Joint Hypermobility: increased risk for injury in sport?

May 11th, 2012

               Health care practitioners in the sports medicine community are constantly seeking ways to evaluate athletes for injury risk and mitigate the risk if possible.  Hypermobility as a risk for sustaining injury in sport has been controversial due to conflicting scientific evidence and skepticism regarding unsubstantiated historical opinions.  Currently most sports medicine practitioners, although well aware of the theoretical link between hypermobility and musculoskeletal injury, do not include any testing for hypermobility in their usual in office physical examination or pre season evaluation of athletes.  Is it time to get off the fence and be more proactive when it comes to hypermobility?

                Generalized joint hypermobility is a feature of several disorders of connective tissue that results in joint laxity.  This joint laxity is generally considered to be genetic in origin, in other words you were born with it!  Hypermobile individuals are commonly reported to suffer dislocations (ie. shoulder), subluxations (ie. rib) and ligament or capsule sprains.  However it is important to note that many patients with hypermobility do not have musculoskeletal pain or any other correlated health concern.  The question is: do these injuries (dislocations, subluxations, sprains, cartilage injuries etc) occur more frequently or with greater severity in those with hypermobility vs. those without?
               

                Two recent pieces of literature from The American Journal of Sports Medicine might help answer said question.

                A 2010 systematic review1 found that subjects categorized as hypermobile were at a significantly increased risk for sustaining knee injuries, but not ankle injuries, compared to their non-hypermobile peers.  The knee relies on passive restraint (ligament and capsule) to a greater extent than the ankle, which has a much greater active tissue (musculotendinous) dependence for stability.

                A more recent study on 54 professional soccer players2 demonstrated that those players with a Beighton scale (see video below) score of 4 or higher had a higher incidence of injuries (no restriction on type or location of injury) over the course of a season.  These hypermobile soccer players were also more likely to experience a re-injury and more likely to sustain a severe injury compared to the non-hypermobile players, which overall resulted in increased lost time from practicing and match play.

                As is often the case, there is still much left unknown on this topic.  However I believe it is prudent for practitioners and athletes to start putting generalized hypermobility on our injury risk radar with more routine screening (it takes less than a minute…see below!).

Beighton Scale
               

                There are several tools used to quantify hypermobility, however, the Beighton scale is easy to implement, with no elaborate equipment or technology involved, and is validated for clinical and research use.  Check out the video below to see the 5 tests utilized to conduct the Beighton scale and the criteria to determine a score from 0-9.  The cut-off point for hypermobility has been reported as 4/9 or 5/9 depending on the source.  Some others have defined a score of 2-3/9 as mildly hypermobile, 4-5/9 as moderately hypermobile and 6+/9 as severely hypermobile.  In general, the higher your score the greater degree of generalized joint laxity.  What is your Beighton score?

References:
1. Pacey et al.  Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis.  American Journal of Sports Medicine.  2010;38(7):1487-1497.
2. Konopinski et al.  The effect of hypermobility on the incidence of injuries in elite-level professional soccer players: a cohort study.  American Journal of Sports Medicine.  2012:40(4):763-769.

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Ankle dorsiflexion: Injury prevention for jumper’s knee?

February 8th, 2012

Explosive jumping, in sports such as volleyball and basketball, expose the patellar tendon to significant strain (forces in excess of 6-8X a person’s bodyweight!). The highest stress to the patellar tendon occurs during the landing phase where the entire lower limb must dissipate the ground reaction forces. The ankle plays a critical role in softening a landing, responsible for almost half of the total kinetic energy absorbed at impact. The degree of dorsiflexion (along with strength of the plantar flexors and landing technique) has been implicated as a key component of shock absorbance during landing.

A recent prospective study in a group of Swedish elite junior basketball players provided evidence that limited dorsiflexion is a risk factor for developing patellar tendinopathy (jumper’s knee). The study followed 75 players over the course of a year. 12 players developed patellar tendinopathy during the year and those players had significantly less dorsiflexion at baseline. The players with reduced dorsiflexion (measured cut off of 36.5 degrees in this study) had a 10X greater risk of developing patellar tendinopathy compared to those with adequate ankle dorsiflexion. So the logical next question is does improving functional dorsiflexion reduce the risk of developing patellar tendinopathy? We await this investigation with optimism!

The theory of limited dorsiflexion possibly increasing the risk of sustaining patellar tendinopathy is a simple compensation rationale. If the ankle is a key shock absorber for jump landing, but poor dorsiflexion reduces its capacity to soften the landing then the knee, and more specifically the patellar tendon, will be responsible for energy absorbtion.

Inadequate dorsiflexion, or restricted dorsiflexion, is a common clinical finding. It can occur due to tension from the calf muscles, stiffness from the ankle joint itself (ankle mortise joint predominantly) or secondary to a previous ankle injury (ie. sprained ankle). The range of dorsiflexion can be improved by a variety of manual therapy techniques. To see how functional ankle dorsiflexion can be assessed and treated check out the video below.
 

 

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The Nordic Hamstring Exercise for Chronic Recurrent Hamstring Strains

December 20th, 2011

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Treatment options for tennis elbow

December 6th, 2011

Tennis elbow is a tendinopathy involving the tendons of the lateral elbow.  Not surprisingly, most who experience this clinical condition are not tennis players at all.  This injury is seen most commonly in individuals who suddenly overuse a relatively deconditioned and possibly degenerated tendon for the task at hand.  A sudden return to vigorous exercise at the gym, unusual work around the house or heavy lifting are common presentations of lateral elbow overuse.     

Although this condition is relatively easy to diagnose (disclaimer there are several important differential diagnosis to consider so please don’t just assume lateral elbow pain is tennis elbow) it is much more difficult to fix over the long term.  A recent clinical review from the British Medical Journal (BMJ) called “The Management of Tennis Elbow” nicely summarized the efficacy of some commonly sought after treatment strategies that I will summarize below.

Rehabilitation exercises

If you go to a baker, they will sell you bread…if you go to an orthopedic surgeon, they will sell you surgery…and if you go to a physio or chiro they will probably sell you, as part of their program of care, rehabilitation exercises.  And while this may be true, the evidence is rapidly mounting for the efficacy of carefully prescribed exercises that challenge the tissue as close to its limits as possible without exceeding them for many musculoskeletal conditions.  Eccentric exercise has become the focal point of rehabilitation programs for most tendinopathies (see Achilles tendinopathy post).  Patients must also be willing to modify their activity level of the elbow during a rehabilitation program for optimal results.  Continued participation in sports or heavy upper limb exercise routines, for example, will inhibit the effectiveness of rehabilitation.

Non-steroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen etc.)

NSAIDs can be helpful to cope with the pain of tennis elbow in the short term.  However these drugs do not improve the long term outcome.  Theoretically NSAIDs may even have deleterious effects on tendon healing (similar to cortisone injections).  Further research is required to demonstrate the long term detrimental effects of NSAIDs on tissue healing. 

Cortisone Injections

Much like NSAIDs, cortisone injections may provide much needed short term relief (especially the first 6 weeks).  However, patients treated with cortisone injections are more likely to have a recurrence.  Therefore in most cases, especially where the long term outcome is more important than the short term outcome, cortisone injections should not be used.

Platelet-Rich Plasma (PRP) Injections

PRP has experienced a rapid rise to fame, especially in the sports medicine community.  Pro Athletes such as Tiger Woods, Hines Ward and Troy Polamalu have all been reported to have benefited from PRP for post surgical healing, ligament and muscle healing respectively.  Recent high quality RCT’s that compared PRP injections with cortisone injections for lateral elbow pain found superior cure rates and pain scores for PRP injections up to two years after injections.  Two conclusions are possible, either PRP is helpful for tennis elbow or cortisone injections are detrimental for tennis elbow.  Considering the known negative long term outcome from cortisone injections, our confidence in PRP with current evidence is weak.  PRP has not been tested against other similar treatments that penetrate the skin (ie. acupuncture or other types of injections such as prolotherapy, hyaluronan or botulinum toxin).  PRP is a relatively new treatment and is expensive.  Evidence for superiority in efficacy is necessary, compared to similar forms of treatment, to warrant the increased costs.   

Acupuncture

A 2004 systematic review published out of McMaster University stated that there is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral elbow pain.  There are a few small studies that also claim that electro-acupuncture is more effective than manual acupuncture in chronic tennis elbow (more research needed).  Clinically I believe acupuncture is an extremely powerful therapeutic option that should be a primary intervention for everyone suffering from tennis elbow.   

Extracorporeal Shockwave

Shockwave treatment may be effective in tennis elbow cases that involve calcifications of the tendon (usually confirmed via imaging).  However, a 2009 Cochrane review concluded that there is strong evidence that shockwave therapy provides little or no benefit in terms of improving pain or function in the majority of tennis elbow cases.  The treatment itself may be quite painful causing irritation of the skin and possibly nausea. 

Surgery

Like many other conditions, as a general guide, surgery has a role in cases of tennis elbow that do not respond to a sustained period of conservative treatment.  Considering tennis elbow usually resolves within 12 months, a surgical intervention should not explored within this time period.  Although there are several techniques (such as releasing, lengthening, excising and repairing the common extensor origin) described to surgically treat tennis elbow, the success of surgeries is likely due to forcing an initial rest period with gradual rehabilitation as the pain from surgery diminishes.

A conservative program of care to consider:

From clinical experience, soft tissue releasing techniques such as Active Release Technique (ART) are effective in the early intervention and long term maintenance for tennis elbow; especially in chronic, recurrent cases.  Generally after an ART treatment patients will state that their elbow and forearm feels immediately “looser” with greater pain free range of motion.  The combination of ART, electro-acupuncture and activity modification improves the intensity of symptoms and functional limitation in the majority of cases (in as little as 3 visits for some patients).  When clinical symptoms become more manageable, the next phase of care involves more intense rehabilitation (including eccentric exercise) which will determine long term success of the treatment. 

Orchard J and Kountouris A.  The management of tennis elbow.  BMJ.  2011;342:d2687.

Trinh KV et al.  Acupunture for the alleviation of lateral elbow pain: a systematic review.  Rheumatology.  2004;43(9):1085-90.

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A long term solution to your Achilles’ heel

November 22nd, 2011

Has your Achilles tendon kept you from training or competing?  This is one nagging injury that seems to re-emerge at the most inopportune time…just when you are ramping up for an event or in a heavy part of your season schedule.  For many people, their Achilles tendon seems to be the weak link.  Although this tendon in relative terms is far from weak (bearing as much as 8-10 times a person’s body weight during strenuous exercise) it is a recurring problem for many that need an effective long term solution.

Long term solution for my Achilles tendon pain?…great, but I hope I don’t have to put too much effort into it!  If you are a product of our Western medicine approach, this is likely your subconscious dialogue.  We all love the quick fix; so for our Achilles pain we try things like orthotics, shock-wave therapy, platelet rich plasma (PRP) injections, corticosteroid injections and even surgery at times.  Some of these may have a time and a place for consideration, but if you are looking for an effective long term solution look no further than eccentric exercises.

Eccentric exercises for the Achilles tendon have been widely accepted as a primary approach to treating mid-portion Achilles tendinopathy, and several other tendinopathies, through more than a decade of work by Alfredson and colleagues.  His treatment program was originally described as 180 repetitions of heel drops, with the knee straight and bent, over a 12 week period (see videos below).

Although the mechanism for why eccentric exercises work so well (compared to other treatments and other forms of exercise) is still up for debate, there is ample evidence to conclude that it does have a significant benefit for the majority of patients.Check out the videos below to see how the protocol is implemented (disclaimer: you should consult a suitable health care professional to confirm the diagnosis of mid-portion achilles tendinopathy…there are several other considerations for pain in the region of the Achilles tendon for which eccentric exercises would not be recommended).

Most recently a follow up study demonstrated that the functional improvements (measured by the validated VISA-A score) continue to improve up to 5 years after the completion of the program.  An interesting component of this study was that the majority of subjects (67%) had never performed the heel drop exercises after the 3 month protocol ended.  So although the compliance to the 3 month program may be time consuming in the short term, in the long term in may save the time wasted seeking other solutions.  Of note, most of the follow up subjects did still have mild pain, so expecting complete resolution of symptoms is not realistic (this expectation applies to the “quick fix” treatments as well).

The take home message is simple: stop looking for a one dimensional quick fix by your physician/practitioner and make sure you include eccentric exercises as part of your mid-portion Achilles tendinopathy treatment plan.

Plas A, Jonge S, Vos RJ et al.  A 5-year follow-up study of Alfredson’s heel-drop exercise program in chronic midportion Achilles tendinopathy.  BJSM.  Published Online First November 10, 2011.

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Concussions: evaluating potential prevention and management solutions

November 15th, 2011

NHL star Sidney Crosby is on the verge of returning to play after a 10 month concussion hiatus.   With all the attention brought to the issue of concussions in the wake of his absence, the question is has his injury sparked positive change?…or are we any closer to a solution that will either reduce the number of concussions sustained or changes that will improve the management of concussions? 

Concussions are an ever increasing controversial topic.  After decades of using loss of consciousness, memory difficulty and confusion as the primary criteria to determine the severity of a concussion these now make up a small component of our current diagnostic tools.  As a team doctor for a junior hockey team we now rely on a large battery of symptoms, memory and cognition tests and balance tests to make a decision.  Some leading experts may even have access to advanced imaging such as functional MRI to help in the diagnostic process.  Although the diagnostic tools have evolved immensely the decision to label a player with a concussion is still (in most cases) highly subjective.  This diagnostic subjectivity makes investigation and research into concussion prevention and management interventions highly problematic.

With a market for the next big concussion solution at an all time high let’s look at some of the ideas being tested right now and discuss their importance in the big picture.

Computerized Concussion baseline testing   

There are several computerized testing platforms that are competing for market share (ImPACT, CogState etc).  These tests take about 25 minutes and cost approximately 25 dollars per player for a preseason test.  ImPACT has published dozens of studies to boost its scientific credibility to establish itself as the go to tool for helping determine when a player is ready to return to play.  Is this potentially a piece of the puzzle?  Maybe…especially at the junior and professional levels where return to play is particularly important for career development.  In fact, Dr.Kissel and I implemented this baseline testing for our junior hockey players this year.  But should the Greater Toronto Hockey League, with over 10,000 rep players age 9-20, be investing approximately 1/4 million dollars on this baseline testing?  Current guidelines require a graded exertion progression prior to clearance for return to play, which still requires a trainer/physician…the computerized pre/post information does not replace this process.  The GTHL has tabled a motion until 2012 to further discuss funding this baseline testing…but several other organizations  have already broken the ice for what seems to be inevitable.        

Role in the big picture?  Theoretically improves timing of return to play and, again, may be a piece of the puzzle…but distracts us from the underlying more important issue of reducing the incidence of concussions in sport.  In my opinion implementing these in minor hockey is unneccessary, cumbersome and a poor allocation of resources.  Instead emphasis on concussion education for minor hockey players, such as this video produced by Think First, would be a better use of team time and effort (leaving a large chunk of change for a more productive long term solution…see video review below). 

Red light lunacy: Battle Science impact indicator 

Battle Science has created a football chinstrap with a LED indicator on the front that changes from green to red if a player sustains a hit that results in a threshold of G forces.  If the indicator turns red the probability that the player has sustained a concussion is 50% or higher.  I was unable to find a link from their site to substantiate the threshold magnitude…this theoritical point where insignificant contact suddenly becomes significant.  For $149.99 you can order the chinstrap…and then what?  Again the diagnosis and management is still up to the trainer/physician on the sidelines…but now trainers/physicians can read a book or catch up on some ZZZ’s on the sidelines during the game I suppose.  And if you don’t want a chin strap that lights up…a mouth guard with similar technology may not be that far behind.

Role in the big picture?  Negligible.  Yes it’s an extra set of eyes, however we know that the magnitude of the impact is poorly correlated to the post concussive symptoms that a player experiences (Guskiewicz et al.  Biomechanics of Sports Concussion: Quest for the Elusive Injury Threshold.  Exercise and Sports Sciences Revews.  January 2011.).  If only the issue was black and white, or red and green as Battle Science seems to claim!

Neck constriction collar

Finally…a prevention oriented idea!  Dr. Joseph Fisher, a University of Toronto anaesthesiologist, claims a simple neck collar that constricts the internal jugular veins is the cheap prevention solution we’ve been waiting for.  The collar restricts just enough to top up the brain bathing fluids to help prevent excessive brain movement within the skull.  Although the analogy of contents in a fluid filled container is captivating, the application to interrupting our normal cerebral cardiovascular flow is much more complex…I would assume more research (beyond that done in rats already) is to come before giving this theory any credibility. 

Role in the big picture?  Although I think the likelihood of this idea gaining momentum is about as likely as the Leafs finishing first overall in the East this season…let’s give Dr.Fisher credit for innovation in the prevention realm (quoting Apple’s think different campaign: the people who are crazy enough to think they can change the world are the ones who do).  

Video Review of headchecks in the NHL

In my opinion, the most valuable change fueled by the Crosby concussion spotlight has come from the league itself: Sheriff Shanahan’s video review approach.  Shanahan has brought transparency and clarity to the leagues decisions on suspensions for illegal checks.  Many hockey purists (see Don Cherry) will argue that this will ruin the game, with players afraid to deliver a check in fear of accidentally hitting an opponent’s head etc.  While this will inevitably tone down the aggression factor, holding players accountable for their actions is the only way to reduce or eliminate head checks.  It will be interesting to see if the incidence of concussions in the NHL is affected by the video crack down on head checks/illegal checks. 

Role in the big picture?  If this accountability and greater respect for your opposition disseminates down the ranks to minor hockey imagine the widespread effect on preventing concussions.    Think implementing video review outside of the NHL is financially unrealistic?…I believe the GTHL could implement a video review system for far less than a 1/4 million annually (instead of paying for computerized concussion baseline testing).

Side Note:  a local concussion researcher and expert, Dr. Paul Echlin who has researched the incidence of concussions in junior hockey and has a particular interest in concussion prevention/education, stated that Hockey Canada has an annual budget in excess of 15 million/year (other sources say as much as 30 millon/year), of which they have never funded concussion research (prevention or other).  Much like our current medical system…Hockey Canada (and their affiliates) seem to be sending a message that they are willing to spend money on reactive measures but not potentially proactive measures. 

Have a question or comment?  Carry on this conversation in the comment section below.

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Barefoot Running Part 2 (Lessons from a course with Irene Davis)

November 12th, 2011

 

INTRODUCTION 

I recently had the pleasure of attending a 2 day course titled “evaluation and treatment of the injured runner” with Dr. Irene Davis and Dr. Richard Willy, arguably two of the world’s leading running researchers.  You may have heard of Dr. Davis as she is often touted as the ‘barefoot running expert’ and appears in Chris McDougall’s iconic book Born to Run.  More appropriately she should be known for being a prominent researcher of such calibre that Harvard Medical School recently created The Spaulding National Running Centre to allow her to further investigate running biomechanics.  The following is a summary of some key research supported findings presented over the weekend.  The take home point…..we really don’t know too much of anything yet!

PREAMBLE

To begin, there are a number of different foot striking patterns.  This video is a cool slow motion clip taken from one of the lead packs at the 2010 Boston marathon.  Check out the variety of different foot strike patterns in this ridiculously fast group.  Some are forefoot strikers, some are rear foot strikers, and some are in between.
Now check out this video of the same race (slower runners this time…..the first group was running sub 5 minute miles!) with a barefoot runner mixed in.  A VERY small sample, but notice how the runners wearing shoes (shod runners) tend to heel strike, while the runner that is barefoot lands more on the ball of his foot.

Over 80% of current runners are rear foot strikers, while just 1-2% are forefoot strikers.  Which strike patterns is the best?  That’s what we are trying to establish…….

RUNNING AND INJURIES

In any given year nearly 80% of runners will sustain an injury, 46% of which will be injury recurrences.  With such a significant number of injured runners and with so many people now running, there is a lot of funding to find out how and why runners get injured.  The first reasonable explanation is on how we are put together (our structure).  Yet there are a number of studies that show no correlation between body structure and running mechanics.  Nor are there studies correlating body structure and injury.  Dr. Davis has an interesting take on these studies where she expressed skepticism as she noted that these studies are taking individuals from a normal population.  This means that for the most part they are within the normal range for structure and have no injuries (typically normal is defined as the mean plus or minus 2 standard deviations for those wondering).  She hypothesizes that if you take a group of individuals outside of ‘normal’ body structure and measured their gait patterns you would see injuries.  Because of this she has reservations about concluding that structure has no impact.  Pretty cool and open minded researcher. 

HER TAKE ON BAREFOOT RUNNING

Dr Davis has no financial relationship or commercial interests tied to barefoot running.  Instead, hers was a personal journey that included a 30 year absence from running following persistent injuries as a physiotherapy student.  Later, in her fifties, she has again began running however this time entirely barefoot (that’s right…..no socks, nothing!) and has so far been injury free.  When questioned she flat out said “Ya last night I did 30 minutes down Leslie Street and back completely barefoot”. 

Why barefoot? Her take is that we as humans have been de-evolving ourselves with the modern shoe.  We were made to run barefoot and have done so for millions of years.  Even previous running shoes up until the 1970s were minimalist, defined as providing no support (no arch support, no heel support) and no cushioning (ie no midsole).  Minimalist shoes simply provide protection for the bottom of the foot.  In 1963 while Phil Knight was still working at Asics, they imported the Onitsuku Tiger shoe to the US, the first shoe with a large cushioned heel.  In 1972 he jumped ship and formed Nike producing the Nike Cortez which brought the ‘contemporary’ shoe to the mainstream.  Now, 40 years later, the ‘modern running shoe’ has an elevated cushioned heel, stiff heel counter, large arch support and a very dense midsole.  Another way to think of this is a cast for your foot!  Dr Davis even showed the Asics Gel-Kayano 16 which was purported to “Adjust stiffness according to your time of the month” for hormonal changes!  Awesome!

We have previously covered the research findings on the potential benefits of running minimalist or completely barefoot.  But do shoes help at all?  When you enter The Running Room now a sales rep will ‘fit’ your foot type to a cushioned sole, or stability shoe.  Contrary to popular belief this is entirely unsupported in the literature.  In fact, a study took a large sample of army recruits and matched half according to their foot type and gave the entire other half stability shoes and surprisingly there were less injuries in the stability only group!  The conclusion? “Assigning shoes based on the shape of the plantar foot surface had no influence on injuries.”  In fact, there has never been a single piece of evidence that footwear in any way reduces injury! 

Other issues with modern shoes include promoting rear foot striking (which has a higher impact transient force – bad), they also increase stride length (it has been shown that injury risk is reduced when taking shorter strides despite the fact that you are taking more steps). Additionally the fact that they are soft makes you land harder (you actually land harder when you land on soft surfaces) and they also PROMOTE pronation or flat footedness at midstance – think of rolling your foot in – due to a longer lever arm. 

The piece of research that was the ‘ah-ha’ moment for Dr Davis?  A study found that simply adding even thin socks to bare feet significantly decreases postural stability compared to bare feet.  But shoes must make us more stable at least?  In truth, a recent study showed that shoes promote greater dynamic INSTABILITY with single leg landing.

Overall we have trained our feet to be lazy!  We have been putting our feet in casts at a very early age and then using these casts the rest of our lives.  This significantly decreases the strength in our feet.  When we put our feet in minimalist footwear there is improved strength, balance and agility over time as seen in a study done on the popular Nike Free 3.0′s. 

So is barefoot the be all and end all?  Not necessarily.  For forefoot strikers, it’s not all pleasant.  There are more injuries in the triceps surae (Achilles and calf).  Also, at midstance (when your foot is flat on the ground), ankle dorsiflexion (ankle flexion) is still the same for forefoot strikers as rearfoot strikers.  This means that there is more total excursion (total motion) through the ankle during gait over the same amount of time.  Also, there is greater demand on the ankle plantar flexors (your calf and achilles).  This results (in general) in more ankle injuries in forefoot strikers.  Conversely for rear foot strikers, your knee flexes more because the ankle is more rigid.  This results in more knee injuries in general.  Which is better?  I don’t have any idea…….

HOW TO TRANSITION TO BAREFOOT RUNNING

Transitioning from something you have done your entire life (wearing shoes) to something entirely new (barefoot) is difficult.  There is no literature on the best approach to transition out of shoes however here is what Dr. Davis suggests:

  • To get out of orthotics, go opposite from how you got IN them (for example 1 hour the first day, 2 the next, 4 the day after that etcetc). 
  • Second, begin walking barefoot or in minimal footwear (up to 30 minutes briskly).  This will increase your proprioception and sensory input and increase your foot strength.  You will likely have heel pain during this phase, and hence the slow work up.
  • Finally start running: Dr Davis prefers a ‘cold turkey’ approach with progression: ie run 9 minutes, walk 1 and increase this as required.
  • During this entire time, you should be performing foot strengthening and arch height exercises to build intrinsic foot musculature – ask a qualified therapist like those at The Proactive Athlete for help in this regard. 
  • For a barefoot transition program Dr. Davis promotes a program that was originally designed to re-integrate people to running following stress fractures.
  • Pain: It is a GIFT to humans to say ‘stop’.  It is mindblowing that we push ourselves through a built in ‘intrinsic stop mechanism’.   

OTHER COOL ITEMS FROM THE COURSE THAT ARE OF INTEREST

Gait retraining is a key, not just for injury prevention, but in the treatment of current injuries.  Although most therapists prescribe exercises in an attempt to change a patients gait pattern (and I am guilty of this also), Dr Davis recently showed that exercises alone DO NOT ALTER GAIT MECHANICS.  All they do is strengthen the muscles you prescribed exercises for.  You need to include gait retraining to affect gait.  Although there are extremely expensive marker based systems to give runners input on their gait patterns, it has been shown that utilizing nothing more than a treadmill, a mirror, and a qualified therapist will have the same impact as high tech equipment.  In fact, treadmills are more useful than you would suppose.  Although research shows that while on a treadmill you run with a slightly shorter slide, and you land slightly more flat footed (less dorsiflexion), otherwise there are very few differences….in fact it is almost exactly the same.  Vertical ground reaction forces are the same, as are AP forces (your braking force).  Therefore it is an extremely useful tool for gait evaluation.  

People get fixated on arch height.  In truth, arch heights DO influence lower extremity mechanics and therefore injury risk:  Runners with high arch heights have a higher vertical load rate meaning they land harder (think of a ‘plodding’ runner with a stiff gait).  These folks trend to lateral (outside) foot injuries and bony injuries while low arch heights trend to medial (inside) foot injuries and soft tissue injuries.  Interestingly, plantar fascia pathology is seen in both arch heights.  The thought process being that high arches place the fascia in a constant state of tension while low heights cause a bottoming out effect, again stretching the fascia.  Both states cause a repetitive strain on the fascia…..so really either way you are screwed. 

CONCLUSION

There really is no conclusion……yet.  The barefoot running literature is now fairly robust (at least more so then what we typically rely upon as manual therapists).  It is a fertile ground for even more research and the landscape is broad.  Dr. Davis hinted at a few pieces that are underway at Harvard including a large prospective trial on barefoot running versus shod (wearing shoes) running on injuries.  I also came across this Canadian study that is ongoing (funded by Nike) chaired by Dr. Jack Taunton, a Sports Medicine Physician who was the past Chief Medical Officer of the Vancouver Olympics.  So where do we go from here?  I’m going to buy a pair of minimalist shoes and attempt to transition into them over the next few months……keep tuned for how that goes.

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The Functional Movement….

October 28th, 2011

                Functional movement assessments, functional testing, functional rehabilitation…what is behind this whole functional movement within manual medicine?  The godfather of functional assessment and rehabilitation is Vladimir Janda who stated that “functional pathology of the motor system, not structural pathology, is the key to musculoskeletal rehabilitation”.  Although the foundations laid decades ago by Janda have been carried on by many eastern European therapists, in North America we primarily focus on the structural/anatomical/biomechanical perspective.  One champion of the functional renaissance in North America is Dr. Craig Liebenson.  Dr. Liebenson integrates the work of many fitness and rehabilitation experts of the past (Janda, Lewit) and present (Stu McGill, Gray Cook) focusing on the clinical art of assessing and addressing movement dysfunction.  I thought I would share some thoughts from a course I took this weekend with Dr. Craig Liebenson.   

“You can’t take a picture of a computer and learn how it functions.” 

                An MRI of our anatomy says little about the software that controls that anatomy.  While the analogy might not be perfect, pain is a physiological and psychological phenomenon that is often far more complex than a tear in tissue or visible tissue pathology.  We now know that the false positive rates for disc pathology (bulge, protrusion, extrusion etc) in middle-aged individuals is greater than 50%.  A recent Stanford study demonstrated that in 33 pain free elite athletes (division 1A volleyball players, swimmers and gymnasts) ALL demonstrated imaging abnormalities in either the shoulder (volleyball players and swimmers) or wrist (gymnasts).1  Many of the lesions found are associated with abnormalities for which medical treatment and sometimes surgery are advised.  Although a great imaging modality, the pendulum has swung too far; our dependency on MRI to determine a diagnosis to then dictate care is costly, inefficient and unhelpful for many patients.  Dr.Liebenson (among others) argue that musculoskeletal assessment and intervention should focus on testing for dysfunctions of mobility and stability.  Gray Cook’s FMS (link) may be helpful in this type of assessment but a skilled clinician can use a diverse arsenal of movement based assessments (“every movement is a test”).

“If you want your body to feel better, you have to feel your body move better.”

                Improving motor control and functional capacity requires education and commitment to movement quality (technique).  Awareness is particularly brought to activate those muscles that are prone to inactivity (inhibition), for example the glutes, deep neck flexors or intrinsic foot muscles.  Reactionary exercises (future blog) are helpful for patients to show and experience rather than reliance on verbal explanation.

“There are no generically good or bad exercises.”

                Exercises are only good or bad in the context of the individual patient, their injury history, their current ability/limitations and their goals.  Concepts of muscle activation, postural control, tissue sensitivity and tissue capacity necessary for sport are all issues that need to be considered in the optimal design of a rehabilitation program.  For example, patients with low back pain are often prescribed exercises such as ‘the bird-dog’ and ‘stir the pot’ (seen below) for spinal stability, however without considering a patient’s individual factors, even these relatively spine sparing exercises may not be appropriate.

“Core: set it, lock it and throw away the key.”

                Core stability is a trendy term that has exploded in many domains of health and performance.  It has been pumped as a panacea for many conditions and more often used to sell care or fitness.  But successful integration of core stability in sport or activity is extremely challenging.  Training proper plank or pillar form is more than just a couple handouts of McGill’s Big 3 (link), it is an ongoing assess-correct-reassess process progressing towards setting and controlling the trunk, shoulder blades and the neck to enable power generation from the hips or shoulders.  See Usain Bolt and his competitors set the pillar of their trunk, generating power from the more mobile hips and shoulders to drive forward.  And Roger Federer, under a highly rotational challenge, aligns his hips and shoulders in the same plane using mobility in his hips knees and ankles to lunge into position prior to striking a forehand.  Athletes will inevitably be forced to their maximum threshold of spinal mobility in many situations of the game.  But those athletes who have the most efficient motor control over muscles of the abdominal wall (through a highly controlled core training process) will have greater protection against spinal injury.

In North America manual therapists still largely rely on diagnoses such as a Grade 2 MCL sprain or L4/5 disc herniation to establish care: however opposition is mounting to de-emphasize this structural/anatomical/biomechanical approach to a more process oriented functional approach.  Watch for a blog in the future on a process oriented approach for patient care.

1. Fredericson M, Ho C, Waite B, Jennings F, Peterson J, Williams C and Matheson GO.  Magnetic resonance imaging abnormalities in the shoulder and wrist joints or asymptomatic elite athletes.  PM&R.  2009;1(2):107-16.

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Functional Movement Screen

October 15th, 2011

In sports medicine and rehabilitation there always seems to be terminology, courses, and techniques that are in fashion (and just as often out of fashion).  An assessment and therapeutic method that is receiving a great deal of attention is the functional movement system (FMS).  The FMS was first described in a 2 part series by Gray Cook in 2006.  Since then there has been an explosion in the number of strength coaches and health care practitioners that utilize the FMS on athletes at all levels.  The FMS is a trademarked system with standard FMS courses and the Selective Functional Movement Assessment (SFMA), a  4 part course created for health care practitioners.  Below we will look at exactly what the FMS is, how it may be applied and as always…..what does the research say?

What is the FMS?

“Put simply, the FMS is a ranking and grading system that documents movement patterns that are key to normal function.  By screening these patterns, the FMS readily identifies functional limitations and asymmetries.  These are issues that can reduce the effects of functional training and physical conditioning and distort body awareness.”

The above quote is taken directly from the FMS website.  After my reading (see references below) to try and decipher some literature, here is my attempt at summarizing the FMS approach in a few coherent thoughts:

  • There is a movement in sports rehabilitation away from an isolated assessment method toward an integrated functional approach….but what exactly is a “functional approach?”
  • The FMS evaluates movements that occur in a variety of athletic endeavours
  • The typical pre-participation exam is strictly for exclusion purposes, never to evaluate the basic movements necessary for sport.  Traditional testing is comparative to normative data but doesn’t assess for function (the often used example is that of performing 100 crunches which is above average, however the form may be horrible).
  • The FMS tests were created to address ‘kinetic linking systems’ (it thinks of the body as a linked system of segments) so analyzes whole body movement patterns and looks for ‘breaks in the pattern’ or compensatory movements in the kinetic link.
  • The movements challenge the body in a proximal to distal sequence as these are seen as more efficient.  The FMS argues that these patterns were formed during growth and development.
  • The FMS is NOT MEANT to be used for diagnosis.  Instead it brings to light limitations and asymmetries in movement patterns. 

How is the FMS applied?

The FMS is made of 7 fundamental movement patterns (and 3 ‘clearing screens’) that evaluate 2 main aspects: Mobility and Stability.  The tests work, as explained by Cook, by placing the body in extreme positions where weaknesses and imbalances become apparent.  Without appropriate mobility and stability, compensatory patterns are used instead of efficient ones which in the long term reinforces poor mechanics and raises the potential for injury.  The 7 movements are scored from 0-3 in a simplistic method for a total score of 21.  Some argue the scoring is too simplistic, however the ‘thinking part’ of the FMS is the interpretation of the tests and the corrective prescription.

The 7 movements are: deep squat, the hurdle step, the in-line lunge, the shoulder mobility test, the active straight leg raise, the trunk stability push up, and the rotary stability test.

What does the research say?

While many techniques and evaluative systems alienate themselves from academic critique, the FMS deserves praise as I found at least 10 scholarly articles on the topic.  While not all are on the upper echelon of quality (to say the least), there are a few decent papers out there. 

Reliability

Minick et al looked at interrater reliability (how often raters agree with each other) utilizing 4 independent raters: 2 novice and 2 expert (expert helped develop the tool and novice took the standard course and used the tool under 12 months).  On a sample of 40 college students the novice and experts agreed 89.6 and 86.7% percent of the time and the novice and expert groups agreed on 14/17 tests (excellent!).  A second study looked at reliability between 2 testers on just 8 subjects and had a score of 0.976 (again excellent).  Like any studies there were limitations (primarily that it was video analysis instead of in-person) however it’s a step in the right direction and the reliability of the FMS appears quite good. 

Identifying Injury Risk

There have been 3 main papers on the use of FMS to identify injury risk.  The first by Chorba et al in 2010 looked at female collegiate athletes (soccer, volleyball and basketball) at an NCAA division 2 school.  Players that sustained an injury in season had scored 13.9 out of 21 on average while those without an injury scored 14.7.  Overall, nearly 69% of those scoring under 14 sustained an injury in season.  Sounds great, however as a diagnostic tool it was not so hot based on sensitivity and specificity (but remember….it’s not supposed to be a diagnostic tool!). 

A second study by Kiesel et al on professional football players had a strength coach (CSCS) perform the FMS on 46 players prior to the 2005 season.  With a fairly strict definition of injury, the authors retrospectively looked at FMS scores and injuries sustained in that season.  Overall, with the key finding was a cutoff of 14.  If players scord under 14 on the FMS they had an 11 fold increase in injury risk!  This study again had poor sensitivity numbers (but a high specificity).

A final study on 433 firefighters found that lower FMS scores were associated with increases in age, rank and tenure (fairly intuitive findings).

Overall, the cut-off point in the literature (which is very little right now), seems to be 14.  Score under this and there is a higher chance for injury. 

FMS and performance

A recent 2011 study looked at the relationship between core stability (utilizing the side plank, extensor endurance and flexor endurance tests as outlined by McGill), the FMS and performance on measures such as vertical jump, single leg squat for endurance, T-Run agility test and overhead backwards medicine ball throw on 28 subjects.  It concluded that because the FMS is designed to evaluate the quality of human movement during dynamic movements that may cause injury, it does not correlate greatly with core tests or measures of performance.  The take home message was one of specificity of training meaning the FMS tests the FMS, and isn’t a measure to determine one’s performance.

Overall the FMS is growing in popularity.  Though it’s not terribly supported yet in the literature as an evaluation or intervention method, intuitively it seems to make some sense.  The most common complaint is the simplistic nature of its assessment approach, however it’s a qualitative assessment……it’s meant to be simplistic on its surface level!  It’s certainly something I’ll have my eye on as more research comes to light and we do utilize functional movements at The Proactive Athlete in the evaluation of athletes.  If you’re interested in more information, don’t hesitate to contact us.  (the references on this blog were many….below are the main 3 as I see them but if you want a list of them all, email me at drkissel@theproactiveathlete.ca)

Cook G, Burton L, Hoogenboom B.  Pre-Participation screening: The use of fundamental movements as an assessment of function – part 1.  North American Journal of Sports Physical Therapy 2006;1(2):62-73

Cook G, Burton L, Hoogenboom B.  Pre-Participation screening: The use of fundamental movements as an assessment of function – part 2.  North American Journal of Sports Physical Therapy 2006;1(3):132-139

Kiesel K, Plisky PJ, and Voight ML.  Can Serious Injury in professional football be predicted by a preseason functional movement screen?.  North American Journal of Sports Physical Therapy 2007;2(3): 147-158

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Orthotics: relief for Anterior Knee Pain

October 13th, 2011

 As many as 1 in 4 active people experience debilitating anterior knee pain.  Orthotics are often prescribed for this population, but which patients respond best to this care and what results should those patients expect?

 An Australian research group recently determined a clinical prediction rule (basically the key factors) for a positive outcome with orthotics in those with longstanding anterior knee pain: 25 years or older, 165cm or less in height, worst pain described as mild-moderate (<53mm on VAS) and above average midfoot mobility (>11mm measered as midfoot width change from non-weight bearing to weight bearing). Individuals with at least 3 of these factors were found to have a much greater success rate.

 

In a subsequent study these same factors were used in a randomized controlled trial to determine the efficacy of orthotics over a wait-and-see policy (a common medical approach). 15 of the 20 patients prescribed a orthotic noted that they were either completely recovered, much improved or improved (on the Global improvement scale) over the 6 week trial period. Only 4 out of 20 in the wait and see group reported the same results. Although some of the secondary measures did not seem to be as dramatic, the authors claim that the 6 week trial period may have been too short to detect changes of pain severity.

 

It appears as though using the above clinical prediction rule, for age, height, pain intensity and midfoot mobility for anterior knee pain can determine potential candidates that will respond well to orthotics.  To measure midfoot mobility a standard digital caliper can be used clinically (as seen below).  If the difference between non-weight bearing and weight bearing is greater than 11mm then you have more than average midfoot mobility.

 As an aside: the same authors previously compared physiotherapy (including patellar mobilisations, patellar taping, and a combination of hip and knee stretches and strengthening exercises), physiotherapy plus orthotics or orthotics alone over a one year period for those with patellofemoral pain syndrome.  In this study all groups demonstrated clinically meanful change over the study period, however there was not a significant difference between the groups in outcomes.  The practitioners at The Proactive Athlete would still recommend a combined program involving manual care, strengthening and stretching exercises and custom orthotics however a case can be made (for those who satisfy the above clinical prediction rule) for simplifying the management with custom orthotics only.

Contact us to have your midfoot mobility measured and/or determine whether you might be a good candidate for custom orthotics.

 

 

 

 

Mills K, Blanch P, Dev P, Martin M and Vicenzino B. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility. Br J Sports Med 2011 Published Online First 18 September 2011.?

 

Vicenzino B, Collins N, Cleland J, et al. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. Br J Sports Med 2010;44:862–6.

 

Collins N, Crossley K, Beller E, Darnell R, McPoil T and Vicenzino B. Foot orthoses and phsiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med 2009;43:169-171.

 

McPoil TG, Vicenzino B, Cornwall MW, et al. Reliability and normative values for the foot mobility magnitude: a composite measure of vertical and medial-lateral mobility of the midfoot. J Foot Ankle Res 2009;2:6.

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