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physiotherapy

Physiotherapy

The most prevalent condition diagnosed in most sports medicine clinics is patellofemoral pain. Professor Irene Davis is one of the world’s leading physiotherapists and researchers who addresses this issue. 

She’s a regular keynote speaker at major international conferences. In this BJSM podcast she shares her approach to assessing the patient with patellofemoral pain. From this basis she outlines a range of therapeutic options. 

Professor Davis was a catalyst for the International Patellofemoral Pain Research Retreats (IPFRR). You can read the full Consensus Statement from the 3rd  of these conferences in the special BJSM theme issue highlighted by the Swiss Sports Physiotherapy Association (http://www.sportfisio.ch/) at the link below. 

See also:

Patellofemoral Pain Consensus statement: http://bit.ly/RzNirr 

Introduction/overview – why have an international patellofemoral pain consensus meeting?: http://bit.ly/TZvtmO

Professor Davis discussing ‘the foot core’ concept in another BJSM podcast: http://goo.gl/nUigMB

Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013: http://bjsm.bmj.com/content/48/6/411.full

The 3rd International Patellofemoral Research Retreat: An international expert consensus meeting to improve the scientific understanding and clinical management of patellofemoral pain: http://bjsm.bmj.com/content/48/6/408.full

Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis: http://bjsm.bmj.com/content/48/14/1088.full

High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: Is PFP itself a predictor for subsequent ACL injury?: http://bjsm.bmj.com/content/early/2014/03/31/bjsports-2013-092536.full

Patellofemoral pain syndrome? Consider orthoses or more comfortable shoes!: http://blogs.bmj.com/bjsm/2011/02/24/patellofemoral-pain-syndrome-consider-orthoses-or-more-comfortable-shoes/

Professor Irene Davis - Does the concept of the abdominal ‘core’ apply to the foot too?: https://soundcloud.com/bmjpodcasts/does-the-concept-of-the-abdominal-core-apply-to-the-foot-too-professor-irene-davis-harvard



Professor Irene Davis (Harvard) on treating patellofemoral pain

Irene Davis is a renowned biomechanics clinician and scientist. Barefoot running has been one of her areas of focus and she co-authored the Nature paper that received cover attention and created mainstream attention to that topic. 

She and first author Dr Patrick McKeon, conceived of the idea of a foot ‘core’; if certain foot muscles act as a core it has immediate implications for management in clinical practice. 

Listen to Professor Davis and see the linked paper (below). Let us know if you agree, disagree. Tweet or write a blog post (email to karim.khan@ubc.ca).

One of few researchers who addresses this issue, Prof Davis is a regular keynote speaker at major international conferences. In this BJSM podcast she shares her clinical approach to assessing patients where the ‘foot core’ may be relevant. 

See also:

‘The foot core system: a new paradigm for understanding intrinsic foot muscle function’: http://bit.ly/1zw4Syw

Listen to Prof Davis discussing how to treat patellofemoral pain in another BJSM podcast: http://goo.gl/kxse10

Barefoot running: an evaluation of current hypothesis, future research and clinical applications: http://bjsm.bmj.com/content/48/5/349.full

The foot core system: a new paradigm for understanding intrinsic foot muscle function: http://bjsm.bmj.com/content/early/2014/03/21/bjsports-2013-092690.full

Running in a minimalist and lightweight shoe is not the same as running barefoot: a biomechanical study: http://bjsm.bmj.com/content/47/6/387.full

Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013: http://bjsm.bmj.com/content/48/6/411.full

Baffled by the barefoot running vs traditional running shoe controversy? How to make an informed choice!: http://blogs.bmj.com/bjsm/2013/10/28/baffled-by-the-barefoot-running-vs-traditional-running-shoe-controversy-dont-be-make-an-informed-choice/

Patellofemoral pain syndrome? Consider orthoses or more comfortable shoes!: http://blogs.bmj.com/bjsm/2011/02/24/patellofemoral-pain-syndrome-consider-orthoses-or-more-comfortable-shoes/

Professor Irene Davis (Harvard) on treating patellofemoral pain: https://soundcloud.com/bmjpodcasts/professor-irene-davis-harvard-on-treating-patellofemoral-pain 

Professor Irene Davis - Does the concept of the abdominal ‘core’ apply to the foot too?

Dr Gino Kerkhoffs is professor of Orthopaedics at the Faculty of Medicine of the University of Amsterdam (AMC-UvA), with a special emphasis on sports traumatology. 

He shares his expertise on ankle injuries with Dr Babette Pluim, and discusses evidence based treatment options of ankle impingement, ligament injuries and osteochondral lesions. 

Prof Kerkhoffs also discusses treatment of the slow healing metatarsal V stress fractures. 

See also:
Economic evaluations of diagnostic tests: treatment and prevention for lateral ankle sprains: a systematic review
http://goo.gl/Pn9FMp

A twist on the athlete's ankle twist: some ankles are more equal than others http://goo.gl/3FhGBT

Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline http://goo.gl/7ITP7S

Treatment of proximal metatarsal V fractures in athletes and non-athletes http://goo.gl/fKaib6

Managing the difficult ankle and foot with Prof Gino Kerkhoffs - Part 1 of 2

This is a podcast by Dr Robert-Jan de Vos, sports physician in the Erasmus Medical Centre in the Netherlands, with Guustaaf Reurink, who is a registrar in Sports medicine in the Netherlands and is currently finishing his thesis on diagnosis and treatment of acute hamstring injuries. Recently, he published a paper in the New England Journal of Medicine about the role of Platelet-rich Plasma (PRP) treatment for acute hamstring injuries (http://www.nejm.org/doi/full/10.1056/NEJMc1402340). 

We start with discussing this interesting study, which did not show a benefit of PRP injections in acute hamstring injuries. Dr Reurink expresses the methods and results of this study and possible explanations for these findings are debated.

Dr Reurink also performed a number of studies on the value of clinical tests and Magnetic Resonance Imaging (MRI) in acute hamstring injuries. Previously, he already showed that most MRIs are still abnormal when the athlete already returned to gameplay (http://bjsm.bmj.com/content/early/2013/11/19/bjsports-2013-092450.abstract?eaf). 

We close by discussing the role of MRI and standardised clinical tests as a predictor of time to return to play and re-injury.

Diagnosing and treating acute hamstring injuries

Shoulder pain – what are the causes, and how can you treat it? Are your special tests around the shoulder really isolating and identifying pathology? How can the rotator cuff still function with small and large tears?

In Episode 21 of the Physio Edge podcast, Jeremy Lewis and David Pope discuss these questions and more including:

What is the value of special tests around the shoulder?
What diagnosis can you provide your patients for their shoulder pain
How can you identify if you need to focus your treatment on the scapula, glenohumeral joint, cervical spine or thorax?
How can you identify a rotator cuff tendinopathy?
What is the Rotator Cable, and how is it important in rotator cuff tears?
Is the acromion really the cause of “impingement” or subacromial pain?
If a patient has a biceps tendinopathy and a rotator cuff tendinopathy, which should be treated first?
What contributes to biceps tendinopathy?
Theraband – valuable?
When imaging of the shoulder is valuable, and when it is a waste of time
Frozen shoulder – what treatments work well
And much more.

PE #021 Shoulder Pain With Dr Jeremy Lewis

Dr Kieran O’Sullivan is back on the Physio Edge podcast after talking previously about hamstring injuries, this time discussing his other big area of interest and expertise – chronic low back pain (CLBP). In this episode, Kieran and David Pope discuss

Recent research on chronic low back pain
Central vs peripheral contributions to CLBP
Sitting postures and behaviours, and the relationship of this to pain
Is there an ideal sitting posture, and does changing sitting behaviour change CLBP?
Manual therapy in CLBP
Lumbar kyhposis/lordosis
Physical and psychological interventions for CLBP
The effect of exercise on CLBP
Movement patterns and retraining in chronic pain states
The challenges of talking to patients about chronic pain states
Enjoy this episode, brought to you by the podcast sponsor, Clinical Edge, and their fantastic face to face and online education. Get 20% off your first months Clinical Edge membership with the code “PHYSIOEDGE”.

PE #022 Chronic Low Back Pain With Dr Kieran O'Sullivan

Lower limb tendinopathies with Dr Peter Malliaras

Tendinopathies are a hot topic, and there are lots of new developments in research and treatment. Dr Peter Malliaras, a Physiotherapist with a PhD studying tendinopathy, has a special interest in the treatment of tendinopathy, and treats elite basketball and volleyball, EPL football, rugby, and cricket players, the Royal Ballet and track and field athletes. Peter has also published numerous studies on tendinopathy.

In this episode of the Physio Edge podcast, Peter and David Pope discuss

The latest research on tendinopathy
Different types of loading programs for tendinopathy
Outcomes for various types of loading
Tendinopathy on Doppler Ultrasound or other imaging, and what changes with a loading program
The tendon pathology continuum by Dr Jill Cook and Craig Purdham
Mid portion Achilles tendinopathy
Insertional Achilles treatment
Patellar tendinopathy treatment, and a loading program for this that may challenge your preconceptions!
Tenosynovitis
Biomechanics contributing to tendinopathy
Return to sport following tendinopathy
Injury reduction/prevention
Injections
Peter shared so much great info on tendinopathy, check it out now on episode 23 of the Physio Edge podcast

Show your love for the podcast sponsor, Clinical Edge, and their fantastic face to face and online education. Get 20% off your first months Clinical Edge membership with the code “PHYSIOEDGE”.

PE #023 Lower Limb Tendinopathies With Dr Peter Malliaras

Barefoot running has been sweeping the globe in the last few years, and as a Physio, which of your patients are best suited to this type of running technique. How does running technique relate to a runner’s pain and dysfunction, and really, what is the ideal running technique?

In this podcast with Blaise Dubois – a Physiotherapist with a clinic, website and courses devoted to helping runners and Physiotherapists that treat runners, we chat about these topics, as well as:

Running assessment
Biomechanics of running
Improving running technique and performance
Which patients should change their running technique
Barefoot running
Heelstrike and landing
Current evidence on running technique
Injury prevention in runners
Downhill running technique
Footwear for running
Improving running in patients with pathology eg Achilles Tendinopathy
Blaise has also been kind enough to provide a PDF handout to go along with this podcast, which is available for free download –

PE #010 Biomechanics Of Running With Blaise Dubois

Hamstrings are one of the more frequently injured muscles in sportspeople, and in this episode, Alison and I discuss hamstring tendinopathy, symptoms, assessment and treatment of this common condition.

Some of the aspects we explore in this podcast are:

Subjective clues that someone may have a Hamstring Tendinopathy
Differentiating Hamstring Tendinopathy from pain of Lumbar origin
Assessment of the hamstring
Tests to confirm or rule out a Hamstring Tendinopathy
Causes
Advice for patients
Rehabilitation
Deep hip muscle activation
Keys to a successful treatment program
a whole lot more
There is currently limited research around the area of hamstring tendinopathy, and Alison’s tips and insights are based on this evidence base as well as her clinical experience.

I hope you enjoy it!

PE #011 Hamstring Tendinopathy With Dr Alison Grimaldi

Physical rehab (physiotherapy), behavioural rehab and combinations of these have been mainstays of back pain treatment.  Dr Kieran O’Sullivan shares his expertise on what to do and what not to do – lessons from 15 years of providing specialised clinical care and engaging in top level research. 

Specifically, what is the role of patient advice, targeted exercises, and novel therapies including injections? 

You can link to Dr O’Sullivan’s home page at the University of Limerick here: http://www.ul.ie/clinicaltherapies/node/443

Interested in back pain? Related resources: 

Editorial: Common misconceptions about back pain in sport: Tiger Woods’ case brings five fundamental questions into sharp focus
http://bjsm.bmj.com/content/early/2015/02/08/bjsports-2014-094542.extract

Podcast:  Professor Peter O’Sullivan on Tiger Woods’ back and ‘core strength’
https://soundcloud.com/bmjpodcasts/professor-peter-osullivan-peteosullivanpt-on-tiger-woods-back-and-core-strength?in=bmjpodcasts/sets/bjsm-1

Effective treatments for back pain: Kieran O'Sullivan’s practical tips within a guiding framework

The BJSM community is well aware of the interest in the role of training load on injury. Dr Dr Tim Gabbett, Dr Alex Kountouris and Dr to be Michael Drew share insights into the principles that underpin successful player management. They give specific examples from football codes and cricket at the elite level. They also discuss what clinicians who do not have access to the full raft of data-gathering technology can do to advise players how to monitor load. 
We thank Sports Physiotherapist Paul Visentini (who invented the VISA score for tendinopathy) for producing the very successful event and for sharing two podcasts with us. (The second will be posted here within a month). (Twitter = @PaulVisentini and @PhysioSports429)
The guests: Dr Tim Gabbett, Applied Sports Scientist who consults to elite teams the world over. He is one of only 5 invited Keynote Speakers at the IOC World Congress in Monaco 2017 #IOCPrev2017 @TimGabbett
Dr Alex Kountouris, Sports Science and Sports Medicine Director Cricket Australia @Alex_Kountouris
Mr Michael Drew Senior Sports Physiotherapist at the Australian Institute of Sport. @_MickDrew
Links to related podcasts: 
Dr Tim Gabbett on how physiotherapists can work well alongside strength & conditioning coaches to prevent injuries and improve performance: http://ow.ly/10aOq2
Dr Alex Kountouris on how to prevent back pain in cricket: http://ow.ly/10aOHX
Link to papers on load monitoring: 
Training – injury prevention paradox. Should athletes be training smarter AND harder (Gabbett) http://bjsm.bmj.com/content/early/2016/01/12/bjsports-2015-095788
Cricket fast bowling workload patterns as risk factors for tendon, muscle, bone and joint injuries. John W Orchard, Peter Blanch2, …, , Alex Kountouris et al, http://bjsm.bmj.com/content/early/2015/03/09/bjsports-2014-093683
And the home page with lots of good background for the conference (March 2016): http://physiosports.com.au/mastering-load-symposium-2016/


Dream Team of training load management: How training influences injury and performance

As evidence based practitioners, is manual therapy for the Cervical spine evidence based? Should we just be using exercise, or is manual therapy appropriate for the C/sp?

A Cochrane review in 2015 by Anita Gross and colleagues found "No high-quality evidence was found, so uncertainty about the effectiveness of mobilisation or manipulation for neck pain remains." So where does that leave us? With no evidence for mobilisation or other manual therapy?

In this weeks 5 Minute Physio tip, find out how you can be evidence based in your treatment of the Cervical spine

5 Minute Physio Tip - Manual Therapy For The Cervical Spine - Is There Any Evidence?

The BJSM community wants practical tips and this podcast earns 10/10 for that feature. The guest, @DarrenBurgess25 is an international leader in working in sports medicine/sports science at the highest level. BJSM Associate Editor Paul Visentini (@PaulVisentini) asks great questions. 

1. How do you bring the evidence into your practical job at High Performance Manager at Port Adelaide Football Club (Australian Rules Football) (1 minute in)

2. The art from a master. What are the clinical features you use to determine what the players need? (4 minutes in)

3. How do you reconcile individual differences when you are working with a team? (7 minutes in)

4. Usain Bolt, Luis Suarez – they don’t follow the textbook. What are the minimum requirements for strength?  (9 minutes in)

5. Capacity in tissue – and for a whole player. How much can we alter/improve capacity? (See also Jill Cook’s podcast on this and paper, link below)

6. What other features – beyond GPS and data – What do you look for in player welfare? (14 minutes in)

Personal note here from Karim Khan: What a great insight into top level sport!! I loved this podcast – the honesty, the specific points. Darren is a master of ‘the sticky message’. Has he read ‘Made to Stick’ or is he just a natural? Wow!! I feel privileged to be part of the BJSM community to learn like this. 

Next week. Dr Kieran O’Sullivan (Ireland, @KieranOSull) and a German-language podcast where Aspetar’s Ekaterina Sandakova asks the questions of Keller Mattias. #InternationalCommunity

Links: 
1. Very closely related podcast on load: Dream Team @TimGabbett and colleagues discuss how to manage load to improve performance and minimize injury risk http://ow.ly/4mYQmZ

2. Hear more from Darren Burgess here: Who should lead the sports medicine / high performance team? http://ow.ly/4mYRtm

3. The core concept of ‘tissue capacity’. @ProfJillCook and @SIDocking are the authors and here’s the link: http://ow.ly/4mYUMI 

4. One cannot leave a load management chat without making sure you know about Tim Gabbett’s early contender for paper of the year. Open access: The training-injury prevention paradox: should athletes be training smarter and harder? http://ow.ly/4mYSkj


Putting load management evidence into practice: Sometimes you can’t! Dr Darren Burgess

Dr Kieran O’Sullivan, PT, PhD, was one of the first podcast guests to crack 9,000 listens! From the University of Limerick, Ireland, he has vast clinical experience and he completed a PhD on the role of sitting in back pain. In this 18-minute podcast he reviews his 2015 podcast in the first 3 minutes and then rattles off at least 7 practical tips. 

Kieran was a guest of PhysioFirst (UK) when BJSM interviewed him in April 2015. The 2017 PhysioFirst conference is on April 1-2 (2017!) in Nottingham (UK) and guest speakers include Professor Paul Hodges, Dr Tania Pizzari and Dr Igor Tak. 

Timeline: 
1.00 m Back pain is neither explained by what patients and clinicians see on scans nor just by load

2.00 m When treating, you need to assess the various factors that could be playing a role, such as load, posture, stress, and address the right one. 

4.00 m Should we try to prevent all back pain? Listen to Dr O’Sullivan challenge the belief that it’s important to never have back pain. He likens back pain to conditions like sadness, constipation – not great but not a major problem as long as it doesn’t persist. Athletes need to load their bodies and adapt rather than avoid load and become vulnerable (See Gabbett papers and podcast, below). Don’t pass on fear (of back pain coming on or persisting) to athletes. 

5.00 m Screen for red flags of course, if the clinical picture warrants it – but most long-term back pain is NOT due to something listed as a red flag. 

6.00 m Reassurance – being empathetic without inducing fear. 

7.00 m Think through. What precipitated the pain? Too much load, too much stress, bad posture, movement patterns? If unknown, have patient create a pain diary. Look for trends. Examine all the dimensions of the biopsychosocial model. 

9:00 m Don’t just make the diagnosis but be practical. Patient sad? Don’t just say ‘You are sad, your back pain will go away’. Provide specific treatment for the specific threat. 

10:00 m Empower the patient to choose the exercises he or she wants and what he or she will do! Exercise has benefits across systems. 

11:00 m Don’t give up. Here Kieran walks us through a challenging real life case. A simple tissue diagnosis would not have helped this person at the centre of the case 

12:00 m Explain! Explain the pain! (HT to Professor Lorimer Moseley and Dr David Butler).  

13:00 m The period at 4-6 weeks of pain can be difficult – patient has not adapted to the contemporary model and may still be on waiting list for imaging. 

14:00 m What is the evidence for this approach? How does the evidence compare, with, for example Hamstring injuries? 

Links to previous podcast: 
2015 – Dr O’Sullivan on “Effective treatments for back pain: Kieran O'Sullivan’s practical tips within a guiding framework” http://ow.ly/4nepGu

BJSM paper: 
O'Sullivan K, O'Sullivan P. The ineffectiveness of paracetamol for spinal pain provides opportunities to better manage low back pain. Br J Sports Med. 2016 Feb;50(4):197-8. http://ow.ly/4neqbS (Members Only/subscribers)

Manual Therapy paper: 
Hurley J, …., O'Sullivan K. Effect of education on non-specific neck and low back pain: A meta-analysis of randomized controlled trials. Man Ther. 2016 Mar 10. pii: S1356-689X(16)00017-5. doi: 10.1016/j.math.2016.02.009. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/27026111


Dr Kieran O’Sullivan on managing back pain: 7 habits of highly effective clinicians. Part 2, 2016

Proximal hamstring tendinopathy (PHT) occurs in athletes, runners, weightlifters, and other athletes, as well as more sedentary patients, causing pain at the hamstring origin and limiting your patients ability to sit, run and continue to be active.
There are a number of structures that can contribute to pain in this area, and in this podcast, Tom Goom and David Pope discuss how to clearly identify PHT and differentiate it from lumbar spine referred pain, hip pain, sciatic nerve pain and other conditions.
Tom recently released an article in JOSPT on Proximal Hamstring Tendinopathy: clinical aspects of assessment and management with Peter Malliaras, Mike Reiman and Craig Purdam. We explore this article, and the research around PHT, and cover in detail:
	•	Subjective clues to guide you towards diagnosis
	•	Aggravating factors and 24 hour pain patterns
	•	Differential diagnosis
	•	Lumbar spine pain
	•	How the lumbar spine could contribute to development of PHT
	•	Hip pain
	•	SIJ pain
	•	Sciatic nerve pain
	•	Development of PHT
	•	Central sensitisation
	•	Diagnostic tests for PHT
	•	Hamstring tests
	•	Other assessment tests
	•	Functional tests
	•	The value of palpation
	•	Tests for involvement of the rest of the kinetic chain
	•	Running assessment/gait analysis
	•	Testing load tolerance
	•	Biopsychosocial aspects of tendon recovery
	•	Other advice for patients
	•	Whether stretching is helpful
	•	When your patient can return to running
	•	Cross training
	•	Does manual therapy have a role in the treatment of PHT?
	•	Starting treatment (Stage 1)
	•	When and how to progress rehabilitation (Stage 2)
	•	Further rehabilitation progressions (Stage 3)
	•	Advanced exercise progressions for high load sports
	•	Exercises you can incorporate during the various stages
	•	How long recovery will take
Links
	•	Free webinar with Tom Goom
	•	Download the free handout summary of this podcast
	•	Tom’s website - Running Physio
	•	Tom on Twitter
	•	Running Repairs courses with Tom
	•	Article in JOSPT on Proximal Hamstring Tendinopathy: clinical aspects of assessment and management
	•	JOSPT
	•	Peter Malliaras
	•	Mike Reiman
	•	Craig Purdam
	•	VISA-H
	•	Become a Clinical Edge member to access Tom’s webinar and other great online education
Tags: running, hamstring, tendinopathy, tom goom, podcast, proximal, peter malliaras, craig purdam, mike reiman, treatment, assessment


Physio Edge 046 Proximal Hamstring Tendinopathy With Tom Goom

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