ISSUE 64 Apr 2015
ISSN 1471-8138
promoting
excellence
in
highlights
sports
n ReseaRch Reviews
n Fai: diagnosis and
tReatment
medicine
n achilles tendinopathy
n gait RetRaining in oa
oF the knee
n tendinopathy loading
pRogRammes
contents
April 2015 Issue 64
Publisher/editor Tor Davies
tor@sportex.net
Art editor DEBBIE Asher
debbie@sportex.net
Sub-editor alison sleigh
Journal watch bob braMah
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commissioning editors
Brad Hiskins - Australia & NZ
Whitney Lowe - USA & Canada
Humphrey Bacchus - UK & Europe
Glenn Withers - Worldwide
Dr Marco Cardinale - Worldwide
Dr Thien Dang Tan - USA & Canada
Dr Joseph Brence, D
PT, COMT,
FAAOMPT, DAC
Technical advisors
Steve Aspinall
BSc (BASRaT), MSc
Bob Bramah
MCSP, MSMA
Paula Clayton
MSc, FA Dip, Mast STT
Stuart Hinds
Dip SST
Rob Granter
Dip SST
Michael Nichol
BSc (BASRaT)
Joan Watt
MCSP, MSMA
Prof Greg Whyte PhD, MSc, BSc
Welcome
apr
2015
With the publication of this issue comes the launch of our brand new
website which we hope you will love! It’s been built from scratch to suit exactly
the needs of you, our readers. The goal is that it will be come a fully flexible
learning community developed on a foundation of great quality ‘translational’,
practical, hands-on content.
We can now work with University courses, education providers, corporate
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publish custom branded websites and mobile apps using the content hosted on
our platform. And the content doesn’t have to originate from sportEX either if you
have some of your own, or if you want to supplement your own with some of
ours. Over the comming months we will be working with one of each of the above
groups as case studies to demonstrate exactly what this means in practical
terms. Basically we can build a content portal for your members, a resource portal
for your students, some education resources for users of your products or an
online community for anyone running events. If you’re interested in any of these
opportunities get in contact. In the meantime, enjoy the new site :)
Tor Davies, physio-turned publisher and sportEX founder tor@sportex.net
is published by
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4 Journal watch
8 R esearch reviews
The latest key research from this
quarter
Management of post-surgery
lumbar pain and is exercise or
advice better for WAD?
emeroacetabular
10 Fimpingement
iagnosing Achilles
19Dtendinopathy
Assessment and management
‘A how to’ guide
Contents
25Gait retraining for OA of the knee
28Tendinopathy loading programmes
33The new sportEX website
Walking ‘properly’ reduces pain
Are your tendinopathy management protocols
up-to-date?
An overview of the launch of the new sportEX
website and our goals and aspirations
To find out more about sportEX visit
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www.sportEX.net
3
online
CLICK ON RESEARCH TITLES TO GO TO ABSTRACT
ACCESSORy SOLEuS muSCLE IN AN ATHLETE. pRESENTATION Of A CASE ANd A LITERATuRE REvIEw. Rubio fJ,
franco L, montero mJ, ugarte p, valero A. Apunts. medicina de l’Esport. 2015;doi:10.1016/j.apunts.2015.01.004
This study examines the incidence of
people having an accessory soleus
muscle. According to autopsy studies
it was found in between 0.5 to 6.0%
of the population. Typically in the live
population it presents as a soft mass in
the posteromedial distal third of the leg,
which increases in size with physical
activity, especially plantar flexion. It is
accompanied by pain with exercise in
Nine medical databases
were searched in May
2014 for treatment studies
in athletes with groin pain;
randomised controlled trials,
controlled clinical trials or case
series; n >10; outcome measures
describing number of recovered
athletes, patient satisfaction, pain
scores or functional outcome scores.
A best evidence synthesis was
performed. Relationships between
quality score and outcomes were
evaluated. Seventy-two relevant
studies were included for quality
analysis. Four studies were high
67% of reported cases. The treatment
of choice is conservative, but when
it causes compartment syndrome,
fasciotomy should be performed. If a
patient has symptoms of claudication
or nerve compression, a complete
excision of the muscle is required.
sportEX comment
You spend years studying
anatomy and then along
comes someone who says,
“Yeah but”. It’s why working
with the human body is so
fascinating. Given the incidence
of people presenting with pain
it is interesting to speculate on
how many of these were missed
in the past before ultrasound
scanning was available.
STudy quALITy ON GROIN INJuRy mANAGEmENT REmAINS LOw: A SySTEmATIC REvIEw ON
TREATmENT Of GROIN pAIN IN ATHLETES. Serner A, van Eijck CH, Beumer BR, Hölmich p, et al.
British Journal of Sports medicine 2015;doi:10.1136/bjsports-2014-094256
quality. There is moderate evidence
that, for adductor-related groin pain,
active exercises compared with
passive treatments improve success,
multimodal treatment with a manual
therapy technique shortens the time to
return to sports compared with active
exercises and adductor tenotomy
improves treatment success over
time. There is moderate evidence that
for athletes with sportsman’s hernia,
surgery results in better treatment
success then conservative treatment.
There was a moderate and inverse
correlation between study quality and
treatment success but not between
study quality and publication year.
sportEX comment
If reviewers can make decisions
about the quality of studies why, oh
why, can’t the editors of peer-reviewed
publications do so and stop publishing
them. Just say No.
THE EffECTIvENESS Of EyE-CLOSuRE IN REpEATEd INTERvIEwS. vredeveldt A, Baddeley Ad, Hitch GJ. Legal
and Criminological psychology 2014;19(2):282–295
This was an experiment in
recall for witnesses to a crime but it
should apply to any event you need
to recall. The participants were
shown a video and asked to recall
what they had seen a few minutes
later with their eyes open and then
with them closed. A week later they
were again asked to recall the event
firstly without being given reminder
cues and then with a cue. Immediately
after the video, eye-closure had no
significant effect on recall performance.
However, eye-closure during the
4
second session increased the amount
of correct visual information reported
by 36.7% in free recall and by 35.3%
in cued recall, without harming the
accuracy of what was recalled. Eyeclosure also facilitated the recall of
new, previously unreported visual
information.
sportEX comment
This one is for anyone taking
exams and struggling to recall the
anatomy lecture from 2 years ago
(or anything else for that matter).
Close your eyes and visualise. Note
to examiners. Your students are not
asleep they are trying to remember the
answers. For the record the scientists
believe the eye closing helps to remove
distractions to the thought process.
They also found that if the person
trying to remember had a rapport with
the person doing the interview the
eyes-closed recall was enhanced. This
is believed to have something to do
with being willing to close your eyes
if you feel safe with another
person in the room.
sportEX medicine 2015;64(April):4-7
JOURNAL WATCH
Journal watch
THE BASES, pRINCIpLES, ANd mETHOdS Of dECISION-mAKING:
A REvIEw Of LITERATuRE. Shahsavarani Am, Abadi EAm.
International Journal of medical Reviews 2015;2(5):214–225
The aim of this paper is to present
an integrated concept of decisionmaking. It was a literature search of the
usual medial databases plus Google
Scholar and a few we don’t usually
come across in this publication such as
Proquest, Ebsco, Springer, IEEE, Kolwer,
and IranDoc using variations on the
words ‘decision’, ‘making’, ‘optimisation’
‘reduction’ and a few others . The
result was that they came up with
9 definitions of decision-making in 3
classes, 4 involved factors, 5 types of
decision-making, processes and steps
of decision-making, 11 techniques of
individual and participatory decisionmaking, 3 groupings of steps of
decision-making, 5 related theories and
7 related constructs.
In general the influencing factors on
decision-making are:
1. Rational factors. Quantitative factors
such as price, time, predictions, etc.
2. Psychological factors. Such as
personality of the decider, her/
his capabilities, experiences,
perceptions, values, goals, and roles
are important factors in decision-
making.
3. Social factors. Others’ agreement,
especially those who influence
decider, is a matter of importance.
Considering these issues reduces
others’ resistance against the
decision.
4. Cultural factors. Surrounding
environment has varied layers which
are called culture of the region,
culture of the country, and culture of
the universe. Also, the culture of the
decider’s organisation should be also
considered. These cultures influence
individual/organisation decisions in
the form of socially accepted values,
trends, and common values.
sportEX comment
If you are reading this you are
in the decision-making business. It is
something you do with every clinical
encounter you have so anything
that can help the process should be
welcomed. There is of course a ‘but’!
The aim of this paper was to
obtain an integrated concept of
decision-making but it seems that it
only succeeded in pointing out the
complexities of the process. It has
a section called ‘Decision-making in
therapeutic environments’ in which it
supports the use of clinical decisionsupport system software to aid
doctors, and other healthcare staff
in determining diagnosis according
to patients’ data. It justifies this as a
method to reduce the need to consult
with professionals, and therefore
reduce consulting rates and costs
of treatment. This is very dangerous
road to go down. It looks good
to accountants but it reduces
healthcare to a tick-box exercise.
INCLuSION Of TRIGGER pOINT dRy NEEdLING IN A muLTImOdAL pHySICAL THERApy pROGRAm fOR
pOSTOpERATIvE SHOuLdER pAIN: A RANdOmISEd CLINICAL TRIAL. Arias-Buría JL, valero-Alcaide R, Cleland JA,
Salom-moreno J, et al. Journal of manipulative & physiological Therapeutics 2015; doi:10.1016/j.jmpt.2014.11.007
Twenty patients (5 M, 15 F; age,
58 ± 12 years) with postoperative
shoulder pain after either open
reduction and internal fixation with
proximal humeral internal locking
system plate or rotator cuff tear
repair were randomly divided into
two groups: a physiotherapy group
(n = 10) who received physical therapy
interventions and a physical therapy
plus trigger point dry needling (TrPt)
group (n = 10) who received the same
www.sportEX.net
intervention plus a single session of
TrPt therapy targeted at active TrPs.
The Constant–Murley score was used
to determine pain, activities of daily
living, range of motion, and strength,
which was captured at baseline and
1 week after by an assessor blinded
to group assignment. The results were
that subjects receiving the trigger
point therapy plus physical therapy
exhibited greater improvement in the
Constant–Murley total score and also
activities of daily living
and strength subscales
than those receiving
physical therapy alone.
Both groups experienced similar
improvements in pain and range of
motion
sportEX comment
This is a double plus. Physical
therapy works alone and with the
addition of a few needles. Good result.
5
online
CLICK ON RESEARCH TITLES TO GO TO ABSTRACT
THERApEuTIC EffECT Of ExTRACORpOREAL SHOCK wAvE COmBINEd wITH ORTHOpAEdIC
INSOLE ON pLANTAR fASCIITIS. yan w, Sun S, Li x. Zhong Nan da xue xue Bao yi xue Ban.
2014;39(12):1326–1330
One hundred and fifty-three people
with plantar fasciitis were randomly
divided into a combined group (n = 51),
an extracorporeal shock wave (ECSW)
group (n = 53) and an orthopaedic
insole group (n = 49). Visual analogue
scale (VAS) pain scores, continued
walking time and thickness of the
plantar fascia were obtained before
and after the treatment at 2 weeks,
1 month and 3 months.
The VAS scores in all three groups
were reduced after the treatment.
The score in the extracorporeal shock
wave group was greater than that
in the orthopaedic group after the
treatment at 2 weeks. The score in
the combined group was smaller than
that in the orthopaedic group after the
treatment at 2 weeks and 3 months.
The VAS scores in the orthopaedic
group and the combined group were
smaller than those in the ECSW group
after the treatment at 1 month and
3 months The continued walking time
and thickness of the plantar fascia
was improved after all the treatment
The cure rate and total effective
rate in the combination group were
obviously greater than those in the
two other groups. The cure rate in the
orthopaedic group was greater than
that in the ECSW group
sportEX comment
It’s International month here
at sportEX Towers. We have studies
from journals we don’t usually follow.
The reason for this is that therapists in
India, China and Japan are producing
good quality research on subjects
ignored by the mainstream Western
academic media and proving that
simple techniques can have dramatic
results. As to this one, sorry but if you
want to read the full paper you will
B
BROKEN
HEART SyNdROmE: A TypICAL CASE.
Therkleson T, Stronach S. Journal of Holistic Nursing
2015:pii:0898010115569883
This is a case of a lady diagnosed with ‘Broken Heart Syndrome’ who was
treated with, amongst other things, massage with oils and a relaxing footbath
once a week for 4 weeks which proved to be effective.
sportEX comment
Ok be honest. When you
read ‘Broken Heart Syndrome’
(BHS) what were you thinking?
Was it a positive thought? BHS
was first reported in Japan in
1991 and is a medical condition
triggered by extreme physical or
emotional stressors that is found
to mainly affect postmenopausal
women. It was originally called
‘Takotsubo cardiomyopathy’ due to
the presentation of cardiac changes,
with weakened heart muscle in
the left ventricle causing transient
ballooning in the apex of the left
ventricle. It has been acknowledged
by the American College of
6
Cardiology and the American Heart
Association as a unique form of
reversible cardiomyopathy. Generally,
the symptoms are chest pain and
tightness accompanied by shortness
of breath. Typical management is
the same as for a heart attack until
symptoms settle. It is suggested that
it is activated by neurogenic stunning
of the myocardium. ECG and cardiac
markers show minimal change and
there is no myocardial arterial blockage
but a definitive diagnosis is obtained
from an echocardiograph. So now
you know that your team members
distraught at losing the cup final on a
penalty shootout have
a genuine medical condition.
have to be able to read Chinese as
there is only a translated summary
available but this confirms earlier work
including a meta analysis [Gerdesmeyer,
et al. Radial extracorporeal shock
wave therapy is safe and effective in
the treatment of chronic recalcitrant
plantar fasciitis results of a
confirmatory randomised placebocontrolled multicenter study. The
American Journal of Sports Medicine
2008;36(11):2100–2109] which states
that extracorporeal shock is great for
plantar fasciitis. If you are not familiar
with ECSW or extracorporeal shock
wave lithotripsy to use its full title it is
usually used for battering kidney or gall
stones into submission. You can buy a
generator for between £7–12,000.
S
SENSORy
NERvE fIBRES CONTAINING
CALCITONIN GENE-RELATEd pEpTIdE IN
GASTROCNEmIuS, LATISSImuS dORSI
ANd ERECTOR SpINAE muSCLES ANd
THORACOLumBAR fASCIA IN mICE. Barry Cm,
THORACOL
Kestell G, Haberberger Rv, Gibbins IL. Neuroscience
2015;doi:10.1016/j.neuroscience.2015.01.062
This study used multiple labelling immunofluorescence
and retrograde axonal tracing to identify dorsal root
ganglion cells associated with muscle, and to characterise
the distribution and density of their nerve fibres in
mouse gastrocnemius and back muscles and the
thoracolumbar fascia. Most nerve fibres in these tissues
contained calcitonin gene-related peptide and two major
subpopulations of neurons were found: those containing
calcitonin gene-related peptide and substance P, and those
containing calcitonin gene-related peptide but not substance
P. Innervation density was three times higher in the
thoracolumbar fascia than in muscles of the back.
sportEX comment
So what? Well what this does show is that in mice
at least there are more nerve fibres that can cause pain in
the thoracolumbar fascia than the underlying muscle. If this
transfers to humans it’s a good clinical reason for
doing fascial techniques on pain sufferers.
sportEX medicine 2015;64(April):4-7
JOURNAL WATCH
pROTECTING THE HEALTH Of THE @HLETE: HOw ONLINE TECHNOLOGy mAy AId OuR COmmON GOAL TO pREvENT
INJuRy ANd ILLNESS IN SpORT. verhagen E, Bolling C. British Journal of Sports medicine 2015;doi:10.1136/
bjsports-2014-094322
This report is based on the authors
keynote presentation at the IOC
World Conference on Injury and Illness
Prevention in Sport (Monaco, 12 April
2014). It outlines the use of eHealth
in research, implementation and
practice, and provides an overview
of possibilities and opportunities
that existing and emerging eHealth
solutions provide for sports and
exercise medicine and physiotherapy.
Contemporary online platforms enable
self-monitoring and provide tailored
feedback to the different stakeholders
who play a role in the health and
care of athletes. Innovations such as
digital monitoring, mobile applications
and connected hardware provide
the critical tools to solve current
enigmas in sports medicine research,
and to streamline and facilitate
injury prevention, management
and rehabilitation. eHealth is not an
emerging future of sports medicine
– the technology to move our field
forward in terms of research and
practice is already available.
The paper highlights numerous
other studies where eHealth has been
used. Examples include, online surveys,
using text message to monitor injury
rehab, the interaction possibilities
of social media, social marketing to
spread messages of improvement of
healthy and safe sports behaviour or
raise awareness of issues. The viral
(or vile) Ice Bucket Challenge is used
as an example. Mobile phones as data
gathering devices are highlighted, eg.
tracking via GPS, heart rate monitors,
accelerometer, pedometers and of
course the massive variety of ‘Apps’
T EffECT Of TwO mOBILIZATION TECHNIquES
THE
ON dORSIfLExION IN pEOpLE wITH CHRONIC
ANKLE INSTABILITy. marrón-Gómez d,
Rodríguez-fernández AL, martín-urrialde J.
physical Therapy in Sport 2015;16(1)10–15
The aim of this study was to compare two manual therapy
techniques for the improvement of ankle dorsiflexion in
people with chronic ankle instability (CAI) over 48h. Fiftytwo participants, (31 M, 21 F; age 15–36 years) with CAI were
randomised to a mobilisation with movement group using
a belt, a talocrural manipulation group or a placebo group,
which involved holding onto the leg and foot in the same
manner as the mobilisation with movement group but without
actually doing very much. Weight-bearing ankle dorsiflexion
was measured with a weight-bearing lunge obtained before
and immediately after intervention, and 10min, 24h and 48h
post-intervention. There was a significant increase in ankle
dorsiflexion in both treatment groups compared to placebo but
no differences between both active treatment groups.
sportEX comment
There are some nice stats in this paper. Ankle sprains
are the most common injury incurred during sports activities
and it is estimated that between 20% and 40% of ankle
sprains will result in chronic ankle instability, with up to 70%
reported in specific sports such as basketball. Nice
also to know that manual therapy techniques work.
www.sportEX.net
for injury prevention and
treatment.
sportEX comment
If the use of ‘@hlete’ rather
than ‘athlete’ puts you off the ‘e’world
then look away now. Whether we like
it or not, eHealth has entered our life.
Ninety percent of the world’s population
has a mobile phone and there are
1.2 billion active Facebook users
and 255 million on Twitter. We have
‘mHealth’, which is ‘eHealth’ delivered
via a portable (mobile) devices. A word
of caution, however. None of this stuff
is regulated. The fancy ‘App’ could be
valuable or dangerous. Maybe it is
time the professional medical bodies
like the BMA, CSP or BASRAT started
endorsing or even producing
a few.
L
LIfE-THREATENING
EvENTS duRING ENduRANCE SpORTS: IS HEAT
STROKE mORE pREvALENT THAN ARRHyTHmIC dEATH? yankelson
L, Sadeh B, Gershowitz L, werthein J, et al Journal of the American
College of Cardiology 2014;64(5):463-469
This retrospective study examined all the long distance popular races that took
place in Tel Aviv from March 2007 to November 2013. The number of athletes at
risk was known. The number of athletes developing serious sport-related events
and requiring hospitalisation was known. Life-threatening events were those
requiring mechanical ventilation and hospitalisation in intensive care units. Overall,
137,580 runners participated in long distance races during the study period. There
were only 2 serious cardiac events (1 myocardial infarction and 1
hypotensive supraventricular tachyarrhythmia), neither of which
were fatal or life threatening. In contrast, there were 21
serious cases of heatstroke, including 2 that were
fatal and 12 that were life threatening. One of the
heatstroke fatalities presented with cardiac arrest
without previous warning.
sportEX comment
As we enter the mass participation
marathon season it is worth taking heed of
this study. For every serious cardiac adverse
event, there were 10 serious events related to
heatstroke. We do like the idea that if you are lucky
enough to have your cardiac event at a sporting
event with high level medical services on hand a
‘myocardial infarction’ is not life threatening.
7
Brought to you By Nxt Gen Institute of Physical Therapy
our regular research reviewer, physical therapist Joseph Brence, reviews research
looking into the benefits of exercise and advice for pain (i) following lumbar surgery,
and (ii) with chronic whiplash-associated disorder.
post-surgery Lumbar pain
BY Joseph Brence
DpT, coMT, DAc
Lumbar discectomies for radicular
symptoms are quite prevalent in the
united States. Despite this, one out of
every four individuals undergoing these
procedures continues to have persistent
pain and disability (1,2). Although many
patients receive education from their
physicians prior to surgery, research does
not support that this influences postoperative pain or disability (3). A recent
article published in Spine may change the
way we approach pre-operative education
and may improve patient’s perception of
surgery and reduce long-term postoperative costs (4).
The sTuDY
the researchers in this multicentre,
randomised controlled trial, investigated
the potential outcomes of providing
pain neuroscience education to patients
undergoing lumbar surgery for radicular
pain. Sixty-seven patients, scheduled
for surgery, were randomly assigned
to receive one of two pre-operative
approaches:
control group
this group had the usual surgeon-led
pre-operative education, focusing on
procedures and anatomical description of
the surgery.
function, pain knowledge, satisfaction with
surgery and healthcare expenses.
experimental group
At 1 year, there were no statistical
differences between the two groups in
regards to back pain, leg pain, fearavoidance, pain catastrophisation and
function. the experimental (pain education)
group, however, rated surgery significantly
more satisfactory on several levels and
spent 45% less of medical tests and
treatment, despite having similar pain
and disability. the one-time Pt session
resulted in savings of more than $2000
per patient.
this group had the usual surgeonled pre-operative education plus one
physical therapist (Pt) session (30
minutes) teaching the patients about the
neurobiology of pain, accompanied by a
$5 neuroscience education booklet.
Material covered in this session
included:
1. the decision to have the surgery
2. the nervous system’s physiology and
pathways
3. Peripheral nerve sensitisation
4. Surgical experiences and environmental
issues effects on nerve sensitivity
5. Calming the nervous system
6. recovery after lumbar surgery
7. Scientific evidence for the neuroscience
education booklet content
8. An opportunity to reflect and write
questions to ask the surgeon prior to
surgery.
Following the education, all of the
patients underwent surgery and then
outcome measures were collected 1, 3, 6
and 12 months after surgery and consisted
of surveys regarding low back pain, leg
pain, fear-avoidance, pain catastrophisation,
THE AUTHOR
JOsEpH BREncE DpT, cOMT, DAc
J
Joseph Brence (DpT,
(D cOMT, DAc) is a physical therapist and clinical researcher from
p
pittsburgh,
pA, UsA. He is also a fellowship candidate with sports Medicine of Atlanta,
GA, UsA.
sA. Joseph’s primary clinical interests involve a better understanding of the neuromatrix and
s
determining how it applies to physical therapy practice. He is currently involved in a wide range of
clinical research projects investigating topics such as the effects of verbalising of pain, the effects
of mobilising v. manipulating the spine on body image perception and validation of an instrument
which will assess medical practitioners’ understanding of pain. clinically, Joseph treats a wide range
of painful conditions in multiple settings including complex regional pain syndrome, fibromyalgia and
chronic fatigue syndrome. Joseph also runs the blog www.forwardthinkingpt.com.
08
The resulTs
so whAT Does This MeAn?
Pts are very well equipped in strategies to
help you better understand and manage
pain. growing research, such as this,
is indicating education, focusing on the
re-conceptualisation of pain, can lead to
improved function, and less care-seeking
due to the pain. It appears that pain is
a normal experience following lumbar
surgery, but as little as one session with a
Pt can ultimately result in lower healthcare
expenditure costs.
References
1. Loupasis gA, Stamos K, et al. Seven- to
20-year outcome of lumbar discectomy. Spine
1999;24:2313–2317
2. yorimitsu E, Chiba K, et al. Long-term
outcomes of standard discectomy for lumbar
disc herniation: a follow-up study of more than
10 year. Spine 2001;26:652–657
3. Johansson K, Nuutila, et al. Preoperative
education for orthopaedic patients: systematic
review. Journal of Advanced Nursing
2005;50:212–223
4. Louw A, Diener I, et al. Preoperative
pain neuroscience education for lumbar
radiculopathy. Spine 2014:39;1449–1457.
sportEX medicine 2015;64(April):08-09
reSeArch review
Is exercI
exercIse better
than advI
advIce for W
Wad
ad?
Whiplash-associated disorder (WAD)
is a complex, multifaceted disorder
that is often the result of the 300,000
plus road traffic accidents that occur
in England per year (1). Evidence has
suggested that 50% of individuals who
acquire WAD do not recover within the
first 3 months (1) and that upwards of
30% of individuals with WAD report the
development of moderate to severe
pain and disability, up to 6-months
following the onset (2). A recent article
in The Lancet set out to investigate
if a comprehensive exercise program
is more effective than advice, for the
treatment of individuals diagnosed with
chronic WAD (3).
this article followed 172
participants, between the ages of 18
to 65, who had a diagnosis of chronic
grade 1 or 2 WAD (>3 months and <12
months). they were allocated into one
of two treatment groups, to receive
either a comprehensive exercise
program (20 sessions) or advice
(1 session and telephone support).
Each participant, regardless of group,
was also given a patient educational
booklet, that provided information
about WAD, advice regarding the
management of symptoms, and a
simple exercise programme to help
reduce pain. here is a detailed analysis
of what each of these groups received:
Group 1: comprehensive
exercise programme
n Participants received 20 individually
tailored and supervised exercise
sessions lasting one hour each over
12-weeks (2×week for 8 weeks;
1×week for 4 weeks).
n For the first 4 weeks, the
participants performed specific
cervical spine exercises (such
as craniocervical flexion training,
neck extensor training, scapular
training, posture re-education, and
sensorimotor exercises).
n Manual therapy techniques (non-
www.sportEX.net
thrust) could be used by the clinician
within the first week.
n In weeks four through six, the
participants transitioned from a focus
on specific neck motor exercises to
integration of this control in entire
body exercises.
n By week 7, individually designed,
graded activity programmes were
completed to help participants
progressively achieve their goals.
n In addition, aerobic activities were
prescribed from week 1 to 12 in a
submaximum way.
Group 2: Advice
n Participants received a 30-minute
consultation with a physiotherapist
during which they read the
educational booklet, practiced the
exercises, and had any additional
questions or concerns clarified.
n Participants were advised to
implement the advice and do the
exercises at their own discretion.
n the participants could contact the
physiotherapist by telephone on
two occasions, if needed, for further
verbal clarification.
the researchers performed follow-up
assessments on the participants at
14 weeks, 6 months and 12 months.
During this time they compared
baseline readings on the following
scales to assess outcomes:
1. primary outcome measure
Average pain intensity during the
preceding week (before the outcome
assessment was measured)
2. secondary outcome measures
a. Average pain intensity over the past
24 hours
b. Self-rated recovery
c. Disability measured on the neck
disability index
d. Disability on the Whiplash Disability
Questionnaire.
After careful analysis, the
researchers found that simple advice
was just as effective as a 12-week
comprehensive exercise programme.
this finding refutes some previously
held beliefs about the treatment of
WAD, supporting some more recent
findings about the diagnosis (4,5,6)
the findings of this study further
support the complex, multifaceted
nature of painful conditions and the
notion that simply understanding pain,
may be beneficial in recovery. Because
central sensitivity is suspected to be a
tenant of chronic WAD, it may be more
beneficial to approach treatment with
interventions which devalue the threat
and hypersensitivity of the nervous
system, prior to performing exercise
interventions. overall this was a tightly
controlled, well-performed study that
gives us more effective approaches to
treatment for this complex disorder.
References
1. Crouch r, Whitewick r ,et al. Whiplash associated disorder:
incidence and natural history over the first month for patients
presenting to a uK emergency department. emergency Medicine
Journal 2006;23:114–118
2. Jull gA, Sterling M, , et al. toward lessening the rate of transition of
acute whiplash to a chronic disorder. Spine 2011;36:173–174
3. Michaleff ZA, Maher Cg, et al. Comprehensive physiotherapy
exercise programme or advice for chronic whiplash (ProMISE): a
pragmatic randomised controlled trial. The Lancet 2014;384:133–141
4. Lamb SE, gates S, et al. Emergency department treatments and
physiotherapy for acute whiplash: a pragmatic, two-step, randomised
controlled trial. The Lancet 2013;381:546–556
5. Soderlund A, Lindberg P. Cognitive behavioural components in
physiotherapy management of chronic whiplash associated disorders
(WAD): a randomised group study. Physiotherapy Theory and
Practice 2001;17:229–238
6. Jull g, Kenardy J, hendrikz J, et al. Management of acute whiplash:
a randomized controlled trial of multidisciplinary stratified treatments.
Pain 2013;154:1798–806.
09
Femoroacetabular
impingement
MechanisMs, diagnosis and
treatMent options using
postural restoration®: part 1
Upon completion of this series, the reader will have
a greater understanding of the biomechanics of
lumbo-pelvic-femoral dysfunction as it relates to
femoroacetabular impingement (FAI) as understood by
the Postural Restoration Institute® (PRI). Restoration
of pelvic-femoral alignment and recruitment patterns
of specific rotational muscles within the lumbo-pelvicfemoral complex will be discussed. Treatment techniques
to recruit, retrain and restore ideal lumbo-pelvic-femoral
position will be discussed. The reader will be able to
apply PRI clinical assessment and management skills
when treating diagnoses such as FAI.
by JaSon maSek ma, Pt atC CSCS PrC
Symmetry and
aSymmetry in the
human body
A common misconception is that
the human body is symmetrical. It is
symmetrical about the midline of the
body for many structures such as eyes,
ears, and limbs. In spite of this outward
noticeable symmetry, there is an
inherent internal organ asymmetry with
regards to the left and right side of the
body. For example, the heart is on the
left side, the right lung has more lobes
than the left, and the liver lies on the
right side of the body. Furthermore, our
respiratory and cardiovascular systems
are designed asymmetrically. The right
hemi-diaphragm, being larger and more
domed than the left, provides greater
force development and therefore
greater transdiaphragmatic pressure.
In regards to the heart function, the
left side of the heart pumps blood
under high pressure to the whole body,
whereas the right side pumps blood at
a lower pressure to the lungs.
10
Nevertheless, there is an
opinion that symmetry generates
the basis on which asymmetry
can be developed, influenced, and
exercised. Recognising the structural
and functional asymmetries of the
human body for what they are, not
for what they should be, proposes an
overwhelming desire on the part of
many to obtain symmetry. Symmetry
is established once there is a balancing
mechanism for identifying different
movement patterns between the left
and right side of the body. Anatomical
asymmetry cannot be eliminated,
but functional asymmetry can be
consistently monitored, assessed and
influenced in order to reduce negative
consequences. These asymmetries
lead humans to function very differently
in regards to the left and right sides
of their bodies. Asymmetries may
not always be disadvantageous or
detrimental to function. In fact they can
allow individuals to adapt to various
task constraints. Through favouring
sportEX medicine 2015;64(April):10-18
evidence inFormed practice
one side over the other, functional
asymmetries can be amplified
through time even though anatomical
asymmetries are an inherent design
of the human body. These side-toside differences may act as functional
mechanisms for adaptation to various
constraints to optimise function.
Patterns evolve and exist in all of
us to some degree. A movement or
recruitment pattern develops as one
trains or habitually repeats the same
action to contribute to a desirable
and/or undesirable activity. Identifying
movement patterns that one wants to
change and factors that are interfering
with the movement one wants to
achieve, will allow one to learn new
movement patterns that are more
productive for the individual. Repetitive
sequential action of muscles, bones
and joints, therefore, contributes
to differences or similarities in the
development of asymmetrical human
behaviour.
PoStural reStoration®
Postural Restoration® as described
by the Postural Restoration Institute®
(PRI), is a form of treatment based on
objective anatomical asymmetry and
correlated predictable asymmetrical
patterns of behaviour. Application
of the treatment requires ongoing
assessment of common postural
patterns found within the human body.
It is understood that all humans have
anatomical asymmetry which influences
the way human body functions. These
asymmetries can predispose our body
to fall into neuromuscular patterns that
may have an undesirable influence
on muscle function and structural
alignment. Postural Restoration®
techniques assist in the treatment
of undesirable asymmetry, restoring
proper joint position, and retraining
proper muscular activity in triplanar
movement patterns. This approach
has shown to be successful in the
management of individuals with anterior
knee pain (1,2), asthma (3), trochanteric
bursitis (4), low back pain (5,6) and
thoracic outlet syndrome (7).
PelviC aSymmetry
Pelvic asymmetry is common among
symptomatic and asymptomatic
individuals (8,9). Pelvic asymmetry
www.sportEX.net
refers to asymmetric pelvic alignment
with respect to the frontal or sagittal
planes (10). Pelvic asymmetry in the
sagittal plane refers to mal-alignments
between the left and right innominate
bones (11). Thus, clinical assessment
of innominate position and motion is
later made by describing motion or
position of one side in relation to the
other. This mal-alignment could either
be unilateral anterior or posterior
rotation of one innominate bone or
bilateral movement of the innominate
bones (12). Furthermore, pelvic
asymmetry has been thought to alter
body mechanics, affect the length of
muscles that originate on the pelvis,
and result increased strain on bony
and soft tissues possible producing
asymmetrical adaptations (12).
FemoroaCetabular
imPingement
Femoroacetabular impingement (FAI)
is a recently understood hip condition
in which there is abnormal mechanical
contact (impingement) between the
‘ball’ and ’socket’ of the hip (13–15).
The femoroacetabular joint is the
medical term for the hip joint. The hip
is a ball-and-socket joint. The socket
is formed by the acetabulum, which
is part of the large pelvis bone. The
ball is the femoral head, which is the
upper end of the femur (thigh bone).
Impingement is a term to describe the
catching, pinching, and/or abnormal
rubbing of the femoral head ball with
the acetabulum socket leading to loss
of motion within the femoroacetabular
joint. Furthermore, this impingement
can occur from changes in the shape
of the acetabulum socket or the
femoral head ball. There are three
types of FAI: pincer, cam and mixed
impingement. FAI due to ‘overcoverage’ of the acetabulum is referred
to as pincer impingement. Pincer
impingement occurs because extra
bone extends out over the normal
rim of the acetabulum. FAI due to
‘lack of femoral head roundness’ is
referred to as cam impingement. In
cam impingement the femoral head is
The ABSeNce OF A
lIveR ON The leFT
SIDe OF The BODy cReATeS
A SITUATION WheRe The
leFT heMI-DIAPhRAgM IS
NOT Well POSITIONeD AND
cReATeS AN ASyMMeTRIcAl
PUll ON The RIBS
not round and cannot rotate smoothly
inside the acetabulum. A bump forms
on the edge of the femoral head
that grinds the cartilage inside the
acetabulum. Mixed impingement
suggests that both the pincer and cam
types are present.
The significance of FAI has been
discussed at both the scholarly and the
clinical level (16–24). FAI has recently
been considered to be one of the
causes of osteoarthritis (OA) of the
hip (2,13,25–27). OA is perhaps best
understood as resulting from excessive
mechanical stress applied to the joint
surface. This cumulative excessive
stress results from biomechanical
alterations and conditions such as
post-traumatic joint incongruity, joint
instability, mal-alignment and altered
joint loading. In recent years, hip
arthroscopy has become an increasing
popular method for the surgical
treatment of FAI because of favourable
outcomes (28).
aSymmetry
ContributionS to Fai
Postural Restoration® recognises
a common pattern of asymmetry
that may contribute to a multitude of
musculoskeletal conditions including
FAI. FAI is an increasingly accepted
cause of hip pain in young active
adults. While the exact cause of hip
impingement is not well understood,
concomitant hip pain is often seen in
individuals who have hip impingement.
Because FAI is a dynamic process,
mechanical hip pain has remained a
diagnostic hurdle for most healthcare
DeSPITe OUTWARD
APPeARANceS, INTeRNAlly The
BODy IS INheReNTly ASyMMeTRIc
11
professionals on the basis of clinical
evaluation. Despite an emergence of
advanced diagnostics and surgical
intervention techniques there remains
a lack of information focused on
specific rehabilitation in regards to FAI.
The high incidence of this condition
necessitates a specialised treatment
and rehabilitation programme in order
to address the specific needs and
challenges associated with FAI. It is
the intent of the forthcoming articles
to provide the reader with a better
appreciation and understanding of
the mechanisms of hip impingement,
diagnosis and treatment/management
options as it relates to dysfunctional
asymmetry and the use of Postural
Restoration® techniques.
It is important to detect
predisposing factors in individuals
presenting with FAI and labral tears;
these factors can include anatomical
asymmetry and asymmetrical patterns
of muscle pull that develop due to
postural habits, repetitive movements
and side dominance. Pelvic asymmetry
alters the body mechanics, puts
various body segments under
strain, and therefore contributes to
musculoskeletal pain (29). Pelvic
asymmetry appears frequently
as a consequence of mechanical
loading of the pelvis. compensation
for pelvic asymmetry occurs in the
musculoskeletal system altering the
mechanics of the lumbo-pelvic-femoral
complex. This is reflected by altered
movement patterns in the upright
standing position, and therefore
a recognised functional alteration
adapts the locomotor system to the
transmission of these asymmetrical
mechanical loads (29). Furthermore, it
Figure 1: Hruska’s left anterior interior
chain (left AIC) pattern of the pelvis. (J.
Masek, 2014)
12
(a) left acetabular-femoral internal
rotation (left aF ir)
(b) left femoral-acetabular internal
rotation (left Fa ir)
(c) left acetabular-femoral external
rotation (left aF er)
(d) left femoral-acetabular external
rotation (left Fa er)
Figure 2: Left acetabular-femoral and femoral-acetabular mechanics. (J. Masek 2014)
is valuable to consider other etiological
factors when evaluating the lumbopelvic-femoral complex for alterations.
The position of the pelvis is affected by
factors such as acetabular orientation,
soft-tissue flexibility, muscular
imbalances and respiratory dysfunction
and all must be considered together
when evaluating pelvic findings.
PatternS oF PelviC
aSymmetry
Janda (30) has described a predictable
pattern of muscular imbalance in the
pelvis, known as the lower crossed
syndrome. he suggests that tight hip
flexors and lumbar erector spinae
and weak gluteal and abdominal
musculature characterise the lower
crossed syndrome. The subsequent
imbalance leads to an anterior pelvic tilt,
increased hip flexion, and hyperlordosis
of the lumbar spine. hip flexor tightness
may lead to increased weight-bearing
load upon the anterior acetabulum and
labrum predisposing it to injury.
Similarly, hruska has described
a predictable underlying postural
pattern of asymmetry known as the
left anterior interior chain (left AIc)
pattern (Fig. 1). hruska’s left AIc pattern
calls attention to the tendency for
the anterior tilt and forward rotation
of the left hemi-pelvis. The position
of the pelvis orients the pelvic girdle
to the right causing a shift in one’s
centre of gravity to the right resulting
in compensatory activity throughout
the frontal and transverse planes of
the thorax and consequently the upper
extremities. The typical left AIc pattern
involves a pattern of pelvic, spinal and
diaphragmatic orientation towards
the right with compensation, usually
occurring above the diaphragm (at
about T8/T9), from the neuromuscular
system to rotate the spine back to the
left. Upon frontal plane observation,
the thorax and lumbar spine will be
side-bent right with the right shoulder
appearing to be lower than the left
(31–34).
Specific movement patterns have
a significant effect on the relative
strength and consequently the length
of the musculature involved in all
three planes. Although muscles are
often prime movers in a single plane,
they must actually be considered as
having an effect on movement in all
three planes – sagittal, frontal and
transverse. Assessing the frontal and
sportEX medicine 2015;64(April):10-18
evidence inFormed practice
transverse planes when it comes to
addressing postural asymmetry is
often overlooked. Janda’s approach
to addressing patterns of muscular
imbalance within the sagittal plane
is rather straightforward. hruska’s
approach addresses muscular
imbalances with a tri-planar viewpoint
in order to manage muscular patterns
of asymmetry and also incorporates
the respiratory system’s influence on
muscular imbalance.
anatomiCal and
reSPiratory inFluenCeS
oF the leFt aiC Pattern
It is beyond the scope of this article
to address in depth all aspects of the
left AIc pattern and its influence on
the management of FAI. Therefore,
this article will focus on providing an
understanding of how respiratory
and lumbo-pelvic-femoral function
accompanies FAI. Moreover, the
reader will have a more complete
understanding of anatomical
considerations in regards to altered
pelvic mechanics and respiratory
function as it relates to FAI.
bones. The right and left innominate
bones articulate anteriorly to form the
symphysis pubis joint and posteriorly to
form the sacroiliac joints. The femurs
articulate with the acetabulum of the
innominates to form the hip and/or FA
joint.
Femoral-acetabular (FA) motion
refers to the femur moving within
the acetabulum. Acetabular-femoral
(AF) motion refers to the acetabulum
moving on the femur. Movement of
the femur relative to the acetabulum
does not produce pure arthokinematic
motion, rather, combinations of
movements (36). The habitual patterns
of motion for the non-weight-bearing
lower extremity are a combination of
flexion with abduction and external
rotation (eR), and extension with
adduction and internal rotation (IR)
(37). Arthrokinematics of both motions
are impure swings (37). however,
acetabular-femoral internal rotation
(AF IR) and femoral-acetabular internal
rotation (FA IR) usually includes a
combination of extension, internal
rotation and adduction (Figs 2,3).
The major function of the pelvic
girdle is to transmit forces and weight
of the trunk and upper extremities to
the lower extremities and to distribute
ground reaction forces. The pelvic girdle
forms the base of the trunk, supporting
the superincumbent body structures
and linking the vertebral column to
the lower extremities (38). In bilateral
asymmetrical stance, muscle activity will
be required to either control osseous
instability or to return the FA joint (hip)
to a symmetrical state. Shifting ones
weight over the right hip results in
relative adduction and internal rotation
of the right hip (right AF IR) (Fig. 4)
and abduction and external rotation of
the left hip (left AF eR). To return the
pelvic girdle to a neutral state, an active
contraction of the right hip abductors
(right AF eR) and/or left hip adductors
(AF IR) is required (Fig. 5) (39).
(a) right acetabular-femoral internal
rotation (right aF ir)
(b) right femoral-acetabular internal
rotation (right Fa ir)
(c) right acetabular-femoral external
rotation (right aF er)
(d) right femoral-acetabular external
rotation (right Fa er)
the thoraCiC and PelviC
diaPhragmS
The thoracic and pelvic diaphragms
interconnect your ribcage, spine, and
pelvis. Because of these relationships
anatomy
The complex anatomy and
biomechanics of the lumbo-pelvicfemoral complex have made it
challenging to propose specific
diagnostic and treatments for FAI. The
muscle attachments about the lumbopelvic-femoral complex provide this
area with significant power accelerating
and pivoting as rapid contractile forces
are applied. The pelvic girdle is a
complex group of skeletal (bone) and
soft-tissue (muscles and ligaments)
structures that transmit power and
weight of the torso and upper body to
the lower extremities for ambulation
and performance (35).
In order to comprehend the
biomechanics of the pelvis, which is
the foundation of the spine, the pelvis
must be defined in relationship to the
bones contained within it and those
affecting it. The pelvic girdle is formed
by six joints: two femoroacetabular (FA)
joints (hip joints), two sacroiliac joints,
the lumbosacral junction (l5–S1), and
the symphysis pubis joint. The pelvis
is formed with the sacrum wedged
between the right and left innominate
www.sportEX.net
Figure 3: Right acetabular-femoral and femoral-acetabular mechanics. (J. Masek,
2014)
13
Figure 4: Shifting one’s weight over the
right hip results in relative adduction
and internal rotation of the right hemipelvis (right AF IR), and abduction and
external rotation of the left hemi-pelvis
(left AF ER). (J. Masek, 2014)
Figure 5: Shifting one’s weight over the
left hip results in relative adduction and
internal rotation of the left hemi-pelvis
(left AF IR), and abduction and external
rotation of the right hemi-pelvis (right
AF ER). (J. Masek, 2014)
the diaphragms are significantly
influenced by posture and continuously
influenced by respiratory function. The
pelvic girdle is important in regards
to respiratory function because of its
relationship to the pelvic diaphragm (Fig.
6). Altered mechanical function of the
pelvic girdle can influence the functional
capacity of the muscles of the pelvic
diaphragm, as does the thoracic
spine; whereas rib mechanical function
influences the functional capacity of
the thoracic diaphragm. When linked
to the thoracic diaphragm, the pelvic
diaphragm acts as a powerful stabiliser
of lumbosacral, sacroiliac, pubic
symphysis and FA joints allowing for
higher efficiency of lower extremity use.
lumbar and pelvic stability is
dependent upon optimal coordination
between the thoracic diaphragm, the
14
pelvic diaphragm and the abdominal
musculature. The pelvis and its
direct attachment to the spine is the
determining factor for the shape of
the two diaphragms, and must be
supported by the muscles that attach
to the ribcage and the pelvis. As the
thoracic diaphragm pulls air into the
lungs upon inhalation, it pushes down
on the viscera, which in turn, press
down on the pelvic diaphragm to move
it downward. On exhalation, the thoracic
diaphragm and pelvic diaphragm both
elevate. When upper respiratory activity
(scalene, sternocleidomastoid, pectoralis
minor) is the predominate pattern
of respiration, the pelvic diaphragm
becomes less efficient during reciprocal
phases of respiration. This lack of
coordinated reciprocal movement
between the two diaphragms tends
to exacerbate respiratory dysfunction
and lumbo-pelvic-femoral mechanical
derangement.
Proper function between the two
diaphragms is fundamental for proper
core stabilisation. Kolar has previously
described how proper core stabilisation
is achieved by the simultaneous
activity of the thoracic diaphragm’s two
functions of respiration and stabilisation
(40–42). The position of the chest
and pelvis affect the synchronised
activity of both the thoracic and pelvic
diaphragms. The area of attachment
(apposition) between the diaphragm
and the ribcage is referred to as the
zone of apposition (ZOA) which is of
great importance for proper diaphragm
function (40,42,43). An elevated chest
position reduces the ZOA between the
diaphragm and the lower ribcage, and
impairs the contraction of the costal
part of the diaphragm (Fig. 7). The
ZOA is controlled by the abdominal
muscles and affects both the thoracic
and pelvic diaphragms’ length–tension
relationships. The efficiency of both
diaphragms largely depends upon the
diaphragm’s position and anatomical
relationship with the lower ribcage
and the pelvic girdle. In other words,
not only can changing the position of
the pelvis affect ribcage position, but
changing ribcage position can affect
pelvic position.
The combination of an elevated
chest with an anteriorly tilted pelvis
is a common posture that severely
compromises the ability to achieve
proper stabilisation. Ideally the
diaphragm and pelvic floor should be
parallel and/or horizontally to each
other for maximal position and function
(Fig. 8). The role of the abdominal
musculature is to oppose the action
of the thoracic diaphragm by way of
eccentrically contracting. This opposing
action of the abdominal musculature
is imperative in controlling the length–
tension relationship of both sides of the
diaphragm muscles. All skeletal muscles,
including the diaphragm, have a length–
tension relationship where decreased
length (contraction) decreases the force
of the contraction. The opposing forces
created by the abdominal muscles in
their eccentric contraction maintain
a normal range of ZOA so that the
needed force generated by the thoracic
diaphragm is not lost.
the leFt aiC
The left AIc pattern describes a
polyarticular chain of muscles that is
anterior to the spine and interior in the
body. There are two anterior interior
polyarticular muscular chains in the
body that have a significant influence
on respiration, rotation of the trunk,
ribcage, spine and lower extremities.
These two tracts of muscles, one
on the left and one on the right, are
interior to the thoraco-abdominalpelvic cavity and are composed of
the diaphragm, psoas, iliacus, tensor
fasciae latae, biceps femoris and vastus
lateralis muscles (Fig. 9). This chain
of muscles provides the support and
anchor for abdominal counterforce,
trunk rotation and flexion movement.
These muscles are all interrelated;
thereby changes in one of them will
affect the others (32–34).
Zone of apposition
The thought is that this chain of
muscles becomes imbalanced because
of several factors such as asymmetrical
position of organs, asymmetrical forces
exerted by the diaphragm and cerebral
hemisphere dominance (31–34). This
pattern is thought to be established in
both right- and left-handed individuals.
The absence of a liver on the left
side of the body creates a situation
where the left hemi-diaphragm is
not well positioned and therefore
sportEX medicine 2015;64(April):10-18
evidence inFormed practice
the area of the diaphragm known
as the ZOA becomes decreased
(43). consequently, the left lower
ribs become more elevated and/
or externally rotated relative to the
right side and the left abdominals may
become lengthened relative to the right
side. The ZOA is the area of the chest
wall where the abdominal contents abut
the lower ribcage.
The influence of the asymmetrical
pull of the hemi-diaphragms on the
ribs is due in part to the asymmetrical
distal diaphragm attachment sites;
asymmetrical domes of the hemidiaphragms and asymmetrical forces
are produced resisting the descent
of the diaphragm upon inhalation. The
distal attachment sites are known as
the crura (singular, crus). The right
diaphragm’s crus is broader and longer
and arises from the anterolateral
aspect of the first three lumbar
vertebral bodies (l1–l3), whereas the
left hemi-diaphragm’s crus corresponds
to the upper two vertebral bodies (l1–
l2). The left and right crura converge
to form the central tendons of the
diaphragm. The right hemi-diaphragm
dome is much larger and more
dome-shaped than the left. The right
diaphragm has the liver directly under
it, giving it more of a dome-shape and
providing a better fulcrum by resisting
downward displacement on which
the diaphragm acts to raise the lower
ribs upon inhalation and therefore
provides a more optimal ZOA. The left
hemi-diaphragm is smaller and flatter
than the right, due to development,
location and lack of a central fulcrum.
It has little oppositional resistant
force upon inhalation and most often
leads to a less than optimal ZOA, and
consequently an elevated lower ribcage
and/or rib flare.
AN INDIvIDUAl
WITh A leFT
AIc PATTeRN WIll
DeMONSTRATe
WeAKNeSS AND
leNgTheNINg OF
SPecIFIc MUScleS
IN All ThRee
PlANeS
Pelvic position
The greater pull of the left hemidiaphragm due to decreased
oppositional demands, when compared
to the right, is thought to contribute to
an asymmetrical lumbo-pelvic-femoral
position. This position contributes to an
anterior pelvic tilt and forward pelvic
rotation on the left side. Accompanying
}
Figure 6: Relationship of
thoracic diaphragm and
pelvic diaphragm in regards
to respiratory function.
(Copyright: Postural
Restoration Institute, 2014.
Image used with permission.)
www.sportEX.net
Figure 7: Forward tilt of
pelvis and elevated lower
ribcage and sub-optimal
zone of apposition (ZOA).
(Copyright: Postural
Restoration Institute, 2014.
Image used with permission.)
Figure 8: Neutral position
of pelvis and depressed
lower ribcage with optimal
ZOA. (Copyright: Postural
Restoration Institute,
2014. Image used with
permission.)
left
anterior
interior
chain (left
aiC)
Figure 9: Left
anterior interior
chain (left AIC).
(Copyright: Postural
Restoration Institute,
2014. Image used
with permission.)
15
positional issues would include
rotation of the lumbar vertebrae and
the sacrum to the right. The right
hip when operating in a closed chain
would therefore be in adduction and
orientated in internal rotation. The left
hip would also compensate for this
right spine and sacrum orientation
by abducting and externally rotating
the lower left extremity to realign
the foot in the sagittal plane. This is
complimented by a left anteriorly tilted
pelvis (sagittal plane) and forwardly
rotated pelvis (transverse plane).
An individual with a left AIc pattern
will demonstrate an anterior tilt and
forward rotation of the left hemi-pelvis.
Due to this position, the individual will
usually demonstrate weakness and
lengthening of specific muscles in all
three planes. Muscles that provide
movement and control of the lumbopelvic-femoral complex have the
ability to perform in more than one
plane. Symmetry is restored when
recruitment of specific muscles are
engaged between the left and right
side of the body. Individuals with a left
AIc pattern who are positioned in a
state of right AF IR and left AF eR will
most likely demonstrate the following
myokinematic relationships: the left
hemi-pelvis is positioned in a state of
flexion, abduction and external rotation;
the right hemi-pelvis is positioned in
a state of extension, adduction and
internal rotation (Fig. 10). All efforts
to restore proper acetabular femoral
position in all three planes are desired
(Fig. 11). Furthermore, it necessitates
Figure 10: Clockwise rotation of the
acetabulum on the femur results in
the acetabulum internally rotating on
the fixed right femur causing right
acetabulum femoral internal rotation
‘right AF IR’ and concomitant left
acetabulum external rotation ‘left
AF ER’ of the acetabulum externally
rotating on the fixed left femur.
(J. Masek, 2014)
16
correction of femoral acetabular
compensatory activity once proper
acetabular femoral position is obtained
(32–34).
The pelvic position with this left
AIc pattern is thought to result in
part from the asymmetrical pull on
the spine by the diaphragm and also
from the weaker left abdominals which
would result in a an anterior tilt and
forward rotation of the left innominate
relative to the right and sacral
orientation to the right (44). If the
femur stays neutral in the acetabulum
when the pelvis goes anterior and
forward it would appear to be oriented
inward with toes pointing inward to the
midline. This position often results in
compensatory left hip external rotation
to reorient the foot on the ground and
the femur back into the sagittal plane
(32–34).
length–tension and positional
influences
Prolonged postural adaptations can
result in muscle length changes. The
time muscle spends in the shortened
range and the amount the muscle is
contracted in the shortened range
determines whether it becomes
shortened. conversely the rationale for
lengthening a muscle is the amount
of tension placed on the muscle
over a prolonged period. Sustained
postures, particularly postures that
are maintained in faulty alignments
can induce changes in the muscle’s
length. These adaptations in the
muscle length may not only contribute
Figure 11: Anticlockwise rotation of
the acetabulum on the femur results
in the acetabulum internally rotating
on the fixed left femur causing left
acetabulum femoral internal rotation
‘left AF IR’ and concomitant right
acetabulum external rotation ‘right
AF ER’ of the acetabulum externally
rotating on the fixed right femur.
(J. Masek, 2014)
to being responsible for the faulty
posture but also may contribute to
altered length–tension properties and
subsequent force couple action of
muscles. Musculature may be unable
to develop the required tension if it
is mal-positioned or if non-desirable
symmetry exists. Therefore the use
of other muscles with similar actions
to control the action otherwise
carried out by the prime mover needs
to occur. This in turn may lead to
abnormal movement patterns (45).
Balance between musculature across
the left and right side of the lumbopelvic-femoral complex is essential
in the development and maintenance
of correct postural alignment and
consequently avoids the development
of a faulty posture (Table 1).
aF/Fa mechanics
The inability to rotate an acetabulum
on a non-moving femur or the inability
to rotate a femur on a non-moving
acetabulum can result in compensatory
shearing forces throughout the pubis
symphysis, sacroiliac joints and
the lumbosacral junction. It would
be beneficial to establish stability
throughout these structures before
addressing the compensatory shear
issues. compensatory rotational
control, throughout the body’s
transverse plane of movement,
secondary to decreased rotational
control throughout the AF/FA joints,
places additional compression and
shearing forces on these same joints.
Rotary movements of the femur
depend largely on the acetabular
position, compression of the femur
in the acetabulum from muscle
activity during open kinetic chain
activities, and from bearing weight
during closed chain kinetic activities
(45). Anterior rotation of the two
hemi-pelvises on the femur places
the femurs in a passively internally
rotated position in relationship to the
pelvis. Anterior rotation of one hemipelvis places one’s centre of gravity
on the contralateral lower extremity.
On the side that the hemi-pelvis is
rotated anteriorly and forwardly, there
is probable accompanying internal
rotation weakness. This occurs
as a result of the passive internal
orientation of the femur or as a
sportEX medicine 2015;64(April):10-18
evidence inFormed practice
result of compensatory activity of the
external rotators to orientate the femur
towards midline if the hemi-pelvis does
not extend or posteriorly rotate. The
lower extremity on the contralateral
side of the posteriorly rotated pelvis
would most likely demonstrate external
rotation weakness secondary to the
orientation of the pelvis on the femur,
for the aforementioned reason.
examination of one’s posture may
reveal an increased lumbar lordosis or
pelvic obliquity that may account for
hip impingement (46,47). Therefore, if
the pelvis is more anteriorly rotated,
the greater the risk for impingement
(46). Acetabular movement on the
femur (AF) and femoral movement
on the acetabulum (FA) occurs with
rotation in all three planes of sagittal,
transverse and frontal direction. At
heel strike the acetabulum adducts
on the femur and then abducts from
midstance until terminal swing. At foot
stance the femur externally rotates
on the acetabulum and then internally
rotates during midstance. Regardless of
the phase, the inability to decrease the
forces of the femur on the acetabulum
or the acetabulum on the femur
because of improper pelvic orientation
or asymmetry leads to possible hip
impingement and/or labral tearing.
This lack of congruent rotation and
stability of AF/FA movement secondary
to asynchronous AF activity and
dyssynchronous FA activity can lead to
undesirable force-coupling and contact
during adduction and internal rotation
table 1: PoSitional and ComPenSatory inFluenCeS oF the
leFt aiC Pattern on muSCulature oF the lumbo-PelviC-Femoral ComPlex (J. maSek, 2014)
Plane
musculature
effect on left lumbopelvic-femoral complex
effect on right lumbo-pelvic-femoral
complex
Sagittal
Iliacus/psoas
Shortened and strong secondary to
flexion of the left hemi-pelvis (Positional)
lengthened and weak secondary to
extension of the right hemi-pelvis (Positional)
Tensor fasciae latae
Shortened and strong secondary to
flexion of the left hemi-pelvis
(Positional)
lengthened and/or normal length secondary
to extension of the right hemi-pelvis
(Positional)
hamstrings
lengthened and weak secondary to
flexion of the left hemi-pelvis (Positional)
Shortened and strong secondary to
extension of the right hemi-pelvis (Positional)
gluteus maximus
lengthened and weak secondary to
flexion of the left hemi-pelvis (Positional)
Shortened and strong secondary to
extension of the right hemi-pelvis (Positional)
Posterior gluteus medius
Shortened and strong secondary to
abduction (compensatory)
lengthened and weak secondary adduction
(Positional)
Anterior gluteus medius
Shortened and strong secondary to
abduction (Positional)
lengthened and weak secondary adduction
(Positional)
Adductor magnus and longus
lengthened and weak secondary to
abduction (compensatory)
Shortened and strong secondary to
adduction (Positional)
Ischiocondylar adductor
magnus
lengthened and weak secondary to
abduction (compensatory)
Shortened and strong secondary to
adduction (Positional)
Iliacus/psoas
Shortened and strong secondary
external rotation (compensatory)
lengthened and weak secondary internal
rotation moment (Positional)
Tensor fasciae latae
Shortened and strong secondary
external rotation (compensatory)
Shortened and/or normal length and strength
secondary to internal rotation (Positional)
gluteus maximus
Shortened and strong secondary
external rotation (compensatory)
lengthened and weak secondary internal
rotation (Positional)
Anterior gluteus medius
lengthened and weak secondary
external rotation (compensatory)
Shortened and/or normal length and strength
secondary to internal rotation (Positional)
Posterior gluteus medius
Shortened and strong secondary to
external rotation (compensatory)
lengthened and weak secondary internal
rotation (Positional)
Adductor magnus and longus
lengthened and weak secondary to
external rotation (compensatory)
Shortened and strong secondary to external
rotation (compensatory)
Ischiocondylar adductor
magnus
lengthened and weak secondary to
external rotation (compensatory)
Shortened and strong secondary to internal
rotation (Positional)
Piriformis
Shortened and strong secondary to
external rotation (compensatory)
lengthened and weak secondary internal
rotation (Positional)
Obturator internus
Shortened and strong secondary to
external rotation (compensatory)
lengthened and weak secondary internal
rotation (Positional)
Frontal
Transverse
www.sportEX.net
17
and abduction and external rotation,
regardless if the lower limb is loaded or
unloaded (34).
Although surgical options
have developed considerably to
reduce or prevent further joint
degeneration, restore structural
anatomic abnormalities and eliminate
biomechanical factors (14,48–50), there
is still a lack of information regarding
the underlying FAI pathomechanics. It is
theorised that correcting the underlying
mechanical pathology in FAI will help
delay the progression of hip arthritis
(51). Although pathomechanics appear
to account for FAI symptoms and
provide insight into the development of
diverse therapeutic approaches for FAI,
there is an absence of biomechanically
based treatments with proven
effects on both structure and pain.
Furthermore, there is limited theoretical
information that has been applied in a
manner that provides understanding or
offers a foundation for clinical decision
making regarding the biomechanics that
may have caused the hip pathology.
key PointS
n the human body has a noticeable outward
appearance of symmetry, with eyes, ears and limbs
being symmetrical around the midline.
n internally, the organs are inherently asymmetrically
arranged.
n Postural restoration techniques assist in the
treatment of undesirable asymmetry, restoring
proper joint position and muscle activity.
n Pelvic asymmetry is common among symptomatic
and asymptomatic individuals.
n Pelvic asymmetry has been thought to alter
body mechanics, affect the length of muscles
that originate on the pelvis, and result increased
strain on bony and soft tissues possible producing
asymmetrical adaptations.
n there are three types of Fai: pincer, cam and mixed
impingement.
n hruska’s postural pattern of asymmetry, the
left anterior interior chain (aiC) pattern, is
characterised by the tendency for the anterior tilt
and forward rotation of the left hemi-pelvis.
n the pelvis and the ribcage are linked through the
pelvic and thoracic diaphragms.
n respiratory and lumbo-pelvic-femoral function can
have an effect on Fai.
Summary
Postural Restoration® recognises a
common pattern of asymmetry that
may contribute to a multitude of
musculoskeletal conditions including
FAI. This article has described the
different types of FAI and the influence
that respiration can have on the
pelvic girdle through two part of the
diaphragm. In part two of this series I
will propose biomechanical mechanisms
and rationale for both cam and pincer
types of FAI as it relates to Postural
Restoration®.
online
References
Owing to space limitations in the print
version, the references that accompany
this article are available at the following
link and are also appended to the end
of the article in the web and mobile
versions. click here to access the
references http://spxj.nl/1zcIQ0h
Further reSourCeS
1. hruska clinic website
(www.hruskaclinic.com)
2.Postural Restoration Institute website
(www.posturalrestoration.com)
18
THE AUTHOR
JASON MASEK MA, PT ATC CSCS PRC
Jason completed his degree in Physical
Therapy from Des Moines UniversityOsteopathic Medical Center in Des Moines,
Iowa, USA. He received his athletic training experience
from the University of Nebraska-Lincoln and the
University of Minnesota. Jason currently practices at the
Hruska Clinic™ Restorative Physical Therapy Services in
Lincoln, Nebraska, USA. Jason has developed a strong
background in sports medicine and athletic injuries with
an emphasis in manual physical therapy. He is a member
of the National Athletic Trainers Association, the National
Strength & Conditioning Association. Jason has earned
the designation of Postural Restoration Certified (PRC)
as a result of advanced training, extraordinary interest
and devotion to the science of postural adaptation,
asymmetrical patterns and the influence of polyarticular
chains of muscles on the human body as defined by the
Postural Restoration Institute® in Lincoln, Nebraska, USA.
DISCUSSIONS
n how are respiration and the lumbopelvic complex linked?
n Name and describe the three types of
femoroacetabular impingement.
n What is the left anterior interior chain
pattern and how is it linked to FAI?
sportEX medicine 2015;64(April):10-18
Evidence informed practice
Femoroacetabular impingement
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eviDence informeD practice
Diagnosing
achilles
tenDinopathy
e
D
i
u
g
’
o
t
a ‘how
BY Dr Sarah Morton MBBS anD
Dr DYlan MorriSSeY PhD
introDuction
Tendinopathy is a very common
condition, seen regularly by sports
physicians, physiotherapists, general
practitioners and others. Indeed
overuse injuries are estimated to
be implicated in between 30–50%
of all sporting injuries (1). It can be
extremely debilitating so requires quick
recognition to enable you to help your
patient and to ensure you commence
the appropriate management. Of the
tendinopathies, Achilles tendinopathy
is likely to be the most common to
present and therefore the aim of this
article is to help with this diagnostic
process and how to differentiate it
from other pathologies. The lifetime
cumulative incidence is estimated at
5.9% in sedentary individuals and 50%
in elite endurance athletes (2). We
recognise that a lot of different opinions
revolve around tendinopathies, from
the aetiology (degeneration versus
inflammation) to when to image or not
(3,4). However, this ‘how to’ guide is
based on both the evidence and rich
clinical experience. Our key message
throughout, therefore, remains always
treat the patient, rather than primarily
the investigations, but do include
diverse forms of information where
possible.
www.sportEX.net
This article aims to act as a ‘how to’ guide for diagnosing Achilles
tendinopathy. We describe the differential diagnoses and look
carefully at the history taking, examination methods and imaging
techniques that we find useful in diagnosing Achilles tendinopathy.
We emphasise the use of imaging only when necessary and that
abnormal imaging does not necessarily translate to symptoms.
Throughout the article our key method remains to always treat the
patient and not the results of the investigations.
hiStorY taking
Achilles tendinopathy is likely to have
an insidious onset over time and
so patients are unlikely to present
immediately (5). Debate continues
about the exact pathology. In recent
years the continuum of tendinopathy
had been (mostly) accepted with
three stages recognised: reactive
tendinopathy, tendon disrepair and
degenerative tendinopathy (3).
However, recent work suggests that
chronic tendinopathy may in fact be
an active process of ongoing tendon
degeneration with an inflammatory
response underlying this (4). More
research will likely build on both of
these models in the future, and they
are something to consider when
managing your patient.
What is agreed upon is that
Achilles tendinopathy is more
commonly mid-tendon Achilles
tendinopathy, although insertional
Achilles tendinopathy is not uncommon.
As the literature (and our clinical
experience) suggests, these two main
types of Achilles tendinopathy require
different management. Therefore, it
is always crucial to determine the
site of the pain: if the patient points
at their calcaneus, insertional must
be considered before midsubstance
Achilles tendinopathy. If the patient
points more generally at their Achilles
tendon, or indeed rubs their hand along
the length of their tendon when asked
where the pain is, this will point you
more towards midsubstance Achilles
tendinopathy. Differentials for heel
pain are numerous but other common
local things to consider are: Achilles
tendon rupture, Achilles partial tear,
Achilles intratendinous tear (described
below), fascia crura tear (described
Our key MessAge
THrOugHOuT,
THerefOre, reMAIns
ALWAys TreAT THe pATIenT,
rATHer THAn prIMArILy
THe InvesTIgATIOns, buT
DO IncLuDe DIverse fOrMs
Of InfOrMATIOn WHere
pOssIbLe
19
if you have a current
subscription, login at
www.sportex.net to view
this video or download the
mobile apps which are free to subscribers with
online access.
online
Youtube Video 1: ‘David beckham injury –
Achilles tendon – 14 March 2010’.
(http://spxj.nl/1LzhQyp).
20
below), posterior impingement of the
ankle, long flexor tendinopathy, plantaris
tendinopathy, sinus tarsi syndrome,
retrocalcaneal bursitis and many
other but less common things such a
referred pain (6).
The type of pain a patient
presents with is also very important
for guiding your diagnostic process.
It should be noted that different
tendon problems have different pain
mechanisms and there are likely to
be interactions between pain beliefs,
central sensitisation, neuropathic
and localised pain (7). Therefore it is
crucial to listen to what your patient
says; what doctors are taught in
the first year of medical school still
applies – you ask an open question,
shut up and actively listen. patients
with Achilles tendinopathy will typically
describe more of a dull throbbing pain
throughout their tendon, that often
worsens with activity and improves
with rest (5). It is often associated
with stiffness in the morning, with a
patient describing the need to warm
their tendon up (5). Indeed the vIsA-A
questionnaire, a validated questionnaire
used in assessing the severity of the
Achilles tendinopathy, uses the time the
stiffness lasts in the morning as one of
its grading questions (8). Interestingly
another question on the vIsA-A
questionnaire is to describe the pain
when walking downstairs, which may
be helpful in clarifying your patient’s
description (8).
In contrast, Achilles tendon rupture
or tear is characterised by a very
sharp, sudden onset pain, which some
patients describe as being shot in the
back of the leg (5). normally it will stop
the patient continuing their activity
immediately; David beckham in March
2010 is a classic example of this (video
1). Interestingly, although normally
asymptomatic, full tendon ruptures do
normally occur on a background of
tendon pathology. partial tears tend
to be a more pin-point sharp pain
with a memory of the event occurring.
These, unlike tendon ruptures, often
have preceding tendinopathy pain
and can co-exist. Intratendinous tears
have been recently described in the
literature and some patients with small
tears appear to be able to train but not
reach maximal loading; these tears will
also tend to occur in active individuals
performing at high levels of sport (9).
patients will also describe an area of
maximum pin-point pain (9). Another
recently described pathology is that of
a fascia cruris tear; again this presents
with sudden onset pain more medially
or laterally to the tendon (10). both
fascia cruris tears and intratendinous
tears also often co-exist with Achilles
tendinopathy. It is recognised that
different tendons have different pain
mechanisms, which is yet another
reason why it is important to take time
to get an accurate description of the
pain (7). Our suggestion is, therefore, to
establish the type of pain, and if in any
doubt, organise suitable imaging. The
likelihood is you won’t need the imaging
to do more than confirm your clinical
suspicions, because if you have really
listened – and examined accordingly –
you will have got the answers.
Although Achilles tendinopathy is
more common in active individuals,
for example male distance runners
are recognised to have a lifetime risk
of 52%, it is by no means exclusive
to active people, as mentioned above
(2,11). Therefore, although it is important
to establish the amount and type of
physical activity and/or exercise your
patient undertakes, if they do not
partake in anything you should not
immediately exclude the diagnosis (12).
In fact, as many as half of all patients
are not sportingly active, hence why
tendinopathy is a major public health
issue. Also, beware of asking patients
only about their exercise. for example,
a builder might reply that he does
not do any exercise when in fact
he spends all day every day lifting
and carrying. Take time to take the
history and make sure you understand
completely the physical activity and
loads the tendon is exposed to –
children are a prime example of this.
so many children and young people will
be doing their three hours of football
training a week which they or their
parents will describe clearly; however,
they will forget to tell you about their
two hours of pe lessons a week, the
lunchtime school football session and
the park session they do with their
friends every weekend. Whereas with
adults the situation may not be so
extreme, do take a helicopter view of a
sportEX medicine 2015;64(April):19-24
eviDence informeD practice
patient’s activity profile and avoid being
beguiled by the immediately offered
explanation.
Autoimmune conditions such as
rheumatoid arthritis and even type 2
diabetes and high cholesterol have
also been found to be associated
with Achilles tendinopathy (13–15).
even drugs such as statins and
fluoroquinolones (antibiotics) have
been shown to be associated with
tendinopathic symptoms, alongside
social factors such as smoking (16–18).
Therefore the classical method of
taking a history is crucial, as past
medical history, drug history, family
history and social history may in
fact alert you to key risk factors for
a particular patient’s development
of the condition. Having access to
advice or guidance mechanisms and
services about factors such as weight
management or smoking cessation
at your finger-tips may help facilitate
holistic care. And remember, the patient
comes to you for help and they will
therefore not only tell you the majority
of what you need to know but also
what they particularly require you to
help with as every patient is different.
remember that a cure is unlikely, but
given that individualised management is
an early goal, this conversation is likely
to optimise successful treatment.
clinical exaMination
examining a tendon has generated
some controversy, especially when
the tendon is not easily palpable.
However, the Achilles tendon is easily
accessible and we suggest you do go
on to do a very full examination. And,
as with any orthopaedic or sports
medicine examination, it is important
to compare both sides. It is also very
useful to assess the patient’s gait to
see what, if any, impact the condition
is having on their ambulation. It may
also identify biomechanical factors,
such as foot pronation, that might
be associated with development of
Achilles tendinopathy (19).
After a thorough standing and
supine examination of function in
related areas, the Achilles tendon is
best examined with the patient prone.
The tendon may feel thickened and
is likely to be tender from about 2 to
6cm proximal to the calcaneal insertion
www.sportEX.net
DIfferenTIALs fOr HeeL pAIn Are
nuMerOus buT OTHer cOMMOn LOcAL
THIngs TO cOnsIDer Are: AcHILLes TenDOn
rupTure, AcHILLes pArTIAL TeAr, AcHILLes
InTrATenDInOus TeAr, fAscIA crurA TeAr,
pOsTerIOr IMpIngeMenT Of THe AnkLe, LOng
fLexOr TenDInOpATHy, pLAnTArIs TenDInOpATHy,
sInus TArsI synDrOMe, reTrOcALcAneAL
bursITIs AnD MAny OTHer (buT Less
cOMMOn) THIngs sucH A referreD pAIn
(5). There may be associated swelling
and crepitus, although this may be
attributable to paratendinopathy (5).
related structures should also be
examined to exclude other differentials,
for example ensuring posterior ankle
impingement is not present and that
there is no retrocalcaneal bursa.
It is always important to exclude
an Achilles tendon rupture and so the
simmond’s squeeze test should be
performed; if the tendon is torn, when
the calf muscle is squeezed the foot
will remain still and will not plantarflex
(5). It can also be noted when the
patient is lying prone whether the
affected foot is less plantarflexed in
comparison to the other – this is useful
in establishing whether there is still an
intact connection between the muscles
and tendons. In terms of specific tests
for Achilles tendinopathy the royal
London Hospital test has found to be
useful; if tenderness that is experienced
in the mid-tendon (approximately 3cm
proximal from the calcaneal insertion)
during slight plantarflexion is reduced
when the muscle contracts or the
foot is dorsiflexed this is said to be a
positive test and points towards the
diagnosis of Achilles tendinopathy (20).
The painful arc sign has also been
described in the literature, although it
may have been found to underestimate
the number of affected tendons (20,21).
passive plantarflexion is very useful for
ruling in or out posterior impingement.
It is, however, important that all these
tests be used alongside the history and
examination findings – if your history
doesn’t fit then think again.
One thing that is also very helpful,
as it gives an indicator of symptom
threshold, is a graded loading challenge.
for example it is important to ascertain
the Achilles tendon pain response
to, for example, a progression from
double- to single-leg slow heel raising
and lowering, to a double-leg jump
and then to hopping. As we progress
through these movements the load
on the Achilles tendon changes and
therefore an insight can be gained into
the pain response of the patient. It can
also be useful to establish the strength
of the tendon and surrounding muscles;
if one leg is affected and not the other
the difference can be significant. This
can then be very useful when treating
the patient to allow comparison and to
monitor progression.
iMaging
Imaging in all areas of medicine is now
bringing new challenges to the forefront.
Indeed one nHs radiologist recently
remarked to me that at least 20%
of scans carried out are as a result
of another imaging modality finding
something that might be ‘suspicious’
and so requiring further investigation.
Once again this comes back to treating
the patient and only using imaging
when necessary because of diagnostic
uncertainty, or to confirm the diagnosis
and rule out confounders. It must be
remembered also that the clinician
must be adept at using and interpreting
the imaging results to maximise benefit.
Also, ‘pathology’ can exist without
symptoms – it is common to have
changes on imaging scans but no
symptoms and therefore imaging
should not be used without real reason
(22). ultrasound is usually considered
first as it can often be carried out in
21
OnLy use IMAgIng
WHen necessAry
becAuse Of DIAgnOsTIc
uncerTAInTy, Or TO
cOnfIrM THe DIAgnOsIs
AnD ruLe OuT
cOnfOunDers
(a)
Figure 2: (a) Ultrasound of a left-sided
fascia cruris tear (blue arrow). (b)
Ultrasound image showing right-sided
fascia cruris tear (blue arrow) with
separate intratendinous tear (red
arrow). (c) A partial tear of the Achilles
tendon (yellow arrow) resulting in
disruption of the overall tendon shape.
(O. Chan, London Independent Hospital,
2015)
(a)
(b)
Figure 1: (a)
Ultrasound
image showing
a tendinopathic
tendon measuring
8.1mm at its
thickest point. (b)
Neovascularisation
seen in a
tendinopathic
Achilles tendon.
(O. Chan, London
Independent
Hospital, 2015)
22
(b)
(c)
a more timely fashion; it also benefits
from being a dynamic assessment that
can easily be followed up (5,23). by
this we mean the foot can be moved
during the assessment and indeed the
ultrasound probe can be used to find
the point of tenderness. commonly,
the anterior-posterior tendon diameter
is measured at the thickest point and
this measurement has been shown to
be a reliable indicator of tendinopathy
(24). One study of controls and cases
of Achilles tendinopathy showed a
statistically significant difference in the
tendon thickness between the groups:
4.4mm for control tendons compared
with 5.6mm for tendinopathic tendons
(25). In our experience, tendons can
be much thicker than this, as seen
in figure 1(a). However, just because
the tendon is thick does not mean
it is problematic so take it into
consideration, but do not allow it to
cloud your judgement.
neovascularisation (fig. 1b) can
also be graded on ultrasound, and has
shown to be weakly related to the
severity of the Achilles tendinopathy
(23–25). Again this can lead to
discrepancies between treating the
patient and treating the results on the
scan; in the absence of symptoms,
the presence of neovascularisation
does not confirm the presence of a
tendinopathy.
ultrasound also allows the
difference to be seen between
other Achilles pathologies including
partial tears, fascia cruris tears and
intratendinous tears (fig. 2). This is
where we feel imaging can be the
most powerful in helping you as
a clinician. It should be noted that
all of these pathologies can coexist with tendinopathy and so, as
described above, the clinical history
and examination is important; it may
be that a tendinopathic tendon is
seen on ultrasound but this is not the
underlying cause of a patient’s pain.
Magnetic resonance imaging, although
not as commonly used, can be good
at providing information regarding the
structures around the Achilles tendon
and other concurrent pathologies, for
example articular pathology (28).
concluSion
Achilles tendinopathy is a common
condition that is important to diagnose
accurately; differentials must be
excluded and co-existent pathology
should not be forgotten. Although this
article is primarily based on Achilles
tendinopathy, it should be noted that
many of these principles apply to other
tendons in the body and they can aid
the diagnosis of these tendinopathies
as well. And remember, your patient is
the primary source of powerful clues
and critical context.
sportEX medicine 2015;64(April):19-24
eviDence informeD practice
References
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4. rees JD, stride M, scott A. Tendons – time
to revisit inflammation? British Journal of
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5. Asplund cA, best TM. Achilles tendon
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6. Alvarez-nemegyei J, canoso JJ. Heel
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7. rio e, Moseley L, et al. The pain
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8. robinson JM, cook JL, et al. The visa-A
questionnaire: a valid and reliable index of the
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Journal of sports medicine 2001;35:335–
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9. Morton s, parkes T, et al. Achilles
intratendinous tears – a new pathology? results
of a 4 year case series. presented at British
association of sports and exercise medicine
annual conference, 2013. london, UK
10. Webborn n, Morrissey D, et al. Tears of the
fascia cruris at the attachment to the Achilles
tendon. British Journal of sports medicine
2014;doi:10.1136/bjsports-2013-093273
11. fields kb. running injuries - changing trends
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reports 2011;10:299–303
12. De Jonge s, van Den berg c, et al.
Incidence of midportion Achilles tendinopathy
in the general population. British Journal of
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13. Ames pr, Longo ug, Denaro v, Maffulli
n. Achilles tendon problems: not just
an orthopaedic issue. Disability and
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14. Akturk M, Ozdemir A, et al. evaluation
of Achilles tendon thickening in type 2
diabetes mellitus. experimental and clinical
endocrinology & Diabetes 2007;115:92–96
15. gaida Je, Alfredson L, et al. Dyslipidemia in
Achilles tendinopathy is characteristic of insulin
resistance. medicine & science in sports &
exercise 2009;41:1194–1197
16. van Der Linden pD, sturkenboom M, et al.
fluoroquinolones and risk of Achilles tendon
disorders: case-control study. the BmJ
2002;324:1306–1307
17. kraemer r, Wuerfel W, Lorenzen J,
busche M, vogt pM, knobloch k. Analysis
of hereditary and medical risk factors in
Achilles tendinopathy and Achilles tendon
ruptures: a matched pair analysis. archives
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2012;132:847–853
18. Marie I, Delafenêtre H, et al. Tendinous
disorders attributed to statins: a study on
ninety-six spontaneous reports in the period
1990-2005 and review of the literature.
arthritis & rheumatism arthritis care &
research 2008;59:367–372
19. nigg bM. The role of impact forces and foot
pronation: a new paradigm. clinical Journal of
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20. Maffulli n, kenward Tg, et al. clinical
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tendinosis. clinical Journal of sport
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21. Williams Jgp. Achilles-tendon lesions in
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22. Malliaras p, purdam c, et al. Temporal
sequence of greyscale ultrasound changes and
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23. Del buono A, chan O, Maffulli n. Achilles
tendon: functional anatomy and novel emerging
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24. fredberg u, bolvig L, et al. ultrasonography
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THE AUTHORS
DR SARAH MORTOn MBBS
D
Sarah is an academic foundation year one
doctor at Hillingdon Hospital. She completed
her medical degree at Imperial College. Her intercalated
degree was in Sports and Exercise Medicine at Queen
Mary University of London. Since then she has published
papers on risk factors in patellar tendinopathy, low
back pain in cricketers and high volume image guided
injections. She was awarded the Helal and Harries
Sports and Exercise Medicine prize in 2014 for her work
on risk factors in patellar tendinopathy. She continues
her research in this around her on-call sessions, even
occasionally managing to make it to a cricket or rugby
match.
DR DyLAn MORRISSEy PHD
D
Dylan Morrissey’s overarching career
objective as a clinical academic is to
combine the best of educational, clinical
and research practice in order to develop and deliver
high quality evidence based physiotherapy for patients
with musculoskeletal disorders. He is a consultant
physiotherapist in Sports and Musculoskeletal
Physiotherapy and clinical reader in Sports and Exercise
Medicine, who recently started a 5-year nIHR/HEE
fellowship with clinical trials as a primary focus. His
key research theme is the link between movement and
pathology, with a particular interest in tendinopathy.
@DrDylanM; d.morrissey@qmul.ac.uk
Further reSourceS
1. Tendon research group at Queen
Mary university London, uk.
http://spxj.nl/1goJbJn
if you have a current subscription,
login at www.sportex.net to view
these videos or download the mobile
apps which are free to subscribers
with online access.
Video 1: achilles tendinopathy: examination in standing
Video 2: achilles tendinopathy:
Video 3: achilles tendinopathy: low Dye taping
Video 4: achilles tendinopathy: Making a temporary orthotic
Video 5: achilles tendinopathy: eccentric loading
Video 6: achilles tendinopathy: Scenarios
Video 7: achilles tendinopathy: Physical examination tips
keY PointS
n achilles tendinopathy is common and has a lifetime
cumulative incidence of 50% in elite endurance
athletes.
n there are numerous differentials for heel pain
including achilles tendon rupture, achilles partial
tear, posterior impingement of the ankle and many
others.
n achilles tendinopathy patients will typically describe
a dull throbbing pain throughout their tendon.
n examination is useful as differentials can be
excluded and contributing factors, such as
biomechanics, identified.
n as with any orthopaedic or sports medicine
examination, always compare both sides of a
patient.
n graded loading challenges can be very useful
when examining a patient and as a baseline for
treatment.
n imagining is useful when diagnostic uncertainty
exists.
n always treat the patient and not the investigations
and listen carefully to what they say as you are
likely to get your answers from this alone.
24
DISCUSSIONS
n What other differentials should be considered in
Achilles tendinopathy? Would age or activity level
change this? Would there be any particular diagnoses
you would consider for children?
n Do you believe imaging is beneficial? Would you want
imaging before starting treatment? Do you use imaging
to follow up your patients?
n What is your examination technique for Achilles
tendinopathy? Are all the tests described in the
article included in your current examination? Are
there additional tests you would include? What is the
justification for this?
continuing education
Multiple choice
questions
This article also has a certificated eLearning test
which can be found under the eLearning section of
our website. for more information on how to access
the test click this link http://spxj.nl/cpdquizzes
this qUiz is
accessiBle
free
with a sUBscription that inclUDes
online access to this JoUrnal.
sportEX medicine 2015;64(April):19-24
eviDence informeD practice
online
if you have a current subscription, login at www.sportex.net
to view this video or download the mobile apps which are
free to subscribers with online access.
Video 1: achilles tendinopathy
lower limb biomechanics – examination in standing
Video 2: achilles tendinopathy
lower limb biomechanics – examination in lying
Video 3 achilles tendinopathy
lower limb biomechanics – low Dye taping
Video 4: achilles tendinopathy
lower limb biomechanics – Making a temporary
orthotic
www.sportEX.net
online
if you have a current subscription, login at www.sportex.net
to view this video or download the mobile apps which are
free to subscribers with online access.
Video 5: achilles tendinopathy – eccentric loading
Video 6: achilles tendinopathy – Scenarios
Video 7: achilles tendinopathy –
Physical examination tips
26
sportEX medicine 2015;64(April):19-24
EvidEncE informEd practicE
Osteoarthritis is a painful condition caused by the
degeneration of the joints. Treatment can involve
a combination of approaches, including exercise,
lifestyle changes and pain relief and ultimately
surgery. This article describes the use of gait
retraining for the reduction of pain and improvement
of function in medial osteoarthritis of the knee.
BY Professor CathY sPeed BMedsCi, diP sPorts
Med, Ma, Phd, frCP, ffseM (i) (UK)
The pain experienced in osteoarthritis (OA) is associated
with a number of factors including body weight, mental
status, co-morbidities and gait biomechanics. These factors
themselves are predictive of persisting pain.
Gait retraining for patients with OA of the knee is based
on the rationale that pain and progression are greater in
those individuals who have certain biomechanical issues. In
medial compartment OA, elevated knee adduction moment
(KAM) has been identified as a key component responsible
for excessive medial compartment loading contributing to
disease progression. Previous studies have implied that poor
neuromuscular control and inadequate muscle activation is
associated with the abnormally high KAM in this condition
(1,2).
KAM cannot be measured easily in clinical practice but
needs sophisticated analytical tools to assess reliably. Hence,
using increased KAM as a criterion for gait retraining is not
possible, but rather clinical assessment of gait to detect any
abnormalities must be used.
Gait retraininG
‘Gait retraining’ simply means teaching patients to walk
normally to reduce abnormal forces across the affected
joint(s). Such retraining should be customised to the patient’s
needs and should always commence with neuromuscular
and proprioceptive training. Given that body mass also
significantly influences knee loads, weight management must
be considered a priority.
More sophisticated approaches to gait retraining have
been described. For example Shull et al. described a 6-week
programme in adults with OA of the medial knee who were
already reasonably functional (adults able to walk unaided for
25 minutes) (3).
Exclusion criteria included: body mass index greater
than 35; inability to adopt an altered gait due to previous
injury or surgery on the back or lower extremities; use of a
shoe insert or hinged knee brace; or corticosteroid injection
within the previous 6 weeks. Gait retraining and analysis was
focused on the leg with greatest self-reported knee pain.
Subjects attended the laboratory and were assessed
using a sophisticated 8-camera system and sensors to
identify abnormal gait patterns. Instructions were given to
the patient to alter trunk sway and foot progression angle
www.sportEX.net
Gait retraininG
retraininG
in medial
osteoarthritis
of the knee
as appropriate. The first session was to determine baseline
pain and function, identify baseline walking patterns, identify
an individualised altered gait pattern for each subject, and to
train the subject to walk with this new, altered gait. Weekly
gait retraining sessions were then followed. during one posttraining session and at 1-month follow-up, walking kinematics,
knee loading, pain, and function were re-assessed.
Gait retraining reduced the first peak KAM by 20%
(P <0.01) post-training as a result of a 7° decrease in foot
progression angle (ie. increased internal foot rotation),
compared to baseline (P <0.01). WOMAc (Western Ontario
and McMaster universities) pain and function scores were
In MEdIAl cOMPArTMEnT OA,
ElEvATEd KnEE AdducTIOn
MOMEnT (KAM) HAS bEEn IdEnTIFIEd
AS A KEy cOMPOnEnT rESPOnSIblE
FOr ExcESSIvE MEdIAl cOMPArTMEnT
lOAdInG cOnTrIbuTInG TO
dISEASE PrOGrESSIOn
25
diagnosis
- OA – medial knee
- non-surgical medial
meniscal pain
GIvEn THAT bOdy MASS AlSO
SIGnIFIcAnTly InFluEncES KnEE
lOAdS, WEIGHT MAnAGEMEnT
MuST bE cOnSIdErEd A PrIOrITy
further evaluation
- bMI
- Exercise habits
- Self efficacy
- WOMAc
- Gait analysis/
biomechanics
Patient
education
Weight
management
Pain
management
Oral/injectable
Physical
therapy
To include
neuromuscular
& proprioceptive
neurotraining
Consider aPos or
other gait retraining
- Persisting pain without
analgesics, in spite of
completion of above
- no contraindications*
*exclusions to aPos
n Mean WOMAc at
baseline >5 (on
WOMAc 0–10, average
of 3 scales)
n bi- or tricompartmental
disease
n Inflammatory arthritis
n Falls
n Severe osteoporosis
and/or history of
fragility fractures
n Significant knee
deformity
n Obesity
n low self-efficacy score
n Inability to mobilise 100
yards (not a radiologic
definition) or maintain
mobility >25 minutes
without aids
n Other restrictions
to mobility, eg.
lymphoedema
n Surgery indicated.
an alternative aPProaCh
to Gait retraininG: aPostheraPY
Another well-publicised approach to gait retraining is
the Apos system, footwear that can be progressively
adapted to change the ‘centre of pressure’ and causes gait
perturbations, presumably with the objective to promote
positive adaptations during progressive daily timed sessions.
In one of the few studies on the device by a non-affiliated
research group, KAM reduction was reported (4).
This was accompanied by elevated walking velocity,
significant pain reduction, and increased functional activity.
The study group was small (n = 25 females) and the severity
of the disease on basis of WOMAc was not severe (mean
4.09 ± 2.29cm (vAS for pain, stiffness, function 0–10cm). The
study was uncontrolled. Similar results have been reported
by the Apos research Group (5), and a further uncontrolled
study by the Apos group reported a significant improvement
was seen in all of the gait parameters and in improvement
in WOMAc scores following 6 months of therapy. However,
again the mean baseline WOMAc scores were low (<5, vAS
scales 0–10, range and Sd not given). The study population
was a multi-ethnic Singaporeans with bilateral medial OA of
the knee.
Gait retraininG as Part
of the rehaBilitation ProCess
Consider orthotics
Additional foot & ankle
disorder/leg length
discrepancy
Figure 1: Non-surgical treatment of medial osteoarthritis of the knee. (C.
Speed, 2015)
26
improved at post-training by 29% and 32%, respectively
(P <0.05) and visual analogue scale (vAS) pain scores
improved by two points (P <0.05). changes in WOMAc
pain and function were approximately 75% larger than the
expected placebo effect (P <0.05). changes in KAM, foot
progression angle, WOMAc pain and function, and vAS were
retained 1 month after the end of the 6-week training period
(P <0.05).
The studies outlined above do indicate that gait retraining
does improve pain and function, at least at short-term
follow-up, in patients with medial knee OA. Sophisticated
biomechanical analysis is not possible in most patients.
Hence, from a pragmatic perspective clinicians – and in
particular rehabilitation specialists – should be trained
to evaluate the patient with medial OA for those gait
abnormalities that are associated with increased KAM: foot
progression angle (6,7), tibia angle (8), hip adduction/internal
rotation (9), and trunk sway (8,10,11), such that adaptations can
be recommended as part of the rehabilitation process. Many
patients will respond to neuromuscular and proprioceptive
training and will not need modifications to their gait. Hence,
sportEX medicine 2015;64(April):25-27
EvidEncE informEd practicE
the former elements must be considered first in the
rehabilitation pathway.
Gait retraining should be reserved for those without
severe deformity and with mild to moderate disease on the
basis of baseline WOMAc indices. radiological grading is
not required. Some patients will become eligible with good
medical management leading to reductions of WOMAc
scores. It is likely that patients with medial meniscal pain
should also follow the same pathway as that for medial OA of
the knee. However, evidence for benefit of gait interventions
in lateral tibiofemoral and global knee OA is lacking.
References
1. Fisher nM, Pendergast dr. reduced muscle function in patients
with osteoarthritis. Scandinavian Journal of rehabilitation
medicine 1997;29:213–221
2. Sharma l, lou c, et al. laxity in healthy and osteoarthritic knees.
arthritis & rheumatism 1999;42;861–870
3. Shull Pb, Silder A, et al. Six-week gait retraining program reduces
knee adduction moment, reduces pain, and improves function for
individuals with medial compartment knee osteoarthritis. Journal of
orthopaedic research 2013;31:1020–1025
4. Haim A, rubin G, et al. reduction in knee adduction moment via
non-invasive biomechanical training: a longitudinal gait analysis study.
Journal of Biomechanics 2012;45:41–45
5. bar-Ziv y, beer y, et al. A treatment applying a biomechanical
device to the feet of patients with knee osteoarthritis results in
reduced pain and improved function: a prospective controlled study.
Bmc musculoskeletal disorders 2010;11:179
6. Shull Pb, Shultz r, et al. Toe-in gait reduces the first peak knee
adduction moment in patients with medial compartment knee
osteoarthritis. Journal of Biomechanics 2013;46:122–128
7. Guo M, Axe MJ, Manal K. The influence of foot progression angle
on the knee adduction moment during walking and stair climbing
in pain free individuals with knee osteoarthritis. Gait & posture
2007;26:436–441
8. Shull Pb, lurie K, et al. Training multi-parameter gaits to reduce
the knee adduction moment with data-driven models and haptic
feedback. Journal of Biomechanics 2011;44:1605–1609
9. barrios JA, crossley KM, davis I. Gait retraining to reduce the
knee adduction moment through real-time visual feedback of
dynamic knee alignment. Journal of Biomechanics 2010;43:2208–
2213
10. Mundermann A, Asay J, et al. Implications of increased
medio-lateral trunk sway for ambulatory mechanics. Journal of
Biomechanics 2008;41:165–170
11. Hunt MA, Simic M, et al. Feasibility of a gait retraining strategy for
reducing knee joint loading: increased trunk lean guided by real-time
biofeedback. Journal of Biomechanics 2011;44:943–947.
fUrther resoUrCes
1. AposTherapy website
(http://apostherapy.co.uk/en/home).
THE AUTHOR
PROf CATHy SPEEd BMEdSCi, diP SPORTS
P
MEd, MA, PHd, fRCP, ffSEM
M
Cathy is a consultant in Rheumatology,
Sport & Exercise Medicine. She is based at The fortius
Clinic, London, and at the Cambridge Centre for Health
and Performance in Cambridge. She is also a senior
physician for the English institute of Sport.
www.sportEX.net
KeY Points
n the pain experienced in osteoarthritis (oa) is associated with a
number of factors including body weight, mental status, co-morbidities
and gait biomechanics.
n Pain and disease progression are greater for individuals with certain
biomechanical issues.
n in medial compartment oa, elevated knee adduction moment (KaM)
is a factor in excessive medial compartment loading and disease
progression.
n KaM cannot be measured easily in clinical practice, so clinical
assessment must be used to detect gain abnormalities.
n Gait retraining reduces the abnormal load on the joint by teaching
patients to walk normally.
n Gait retraining should always start with neuromuscular and
proprioceptive training.
n studies have shown that a 6-week gait retraining programme caused
changes in KaM, foot progression angle, WoMaC pain and function,
and vas that were retained at the 1-month follow-up assessment.
n apostherapy involves footwear that can be progressively adapted to
change the ‘centre of pressure’ and causes gait perturbations.
n Gait retraining should be reserved for those with only mild to
moderate disease on the basis of baseline WoMaC indices.
DISCUSSIONS
n What factors are associated with the pain experienced
in osteoarthritis (OA)?
n What is elevated knee adduction moment (KAM), and
how does this affect medial compartment OA?
n What are the gait abnormalities associated with
increased KAM?
n What is gait retraining and which OA patients is it
suitable for?
online
if you have a current subscription, login
at www.sportex.net to view this video
or download the mobile apps which are
free to subscribers with online access.
video 1:
AposTherapy
– how it works
http://spxj.
nl/1dT31I7
video 2:
AposTherapy
for knee pain
after surgery
http://spxj.
nl/1lcr90P
Videos by YouTube user
‘AposTherapyUK
27
TendinopaThy loading
programmes
An overview of current concepts
This article is an overview of a review by Malliaras et al. (1) looking at Achilles
and patellar tendinopathy rehabilitation. There has been much research into the
pathophysiology of tendinopathy and management of the condition has changed
distinctly in the last 10 years. However, therapists are still using these old protocols
(observed as little as 4 weeks ago) despite an incredible 45% of patients not
responding significantly to eccentric exercise programmes.
By Paula
clayTon MSc, Fa
diP, MaST STT
Background
There have been advances in the
research surrounding the pathophysiology
of tendinopathy but focus on treatment
appears to a degree to be in the
incunabulum stage. Ten years ago,
the management of tendinopathy was
distinctively different to what you will
see today. Finding high quality clinical
trials providing proven clinically significant
advancement following treatment is tricky
(which was unanticipated) despite the
apparent plethora of theoretical research
Stress shielded
unloaded
optimised
load
normal tendon
normal or
excessive
load +/- excessive appropriate
load +
modified
individual
load
factors individual
factors
reactive tendinopathy
Tendon dysrepair
optimised
load
adaptation
strengthen
looking at tendon pathology, function and
rehabilitation.
Malliaras and colleagues’ systematic
review on Achilles and patellar
tendinopathy loading programmes
compared clinical outcomes and
identified potential mechanisms for
effectiveness (1). Methodological flaws
were found in abundance and they only
found two studies that were accepted
as high quality, the majority had not used
validated outcome measures, and they
only found two that defined sufficient
blinding.
Malliaras et al. (1) found that an
incredible 45% of patients did not
respond significantly to eccentric
exercise programmes. Treatment options
for tendinopathy are in abundance
with many factors to consider; it can
be helpful to think of what your main
treatment goal is and keep this in mind. If
the key goal in tendinopathy rehabilitation
is improving the capacity of the tendon
and muscle to manage load (tendon
and muscle function together as a
musculotendinous unit) this needs to be
considered in the rehabilitation phase, not
just the tendon structure.
TendinoPaThy
degenerative tendinopathy
Figure 1: Physiopathology of tendinopathy.
[cook and Purdam, 2009 (2)]
28
Before we delve into this it would be
helpful to remind ourselves what we
currently know about tendinopathy.
Cook and Purdam’s (2) tendinopathy
continuum describes three different
stages of tendinopathy: reactive,
dysrepair and degenerative (Fig. 1).
Reactive tendinopathy
Usually involves the tendon responding
to a rapid increase in loading or from
direct trauma – initially believed to
involved inflammation but now it is
understood that although the tendon
does swell this is due to movement of
the water into the extracellular matrix (3),
not inflammatory products. A key feature
of a reactive tendon is that structurally
it remains intact and there is minimal
change in collagen integrity – meaning
this is a reversible process.
Tendon dysrepair
Typically the stage that would follow
reactive tendinopathy if the tendon
continues to be excessively loaded. It
is similar to the reactive stage but the
tendon structure begins to change with
greater matrix breakdown.
Degenerative tendinopathy
More common in the older generation/
older athlete. Typically represents a
response of the tendon to chronic
overloading. There are multiple tendon
structure changes making it less efficient
at dealing with load. Collagen becomes
disorganised and advanced matrix
breakdown takes place alongside further
increases in vascularity and neuronal
ingrowth. The tendon can appear
thickened and nodular and there is a
risk of tendon rupture with advanced
degeneration.
sportEX medicine 2015;64(April):28-32
liTeraTure review
ManageMenT oF
TendinoPaThy
Figure 2 shows the aim of
tendinopathy rehabilitation and the
factors needed to achieve it.
“Each component of the rehabilitation
programme in particular loading,
must be manipulated in relation to
the nature, speed and magnitude of
the forces applied to the muscle/
tendon/bone unit in order to
achieve the goals of the particular
management phase without causing
an exacerbation of the pathological
state or pain” Scott et al. (4)
Cook and Purdam (2) simplify the
management of tendinopathy by
dividing it into two stages:
1. Reactive/early disrepair
2. Late dysrepair/ degenerative
Reactive/early dysrepair
The focus tends to be on load
management – a reduction of both
tensile (muscle contracts or resists
a stretching force) and compressive
load on the tendon. Cook & Purdam
(5) state that this phase lasts for
approximately 5–10 days, however, the
tendon will be sensitive to high loads
and training needs to be progressed
gradually to prevent relapse (tensile
loads can be reduced with adaptation
to training – reducing the distance,
time, etc.). Tendinopathy on the
other hand, often has a compressive
component that requires attention.
TaBle 1. iS coMPreSSive load a FacTor in The develoPMenT oF
TendinoPaThy? [Adapted from Cook and Purdam (5)]
Tendon
Site
Position
Modification
Effective
Achilles
Superior
calcaneus
dorsiflexion
Heel raise
Yes
Proximal
hamstring
Ischial tuberosity
Hip flexion
Limiting sitting/lunging
Moderately
Gluteus
medius/
minimus
Greater
trochanter
Hip adduction
Lumbopelvic control/sleep
supine
Yes
Adductor
longus/rectus
abdominus
Pubic ramus
Hip abduction/
extension
Limit loads in abduction/
extension
Moderately
Quadriceps
Femoral condyle
Deep knee flexion Limit loads in deep knee flexion
Late disrepair/degenerative
tendinopathy
The irritable tendon that is abnormally
larger than normal, with palpable nodules
is inclined to be degenerative – in
addition, an unusual increase in pain
responding to an increase in training/
running/exercise tends to indicate
reactive tendinopathy.
If this should happen, principles
of managing a reactive tendon apply
(load management, anti-inflammatories,
isometrics) until the tendon calms down.
The chronically irritable tendon
without the sudden increase in pain
is managed with a mixture of load
management, isometric, concentric and
eccentric work. Changes within the
tendon may be reversible but more
commonly this becomes a condition in
need of long-term management.
Moderately
reduce pain
exercise
selection
improve muscle
and tendon
capacity
to manage
load
compliance
from
athlete
effective ‘loading
strategy’
Figure 2: The key goal in tendinopathy rehabilitation and how
to achieve it. [RunningPhysio blog by Tom Goom
(http://spxj.nl/1FXJuHd/)]
TaBle 2: coMPariSon oF loading PrograMMeS [Adapted from Malliaras et al. (1)]
Exercise
Research
Sets/reps
Load
Frequency
Plan
Eccentric
Alfredson
et al. (8)
3 × 15
Body weight then increase, pain
permitting
2 × day
12/52
‘Heel drops’
n gastrocnemius bias
n soleus bias
Combined
Slibernagel et
al. (13)
Varies
Body weight, then increased in
phases based on status of person
being treated.
Daily
12/52 – 6/12
Comprehensive
n concentric
n eccentric
n balance
n plyometrics
n return to sport
Heavy slow
resistance
(HSR)
Kongsgaard
et al. (10,11)
4 × 15–6RM
15–6RM progressed over 12
weeks, pain permitting.
3/7 for 12/52
Bilateral squat Leg press Hack squat
Gradual progressions in load
Includes 6 seconds per rep of eccentric
(3 sec) and concentric (3 sec).
15–6rM, indicates progression from the maximum load that can be lifted 15 times (15rM) to the maximum load that can be lifted 6 times (6rM).
www.sportEX.net
29
is compressive load a factor in the
development of tendinopathy?
Cook and Purdam (5) describe the
potential role of compression in
tendinopathy, which is reflected in Table
1. There is also a suggestion that when
managing load, always be guided by the
tendon’s 24-hour behaviour due to the
tendon’s latent response to loading.
Cook and Purdam (5) also suggest
that massage is a far better option than
stretching when managing tendinopathy
due to the potential for tendon
compression during the stretching
process. Also isometric exercise may
reduce pain and maintain muscle
strength in the reactive phase providing
the position held during the exercise
does not compress the tendon.
Pain management
In the first instance plan to reduce
excessive load and aggravating
movements (6), discuss the use of
anti-inflammatories with your doctor
(reduction of tenocyte activity) and
use isometrics to help reduce pain and
maintain strength (7).
Primary goal: reduce the pain
Henriksen et al. (6) tested the effect of
experimentally induced Achilles tendon
pain and deduced that tendon pain
causes:
“…widespread and reduced motor
responses with functional effects on
the ground reaction force.”
As discussed previously, pain is often
more severe during the reactive phase
of tendinopathy and the key to managing
that pain is by managing the load,
compressive forces and cutting out
stretch shortening cycle (SSC) activities.
Reduce the load – reduce the reactive
response.
According to Naugle et al. (7)
isometric exercises appear to reduce
pain in reactive tendinopathy:
“… isometric exercise appears to
exert a generalised pain inhibitory
response”
Long duration, low to moderate intensity
contractions (25–50% maximal voluntary
contraction) during isometric loading
appeared to have optimal analgesic
effect.
30
Secondary goal: improve strength,
once the pain has settled
The reduction in strength and function
following tendinopathy must be
addressed and is essential for the longterm health of the tendon. Gradually
increasing the load on the muscle and
tendon whilst monitoring pain levels is
recommended with strength sessions
performed in mid range positions to
avoid compression (8–12 reps should be
sufficient, pain permitting).
Malliaras et al. (1) systematic review
states that tendinopathy programmes
generally fit within three categories,
eccentric, combined or heavy slow
resistance training (Table 2).
In the late 1990s eccentric exercises
(such as heel drops) were considered
the ‘gold standard’ following research
by Alfredson et al. (8). They remain an
option but more recently the realisation
is that the concentric part of the
exercise should not be left out.
Peter Malliaras, a contributor to
clinical edge podcast (9), is not a huge
fan of the Alfredson (8) programme for
the following reasons:
1. There are too many limiting factors:
by the time the person who fits the
programme walks into your clinic, you
are looking at 1/10 people.
2. It’s not good clinically: to be able to
use the programme the patient needs
a lot of lumbo pelvic stability; it’s
pitched too high; also, most patellar
tendon (PT) patients have atrophy in
their quadriceps.
3. It’s a terrible programme for reversing
atrophy and building hypertrophy as
there is too much going on at once.
4. The consideration of the PT strength
paradox – during a leg press the
affected side appears strong; however,
the leg extension exercise is weak on
the affected side.
Malliaras (9) suggests that the PT
strength paradox highlights the masking
of quadriceps strength deficit, due to
the gluteus and other structures in
the kinetic chain getting so strong,
after following Alfredson’s (8) decline
programme.
Heavy slow resistance training (HSR)
has emerged more recently as another
exercise option (10,11). Gaida and Cook
(12) also discuss HSR and eccentric
exercise briefly in their 2011 paper on
TaBle 3: eSTiMaTion oF
PercenTage oF 1rM
[Adapted from RunningPhysio blog by
Tom Goom (http://spxj.nl/17BeRc1)]
Percentage of
1rM
rM
equivalent
50%
25RM
60%
17RM
70%
12RM
80%
8RM
90%
5RM
100%
1RM
1RM is the load that can be lifted
for a maximum of 1 repetition. 5RM
is the load that can be lifted for a
maximum of 5 repetitions, etc.
PT and note there are pros and cons of
each approach:
1. Eccentric work is often prescribed
as a high frequency exercise with
Alfredson and colleagues’ (8) work
recommending 3 × 15 of two exercises
done twice per day. That’s 180 reps per
day altogether!
2. HSR in contrast is usually done 2–3
time per week but in many cases will
require access to gym equipment.
3. HSR involves high loads –
approximately 70–85% of 1RM (See
Table 3 for estimating loads).
Kongsgaard and co-workers’ (10, 11) HSR
training (recommended by Malliaras
for patellar tendinopathy, if you want
a programme to follow) suggest a
graduated approach beginning with low
loads at 15RM and progressing up to
6RM over 9–12 weeks providing there
is no significant increase in pain (see
Table 2) they recommend 4 sets of
each exercise with a 2–3 minute rest
between, repeating 3 times per week.
Silbernagel and co-workers’ (13)
combined approach (See Table 4:
recommended by Malliaras for Achilles
tendinopathy, if you want a programme
to follow) is the only evidence-based
programme in the literature that has a
plyometric SSC type progression! They
begin with resistance of body weight
for calf raises and progress in a similar
manner to Alfredson et al. (8), using back
packs or weights machines to increase
the load. There are, however, several key
sportEX medicine 2015;64(April):28-32
liTeraTure review
differences. Silbernagel et al. (13) include
both the concentric and the eccentric
component of the exercise and progress
to include power and plyometric
exercises (see Table 2). Therefore,
the findings from Silbernagel (13) apply
across most of the phases discussed by
Malliaras et al. (1), not just strength.
concluSion
Malliaras et al. (1) found Silbernagel and
colleagues’ combined training (eccentricconcentric progressing to eccentric) for
Achilles tendinopathy as well as HSR
loading (eccentric-concentric isotonic)
for patellar tendinopathy had the
highest level of evidence for improving
neuromuscular function, stating:
“Clinicians should consider eccentricconcentric loading alongside or instead
of eccentric loading in Achilles and
patellar tendinopathy”
There is a paucity of quality research
comparing tendon loading programmes
and these appear to be limited and
focus mainly on Achilles and patellar
tendinopathy. Malliaras et al. (1) reviewed
the literature on Achilles and patellar
tendinopathy and found that HSR training
was more likely to lead to tendon
adaptation but required further research.
They found no evidence to support
isolating the eccentric component [as in
Alfredson et al. (8)].
The disadvantages of eccentric
exercises in the older population (over
60) are that most cannot perform 3–4
calf raises in a concentric-eccentric
fashion; therefore, why are these people
given eccentrics? This demographic
become very good at the eccentric
programme but their concentric strength
does not improve, they are still as
dysfunctional as they were before the
rehabilitation programme started – there
is no functional carryover.
Eccentric exercise requires full
range of motion (ROM). Malliaras (9)
states that double leg (DL) should be
followed by single leg (SL), making sure
that quality and full ROM is achieved
with each repetition, therefore, If the
person you are attempting to rehabilitate
cannot do SL calf raises or cannot hold
their body weight in full plantarflexion
isometrically then they shouldn’t be
starting an eccentric programme. That
person is never going to have the quality in
an eccentric programme required to benefit
from it. Time under tension is the key, if
they cannot get full range the exercise is
pointless.
Eccentric exercises have been seen
as the imperative or deemed essential.
Malliaras (9) states that you do not need
to do eccentric exercises to get a tendon
better and states that this is supported by
the literature. However, he does accept that
it is a useful part of a rehab programme
to maximise load intensity. He goes on to
discuss that eccentrics are good at very
heavy loads, this is the time to use them
or at end of range to improve the
compliance of the musculotendinous unit
(MTU) due to the shift in length tension
(sarcomeres are in series, increased
length of fascicles, contribution to stronger
function of the MTU in the functional
range). Heavy-load eccentrics are great
for sporting demands – running, jumping,
basketball, etc. Malliaras (9) suggests that
for athletes the following programme is
ideal for tendons: isometric, concentriceccentric, functional concentric-eccentric,
heavy load eccentrics – supramaximal
(above concentric maximum).
TaBle 4: SilBernagel eT al.’S TreaTMenT ProTocol For achilleS TendinoPaThy
[Silbernagel et al. 2007 (13), and recommended by Malliaras et al. (1)]
Phase 1: Weeks 1–2
Phase of
rehabilitation
Phase 2: Weeks 2–5
Phase 3: Weeks 3–12
(Longer if necessary)
Phase 4: Week 12 – 6
months
(Longer if necessary)
Pain with exercise, morning
stiffness, pain when
performing toe raises.
Handled the phase 2 exercise
programme, no pain distally in tendon
insertion, possibly decreased or
increased morning stiffness.
Minimal symptoms, morning
stiffness not every day, can
participate in sports without
difficulty.
Heavier strength training, increase or
start running and/or jumping activity.
Maintenance exercise, no
symptoms.
Patient
status
Pain and difficulty with all
activities, difficulty performing
ten 1-legged toe raises.
Goal
Start strengthening.
Start to exercise, gain
understanding of their injury
and of pain-monitoring model.
Treatment
programme
www.sportEX.net
Perform exercises every day:
Perform exercises every
day:
Perform exercises every day and with
heavier load, 2–3 times per week:
Perform exercises 2–3
times per week:
1. Pain-monitoring model
information and advice on
exercise activity
2. Circulation exercises
(moving foot up/down)
3. 2-legged toe raises
standing on the floor
(3 × 10-15 repetitions/set)
4. 1-legged toe raises
standing on the floor (3 × 10)
5. Sitting toe raises (3 × 10)
6. Eccentric toe raises
standing on the floor (3 × 10).
1. 2-legged toe raises
standing on edge of stair
(3 × 15)
2. 1-legged toe raises
standing on edge of stair
(3 × 15)
3. Sitting toe raises (3 × 15)
4. Eccentric toe raises
standing on edge of stair
(3 × 15)
5. Quick-rebounding toe
raises (3 × 20).
1. 1-legged toe raises standing on edge
of stair with added weight (3 × 15)
2. Sitting toe raises (3 × 15)
3. Eccentric toe raises standing on
edge of stair with added weight
(3 × 15)
4. Quick-rebounding toe raises
(3 × 20)
5. Plyometric training.
1. 1-legged toe raises
standing on edge of stair
with added weight (3 × 15)
2. Eccentric toe raises
standing on edge of stair
with added weight (3 × 15)
3. Quick-rebounding toe
raises (3 × 20).
31
References
1. Malliaras P, Barton CJ, et al. Achilles and
patellar tendinopathy loading programmes: a
systematic review comparing clinical outcomes
and identifying potential mechanisms
for effectiveness. sports medicine
2013;43(4):267–286
2. Cook JL, Purdam CR. Is tendon pathology
a continuum? A pathology model to explain
the clinical presentation of load-induced
tendinopathy. British Journal of sports
medicine 2009;43(6):409–416
3. Magnusson SP, Langberg H, Kjaer M. The
pathogenesis of tendinopathy: balancing
the response to loading. nature reviews,
rheumatology 2010;6(5):262–268
4. Scott A, Docking S, et al. Sports and
exercise-related tendinopathies: a review
of selected topical issues by participants
of the second International Scientific
Tendinopathy Symposium (ISTS) Vancouver
2012. British Journal of sports medicine
2013;47(9):536–544
5. Cook JL, Purdam C. Is compressive load
a factor in the development of tendinopathy?
British Journal of sports medicine
2012;46(3):163–168
6. Henriksen M, Aaboe J, et al. Motor
responses to experimental Achilles tendon
pain. British Journal of sports medicine
2011;45(5):393–398
7. Naugle KM, Fillingim RB, Riley JL 3rd. A
meta-analytic review of the hypoalgesic
effects of exercise. The Journal of pain
2012;13(12):1139–1150
8. Alfredson H, Pietilä T, et al. Heavyload eccentric calf muscle training for the
treatment of chronic Achilles tendinosis. The
american Journal of sports medicine
1998;26(3):360–366
9. Clinical Edge. Podcast.
http://spxj.nl/1ajmFke
10. Kongsgaard M, Kovanen V, et al.
Corticosteroid injections, eccentric
decline squat training and heavy slow
resistance training in patellar tendinopathy.
scandinavian Journal of medicine &
science in sports 2009;19(6):790–802
11. Kongsgaard M, Qvortrup K, et al. Fibril
morphology and tendon mechanical
properties in patellar tendinopathy: effects
of heavy slow resistance training. The
american Journal of sports medicine
2010;38(4):749–756
12. Gaida JE, Cook J. Treatment options
for patellar tendinopathy: critical review.
Current sports medicine reports
2011;10(5):255–270
13. Silbernagel KG, Thomeé R, et al.
Continued sports activity, using a painmonitoring model, during rehabilitation
in patients with Achilles tendinopathy:
a randomized controlled study. The
american Journal of sports medicine
2007;35(6):897–906.
FurTher reSourceS
1. For further information on this area
the author recommends reading any
papers by Professor Jill Cook or Dr
Peter Malliaras.
2. Physioedge podcast: Tendons and
tendinopathy by Prof. Jill Cook
(http://spxj.nl/1fYRpma).
3. Physioedge podcast: Lower limb
tendinopathies by Dr Peter Malliaras
(http://spxj.nl/1EQjt99).
n When was the last time you
reviewed any of your current
protocols?
n Are you utilising any form or
DISCUSSIONS
information every week (journal/
articles/magazines/blogs/podcasts)
to keep you abreast of what is happening in your
profession?
n When was the last time you collaborated with a
college/mentor/peer to renew your enthusiasm in
the work you do making you a better therapist?
key PoinTS
n despite current research we are still far from
finding a definitive answer to management of
achilles and patellar tendinopathy.
n Therapists are still using what used to be deemed
the ‘gold standard’ programme for achilles
tendinopathy written in 1998!
n recommendations are supported by clinical practice
as well as research.
n complacency leads to poor results.
n an incredible 45% of patients did not respond
significantly to eccentric exercise programmes.
n Treatment options for tendinopathy are in
abundance with many factors to consider.
n in the first instance plan to reduce excessive load
and aggravating movements.
n The reduction in strength and function following
tendinopathy must be restored and is essential for
the long-term health of the tendon.
32
THE AUTHOR
PAULA CLAyTOn MSC, FA DiP,
P
M
MAST STT
Paula has worked as a senior
performance therapist for the English
institute of Sport (2003–2013) and British
Athletics since 2003. She has travelled
extensively to Olympic Games (Athens,
Beijing and London), Commonwealth Games,
World and European Championships with GB
track and field as part of the medical team
during this time.
Before 2003, Paula worked in premiership
and championship football for 4 years.
Paula has taught on two sports therapy
degree programmes, delivered sessions
to MSc students, written a number of
articles and has an MSc in Sports injury
Management. Paula also delivers soft tissue
masterclasses to senior physiotherapists
and soft tissue therapists within premiership
and championship football clubs, national
governing bodies (nGBs) and to soft tissue
therapists nationally and internationally
through her company
www.stt4performance.com.
Paula also runs a very successful sports
injury clinic private practice (established in
1994) in Shropshire with her husband Rick.
continuing education
Multiple choice
questions
This article also has a certificated eLearning test
which can be found under the eLearning section of
our website. For more information on how to access
the test click this link http://spxj.nl/cpdquizzes
This quiz is
aCCessiBle
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wiTh a suBsCripTion ThaT inCludes
online aCCess To This Journal.
sportEX medicine 2015;64(April):28-32
Sportex update
tHe All New
Singing & dancing
By Tor Davies, puBlisher anD
sporTeX founDer
over the last 6 months there’s
been a huge amount of work going
on behind the scenes at sporteX,
stimulated by 4 main motivations:
1. A desire to vastly increase the
flexibility and options for people
wanting to engage with our content
2. A strong yearning to create a totally
different type of business model,
one built on a basis of cooperation
and ethiconomics* and driven by a
“virtuous circle”.
3. A quest to build a state of the
art publishing platform that
harnesses the last 5 years of web
developments in delivering and
building community through learning
and professional development.
4. An aspiration to use our new
platform to widen our content
framework into areas outside just
sport.
In order to achieve our goals, we’ve
completely rethought and restructured
just about every aspect of what
we do from the financial modeling,
planning and budgeting, to the way we
commission and pay for content, and
finally through to the way we deliver
this content.
The sTarTing poinT
At the heart of everything we do is
the interaction between you and the
www.sportEX.net
content we produce. We want to
create the very best content we can
to help you do your job in the most
effective way possible. In order to
achieve this we’ve done several things:
refined and expanded our
content structure:
In collaboration with some of our
longest serving most committed
subscribers, we’ve identified the
‘streams’ of content that you feel
would add most value to your work
(see Box 1 for details of the content
streams)
appointed hand-picked content
commissioners:
We’ve identified 1-2 commissioning
editors per content stream who
are responsible for commissioning
articles under that topic area. These
are people who have a strong track
record for developing ‘translational’
content. ‘Translational’ content has
always been our USP – the ‘read
it now, use it in an hour’ approach.
We publish for practitioners, these
are hands on people who want to
know how to translate the research
evidence into practical application.
Throughout we’ve focused on
the “virtuous circle” approach:
Authors will earn up to 25% of
all sales of their content and
commissioning editors will earn 1-2%
of sales for every article they have
commissioned for the entire time
that the content is live and available
through our platform. The clever bit is
in the algorithm that calculates how
these royalties are divided particularly
when content is sold as part of a
‘subscription’ to a bigger product.
Here we use an algorithm that
takes total sales and then divides it
proportionally based on number of
times that piece of content has been
1
2
3
4
purchased as either a single item or
as part of a group, combined with
a range of engagement measures
like social media influence, discussion
activity and viewing statistics. The
end goal is that great content is
rewarded - the more an article is
purchased, read, engaged in and
shared, the more of the content
royalty pot it will earn.
implemented a self-refining,
constantly improving content
model: The platform allows (and
actively encourages) authors to
regularly update, enhance and
improve their content so that
not only does it always remain
current but the author always
has the power to make it better
(and encourage more sales). If the
content isn’t updated then after
a period it expires and ceases to
earn royalties.
It’s a simple philosophy both in functional
as well as economic terms that is
designed above all to be fair, transparent
and one in which everyone wins.
so where Does The
oTher 75% go?
n 25% is for our affiliates who help
to promote and sell our content
through their own channels (if you’re
interested in becoming an affiliate
email me tor@sportex.net)
n 25% is set aside for costs relating
to publishing the content, mobile
app publishing, supplementary
content resources such as images
and animations
n 25% goes towards business
administration including customer
technical and billing support,
salaries, ongoing platform hosting
and support costs and marketing.
33
Key feaT
ures of
The new
siTe
n co
om
mm
muunnit
ity
y building Througho
ut the site you’ll no
and content engage
tice a start on the
ment through the
community building
discussion forums
aspect
are also many socia
at the end of all pie
l media sharing op
ces of content. Th
portunities through
n flexible purcha
ere
out the articles.
sing From a purch
asing perspective
as you want right
yo
u
ca
n
no
w buy as little or as
down from a single
much content
article, a stream of
to the journals.
content, a ‘tag’ or
a bundled subscripti
n a simplified pa
on
yment system Ou
r previous system
based on paymen
ha
d
7
dif
fer
ent payment types
t methods. It was
over-complicated (if
with discounts
methods, don’t wo
you’re currently pa
rry, we’ll continue
ying by one of the
to
su
pp
or
se
t
it and you don’t ne
going forward it’s no
ed to change anyth
t only much simple
ing
r
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bu
t
als
t
next-generation pa
o much more flexib
yment system know
le thanks to the ex
istence of a
n as Stripe. (see Bo
n archving Initially
x 2 for more detai
we will be working
ls)
.
ba
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wa
rd
s
content archives. Ou
from recent to the
older material, to ad
r goal is that Jan
2012 up to April 20
d the
will also be a fully
15 will be available
searchable databas
at launch. The archiv
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n multi-media fri
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r launch in 1999!
endly While we’ve
launched initially wi
main format of conte
th
art
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s
(as historically this
nt), the platform is
has been our
built to host all typ
audio, presentation
es of media secure
s and any type of
ly
inc
luding video,
me
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yo
u
media offerings as
want to throw at us
we take on more
and we’ll be expand
content creators.
ing the
Our goal with this new platform has
been simplicity, transparency, mutuality
and ongoing self-refinement.
new TargeTeD
aDverTising
opporTuniTies
At last we have a whole range of
advertising opportunities available also.
You can advertise at any point on
the site. This could be within a given
content stream, under a given tag
(keyword section) or even down to a
specific article (particularly useful for
authors of articles wanting to promote
other activities such as books they’ve
written or courses they’re running).
And as you’d hope, the process is
simple and transparent.
sTep 1: Navigate on the site to the
position you want to place your advert
sTep 2: Pick the advert type you
want ie. Banner size – just under the
existing banner will be an “Advertise
here” link – go ahead and click it!
sTep 3: Choose the start and end
dates for your ad and the system will
calculate the price and display this
as well as some other options in the
same area so you can adjust your
booking to fit your budget
sTep 4: Once you’re happy, place
the booking and you will be asked
to upload your artwork which once
approved will go live at the time
designated.
34
in summary
This is a very short overview of the foundations
of a much more complicated project that I believe
will form a new way of publishing and growing
communities in professional sectors not only in
our core area of physical and manual therapy but
across a whole range of vocational groups. This is
just the start. I hope you enjoy the new site!
* Ethiconomics = a name given by author Philip Birch, for
the principles and practice of ethical business
conTenT sTreams
n Musculoskeletal Diagnosis, Treatment and
Rehabilitation Articles
n Musculoskeletal Diagnosis, Treatment and
Rehabilitation Case Studies
n Current Trends in Sports Medicine
n Research Reviews
n Pain and Brain
n Sports Performance
n Journal Watch – Sports Medicine
n Journal Watch - Manual Therapy
n Current Trends in Manual Therapy
n Movement - Assessment and Retraining
n Manual Therapy Case Studies (non-sport)
n Sports Massage Case Studies (sports-specific)
n Sports Massage Articles (sports-specific)
n Soft Tissue Practice Articles (non-sport)
We will also be adding two new dedicated streams
of content on taping and business development
commencing later in 2015.
suBscripTions anD
paymenT wiTh sTripe
n The first BIG
benefit is
that Stripe takes responsibility
for adhering to the stringent PCI
Compliance rules that in the past
has made the wonderful but hugely
expensive ability to store credit
card details completely prohibitive
for small companies. Only behemoth
retailers like Amazon could afford the
sort of security this requires, that
is until Stripe came along to give
us ‘little guys’ access to the same
convenience and security.
n This means once you’ve entered your
details once, Stripe securely stores
these, meeting all the required PCI
standards, and when you login to
make a new purchase, there’s no need
to enter your details again. It simply
looks at your existing plan with Stripe,
updates it to take account of the new
content and off you go. One click
purchasing! This means you can add
content streams to your subscription,
or delete them at any time in the year
and all the billing will adjust accordingly
at that exact point in time.
n It does however mean that your
subscription expires the minute you
lapse it – if money is owed against
unused days this is credited to your
card. Transparent and fair, as we like it.
sportEX medicine 2015;64(April):33-34
BOLD HEAD LIGHT HEAD
ANATOMY &
SOFT TISSUE
INJURY REVIEW
By Dr Simon Kaye, Sports Physician and General Practitioner
ONLINE & MOBILE £24.95
PRINT COPY AVAILABLE AT TIME OF PURCHASE
AS A £6.99 UPGRADE WITH ONLINE PURCHASE
This resource is packed with animations and is highly visual coviering all
the major joints and surrounding soft tissues. This guide offers valuable
advice and tips to identify injuries, make good diagnoses, give sensible
treatment advice and make appropriate referrals. It is also a perfect tool
for showng patients and clients exactly which anatomical structures they
have injured. The resources is regularly updated and expanded with new
images and animations.
ANATOMY &
SOFT TISSUE
INJURY REVIEW
by Dr Simon Kay
■ Back to basics revision of
anatomy of each joint
■ Includes 53 anatomy animations
and video clips to bring the facts
to life
■ Covers diagnosis and treatment
options with background theory
and evidence based medicine
www.sportex.net
11/07/2013 10:58
CONTENTS
rTs
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T
ass
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t jo
o
tion
wris introduc nd diAgn
en
– An ssment
Asse
A
s 2011
■ Overview of diagnosis and
treatment of sports injuries
■ Shoulder Joint and girdle
■ Elbow and Wrist
■ Ankle ■ Knee ■ Spine
■ Hip joint and pelvic girdle
spo
Picture
InjuryRefresher_proofed AS.indd 1
®
As
s
s
to a diagno
and
© Primal
Produced by
■ Provides tips for examination,
learning exercises and highlights
key points
■ Gives links to further reading
■ Useful for practitioners and
those in training
+
31
et
tEX.n
.spor
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