pulse Spring 2010
In this issue...
Sport Nutrition: The Challenges of Travel Erin Pinder
5 SPORTS INJURIES
Factors Related to Posterior Tibial Tendon Dysfunction Melissa Rabbito, Dr. Michael Pohl, & Dr. Reed Ferber
SPORT SCIENCE RESEARCH
Reliability of a Single Leg Squat Test in Varsity Athletes L. Burrows, E.C. Parent, & M.D. Kennedy
11 1 Pulse
Upcoming SMCA Courses Sport Nutrition Level 1
May 15, 2010 Location: Edmonton Host: SMCA 10:00 a.m.—4:00 p.m.
June 5, 2010 Location: Calgary Host: SMCA 10:00 a.m.—4:00 p.m.
June 5, 2010 Location: Edmonton Host: SMCA 10:00 a.m.—4:00 p.m.
Spring 2010 Vol. 25 No. 1
SMCA Board of Directors
Athletic First Aid
May 8, 2010 Location: Calgary Host: SMCA 8:30 a.m.—4:30 p.m.
May 15, 2010 Location: Edmonton Host: SMCA 8:30 a.m.—4:30 p.m.
June 26, 2010 Location: Edmonton Host: SMCA 8:30 a.m.—4:30 p.m.
Ray Kardas—President Dwayne Laing—Past President Gabrielle Cave—Vice-President Breda Lau—Secretary Michael Becher—Treasurer Dr. Herbert Janzen—CASM Rep Chris Holt—CPA Rep Maria Novak—AATA Rep Stephane Simard—SSAA Rep Steve Johnson—SNS Rep Kristine Godziuk—Member at Large Koralee Samaroden—Member at Large Michael Wagner—Member at Large
Taping & Strapping
May 9, 2010 Location: Calgary Host: SMCA 8:30 a.m.—4:30 p.m.
May 16, 2010 Location: Edmonton Host: SMCA 8:30 a.m.—4:30 p.m.
June 27, 2010 Location: Edmonton Host: SMCA 8:30 a.m.—4:30 p.m.
*Combination of Athletic First Aid and Taping & Strapping May 8/9, 2010 May 15/16, 2010 Location: Calgary Location: Edmonton Host: SMCA Host: SMCA 8:30 a.m.—4:30 p.m. 8:30 a.m.—4:30 p.m. June 26/27, 2010 Location: Edmonton Host: SMCA 8:30 a.m.—4:30 p.m.
For more information on any of the above courses or to register, visit sportmedab.ca/courses
SMCA Employees Barb Adamson—Executive Director Janice Peters—Office Manager Nicole Lemke—Technical Director Desi McEwan—Special Projects Coordinator
Pulse Magazine Published by: Sport Medicine Council of Alberta 11759 Groat Road Edmonton, Alberta, Canada T5M 3K6 Phone: (780) 415-0812 Fax: (780) 422-3093 Website: www.sportmedab.ca Contents copyright 2009 by SMCA. Articles may not be reprinted without permission. The opinions are those of the respective authors and are not necessarily those of the SMCA. ISSN: 1181-9812 Publication agreement no. 40038086
SPORT CONCUSSION SEMINAR
The Sports Medicine Council of Alberta has partnered with Dr. Martin Mrazik and the University of Alberta to provide an important free presentation on the myths, facts, and new evidence-based practices related to concussions. Turn to page 9 or visit sportmedab.ca/sport-concussion-seminar-series for more information.
JUNE IS NATIONAL ATHLETIC THERAPY MONTH
Get Involved! The Sport Medicine Council of Alberta would like to recognize the Canadian Athletic Therapist’s Association (CATA) in June. To promote Athletic Therapy, the SMCA is volunteering at the June 6 Loops for Troops run on the Edmonton Garrison. The event is in support of our Canadian military, veterans, their families and in remembrance of our fallen who paid the ultimate sacrifice. Come out on June 6 and meet local Athletic Therapists, the SMCA or take part in the run.
We at the SMCA would like to congratulate our Special Projects Coordinator, Desi McEwan, on his acceptance to McMaster University! Desi will be leaving us this June to pursue his Master’s and PhD in Sport & Exercise Psychology. We will miss Desi’s fun loving attitude and his expertise in the office. We wish him all the best in the future and we look forward to showcasing his research in future Pulse issues. Cheers!
The SMCA Would Like to Thank our Partners for Their Support:
New SMCA Sport Taping Manual The SMCA is pleased to announce that our new Sport Taping Manual is now available for purchase. At just $30 for members ($35 for non-members), this manual & DVD set is an essential resource for anyone seeking to learn the most common sport taping techniques.
Visit sportmedab.ca/manuals to purchase your copy today!
Sports Nutrition 5 Pulse
Sport Nutrition: The Challenges of Travel Erin Pinder, BSc, RD, Sports Dietician Body Fuel Nutrition
athletes are required to travel to games, tournaments, and camps. Although most athletes are concerned with packing their gear, they rarely focus on a vital component of travelling and performing well at these events: nutrition! Many athletes eat well during training. They eat home-cooked meals and have access to healthy food choices. However, travelling for competition poses a new challenge. On the road, it can be difficult to eat familiar foods, depend on restaurants or convenience stores for healthy choices, and get the timing right. Athletes, coaches, parents, trainers, and team managers can share the responsibility of nutrition planning. Planning ahead is essential to avoid athlete hunger, unhealthy food choices, and upset stomachs. Many nutrition planning strategies can be used by athletes and teams to ensure their bodies are properly fuelled for success. When athletes are younger, they depend on parents to make appropriate foods available. Stocking the fridge and pantry with great foods will allow young athletes to freely choose how much and which foods they would like to take with them when travelling. By choosing their own foods out of the pantry, they are more likely to actually eat the food and benefit from it.
Older athletes need to assume responsibility for their food choices. If athletes are picky eaters, have allergies, or have specific food preferences, they should plan to bring as much food as possible with them in their sports bags or a small cooler. This will prevent them from going hungry and making poor food choices. If athletes are not experienced travellers, they will soon learn that relying on the concession stand or vending machine is a recipe for disaster. Athletes need to follow a hydration plan when travelling. Athletes should plan to have one litre of fluid per hour of exercise, as well as fluids before and after. Athletes should always have their own water bottle with them, at least one litre in size. This will prevent sharing amongst athletes and germs from spreading. Athletes often forget about planning fluids, only to realize that the facility they are competing at doesn’t have a water fountain nearby, or sports drinks available in the vending machine. Any activity lasting over one hour requires a suitable carbohydrate source, such as a sports drink. Gatorade® powder is a great solution when travelling, as it is easily portable and can be mixed with tap water in a water bottle. A lack of sufficient fluids can lead to dehydration, poor performance, and even worse, life-threatening health issues.
Team nutrition planning is beneficial in targeting all of the athletes on a team to ensure optimal nutrition. Trainers, team managers, and coaches can have a team cooler available for each trip away. Tape a food list to the top of the cooler, and stock it prior to each travel event with snacks such as granola bars and fruit bars, bagels, trail mix, and other preferred snacks, as well as appropriate fluid choices such as Gatorade® powder, Carnation Instant Breakfast®, water, chocolate milk, and juice boxes. If a group of athletes is away from home for more than a day, it is a good idea to make a pit stop at a grocery store for athletes to buy some healthier food choices such as fruit and raw veggies. Yogurt, chocolate milk, deli meats, and other perishable foods can be bought if a mini-fridge is available in the hotel room. Having more of these foods will help an athlete to stay healthy and well-fuelled.
Checklist for the Road: √ √ √ √ √ √
One litre of fluid per hour of exercise Gatorade for activities lasting over an hour Foods high in carbohydrates and low in fat 2 servings of fruit/veggies Avoid anything deep-fried or potentially harmful foods Pack as much food as you can!
Coaches or team managers can assume the responsibility of team dinners by searching for an appropriate restaurant the day before. They can make reservations at the selected restaurant, select three nutritionally appropriate meals for the
athletes to choose from, and call ahead with orders prior to the team’s arrival. This will allow for a quicker post-game recovery meal and much healthier food choices. Sometimes teams will eat at a buffet or a restaurant with “bottomless” foods, where making good food choices is potentially more challenging. When first approaching a buffet, the athlete should first take a look at all foods available. This allows the athlete to plan their plate, and to make nutritious choices. Obviously, deep-fried foods are unhealthy and should be avoided. Athletes should choose lower-fat, highcarbohydrate foods such as pasta, rice, whole wheat bread, mashed or baked potatoes, or cereals, and focus on lean proteins like chicken, fish, lean beef, back bacon, eggs, and peanut butter. They should also get at least two servings of vegetables or fruits. Athletes should stay away from foods that are at a high risk of causing food poisoning, including tuna salad, egg salad, sprouts, shellfish, sushi, and undercooked meats. When you eat healthy and safe foods, you are more likely to stay healthy during a competition. Planning nutrition prior to travelling for a sporting event is the best way to avoid nutrition-related troubles. Athletes should pack as much food as they can with them to avoid hunger between events and meals, and to avoid poor nutrition choices due to rumbling bellies. Parents should stock the kitchen with nutritionally dense foods for their young athletes to choose from. Coaches and other staff can ensure athletes are making healthier food choices by keeping a food supply and arranging restaurant meals ahead of arrival. Ultimately athletes are responsible for their own nutrition, but with support from others they will eat and compete at their best!
University of Calgary 7 Pulse
Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction Melissa Rabbito C.A.T.C., C.Ped.C. Dr. Michael Pohl PhD. Dr. Reed Ferber PhD., C.A.T.C, ATC University of Calgary, Running Injury Clinic, Faculty of Kinesiology Introduction Posterior tibial tendon dysfunction (PTTD) is a progressive condition which is widely recognized as a major contributor to adult acquired flat foot disorder (AAFD). PTTD is estimated to affect nearly 5 million people in the United States and it is one of the most common running injuries. The progression of PTTD has been categorized into four stages: stage I PTTD begins as pain and/or tenderness posterior to the medial malleolus, with a unilateral rearfoot deformity becoming present in stage II. Left untreated PTTD can lead to osteoarthritic changes in the ankle joint, or rupture of the Tibialis Posterior tendon in stages III and IV. Given that PTTD is a progressive condition, early recognition and treatment are essential to help delay or reverse the progression. To help direct the development of effective treatment protocols, a thorough understanding of the strength, anatomical structure, and biomechanical walking patterns must be assessed. However, to date, no research has been published regarding these data for stage I PTTD patients. Purpose The purpose of this study was to investigate the relationship between clinical factors such as strength and structure, and biomechanical factors such as gait mechanics, in stage I PTTD subjects, in comparison to healthy individuals. We hypothesized the PTTD group would demonstrate no differences in static structure, decreased tibialis posterior isometric strength, and greater
rearfoot eversion and a lower longitudinal arch angle (LAA) when walking compared to healthy control subjects.
Methods Twelve stage I PTTD subjects (30.3 y, 23.2 BMI) and 12 age and BMI matched control subjects (28.5 y, 23.7 BMI) participated in this study. PTTD subjects were examined by a Canadian Certified Athletic Therapist, who is also a Canadian Certified Pedorthist, for set inclusion and exclusion criteria. Structural, strength and biomechanical data were collected from all 24 subjects. Structural measurements of seated and standing arch height index (AHI) were obtained, and these measurements were used to calculate arch rigidity index (ARI), a ratio of seated AHI to standing AHI. Tibialis posterior strength was measured using a force dynamometer (Model #01163, Lafayette Instruments, Lafayette, Indiana) while subjects were in a plantarflexed and inverted position. Each subject performed 4 maximum voluntary isometric contractions (MVIC) and the average of those 4 trials was calculated. Subjects were then fitted with 16retro-reflective markers, placed on anatomical landmarks of the foot, ankle and lower leg and were asked to walk barefoot on a treadmill at a speed of 1.1 ms-1. Biomechanical data were captured using a 3D motion capture system (Vicon Motion Systesms Ltd, Oxford, UK) over 10 consecutive footfalls. Values for peak rearfoot eversion angle, time to peak rearfoot eversion angle, peak LAA, and time to peak LAA were calculated for analysis. LAA was
Table 1.1: Mean (SD) static structural measurements and Tibialis Posterior strength for PTTD and control groups. * Significant at the P < 0.05 level. PTTD
TP Strength Normalized [(N/Kg)*100]
used to measure medial longitudinal arch height and was obtained from the 3 landmarks of the medial malleolus, navicular tuberosity and the head of the first metatarsal.
While greater rearfoot eversion was measured in the PTTD group, the higher LAA values obtained may not be an accurate representation of the arch mechanics. Further analysis of the LAA measurements indicated they were strongly influenced by tibial rotation, hence, it was difficult to draw conclusions on the arch mechanics of either subject groups. Long term, prospective studies are required to assess the relationship between structure and incidence of PTTD. Additional research should also be directed towards assessing the effects of a rehabilitation program on the clinical and biomechanical factors for individuals in the early stages of PTTD.
Results The PTTD group demonstrated no differences in standing AHI (p=0.14) but significantly lower seated AHI (p=0.01) and ARI (p=0.03) values compared to healthy controls (Table 1.1, above). The PTTD group demonstrated no differences in strength when compared to healthy individuals (Table 1.1). The PTTD group exhibited greater rearfoot eversion (p=0.03) and greater peak LAA (p=0.02) when compared to healthy controls (Figures 1.2 and 1.3, References below). Available upon request. Conclusions From the results of this study we conclude that the PTTD subjects exhibit a lower and more rigid anatomical foot structure, no difference in tibialis posterior MVIC strength, and altered lower extremity gait kinematics, when compared to healthy controls.
Call for Subjects We are still actively recruiting subjects for this study. If you are in the Calgary area and are: currently experiencing medial ankle pain, physically active, and between the ages of 18 and 45 please contact Melissa at firstname.lastname@example.org.
Figure 1.2: Rearfoot eversion patterns relative to the tibia during the stance phase of gait. Healthy controls are represented with a solid line and their standard deviation is shaded grey. PTTD data is represented with a dotted line.
Figure 1.3: Longitudinal arch angle patterns during the stance phase of gait. Healthy controls are represented with a solid line and their standard deviation is shaded grey. PTTD data is represented with a dotted line.
2010 Sport Concussion Seminar Series Approximately 80% of Canadians watched the men’s Olympic Gold Medal game in Vancouver. We know Canadians love hockey and other contact sports. Over 545,000 players compete annually in minor ice hockey. Concussions have been a topic of concern raised in recent years, and many professional hockey players are talking about their experiences with concussions. Concussions are considered a mild injury, but for some people they can have more serious problems. There are still many myths about concussions and misunderstandings on how to manage them. The Sports Medicine Council of Alberta has partnered with Dr. Martin Mrazik and the University of Alberta to provide an important free presentation on the myths, facts, and the new evidence-based practices related to concussions.
Upcoming Dates -Edmonton: May 12 at 7:00 PM, Kingsway Ramada Hotel -Calgary: September 21 at 7:00 PM, Executive Royal Inn Visit sportmedab.ca/sportconcussion-seminar-series for more info.
Mental Skills for the Artistic Sports By: Dr. Murray Smith Noted Sport Psychologist, Dr. Murray Smith, draws on decades of coaching and consulting experience to provide a comprehensive mental training program in Mental Skills for the Artistic Sports. Coaches and athletes using his techniques will:
Be better equipped to behave intelligently and responsibly in the face of adversity or challenges
Learn how to control their thinking and emotions to perform consistently and effectively at their highest level of personal excellence
Learn how to set personal, achievable goals
Learn how mental skills training can positively affect all aspects of athletes’ lives in addition to their participation in sports
*Mental Skills for the Artistic Sports and all of the other books and DVDs in our library are available to borrow for FREE to all SMCA members. Other Titles:
University of Alberta
Intra- and Inter-Rater Reliability of a Single Leg Squat Test in Varsity Athletes L. Burrows1, E.C. Parent2, M. D. Kennedy1 1Faculty
of Physical Education and Recreation, University of Alberta 2Faculty of Rehabilitation Medicine, University of Alberta Introduction: Functional testing is used to monitor recovery during rehabilitation or as a screening tool for athlete pre-participation evaluations (Mottram & Comerford, 2008). Functional testing can indirectly measure muscular strength and power (DiMattia et al., 2005). Many lower extremity functional testing protocols include unilateral or bilateral squats. The single leg squat (SLS) is preferred as it displays a common athletic position and requires the control of the body over a single leg challenging all lower extremity joints (Zeller et al., 2003). Three-dimensional (3D) kinematic analysis is considered the gold standard to assess lower extremity function, but it is expensive and laboratory-based (Willson & Davis, 2008, McLean et al., 2005). Thus, subjective evaluation of the SLS has been the conventional approach used clinically. However, the subjective nature of non-kinematic SLS evaluation, may reduce the intra- and inter-rater reliability. Crossley et al. (2006) and DiMattia et al. (2005) reported good agreement among physical therapists (57% to 71%) on a standard SLS for rating the SLS as good or poor in healthy participants. The aim of this study was to determine intra- and inter-rater reliability of a standardized single leg squat screening test in a large cohort of varsity athletes. Methods: Subjects: Forty-two varsity athletes were randomly
selected from a pool of 281 athletes, representing 11 varsity teams. Inclusion criteria included completion of a pre-participation medical questionnaire, active varsity athlete status and participation in pre-season fitness testing. All participants provided written informed consent. Three certified athletic therapists with equal training in administering the test conducted the tests.
Procedure: To ensure consistency in squat depth, a horizontal bar was raised to the knee joint line. Participants were asked: “think about sitting on a chair (posterior focus) and extend your non-weight bearing leg at the knee with your foot just off the floor.” Participants were asked to perform 5 repetitions on each leg starting with the right leg. The tester stopped the athlete once they could not perform a proper squat (judged by a loss of balance affecting performance of the subsequent repetition). One practice attempt was allowed on each leg. All squats were filmed in the frontal plane. Four investigators reviewed the videos to count the number of repetitions completed and select the most significant factor limiting perfect performance among the following list: (1) prefect, (2) core, (3) hip, (4) knee, (5) lower leg, and (6) other (See definitions Table 1). Intra-rater reliability was evaluated based on 2 separate viewing of the same test by the main rater; whereas inter-rater reliability was estimated by using 1 viewing of each test by all 4 raters.
Table 1. Description of limiting factors
Limiting Factor Core Hip Knee valgus Lower leg Other
Description twisting, lateral sheering, leaning laterally starting at the torso non weight bearing hip drops lower than the standing hip. The weight bearing hip falls laterally outside of knee and ankle plumb line. knee collapses medially. The knee falls medially beyond the medial maleolus Shaking of the lower leg is observed at the ankle. anything else more obvious than any of the above
Statistical Analyses: Intra-class correlation coefficient (ICC) and standard error of measurement (SEM) were calculated for the intra- and inter-rater reliability of counting of repetitions. The intra- and inter-rater reliability of all limiting factors was calculated using KAPPA coefficient. The inter-rater reliabilities for determining a perfect versus an imperfect performance was also estimated using the KAPPA coefficient. Results: Table 2. Mean number of repetitions, frequencies of each limiting factor and of the presence of any limiting factor during a single leg squat for rater 1.
Descriptive statistic (n =42 athletes)
Number of repetitions (right) Number of repetitions (left) Percentage with each limiting factor (right) 1 2 3 4 5 6 Percentage with each limiting factor (left) 1 2 3 4 5 6 Percentage with any limiting factor (right) Percentage with any limiting factor (left)
4.17 ± 1.53 reps 4.26 ± 4.50 reps
21.4% 23.8% 11.9% 26.2% 7.1% 9.5%
19.0% 21.4% 9.5% 16.7% 23.8% 9.5% 78.6% 81.0%
Table 3. Summary of Intra- and Inter-rater reliabilities for the number of repetitions and limiting factors of the SLS.
Repetitions ICC (SEM) Right leg 0.85 (0.61) 0.80 (0.68)
Left leg 0.95 (0.33) 0.92 (0.45)
Limiting Factor Kappa Right leg Left leg 0.31 0.53 0.37 0.26
The reliability of determining athletes with perfect versus imperfect performance was better (collapsing limiting factors) with inter-rater Kappa estimates as follows: Right 0.62; Left 0.40.
ments. They found that the 2D evaluation only accounted for 25% of variance with the 3D method suggesting that a 3D kinematic analysis may be needed to improve the SLS clinical test.
Discussion: The reliability for counting repetitions completed during the SLS test was sufficiently reliable but was suboptimal because of a lack of agreement on when to stop counting repetitions even though training was provided. Intra-rater reliability of repetition count was only marginally higher than inter-rater reliability. The results suggest a need to further standardize the guidelines for judging the number of valid repetitions. The reliability for identifying the primary limiting factor was poor. Many athletes displayed more than one limiting factor and raters differed in their selection of the primary limiting factor. DiMattia et al. (2004) also indicated that not just one muscle or joint may be responsible for the change in mechanics. Improved standardized definitions are needed to guide the identification of the factors limiting the SLS performance. The reliability improved when the raters were asked to determine poor vs good SLS performance. This is similar to results by both DiMattia and Crossley where they observed low to moderate reliability to discriminate perfect vs impaired performance. A 3D kinematic analysis allows quantification of the movement and may allow formulating clear definitions to guide the subjective assessment of the SLS. This method is costly and time consuming and therefore impractical for screening purposes. McLean et al. (2005) examined fontal plane knee motion captured with a digital camera (2D) compared with a 3D analysis of true knee valgus during three dynamic move-
Conclusion: The subjective nature of the test makes it difficult to identify the primary anatomical region limiting performance. Raters had acceptable reliability in determining if performance was perfect or impaired. Raters had good to excellent reliability in determine the number of completed repetitions on the SLST. The SLST may be an important lower extremity screening test, but further refinement is required to create better objectivity in determining the source of the impairment limiting performance.
References: Mottram S, Comerford M. A new perspective on risk assessment. Phys Ther Sport 2008 Feb;9(1):40-51. DiMattia MA, Livengood AL, Uhl TL, Mattacola CG, Malone TR. What are the validity of the single-leg-squat test and its relationship to hip-abduction strength? Journal of Sport Rehabilitation 2005 May;14(2):108-23. Zeller BL, McCrory JL, Kibler WB, Uhl TL. Differences in kinematics and electromyographic activity between men and women during the single-legged squat. Am J Sports Med 2003 May;31(3):449-56. Willson, J. D. & Davis, I. S. (2008a). Utility of the frontal plane projection angle in females with patellofemoral pain. J.Orthop.Sports Phys.Ther., 38, 606-615. McLean, S. G., Walker, K., Ford, K. R., Myer, G. D., Hewett, T. E., & van den Bogert, A. J. (2005a). Evaluation of a two dimensional analysis method as a screening and evaluation tool for anterior cruciate ligament injury. Br.J Sports Med, 39, 355-362. Crossley, K. M., Cowan, S. M., Bennell, K. L., & McConnell, J. (2004). Knee flexion during stair ambulation is altered in individuals with patellofemoral pain. J Orthop Res., 22, 267-274.