SPNZ BULLETIN PAGE
Issue 3 June 2015
FEATURE Phoenix Physiotherapist SPNZ NEWS BMJ Learning Modules EXERCISE PROMOTION & PRESCRIPTION Level 1 SPNZ Certificate Course
FEATURE TOPIC: Football
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Contents
SPNZ MEMBERS PAGE See our page for committee members, links & member information
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EDITORIAL By SPNZ President Hamish Ashton
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LATEST NEWS BJM Learning Modules
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MEMBERS’ BENEFITS Discounts
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FEATURE
In this issue:
Robert Lee: Head Physiotherapist, Wellington Phoenix FC
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SPRINZ Progressing Rehabilitation Training with Exogen Exoskeletons
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RESEARCH PUBLICATIONS JOSPT Volume 45, Number 6, June 2015
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BJSM Volume 49, Number 12, June 2015
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CLINICAL SECTION - ARTICLE REVIEW The Football Association medical research programme: an audit of injuries in academy youth football
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Three distinct mechanisms predominate in noncontact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases
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CASE STUDY Grade 1 ACL rupture in an elite football player
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CONTINUING EDUCATION AUT Enhancing Muscular Performance online paper
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Local course and APA CPD Event Finder
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The Biomechanics Lab: Managing runners in practice
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CLASSIFIEDS
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SPNZ Members’ Page Welcome to Sports Physiotherapy New Zealand SPNZ EXECUTIVE COMMITTEE President
Hamish Ashton
Secretary
Michael Borich
Treasurer
Michael Borich
Website & IT
Hamish Ashton
Committee
Monique Baigent Timofei Dovbysh
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ASICS EDUCATION FUND A reminder to graduate members that this $1000 fund is available twice a year with application deadlines being 31 August 2015. Through this fund, SPNZ remains committed to assisting physiotherapists in their endeavours to fulfil ongoing education in the fields of sports and orthopaedic physiotherapy.
CONTACT US Michael Borich (Secretary) 26 Vine St, St Marys Bay Auckland mborich@ihug.co.nz
An application form can be downloaded on the SPNZ website sportsphysiotherapy.org.nz.
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Editorial Hamish Ashton, SPNZ President The last few weeks have been full of football. The U20 World Cup would have just finished by the time this goes out and the Women’s World Cup will be reaching the finishing stages. The U20 boys have performed their best ever reaching the knockout rounds. Having worked with a number of them as U17’s it has been interesting to see them play and it has been a huge step up from two years ago. Though we have still a long way to go, we, as a nation, are becoming competitive. Hopefully the women will win this week and make it through to the knock out rounds as well. They have been playing well over the last year, but not quite been there.
Justin – one of our exec members - is currently in Canada with the women’s team. I would like to congratulate him on his efforts and representation of SPNZ. Congratulations also to any of our members that were involved with the U20’s. Talking of stepping up, we had our AGM in Auckland recently. Attendance numbers were very low, not helped by being a wet and windy Monday night. Hopefully the turnout is not a reflection of the interest and enthusiasm of the membership. Though we are all busy these days it is good to remember we are all volunteers and support in any form or shape in what we do is appreciated. Ideas and a helping hand are also very welcome. However, following the meeting we have two new executive members: Monique Baigent, who was one of our newsletter helpers, has joined the exec, along with Emma Mark from Wellington who has joined us also. Thanks to these two new exec members and others who expressed interest in helping out. We are starting to think about planning for next year and hopefully the exec will have a weekend planning
meeting at the end of the winter season. PNZ has just released the dates for the next SIG Superconference. It will be held mid-September in Auckland again, and PNZ are starting to look for speakers. So if anyone has any ideas for speakers please send them through to me (help@spnz.org.nz). Due to this now looking like it will be a regular feature we have had thoughts on where our symposium fits in. From comments I hear it is something we intend to continue with but at this stage are looking to shift it to the alternative year to the Superconference. We are looking at the possibility of something smaller next year as a fill in. SPNZ has worked hard over many years to develop and secure a number of benefits for its members. Despite advertising them regularly in the bulletin we feel they are under-utilised, possibly due to members’ lack of awareness of them. I invite you to take this opportunity to check what we have to offer – click here. One of the recent major benefits has been our agreement with the BJSM. There are two new updates on this. Firstly, as part of our agreement we have a NZ edition of their journal. This is coming out in July. What does this mean to us? We get to promote SPNZ, its courses and events, as well as choosing the publications for the issue. This issue has been a test case for us as we didn’t have a long time to prepare. We however have managed to find a number of articles that reflect us as New Zealanders, as well as our approach of providing practical hands on information that can be used in day to day practice. The second part is we now have access to their learning modules. These are great CPD tools that are done online, so great for the person that needs that extra few hours, or just can’t get out of town to the next course. They are also free!! Enjoy the arrival of winter and be safe Hamish
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Latest News BMJ LEARNING MODULES As part of our agreement with BJSM we also get access to the BMJ Learning modules. Examples of the available modules include: Managing patients with minor skiing and snowboarding injuries in primary care Frozen shoulder (adhesive capsulitis) Tennis elbow: diagnosis and treatment Jumper's knee - in association with the British Journal of Sports Medicine Acute lateral ankle ligament injuries - in association with the BJSM Learning outcomes are given for each module so you have a good understanding of what you are going to cover. An example of the ankle one is included below.
Acute lateral ankle ligament injuries - in association with the BJSM After completing this module you should know:
After completing this module you should be able to:
When to suspect an ankle fracture
Apply the Ottawa ankle rules
What the most frequent acute ankle injuries are
How different ankle sprain severities can be ascertained
Differentiate the most frequent acute ankle injuries based on presentation
Ascertain the severity of an ankle sprain
Advise a patient on preventive measure.
Which diagnostic test to use to ascertain ankle sprain severity
What treatment options there are for an ankle sprain
Why secondary prevention after an initial ankle sprain is important.
the
best
secondary
Throughout the modules there are small tests to assess your knowledge to make it a more objective learning experience. For instructions on how to access these modules go to the BJSM page on our website and follow the instructions in the document enclosed.
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Members’ Benefits
There are many benefits to be obtained from being an SPNZ member. For a full list of members’ benefits visit http://sportsphysiotherapy.org.nz/benefits/ In each bulletin we will be highlighting individual member benefits in order to help members best utilise all benefits available.
DISCOUNTS McGraw Hill Education
25% off Medical books http://sportsphysiotherapy.org.nz/members/reviews/book-order-form/ for details on how to order.
Asics
Members rates on Asics shoes and apparel http://sportsphysiotherapy.org.nz/members/asics-information/ for how to order
SPNZ Member discounts to all SPNZ courses and Symposium http://sportsphysiotherapy.org.nz/courses/ for what is upcoming
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Feature
Robert Lee: Head Physiotherapist, Wellington Phoenix FC I am a New Zealand born and trained physiotherapist currently working for the Wellington Phoenix Football Club. Football became my passion at an early age as I enjoyed many years representing at a national level. Both fortunately and unfortunately, this led to spending a considerable amount of time on the physio table and although this led to less playing time, it was here that my interest in sports physiotherapy really began as I came in contact with some very skilled and driven physiotherapists. As my football career seemed less and less likely, (as I became slower and less agile), a career in physiotherapy and football physiotherapy seemed more and more like a suitable vocation and one I actively pursued. I graduated from AUT (BHSc Physio) in 2007 and completed my Post Graduate Diploma in Musculoskeletal Physiotherapy from AUT in 2010. Working in private practice post graduation for Roland Jeffery I learnt the ropes of football physiotherapy and developed clinical practice skills. Initially, I worked as a football physio for various club teams, including my own (player/physio can be an interesting role), and I spent numerous weekends working voluntarily for federation football tournaments and age group teams. This progressed to National League teams, such as Waitakere United, which involved travelling nationally and internationally, and from there I became heavily involved in the NZ under 17 qualifiers for two World Cup campaigns. I was then very fortunate to progress my football physiotherapy career to a full time role in 2010 as I was appointed as the head academy physiotherapist at Celtic FC, Glasgow, Scotland. During my time at the club I progressed to the reserve/under 21 physiotherapist. This was certainly an eye opening experience. The sheer scale of professional football in the UK was a huge step up. The most outstanding differences were the facilities available to the players and medical/conditioning staff. This included customised gymnasiums, on-site isokinetic dynamometers, pool conditioning and recovery facilities, Alter G treadmills, and indoor and outdoor heated fields. Not to mention very expensive travel protocols such as a chef on the bus for longer away trips to optimise nutrition/recovery. Dealing with players that are worth unimaginable amounts of money was an interesting and daunting task at times, but hugely rewarding. While at Celtic I travelled to many European top clubs, visiting facilities and sharing knowledge with the medical staff, including those of Barcelona and Marseilles, UK clubs such as Sunderland and Aston Villa, and the English FA national training centre.
Please describe your current role and how you ended up there. Through my previously established NZ based contacts in football I was offered the Phoenix head physiotherapist role in 2013. This is an unique role as it is NZ’s only professional football team, playing in the Hyundai A
League. I am with the team full time on a day to day basis. I cover all trainings, rehabilitation of injured players and I also travel with the squad to all away games. In season I typically work six days a week, however working seven is not uncommon depending on the injury load and travel schedule. CONTINUED ON NEXT PAGE
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Feature Robert Lee: Head Physiotherapist, Wellington Phoenix FC continued... Who else is involved in the “support” team that you communicate with and how do you integrate with them to optimise injury prevention and rehabilitation? At the Phoenix we are fortunate to have two full time sports scientists - Lee Spence and Adam Allan and a second physiotherapist that works alongside me, Brent O’Conner. We are a very close knit team. The integration with the sport science staff is crucial in the effective management of our players which is enabled by a flow of communication regarding player wellness and performance. We converse and analyse on a daily basis regarding the training load of all our players. We track daily-weekly-monthly GPS and HR data to pick dramatic increases or decreases in training load that may signal potential injury risk. This also helps us prepare the players just right for the weekend, avoiding over- or under-training. We meet formally in weekly and daily meetings, however running conversations throughout the training day are just as important. I am also very fortunate to work closely with sports physician Dr Jake Pearson. His knowledge and advice, especially on more complex injuries involving multiple structures or those requiring further investigations and interventions, are crucial in optimal management of our players. Last but not least, my relationship and communication with the coaching staff is very important. Daily meetings ensure we are all on the same page regarding player training and health status, optimising team selection for each match. Coaches are inherently good at picking up on a drop in performance that may relate to a musculoskeletal or a health related disorder that can be addressed by the physiotherapist. What are your specific areas of interest/research? Due to the nature of my role my interests naturally lie in efficient injury management and rehabilitation. I get very excited about rehab and return to play protocols that both ensure a quick return to play while minimising the risk of re-injury. In particular, protocols regarding groin/ adductor and hamstring are useful as these muscle
groups rank highest in the frequency of muscular strains. I’m always on the look out for research that has excellent transferability to the professional athlete setting, especially research that is conducted amongst professional football players. There is a wealth of literature on both these areas. Recently I have found the Asklings et al. (2014) study regarding hamstring rehabilitation and eccentric exercises in elite footballers useful as it provides some great exercises and a suggested protocol. Injury prevention is also an interest of mine as it may save lost training days and missed matches. This includes both pre-season screening and ongoing daily analysis. I am constantly fine-tuning and adapting prescreening protocols to elicit the most relevant, readily accessible information in the most streamlined fashion. Pre-season I look closely at biomechanics and clues to potential overload with the Movement Competency Screen developed by Dr Matt Kritz. Also strength profiling of the adductors (dynamometry) and hamstring/ quadriceps (isokinetic dynamometer). Ongoing daily analysis involves everything from subjective markers like daily wellness scores, readiness to train scores, reported muscle soreness, sleep quality and fatigue levels, which we gather on a daily basis. Objective daily assessment of joint range of motion, muscle length and muscle strength (dynamometry) will be assessed for players that are identified as having low subjective scores or those we are keeping a close eye on due to recent injury, under performance or possible over- or under- training, as indicated by GPS or performance. Values are frequently compared to baselines gathered in pre-season screening. What do you think are the key elements in successfully preventing injury? In addition to the screening methods mentioned above, I believe injury prevention in the professional or semiprofessional environment really comes from early identification of risk factors, whether this be objective or subjective. Maximising recovery and nutrition is another key factor, especially when a lot of travel is involved. It is also critical to really “know” the players. This means knowing how much individuals can be pushed or when to back off. CONTINUED ON NEXT PAGE
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Feature Robert Lee: Head Physiotherapist, Wellington Phoenix FC continued... It is the combination of all the above information that creates a wider picture of an athlete and helps identify the level of injury risk. What are the types of injuries you commonly see? Typically muscular strains of the adductor group and hamstrings rank the highest in frequency. Due to the dynamic nature of football, alongside the heavy kicking load, inguinal/hip pain is often associated with groin injuries and therefore all possible contributors to dysfunction must be examined and addressed. Contact injuries such as ligament sprains of the ankle and knee are also common but are unpredictable in frequency and vary from season to season. Injury mechanisms in football continually surprise me, due to the high paced and truly agile nature of the game combined with varying physical presentations of players.
What are the key attributes you feel are required to work with elite level athletes? Working with elite athletes is certainly challenging as it is a demanding environment which is results driven. Key attributes to work in this environment are confidence in your training and practical experience. This goes a long way in effectively treating elite athletes as they need to trust and buy in to your methods. You need to be organised and truly a team player. It is very important to not only know the sport you are involved in, as you will gain added insight into what is required of the athlete, but to also have a passion for the sport as this will drive your performance as a physiotherapist in this environment. What do you see as the major challenges for Sports Physiotherapy? In sports physiotherapy it is key to not only rehabilitate the injury but to keep levels of conditioning and strength
maintained. This involves working around and with the injury which can be a challenge for mid to long term injuries. However if approached appropriately it is an excellent opportunity to work on general conditioning and strength and return the player to competition in a better condition than prior to injury. This can reduce chance of re-injury and translate to an increase in performance. In the professional environment this is especially important and involves a diverse range of training modes such as spin, pool work, off feet gym based conditioning, fitness work such as boxing, cross training and added core/ stability strength sessions. It is here again that the relationship with the conditioning staff is very important as the load will be both shared and integrated. It can also be a challenge to continually manage ongoing causes of dysfunction or potential injury. As generally in sports, if the athlete is performing well and results are positive, underlying causes can be neglected or overlooked as they are seen as unimportant (until they present with pain!). Therefore, the challenge is not only getting the athlete to buy into ongoing maintenance or prevention work but to keep it interesting and sport specific with a clear correlation to their performance. It is also important to be open minded to management strategies. There is a wealth of knowledge and expertise that can be gained and shared across codes, and being equipped with many options while working in professional sports, particularly football is very helpful. Reference: Askling, Tengvar and Thorstensson. (2014) Acute hamstring injuries in Swedish elite football: a prospective randomized controlled trial comparing two rehabilitation protocols. British Journal of Sports Medicine, 47,953-959. Development, reliability and effectiveness of the movement competency screen (MCS) Matt Kritz, MSc, A Thesis submitted to the AUT University in the fulfilment of the degree of Doctor of Philosophy. May 2012.
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SPRINZ
Progressing Rehabilitation Training with Exogen Exoskeletons By Kim Simperingham and John Cronin The Lila Exogen exoskeleton is a compression-based suit that enables small amounts of added weight to be attached to almost any part of the arms, legs or torso. This new technology opens a whole range of novel training possibilities such as: loaded speed, agility and skill training; acute enhancement of training and sports performance through contrast loading; and of particular interest to sports physiotherapists, a means of adding progression to rehabilitation exercises through targeted loading in increments of 100 g in an activity specific or sport specific manner.
Researchers at the Sports Performance Research Institute New Zealand (SPRINZ) have begun to quantify the effects that added weight has on a range of sporting movements. One such study involved quantifying the kinematic and kinetic changes in sprint-running performance that occurred when an added load of 5 % of body mass was attached to either the upper or lower body. Upper and lower body loading had differential effects on sprinting performance and a short video clip regarding the findings from this study is available at www.sportsphysiotherapy.org.nz/exogen. Currently SPRINZ researchers are working with an elite rugby sevens athlete that is progressing towards a return to the rugby field and ultimately towards Rio Olympic goals following a broken leg during the 2014 season. Recent testing at AUT Millennium’s Running & Cycling Clinic (http://www.autmillennium.org.nz/healthand-fitness/clinics/rcc) was completed to quantify the asymmetries between legs during running. A horizontal impulse deficit (-27 %) in the affected leg was particularly noticeable, however by wearing an Exogen suit
with an added mass equivalent to just 2 % of body mass attached to the lower body (i.e. 0.6 kg on each leg), horizontal impulse from the affected leg was acutely increased by 34 % (and by 10 % on the noninjured side). It is anticipated that the acute improvement in balance between left and right legs, and the chronic benefit from the additional specific loading provided by the Exogen suit will positively contribute to the athletes’ successful rehabilitation and return to sport. Our researchers will track the progress of this athlete as well as those from a range of sports as we continue to quantify and understand the benefits of this new technology. If you would like to find out more about the Exogen product, then you can visit the Lila company website www.movementrevolution.com or contact Kim Simperingham (ksimperingham@gmail.com) regarding Exogen-related SPRINZ research; and for more information about SPRINZ research in general you can visit www.sprinz.aut.ac.nz.
To see the Exogen suit in action click on these video links: on YouTube: http://youtu.be/k_3WOE1V_GA or down load (20MB) http://sportsphysiotherapy.org.nz/?p=2200
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Research Publications JOSPT www.jospt.org JOSPT ACCESS All SPNZ members would have been sent advice directly from JOSPT with regards to accessing the new JOSPT website. You will have needed to have followed the information within that email in order to create your own password. If you did not follow this advice, have lost the email, have any further questions or require more information then please email JOSPT directly at jospt@jospt.org in order to resolve any access problems that you may have. If you have just forgotten your password then first please click on the “Forgotten your password� link found on the JOSPT sign on page in order to either retrieve or reset your own password. Only current financial SPNZ members will have JOSPT online access.
Volume 45, Number 6, June 2015 CASE REPORT Orthopaedic Manual Physical Therapy for Shoulder Pain and Impaired Movement in a Patient With Glenohumeral Joint Osteoarthritis: A Case Report
MUSCULOSKELETAL IMAGING Avascular Necrosis in a Patient With Hip Pain
RESEARCH REPORT Low Back and Lower-Limb Muscle Performance in Male and Female Recreational Runners With Chronic Low Back Pain Performance on the Modified Star Excursion Balance Test at the Time of Return to Sport Following Anterior Cruciate Ligament Reconstruction The Use of Compression Stockings During a Marathon Competition to Reduce Exercise-Induced Muscle Damage: Are They Really Useful? Thrust Joint Manipulation Curricula in First-Professional Physical Therapy Education: 2012 Update Epidemiology of Ankle Sprains and the Risk of Separation From Service in US Army Soldiers Cross-cultural Adaptation and Validation of the Exercise-Induced Leg Pain Questionnaire for English- and GreekSpeaking Individuals
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Research Publications British Journal of Sports Medicine www.bjsm.bjm.com Volume 49, Number 12, June 2015 CONSENSUS STATEMENT Doha agreement meeting on terminology and definitions in groin pain in athletes Adam Weir, Peter Brukner, et al. http://bjsm.bmj.com/content/ ANALYSIS Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? Michael P Reiman, Kristian Thorborg http://bjsm.bmj.com/content/ REVIEWS Prevention of groin injuries in sports: a systematic review with meta-analysis of randomised controlled trials E Esteve, M S Rathleff, C Bagur-Calafat, G Urrútia, K Thorborg http://bjsm.bmj.com/content/ The epidemiology of groin injury in senior football: a systematic review of prospective studies Markus Waldén, Martin Hägglund, Jan Ekstrand http://bjsm.bmj.com/content/ Men at higher risk of groin injuries in elite team sports: a systematic review John William Orchard http://bjsm.bmj.com/content/ Risk factors for groin injury in sport: an updated systematic review Jackie L Whittaker, Claire Small, Lorrie Maffey, Carolyn A Emery http://bjsm.bmj.com/content/ Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis Andrea B Mosler, Rintje Agricola, Adam Weir, Per Hölmich, Kay M Crossley http://bjsm.bmj.com/content/ Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis M P Reiman, A P Goode, C E Cook, P Hölmich, K Thorborg http://bjsm.bmj.com/content/ Return to sport after hip surgery for femoroacetabular impingement: a systematic review Nicola C Casartelli, Michael Leunig, Nicola A Maffiuletti, Mario Bizzini http://bjsm.bmj.com/content/ Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes Matthieu Sailly, Rod Whiteley, John W Read, Bruno Giuffre, Amanda Johnson, Per Hölmich http://bjsm.bmj.com/content/
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Clinical Section - Article Review The Football Association medical research programme: an audit of injuries in academy youth football Price RJ, Hawkins RD, Hulse MA and Hodson A British Journal of Sports Medicine 2004; 38:466-471. Abstract Objectives: To undertake a prospective epidemiological study of the injuries sustained in English youth academy football over two competitive seasons. Methods: Player injuries were annotated by medical staff at 38 English football club youth academies. A specific injury audit questionnaire was used together with a weekly return form that documented each club’s current injury status. Results: A total of 3805 injuries were reported over two complete seasons (June to May) with an average injury rate of 0.40 per player per season. The mean (SD) number of days absent for each injury was 21.9(33.63), with an average of 2.31 (3.66) games missed per injury. The total amount of time absent through injury equated to about 6% of the player’s development time. Players in the higher age groups (17-19 years) were more likely to receive an injury than those in the younger age groups (9-16 years). Injury incidence varied throughout the season, with training injuries peaking in January (p<0.05) and competition injuries peaking in October (p<0.05). Competition injuries accounted for 50.4% of the total, with 36% of these occurring in the last third of each half. Strains (31%) and sprains (20%) were the main injury types, predominantly affecting the lower limb, with a similar proportion of injuries affecting the thigh (19%), ankle (19%), and knee (18%). Growth related conditions, including Sever’s disease and Osgood-Schlatter’s disease, accounted for 5% of total injuries, peaking in the under 13 age group for OsgoodSchlatter’s disease and the under 11 age group for Sever’s disease. The rate of re-injury of exactly the same anatomical structure was 3%. Conclusions: Footballers are at high risk of injury and there is a need to investigate ways of reducing this risk. Injury incidence at academy level is approximately half that of the professional game. Academy players probably have much less exposure to injury than their full time counterparts. Areas that warrant further attention include the link between musculoskeletal development and the onset of youth related conditions such as Sever’s disease and Osgood-Schlatter’s disease, the significant number of non-contact injuries that occur in academy football, and the increased rates of injury during preseason training and after the mid season break. This study has highlighted the nature and severity of injuries that occur at the academy level, and the third part of the audit process now needs to be undertaken: the implementation of strategies to reduce the number of injuries encountered at this level. Review: This is an older article, but the statistics are probably still relevant today. The authors state that football is associated with relatively high incidences of injury. “In the professional game in England, a player suffers, on average, 1.3 injuries a season and misses an average of 24 days of training and competition per injury.” This study wanted to clarify if the type and rate of injury in younger players was similar, they hypothesised that young footballers would be more at risk of overuse injuries because of the immaturity of their musculoskeletal system. To do this they studied the type and number of injuries at 38 English football academies. These academies were set up in 1998 to help develop the next generation of elite footballers. Each academy was required to have a physiotherapist on staff. Player injuries were prospectively reported from July 1999 to the end of May 2001. The study looked at all registered players in the academies from age 9 to 19 years. All injuries were recorded on standard forms. A recordable injury was defined as one that prevented the participant from training or playing for more than 48 hours, not including the day of the injury. Injuries unrelated to football were not included, nor was absence due to illness. A total of 4773 players were included in the audit, and during the trial period, 3805 injuries were reported, giving an average injury rate of 0.40 per player per season. It would have been interesting to note if that was an even spread across players or whether some players had higher injury rates than average. It was found that defenders and midfielders were injured most often. The incidence of injury occurred linearly with age i.e. the older the player the more injuries (except at 18 years, the authors thought this might be due to a reporting error, due to age group categories in competition being U17 and U19). Interestingly goalkeeper injuries did not increase with age. Soft tissue strains, sprains and contusions were the most commonly reported (66%), 54% were on the dominant side and 90% of all injuries were to the lower limb. CONTINUED ON NEXT PAGE
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Clinical Section - Article Review The Football Association medical research programme: an audit of injuries in academy youth football continued... Price RJ, Hawkins RD, Hulse MA and Hodson A British Journal of Sports Medicine 2004; 38:466-471. 85% of knee injuries were to the MCL, and 83% of ankle injuries were to the AFTL. Osgood-Schlatters and Sever’s disease accounted for 5% of overall injuries, however between the ages of 11 and 13, these two conditions account for nearly 14% of all injuries, this corresponds to the beginning and end of the pubertal growth spurt in males. The peak incidence for Osgood-Schlatter’s was in the under 13 and 14 age groups, and for Sever’s in the under 11 age group. This was a significant group of injuries and maybe training and management strategies need to be implemented to manage or even prevent these injuries, as although they are naturally self-limiting with little long term implications they can be quite distressing and be problematic often affecting players over quite a long duration. Interestingly only 3% of reported injuries were re-injuries, mostly to the AFTL and MCL. Most of the recurrent strains were to the quadriceps, hamstrings and hip adductors in that order. Injury rates were higher at the beginning of the season and after the mid-season break, which is in line with professional football statistics. They hypothesised the reasons for this could be: result of resuming activity after rest, increased activity, a change in activity, or chance. During the game most injuries occurred in the last 15 minutes of each half, with more in the second half than the first half. The authors state they believe the reasons are probably multi-factorial, including neuromuscular fatigue, but also the immaturity of the musculoskeletal and physiological systems of the players must be considered. In conclusion, it would seem that in Academy Football Players there is a high level of injury, although mostly softtissue, this affects training and availability to play. How these rates compare to adolescents playing football in NZ is unknown, but the types of injuries and location of injury is likely to be similar. In looking at adolescent footballers (and pre-pubescent), special consideration should be given to the lower limb, fitness (especially in the early part of the season) and how to watch out for and manage growth related conditions such as Sever’s and OsgoodSchlatter’s. Physiotherapists should be actively working with coaches in their communities to ensure they are aware of these factors so a collaborative approach to managing them can be achieved. By Karen Carmichael BSc, BPhty, M(SportsPhysio)
Three distinct mechanisms predominate in noncontact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases Waldén, M., Krosshaug, T., Bjørneboe, J., Andersen, T. E., Faul, O., & Hägglund, M. (2015). British Journal of Sports Medicine, 2015 (0), 1-10. doi: 10.1136/bjsports-2014-094573 ARTICLE REVIEW On average, one player every second season will sustain an ACL injury in professional football squads. This incidence has not changed for over a decade, making prevention of ACL injury a priority area within sports medicine research. This prospective cohort study looked at ACL injury mechanisms in professional male footballers. Three different professional clubs in Europe were followed from 2000 to 2011 in order to obtain video footage of ACL injury. Only injuries which occurred during first team match play at club level competition (national and international cup matches) were included. All videos were viewed independently by five different assessors. A structured format was used to describe joint biomechanics, injury circumstances, initial foot contact with the ground and the time of ACL tear. Thirty nine complete tears, confirmed by surgery or MRI, were available for video analysis. Results showed that 25 out of 39 (64%) injuries were noncontact, eight were indirect contact and six injuries were direct contact injuries. Most of the ACL incidences (n=30) observed, occurred when the player was involved in a defensive action. No injury occurred during pre-determined set play. Twenty of the ACL injuries happened while the player had no ball possession. The majority of the injuries (n=34) occurred in a one leg stance, and in the remaining five subjects the main load was on the injured leg. Ninety four percent of the injuries occurred during dry playing conditions. Six of the injuries were judged as foul play by the referee. CONTINUED ON NEXT PAGE
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Clinical Section - Article Review Three distinct mechanisms predominate in noncontact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases continued... This study identified three main categories in the non-contact and indirect contact injuries: (1) pressing (n=11), (2) re-gaining balance after kicking (n=5) and (3) landing after heading (n=5). Direct contact to the injured leg or knee (n=6) was the final main category. The remaining twelve injuries followed no distinct pattern and did not conform to the categories above. Pressing is a defensive move where the player makes a sidestep cut to reach the ball or to tackle an opponent. 10 of 11 of pressing related injuries were from non-contact mechanisms. In six of these cases the injured player went in for a tackle but did not achieve any contact with the opponent. These injuries occurred at high speed with less than 40° hip flexion and 20° or less knee flexion. Median flexion values were low at 25° for the hip and 5° for the knee. Hip abduction was seen in eight cases, knee valgus in six cases and no clear pattern was seen with ankle eversion. Losing their balance following kicking (n=5) was another commonly seen category. All of these players were in a non -contact or indirect contact situations. In most of these injuries the player was clearing the ball at high speed with unstable balance. Significant hip abduction was identified in three cases as well as knee valgus in three. All hip flexion was less than 30 °and knee flexion was 20°. The median of both of these flexion values was 10°. Injuries sustained while landing after heading the ball (n=5) were all non-contact injuries. The players were injured mainly while landing on one leg only. In all of these situations the injured player landed on his forefoot. The median flexion angles were 10° for the hip and 5° for the knee at initial contact. Estimates of ankle eversion showed no clear trend. The six direct contact injuries were a consequence of tackling or collision situations. The direct tackling injuries (n=3) were sustained from behind with lateral impact to the knee causing a valgus collapse. In the three collision injuries there was no specific pattern. Regardless of the playing situation, knee valgus was commonly seen however dynamic valgus collapse was not. Except in the case of the three direct-contact injuries resulting from tackling where they all had a dynamic valgus collapse. 77% of the ACL injuries recorded occurred during defending, which corresponds with other articles’ findings. The findings showed all injuries sustained while kicking were due to loss of balance and most of the post heading injuries due to overbalancing on one leg. This suggests that prevention strategies may need to focus on neuromuscular and postural strategies in jumping, landing and changes of direction. ACL injuries also occurred with direct contact to the injured leg (15%) all three had concomitant injury to the medial collateral ligament and two had lateral meniscus injury suggesting a valgus mechanism. This study found in most circumstance the injured knee had less than 20° of knee flexion at initial contact. This coincides with video analysis seen in Australian Rules football, all indirect and all but one non-contact ACL injury had minimal knee flexion (less than 30°) at the time of injury. The theory is that vertical compression at a straight knee loads the ACL through anterior tibial drawer and internal rotation. Knee valgus also appears to be a common factor in ACL injury with 15 of 19 measurable video cases being in valgus at initial contact. Clinical relevance These findings suggest that prevention programmes should include: Postural and neuromuscular control of the core and lower limb during drills; Footwork and changes of direction in defensive playing actions, mimicking the pressing situation; Practicing landing with a greater angle of hip and knee flexion Maintaining balance during shooting, passing and ball clearing; Practicing jumping and landing technique during heading Promotion of good sportsmanship to avoid aggressive tackling from behind.
Reviewed by Monique Baigent MHsc (Physiotherapy)
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Case Study Grade 1 ACL rupture in an elite football player Background Rehabilitation of a partial rupture of the medial collateral ligament and anterior cruciate ligament of the knee in an elite football player during final build up to age group world cup football qualifying tournament. Case Description 17 year old male football goal keeper taken out by another player from lateral side on single leg contact with the ground during landing. Immediate medial knee pain VAS 8 severity with inability to continue training. Slight medial swelling of the knee, progressive during the evening. Ongoing deep, intense medial knee pain. Ice applied directly at time of injury and at hourly intervals for 10minutes over the following four hours and rest. Compression applied in the form of elastic sports bandage. No anti-inflammatory medication taken. Panadol as required for pain relief. MRI done the following morning revealing Grade 2 tear of MCL and Grade 1 tear of ACL. On immediate consultation with orthopaedic surgeon was put in a Range of Movement brace for 4 weeks. Physiotherapy assessment: patient partial weight bearing in a range of movement brace set at zero degrees knee flexion. Slight effusion over the medial aspect of the knee. Tenderness on palpation of the femoral attachment of the medial collateral ligament. Medial collateral and anterior cruciate ligament testing positive for laxity and pain response. Physical problems: pain, reduced range of movement, reduced strength, reduced proprioception, knee instability Potential problems: knee instability ongoing, fear avoidance of return to sport, physical deconditioning, psychological loss of top position in team Goals: relieve pain, increase mobility, increase strength, increase proprioception, return to elite level football training and compete in World Cup qualifying tournament. Physiotherapy commenced on day 2 consisting of acupuncture and inner range quadriceps contractions done in the brace with an allowance of zero degrees knee flexion. Continuing physiotherapy of friction therapy applied to the ligament, acupuncture, deep tissue massage of the quadriceps, and active straight leg raises, were maintained with the brace at 30 degrees flexion from week 2. Weight bearing activities including wall squats, mini squats, bridging, rowing, cycling and proprioceptive exercises were introduced at week 3 in the brace. The brace was removed in after 4 weeks and single leg strengthening activities such as lunges, squats, Swiss ball curls, single-leg deadlifts and step ups were commenced. The athlete was also able to start running in straight lines. Ball skills and bounding and cutting drills were introduced as the player returned to full strength and was pain-free on normal daily activities. At week 6 the athlete was pain-free with good strength and a stable knee and was able to return to football training. Outcome Patient had good quadriceps strength with symmetrical bulk and good endurance. There was minimum tenderness on palpation of the ligament and testing of instability of the medial ligament and the ACL was negative. The patient show good proprioception and balance and was able to perform all training drills without any residual effect from the injury. Patient made a full physical recovery to allow him to continue to compete at international level Athlete was struggling with mental component of having been dropped from the squad to travel to qualifying tournament following a significant knee injury
CONTINUED ON NEXT PAGE
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Case Study Grade 1 ACL rupture in an elite football player continued... Discussion Immediate imaging and correct bracing with appropriate progressive physiotherapy treatment enhances full recovery of Grade 2 MCL and Grade 1 ACL ligament injury in elite football players. Significant knee injury when managed correctly need not be career ending. When MRI is not available immediately, it is important that clinicians make a correct specific clinical diagnosis to enable to athlete to receive appropriate early intervention, or refer for orthopaedic opinion as soon as possible. Psychological impact of injury on elite athletes should be addressed during rehabilitation.
By Pip Sail, physiotherapist
Continuing Education
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Continuing Education Upcoming courses and conferences in New Zealand and overseas in 2015. For a full list of local courses visit the PNZ Events Calendar For a list of international courses visit http://ifspt.org/education/conferences/
LOCAL COURSES & CONFERENCES When?
What?
Where?
4-5 July 2015
Promotion and Prescription of Physical Activity and Exercise
Hamilton
5 July 2015
Hydrotherapy- Introductory course (4-hours)
Wellington
6-10 July 2015
New Zealand Shoulder and Elbow Society Conference
Rarotonga
6 July 2015
PhysioScholar - Influence of lumbar posture on biomechanics and functional anatomy
Nationwide
9-16 July 2015
PNZ Wellington Branch and Clinical Edge Webinar Series
Nationwide
10-11 July 2015
Myofascial Release Therapy Training Courses - The Fundamentals
Christchurch
8-9 August 2015
Kinesio Taping Course - KT 1 & 2
Wellington
13 August 2015
Otimising Cycling Biomechanics & Bike Setup
Auckland
21-23 August 2015
MNZ 2015 Conference Delegates Information and Registration pack
Tauranga
APA CPD EVENT FINDER SPNZ members can now attend APA SPA (Sports Physiotherapy Australia) courses and conferences at APA member rates. This includes all webinars and podcasts (no travel required!). To see a full list visit the APA and SPA Events Calendar
APA SPA COURSES & CONFERENCES When?
What?
Where?
24-25 July 2015
Running Workshop - Level 1
Riverside, TAS
15 August 2015
Optimising Running Mechanics - Clinical Considerations
Fitzroy, VIC
16 August 2015
Level 1 ASCA Strength and Conditioning Coaching Course
Sydney Olympic Park, NSW
19 August 2015
Imaging of the Hip Through Our Lifespan
Eight Mile Plains, QLD
23 August 2015
Level 1 ASCA Strength and Conditioning Coaching Course
Spring Hill, QLD
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Continuing Education
Managing runners in practice: Considerations in the assessment & prevention of running injuries Auckland – August 29th 2015 Christchurch – September 6th 2015 Venue: TBC Time: 9:00 – 5:30 Presenter: Chris Bishop Director: Biomechanics & Gait Analysis at The Biomechanics Lab
Cost: $300 NZD Program schedule: 9:00 - 10:30: Morning Session 1 – Principles of athlete screening & determinants of performance This session will assume background knowledge of the biomechanics of running, and will provide a clinical template to assess the runner. A method of screening the athlete for injury risk will be demonstrated, as well as a discussion of considerations that affect the performance of runners such as alterations in human physiology, biomechanics, speed, footwear, strength etc. Participants will have the opportunity screen each other in small groups to gain practical experience with the template. 10:45 - 12:15: Morning Session 2 – Principles of exercise prescription and rehabilitation. This session will focus on load management, and provide attendees with the background knowledge and template to accurately prescribe exercise and strength & condition programs in practice. Practical demonstrations of a staged program will occur, focussing on core stability and dynamic control of the lower limb as it relates to the runner. 12:15 – 1:00: LUNCH 1:00 – 3:00: Afternoon session 1 – Consideration in injuries to the leg during running This session will focus on three main injuries to the leg experienced by the runner; hamstring strains, ITB Syndrome and MTSS. Consideration in injury mechanisms of each will be discussed, as well as diagnostic strategies, assessment techniques, gait patterns, treatment direction tests, off-loading techniques and return to running strategies. 3:30 – 5:30: Afternoon session 2 – Consideration in injuries to the foot during running This session will focus on three main injuries to the foot experienced by the runner; Achilles tendinopathy, plantar heel pain and metatarsal stress fractures. Consideration in injury mechanisms of each will be discussed, as well as diagnostic strategies, assessment techniques, gait patterns, treatment direction tests, off-loading techniques and return to running strategies. *Please bring shorts & shaved legs*
76a Kensington Road, Rose Park SA 83646800 info@thebiomechanicslab.com.au www.thebiomechanicslab.
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Classifieds
DUNEDIN Sportsmed Mosgiel Physiotherapist â&#x20AC;&#x201C; Full Time Sportsmed Mosgiel Physiotherapy requires a full time physiotherapist to start in May/June 2015. Sportsmed Mosgiel is a musculoskeletal physiotherapy clinic situated beside the Olympic Gym in Mosgiel. There is an emphasis on manual/manipulative and rehabilitative physiotherapy with appointment times of 30-45 minutes duration to ensure quality treatment. The ideal applicant should have sound musculoskeletal skills, a great work ethic and hold a current annual practicing certificate. Remuneration is excellent, ongoing education is encouraged and regular in-services are held in a relaxed and friendly setting. The applicant should have an interest in sport and dealing with athletes although a wide variety of patients are seen. New graduates are welcome to apply. Please forward CV and cover letter in strict confidence to: Adam Letts Sportsmed Mosgiel Physiotherapy Olympic Gym, 9b Gladstone Road Mosgiel 9024 Email: sportsmedmosgiel@gmail.com
AUCKLAND Ponsonby Rugby Club Sports Physiotherapists Sports physiotherapists wanted for teams at Ponsonby Rugby Club. We are looking for keen enthusiastic physios who would like to do some team work at our very busy rugby club. This involves two training nights and Saturday work. Lovely facilities, great people, plenty of business. I am keen to hear from Independent qualified and experienced physios looking for paid team work. I am also keen to provide training and supervision to any interested students or less experienced physios (your expenses will be covered by the club). Please contact Tanya Browne at Sports Physio (NZ) Ltd ASAP on 0274990539 Or email tanya.browne42@gmail.com
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Classifieds AUCKLAND - NORTH SHORE Forrest Hill Physiotherapy Full or Part-Time positions A full or part time role with immediate start is available with Forrest Hill Physiotherapy. This position would ideally suit an experienced physiotherapist with strong manual therapy skills or an experienced physiotherapist undergoing post-graduate studies. Our musculoskeletal practice is a certified and community based clinic with NZ representative team providers amongst the six other post-grad or Masters qualified physiotherapists. Established over 25 years ago, the clinic has a loyal patient and GP base and an excellent reputation within the community. Our clinic has a strong manual therapy and exercise rehab focus, facilitated by a fully equipped Clinical Pilates studio, rehab gym and a Real Time Ultrasound Imaging service. In addition to fortnightly in-service education, the successful applicant will work alongside Clinical Pilates Instructors, a continence physiotherapist and massage therapists. All staff are supported by a skilled and experienced administration team and practice manager. A comprehensive financial package is offered including support of ongoing education, conferences, courses and work in special interest areas, e.g. sports teams. A strong history of clinical acumen and post-graduate qualifications are desirable but PG students with private practice experience will be considered. If you fit these criteria and are motivated to work in a dynamic clinical environment, then please email your CV to Chris McCullough at info@forresthillphysio.co.nz
CHRISTCHURCH Ilam Physiotherapy Clinic Permanent Part-Time Physiotherapy Position The Ilam Physiotherapy Clinic is a well established, accredited practice in the Ilam/Fendalton area of Christchurch and is part of an integrated health provider facility. The Clinic offers a supportive work environment with regular in-services. This is a well remunerated part-time position which includes a fixed Wednesday afternoon. Please email your details and CV to Gerald Cummins on rgcummins@xtra.co.nz
CHRISTCHURCH Ilam Physiotherapy Clinic Locum Required A locum physiotherapist is needed for the Ilam Physiotherapy Clinic, located in the Ilam/Fendalton area of Christchurch for the first week of July 2015 and the first week of September 2015. Please contact Gerald Cummins on rgcummins@xtra.co.nz
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Classifieds
AUCKLAND Part-Time Physiotherapist Location: Start date:
WSAFC, Seddon Fields, 108 Meola Rd, Western Springs, Auckland July 2015
Back To Your Feet Physiotherapy is a central Auckland ACC accredited physiotherapy and sports clinic based onsite at the best footballing facility in the country. We focus on prevention, treatment and performance and provide services to New Zealand Football, New Zealand Roller Derby, New Zealand Ice Hockey, Auckland City FC and a whole lot more national and regional teams. We are looking for an enthusiastic and reliable part time physiotherapist. The successful applicant will be part of a sports focused team and will benefit from a significant mentoring and a comprehensive CPD programme. You must hold NZ Board registration and an APC to apply. Please direct any questions or email your CV to Justin at info@backtoyourfeet.health.nz Deadline for applications is July 1st 2015.
AUCKLAND Full time physiotherapist Location: Start date:
WSAFC, Seddon Fields, 108 Meola Rd, Western Springs, Auckland July 2015
Back To Your Feet Physiotherapy are a central Auckland ACC accredited physiotherapy and sports clinic based onsite at the best footballing facility in the country. We focus on prevention, treatment and performance and provide services to New Zealand Football, New Zealand Roller Derby, New Zealand Ice Hockey, Auckland City FC and a whole lot more national and regional teams. We are looking for an enthusiastic and reliable full time physiotherapist. The successful applicant will be part of a sports focused team and will benefit from a significant mentoring and a comprehensive CPD programme, and a competitive remuneration package, You must hold NZ Board registration and an APC to apply. Please direct any questions or email your CV to Justin at info@backtoyourfeet.health.nz The deadline for applications is July 1st 2015.