day lifting and carrying. Take time to take the history and make sure you understand completely the physical activity and loads the tendon is exposed to – children are a prime example of this. so many children and young people will be doing their three hours of football training a week which they or their parents will describe clearly; however, they will forget to tell you about their two hours of pe lessons a week, the lunchtime school football session and the park session they do with their friends every weekend. Whereas with adults the situation may not be so extreme, do take a helicopter view of a sportEX medicine 2015;64(April):19-24

eviDence informeD practice

patient’s activity profile and avoid being beguiled by the immediately offered explanation. Autoimmune conditions such as rheumatoid arthritis and even type 2 diabetes and high cholesterol have also been found to be associated with Achilles tendinopathy (13–15). even drugs such as statins and fluoroquinolones (antibiotics) have been shown to be associated with tendinopathic symptoms, alongside social factors such as smoking (16–18). Therefore the classical method of taking a history is crucial, as past medical history, drug history, family history and social history may in fact alert you to key risk factors for a particular patient’s development of the condition. Having access to advice or guidance mechanisms and services about factors such as weight management or smoking cessation at your finger-tips may help facilitate holistic care. And remember, the patient comes to you for help and they will therefore not only tell you the majority of what you need to know but also what they particularly require you to help with as every patient is different. remember that a cure is unlikely, but given that individualised management is an early goal, this conversation is likely to optimise successful treatment.

clinical exaMination examining a tendon has generated some controversy, especially when the tendon is not easily palpable. However, the Achilles tendon is easily accessible and we suggest you do go on to do a very full examination. And, as with any orthopaedic or sports medicine examination, it is important to compare both sides. It is also very useful to assess the patient’s gait to see what, if any, impact the condition is having on their ambulation. It may also identify biomechanical factors, such as foot pronation, that might be associated with development of Achilles tendinopathy (19). After a thorough standing and supine examination of function in related areas, the Achilles tendon is best examined with the patient prone. The tendon may feel thickened and is likely to be tender from about 2 to 6cm proximal to the calcaneal insertion

DIfferenTIALs fOr HeeL pAIn Are nuMerOus buT OTHer cOMMOn LOcAL THIngs TO cOnsIDer Are: AcHILLes TenDOn rupTure, AcHILLes pArTIAL TeAr, AcHILLes InTrATenDInOus TeAr, fAscIA crurA TeAr, pOsTerIOr IMpIngeMenT Of THe AnkLe, LOng fLexOr TenDInOpATHy, pLAnTArIs TenDInOpATHy, sInus TArsI synDrOMe, reTrOcALcAneAL bursITIs AnD MAny OTHer (buT Less cOMMOn) THIngs sucH A referreD pAIn (5). There may be associated swelling and crepitus, although this may be attributable to paratendinopathy (5). related structures should also be examined to exclude other differentials, for example ensuring posterior ankle impingement is not present and that there is no retrocalcaneal bursa. It is always important to exclude an Achilles tendon rupture and so the simmond’s squeeze test should be performed; if the tendon is torn, when the calf muscle is squeezed the foot will remain still and will not plantarflex (5). It can also be noted when the patient is lying prone whether the affected foot is less plantarflexed in comparison to the other – this is useful in establishing whether there is still an intact connection between the muscles and tendons. In terms of specific tests for Achilles tendinopathy the royal London Hospital test has found to be useful; if tenderness that is experienced in the mid-tendon (approximately 3cm proximal from the calcaneal insertion) during slight plantarflexion is reduced when the muscle contracts or the foot is dorsiflexed this is said to be a positive test and points towards the diagnosis of Achilles tendinopathy (20). The painful arc sign has also been described in the literature, although it may have been found to underestimate the number of affected tendons (20,21). passive plantarflexion is very useful for ruling in or out posterior impingement. It is, however, important that all these tests be used alongside the history and examination findings – if your history doesn’t fit then think again. One thing that is also very helpful, as it gives an indicator of symptom

threshold, is a graded loading challenge. for example it is important to ascertain the Achilles tendon pain response to, for example, a progression from double- to single-leg slow heel raising and lowering, to a double-leg jump and then to hopping. As we progress through these movements the load on the Achilles tendon changes and therefore an insight can be gained into the pain response of the patient. It can also be useful to establish the strength of the tendon and surrounding muscles; if one leg is affected and not the other the difference can be significant. This can then be very useful when treating the patient to allow comparison and to monitor progression.

iMaging Imaging in all areas of medicine is now bringing new challenges to the forefront. Indeed one nHs radiologist recently remarked to me that at least 20% of scans carried out are as a result of another imaging modality finding something that might be ‘suspicious’ and so requiring further investigation. Once again this comes back to treating the patient and only using imaging when necessary because of diagnostic uncertainty, or to confirm the diagnosis and rule out confounders. It must be remembered also that the clinician must be adept at using and interpreting the imaging results to maximise benefit. Also, ‘pathology’ can exist without symptoms – it is common to have changes on imaging scans but no symptoms and therefore imaging should not be used without real reason (22). ultrasound is usually considered first as it can often be carried out in 21

OnLy use IMAgIng WHen necessAry becAuse Of DIAgnOsTIc uncerTAInTy, Or TO cOnfIrM THe DIAgnOsIs AnD ruLe OuT cOnfOunDers

(a) Figure 2: (a) Ultrasound of a left-sided fascia cruris tear (blue arrow). (b) Ultrasound image showing right-sided fascia cruris tear (blue arrow) with separate intratendinous tear (red arrow). (c) A partial tear of the Achilles tendon (yellow arrow) resulting in disruption of the overall tendon shape. (O. Chan, London Independent Hospital, 2015)


(b) Figure 1: (a) Ultrasound image showing a tendinopathic tendon measuring 8.1mm at its thickest point. (b) Neovascularisation seen in a tendinopathic Achilles tendon. (O. Chan, London Independent Hospital, 2015)

(b) a more timely fashion; it also benefits from being a dynamic assessment that can easily be followed up (5,23). by this we mean the foot can be moved during the assessment and indeed the ultrasound probe can be used to find the point of tenderness. commonly, the anterior-posterior tendon diameter is measured at the thickest point and this measurement has been shown to be a reliable indicator of tendinopathy (24). One study of controls and cases of Achilles tendinopathy showed a statistically significant difference in the tendon thickness between the groups: 4.4mm for control tendons compared with 5.6mm for tendinopathic tendons (25). In our experience, tendons can be much thicker than this, as seen in figure 1(a). However, just because the tendon is thick does not mean it is problematic so take it into consideration, but do not allow it to cloud your judgement.



neovascularisation (fig. 1b) can also be graded on ultrasound, and has shown to be weakly related to the severity of the Achilles tendinopathy (23–25). Again this can lead to discrepancies between treating the patient and treating the results on the scan; in the absence of symptoms, the presence of neovascularisation does not confirm the presence of a tendinopathy. ultrasound also allows the difference to be seen between other Achilles pathologies including partial tears, fascia cruris tears and intratendinous tears (fig. 2). This is where we feel imaging can be the most powerful in helping you as a clinician. It should be noted that all of these pathologies can coexist with tendinopathy and so, as described above, the clinical history and examination is important; it may be that a tendinopathic tendon is

seen on ultrasound but this is not the underlying cause of a patient’s pain. Magnetic resonance imaging, although not as commonly used, can be good at providing information regarding the structures around the Achilles tendon and other concurrent pathologies, for example articular pathology (28).

concluSion Achilles tendinopathy is a common condition that is important to diagnose accurately; differentials must be excluded and co-existent pathology should not be forgotten. Although this article is primarily based on Achilles tendinopathy, it should be noted that many of these principles apply to other tendons in the body and they can aid the diagnosis of these tendinopathies as well. And remember, your patient is the primary source of powerful clues and critical context.

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References 1. scott A, Ashe Mc. common tendinopathies in the upper and lower extremities. current sports medicine reports 2006;5:233–241 2. kujala uM, sarna s, kaprio J. cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. clinical Journal of sport medicine 2005;15:133–135 3. cook JL, purdam cr. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of sports medicine 2009;43:409–416 4. rees JD, stride M, scott A. Tendons – time to revisit inflammation? British Journal of sports medicine 2013;48:1553–1557 5. Asplund cA, best TM. Achilles tendon disorders. BmJ 2013;346:f1262 6. Alvarez-nemegyei J, canoso JJ. Heel pain: diagnosis and treatment, step by step. cleveland clinic Journal of medicine 2006;73:465–471 7. rio e, Moseley L, et al. The pain of tendinopathy: physiological or pathophysiological? sports medicine 2014;44:9–23 8. robinson JM, cook JL, et al. The visa-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. British Journal of sports medicine 2001;35:335– 341

9. Morton s, parkes T, et al. Achilles intratendinous tears – a new pathology? results of a 4 year case series. presented at British association of sports and exercise medicine annual conference, 2013. london, UK 10. Webborn n, Morrissey D, et al. Tears of the fascia cruris at the attachment to the Achilles tendon. British Journal of sports medicine 2014;doi:10.1136/bjsports-2013-093273 11. fields kb. running injuries - changing trends and demographics. current sports medicine reports 2011;10:299–303 12. De Jonge s, van Den berg c, et al. Incidence of midportion Achilles tendinopathy in the general population. British Journal of sports medicine 2011;45:1026–1028 13. Ames pr, Longo ug, Denaro v, Maffulli n. Achilles tendon problems: not just an orthopaedic issue. Disability and rehabilitation 2008;30:1646–1650 14. Akturk M, Ozdemir A, et al. evaluation of Achilles tendon thickening in type 2 diabetes mellitus. experimental and clinical endocrinology & Diabetes 2007;115:92–96 15. gaida Je, Alfredson L, et al. Dyslipidemia in Achilles tendinopathy is characteristic of insulin resistance. medicine & science in sports & exercise 2009;41:1194–1197 16. van Der Linden pD, sturkenboom M, et al. fluoroquinolones and risk of Achilles tendon disorders: case-control study. the BmJ 2002;324:1306–1307

17. kraemer r, Wuerfel W, Lorenzen J, busche M, vogt pM, knobloch k. Analysis of hereditary and medical risk factors in Achilles tendinopathy and Achilles tendon ruptures: a matched pair analysis. archives of orthopaedic and trauma surgery 2012;132:847–853 18. Marie I, Delafenêtre H, et al. Tendinous disorders attributed to statins: a study on ninety-six spontaneous reports in the period 1990-2005 and review of the literature. arthritis & rheumatism arthritis care & research 2008;59:367–372 19. nigg bM. The role of impact forces and foot pronation: a new paradigm. clinical Journal of sport medicine 2001;11:2–9 20. Maffulli n, kenward Tg, et al. clinical diagnosis of Achilles tendinopathy with tendinosis. clinical Journal of sport medicine 2003;13:11–15 21. Williams Jgp. Achilles-tendon lesions in sport. sports medicine 1986;3:114–135 22. Malliaras p, purdam c, et al. Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. British Journal of sports medicine 2010;44:944–947 23. Del buono A, chan O, Maffulli n. Achilles tendon: functional anatomy and novel emerging models of imaging classification. international orthopaedics 2013;37:715–721 24. fredberg u, bolvig L, et al. ultrasonography


in evaluation of Achilles and patella tendon thickness. Ultraschall in Der medizin 2008;29:60–65 25. Leung JL, griffth Jf. sonography of chronic Achilles tendinopathy: a case-control study. Journal of clinical Ultrasound 2008;36:27–32 26. peers kHe, brys ppM, Lysens rJJ. correlation between power Doppler ultrasonography and clinical severity in Achilles tendinopathy. international orthopaedics 2003;27:180–183 27. De Jonge s, Warnaars JL, et al. relationship between neovascularization and


clinical severity in Achilles tendinopathy in 556 paired measurements. scandinavian Journal of medicine and science in sports 2014;24:773–778 28. Maffulli n, sharma p, Luscombe kL. Achilles tendinopathy: aetiology and management. Journal of the royal society of medicine 2004;97:472–476.

THE AUTHORS DR SARAH MORTOn MBBS D Sarah is an academic foundation year one doctor at Hillingdon Hospital. She completed her medical degree at Imperial College. Her intercalated degree was in Sports and Exercise Medicine at Queen Mary University of London. Since then she has published papers on risk factors in patellar tendinopathy, low back pain in cricketers and high volume image guided injections. She was awarded the Helal and Harries Sports and Exercise Medicine prize in 2014 for her work on risk factors in patellar tendinopathy. She continues her research in this around her on-call sessions, even occasionally managing to make it to a cricket or rugby match. DR DyLAn MORRISSEy PHD D Dylan Morrissey’s overarching career objective as a clinical academic is to combine the best of educational, clinical and research practice in order to develop and deliver high quality evidence based physiotherapy for patients with musculoskeletal disorders. He is a consultant physiotherapist in Sports and Musculoskeletal Physiotherapy and clinical reader in Sports and Exercise Medicine, who recently started a 5-year nIHR/HEE fellowship with clinical trials as a primary focus. His key research theme is the link between movement and pathology, with a particular interest in tendinopathy. @DrDylanM;

Further reSourceS 1. Tendon research group at Queen Mary university London, uk.

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Video 1: achilles tendinopathy: examination in standing Video 2: achilles tendinopathy: Video 3: achilles tendinopathy: low Dye taping Video 4: achilles tendinopathy: Making a temporary orthotic Video 5: achilles tendinopathy: eccentric loading Video 6: achilles tendinopathy: Scenarios Video 7: achilles tendinopathy: Physical examination tips

keY PointS n achilles tendinopathy is common and has a lifetime cumulative incidence of 50% in elite endurance athletes. n there are numerous differentials for heel pain including achilles tendon rupture, achilles partial tear, posterior impingement of the ankle and many others. n achilles tendinopathy patients will typically describe a dull throbbing pain throughout their tendon. n examination is useful as differentials can be excluded and contributing factors, such as biomechanics, identified. n as with any orthopaedic or sports medicine examination, always compare both sides of a patient. n graded loading challenges can be very useful when examining a patient and as a baseline for treatment. n imagining is useful when diagnostic uncertainty exists. n always treat the patient and not the investigations and listen carefully to what they say as you are likely to get your answers from this alone.



n What other differentials should be considered in Achilles tendinopathy? Would age or activity level change this? Would there be any particular diagnoses you would consider for children? n Do you believe imaging is beneficial? Would you want imaging before starting treatment? Do you use imaging to follow up your patients? n What is your examination technique for Achilles tendinopathy? Are all the tests described in the article included in your current examination? Are there additional tests you would include? What is the justification for this?

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. for more information on how to access the test click this link

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Video 1: achilles tendinopathy lower limb biomechanics – examination in standing

Video 2: achilles tendinopathy lower limb biomechanics – examination in lying

Video 3 achilles tendinopathy lower limb biomechanics – low Dye taping

Video 4: achilles tendinopathy lower limb biomechanics – Making a temporary orthotic


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Video 5: achilles tendinopathy – eccentric loading

Video 6: achilles tendinopathy – Scenarios

Video 7: achilles tendinopathy – Physical examination tips


sportEX medicine 2015;64(April):19-24

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Osteoarthritis is a painful condition caused by the degeneration of the joints. Treatment can involve a combination of approaches, including exercise, lifestyle changes and pain relief and ultimately surgery. This article describes the use of gait retraining for the reduction of pain and improvement of function in medial osteoarthritis of the knee. BY Professor CathY sPeed BMedsCi, diP sPorts Med, Ma, Phd, frCP, ffseM (i) (UK) The pain experienced in osteoarthritis (OA) is associated with a number of factors including body weight, mental status, co-morbidities and gait biomechanics. These factors themselves are predictive of persisting pain. Gait retraining for patients with OA of the knee is based on the rationale that pain and progression are greater in those individuals who have certain biomechanical issues. In medial compartment OA, elevated knee adduction moment (KAM) has been identified as a key component responsible for excessive medial compartment loading contributing to disease progression. Previous studies have implied that poor neuromuscular control and inadequate muscle activation is associated with the abnormally high KAM in this condition (1,2). KAM cannot be measured easily in clinical practice but needs sophisticated analytical tools to assess reliably. Hence, using increased KAM as a criterion for gait retraining is not possible, but rather clinical assessment of gait to detect any abnormalities must be used.

Gait retraininG ‘Gait retraining’ simply means teaching patients to walk normally to reduce abnormal forces across the affected joint(s). Such retraining should be customised to the patient’s needs and should always commence with neuromuscular and proprioceptive training. Given that body mass also significantly influences knee loads, weight management must be considered a priority. More sophisticated approaches to gait retraining have been described. For example Shull et al. described a 6-week programme in adults with OA of the medial knee who were already reasonably functional (adults able to walk unaided for 25 minutes) (3). Exclusion criteria included: body mass index greater than 35; inability to adopt an altered gait due to previous injury or surgery on the back or lower extremities; use of a shoe insert or hinged knee brace; or corticosteroid injection within the previous 6 weeks. Gait retraining and analysis was focused on the leg with greatest self-reported knee pain. Subjects attended the laboratory and were assessed using a sophisticated 8-camera system and sensors to identify abnormal gait patterns. Instructions were given to the patient to alter trunk sway and foot progression angle

Gait retraininG retraininG in medial osteoarthritis of the knee as appropriate. The first session was to determine baseline pain and function, identify baseline walking patterns, identify an individualised altered gait pattern for each subject, and to train the subject to walk with this new, altered gait. Weekly gait retraining sessions were then followed. during one posttraining session and at 1-month follow-up, walking kinematics, knee loading, pain, and function were re-assessed. Gait retraining reduced the first peak KAM by 20% (P <0.01) post-training as a result of a 7° decrease in foot progression angle (ie. increased internal foot rotation), compared to baseline (P <0.01). WOMAc (Western Ontario and McMaster universities) pain and function scores were


diagnosis - OA – medial knee - non-surgical medial meniscal pain


further evaluation - bMI - Exercise habits - Self efficacy - WOMAc - Gait analysis/ biomechanics

Patient education

Weight management

Pain management Oral/injectable

Physical therapy To include neuromuscular & proprioceptive neurotraining

Consider aPos or other gait retraining - Persisting pain without analgesics, in spite of completion of above - no contraindications*

*exclusions to aPos n Mean WOMAc at baseline >5 (on WOMAc 0–10, average of 3 scales) n bi- or tricompartmental disease n Inflammatory arthritis n Falls n Severe osteoporosis and/or history of fragility fractures n Significant knee deformity n Obesity n low self-efficacy score n Inability to mobilise 100 yards (not a radiologic definition) or maintain mobility >25 minutes without aids n Other restrictions to mobility, eg. lymphoedema n Surgery indicated.

an alternative aPProaCh to Gait retraininG: aPostheraPY Another well-publicised approach to gait retraining is the Apos system, footwear that can be progressively adapted to change the ‘centre of pressure’ and causes gait perturbations, presumably with the objective to promote positive adaptations during progressive daily timed sessions. In one of the few studies on the device by a non-affiliated research group, KAM reduction was reported (4). This was accompanied by elevated walking velocity, significant pain reduction, and increased functional activity. The study group was small (n = 25 females) and the severity of the disease on basis of WOMAc was not severe (mean 4.09 ± 2.29cm (vAS for pain, stiffness, function 0–10cm). The study was uncontrolled. Similar results have been reported by the Apos research Group (5), and a further uncontrolled study by the Apos group reported a significant improvement was seen in all of the gait parameters and in improvement in WOMAc scores following 6 months of therapy. However, again the mean baseline WOMAc scores were low (<5, vAS scales 0–10, range and Sd not given). The study population was a multi-ethnic Singaporeans with bilateral medial OA of the knee.

Gait retraininG as Part of the rehaBilitation ProCess

Consider orthotics Additional foot & ankle disorder/leg length discrepancy

Figure 1: Non-surgical treatment of medial osteoarthritis of the knee. (C. Speed, 2015)


improved at post-training by 29% and 32%, respectively (P <0.05) and visual analogue scale (vAS) pain scores improved by two points (P <0.05). changes in WOMAc pain and function were approximately 75% larger than the expected placebo effect (P <0.05). changes in KAM, foot progression angle, WOMAc pain and function, and vAS were retained 1 month after the end of the 6-week training period (P <0.05).

The studies outlined above do indicate that gait retraining does improve pain and function, at least at short-term follow-up, in patients with medial knee OA. Sophisticated biomechanical analysis is not possible in most patients. Hence, from a pragmatic perspective clinicians – and in particular rehabilitation specialists – should be trained to evaluate the patient with medial OA for those gait abnormalities that are associated with increased KAM: foot progression angle (6,7), tibia angle (8), hip adduction/internal rotation (9), and trunk sway (8,10,11), such that adaptations can be recommended as part of the rehabilitation process. Many patients will respond to neuromuscular and proprioceptive training and will not need modifications to their gait. Hence, sportEX medicine 2015;64(April):25-27

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the former elements must be considered first in the rehabilitation pathway. Gait retraining should be reserved for those without severe deformity and with mild to moderate disease on the basis of baseline WOMAc indices. radiological grading is not required. Some patients will become eligible with good medical management leading to reductions of WOMAc scores. It is likely that patients with medial meniscal pain should also follow the same pathway as that for medial OA of the knee. However, evidence for benefit of gait interventions in lateral tibiofemoral and global knee OA is lacking. References 1. Fisher nM, Pendergast dr. reduced muscle function in patients with osteoarthritis. Scandinavian Journal of rehabilitation medicine 1997;29:213–221 2. Sharma l, lou c, et al. laxity in healthy and osteoarthritic knees. arthritis & rheumatism 1999;42;861–870 3. Shull Pb, Silder A, et al. Six-week gait retraining program reduces knee adduction moment, reduces pain, and improves function for individuals with medial compartment knee osteoarthritis. Journal of orthopaedic research 2013;31:1020–1025 4. Haim A, rubin G, et al. reduction in knee adduction moment via non-invasive biomechanical training: a longitudinal gait analysis study. Journal of Biomechanics 2012;45:41–45 5. bar-Ziv y, beer y, et al. A treatment applying a biomechanical device to the feet of patients with knee osteoarthritis results in reduced pain and improved function: a prospective controlled study. Bmc musculoskeletal disorders 2010;11:179 6. Shull Pb, Shultz r, et al. Toe-in gait reduces the first peak knee adduction moment in patients with medial compartment knee osteoarthritis. Journal of Biomechanics 2013;46:122–128 7. Guo M, Axe MJ, Manal K. The influence of foot progression angle on the knee adduction moment during walking and stair climbing in pain free individuals with knee osteoarthritis. Gait & posture 2007;26:436–441 8. Shull Pb, lurie K, et al. Training multi-parameter gaits to reduce the knee adduction moment with data-driven models and haptic feedback. Journal of Biomechanics 2011;44:1605–1609 9. barrios JA, crossley KM, davis I. Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment. Journal of Biomechanics 2010;43:2208– 2213 10. Mundermann A, Asay J, et al. Implications of increased medio-lateral trunk sway for ambulatory mechanics. Journal of Biomechanics 2008;41:165–170 11. Hunt MA, Simic M, et al. Feasibility of a gait retraining strategy for reducing knee joint loading: increased trunk lean guided by real-time biofeedback. Journal of Biomechanics 2011;44:943–947.

fUrther resoUrCes 1. AposTherapy website ( THE AUTHOR PROf CATHy SPEEd BMEdSCi, diP SPORTS P MEd, MA, PHd, fRCP, ffSEM M Cathy is a consultant in Rheumatology, Sport & Exercise Medicine. She is based at The fortius Clinic, London, and at the Cambridge Centre for Health and Performance in Cambridge. She is also a senior physician for the English institute of Sport.

KeY Points n the pain experienced in osteoarthritis (oa) is associated with a number of factors including body weight, mental status, co-morbidities and gait biomechanics. n Pain and disease progression are greater for individuals with certain biomechanical issues. n in medial compartment oa, elevated knee adduction moment (KaM) is a factor in excessive medial compartment loading and disease progression. n KaM cannot be measured easily in clinical practice, so clinical assessment must be used to detect gain abnormalities. n Gait retraining reduces the abnormal load on the joint by teaching patients to walk normally. n Gait retraining should always start with neuromuscular and proprioceptive training. n studies have shown that a 6-week gait retraining programme caused changes in KaM, foot progression angle, WoMaC pain and function, and vas that were retained at the 1-month follow-up assessment. n apostherapy involves footwear that can be progressively adapted to change the ‘centre of pressure’ and causes gait perturbations. n Gait retraining should be reserved for those with only mild to moderate disease on the basis of baseline WoMaC indices.


n What factors are associated with the pain experienced in osteoarthritis (OA)? n What is elevated knee adduction moment (KAM), and how does this affect medial compartment OA? n What are the gait abnormalities associated with increased KAM? n What is gait retraining and which OA patients is it suitable for?


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video 1: AposTherapy – how it works http://spxj. nl/1dT31I7

video 2: AposTherapy for knee pain after surgery http://spxj. nl/1lcr90P Videos by YouTube user ‘AposTherapyUK


TendinopaThy loading programmes An overview of current concepts This article is an overview of a review by Malliaras et al. (1) looking at Achilles and patellar tendinopathy rehabilitation. There has been much research into the pathophysiology of tendinopathy and management of the condition has changed distinctly in the last 10 years. However, therapists are still using these old protocols (observed as little as 4 weeks ago) despite an incredible 45% of patients not responding significantly to eccentric exercise programmes. By Paula clayTon MSc, Fa diP, MaST STT

Background There have been advances in the research surrounding the pathophysiology of tendinopathy but focus on treatment appears to a degree to be in the incunabulum stage. Ten years ago, the management of tendinopathy was distinctively different to what you will see today. Finding high quality clinical trials providing proven clinically significant advancement following treatment is tricky (which was unanticipated) despite the apparent plethora of theoretical research

Stress shielded unloaded

optimised load

normal tendon normal or excessive load +/- excessive appropriate load + modified individual load factors individual factors reactive tendinopathy

Tendon dysrepair

optimised load adaptation strengthen

looking at tendon pathology, function and rehabilitation. Malliaras and colleagues’ systematic review on Achilles and patellar tendinopathy loading programmes compared clinical outcomes and identified potential mechanisms for effectiveness (1). Methodological flaws were found in abundance and they only found two studies that were accepted as high quality, the majority had not used validated outcome measures, and they only found two that defined sufficient blinding. Malliaras et al. (1) found that an incredible 45% of patients did not respond significantly to eccentric exercise programmes. Treatment options for tendinopathy are in abundance with many factors to consider; it can be helpful to think of what your main treatment goal is and keep this in mind. If the key goal in tendinopathy rehabilitation is improving the capacity of the tendon and muscle to manage load (tendon and muscle function together as a musculotendinous unit) this needs to be considered in the rehabilitation phase, not just the tendon structure.

TendinoPaThy degenerative tendinopathy Figure 1: Physiopathology of tendinopathy. [cook and Purdam, 2009 (2)]


Before we delve into this it would be helpful to remind ourselves what we currently know about tendinopathy. Cook and Purdam’s (2) tendinopathy continuum describes three different stages of tendinopathy: reactive,

dysrepair and degenerative (Fig. 1). Reactive tendinopathy Usually involves the tendon responding to a rapid increase in loading or from direct trauma – initially believed to involved inflammation but now it is understood that although the tendon does swell this is due to movement of the water into the extracellular matrix (3), not inflammatory products. A key feature of a reactive tendon is that structurally it remains intact and there is minimal change in collagen integrity – meaning this is a reversible process. Tendon dysrepair Typically the stage that would follow reactive tendinopathy if the tendon continues to be excessively loaded. It is similar to the reactive stage but the tendon structure begins to change with greater matrix breakdown. Degenerative tendinopathy More common in the older generation/ older athlete. Typically represents a response of the tendon to chronic overloading. There are multiple tendon structure changes making it less efficient at dealing with load. Collagen becomes disorganised and advanced matrix breakdown takes place alongside further increases in vascularity and neuronal ingrowth. The tendon can appear thickened and nodular and there is a risk of tendon rupture with advanced degeneration. sportEX medicine 2015;64(April):28-32

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ManageMenT oF TendinoPaThy Figure 2 shows the aim of tendinopathy rehabilitation and the factors needed to achieve it. “Each component of the rehabilitation programme in particular loading, must be manipulated in relation to the nature, speed and magnitude of the forces applied to the muscle/ tendon/bone unit in order to achieve the goals of the particular management phase without causing an exacerbation of the pathological state or pain” Scott et al. (4) Cook and Purdam (2) simplify the management of tendinopathy by dividing it into two stages: 1. Reactive/early disrepair 2. Late dysrepair/ degenerative Reactive/early dysrepair The focus tends to be on load management – a reduction of both tensile (muscle contracts or resists a stretching force) and compressive load on the tendon. Cook & Purdam (5) state that this phase lasts for approximately 5–10 days, however, the tendon will be sensitive to high loads and training needs to be progressed gradually to prevent relapse (tensile loads can be reduced with adaptation to training – reducing the distance, time, etc.). Tendinopathy on the other hand, often has a compressive component that requires attention.

TaBle 1. iS coMPreSSive load a FacTor in The develoPMenT oF TendinoPaThy? [Adapted from Cook and Purdam (5)] Tendon






Superior calcaneus


Heel raise


Proximal hamstring

Ischial tuberosity

Hip flexion

Limiting sitting/lunging


Gluteus medius/ minimus

Greater trochanter

Hip adduction

Lumbopelvic control/sleep supine


Adductor longus/rectus abdominus

Pubic ramus

Hip abduction/ extension

Limit loads in abduction/ extension



Femoral condyle

Deep knee flexion Limit loads in deep knee flexion

Late disrepair/degenerative tendinopathy The irritable tendon that is abnormally larger than normal, with palpable nodules is inclined to be degenerative – in addition, an unusual increase in pain responding to an increase in training/ running/exercise tends to indicate reactive tendinopathy. If this should happen, principles of managing a reactive tendon apply (load management, anti-inflammatories, isometrics) until the tendon calms down. The chronically irritable tendon without the sudden increase in pain is managed with a mixture of load management, isometric, concentric and eccentric work. Changes within the tendon may be reversible but more commonly this becomes a condition in need of long-term management.


reduce pain

exercise selection

improve muscle and tendon capacity to manage load

compliance from athlete

effective ‘loading strategy’

Figure 2: The key goal in tendinopathy rehabilitation and how to achieve it. [RunningPhysio blog by Tom Goom (]

TaBle 2: coMPariSon oF loading PrograMMeS [Adapted from Malliaras et al. (1)] Exercise







Alfredson et al. (8)

3 × 15

Body weight then increase, pain permitting

2 × day 12/52

‘Heel drops’ n gastrocnemius bias n soleus bias


Slibernagel et al. (13)


Body weight, then increased in phases based on status of person being treated.

Daily 12/52 – 6/12

Comprehensive n concentric n eccentric n balance n plyometrics n return to sport

Heavy slow resistance (HSR)

Kongsgaard et al. (10,11)

4 × 15–6RM

15–6RM progressed over 12 weeks, pain permitting.

3/7 for 12/52

Bilateral squat Leg press Hack squat Gradual progressions in load Includes 6 seconds per rep of eccentric (3 sec) and concentric (3 sec).

15–6rM, indicates progression from the maximum load that can be lifted 15 times (15rM) to the maximum load that can be lifted 6 times (6rM).


is compressive load a factor in the development of tendinopathy? Cook and Purdam (5) describe the potential role of compression in tendinopathy, which is reflected in Table 1. There is also a suggestion that when managing load, always be guided by the tendon’s 24-hour behaviour due to the tendon’s latent response to loading. Cook and Purdam (5) also suggest that massage is a far better option than stretching when managing tendinopathy due to the potential for tendon compression during the stretching process. Also isometric exercise may reduce pain and maintain muscle strength in the reactive phase providing the position held during the exercise does not compress the tendon.

Pain management In the first instance plan to reduce excessive load and aggravating movements (6), discuss the use of anti-inflammatories with your doctor (reduction of tenocyte activity) and use isometrics to help reduce pain and maintain strength (7). Primary goal: reduce the pain Henriksen et al. (6) tested the effect of experimentally induced Achilles tendon pain and deduced that tendon pain causes: “…widespread and reduced motor responses with functional effects on the ground reaction force.” As discussed previously, pain is often more severe during the reactive phase of tendinopathy and the key to managing that pain is by managing the load, compressive forces and cutting out stretch shortening cycle (SSC) activities. Reduce the load – reduce the reactive response. According to Naugle et al. (7) isometric exercises appear to reduce pain in reactive tendinopathy: “… isometric exercise appears to exert a generalised pain inhibitory response” Long duration, low to moderate intensity contractions (25–50% maximal voluntary contraction) during isometric loading appeared to have optimal analgesic effect.


Secondary goal: improve strength, once the pain has settled The reduction in strength and function following tendinopathy must be addressed and is essential for the longterm health of the tendon. Gradually increasing the load on the muscle and tendon whilst monitoring pain levels is recommended with strength sessions performed in mid range positions to avoid compression (8–12 reps should be sufficient, pain permitting). Malliaras et al. (1) systematic review states that tendinopathy programmes generally fit within three categories, eccentric, combined or heavy slow resistance training (Table 2). In the late 1990s eccentric exercises (such as heel drops) were considered the ‘gold standard’ following research by Alfredson et al. (8). They remain an option but more recently the realisation is that the concentric part of the exercise should not be left out. Peter Malliaras, a contributor to clinical edge podcast (9), is not a huge fan of the Alfredson (8) programme for the following reasons: 1. There are too many limiting factors: by the time the person who fits the programme walks into your clinic, you are looking at 1/10 people. 2. It’s not good clinically: to be able to use the programme the patient needs a lot of lumbo pelvic stability; it’s pitched too high; also, most patellar tendon (PT) patients have atrophy in their quadriceps. 3. It’s a terrible programme for reversing atrophy and building hypertrophy as there is too much going on at once. 4. The consideration of the PT strength paradox – during a leg press the affected side appears strong; however, the leg extension exercise is weak on the affected side. Malliaras (9) suggests that the PT strength paradox highlights the masking of quadriceps strength deficit, due to the gluteus and other structures in the kinetic chain getting so strong, after following Alfredson’s (8) decline programme. Heavy slow resistance training (HSR) has emerged more recently as another exercise option (10,11). Gaida and Cook (12) also discuss HSR and eccentric exercise briefly in their 2011 paper on

TaBle 3: eSTiMaTion oF PercenTage oF 1rM [Adapted from RunningPhysio blog by Tom Goom (] Percentage of 1rM

rM equivalent













1RM is the load that can be lifted for a maximum of 1 repetition. 5RM is the load that can be lifted for a maximum of 5 repetitions, etc. PT and note there are pros and cons of each approach: 1. Eccentric work is often prescribed as a high frequency exercise with Alfredson and colleagues’ (8) work recommending 3 × 15 of two exercises done twice per day. That’s 180 reps per day altogether! 2. HSR in contrast is usually done 2–3 time per week but in many cases will require access to gym equipment. 3. HSR involves high loads – approximately 70–85% of 1RM (See Table 3 for estimating loads). Kongsgaard and co-workers’ (10, 11) HSR training (recommended by Malliaras for patellar tendinopathy, if you want a programme to follow) suggest a graduated approach beginning with low loads at 15RM and progressing up to 6RM over 9–12 weeks providing there is no significant increase in pain (see Table 2) they recommend 4 sets of each exercise with a 2–3 minute rest between, repeating 3 times per week. Silbernagel and co-workers’ (13) combined approach (See Table 4: recommended by Malliaras for Achilles tendinopathy, if you want a programme to follow) is the only evidence-based programme in the literature that has a plyometric SSC type progression! They begin with resistance of body weight for calf raises and progress in a similar manner to Alfredson et al. (8), using back packs or weights machines to increase the load. There are, however, several key sportEX medicine 2015;64(April):28-32

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differences. Silbernagel et al. (13) include both the concentric and the eccentric component of the exercise and progress to include power and plyometric exercises (see Table 2). Therefore, the findings from Silbernagel (13) apply across most of the phases discussed by Malliaras et al. (1), not just strength.

concluSion Malliaras et al. (1) found Silbernagel and colleagues’ combined training (eccentricconcentric progressing to eccentric) for Achilles tendinopathy as well as HSR loading (eccentric-concentric isotonic) for patellar tendinopathy had the highest level of evidence for improving neuromuscular function, stating: “Clinicians should consider eccentricconcentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy” There is a paucity of quality research comparing tendon loading programmes and these appear to be limited and focus mainly on Achilles and patellar tendinopathy. Malliaras et al. (1) reviewed the literature on Achilles and patellar

tendinopathy and found that HSR training was more likely to lead to tendon adaptation but required further research. They found no evidence to support isolating the eccentric component [as in Alfredson et al. (8)]. The disadvantages of eccentric exercises in the older population (over 60) are that most cannot perform 3–4 calf raises in a concentric-eccentric fashion; therefore, why are these people given eccentrics? This demographic become very good at the eccentric programme but their concentric strength does not improve, they are still as dysfunctional as they were before the rehabilitation programme started – there is no functional carryover. Eccentric exercise requires full range of motion (ROM). Malliaras (9) states that double leg (DL) should be followed by single leg (SL), making sure that quality and full ROM is achieved with each repetition, therefore, If the person you are attempting to rehabilitate cannot do SL calf raises or cannot hold their body weight in full plantarflexion isometrically then they shouldn’t be starting an eccentric programme. That

person is never going to have the quality in an eccentric programme required to benefit from it. Time under tension is the key, if they cannot get full range the exercise is pointless. Eccentric exercises have been seen as the imperative or deemed essential. Malliaras (9) states that you do not need to do eccentric exercises to get a tendon better and states that this is supported by the literature. However, he does accept that it is a useful part of a rehab programme to maximise load intensity. He goes on to discuss that eccentrics are good at very heavy loads, this is the time to use them or at end of range to improve the compliance of the musculotendinous unit (MTU) due to the shift in length tension (sarcomeres are in series, increased length of fascicles, contribution to stronger function of the MTU in the functional range). Heavy-load eccentrics are great for sporting demands – running, jumping, basketball, etc. Malliaras (9) suggests that for athletes the following programme is ideal for tendons: isometric, concentriceccentric, functional concentric-eccentric, heavy load eccentrics – supramaximal (above concentric maximum).

TaBle 4: SilBernagel eT al.’S TreaTMenT ProTocol For achilleS TendinoPaThy [Silbernagel et al. 2007 (13), and recommended by Malliaras et al. (1)] Phase 1: Weeks 1–2 Phase of rehabilitation

Phase 2: Weeks 2–5

Phase 3: Weeks 3–12 (Longer if necessary)

Phase 4: Week 12 – 6 months (Longer if necessary)

Pain with exercise, morning stiffness, pain when performing toe raises.

Handled the phase 2 exercise programme, no pain distally in tendon insertion, possibly decreased or increased morning stiffness.

Minimal symptoms, morning stiffness not every day, can participate in sports without difficulty.

Heavier strength training, increase or start running and/or jumping activity.

Maintenance exercise, no symptoms.

Patient status

Pain and difficulty with all activities, difficulty performing ten 1-legged toe raises.


Start strengthening. Start to exercise, gain understanding of their injury and of pain-monitoring model.

Treatment programme

Perform exercises every day:

Perform exercises every day:

Perform exercises every day and with heavier load, 2–3 times per week:

Perform exercises 2–3 times per week:

1. Pain-monitoring model information and advice on exercise activity 2. Circulation exercises (moving foot up/down) 3. 2-legged toe raises standing on the floor (3 × 10-15 repetitions/set) 4. 1-legged toe raises standing on the floor (3 × 10) 5. Sitting toe raises (3 × 10) 6. Eccentric toe raises standing on the floor (3 × 10).

1. 2-legged toe raises standing on edge of stair (3 × 15) 2. 1-legged toe raises standing on edge of stair (3 × 15) 3. Sitting toe raises (3 × 15) 4. Eccentric toe raises standing on edge of stair (3 × 15) 5. Quick-rebounding toe raises (3 × 20).

1. 1-legged toe raises standing on edge of stair with added weight (3 × 15) 2. Sitting toe raises (3 × 15) 3. Eccentric toe raises standing on edge of stair with added weight (3 × 15) 4. Quick-rebounding toe raises (3 × 20) 5. Plyometric training.

1. 1-legged toe raises standing on edge of stair with added weight (3 × 15) 2. Eccentric toe raises standing on edge of stair with added weight (3 × 15) 3. Quick-rebounding toe raises (3 × 20).


References 1. Malliaras P, Barton CJ, et al. Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. sports medicine 2013;43(4):267–286 2. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of sports medicine 2009;43(6):409–416 3. Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. nature reviews, rheumatology 2010;6(5):262–268 4. Scott A, Docking S, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. British Journal of sports medicine 2013;47(9):536–544 5. Cook JL, Purdam C. Is compressive load a factor in the development of tendinopathy? British Journal of sports medicine 2012;46(3):163–168 6. Henriksen M, Aaboe J, et al. Motor responses to experimental Achilles tendon pain. British Journal of sports medicine 2011;45(5):393–398 7. Naugle KM, Fillingim RB, Riley JL 3rd. A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain 2012;13(12):1139–1150 8. Alfredson H, Pietilä T, et al. Heavyload eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The american Journal of sports medicine 1998;26(3):360–366 9. Clinical Edge. Podcast. 10. Kongsgaard M, Kovanen V, et al.

Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. scandinavian Journal of medicine & science in sports 2009;19(6):790–802 11. Kongsgaard M, Qvortrup K, et al. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. The american Journal of sports medicine 2010;38(4):749–756 12. Gaida JE, Cook J. Treatment options for patellar tendinopathy: critical review. Current sports medicine reports 2011;10(5):255–270 13. Silbernagel KG, Thomeé R, et al. Continued sports activity, using a painmonitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The american Journal of sports medicine 2007;35(6):897–906.

FurTher reSourceS 1. For further information on this area the author recommends reading any papers by Professor Jill Cook or Dr Peter Malliaras. 2. Physioedge podcast: Tendons and tendinopathy by Prof. Jill Cook ( 3. Physioedge podcast: Lower limb tendinopathies by Dr Peter Malliaras (

n When was the last time you reviewed any of your current protocols? n Are you utilising any form or DISCUSSIONS information every week (journal/ articles/magazines/blogs/podcasts) to keep you abreast of what is happening in your profession? n When was the last time you collaborated with a college/mentor/peer to renew your enthusiasm in the work you do making you a better therapist?

key PoinTS n despite current research we are still far from finding a definitive answer to management of achilles and patellar tendinopathy. n Therapists are still using what used to be deemed the ‘gold standard’ programme for achilles tendinopathy written in 1998! n recommendations are supported by clinical practice as well as research. n complacency leads to poor results. n an incredible 45% of patients did not respond significantly to eccentric exercise programmes. n Treatment options for tendinopathy are in abundance with many factors to consider. n in the first instance plan to reduce excessive load and aggravating movements. n The reduction in strength and function following tendinopathy must be restored and is essential for the long-term health of the tendon.


THE AUTHOR PAULA CLAyTOn MSC, FA DiP, P M MAST STT Paula has worked as a senior performance therapist for the English institute of Sport (2003–2013) and British Athletics since 2003. She has travelled extensively to Olympic Games (Athens, Beijing and London), Commonwealth Games, World and European Championships with GB track and field as part of the medical team during this time. Before 2003, Paula worked in premiership and championship football for 4 years. Paula has taught on two sports therapy degree programmes, delivered sessions to MSc students, written a number of articles and has an MSc in Sports injury Management. Paula also delivers soft tissue masterclasses to senior physiotherapists and soft tissue therapists within premiership and championship football clubs, national governing bodies (nGBs) and to soft tissue therapists nationally and internationally through her company Paula also runs a very successful sports injury clinic private practice (established in 1994) in Shropshire with her husband Rick.

continuing education Multiple choice questions This article also has a certificated eLearning test which can be found under the eLearning section of our website. For more information on how to access the test click this link

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wiTh a suBsCripTion ThaT inCludes online aCCess To This Journal.

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Sportex update

tHe All


Singing & dancing By Tor Davies, puBlisher anD sporTeX founDer over the last 6 months there’s been a huge amount of work going on behind the scenes at sporteX, stimulated by 4 main motivations: 1. A desire to vastly increase the flexibility and options for people wanting to engage with our content 2. A strong yearning to create a totally different type of business model, one built on a basis of cooperation and ethiconomics* and driven by a “virtuous circle”. 3. A quest to build a state of the art publishing platform that harnesses the last 5 years of web developments in delivering and building community through learning and professional development. 4. An aspiration to use our new platform to widen our content framework into areas outside just sport. In order to achieve our goals, we’ve completely rethought and restructured just about every aspect of what we do from the financial modeling, planning and budgeting, to the way we commission and pay for content, and finally through to the way we deliver this content.

The sTarTing poinT At the heart of everything we do is the interaction between you and the

content we produce. We want to create the very best content we can to help you do your job in the most effective way possible. In order to achieve this we’ve done several things: refined and expanded our content structure: In collaboration with some of our longest serving most committed subscribers, we’ve identified the ‘streams’ of content that you feel would add most value to your work (see Box 1 for details of the content streams) appointed hand-picked content commissioners: We’ve identified 1-2 commissioning editors per content stream who are responsible for commissioning articles under that topic area. These are people who have a strong track record for developing ‘translational’ content. ‘Translational’ content has always been our USP – the ‘read it now, use it in an hour’ approach. We publish for practitioners, these are hands on people who want to know how to translate the research evidence into practical application. Throughout we’ve focused on the “virtuous circle” approach: Authors will earn up to 25% of all sales of their content and commissioning editors will earn 1-2% of sales for every article they have commissioned for the entire time that the content is live and available through our platform. The clever bit is in the algorithm that calculates how these royalties are divided particularly when content is sold as part of a ‘subscription’ to a bigger product. Here we use an algorithm that takes total sales and then divides it proportionally based on number of times that piece of content has been





purchased as either a single item or as part of a group, combined with a range of engagement measures like social media influence, discussion activity and viewing statistics. The end goal is that great content is rewarded - the more an article is purchased, read, engaged in and shared, the more of the content royalty pot it will earn. implemented a self-refining, constantly improving content model: The platform allows (and actively encourages) authors to regularly update, enhance and improve their content so that not only does it always remain current but the author always has the power to make it better (and encourage more sales). If the content isn’t updated then after a period it expires and ceases to earn royalties.

It’s a simple philosophy both in functional as well as economic terms that is designed above all to be fair, transparent and one in which everyone wins.

so where Does The oTher 75% go? n 25% is for our affiliates who help to promote and sell our content through their own channels (if you’re interested in becoming an affiliate email me n 25% is set aside for costs relating to publishing the content, mobile app publishing, supplementary content resources such as images and animations n 25% goes towards business administration including customer technical and billing support, salaries, ongoing platform hosting and support costs and marketing.


Key feaT ures

of The n ew siTe

n co om mm muunnit ity y building Througho ut the site you’ll no and content engage tice a start on the ment through the community building discussion forums aspect are also many socia at the end of all pie l media sharing op ces of content. Th portunities through n flexible purcha ere out the articles. sing From a purch asing perspective as you want right yo u ca n no w buy as little or as down from a single much content article, a stream of to the journals. content, a ‘tag’ or a bundled subscripti n a simplified pa on yment system Ou r previous system based on paymen ha d 7 dif fer ent payment types t methods. It was over-complicated (if with discounts methods, don’t wo you’re currently pa rry, we’ll continue ying by one of the to su pp or se t it and you don’t ne going forward it’s no ed to change anyth t only much simple ing r bu ), bu t als t next-generation pa o much more flexib yment system know le thanks to the ex istence of a n as Stripe. (see Bo n archving Initially x 2 for more detai we will be working ls) . ba ck wa rd s content archives. Ou from recent to the older material, to ad r goal is that Jan 2012 up to April 20 d the will also be a fully 15 will be available searchable databas at launch. The archiv e going back to ou n multi-media fri e r launch in 1999! endly While we’ve launched initially wi main format of conte th art icle s (as historically this nt), the platform is has been our built to host all typ audio, presentation es of media secure s and any type of ly inc luding video, me dia yo u media offerings as want to throw at us we take on more and we’ll be expand content creators. ing the Our goal with this new platform has been simplicity, transparency, mutuality and ongoing self-refinement.

new TargeTeD aDverTising opporTuniTies At last we have a whole range of advertising opportunities available also. You can advertise at any point on the site. This could be within a given content stream, under a given tag (keyword section) or even down to a specific article (particularly useful for authors of articles wanting to promote other activities such as books they’ve written or courses they’re running). And as you’d hope, the process is simple and transparent. sTep 1: Navigate on the site to the position you want to place your advert sTep 2: Pick the advert type you want ie. Banner size – just under the existing banner will be an “Advertise here” link – go ahead and click it! sTep 3: Choose the start and end dates for your ad and the system will calculate the price and display this as well as some other options in the same area so you can adjust your booking to fit your budget sTep 4: Once you’re happy, place the booking and you will be asked to upload your artwork which once approved will go live at the time designated.


in summary This is a very short overview of the foundations of a much more complicated project that I believe will form a new way of publishing and growing communities in professional sectors not only in our core area of physical and manual therapy but across a whole range of vocational groups. This is just the start. I hope you enjoy the new site! * Ethiconomics = a name given by author Philip Birch, for the principles and practice of ethical business

conTenT sTreams

n Musculoskeletal Diagnosis, Treatment and Rehabilitation Articles n Musculoskeletal Diagnosis, Treatment and Rehabilitation Case Studies n Current Trends in Sports Medicine n Research Reviews n Pain and Brain n Sports Performance n Journal Watch – Sports Medicine

n n n n n n n

Journal Watch - Manual Therapy Current Trends in Manual Therapy Movement - Assessment and Retraining Manual Therapy Case Studies (non-sport) Sports Massage Case Studies (sports-specific) Sports Massage Articles (sports-specific) Soft Tissue Practice Articles (non-sport)

We will also be adding two new dedicated streams of content on taping and business development commencing later in 2015.

suBscripTions anD paymenT wiTh sTripe n The first BIG benefit is that Stripe takes responsibility for adhering to the stringent PCI Compliance rules that in the past has made the wonderful but hugely expensive ability to store credit card details completely prohibitive for small companies. Only behemoth retailers like Amazon could afford the sort of security this requires, that is until Stripe came along to give us ‘little guys’ access to the same convenience and security. n This means once you’ve entered your details once, Stripe securely stores these, meeting all the required PCI standards, and when you login to make a new purchase, there’s no need to enter your details again. It simply looks at your existing plan with Stripe, updates it to take account of the new content and off you go. One click purchasing! This means you can add content streams to your subscription, or delete them at any time in the year and all the billing will adjust accordingly at that exact point in time. n It does however mean that your subscription expires the minute you lapse it – if money is owed against unused days this is credited to your card. Transparent and fair, as we like it.

sportEX medicine 2015;64(April):33-34


ANATOMY & SOFT TISSUE INJURY REVIEW By Dr Simon Kaye, Sports Physician and General Practitioner


InjuryRefresher_proofed AS.indd 1


11/07/2013 10:58

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


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








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This arti es Midd ees, o-ma Pictur toe) most the samthe article 180 degr stly at Primal (5th port und as and stern walking t as ©2010 change follows joint ter than cic rotation e is the ulder mo w sup the gro y, as in imal this end of and the AC of abduction and grea thora the foo Prox with rds The kne the sho e is to allo o near sly in joint of some ees n of at the onwa the bod phalanxGP mediate some like tors box ved with 180 degr degrees toe) Inter Previou (issue ving acceleratio ates limb, n of the kne of the Kay, iform in 150 (see is achie n(5th cles. t st be mo demonstr cune id joint ing Simo um es n From ction/flexion roer arti , hip join and wri patient Pictur Sacr functio g position can either wing rap hume joint By Dr nt injured abdu d the Primal e w ral erview : l refresh ue 44) allo behin ts well. Fifth ©2010 radia lloy ov monly ular ligame ple tarsofaltwo joints ral joint n of femo is T1-3. n from injury the elbo of the spin Pate allowin Propulsion the foot men t (iss ortio meta tom com m, rvatio ding Kay femo ists move ral prop -fib st n ies of ulder join 46) and ana cons the tibioabulu ilium Obse provi title joint ly sim femo of the as Simo the tibia Medial body the high the acet m of thick sitting. or moving ges in ue s of the mo erior taloa relative inversion of ment gross iform the ser sho joint By Dr by The knee joint ral cle the S of the r limb as well ing. ruent due to move cune ant labru le is the chan joint er two main Late of the facettwo cong e is of ed in abulum last in ered the le joint (issn this arti girdles. covered by a cles running vement d into 1. the ists iform to furth acet uction flexible of the uppe lifting and carrybility and head lised (behind The anker limb, the d ankle) severity the mortic as cov is the cons cune with the er arti ing. stabi femur e mo ps are involvbe divide , ank acting give muscle ioned 1-2). lla) , introDlder the mostof motion like throwing, nse of insta my which This we have GP further tissue, pate les tures in kick refresh Dr Simon m (figs. hip is more id r, cush muSclmuscle grout can roughly ue 45) we have articulate anato ted the low sic spraine but as the joint and ch can be le, musc expe ective n Kay, of the Cubo the femu cular struc The shoua wide range ments ent which ome tomy ilising acetabulu of the conn men Simo at the reviews the in entS neck r r, and series e joint (issAlthough Differ clas associa /stab ces on two avas r move comes r mino e bec difficult to s ana le and hip, wrist and en the ral position r projected the injury - sub-talar upted whi r the ank vem are involved By Dr a more us with actor (the surfa is lder. Move briefly powe Navicula . and hav femu us kne ility deep by teres mo e viou into I , lity e radio contr shou joint femu e dsneut t ion 49) mob nto (IS), ps rating from Talus thejoint be disr articl 47) -a The – the e going various soft : gene uct to its stabi ly. of the stabilisedsici es,ulnar dorsi, conside our pre r, knee, ank ts of the regions pinatus tely this ntial. This nd tha gmatic but ctical, han s on laterally l joint (RC) (issue ligame muSclmuscle grou the spin e e areas . s imus infras les ie. facet lder befor s to the join mora the neck ly and outlin 1) other. , knee e fou introDmostly due at least acute ent tor cuff increas joint can ry. We will Unfortuna injury pote ing on pra ulde the men r, latiss triceps. Thes pra joints re about ical musc lla-fe ulate aped with . We erior video s Calcaneu Differ of the the shou of injurie 1. Rota spinatus (SS),(see Video le tring each cle. herapy , injury nosu Follow g the sho issue, at the h anatom inju tly post the pate ralis majo s and ch I hav ies in a it is a move mo to ow V-sh which artic patella ment The hip, injured joint, of femoro- injuries )) Pictures ank osis arti hams lder girdle mpanying and high ments of , 2. e siot to mbra is sligh tibio supra roa shall Primal n (SSc pecto lla n move ted y from shou bicep on, diagn m. it rap ory this of – of and phy r, acco ©2011 ) een laris app pate flexio fashi ral h. The rela g d bot semi-me e help h (PM) a rarel recognitio ent and mino with view ssed and movelook at the ng up the the true as any kne foot in this betw coverin ks in this r is ntric acetabulu femo of undin the own various the logy for therapy, ofascial the ple, riorthe som 1. Knee dinosus, iques subscapu movers pectoralis the ral troug ately two main gem maki whic be asse /ecce surro menisci like an with groupe (supe um the femu Pubis ary Peo femo fulcrum for With r, detailed the back tures nt techn ture can r impin joint and ists of ischi joint ing my ing und it no apo severe ar joint and semi-ten s femoris le, popliteus, st sports cture, my Kay loo We have are so intim 2. Prim teres majo in a concentric entS head of struc the foot with the cons by three in front ges. as a ) dicine. patientn. s of ice acetabula -iliac assessmeeach struc lling es roand surro head again ly tissue chan id, only view Review politan, mix ch. I make involves acts LiGamstanding, the acetabulum allow bone mort ists Pictur sacro and bicepssory musc to flexio muscles x me pun trave joint most hume The ankle rior delto simple the tibia, rus how ntially sub-tal to a stic dial joint, main elbow. er as they t Primal situation hip is to , s joint (ante prior to the to the Femur les act some showing esse muscle, s The ro-ra s ch. It . Whils ting into efficient. ricep s©2010 ns, acu ulna into the ): : orthodo y holi the hume g shoulder ) - cons (similar the acce the knee close is one cosmo ce’ approa musc les, the ion of the the hip vastu e 1a: hume osed ge, ricep and inser rus. joints work the joint - quad tightly joint, s of in musc the limbs ver ks Figur to hold approa mobilisatio good old that a trul durin (fig.3 foota les like quad togeth the radiuination) held rotating lateralis, lly diagn ankle bone red by unloc in wood the talus n/ ent ally more no part ents the humeRC musc job is g stability knee The funct trunk on otion. Howetibia eral (GH) joints are GP extension vastus t 1. the 2. the rotation of ‘eviden ary care of e 1: The the n joint differentia are cove h contractio pays of the it mechanic e. Their The key ligam oral ligam the two the elbow rview gleno-humgirdle. These ation/sup medialis. also aid N Kay, 2. Knee s femoris, ing ssage, iatry and differen Figur including sleev ort of is to fibula g locom maintainin les are -fem ent s of the and teno ular facet allow twitc GP s with SIMo . s inter supp plete durin les ments ing and so thus y ove ifically the ally (pron and the making that the by on, primlation, ma musc lder artic ulate 1. Ischio moral ligam ent. , pod Pictures and footstrike ie. rectu and vastu e 1: Joint n Kay, musc the incom ularly e of move By Dr facilitates Man the knee femur in a slow rus into Primal spec id fossa rotator cuff jump of Note of the which artic on the tibia longitudinthe ulna Figur ankle Simo mius the shou ©2011 partic n of fixed. the which anatom Tibia nipu techniques sports, are ential. fibula les act the hume the head 2. Ilio-fe femoral ligam tighten with h lder or make up d at heel n) medialis gastrocne of the ulatio e rang d to joint running, to greater ma ces – the the gleno ts. The By Dr ice) foot is musc whic stand shou ir ion legs of artic linke whol (teno aroun ing, level force of joints the surfa -ulna to ents mort ents RC ess pulled a is ns t his that men move The The of the the r rigid : 3. Pubo e ligam the r. radio n is each t. ligam e joint ruen ing us ) and the hip, move ing, walk on the or The funct pation eve, joints the head rs. 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The (Figure of from: ments direc tilted etabular allow (palm extension ion or girdle unt witho move ee of angu abduction embryolo centres main an artic d apart sligh aspects ro-ac (SIJ) the majo The slightly lar facet the the floor) off stret of rotat knee to on and The elbow ro-ulna g ees, three articu into acco faces of age. 2 x femo -iliac joints of GH with the degr ple durin hume the from n Flexi ll amount be prise e the 3-D 0 degr of the ratio r. lates 1. the 15 years 25-3 sma to allow is 2:1 2 x sacro symphysis ion consists For examneutral to h articu 8 and nA appreciat joint. can occu ion is ment stable play junct which rotat re flexion rus whic on the ulna s into 1 x pubic ar-sacral n from the GH joint, ees the move ment This subtalar ugh very befo the hume surface altho move le come is at 1 x lumb FA joint, 0 degr oracic ‘unlock’ ruent the clavic 30-9 cong ula-th The et n from t to scap of abduction et et tEX.n men .spor tEX.n tEX.n move 90 degrees www 20 .spor .spor www www n after 26

intr And – An ssment Asse

s 2011 Produced by

■ Back to basics revision of anatomy of each joint ■ Includes 53 anatomy animations and video clips to bring the facts to life ■ Covers diagnosis and treatment options with background theory and evidence based medicine


by Dr Simon Kay



© Primal


This resource is packed with animations and is highly visual coviering all the major joints and surrounding soft tissues. This guide offers valuable advice and tips to identify injuries, make good diagnoses, give sensible treatment advice and make appropriate referrals. It is also a perfect tool for showng patients and clients exactly which anatomical structures they have injured. The resources is regularly updated and expanded with new images and animations.





.spor www

SUBSCRIPTION INCLUDES ACCESS ON IPAD, ANDROID AND KINDLE FIRE TABLETS. For more information visit the Manuals + Guides section at


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