Football Medic & Scientist - Issue 17 by Football Medicine & Performance Association

football medic & scientist The official magazine of the Football Medical Association

Issue 17 Summer 2016

In this issue: Football to Amsterdam Swansea City Case Study Knee Injuries & Surgery Non-League Diary

Exclusive:

_ëĎáëŀŇëļǝ ĎŇŨ Scoop Team Award at FMA Conference 2016

FMA FOOTBALL MEDICAL ASSOCIATION SPONSORED BY

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Contents

FMA FOOTBALL MEDICAL ASSOCIATION

Welcome 4

Members News

Features 8

14 16

23 24 25 26

SPONSORED BY

Recruitment: A Level Playing Field Dave Reddin Background of Lateral Patellofemoral Overload Syndrome Mr. Simon Ball Case Study: The role of Geko Kate Rees Imaging in Femoroacetabular Impingement E.Rowbotham, A.Grainger, P.Robinson The Importance of Neuromuscular Measures in RTP Assessments from ACL Injuries Dr. Carl Wells Conference Success Sets the Standards Conference Gallery Award Winners Training Loads, Hamstring Injury Risk & Occurence Jamie Harley Why Research should Focus on Youth Hip & Groin Pain Neil Light

35 Early & Middle-Stage Rehabilitaion After Knee Injury & Surgery in Football Nicholas C. Clark

CHIEF EXECUTIVE OFFICER “Once again the success of our Conference and Awards event this year has laid the foundations for the coming season for the FMA”

n the closing address I made reference to the FMA becoming a proactive association wherein we can affect change for the betterment of our Members. This is now one of our main aims in the coming season and means further engagement with the Premier League, Football Association, Football League, Professional Footballers Association and the League Managers Association. Working with these bodies to address issues that concern us gives us a chance to improve the quality and effectiveness of our working environment. It is worth repeating again that, everything we do that is of benefit for our Members, in turn will benefit the players, the clubs and the leagues. Working with us is clearly a win win for all parties interested in the welfare of players. I also had the opportunity to highlight the work of our legal team who offer incredible support and expertise to our members not only at a time of real need but in an ongoing capacity and throughout the legal spectrum. Last season alone we dealt with over 30 cases of dismissals from post/redundancy all of which were taken to a satisfactory outcome for our members. Inside knowledge and experience of how clubs work and the nuances that exist in football are absolutely vital in these circumstances. Alongside this service our lawyers also conducted evaluations on 29 employment contracts giving recommendations that ensured our Members had a more satisfactory and appropriate contract in place. This of course would go on to be vitally important for those whose positions were terminated since it is that very contract that forms the basis of negotiation. The value of our legal support framework should not be underestimated. Eamonn Salmon CEO Football Medical Association recruitment

football medic & scientist

ACL injuries

THE IMPORTANCE OF

NEUROMUSCULAR

Pictured: Steve Kemp joins Phil Jones and John Stones whilst in a break from training before the 2014 World Cup.

RECRUITMENT FEATURE/DAVE REDDIN, HEAD OF TEAM STRATEGY & PERFORMANCE - THE FOOTBALL ASSOCIATION

MEASURES IN RETURN TO PLAY ASSESSMENTS

FROM ACL INJURIES FEATURE DR. CARL WELLS, SPORT SCIENCE LEAD, PERFORM ST GEORGES PARK

he increasing physical demands of elite football are clearly reflected by significant increases in the amount of high-intensity activity performed by Premier League players over recent years (Barnes

et al., 2014). Consequently, the ability to ensure players return from injuries with the necessary physical resilience is greater than ever to prevent re-injury and ensure the player can perform at the necessary level of

intensity. With recent research by Walden et al., (2016) indicating that three years post an ACL injury, only 65% of players still play at the top level of competition, the effective and robust assessment of physical status before returning a player to full training and match involvement is particularly pertinent. The invasive nature of ACL reconstructive surgery, which typically involves hamstring or now more commonly patella grafts, significantly impacts a player’s neuromuscular capabilities, leading to a major asymmetry in the force producing capabilities of the lower limbs. The use of technology such as isokinetic dynamometry is a well-established tool to assess neuromuscular function during rehabilitation from ACL injuries as it provides data relating to the torque producing capabilities of muscle groups associated with affected joint at both a range of speeds and contraction types. Isokinetic assessments however only provide the practitioner with information relating to the affected joint / limb in isolation during a restrictive movement pattern. Therefore, any isokinetic assessment as part of a return to play assessment should be complimented with measures that highlight a player’s neuromuscular capabilities in the affected limb during multi-joint, sport-specific actions. This is a particularly important aspect to quantify during ACL rehabilitation as reduced neuromuscular control during ballistic movements negatively impacts a player’s movement characteristics, resulting in the creation of greater stresses and instability in the affected limb. To address this issue, Perform at St. George’s Park has integrated force plate assessments of neuromuscular capabilities during specific football actions into its RTP assessment protocol alongside the isokinetic assessment. Although force plate analysis is commonly used within sport science, deeper analysis of the measures that such technology can provide is providing novel information regarding a players levels of neuromuscular control in an efficient manner that can directly inform practise when working within end stage rehabilitation.

The Analysis of jump force profiles in RTP Assessments The performance of a counter movement jump (CMJ), both bi- and uni-laterally on a force platform provides informative data relating to football performance as the action involves neuromuscular effort and co-ordination to develop maximal upward acceleration utilising the stretch shortening cycle followed by rapid deceleration upon landing. The data provided by CMJ force plate assessments is well complimented with that obtained from a hop and hold protocol where time to stabilisation can be measured to provide an indication of proprioceptive and ankle / knee stability capabilities. Below are examples of force plate traces from unilateral CMJ and hop and hold assessments for a professional football player nine months post ACL. Analysis of the above force traces reveal that during the stretch-shortening phase of take-off, both eccentric (the squat phase of the jump) and concentric (upward drive phase of the jump) force production has returned close to pre-injury levels. In contrast, during the landing phase, peak landing force is substantially higher in the affected leg and consequently, the rate of force development upon landing (the force absorbed over a period of time) is almost 100 N/s higher on the left side. The significance of this observation is that the player is being exposed to greater forces through the affected limb, placing greater stresses on an already compromised kinetic chain. The cause of such higher landing forces in injured limbs appears to be produced by greater stiffness and reduced flexion at the knee, caused either by diminished eccentric strength of the quadriceps and or reduced proprioceptive capabilities within the affected joint. Recent guidelines provided by the National Strength and Conditioning Association suggest peak landing forces in excess of 3 x body weight is a potential for increased injury risk. As the player in this example weighs 80 kg (784 N), it would appear from the above traces the acceptance of landing forces is compromised on both sides although at 2600 N the affected limb exceeds the 3 x body weight guidelines.

Figure 2. Player performing a bi-lateral CMJ of Dual Force Decks Platforms

The Football Association has introduced a new process to recruit the team behind the team – the coaches and support staff dedicated to helping our players to realise optimum performance Dave Reddin, Head of Team Strategy & Performance, outlines the structured process that aspiring candidates undergo when they apply to join the association. THE WHOLE PLAYER Our ultimate goal is for the England team to win the World Cup. It’s a bold ambition and one we’re working hard to make a reality. We’re investing in building multidisciplinary teams to cover the five major areas that we’ve identified as making up the whole player: technical, tactical, psychological, social and physical. It’s vital that we select the right people in these areas, with the skills, experience and mindset to take us forward.

A DAY TO SHOW WHAT YOU CAN DO Since September 2015, we have been working with Buckinghamshire-based HR consultancy Lane4 to design and run an assessment centre process to help us recruit coaches, physios, doctors, talent identification specialists, performance analysts and physical performance specialists. During the day candidates spend at the assessment centre, we can appraise their suitability for the post in

question through a range of assessment techniques and practical tasks. It allows us to evaluate their performance and potential to a depth that is simply not possible under traditional interviewing models. Lane4’s roots are firmly grounded in the world of sport, so they understand our drivers and challenges. The consultancy was co-founded by Olympic gold medallist swimmer Adrian Moorhouse (Seoul 1988) and draws on sport and elite performance

Figure 1. Uni-lateral (Left Leg) CMJ performance on the affected limb. A = Pre-injury, B = 9 months post ACL injury.

Figure 3. Hop and hold assessment 9 months post ACL injury for; A = non-affected (right) and B = affected limb.

Football Medic & Scientist Gisburn Road, Barrowford, Lancashire BB9 8PT Telephone 0333 456 7897 Email info@footballmedic.co.uk Web www.footballmedic.co.uk Chief Executive Officer

Eamonn Salmon

Business Development Manager

Jayne Maddison

COVER IMAGE

Senior Administrator

Lindsay McGlynn

Leicester City’s Shinji Okazaki receives treatment for an injury from Head Physiotherapist Dave Rennie in a Premier League match against Stoke City in January, 2016. Mike Egerton/PA Wire/PA Images

Administrator

Nichola Holly

Francis Joseph

Contributors

Dave Reddin, Mr. Simon Ball, Kate Rees E.Rowbotham, A.Grainger, P.Robinson Dr. Carl Wells, Jamie Harley, Neil Light Nicholas C. Clark

Editorial

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Design

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Marketing/Advertising

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Football Medical Association. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMA.

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MEMBERS’ NEWS

THE FOOTBALL MEDICAL ASSOCIATION ARE DELIGHTED TO ANNOUNCE OFFICIAL PARTNERSHIP WITH PROSTATE CANCER UK

ames Beeby, Director of Fundraising at Prostate Cancer UK, commented: “We’re absolutely thrilled that Prostate Cancer UK will continue working with the Football Medical Association (FMA) next season. Ignoring prostate cancer will not beat it, and over the last year Prostate Cancer UK and the FMA have established a strong relationship, which has not only helped to raise vital funds to support ground-breaking research to help fight the disease, but also awareness of prostate cancer throughout the footballing fraternity. “We’ve been delighted by the FMA’s and its members’ support, particularly their involvement in two of this year’s

flagship events: Jeff Stelling’s Men United March, and the fourth annual Football to Amsterdam charity cycle ride. In March 2016 – through its network of physios at football clubs across the country – the FMA was fundamental in helping to treat Soccer Saturday presenter, Jeff Stelling at the end of each of the 10 days, which ultimately helped him complete the gruelling 262-mile walk from Hartlepool to Wembley Stadium. Then, in June 2016, the Football Medical Association Team collectively raised nearly £20,000 for Prostate Cancer UK, when its group of five riders [Dr Tom Little, Anthony Colman, Chris Mountfort, Daniel Carter and Luke Hemmings] each cycled 145 miles from

Barnsley to Amsterdam over the course of just two days. That inspirational group of riders from across the UK demonstrates what we call Men United: people joining one team to fight a common opposition – prostate cancer. One man every hour dies from prostate cancer, and it is estimated that by 2030, prostate cancer will be the most common cancer overall in the UK; but we want to make prostate cancer a disease that the next generation of men do not fear. We thank the FMA and its member for their continued support, and look forward to developing this relationship further over the coming years.”

football medic & scientist

FOOTBALL TO AMSTERDAM - TEAM FMA

eam FMA have raised almost £20,000 for Prostate Cancer UK cycling 145 miles to Amsterdam! As well as our team the event saw 350 riders representing 50 Football League clubs start out from Barnsley FC’s Oakwell Stadium and London’s Olympic Park cycle 145 miles to the Dutch capital over the weekend, raising over £500,000 to help beat prostate cancer. FMA Members Dr Tom Little, Sports Scientist at Preston North End and Anthony Colman, Physiotherapist formerly of West Bromwich Albion FC and Portsmouth FC, were joined by Chris Mountfort, Daniel Carter and Luke Hemmings from Preston North End FC who helped raise this fantastic amount.

Tom’s Story Tom wanted to do this challenge to raise money in memory of his Dad, David Little. Tom’s father had previously suffered with prostate cancer. Tom was undecided between a few challenges, and so not to discriminate he decided to go for a triple whammy! On riding the 145 miles from Barnsley to Amsterdam Tom received the “orange jersey” for his staggering individual fundraising amount of £10,393.21 (to date). Tom (pictured in his orange jersey) told the FMA “The Football to Amsterdam ride was fantastic. Seamless organisation from start to finish. 240km is a long way but the comradery, views and good cause make it feel pretty easy. The night out is not bad either! I would heartily recommend to anyone.” Tom is continuing to raise money for this worthwhile charity and has gone on to mountain bike the Pennine Bridleway - 200 miles of fairly unforgiving terrain and is also participating in Toughguy probably the most brutal obstacle race around! Anthony’s Story Anthony is also not one to do things by halves. Anthony is participating in 3 events this summer! The first was the Football to Amsterdam for Prostate Cancer UK. Anthony said that he had a patient who was only 21 when he died

from prostate related Cancer which is why he wanted to cycle for this worthwhile cause. Said Anthony “ the event was “fantastic!” Anthony is also participating in the Prudential 100 mile bike ride and the London Triathlon Olympic distance both for Children with Cancer UK. We would like to wish both Tom and Anthony the best of luck as they continue with their events this summer and would also like to thank Chris, Daniel and Luke from Preston North End for joining Team FMA. If you would like to donate please visit the Just Giving page www.justgiving. com/teams/footballmedicalassociation and if you think that you would like to join Team FMA on next years Football to Amsterdam then please contact Lindsay@Footballmedic.co.uk

WORKING WITH UCFB

FMA TO PROMOTE FOOTBALL MEDICINE & SCIENCE AT THE NATIONAL FOOTBALL MUSEUM

he FMA is in the process of highlighting the work of the medical and science community in the Professional game. Following recent discussions with director, Dr Kevin Moore, the intention is to display the role of the “trainer” through the decades, from sponge man to GPs. As such we would like to appeal to Members and the wider medical and science fraternity to offer any artefacts, memorabilia, medical equipment, literature, photographs or anything that they may have that would

be appropriate for this project. Items submitted can be ‘donated’ to the museum or ‘loaned’ and your contribution would be acknowledged. Over 500,000 visitors attend the National Football Museum each year and we know there is a strong interest in the work that we do in the professional game. Any items of information we can gather that represents the past 10 decades would help to set up a fantastic exhibition representing us, and the FMA!

he FMA has been working in collaboration with the University of Football Business (UCFB) for the past 2 years. This has led to us supporting their ground-breaking project on Mental Health awareness and education. As health care practitioners, we are in the perfect position to help identify the many signs of impending mental health issues and it is a natural step for us to adopt some level of awareness in this field. Those who witnessed the final session at our recent Conference, in which we were given a dramatic and frank view of addiction and mental health issues from Clarke Carlisle and Shane Nicholson, will no doubt testify the need for us to become more involved in this area. As such, we are delighted to support UCFB in their proposal to increase awareness of this issue in professional football.

PARTNERS ON BOARD FOR THE COMING SEASON

PIRE continue as our lead sponsor for the forthcoming season and will be joined by BSN Medical, Cryoaction, Physiolab, Renew Health and Knights, who have all signed up as Business Partners ahead of the new campaign. We will also continue to work closely with Fit 4 sport, Game Ready and a host of supporting service providers over the next 12 months.

MEMBERSHIP

MARTIN PRICE JOINS KNIGHTS PROFESSIONAL SERVICES

artin has provided our members with legal advice since the Association was founded and members have benefited enormously from his 20 plus years’ experience within the football industry. The feedback we have received from members whom Martin has helped has been universally outstanding. Martin also advises the members of the LMA and has been involved in many

high profile cases over the years, including acting for Steve McClaren when he was appointed England Manager and for Henning Berg in his high profile claim against Blackburn Rovers. Martin has now joined Knights Professional Services, Limited one of the fastest growing legal services providers in the UK and we are delighted to continue our association with him.

ecuring the best lawyers in the industry is clearly a huge positive for members when they find themselves in need of such services. This is evidenced by the number of membership applications we receive when a problem is looming over a Club and jobs are potentially threatened. While membership to the FMA is actioned on application, it must be pointed out that there is a 3 month moratorium on access to legal services. As medics you prepare for most eventualities in the game and protecting your players is paramount. So, isn’t it time you put yourself to the top of the list and started looking after you? The answer is simple - don’t wait until it is too late, join the FMA now and get yourself covered so that you have peace of mind knowing you have the FMA support behind you.

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RECRUITMENT FEATURE/DAVE REDDIN, HEAD OF TEAM STRATEGY & PERFORMANCE - THE FOOTBALL ASSOCIATION The Football Association has introduced a new process to recruit the team behind the team – the coaches and support staff dedicated to helping our players to realise optimum performance Dave Reddin, Head of Team Strategy & Performance, outlines the structured process that aspiring candidates undergo when they apply to join the association. THE WHOLE PLAYER Our ultimate goal is for the England team to win the World Cup. It’s a bold ambition and one we’re working hard to make a reality. We’re investing in building multidisciplinary teams to cover the five major areas that we’ve identified as making up the whole player: technical, tactical, psychological, social and physical. It’s vital that we select the right people in these areas, with the skills, experience and mindset to take us forward.

football medic & scientist to help organisations, teams and individuals reach their potential and build sustainable competitive advantage. Together, we’ve invested time and energy into making the recruitment process as effective and transparent as possible. The outcome is a robust, structured yet flexible format for the assessment centre that can be adapted according to the role for which we’re selecting. We want it to be a positive experience for candidates: challenging, engaging and memorable for all the right reasons. We put candidates through their paces by seeing how they react in different scenarios. So, this might include gauging how they cope with conflict through role play with a professional actor, or planning a strategy to communicate with stakeholders and the media following a major medical crisis on the pitch. Again, we might put their adaptability under the spotlight. For example, coaching candidates may be required to coach an unfamiliar sport. In one instance, we invited the Great Britain Women’s Wheelchair Basketball team to participate in a coaching exercise. All these different activities are designed to form a rounded view of candidates’ performance. It’s worth noting that before they go through to the assessment centre, candidates also undergo rigorous psychometric testing, using objective, established tools. SEEING FAIR PLAY DONE The assessment centre day itself contributes to our constant drive to

improve football across the country. All candidates, successful or not, are offered detailed feedback on their performance from trained assessors. This is aimed at

giving them a clearer understanding of their strengths and weaknesses, with actionable recommendations for areas of development. Above all, we want every candidate to feel that the FA has appointed the man or woman best equipped for the role, with no hint of ‘jobs for the boys’. One recent recruit who has gone through the assessment centre as part of the recruitment process is Steve Kemp, who joined the association as Lead Men’s Physiotherapist earlier this year. Steve was the Assistant England Physiotherapist, as well as working as Elite Football Physiotherapist at the Perform Sport Medicine centre at St Georges Park. Steve was selected from an outstanding group of candidates who included a number of leading physiotherapists in English football. I’ll give Steve the last word on the FA’s recruitment process: “The assessment centre was an intense, challenging process, where we were placed in high-pressure situations. It gave us the opportunity to show a broad range of our key skills and behaviours in challenging tasks that could occur in day-to-day practice. This was in stark contrast to previous ‘panel’ interviews I have experienced in the past with other organisations, which may favour those candidates blessed with the gift of the gab. With the FA, you left feeling you had been part of a very thorough, fair process.”

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Pictured: Leicester Tigers’ Miles Benjamin screams out in pain after suffering a knee injury versus Exeter Chiefs in May, 2015.

BACKGROUND OF LATERAL PATELLOFEMORAL OVERLOAD SYNDROME FEATURE/ MR SIMON BALL CONSULTANT KNEE SURGEON A SUMMARY OF SIMON BALL’S TALK BY ALISON LEIGH Mr Simon Ball began the evening’s session with a review of lateral patellofemoral overload syndrome. Introduction: Anterior Knee Pain Anterior knee pain is very common, with 2.5 million runners in the USA presenting each year. It has a 20% prevalence in female athletes and 15% in male athletes. It particularly affects young females with 12% of all young adult females suffering from the condition. It is also prevalent amongst those who have recently taken up sport; for example 37% of military recruits

suffer in their basic training. However, anterior knee pain is not a diagnosis. There are many causes of anterior knee pain and many distinct diagnoses. It is important that clinicians search for the diagnosis and cause of the knee pain so that appropriate treatment may be administered. (Table. 1) Previous Treatment Outcomes Reported treatment outcomes are not satisfactory. Five years after the completion of a rehabilitation programme

80% of patients remain symptomatic and 74% have a reduced activity level. The outcomes after surgery are no better. After lateral release, 50% of patients are unchanged or worse. Chondroplasty works well for patients with mechanical symptoms but is not a good operation for a patient with degeneration. The results of patellofemoral realignment in the absence of instability are also not good, with only 25% of patients feeling satisfactory or better. The poor outcomes demonstrate that this is a difficult condition to treat. The failure to achieve better outcomes also reflects the complexity of the condition and most probably highlights a lack of understanding, with patients not receiving an individualised programme of care. Aetiology Table 1 lists the causes of anterior knee pain. There is significant overlap between the conditions listed on the left. These conditions are common and are the most difficult to manage because the aetiology is complex and multifactorial. Each patient is different and deserves a robust assessment and an individualised treatment pathway. To do this, it is important to recognise the different factors associated with the problem and to assess each of them. Proximal factors include problems with the trunk and pelvic stability, as well as gluteal musculature. Local factors occur around the knee and distal factors are at the foot and ankle. During running many patients, especially young females, will demonstrate dynamic valgus. The hip drops into adduction and the knee internally rotates. This increases

football medic & scientist

Pictured: England’s Ben Stokes (right) suffers a knee injury during the opening Test Match against Sri Lanka in May 2015.

Table 1. Causes of anterior knee pain ~ ~ ~ ~ ~ ~

Patellofemoral pain syndrome Chondromalacia patellae Osteoarthritis Superolateral fat pad impingement Iliotibial band friction syndrome Patellofemoral instability

Patellar tendinopathy Quadriceps tendinopathy Bursitis Plica syndrome Sinding-Larson and Johansson disease Osgood–Schlatter’s disease Patellar stress fracture Tumour/infection Referred pain from hip

~ ~ ~ ~ ~ ~ ~ ~ ~

the Q angle and therefore alters the patellofemoral joint kinematics. An important factor is gluteal weakness. The question is whether there is a lack of activation of the gluteals, a natural weakness, or have they become weak over time due to poor technique? The role of the iliotibial band (ITB) is also important. The ITB is a lateral condensation of fascia lata that begins at the iliac crest and inserts into Gerdy’s tubercle on the anterolateral aspect of the tibia. It is tensioned by the tensor fasciae latae (TFL). The ITB has important connections to the quadriceps muscle, the femur and the patella, and, therefore, plays a very important role in tibial and patellar kinematics. The ITB seems to play an important role in anterior knee pain as a tight ITB causes lateral patellar translation, tilt and rotation. Also, studies have shown that patellofemoral pain syndrome patients with anterior knee pain often have a tight ITB compared to normal controls.

The ITB is notoriously difficult to stretch and any stretching should focus on the muscle component of the TFL/ ITB musculotendinous complex. When planning a physiotherapy intervention for anterior knee pain, hip strengthening and ITB stretching has a 93% success. Conversely, if these aren’t addressed, the success rate is 0%. Lateral Patellofemoral Overload Syndrome By grouping the conditions listed on the left-hand side of Table 1 together, lateral patellofemoral overload syndrome can be defined as activity-related anterior knee pain with the presence or absence of any combination of the following: ~ ~ ~ ~ ~

ITB tightness Gluteal weakness Superolateral fat pad impingement ITB frictional syndrome Lateral patella chondromalacia/ degeneration

A patient may simply present very early on with just pain. However, a patient may also present with all of these conditions. For example, ITB tightness may cause ITB frictional syndrome and will lead to gluteal muscle weakness (or inability to activate the gluteals). This will lead to superolateral fat pad impingement because of the patella translation tilt and rotation, which in turn may eventually lead to lateral patella chondromalacia/degeneration. In summary, it is important to think of all of these conditions as one syndrome, with related aetiology. However, it is important treat each patient individually: identify the cause and develop a specifically tailored treatment programme. Mr Simon Ball Consultant Orthopaedic Surgeon MA FRCS (Tr & Orth) Mr Ball Specialises in all aspects of knee surgery. Mr Ball iis an extremely keen sportsman. having captained Cambridge University Football Club and has played semiprofessional football, thus understands the needs and exceptions of sports people. Mr Ball has a special interest in sports knee injuries, complex ligament reconstruction and re-alignment surgery.

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Pictured: England’s Wayne Rooney holds his ankle during a UEFA European Championship Qualifying match against Slovenia in June, 2015.

CASE STUDY: THE ROLE OF GEKO™ A portable neuromuscular electrical stimulation device, in treating lateral Tibial pain, swelling and spasm following a high Ankle sprain. FEATURE/KATE REES HEAD PHYSIOTHERAPIST, SWANSEA CITY FOOTBALL CLUB Subject The subject is a 27-year-old male professional footballer. Relevant Clinical History The player sustained the injury during a match. The mechanism consisted of the player being tackled and landing onto a forced plantar flexed foot. He felt immediate pain but was able to carry on. However he was substituted tactically and removed from the field of play 5-minutes later. The following day his pain had lessened but he was experiencing difficulty walking. Clinical Presentation and Clinical Management (29/11/2015): The ankle presented with swelling around the lateral aspect extending up into the leg. The pain was reported in the corresponding areas. On examination there was reduced range of movement

in all directions. There was some mild pain on manual muscle testing into an everted position, stressing the peroneal muscles. On special testing, the anterior drawer showed some laxity with a firm end-feel and the ‘crank’ test was positive for pain. Further testing was performed to the syndesmosis which found it to be stable but painful. On palpation there was tenderness around the Anterior Talofibular Ligament (ATFL) and the Anterior Inferior Tibiofibular Ligament (AITFL). These clinical findings led us to believe that there was an injury to the AITFL +/- the ATFL. Further investigations were performed including an ultrasound and MRI scan. They confirmed an injury to the AITFL with some old scarring noted over the ATFL. The player was seen by an orthopaedic consultant who advised him to wear a brace for the next 2 weeks with minimal lower limb activity out of the brace.

Rationale for treating with the geko™ device The geko™ device was utilised for the following reasons: To increase circulation to the LL muscles, aiding the healing process and helping to prevent deep vein thrombosis whilst the player was less active than usual. The player was also flying abroad during this period so it was used during the flight for the same reasons. By increasing the circulation to the area, the geko™ may also aid in reducing swelling. The geko™ was also used to reduce pain and muscle spasm in the peronei by stimulating the motor nerve of the common peroneal nerve. The geko™ device treatment regime The geko™ device was applied to the fibula

football medic & scientist

Pictured: Chelsea’s Michael Ballack clutches his ankle after picking up an injury during the First Leg of a Champions League Semi-Final against Barcelona in April,2009.

head and pressed on to a level where a visual twitch was observed and the impulse feeling was comfortable to the player. We advised the player to be in situ for 2-hours and to complete this twice per day. The player was instructed to use the geko™ device during periods of inactivity. This was used alongside a PRICE regime and implemented over a 5-day period. Results/Outcome The outcomes used to measure any changes were calf circumference and the knee to wall (KTW) test. Calf circumferences were measured 10cm from the distal patellar pole. The circumferences measured equally at time of the injury and there was no loss in circumference one week later. KTW test was measured by a piece of tape on the floor. The big toe was placed as close to the wall as possible and the player was asked to push the knee towards the wall whilst keeping the heel placed firmly on the ground. The distance between the big toe and wall was measured. At the time of injury the measurements were 0cm on the right side and 4cm on the left side. One week later the KTW measurements were 2cm on the right side and 4cm on the left side. The results showed no changes in calf

circumference and an improvement of 2cm on the KTW measurement of dorsiflexion range of movement. Conclusions The geko™ device alongside a PRICE regime appeared to show no change in calf muscle bulk and improved dorsiflexion range of motion in a premier league football player with a high ankle sprain. As this was a single case study no comparisons can be made to the natural healing process or compared to the PRICE regime alone. However the improvements in outcome measures do appear positive. The improvement in KTW measure can be interpreted as an improvement in ankle dorsiflexion range of motion. This is often reduced when swelling around the ankle joint is experienced. The player showed an improvement in ankle dorsiflexion range after using the geko™ device for 5-days, which is likely to be due to a reduction in swelling. The KTW measure can also be a measure of the length of the Soleus muscle. Muscle spasm can be associated with pain in early injury and therefore a possible treatment rationale of the geko™ device would be for pain reduction and hence increased movement and a reduction of spasm within the Soleus muscle by increased movement around the structures caused by the muscle twitch.

Calf circumference was also measured. This can be a measure for swelling but can also be a measure of muscle wasting by measuring the circumference of the muscle. If a muscle were wasting, the calf circumference would be reduced and if there were any swelling in the crura, the circumference would be raised. This is an effect that is likely to happen within the first week of an injury. Therefore, no change in calf bulk may suggest that no muscle wasting occurred, a positive outcome for long-term rehabilitation when using geko™ in the early stages on injury. The changes seen in this player, improvement in outcome measures and visual swelling and movement of the ankle, appeared better than previous treatments of a PRICE regime alone. However, as this was a single case study no comparisons could be made in this specific case to using PRICE regime in isolation. One must also consider the differences between individuals and their healing timescales that can vary according to age, general health alongside many more variables. In general the player found the geko™ easy to apply and easy to use, it was comfortable to wear and we would use it again for recovery or for any further lower limb injury.

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IMAGING IN FEMOROACETABULAR IMPINGEMENT The term Femoroacetabular impingement (FAI) describes a concept of painful abutment of the femoral neck against the acetabular rim FEATURE/E ROWBOTHAM, A GRAINGER, P ROBINSON LEEDS TEACHING HOSPITALS

n turn this can lead to both labral and cartilage damage and ultimately to secondary osteoarthritis of the hip joint [1]. Depending on clinical and radiographic findings, two types of impingement are distinguished;

antero superior labrum during hip flexion and internal rotation. The resultant force on the labrum leads to tearing between the labral base and the adjacent acetabular cartilage.

an abnormally shaped femoral head–neck contour. A recent large systematic review concluded that an increased alpha angle is the only prognostic factor in symptomatic FAI associated with the development of early osteoarthritis and a labral tear [4].

Role of Imaging ~ ~

Pincer type deformity, more common in middle aged women, where there is primarily an acetabular deformity CAM type deformity, more common in young men and particularly athletes, where there is an aspherical portion of the femoral head/neck junction.

In practice the vast majority of cases of FAI have a mixed pattern of both CAM and Pincer deformity [2]. Whilst the exact aetiology of FAI remains unclear, there are several predisposing factors which have been described; in terms of footballers, it has been proposed that there is a relationship between the frequency of football practice during skeletal growth and the presence of a CAM deformity in adulthood [3]. The abnormal femoral head prominence which is seen with a CAM deformity leads to impaction on the

MR Imaging Imaging in cases of suspected FAI is often performed both to confirm the diagnosis and to assess the joint for cartilage and soft tissue damage. Ultimately the extent of cartilage damage will affect not only the therapeutic options for the player but also give an indication of the long term prognosis for the hip joint. Plain film Imaging The pistol grip deformity seen in CAM impingement (Figure 1) or acetabular retroversion (pincer) shown as a cross over sign, are typically demonstrated on plain film imaging. The degree of CAM deformity may be quantified by the amount of asphericity which is measured by way of the angle. It can be measured on radiographs or on MR imaging (Figure 2); an angle of greater than 55° is an indicator of

Standard MRI at 3T or direct MR Arthrography at 1.5T are currently used as the imaging modalities to detect both labral tears and cartilage defects. The current literature suggests that there is little difference between these imaging techniques in terms of detecting labral lesions but there is a reported advantage of direct arthrography over standard MRI in the detection of acetabular chondral defects [5]. Imaging Findings A triad of abnormal imaging findings has been described in patients with CAM type FAI: abnormal head-neck morphology, anterosuperior cartilage abnormality (Figure 3), and anterosuperior labral abnormality [6].

football medic & scientist

Labral tears may be classified according to their location, morphology or aetiology [7]. Tears are depicted on MRI as high signal tracking either between the labrum and acetabulum at the labral base, or within the substance of the labrum itself (Figure 4 and 5). Cam type FAI typically leads to separation of the antero superior labral junction which in turn may progress to labral detachment and cartilage delamination [2]. Even with direct arthrography, assessment of articular cartilage damage can be difficult; the cartilage layer is thin, has a large degree of curvature and femoral and acetabular surfaces are usually closely opposed. Both subchondral bone oedema and subchondral cyst formation are therefore useful secondary indicators of cartilage defects. The location and extent of labral and cartilage damage are usually described using the clock face analogy. Accurate characterisation is important particularly for atypically located lesions which may be difficult to access at arthroscopy [8]. Conclusion: Radiographic features of FAI are very common among athletes; in a study of asymptomatic collegiate football players, up to 95% were shown to have at least one radiologic sign of cam or pincer impingement [9]. The increased prevalence compared with the normal

population is thought to be due to the increased hip loading during certain sports. Intra articular injection of local anaesthetic can be a useful diagnostic

tool when assessing whether the symptoms a player is experiencing are emanating from the hip joint itself or related to an extra articular pathology.

References 1. Ganz, R., et al., Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res, 2003(417): p. 112-20.

detection of acetabular labral tears and chondral defects in the same patient population. Br J Radiol, 2015. 88(1053): p. 20140817.

2. Beck, M., et al., Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br, 2005. 87(7): p. 1012-8.

6. Kassarjian, A., et al., Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement. Radiology, 2005. 236(2): p. 588-92.

3. Tak, I., et al., The relationship between the frequency of football practice during skeletal growth and the presence of a cam deformity in adult elite football players. Br J Sports Med, 2015. 49(9): p. 630-4. 4. Wright, A.A., et al., Radiological variables associated with progression of femoroacetabular impingement of the hip: a systematic review. J Sci Med Sport, 2015. 18(2): p. 122-7. 5. Magee, T., Comparison of 3.0-T MR vs 3.0-T MR arthrography of the hip for

7. Groh, M.M. and J. Herrera, A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med, 2009. 2(2): p. 105-17. 8. Larson, C.M., Arthroscopic management of pincer-type impingement. Sports Med Arthrosc, 2010. 18(2): p. 100-7. 9. Kapron, A.L., et al., Radiographic prevalence of femoroacetabular impingement in collegiate football players: AAOS Exhibit Selection. J Bone Joint Surg Am, 2011. 93(19): p. e111(110).

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THE IMPORTANCE OF

NEUROMUSCULAR

MEASURES IN RETURN TO PLAY ASSESSMENTS

FROM ACL INJURIES FEATURE DR. CARL WELLS, SPORT SCIENCE LEAD, PERFORM ST GEORGES PARK

he increasing physical demands of elite football are clearly reflected by significant increases in the amount of high-intensity activity performed by Premier League players over recent years (Barnes

Figure 1. Uni-lateral (Left Leg) CMJ performance on the affected limb. A = Pre-injury, B = 9 months post ACL injury.

football medic & scientist The Analysis of jump force profiles in RTP Assessments The performance of a counter movement jump (CMJ), both bi- and uni-laterally on a force platform provides informative data relating to football performance as the action involves neuromuscular effort and co-ordination to develop maximal upward acceleration utilising the stretch shortening cycle followed by rapid deceleration upon landing. The data provided by CMJ force plate assessments is well complimented with that obtained from a hop and hold protocol where time to stabilisation can be measured to provide an indication of proprioceptive and ankle / knee stability capabilities. Below are examples of force plate traces from unilateral CMJ and hop and hold assessments for a professional football player nine months post ACL. Analysis of the above force traces reveal that during the stretch-shortening phase of take-off, both eccentric (the squat phase of the jump) and concentric (upward drive phase of the jump) force production has returned close to pre-injury levels. In contrast, during the landing phase, peak landing force is substantially higher in the affected leg and consequently, the rate of force development upon landing (the force absorbed over a period of time) is almost 100 N/s higher on the left side. The significance of this observation is that the player is being exposed to greater forces through the affected limb, placing greater stresses on an already compromised kinetic chain. The cause of such higher landing forces in injured limbs appears to be produced by greater stiffness and reduced flexion at the knee, caused either by diminished eccentric strength of the quadriceps and or reduced proprioceptive capabilities within the affected joint. Recent guidelines provided by the National Strength and Conditioning Association suggest peak landing forces in excess of 3 x body weight is a potential for increased injury risk. As the player in this example weighs 80 kg (784 N), it would appear from the above traces the acceptance of landing forces is compromised on both sides although at 2600 N the affected limb exceeds the 3 x body weight guidelines.

Figure 2. Player performing a bi-lateral CMJ of Dual Force Decks Platforms

Figure 3. Hop and hold assessment 9 months post ACL injury for; A = non-affected (right) and B = affected limb.

Figure 4. Graphical representation of force producing asymmetry in the affected limb during the first 150 mms of an isometric mid-thigh pull. The hop and hold exercise provides further evidence that the player’s neuromuscular control of the affected side following the ACL injury is still comprised even though they are deemed as being close to a return to play. A key observation is that time to stabilisation is 14% longer on the affected side. A lack of lower limb stability during rapid deceleration can negatively impact performance by increasing the amortization period of plyometric type movements, reducing reactive force generation from the stretch shortening cycle. Furthermore, a lack of limb stability is a risk factor for re-injury as it is would predispose the player to joint malalignment during periods of intense deceleration. Force Production Profiles during Isometric Mid-thigh Pull A limitation of jump assessments on the force platforms is the achievement of reliable peak force and RFD measures during the concentric phase of the movement due to the natural variability of such a dynamic multi-jointed movement. A solution is provided by the use of a closed chain isometric exercise such as a mid-thigh pull. Such an assessment typically involves positioning a player in an isometric rig that contains embed force platforms. The bar to be pulled is set at the anatomical mid-

during this isometric movement. As can be seen from the graphs below for the player rehabilitating from the ACL injury, although there is only a deficit of 6% in peak force production in the affected leg, when measured as force produced within the first 150 ms of the pull (i.e. the initial explosive application of force), the affected side generates 16.9% less force in this time period. Such asymmetry indicates the affected side is still comprised in the performance of explosive concentric actions.

Figure 5. The performance of a mid-thigh pull in the isometric dual platform rig at Perform, St. George’s Park thigh position with hip and knee angles falling within 125 – 150 degrees and 125 – 145 degrees respectively. The dual force platform system allows any asymmetry to be detected in force producing capabilities

Figure 6. The Perform RTP neuromuscular assessment process

A Holistic Approach to RTP Assessment To gain the most accurate insight into a player’s readiness to train following a serious knee injury such as an ACL, an RTP assessment should contain a battery of assessments that provide a multi-faceted quantification of the player’s neuromuscular capabilities. Ideally such data would allow for comparison with pre-injury data if available but also with the non-affected limb. Importantly, a field based measure of performance that stresses the dynamic and load acceptance capabilities of the affected limb should also be implemented to provide data relating to the transfer of injury integrity to a pith based performance scenario.

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CONFERENCE SUCCESS SETS THE STANDARDS! “A fantastic conference in every way. Definitely among the best I have been to in my 30 years in football” Steve Allen, Bristol City FC

“I had a terrific weekend at the FMA conference, it’s getting better and better. The line up was really superb”

“Back from a fab weekend at the FMA Conference 2016 lots of notes written and new friends made. Definitely the best one yet.”

“Superb weekend at the FMA Conference. Great to catch up, meet new people and listen to some great presentations.”

here’s no question that the FMA Conference and Awards evening continues to go from strength to strength. Educationally, delegates this year were witness to an outstanding group of speakers who gave us an insight in to the practical application of strategies relating to hip and groin issues in the modern game. “Not only was the content exceptional, the speakers delivered in such a confident and clear manner their presentations had so much more impact”. With an emphasis on rehabilitation and prevention strategies, the first session on day 1 was led by keynote speaker Professor Per Hölmich who as a world authority on this subject, delivered an outstanding talk on “Taxonomy diagnosis and treatment of groin injuries in football”. Delegates rightly described this session as “incredible”. The afternoon saw James Allen’s present his talk on “Rehabilitation strategies in tackling the hip & groin in field sports: from theory to practice”. Opening the question and answer session after, Per Hölmich said this was the best presentation he had ever heard on

rehabilitation strategies in the hip and groin. Praise indeed!! - and a clear indication as to the level of expertise that James reached. Mixing his session with a sense of humour that was to become a familiar trademark, James grabbed the audiences attention and kept their interest throughout what was a fantastic presentation. Delegates then gathered to watch the FA Cup Final and over a glass or two …. or more in many cases…… were able to meet up and chat to colleagues in an informal setting. This once again proved to be a terrific platform for sharing ideas, re-acquainting with colleagues and connecting in a way that forges valuable professional contacts that can be called upon up at anytime during in the future. This year’s awards dinner was attended by over 160 guests. The relaxed and informal atmosphere once again conducive to a great evening where guests were able to come together to show their appreciation of the award winners. each and every recipient was much deserved. Day two opened up with a multi-disciplinary approach to hip and groin injury prevention which was again very well received. But with a

“What an excellent weekend. Top of the range speakers and so well organised. Will have 2017 conference first on must do list for next year.” “Enjoyed the conference and thought the content and guest speakers were excellent.”

twist to normal protocol, this session uniquely ended in a presentation totally abstract to the core subject finishing with a talk by Colin Bland from the Sporting Chance Clinic which gave delegates a thoughtful insight in to service provision of this clinic for players with mental health issues. Graham Smith, Professor Per Hölmich and James Allen then teamed up for a session entitled “Golden Nuggets from the Groin” in which each gave their own personal “gems” of wisdom for delegates to take away with them. The final session of the event then stunned the audience as former professional players Shane Nicholson and Clarke Carlisle each gave an insight into their individual battles with drug addiction and mental health issues. Delegates were clearly speechless as both players gave a frank and very open account of their experiences and it was certainly eye opening for everyone to hear these very personal accounts. As one delegate pointed out: “I learnt more in today’s first session than I did the whole weekend at a recent conference I attended. I will most definitely be back next year”.

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football medic & scientist

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AWARD WINNERS 2016 Premier League Medical & Science Team Award 2015/2016 Season winners – Leicester City FC

Championship Medical & Science Team Award 2015/2016 Season winners - Middlesbrough

Sponsored by:

Division 1 Medical & Science Team Award 2015/2016 Season – Barnsley FC

Sponsored by:

Division 2 Medical & Science Team Award 2015/2016 Season winners – Carlisle United FC

Sponsored by:

Scottish Leagues Award – Victoria McIntyre

Exceptional Service Award 2016 – Nick Oakley Sponsored by:

Sponsored by:

Longstanding Service Award– Alan Sutton

Outstanding Contribution to Football Medicine – Professor Myles Gibson OBE (accepted by Corville Laird, Royal College of Surgeons (Edinburgh))

Sponsored by:

21 Club Award Winners Philip Yeates, David Muckle, Brian Owen, Mike Stone, Steve Allen, Tony Flynn, Alan Rankin, Ronnie Evans, Mick Rathbone, Kevin Kewn, Brian Morris

Sponsored by:

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Pictured: Aston Villa’s Rudy Gestede lies injured holding his hamstring during their Premier League match against West Bromwich Albion in January, 2016.

TRAINING LOADS, HAMSTRING INJURY RISK & OCCURRENCE FEATURE/JAMIE HARLEY

Many teams quantify physical load data from matches using automated camera systems (eg. Prozone), with wearable tracking devices used in training (eg. Catapult).

e have previously demonstrated that caution should be applied when using such data interchangeably, particularly for highintensity and sprinting parameters1. With the improvements in player tracking technologies over recent years, we are now able to determine the loads of players in both training and matches using wearable devices, the use of which has been permitted in the Premier League from the 2015/16 season. Therefore, for the first time and in line with other sports, the physical loading of football players in England can be quantified to an accurate and reliable level using one tracking device, and this will improve further as the

technology companies develop new ways to improve tracking accuracy inside stadia, where GPS signal can be compromised. Nevertheless, as medical and science practitioners we now have the tools and research base to help manage the physical loading of players to the highest degree possible. Jan Ekstrand and colleagues2 have recently reported an increase in incidence of hamstring injuries by 4.1% annually, between 2001 and 2014. An interesting research finding from Chris Barnes and colleagues3 using automated camera tracking data was the observed increase in sprint distance (+35%) and number of sprints (+80%) in the Premier League

between 2006/7 – 2012/13. Sprinting loads and mechanics can be a key factor in hamstring injury occurrence, whether at the maximal net moment in the late swing phase, at push-off, or during the deceleration phase. In fact, Gabbett et al reported that players who performed greater amounts of very high-speed running were 2.7 times more likely to sustain a non-contact soft-tissue injury than players with lower running loads.4 Therefore we know that players are sprinting more in the Premier League, and that this results in a higher risk of injury, and there has been an increase in hamstring injuries annually in professional football – so how can we best manage the

football medic & scientist sprinting loads of players? Is it advisable to restrict sprinting loads in training so as not to expose players to an increased injury risk, or conversely does this underprepare them for the high demands of competition, and in particular during periods of fixture congestion? Recent studies examining training loads and injury occurrence by Tim Gabbett and colleagues4 have addressed the relationship between a longer time period of work (chronic workload, related to fitness) and a shorter time period of work (acute workload, related to fatigue). In line with traditional principles of training, the Figure 1

Figure 2

Figure 3

‘acute:chronic workload ratio’ is one way of determining when an athlete’s training load has ‘spiked,’ which may exceed the normal principles of progression and overload to an extent that the risk of injury in the athlete is increased. The idea is that an A:C Ratio of >1.5 reflects a recent spike in training load compared to the previous four weeks of loading. There is therefore a suggestion that training loads should be consistent from week to week, to enough of a degree to prevent such ‘spikes’ from occurring, subsequently reducing injury risk. Therefore it could be suggested that players should be given the opportunity

to sprint in training on a prescribed and consistent basis, so that the increase in sprinting load from high-intensity matches and a congested fixture schedule can be mitigated. CASE STUDY Figures 1, 2 and 3 show the weekly physical loads of Player A over an 8 week period, in which a hamstring injury was sustained in Week 8. ~ 5XVdaT C^cP[ SXbcP]RT [^PSb fTaT variable but within recommended A:C Ratio levels (0.9 – 1.3) ~ 5XVdaT ! 0RRT[TaPcX^] [^PSb fTaT Pa^d]S the recommended A:C Ratio levels (0.71.4) ~ 5XVdaT " B_aX]cX]V [^PSb zb_XZTS{ X] Week 7 with an A:C Ratio of 2.2 (increased injury risk). In the case of Player A, he played in 2 matches in Week 7 following 4 weeks without any match exposure. During Weeks 3-6, physical loads were accumulated entirely from training, including high distance and acceleration loads from a combination of football and running drills, and small sided games. However, it can be observed that sprinting loads (classed as distance >24km.h) were low-moderate in these weeks, due to a combination of not being selected for games and completing small sided games and high-intensity (not sprinting) running drills in place of match minutes. Consequently, when Player A plays 2 matches in Week 7, a spike in sprinting load occurs which results in an A:C Ratio of >2.0. In theory, had Player A’s sprinting loads in Weeks 3-6 been consistent with Weeks 1-2, the overload in Week 7 may not have been to as high a degree and therefore he may have experienced less relative stress on the muscle tissue during these maximal bouts of running. The individualisation of training loads relative to individual expected match outputs seems the most effective way of mitigating injury risk associated with spikes in training load. Although the literature commonly quantifies external load using RPE derived measures, it can be useful to apply load management techniques to several relevant parameters including sprinting loads, in order to reduce the risk associated with the increasing maximal work efforts from players seen in the Premier League.

References 1. Harley et al., J Str Cond Res 2011 doi: 10.1519/JSC.0b013e3181f0a88f 2. Ekstrand et al., Br J Sports Med 2016 doi:10.1136/bjsports-2015-095359 3. Barnes et al., Int J Sports Med 2014; doi:10.1055/s-0034-1375695 4. Gabbett TJ. Br J Sports Med 2016; 0:1– 9. doi:10.1136/bjsports-2015-095788

football medic & scientist

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Pictured: Coventry City’s James Maddison lies injured after a tackle during their League One game against Rochdale in March.

WHY RESEARCH SHOULD

FOCUS ON YOUTH HIP & GROIN PAIN FEATURE/NEIL LIGHT At the excellent, recent FMA conference a former colleague of mine asked how I had decided upon my PhD topic. I was surprised how naturally my answer came to mind; it was to approach a problem which I felt challenged me more than any other in my clinical career.

rom a senior player perspective, longstanding groin pain represented a challenge that I never feel I competently conquered. Such players would often dip in and out of full squad availability, perhaps playing on a Saturday but unavailable for the following Tuesday or require some form of reduced training load and bags of medical attention in between. This often tested the patience of the coaching staff but equally the medical team and the players themselves. Like most, the conservative management was always my preferred option. However, with the immense pressure to maintain player availability, the seduction of a latest surgical technique ‘claiming’ to get them fighting fit in just a few weeks was an ever present variable to deal with. One way or another, they were managed

and I’m glad to report that all maintained their already established playing careers and long after my care. But on reflection these weren’t my true problem players, nor the ones who have since informed my research interest or I wished I could have done more for. Those I remember most are the ones who never quite established a career or those failing to fulfil potential. I am referring specifically here, to youth players whom suffered significant hip or groin pain which in reality had a major impact on their development as players. Furthermore, and upon reflection, those problematic senior players all reported a history of groin, hip, lumbar or abdominal injury as youth players and whilst anecdotal, I believe this is no coincidence. So the combination of a problem area (hip

/ groin) matched with a problem population (youth footballers) was the birth of my research interest. I am now in a position where I am able to study this exciting area in detail, with expert guidance from Dr Neal Smith (Chichester) and Dr Kristian Thorborg (Copenhagen). My goal is simply to contribute towards better prevention and management of hip / groin pain in youth footballers. If you were lucky enough to attend the recent FMA (2016) conference, you will have heard a wealth of expert speakers including Prof Per Holmich, who despite having more knowledge than most in this area, admits (rather refreshingly) that there are things we simply still don’t know. Nevertheless, athlete hip and groin related injury has received much research attention in the last few years, somewhat culminating in the 2014 Doha

consensus statement (1) which both Prof Holmich and a number of other speakers referred to. The statement serves to clarify the mass of diagnostic terminology into reasoned clinical entities of which, adductor related groin pain is most prevalent. This is supported by epidemiological research reporting that adductor related injury accounts for nearly two-thirds of hip and groin pathology, which itself represents approx. 12-16% of all injuries in elite senior football (2). Surprisingly, despite the vast investment clubs make in nurturing young players, there is limited research related to youth footballer injury. One epidemiological study notes that 7-12% of all injuries are hip / groin related in nature (3). Epidemiology provides us with data to gauge the extent of a problem and arguably by these statistics, one would suggest not that much and indeed, this was echoed at the FMA conference; I disagree. Epidemiological data is often derived from ‘time-loss’ methodology whereby a players’ problem only contributes to the data when they are ‘absent’ from training or match play. However, fellow clinicians will agree that players often play with persistent symptoms and recent research utilising patient reported outcome measures (such as the HAGOS questionnaire) supports this. Findings suggest high numbers of player’s experience symptoms during the season, whilst more severe symptoms can transfer into the next season (4). Players who are unable to play may simply represent just the tip of the iceberg. A little closer look at research surrounding youth footballers, show's that groin injury occurs more frequently in early maturing players (5), whilst bony morphological changes occur in the hip during these developmentally important years particularly

Pictured: Manchester United’s Marcus Rashford leaves the field after picking up a injury during the FA Cup Final in May.

in those playing prior to 12 years old (6). At present, we can only assume that there is a dose-injury / symptom relationship in maturing footballers but with prospective future research, we may clarify this link and establish ways to optimise management of such problems in this valuable population. It is worth noting that research from Australian football, has shown how youth groin injury can predict absence from activity in

Pictured: Nottingham Forest’s Todd Kane collides with Middlesbrough’s Patrick Bamford in March.

senior years (7) and thus should be enough justification for us to take a closer look. Screening / monitoring Most clubs utilise common clinical examination screening tests during preseason, serving primarily to offer baseline scores in case of injury. Some clubs further perform these tests during the season, perhaps weekly or monthly for monitoring purposes. One key outcome measure related to groin injury is some form of objectifying adductor muscle strength, commonly in the form of a squeeze test. Deficits in adductor strength are a consistent risk factor for groin injury and previous research has shown that footballers are up to 4 times more likely to suffer groin injury with an existing deficit (8). Furthermore, previous research has shown that injury is preceded by deficits of 5-10% two-weeks prior to injury (9). The adductor squeeze test therefore represents a potentially vital part of our practice, whereby sound interpretation may allow a problem to be detected before it fully develops. Naturally, we require confidence in the methods we use to perform such tests and arguably the most common form of Adductor squeeze testing is using a pressure sphygmomanometer placed between the knees with the player supine, in 45 degrees of hip flexion. This test has previously been shown to be reliable and demonstrate highest levels of adductor longus EMG activity (10). However, clinically I never found this test position particularly provocative with symptomatic players, whilst interpreting EMG activity as a representation of musculoskeletal stress could be questioned. A paper I have recently published with Dr

Kristian Thorborg sheds more light on the precision and torque output of different squeeze tests (11), both of which are vital if we are to assume that the squeeze test is capable of detecting the deficits that may be so clinically relevant. I encourage anyone who intends to utilise squeeze testing in the coming months to consider this papers findings, which favour the use of a long-lever squeeze test; with hips in a slightly abducted position and resistance applied dismally. Detection is pro-active The excellent work of sports science staff often involves some form of monitoring of biological or performance markers, which can serve to inform subsequent training plans or indeed ‘flag-up’ players potentially at risk. Indeed, recent research by the likes of Tim Gabbett surrounding training load / stress balance provides us with a logical framework in which such markers can be viewed in an injury risk model (12). It is possible that monitoring of Adductor squeeze scores can be utilised in a similar manner through investigating the player when scores fluctuate abnormally or in relation to player symptoms. Of course deficits in a strength can be caused by an abundance of reasons but ensuring our methods are as precise and reliable as possible, we can have confidence that any clinically relevant changes in score are likely to be detected and subsequently investigated further. Research into practice or practice into research? One of the biggest risk factors for nearly all football related injury is previous medical history. Subsequently, one could argue that research targeting senior players represents an approach that is reactive in nature and

Pictured: Benfica goalkeeper Julio Cesar takes catch but teammate Benfica’s Raul Jimenez is hit in the face by the goalkeepers hips.

simply too late to inform. We need to be pro-active in future research and for me, that starts with the population whom we regard as the future of our game. Whilst injury prevention research has failed generally to make an impact in reducing hip / groin injury in athletes, this is arguably due to the multi-factorial nature of such injuries, that render them difficult to address in a research capacity. Club academies are without doubt

doing fantastic work in exercise based hip / groin injury prevention and it is exciting to see some clubs starting to share their great work amongst peers at conferences. We need more clubs of all levels to share their practice (and data) that can in turn inform researcher focus and offer collaborative opportunity. In the meantime, we should consider how effective early detection put simply, can be vital in prevention.

Neil currently has an online survey available which many clubs (and some of you reading) will have already participated in. A medical or academy staff member should have received an email regarding this via league representatives (note: the survey is not endorsed directly by with either the football or premier league). Please email Neil directly if you have not received the email or for further information. The anonymous survey takes approximately 15 minutes to complete and is based purely on finding out what clubs currently do in the prevention & management of hip / groin injury in academy age footballers. The findings will, in-turn, inform an exciting prospective longitudinal study due to commence in 2017. This reflects Neil’s intention to deliver a clinically valid research contribution, serving staff on the front line and he would be very appreciative if you were willing to play an active role in this. The link to the survey is here (please contact me for the password): https://chichester.onlinesurveys.ac.uk/ hip-groin-prevention-management-inyouth-academy-footb Pictured: Didier Drogba injures his groin during the 2012 FA Cup Final against Liverpool

N.light@chi.ac.uk

CAR NEWS FOR MEMBERS

IN ASSOCIATION WITH

INSURANCE RULES TO CHANGE AS DRIVERLESS CARS HIT THE ROAD

he development in autonomous systems requires a new framework to allow for companies to trial the vehicles on open roads. This then leads to a requirement for insurers to establish rules surrounding liability in the event of an accident involving a car in driverless mode. This has led to the inception of the Centre for Connected and Autonomous Vehicles (CCAV). The CCAV is a joint venture between the Department for Transport and the Department for Business, Innovation and Skills and has been tasked with plotting the path to the successful introduction of autonomous vehicles. The current law as it stands requires the driver to always to be in control of the vehicle. However, it has recently been claimed that autonomous driving systems could cut accident rates by 80% within a

decade; meaning a change in the law must be introduced. “The current system is a negligence-based system and it will have to evolve,” said Tim Marlow, head of autonomous and connected vehicle research at the insurer Ageas. “When an autonomous vehicle is involved in an accident we will need to understand the extent to which any blame may be assigned to the vehicle or the driver. Once you get to the stage where the vehicle is in control completely for whole segments of a journey, then the manufacturer is liable and should take responsibility for the incident.” Yes, you read that right. As driverless cars take over more and more of the responsibilities within a journey, the liability could shift from the driver to the manufacturer themselves. In fact, Volvo Cars has already committed to accepting liability

for accidents due to a malfunction in its autonomous technology. “When the car is driven in autonomous mode it’s our responsibility. A malfunction should not happen and if it does it’s our problem,” said Hakan Samuelsson, president and CEO of Volvo Car Group, which is to launch a trial of 100 autonomous cars in London next year. It is expected that every driverless car will be fitted with telematics systems to determine when a car is in autonomous mode and when in ‘manual’ mode, whilst another rumour is that every car will be fitted with a dash cam to prove who is at fault in every accident. As with everything, there will be teething problems as more driverless cars hit the road; however that will not stop innovation happening and we all need to be ready for it.

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football medic & scientist

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Pictured: Carlos Tevez holds his knee following a robust challenge whilst playing for Manchester United against Blackburn Rovers in February, 2009

EARLY- & MIDDLE-STAGE REHABILITATION AFTER KNEE INJURY & SURGERY IN FOOTBALL FEATURE/NICHOLAS C. CLARK, PHD, MSC, MCSP, MMACP, CSCS.1,2,3 Senior Lecturer, Sport Rehabilitation, St Mary’s University, Twickenham, London. 2 Group Lead, Knee Injury Control and Clinical Advancement (K.I.C.C.A.) Research Group, St Mary’s University, Twickenham, London. 3 Knee Consultant Physiotherapist, Integrated Physiotherapy and Conditioning, London. Email: nicholas.clark@stmarys.ac.uk Twitter: @DrNickCC 1

Introduction Rehabilitation after knee injury and surgery can be a complex task. Rehabilitation after knee injury and surgery can also be controversial, with different clinicians and researchers having different opinions and philosophies regarding the stages and content of knee rehabilitation programmes.(1) The clinician’s task of safely and effectively guiding the professional footballer

with an injured or post-surgical knee through rehabilitation and return-toplay (RTP) is made potentially more complex by psychosocial factors including, for example, player expectations, coach/manager expectations, team selection pressures, and league and competition schedules.(2,3) With many factors in mind, the ‘early’ and ‘middle’ stages of knee rehabilitation are the most important stages of the

knee rehabilitation process for any athlete. This is because the early and middle stages of knee rehabilitation lay a solid foundation for the safe and effective implementation of late-stage rehabilitation techniques (e.g. plyometric training). Inappropriate or rushed earlyand middle-stage knee rehabilitation can threaten failed late-stage rehabilitation due to re-injury and new injury. This article is the second in a series of four

Pictured: Everton’s Dan Gosling lies on the floor to receive attention after having a shot at goal saved and colliding with Wolverhampton Wanderers goalkeeper Marcus Hahnemann in March, 2010.

articles addressing knee joint stability, stages of rehabilitation and RTP decisionmaking. This article will continue the series by specifically introducing critical concepts and basic principles in early- and middle-stage knee rehabilitation for the football player. Emphasis is placed on presenting the reader with a clinicallyreasoned, evidence-informed and rational approach to early- and middle-stage post-injury and post-surgery knee rehabilitation. The author’s approach to early- and middle-stage post-injury and post-surgery knee rehabilitation has been presented in detail previously.(1,4–7) Due to the vast array of post-injury and post-surgery presentations that are possible, the author has limited this commentary to generic principles of knee rehabilitation. The reader is encouraged to apply the principles presented in this commentary as appropriate to the specific knee soft tissue injuries and operative procedures with which individual players present. Basic Principles of Knee Rehabilitation As stated previously, rehabilitation after knee injury and surgery can be a complex task. In particular, different clinicians and researchers can have different opinions and philosophies with regard to when and how different interventions are implemented to achieve specific rehabilitation goals.(1) Therefore, before specific rehabilitation interventions can be safely and effectively implemented with an injured football player, it is important to acknowledge seven basic principles of knee rehabilitation that form the foundation for and drive the

design of the overall knee rehabilitation programme.(1) According to past work,(1) the seven basic principles of knee rehabilitation are: ~ A thorough subjective assessment must be performed: the player must be understood as a person, including lifestyle away from the team, postinjury anxieties and fears, short-term needs and long-term goals. ~ Every player is a unique individual: rehabilitation progressions should be based on subjective and objective assessment of individual ability and status versus generic timeframes for healing. ~ No single rehabilitation paradigm is the best: safe and effective rehabilitation progressions require an integration of different intervention methods at different stages of the rehabilitation process. ~ The effects of immobilisation and reduced physical activity must be attenuated without overloading healing tissues: non-contractile tissue mechanical characteristics and neuromuscular function must be maintained whenever possible with due consideration for the specific type of injury or post-surgery restrictions. ~ Passive interventions (manual therapy, taping) should be employed whenever indicated: passive interventions should be used with the primary intent of preparing the patient for immediately consecutive active interventions (exercise therapy). ~ Exercise therapy (e.g. strength

training) should be selected using a combination of research types: biomechanical, neurophysiological and clinical outcomes research should be used to objectively select specific exercises employed in the rehabilitation programme. Optimal clinical outcomes are dependent on a collaborative MDT approach: the MDT is composed of the player, physiotherapist, team doctor, surgeon, any other healthcare professional involved in the player’s care, and the team coach/manager.

Knee rehabilitation can be a complex task, particularly with regard to clinical decision-making and when and how different rehabilitation intervention methods are employed. As such, it is advisable for the football clinician to recognise and practice clear principles of rehabilitation that are scientific and rational in basis and are employed for a football player’s safe and effective progression through all stages of knee rehabilitation. Stages of Knee Rehabilitation Historically, timeframes for tissue healing have been the guiding and driving factors for how and when rehabilitation is progressed after knee injury and surgery.(1,4,8) The problem, however, is that there can be profound individual differences in physiology and biochemistry, and different players can heal at very different rates depending on gender, age, co-existing medical conditions (e.g. diabetes), nutrient intake profiles (e.g. vegan), and drug habits

Pictured: England’s Alex Oxlade-Chamberlain (left) has to be substituted off the pitch due to injury during a warm-up match against Ecuador prior to the 2014 World Cup.

(e.g. alcohol).(1,9) It is not possible or prudent, therefore, to perform clinical decision-making driven by tissue healing timeframes because there are too many external variables outside of the football clinician’s scope of influence or control. (1,4,6) The alternative approach is to recognise stages of rehabilitation, with each stage requiring specific subjective and objective goals to be achieved before progression to the next stage is permitted. With this in mind, there are at least four stages of rehabilitation: the early, middle, late and RTP testing stages.(10) Specific interventions and outcome measures for each stage of rehabilitation can be selected according to the individual player’s unique presentation as well as the clinician’s knowledge-base, level of experience and preferred intervention techniques. The early-stage of knee rehabilitation is characterised by the presence of symptoms and signs of inflammation, and post-injury or post-surgery weightbearing, range-of-motion (ROM) and knee bracing restrictions will apply if necessary. (10) Intervention priorities and goals in the early-stage of rehabilitation include: player education, pain control, effusion control, restoration of joint mobility, muscle disinhibition and restoration of muscle strength.(10) The middle-stage of rehabilitation is characterised by the resolution of symptoms and signs of inflammation and the cessation of post-injury or postsurgery weight-bearing, ROM and knee bracing restrictions.(10) Intervention priorities and goals in the middle-stage of rehabilitation include: preparing injured/

repaired/graft tissues to tolerate highload and high-impact exercises in the late-stage of rehabilitation, increasing isolated muscle group and functional strength, as well as stimulating basic proprioception and neuromuscular control mechanisms.(1,6,10) The late-stage of rehabilitation is characterised by the introduction of highimpact and high-velocity rehabilitation exercises.(10) Intervention priorities and goals in the late-stage of rehabilitation include: restoration of muscle power, stimulation of advanced proprioception and neuromuscular control mechanisms, introduction and progression of positionspecific football drills, and gradual return to full team training.(1,10) The RTP testing stage is characterised by successful participation in and progression through the early-, middleand late-stage of rehabilitation, successful execution of position-specific skills and return to full team training, restoration of metabolic (aerobic, anaerobic) fitness, and restoration of player confidence.(1,6,8,10) Priorities in RTP testing stage are to generate data that demonstrate the player is in fact ready to RTP or to highlight the need for ongoing rehabilitation. Thus, because the RTP testing stage can generate data that is used for refinement of ongoing rehabilitation and re-injury prevention,(8,10) the author considers the RTP testing stage to be a legitimate stage of rehabilitation and not just a potential point of discharge. Successful completion of the RTP testing stage of rehabilitation is entirely dependent on the clinician’s ability to select a battery

of objective and subjective tests and outcome measures that are appropriate to the player’s position and level of play. Timeframes for tissue healing after knee injury and surgery should not be employed for guiding and driving how and when rehabilitation is progressed because different football players can heal at different rates due to multiple biopsychosocial variables. Therefore, the football clinician should consider recognising and employing clear stages of knee rehabilitation that are delineated by well-defined physical, physiological, psychoemotional, social and occupational criteria related to, for example, pain, effusion, joint ROM, muscle strength, fear of movement and player confidence. (1,4,8,10) Pain Control Pain is described as an unpleasant sensory experience that can affect an individual’s mood and behaviour.(11) Following acute injury and or surgery, as well as many overuse injuries, pain is a clinical problem because it not only affects a player’s life experience but can also have profound and negative physiological effects. Pain can result in impaired proprioception.(12) Pain can also result in quadriceps inhibition and weakness.(13,14) Pain, consequently, can also result in abnormal movement patterns.(15) Thus, the result of pain due to both acute or overuse injuries can be both psychoemotional and physiological, and present clinically important barriers to expedient rehabilitation progression. As such, the football clinician should employ as many interventions as

Pictured: England Rio Ferdinand Englands first training session prior to going to hospital for a scan on a knee injury during the 201 World Cup in South Africa.

appropriate with the intent of reducing a player’s pain levels (e.g. player education and re-assurance, analgesia advice, manual therapy, electrotherapy). (1,4,5) Gentle isometric quadriceps and hamstrings exercises can also be used to generate an almost immediate hypoalgesic response(16) that can reduce a player’s pain experience and facilitate a ‘window of opportunity’ for a greater intensity or volume of exercise rehabilitation. Following knee injury and surgery, pain has both psychoemotional and physiological effects that can strongly influence the safety and effectiveness of knee rehabilitation. The football clinician should consider and employ as many interventions as appropriate and possible for an individual player’s unique pain presentation in order to minimise the potentially negative psychoemotional and physiological effects of pain and facilitate the opportunity to more ‘aggressively’ treat other postinjury/post-surgery physiological and physical impairments. Effusion Control An effusion is swelling within a joint capsule, with a knee effusion being a very common impairment after knee injury and surgery.(1,4) Effusion can result in impaired proprioception.(17) Effusion can also result in quadriceps inhibition and weakness.(18,19) Effusion, consequently, can also result in abnormal knee biomechanics during athletic tasks. (18) The clinical implications of a knee effusion are, therefore, potentially quite profound from both a sensory, motor and biomechanical perspective.(5) Because a

knee effusion can have profound sensory and motor effects that are negative in nature with regards to recovery of normal knee function, the football clinician should employ as many interventions as appropriate with the intent of resolving and preventing the recurrence of a knee effusion (e.g. pacing advice/load management education, limb elevation, elastic bandage compression, continuous passive movement (CPM) machine, manual therapy).(1,4,5,7,20) A knee effusion can cause profound impairment of sensorimotor control mechanisms and, consequently, result in sub-optimal knee biomechanics. Impaired sensorimotor control and sub-optimal knee biomechanics can threaten knee re-injury or new injury. Resolution of an existing knee effusion and prevention of recurrent knee effusions is, therefore, a priority of treatment for the football clinician in order to facilitate normal proprioception and activation and strengthening of knee muscles. Muscle Inhibition and Disinhibition: Disinhibitory Modalities As described previously, both pain and effusion can cause muscle inhibition. Quadriceps inhibition is, in particular, common after knee injury and surgery, and can occur at both spinal and supraspinal levels of the CNS.(21,22) Quadriceps inhibition is a major clinical problem because prolonged quadriceps inhibition is a barrier to recovery of quadriceps muscle strength and the safe and expedient progression of rehabilitation.(23) As such, the football clinician should employ as many muscle

disinhibition interventions as possible in order to facilitate quadriceps activation and recovery of quadriceps muscle performance. Muscle disinhibition can be performed using specific modalities termed ‘disinhibitory modalities’.(24) Disinhibitory modalities are intended to target the peripheral nervous system in a way that counteracts the inhibitory effects of peripherally-generated inhibitory stimuli (e.g. nociceptive pain, joint effusion). Muscle disinhibition modalities such as pre-exercise cryotherapy, pre-exercise transcutaneous electrical nerve stimulation (TENS), and direct neuromuscular electrical stimulation (NMES) show promising results.(25–27) A key consideration in the clinical application of disinhibitory modalities is that therapeutic effects are typically short-term and, therefore, disinhibitory modalities should be applied before rehabilitation exercises are performed.(24,27) The pre-exercise application of disinhibitory modalities is intended to provide another window of opportunity for effective rehabilitation exercise during which the appropriate voluntary activation of motor units can occur.(24,27) Quadriceps inhibition is a major clinical impairment because it impedes recovery of quadriceps muscle activation and strength and, consequently, is a major barrier to safe and effective progression of knee exercise rehabilitation. Disinhibitory modalities have the potential to be powerful facilitatory adjuncts to early- and middle-stage knee exercise rehabilitation interventions for the football player with an injured knee.

Pictured: Middlelsbrough’s Juninho feels the pain after hurting his knee in their Coca Cola Cup Final replay against Leicester at Hillsborough in April, 1997

Joint Mobility Knee joint hypomobility (reduced extension/flexion/rotation mobility) can be due to many factors including pain, effusion, an intra-articular block such as a meniscal flap or loose-body, and capsular shortening/stiffening.(1) There are three reasons why it is critical for optimal knee rehabilitation outcomes for the football clinician to restore joint mobility to the injured player’s knee. First, from a biomechanical perspective, normal or optimal gait biomechanics cannot occur without normal or optimal accessory (spin, glide) and physiological (extension, flexion) joint motion.(1,4) Second, from a neurophysiological and sensorimotor control perspective, normal or optimal afferent (proprioceptive) feedback to the central nervous system (CNS) also cannot occur without normal or optimal accessory and physiological joint motions.(1,4) Third, knee joint hypomobility secondary to capsular shortening/stiffening is associated with poorer clinical outcomes after knee injury and surgery.(28) Therefore, the clinical implications of persistently reduced knee joint mobility due to, for example, capsular shortening/ stiffening are potentially serious relative to an injured football player’s potential for attaining normal or optimal knee function and RTP. The football clinician should, consequently, implement as many interventions as possible to restore knee joint mobility after knee injury and surgery (e.g. manual therapy, joint mobility exercises).(1,4,5) When acute pain and effusion have resolved due to progressive resolution of the

inflammatory process, restoration of knee joint mobility is a priority of treatment if there is to be maximum rehabilitation potential of the football player with an injured knee. Restoration of joint mobility is critical for the recovery of normal or optimal gait biomechanics and proprioception. Restoration of joint mobility is also a critical prerequisite for effective isolated and functional muscle strength training because a hypomobile knee joint will prevent desired shortening and lengthening of knee muscles during dynamic exercise rehabilitation. Taping, Elastic Bandaging and Bracing Taping, elastic bandaging and bracing is widely used in knee rehabilitation. Here, taping refers to the use of athletic tape, elastic bandaging refers to the use of both rolled elastic bandages and tubular elastic bandages, whilst bracing refers to the use of neoprene sleeves or hinged knee braces. The application of athletic tape, elastic bandages and neoprene sleeves has been reported to immediately reduce the magnitude of knee pain. (29–31) The application of athletic tape, elastic bandages and neoprene sleeves has also been reported to immediately enhance knee proprioception,(32,33) modulate activity of the sensorimotor cortex,(34,35) and enhance lower limb biomechanics during gait.(31) Hinged knee braces are widely used in knee rehabilitation and, in certain contexts, are clinically important with regard to temporarily protecting injured or surgically repaired knee tissues from excessive forces.(1,4) Thus, athletic tape, elastic bandages and neoprene sleeves

can be clinically useful for reducing knee pain and enhancing knee sensorimotor function and biomechanics. Therefore, the football clinician can consider how to employ athletic tape, elastic bandages and neoprene sleeves with the football player recovering from knee injury or surgery and, if necessary, also consider how to combine their use with hinged knee braces during post-injury or postsurgery ROM restrictions. Proprioception Training Proprioception is defined as the sense of joint position (joint position sense (JPS)), joint motion (kinaesthesia) and force (force sense).(5,20,36) Proprioception is the sensory component of sensorimotor control, where appropriate sensory (proprioceptive) input to the CNS is necessary before appropriate motor output (muscle activation) can be generated by the CNS. (5,20,36) Proprioception is the result of mechanoreceptor stimulation in joint (non-contractile) and muscle-tendon tissues, where the muscle spindle is the most sensitive and potent of all mechanoreceptors.(37–39) The muscle spindle is always stimulated with muscle activation and active movements as a result of alpha-gamma coactivation. (37–39) The GTO is also always stimulated with muscle activation and active movements as a result of active tension being transmitted through tendon tissues.(37–39) Any muscle activation (e.g. isometric strength training) or active movements (e.g. dynamic strength training) can, therefore, be considered as ‘proprioceptive training’

Pictured: Bolton Wanderers Mark Davies holds his knee as he waits for treatment during their Championship match against Peterborough United in February, 2013.

because of stimulation of the most sensitive and potent mechanoreceptors that generate sensory stimuli which are transmitted to the CNS.(5,7,20) Proprioception is composed of distinct sensory modalities that result from stimulation of mechanoreceptors located in joint and muscle-tendon tissues, and all mechanoreceptors are inevitably stimulated with muscle activation during both static and dynamic active exercises. Because all mechanoreceptors are inevitably stimulated with muscle activation during both static and dynamic active exercises, the football clinician can be confident that early- and middlestage rehabilitation exercises such as, for example, isolated (open kinetic chain (OKC); e.g. knee extension) and functional (closed kinetic chain (CKC); e.g. leg press) muscle strength training contribute to proprioception training as well as to strength training. Thus, a single exercise type can result in adaptations that affect more than one physiological system and physical characteristic.(5,7,20) Isolated Muscle Strength Training: Open Kinetic Chain Strength Training Muscle strength is defined simply as the ability of a muscle to produce force.(8) Muscle ‘strength training’ is, therefore, defined as any form of exercise aimed at increasing a muscle or muscle group’s ability to generate force.(1,8) Knee isolated muscle strength training includes exercises such as an isometric knee extension to resolve a quadriceps lag, resisted knee extension against an external load (e.g. ankle-weight, knee extension machine), and resisted knee

flexion against an external load (e.g. ankle-weight, hamstring curl machine). (1) When quadriceps weakness is identified, isolated quadriceps strength training should be implemented wherever possible within the desired constraints (e.g. ROM limitations) of a specific knee injury or surgical procedure.(1) This is because functional exercises that are aimed at increasing quadriceps muscle strength (e.g. squat) actually result in biomechanical compensations and ‘cheating’ where the hip extensors are used to extend the limb instead of the knee extensors.(40) Therefore, functional exercise alone is an inadequate means for resolving quadriceps weakness and restoring normal quadriceps strength.(41) As isolated quadriceps strength increases, functional muscle strength training can be implemented. (1) Isolated quadriceps strength is clinically important because isolated quadriceps weakness is associated with sub-optimal biomechanics during gait and is considered to be a risk factor for the onset and progression of knee osteoarthrosis (OA).(41) Quadriceps weakness is a common complication that follows knee injury and surgery, is associated with sub-optimal gait biomechanics, and is not effectively resolved with functional exercises. Because isolated quadriceps strength training is an effective method of increasing quadriceps muscle strength, isolated quadriceps strength training should be employed by the football clinician within any post-injury/ post-surgery ROM restrictions before functional strength training in order to

prepare the knee and lower limb for more functional exercises.(1,4,10) Functional Muscle Strength Training: Closed Kinetic Chain Strength Training Functional muscle strength refers to whole lower limb force production during multi-joint, multi-muscle group movement patterns (e.g. sit-to-stand, stair ascent, jumping).(1,4) Knee functional muscle strength training includes exercises such as a leg press, squat and lunge.(1,4) Functional muscle strength training is a critical component of a football player’s knee rehabilitation programme because it applies the specificity principle of training and the recruitment of task-specific motor units. (42) The specificity of training concept is functionally important because increased functional muscle strength is associated with increased athletic performance. (43) Thus, when isolated quadriceps weakness has been reversed with isolated quadriceps strength training, functional strength training can be used to integrate isolated muscle strength gains into functional movement patterns that are transferrable to football-specific athletic performance.(1) Functional muscle strength training is clinically and critically important particularly in the middle-stage of knee rehabilitation because it is used to prepare the knee and whole lower limb for the high forces encountered during, for example, plyometric training in the late-stage of knee rehabilitation.(1,8,10) Generally, the stronger a football player is relative to bodyweight the better. (1,8,10) Functional muscle strength training includes exercises such as a leg

Pictured: Referee Martin Atkinson checks on Birmingham Cityâ&#x20AC;&#x2122;s Barry Ferguson as he holds his knee following a challenge during a home match against Liverpool in April, 2010.

press, squat and lunge, and is related to functional movement patterns that are inherent in football-specific performance (e.g. running, jumping). Functional muscle strength training should be employed by the football clinician to increase the football playerâ&#x20AC;&#x2122;s functional muscle strength relative to bodyweight as much as possible to both prepare the knee and lower limb for the safe execution of higher intensity end-stage rehabilitation exercise such as plyometrics as well as enhance footballspecific athletic performance. Summary Rehabilitation after knee injury and surgery can be complex, with different clinicians and researchers having different opinions and philosophies regarding the stages and content of knee rehabilitation programmes. The early and middle stages of knee rehabilitation are the most important stages of the knee rehabilitation process because they lay a solid foundation for the safe and effective implementation of late-stage rehabilitation techniques (e.g. plyometric training). Inappropriate or rushed early- and middle-stage knee rehabilitation can threaten failed late-stage rehabilitation due to re-injury and new injury. There are seven basic principles of knee rehabilitation that form the foundation for and drive the design of the overall knee rehabilitation programme. The four stages of knee rehabilitation include the early, middle, late and RTP stages, and these should be used in clinical decision-making for progressing knee rehabilitation versus timeframes for tissue healing because different football players heal at different rates due to multiple biopsychosocial

variables. The seven basic principles of knee rehabilitation form the foundation for clinical decision-making within each stage of rehabilitation. Fear of movement, loss of confidence, pain, effusion, muscle inhibition and joint hypomobility are all impairments that frequently present after knee injury and surgery, and act as clinically significant barriers to safe and effective knee rehabilitation progression. Player education, player re-assurance, pacing advice, load management advice, pain control advice and modalities,

disinhibitory modalities, taping, elastic bandaging, bracing, manual therapy and exercise therapy are all potential interventions that the football clinician can use to reverse specific impairments that present after knee injury and surgery. The football clinician is encouraged to apply the principles presented in this commentary as appropriate to specific knee soft tissue injuries and operative procedures with which individual players present in order to best prepare players for the late and RTP stages of knee rehabilitation.

Biography Nick is a Chartered Physiotherapist with more than 17 years of clinical experience in lower limb and knee injury prevention and rehabilitation and more than 23 years of practical experience as a Gym Instructor and Certified Strength and Conditioning Specialist. He also has more than 19 years of sports medicine and military injury prevention and rehabilitation research experience in UK and US universities. Continuing Professional Development Courses Nick has taught continuing professional development courses in the UK, US, wider EU and Asia for more than 15 years. He has also provided bespoke inservice training to private hospitals, professional sports teams and the British military for more than 13 years. Contact Nick directly if you are interested in attending or hosting one of the courses or would like to arrange an in-service training. Courses include: ~ Open and Closed Kinetic Chain Exercise in Early-Stage and Middle-Stage Knee Rehabilitation ~ Proprioception and Neuromuscular Control in Knee Functional Joint Stability ~ Clinical Plyometrics in Knee Injury Prevention and Rehabilitation ~ Re-Injury Prevention and Return-to-Play Testing Following Knee Joint Injury Contact Information Follow Nick on Twitter via @DrNickCC Contact Nick Directly at nicholas.clark@stmarys.ac.uk

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