Sportsmith Rehab Conference
I was lucky enough to attend the fantastic Sportsmith Rehab Conference earlier this month at the Etihad Stadium in Manchester. Below are some of the learnings and rough notes I took from the two days:
James Moore – Hip/Groin Pain
Kicking sports lead to pubic overload; straight line running leads to hip pathology
Hip joint a big player in groin pain – approx. 50% of cases have hip joint involvement. Arthrogenic muscle inhibition causes adductor overload. Hip micro-instability can do the same.
Anteverted hip joint will affect loading and how the muscles function.
Iliopsoas is an adductor as well as hip flexor, adductor magnus offloads hamstrings
In evasion team sports players cut stride length but this increases load through hip and hamstrings
Ratios important – hip flex/ext; abd/add
Stance leg function very important in kicking sports
Adductor muscle strength increases a lot U12-15 but tendon lags
Load abs in outer range, load them in extension
Short lever Copenhagen increased adductor load – eccentric between two plinths + 6kg weight is elite level
To increase adductor work in squat, depth is key rather than foot position
Use unilateral band work e.g. hip flex in SL bridge, hip add/abd in prone plank
Key references:
https://www.tandfonline.com/doi/abs/10.1080/14763141.2021.1951827 (Kicking biomechanics)
https://pmc.ncbi.nlm.nih.gov/articles/PMC4325295/ (kicking progression)
https://journals.healio.com/doi/abs/10.3928/01477447-20151228-08 (hip microinstability)
Seth O’Neill – Achilles Tendon
Tendon structure biggest risk factor for rupture – poor structure on screening 7x more likely to rupture – but doesn’t correspond to pain.
Can only rupture in pathological tendon – not necessarily painful prio
Soleus has largest physiological CSA – key propulser
When testing, have to compare to normative data rather than opposite limb
- Injured cohort weaker in both limbs
- Weaker muscle - greater tendon load
- IKD @90d/s >1.15x BW
Need to train with high loads - >90% MVC – and need to rehab in DF and “dirty” combined positions
Roula Kotsifaki – Jump Testing
Vertical hop 1/3 each from hip/knee/ankle
Horizontal hop only 13% contribution from knee – but is good for Ax landing strategy and forces
No need to measure hop distance as it adds nothing over the jump tests on force plate
6x BW landing force at end of triple hop
Cueing important:
- CMJ/SL “jump as high as possible”
- DL DJ/SL DJ “ jump as high and as fast as possible”
Squat jump best for Ax RFD
Main 4 variables:
- Jump height
- RSI
- Contact time
- Peak landing force – variance between R+L is normal
RSI often highlights biggest differences between limbs – linked to jump height
Force @ zero velocity also good to look at
With results look at LSI, pre-injury data, and normative data sets
Key reference:
https://bjsm.bmj.com/content/57/20/1304.abstract (jump testing)
Fearghal Kerin – Hamstring
Consider length, load and speed when selecting exercise
Banded ER (band around foot) a good way to increase BF activation during exercises
Introduce body contacts in hip hinge isometrics, etc
Is aponeurosis size a risk factor? Area of emerging research – as well as what exercise programme may change this
Villa research suggests T junction injuries more likely to break down in rehab
Romain Tourillon – Foot and Ankle
Foot and ankle important to “absorb, propel, recoil” – neuromuscular as well as structural
Important for robustness, performance, biomechanical efficiency
Need good intensity to train tib ant, post, peroneals – not just bands
e.g. shin bar, slant boards, iso catchs
Target strengthening into EOR DF ROM – strongest here and most functional
Involve mid-foot and 1st ray
Ankle DF during flight posture increase force output on jump testing
Testing KPI
SL HR>33
Tib post >35% BW
Tib ant 35-40% BW
Soleus >180% BW
Short presentations – Johan Lahti, Chris Bramah, Tom Dos Santos
Sprint technique changes with fatigue
Sprint technique can’t predict injury but can highlight those at risk
Anterior pelvic tilt/ trunk side flex alters trunk mm activity
This reduces horizontal force
Penultimate foot contact vital for COD
Key references:
https://www.mdpi.com/1660-4601/19/22/14643 (Fatigue)
https://journals.sagepub.com/doi/full/10.1177/03635465241235525 (S-MAS)
https://journals.sagepub.com/doi/abs/10.1177/1747954120922548 (Skill training)
Matt Taberner – Return to Performance
Performance means different things to different people. It is ill defined in the literature but research tends to agree a large proportion of players don’t return to pre-injury levels post long term injury.
Day 2
Brady Green – Calf Injuries
Identify risk factors at baseline and then address throughout the rehab
Indigenous athletes have increased risk and reduced SL HR performance
Hip function often poor – reduced proximal function can lead to calf overload
Calf strength should increase across season – if it’s not, may indicate issue
Soleus injuries on average 25 days to RTP – Grade 3 varies from 12-70 days – generally 4-8 weeks
Acute phase – approx. 4/7 to pain free walking
Palpation, ROM/tissue extensibility/ADLS/isolated PF key markers to exit this phase
Early rehab:
SL HR reps to failure aim for >25 @60bpm to transition out of this phase – cueing makes a big difference
Load isotonically in bent knee and straight knee positions
Test isometric capacity around 2/52 post injury
Progress walking drills to prep for running
Intermediate
As above plus directional power and SSC profiling
Aim for SL yielding isometric 1.5x BW
Pulsing exercises 100-160bpm
Higher bpm should have higher peak and average force – tidy up before high speed running
Testing RFD 1-3 reps 30/50/70/100% MVC
Straight knee PF in iso rig on force plates
Hinge with BB into step forward for horizontal force
PF in BB split squat for vertical force
SSC diagnostics:
Self-directed 20s hopping on force plate
Strict pogo
SL Squat Jump and SL CMJ – peak force >2000N
Prowler push for horizontal force development – 0.7-0.8xBW load -play around with trunk lean, A march, pushes
Keep monitoring once RTP – Ax data 6/52 prior to injury and then monitor for 16/52 post injury
“Don’t try to do everything, the exercise can be the test”
Alan Murdoch – Fit to Fast ACL Approach
Train high intensity movements as early as possible
Acceleration/upright max velocity/deceleration/change of direction
“Prep with purpose” – link to the above
Drill early to get fast
Less knee work with drill based running vs plod. More ankle work.
Tests for phase progression:
Return to function – hip ROM, trunk rotation
Return to run – quad strength
Return to sprinting – kinematic Ax
Return to COD/agility – reactive broad jump
Coaches Eye Ax:
Acc - “Throw to float” - Reduced power - Train with Leaning hip extension with band, ankle iso, heavy sleds
Max. V - “Studs to Jesus” - Reduced knee flex - Train with Knee flex, hip ext resisted step ups
COD - “Willow tree” - Lateral flex - COD isom, flamingos, banded lateral lunge
Decel - “Skimming stone” - Reduced ground contact - K box/overspeed decel/deep SLsquat
Simon Harries – Rehab Frameworks
Profile demands of the sport:
Attacking/defending
Tactical/technical
Physical load/actions
Consider linear, multi-directional speed agility (MDSA), and sport skills
Manipulate complexity, intensity, volume
Velocity drives intensity
MDSA manipulate: Changes in velocity, entry velocity, COD angle, time to prep
What to manipulate for on field rehab sessions:
% effort and space available
Task parameters
Sports skills
Drill type and movement opportunities – use constraints based learning design
Common approach makes it easier to individualise to the athlete in front of you.
Michael Giakoumis – Complex Hamstring
Ax - History, benchmarks, other considerations
Profile knee relative to hip
20-30% increase in hams work from 80-100% max. velocity
Negative work doubles
From 95-100% max. velocity load goes to ST>SM>BF
KPIs
Calf isom: 3.3-3.5xBW
Knee isom: 3.8-4.0xBW
Knee extension IKD >3xBW
Ankle PF seated isom 2xBW
Hip ratios – hip ext + abd = hip flex + add
Endurance
SL hams bridge 90/90 >30; NIRS rate of re-oxygenation
Force
90/90, 50/40, IKD
RFD
90/90 F@100ms
Tensile
Peak torque angle, outer ROM isom.
Co-ordination
2D/3D; Clinical Ax
Lee Herrington – ACL
Start with the end in mind and then measure performance backwards
Initial markers:
Knee circumference a sensitive measure and will change across the day if knee not quiet
Step count a usual measure to quantify ADLs
Quads activation – SLR no lag the best we have clinically
Need full extension and functional flexion
DL squat to thighs parallel – use force plates to look at force distribution
Then:
SEBT – anterior reach 67% of leg length
1.5x BW – SL leg press or smith machine + 50% BW SLSq or step down
Isometric knee extension 3Nm/Kg
Hip abd >35% BW
LSI not useful – need benchmarks
Introduce vertical landings before horizontal – start with 2 up/1 down
For RT run:
Eccentric quad strength/step count/horizontal landing
Time on feet progression
Biomechanics related to greater quad and hams strength
For MD running:
Hop test performance key – use force plates not hop distance
Train penultimate foot contact
Ensure athlete can cope with addition of cognitive load
Use CMAS https://www.sciencedirect.com/science/article/abs/pii/S1466853X19301129
Build training volume in end stage
Treat like pre-season
