Sean Docking – Tendinopathy.

 

Sean Docking is a physiotherapist and research academic at Monash University in Melbourne. Both his clinical and research work focuses on lower limb tendinopathy, particularly patellar and Achilles. Recently he gave a presentation that I was lucky enough to see and wrote the following summary.

•  What is tendinopathy?

It affects many tendons and many different types of people ranging from   inactive individuals to elite athletes. Tendon pain is focal localized pain – the pains doesn’t move and there is no referred pain as such. Pain is load dependent – as load increases then generally the pain should increase also. Pain usually is worse the day after loading and something to look out for as a marker of tendon pain. Tendinopathy is NOT tendinitis – as there are NO inflammatory cells – this is important to know as it will govern the type of treatment.

The Continuum of tendon pathology (outlined by Cook & Purdam) tried to put the pathological changes in a sequence to ascertain what was going on with this injury type. This process was then further summarised by Sean: Within the tendon you start off with brown collagen fibres with very little water between tendon fibres. With the onset of this injury type we get an increase in tenocytes and an influx of inbound water into the tendon which causes the tendon to thicken and partially separate. Then as this continues we start to get disruption in collagen fibres and then blood vessels grow into the spaces where separation has occurred.  Key message here – This is a cell driven pathology as the tenocyte has such control of the extracellular matrix that it is driving these pathological changes – Sean calls it “ an angry cell!”

Sean then went on to describe the sequential stages a tendon goes through when injured and how they can be imaged.  Reactive tendinopathy is where very little change in the fibrillar structure. If we excessively overload our tendon it will get to this initial stage. We can easily transition back to a normal tendon by calming down the cells and removing the bound fluid within the tendon.  It is a recoverable tendon if you can intervene early enough.  Next you can shift into Tendon disrepair and if you continually overload a tendon in the reactive stage then this is how your tendon reacts .   It is still possible to repair if the disruption isn’t too excessive.  Finally you may reach Degenerative tendinopathy where this is very difficult to go back to being pain pain free or back to a normal tendon.  The main aim in this stage is to build up the tendon as much as possible and be able to deal with the loads that are given with limited pain.

• How do we image Tendons?

– Ultrasound or MRI is commonly used by practitioners to identify tendinopathy. MRI is most useful as it gives a 3D image of the structure and surrounding aspects of that tendon structure.

– The Issues with these modalities is that ultrasound is highly user dependent as the transducer tilt can effect results and relies on subjective interpretation. This is also the case for MRIs but to a lesser extent. This allows for little ability to monitor change over time and details can be missed.

-Ultrasound Tissue Characterisation (UTC) is a technique that reliably quantifies the structure of the tendon using a transducer over the length of the tendon to produce 3D image of the area. This allows effective comparisons between changes in the tendon using repeat scans. This technique is also effective in detecting mixed pathology of a tendon. Mixed Pathology most commonly presents itself as degenerative tissue with normal tendon surrounding it. If pushed to the limit then this can change in that the normal tendon tissue will then move into a reactive tendon phase. This was previously not detectable until the introduction of UTC imaging.

– Why else is this important though? By identifying the structure of the tendon it is helpful in detecting injury or injury risk. For example, you can present pathology that is not painful. Common examples of this occur in the patella tendon. Having a structure abnormality though does increase your risk of developing an issue in the future. Therefore by highlighting these structural differences with the use of techniques, such as UTC, practitioners can implement techniques to mitigate further degeneration of the injury.

• Associated Risk factors?

-Age plays a factor with the Achilles as the older you are the more likely you are to be at risk of injuring this tendon. For the Patella tendon this is primarily seen from 16yrs to late 20s.

-Tendonopathy is most prevalent in Males: Estrogen is protective for our tendons so that is why we see less in females. Therefore, if a female in her early 20s has been diagnosed with patella tendonopathy then you should question that diagnosis. This only occurs when tendon is greatly overloaded.

-Genetic predisposition: The COL5A1 gene is associated with tendon stiffness and generally helps you to be a better athlete but makes you more susceptible to tendonopathy.

-Adiposity: Waist circumference over 83cm increases the risk of having tendonopathy.

 

Application to the High Performance Environment:

-Overall, load is what causes tendons the most stress and tests the tendons capacity. You can change your tendon capacity based on the loads you frequently expose it to (E.g. Low Vs Medium Vs High tendon loads). The higher the loads occur the faster the tendon is working which involves movements like plyometric and changes of directions at speed.

-Considering Preseason loads: many injuries occur at this stage of training due to continually consistent high loads with limited recovery. So if we know this why not modulate the loads using periodization? Ofcourse there comes a time for functional overreaching – however appropriate recovery sessions and days off should be implemented during this part of the season.

–Key message: if we get the load right then the tendon structure will improve – However there is a tipping point and we need to find this early on and identify appropriate actions to mitigate risk.

-It is important to gradually increase loads as major changes are not good for tendons. Also, if you completely drop the load for too long then you will lose tendon capacity. Practioners may sometimes want to rest the injury due to pain but this is an adverse practice. The tendon needs constant stimulus – endevour to keep load on the injury as the tendons capacity will closely mirror the loads that it is exposed to.

Ben Serpell – ACL Injury

Ben Serpell is currently the Athletic performance coach at the ACT Brumbies Rugby Union club. He works closely with the team physios, coaches and medical department to make sure each athlete is training optimally. Bens previous work includes weights & rehab for Port Adelaide AFL club and before that was in England working in Rugby Union where he completed a Bachelor of Occupational therapy.

Ben’s research at ANU is looking at ACL injury and the role of pre-tension and pre-activation – the dynamic muscle stiffness and the relation to ACL injury. This stops the ligaments being stressed during ground reaction forces. The method of training for this is plyometric training in order to increase performance and potentially protect against injury. Ben recently presented his thoughts and experience on ACL injury as part of the Master of High Performance Sport degree. His presentation is summarized below along with some reflection from myself.

Key Points:

Ben regularly sees common mechanisms of ACL injury. A high proportion come from snow sports as the foot is locked or fixed in ski boots for example. Roughly 70% of injuries occur from non-contact mechanisms for field and court sports. Over last 4 years though he has seen 6 out of 9 ACL’s from contact so research can give one indication but it may be something completely out of our control. Typically there will be a low flexion angle, rotation about the knee and a valgus movement. You will see an almost straight legged foot plant from outside the centre of mass of the body. With contact injuries you will see the same things at the knee joint in the kinematics of the injury. This is the 2^nd most severe injury in sport after hamstring injury in regards to lost game time and cost to rehab, surgery and physio.

A couple of non-contact movements leading to injury were then described by Ben. A Power cut – An example of such a movement was explained wherein a left change of direction is made off the right leg. A Speed cut – is where the left change of direction comes off the left leg. This comes back to improving cutting techniques and knee flexion angle.  By being better able to absorb load and then reproduce that force during dynamic cutting movements will reduce injury risk in his opinion.

Ben went on to list other known contributors to ACL injury: females, a fixed foot position, skill level and the genetics of the knee. In a roundabout way this justifies much of his interest in this injury as even though these contributors have been known for many years injury occurrence has not improved. Therefore you would think it is worth more research to further understand the injury and to decrease the risk of injury.

How does Ben identify risks within his athletes? Firstly, looking for a weak hip or core that is causing the foot to be planted out wide from the body. Then poor hip control, especially when fatigued, you can unnecessarily load up the glutes, then the hamstrings and then the hips so you can no longer properly unload the knee. The athlete needs to get to the point where they can plant their foot whilst having synchronisiation of your shoulders and hips to control the foot plant.

What can you do once risks are identified? The training of leg stiffness through plyometric exercises is a good start. Begin training pre-tension through running on the sand or uneven surfaces. Hip control is important as the legs will go all over the place if poor control in hips – try practicing sticking landings to improve this. Foot plant needs to be right below your centre of mass – if you can teach someone to run well in a straight line first then you can translate that into sideways movements by using the shoulders to change direction. Instruct the athlete to concentrate on dropping the shoulder to steer the rest of the kinetic chain and the rest of the body will naturally follow.

Ben stressed that it is important to remember during the rehab process that no two injuries are the same.  Therefore, we must customise the program for each individual.  Also, sports are different too – For example, Rugby league players will be back quicker as they spend more time strengthening the lower extremity in normal circumstances compared to AFL (usually out to 12 months) or soccer but there is no general rule of thumb.  Also the type of surgery undertaken will also govern the type of rehab. For example, at the 6-10 week mark the new graft is at the most vulnerable state and you really don’t want to stress it too much with high impact forces during this period. Preferably Ben would only introduce gentle strengthening work during this time of rehab.

After Full rehab is there anything that he looks for? Hip, hamstring and core weakness in particular – especially if a hamstring graft has been used for the surgery there will be weakness in the hamstring and at a higher risk of a tear. It is a good idea to test hamstring strength during this period along with integrating plenty of gliding movements that progressively stretch the hamstrings in the first 6 weeks. Continue working hamstring strength and function throughout to minimise injury in this area and by 12 weeks you ideally want full extension of the knee.

At the return to play stage is there anything to look out for? Yes, the hamstrings again (stretching / strength) and also consider the adductors as they can become sore and overworked by compensating for a lack of hamstring strength. ITB lengthening and stretching to reduce fat pad impingement whilst limiting asymmetry around all these areas. This is important during the first 12 months as once you run asymmetrically you increase the risk of injury recurrence in all areas.

Any advice for those getting into High Performance Sport? Don’t expect $$$ but keep knocking on doors and opportunities will come. Ask plenty of questions as you can learn from anyone you meet. Be prepared to move and be away from home as often the best opportunities aren’t always in your own backyard. If you really want to do it you will get a chance so just grab it and run with it by trying to learn as much as possible. Spend time with different types of coaches that work in the sport to get the whole picture around the sport. Having an attitude where you “Never want to stop learning” creates a great depth of understanding that can transfer across to many other areas of sport. In dealing with injuries and in closing – Understand where you would like the athlete to be by the end of the injury so that you can gauge how far they are – as every injury type will be different.

Application to High Performance Environment:

Ben touched on the effect of diet and how we as practitioners can impact their recovery early in rehab up until 12 week phase. For me, I hadn’t really factored the importance of diet into recovery from surgery as I was concentrated on his implementation of different exercises.  So for Ben to mention this made me consider it rather than just the rehab protocols themselves in returning an athlete from injury or surgery. By effecting diet you can aid in creating stiffness through the ligament during that period along with the necessary rehabilitation exercises as previously mentioned.

Ben also commented on the best graft type is in his opinion – The Hamstring or patella tendon? This would be a common question asked of you in a high performance environment so having experience with each methodology along with solid research to back up your recommendations would be important. The patella has risk of patella tendonopathy down the track whilst the hamstring graft has its drawbacks also. If it is on the same limb as the knee you are at risk of injuring your hamstring with a particularly increased risk in this in first 12 months. Ben sited no preference but either way you should be stronger in hamstring strength and function post injury compared to before the injury regardless of what graft is chosen.

Kristian Thorborg – Groin Pain

Kristian Thorborg is a Sports physiotherapist from Denmark who presented his thoughts and research on the Prevention of groin injuries in Sports.

As part of my “Performance and Injury” subject these concepts are summarized below:

Previously groin injuries were always thought to be hernias – the problem with this term is that with sports hernia is that no actual hernia exists and there is more abdominal related problems present.  Kristian highlighted that there are so many different interpretations and labels given to groin pain depending on what part of the world you are practicing. This is where confusion is created in that the injury mechanisms become difficult to define due to variety of terminologies being used.

•  Groin pain can be divided into 4 different Clinical entities:

1. Adductor related
2. Abdominal related
3. Psoas related
4. Hip related

Kristian then explained that it is difficult to diagnose groin pain but he believes they can be narrowed down to the 4 areas listed above. Referencing a study in soccer that he was involved with he outlined the % occurrence for each type with Adductor related groin pain being the most prominent (50-70%). Therefore, in working with athletes in soccer you could reasonably assume that clinical entity as a highly probable source of pain and appropriately test for it to confirm before proceeding with treatment.

Real Madrid’s Karim Benzema sits on the pitch after sustaining a groin injury during their Champions League Group D soccer match.

Kristian went on to further discuss soccer & ice hockey where both abdominal (5-20%) and adductor (50-70%) related groin pain were the most prominent types of groin injuries occurring. It was also noted that when you have an abdominal injury then it adds to injury recovery time and hence takes longer to return to play.  Specifically in Ice Hockey, muscle activity during skating stride consists of both concentric and eccentric work done by the adductors. The faster they skate the more muscle activity occurs and you increase skating speed by increasing your stride rate.  It has also been highlighted in Ice Hockey that if there is a low adduction / abduction strength ratio then this increases hip adductor strain risk up to 17x. In particular, hip adduction strength asymmetry of >25% has also been shown to be related to adductor strain on the weak side. Another study by Emery et al  in Canadian ice hockey players found that there was no increased risk in players with peak isometric adduction force. They couldn’t predict any injuries and did show as a risk for a groin strain.

• Risk Factors shown in the Literature in regards to Soccer, Ice Hockey and Rugby players are as follows:
  • Previous Injury
  • Weak adductors
  • Decreased eccentric hip adductors to abductors strength ratio
  • Groin injuries commonly occur to the adductors in the kicking leg.

Pittsburgh Penguins’ Sidney Crosby

By knowing the common risk factors then injury prevention programs should try to include the neuromuscular system which is highly plastic and can adapt very quickly when exposed to any stimuli.  An effort should be made to increase eccentric muscle strength, rate of force development and  maximal muscle strength.  Exercise intensity also needs to be included with at least 60% 1RM needed according to ACSM guideline and 80-95% of 1RM for optimal hypertrophy.

In the Applied Environment?

• A four step injury prevention cycle was outlined in the presentation which could be implemented:

1. Establishing the extent of injury – looking at both the incidence and severity.
2. Establishing the aetiology & mechanisms
3. Introduce Preventative measures
4. Assessing effectiveness by repeating Step 1.

• By measuring hip adduction you can monitor muscle strength as a risk factor and implement treatment or exercises to reduce injury.  There are 2 common ways of measuring hip adduction:

1. A Squeeze test in between the knees to measure maximum force. The problem with this test is that maximal force will be limited by the weaker leg.
2. A break test with dynometer on both the hip adductor and abductor. This is a useful test as it is unilateral in nature – testing one leg at a time for weakness.

• 

• For the Neuromscular system the use of plyometric jumping exercises is recommended. They have been shown to increase the pre-activity of adductor muscles over 6 weeks with 2 sessions per week specifically using drop jumps.
• Isometric ball squeezes on the back with both bent and straight knees to improve strength.
• Hip adduction exercises with an elastic band program have been shown to improve Eccentric strength – 30% increase in conjunction with soccer training.
• Strengthening the abdominals: Swiss ball crunch is good for prevention in relation to abdominal groin injuries.
• Monitoring: Use of the HAGOS score developed by Thorborg. Based on Questionnaire with 6 separate scores that try to capture information on groin injuries of players still playing – Athletes often don’t get noticed until they actually miss training / game. It is good practice to capture how they are feeling while they are still playing.
• In a club scenario: It is difficult to introduce new interventions so the alternative is to monitor their loads to look out for injury risks. Then implement on an individual scale and monitor how the athlete responds to stimulus.

Only the tip of the iceberg – We must realise that many athletes show signs of groin injury but continue to train and play regardless. It may take long periods of time for the injury to manifest itself and by that time it may be too late for the athlete to avoid serious ramifications – i.e. surgery. So it is important to preparing the athlete for specific and repetitive loading whilst also monitoring load and overload to best protect the groin.

Darren Burgess – Monitoring Players

Darren Burgess is the former head of sports science for the Socceroos and has worked in the English Premier League at Liverpool.  He is currently the high performance manager at Port Adelaide football club in the AFL.  In a recent presentation he offered up his thoughts on player monitoring and below are some of the key points along with my reflection on what he had to say.

• For any test that is implemented to monitor it is important to know each athletes relative scores for any test they complete. The example Darren used would be for Heart Rate Variability (HRV) and Resting HR.  How do you know where a player is at in regards to how they were a few weeks ago?  For Darren HRV is a test that gives him a good assessment of his players stress.  It can tell him that a player is stressed from training, everyday first world problems, or the onset of overtraining.  It is then his job to find the source of the stress and then get rid of it if possible.  This can be a useful tool if everything is kept constant in regards to athlete compliance and how the testing process is completed.

• Darren described visiting a number of different international and world class clubs as the – “Best experience of his life.” Seeing how everything is done in a practical environment rather than just in text books enhanced his learning and progression.  This is something I look forward to doing whilst visiting and working with other teams.  Every player is different – When he was at Liverpool Football Club prehab was very individualized – not every player can be put through the same program, you have to cater to their needs based on history of injury and even cultural background.  What have they been doing as exercises throughout their lives to get them to this point? Darren commented that he learnt a lot from Brazilian and Portuguese physios who did less common or well known techniques that were effective.  Sometimes it’s OK to think outside the box and consider others practices and opinions to build on your own.

• Injury Prediction through Monitoring – Having a periodised plan that you then alter your monitoring protocols to in the lead up to games is important. The example Darren used was a plan used by most EPL clubs starting 6 days prior to a game.  This plan is strictly regimented and something that teams stick to 100%.  The overall message was to adhere to this periodised approach to minimize injury and maximize performance.

• When communicating information to players and coaches it is important not to overload them. Darren spoke of the Training Reports he produces and how he caters to his audience.  For example, On reports for players and coaches he would only include information on Total Distance (volume measure) / High Intensity Distance (Intensity measure)/ Heart Rate Load (Internal load measure – what did it cost the player?). The GPS and Heart rate data in this case would act as a fitness assessment to gauge where a player was at for that session. Eg: low distance / low intensity / then high heart rate load then that is an indicator that something is wrong.

• A key part of the monitoring of players is that as their training loads increases it is important to pick up on any markers of stress that they exhibit. Once these markers have been identified the decision must be made to modify the individuals program.  An example Darren used was the Isometric Mid-Thigh pull: which is a test of strength and an assessment to see if players are responding to programs.  This leads to a better resistance to injury but also can indicate when players are suffering from fatigue.

• I enjoyed listening to Darren speak about the Fitness Vs. Fatigue Model: He outlined a process to warn you of injury risk for an athlete. First by identifying outliers and risk factors based on each individuals performances and team performances.  Then using neural networks in choosing the variables that you think contribute to injury risk and identifying points in your season where players get injured most. You can look back at the combination or interaction of risk factors and see what lead to the injury.  Finally, set up an alert to let you know if the same combination of risk factors pop up again in the future you can react to reduce injury risk.  I agree with this approach as there are so many examples of when practitioners are reactive to injury rather than being proactive like this to reduce injury occurrence.

• Darren finished up with some advice for those who want to work in High performance sport: “You have to go and get as many experiences working with teams as much as you can – anywhere!” What he looks for when recruiting people to work with him? He prefers masters or post grad experience and  experience in front of players at any level in the applied environment.

Application to the High Performance Environment:

Darren made a number of points that I would like to expand upon based on my own personal experiences….

• Athlete compliance for testing is important and the need to keep things constant – How do we do this? You will always get the one or two players that you will have to chase every session to fill out their data, do a test, or fill out a questionnaire.  The key I think is educating your athletes on why their input is important and that any unreliable or non-entry of data blurs the picture they are portraying to you of their current status.

• One size doesn’t fit all – Treating athletes as individuals was a message Darren repeated throughout his talk. Just because one exercise or treatment works well for one athlete doesn’t mean it will for another.  This also leads into keeping your athletes guessing when it comes to things like prehab – try to stimulate them by mixing it up so things don’t become monotonous.

• Communicating data: The info you have available Vs. what they need to hear or see? By catering your data to an audience they will be much more receptive to your message. Just because you have every variable at your fingertips doesn’t mean coaches want to know about – sure, collect it for further research that is going on behind the scenes but only present what they absolutely need to know about.  And if they would like to see more – then for sure let them have it!

• Identifying tests that you can rely on through known markers of stress and fatigue. Darren has a number of “go to” tests that he is comfortable with using and has had many years’ experience with such as the mid-thigh pull and HRV testing.  I’ve noticed with many of the practitioners I have been involved with that they are similar in this sense.  Being able to track a player’s progress and knowing the sensitivity / reliability of your tests inevitably leads to the basis of how you get to know your athletes inside and out.

• He also mentioned EPL clubs implementing more aggressive rehab on injuries and getting players back on the pitch quicker with similar re-injury occurrence to that of Australian sporting clubs. So why don’t we adopt the same approach so that players miss less games if injury occurrence has no difference? How do we shift in this direction of aggressive practice? The answer to that is that we haven’t really needed to…yet –  we don’t have the same amount of games and therefore as limited time constraints between games compared to that of EPL clubs.  Although an argument could be raised to the contrary with more A-League clubs, such as Western Sydney, qualifying and going deep into the Asians Champions League.  We may see a shift towards this type of practice in Australia soon due to the increased amount of matches completed by these clubs.