Category: Blog

The broader impact of an ACL injury – Dr Andrew Jowett, Director of Olympic Park Sports Medicine Centre, Melbourne, Australia.

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Speaking at the Return to Play Conference 2014 in Melbourne, Dr Jowett revealed that ACL injuries do not only affect professional sports stars, they also impact the community level athlete.
This leads to broader impacts on employment and the ability to work in a physical environment and go well beyond the cost of surgery and rehabilitation.
To help study the prevention of ACL injuries and rehabilitation, there is a requirement to understand how often they occur, and not just at the elite level either where there is a lot of data available.
For example, ACL injuries are 4-6 times more common for Australian international women footballers compared to their male counterparts, stats that correlate with data at an international level however according to Dr Jowett there is no data as to what happens on the levels below.
The gaps exist where people do not get ACL injuries treated, or they are simply not recorded.
In general, there appears to be a change in the modern lifestyle, there is less unstructured play. Kids nowadays don’t really climb, they play and train to structured sports programmes.
Physical Education in the school system should be more about unstructured movement rather than competitive sports.
A change in direction is needed at an administration and programme level. A register of injuries at all levels would help the collection of data while a prevention programme at a younger level would help stem the number of ACL injuries.

The role of functional movement in ACL injury prevention with Mike Snelling, Physiotherapist at Geelong Football Club Australia.

Posted on | by Mark Brady | Leave a Comment on The role of functional movement in ACL injury prevention with Mike Snelling, Physiotherapist at Geelong Football Club Australia.

Young athletes and amateur sportspeople are not training the same way as they did 30 years ago and as a result kids functional movement, actions based on real-life situational biomechanics, are poor, leading to more ACL injuries.

Teaching and coaching proper talents is key to this. Snelling believes that coaches and trainers have moved away from raw coaching and need to get back to basics.  It is about addressing certain areas and learning how people learn to move.

Some people use vision, while others use feeling. Depending on the situation coaches can help kids and athletes learn through visual feedback or a more hands-on approach.

Modern technology can play its part too. These days almost everyone has access to video, whether is it through smart-phones, iPads or other devices. These can be used to tape amateur and sub-elite sportspeople and allow feedback to be given very quickly.

As well as focusing on prevention, autogenic muscle inhibition, where the receptors in the knee have been damaged, is another key component in the battle against ACL injuries. This inhibition causes a change in the pathway back to the brain leading to a quadriceps weakness. This “weakness” can be present in the knee for up to 2/3 or 4 years while others often never get it back.

Voluntary exercise can help in this instance however neuromuscular exercises can also aid with the recovery to make sure that when the sportsperson is ready to return to the field of play their strength is back.

Research is key to the prevention of ACL injuries. For instance, studies have shown that dancers and ice skater have low incidents of ACL injuries. This is due to a lack of unanticipated movements, everything is pre-planned and choreographed.

However, in the various codes of football, there are a lot of unanticipated movements. The only way you can protect and prevent is by exposing the player to as many of those movements as possible and that feeds into the situation where for an unanticipated they have the right foot placement to minimise injury.

enda king head of performance rehabilitation ssc

Enda King, Head of Performance Rehabilitation at SSC, discusses the Components of ACL Rehabilitation.

Posted on | by Mark Brady | Leave a Comment on Enda King, Head of Performance Rehabilitation at SSC, discusses the Components of ACL Rehabilitation.
Enda has responsibility for looking after the ACL and GROIN programmes as well as the residential athletes that stay at the clinic. Currently finishing his PHD in Biomechanics in ACL reconstruction, he reveals that when his team analyse an athlete, they do so by breaking them down in to their component parts.

Anatomy, posture, static vector alignment, motor patterns and motor neuron control all play a part in determining the rehabilitation, while on top of that the team also look at the strength, power and the rate of force development, a secondary measure for return-to-sport decisions after anterior cruciate ligament reconstruction.

All these methodologies are combined to develop a multi-directional and planar activity is driven sport-specific programme.  Using 3D biomechanical analytics, the team not only assess the kinetics around each joint but also how the joints interact with each other.

Starting with single plan movement patterns, hoping and landing, before progressing those in terms of the depth of the jump and the power of the landing.

Currently, there are huge overlaps in prevention, rehabilitation and performance enhancement. The prevention and rehabilitation process, which involves an analysis of the athlete’s functional movement, are designed to help the joints interact allowing them to progress from the gym setting to the field of play.

The performance enhancement is aimed at not only restoring them to optimal biomechanical performance ensuring that their rehabilitation and prevention measures include the ability to move at high speed, take high challenges and manage multi-directional movements. It’s about re-educating those movement patterns before letting the athlete back to play

While the technological advancements ensure that prevention and rehabilitation have evolved, there is a no-shoes fits all approach to their science.

According to King, initial data gathered from athletes shows variability no degree of predictability from the time of surgery to a return to action further reinforcing the belief timeline lead progression through ACL rehabilitation is flawed and the need for individual programmes for athletes.

ciaran cosgrave sports and exercise medicine consultant

Patellar Tendinopathy by Dr Ciaran Cosgrave

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Knee Surgery SantryPatellar tendinopathy is a condition we see commonly in clinic and can cause athletes from many sports a lot of discomfort and frustration. The Patellar tendon runs from the patella (kneecap) to the tibia (shin) and transmits the force from the quadriceps muscle to the lower leg to allow you to straighten your leg against resistance.

Tendinopathy arises when a tendon is repeatedly loaded with inadequate rest and recovery between loading episodes. This leads to disorganisation of tendon cells and an increase in tendon fluid, blood vessels and nerves. Activities such as landing from a jump and decelerating put increased force through the patellar tendon which is why patellar tendinopathy is more common in sports such as football, basketball and volleyball.

Athletes with patellar tendinopathy usually describe pain in the front of the knee during and after activity. They can often pinpoint the tender area just under the patella. Initially, symptoms are mild and the athlete will often try to play on for several weeks or months until they seek medical attention.

The treatment for patellar tendinopathy requires a multi-faceted approach.

  1. Reduce the load – This is a load issue so you must reduce the daily load on the tendon. This can be done by reducing the frequency, duration and intensity of training and competition. Depending on the time of the season it may be necessary for you to continue playing, but you must realise that this reduces the chance of a successful outcome and will increase the time to full recovery.
  1. Address the biomechanics – The load through the tendon can also be reduced by addressing your biomechanics (the way you move). Many of the patients we see with patellar tendinopathy have a very quadriceps-dominant running and squatting pattern which puts a lot of unnecessary force through the patellar tendon. Changing this pattern to a more glute-dominant movement, focussing on single-leg control exercises and strengthening your posterior chain will help spread the load more globally, significantly off-load the patellar tendon, improve recovery and prevent a recurrence.
  1. Strengthen the tendon – Tendons respond in a positive manner to controlled load with appropriate recovery. All patellar tendon treatment plans should include a programme of isometric and eccentric tendon loading through exercises such as box-squats. This gradually progressive controlled loading stimulates the tendon to repair and heal.
  1. Medical therapies – There are also a few medical therapies that have proven effective in speeding up recovery from patellar tendinopathy. After the clinical assessment, we will often arrange an MRI scan to confirm the suspected diagnosis and also to assess the condition of the tendon.

PRP injection – When a tear is present in the patellar tendon we recommend a Platelet Rich Plasma (PRP) injection. Platelets are the cells in your blood that contain the growth factors and are therefore involved in the healing of all tissue. For a PRP injection, we take a 10ml sample of blood from a vein in your arm, spin it in a centrifuge to separate the cells and isolate the platelets. Approximately 3mls of Platelet Rich Plasma is injected into and around the tear within the patellar tendon. The addition of these growth factors promotes tendon healing and enhances recovery.

ESWT – If the MRI shows patellar tendinopathy but no tear in the tendon we recommend Extracorporeal Shockwave Therapy (ESWT). ESWT transmits shockwaves into the injured tendon which stimulates the release of growth factors leading to increased tendon healing. It also breaks down any calcification which has developed in the tendon.

  1. Surgery – Most surgeons would agree that surgery should only be considered as a last resort treatment for patellar tendinopathy. The vast majority of cases can be successfully treated by addressing the points outlined above and only a very small percentage of our patients require surgery.
Important points to consider:
  • The changes in the tendon seen in patellar tendinopathy have been developing long before you felt symptoms – possibly even months before. It, therefore, requires time, patience and hard work to reverse these changes. This process can take several months.
  • Continuing to participate and play in your sport will continue to aggravate the tendon. This will prolong recovery and reduce the chance of a successful outcome.
  • Steroid has been shown to be ineffective in the long term treatment of tendinopathy. Any benefit tends to be temporary and potentially detrimental to the tendon and therefore should not be considered as a viable treatment option.
  • The treatment of patellar tendinopathy is multi-faceted. Neglecting one or more of these facets reduces the chances of successful resolution of your symptoms.
mihai vioreanu

The ACL Injury – A Surgeon’s Perspective

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HOW DO WE TEAR THE ACL?

The ACL is commonly injured whilst playing ball sports or skiing. Whilst playing ball sports upon attempting a pivot, sidestep or landing from a jump, the knee gives way. The foot is planted on the ground and the rest of the body rotates about the knee creating the force required to snap the cruciate ligament. When rupturing the ACL patients frequently hear or feel a snap, a pop or a crack accompanied by pain. They fall to the ground, stop playing and come off the pitch. Swelling commonly occurs within the hour. Frequently pain is felt on the outer aspect of the knee. Occasionally the medial ligament of the knee joint (MCL) may also be disrupted resulting in severe pain and swelling at the medial aspect of the knee.

 

HOW DO WE DIAGNOSE AN ACL RUPTURE?

The majority of the ACL ruptures can be diagnosed by:

  • Taking the relevant history from the patient.

This is the classical story that is given by the typical patient: “I twisted my knee with my foot on the ground or landed after a jump. I fell to the ground and felt the knee giving way. I felt a crack/pop or snap inside the knee with intense pain. I couldn’t play on. My knee swelled up ’like a balloon’ immediately. When pain eventually settled I found it hard to bend my knee. Since then my knee gives way and I don’t fully trust it”

When hearing a similar story we should treat this as an ACL tear until proven otherwise.

  • Doing a clinical examination of the knee.
The patients may present at a variable interval (days or weeks/months) complaining of their knee giving way during simple activities. When presenting early, within days of injury the knee is often stiff, swollen and painful. In these cases the examination is difficult and signs may be subtle. When presenting late (weeks or months) following injury the knee is often pain-free, has full range of motion, it may be slightly swollen (small effusion) and is loose when testing for the ACL.

Taking as history as outlined above is often sufficient to raise the suspicion of an ACL injury.

 

WHAT IMAGING IS REQUIRED WHEN SUSPECTING AN ACL TEAR?

When we suspect an ACL injury we should request an X-ray (Both AP and Lateral) and an MRI of the affected knee. The X-ray will show if there are any fractures caused by the injury involving the knee. The MRI will outline the anatomy of the ligaments, menisci and chondral surfaces. It will diagnose the ruptured ACL and the associated injuries when present.

WHAT IS THE BEST ADVICE TO SOMEONE WITH AN ACL TEAR?

If the patient is in the acute phase (i.e. the first week or two after the injury) and the knee is still swollen, he/she should follow the RICE treatment principle: Rest, Ice, Compression and Elevation. For pain control he should take Paracetamol up to eight tablets a day. In the majority of cases we should encourage weight-bearing and range of motion mobilisation with no brace as pain allows. Sometimes depending on the associated injuries a knee brace allowing range of motion exercises could help.

When suspecting or dealing with a confirmed ACL injury we should refer the patient for further evaluation and treatment to an Orthopaedic Surgeon with an interest and sub-specialised training (Fellowship) in Sports Knee surgery.

SHOULD EVERYBODY WITH AND ACL TEAR HAVE SURGERY?

No, not all patients with ACL rupture should have surgery. The patients, along with their Orthopaedic Surgeon, should decide during the consultation what is the best treatment for them.

The goal of treatment for anybody with an injured knee is to return to their desired level of activity without risk of further injury to the joint. Treatment may be surgical or non-surgical. Patients who have a ruptured ACL and are content with activities that require little in the way of side-stepping (i.e. running in straight lines, cycling and swimming) may opt for conservative treatment. Surgical treatment cannot guarantee that further injury to the joint will not occur.
Conservative Treatment
Conservative treatment is by physical therapy aimed at reducing swelling, restoring the range of motion of the knee joint and rehabilitating the full muscle power. Intense proprioceptive training to develop the necessary protective reflexes is required to protect the joint for normal daily living activities. As the cruciate ligament controls the joint during changes of direction, it is important to alter your sports to the ones involving straight-line activity only. Social (non-competitive) sport may still be possible without instability as long as one does not change direction suddenly. Skiing is possible with conservative treatment. A brace and adherence to groomed runs may be required.
Surgical Treatment

Those patients who wish to pursue competitive ball sports, or who are involved in an occupation that demands a stable knee are at risk of repeated injury resulting in tears to the menisci, damage to the articular surface leading to degenerative arthritis and further disability. In these patients, surgical reconstruction is recommended. Surgery is best carried out on a pain free, healthy joint with a full range of motion. This is achieved with a pre-habilitation program supervised by a Physiotherapist.

MY SURGICAL TREATMENT FOR PATIENTS WITH ACL TEAR?

All reconstructive procedures for the ACL require a graft. My reconstructive technique involves grafting the torn ACL with segments of the patient hamstring tendons. This technique uses specially designed screws allowing secure immediate fixation of the tendon within the joint allowing for a rapid, early rehabilitation. Stabilising the joint protects the menisci and thus it may reduce the chances of developing later osteoarthritic degenerative changes. Although ACL reconstruction surgery has a high probability of returning the knee joint to near normal stability and function, the end result for the patient depends largely upon a satisfactory rehabilitation and the presence of other damage within the joint. Advice will be given regarding the return to sporting activity, depending on the amount of joint damage found at the time of reconstructive surgery.
Read more from Mr Mihai Vioreanu at www.mrmv.ie

Mike Young, Strength & Conditioning Coach at Vancouver Whitecaps on how to make footballers faster & stronger

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Physical preparation is one of the cornerstones of sports strength and conditioning, however, according to Mike Young, director of performance at Athletic lab sports, football still has some catching up to do compared to other mainstream sports.
Based in North Carolina, with a background in professional football and Sports biomechanics, Mike is well based to talk on the subject especially as he now works in as a Sports conditioning coach.
Shorter pre-seasons and longer seasons coupled with less off-season time mean that players have even more demands on their bodies nowadays. The preparation time for football stars today is shorter than before while the games are more high pressured and intense. Coupled with that the additional strain of international games which have also increased in stature means that players now have to manage travelling longer distances and the different pressure that comes with international football. All of which can leave a player feeling fatigued. The coaching team assess the weaknesses in a team and bring them back up to par.
Just three days of training can have a physiological impact on performances. Fatigue plays an important role in players conditioning. If a player is tired, then simply put he needs time to recover. If the athlete feels good, then the fitness then shines through. Performance is the cross-section of fatigue/fitness so if out of balance, then your performance levels drop.  If your fitness is high but your fatigue is low then your performance will be impacted, and vice-versa.  For the club’s it is about managing this. You don’t want an overload to happen as this will lead to injury, so you advise the players to get plenty of rest. Likewise you won’t want players burning out in-preseason and having nothing left in the tank halfway through the campaign. You need to build your fitness up and then manage it throughout the season.
Sports have developed best practice for becoming fast and strong, they know what Athlete’s need to be run faster, jump higher and endure more. Football is slightly unique as a sport as it encompasses elements of many sports each of which has its own requirements. Coaches are now tweaking these practices to help footballers become even faster and stronger.

Groin Injuries – Facts and figures

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Groin Pull/Strain – Facts and Figures

  • Both the Belgian Captain Vincent Kompany & English captain Steven Gerard were managing chronic groin injuries during their World Cup campaign
  • Alex Oxlade-Chamberlain missed much of the 2013/14 season with Athletic Groin pain.
  • A number of Premier League Clubs lost players to athletic groin pain for 16 weeks or more, potentially costing them over 2 million in wages.
  • Previous acute injury has significant risk factors for future injury in soccer players.
  • Six premier league clubs already had a player missing with groin pain on opening weekend.
  • Research suggests athletic groin pain linked to pelvic biomechanical overload.

Groin Strain is also known as Sportsman’s hernia, Gilmore’s groin, osteitis pubis and slapshot groin depending on which country you are in, they all describe the same problem.

What typically is the cause of a groin injury?

  • Mechanical overload
  • in high speed, change of direction

3D Biomechanics allows analysis of high-speed sport-specific movement

  • Caleb Sturges Miami Dolphins NFL$2.3 million players is currently out with groin injury.
  • Commonly a condition managed by surgery for a hernia, which few studies have shown exists, or indeed by cutting healthy tissues.
  • Tom Barrass West Coast Eagles AFL player is out for the season with Groin Injury

SSC Research recently submitted to the British Journal of Sports Medicine finds rehabilitation superior to surgery.

Click here for full infographic.

SSC Groin Rehab Programme Supports 9 weeks return to play-based, faster in residential athletes to 4 weeks

 

Dr Martin Hagglund discusses the impact too many games has on players today.

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In 1999/2000 former president of UEFA Nils Lennart Johansson initiated a football injury research project, the aim of the study was to reduce the number and severity of injuries in football, and ultimately improve the safety of players.
Now entering its 16th year, the group, led by Professor Jan Ekstrand (Vice-chairman of the UEFA Medical Committee and professor at Linköping University, Sweden) has studied data from some of Europe’s top clubs spread across 10 countries.
Martin Hagglund, an associate professor and colleague of Professor Ekstrand at Linkoping University and a member of the UEFA Injury study group, is better placed than most to talk about the impact of match congestion and injury rates.
According to Hagglund, increased match congestion, shorter periods of recovery and the added pressure of playing UEFA Champions league football has led to an increase in muscle injuries, especially to the thigh and the hamstring muscle groups.
These muscles, primarily used for high speed running injury, can be injured due to fatigue and playing intensity caused by increasing matching, or shorter time periods between games.
It’s a difficult situation for managers and medical professional to manage. Managers and coaches want to their want best players on the pitch and will often take chances with minor injuries, leading to increased re-injury rates.
At the business end of the season, with the Champions League and domestic leagues entering its final stages, the intensity and pressure are increased with the games even more high profile.
Studies by the group have also revealed that that players playing high intensity and high levels of games 10 to 12 weeks before major tournaments do worse than those that have played less.
Big squads mean that the larger teams are able to manage their squads to a degree and can rotate their players however that same competitive level is not at the smaller clubs so players play more.
Medical professionals tend to normally speak a different language but if they speak using language that coaches and managers understand it helps, using words like decreasing team and players performance help, as does explain how the risk taken with a player can impact the planning and physiological of the team.

Irish Physio Ciaran Murray on injury management in international football

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The club versus country debate is a thorny issue when it comes to international football. All too often, especially when it comes to perceived meaningless friendlies, key players return to their clubs with slight strains only to appear the following weekend.
With 16 years’ experience of working with the Irish national team, senior physiotherapist Ciaran Murray is better placed than most to talk about player management.
Without delving into the debate too much, Murray admits that first and foremost, the players are contracted to the club. They are released by the club on request from the International team and they will only do so once they are fit and ready for action.
Once with the national team, it is the responsibility of Murray and his team to ensure that they manage the player.
If a player is unfit or injured they examine him and investigate the cause. They listen to the player and they communicate with the national team manager and the club, offering their insight into the situation.
The medical team’s responsibility is to protect the welfare of the player and they use the tools available to them to build the case for exclusion. Ultimately though it is the manager that makes the final call.
Younger players are harder to manage. They are often less-established at club and international level and are keen to make their mark.
More than an experienced player, one who has either suffered from injury or engaged with someone who has, the young player often thinks with their heart more so than their head.
The correct course of rehabilitation and rest is required to get back to full fitness however that is something that less experienced players don’t often think about.