NEW ZEALAND

Vol 41 • No 1 • 2014 Official Journal of Medicine New Zealand Inc.

Contents

OBITUARY Norris Roy (Norrie) Jefferson 1 David Gerrard

Editorial The man who knew too much 2 Bruce Hamilton Are we promoting the right attitude to injury in ? 4 Chris Whatman

Best of British 5 Chris Milne

CASE STUDY Metal Bars: A Case Study 8 Lynley Anderson, Peter Burt

COMMENTARY A Code of Conduct for Sports Physiotherapists in New Zealand 11 Lynley Anderson, Angela Cadogan, Michael Borich, Anthony Schneiders

Sports Physiotherapy Code of Conduct 12

CASE STUDY The opinions expressed throughout this Teres Major Strain: Not a Minor 16 journal are the contributors’ own and do Greg Usherwood, Steve Williams not necessarily relfect the view or policy of New Zealand (SMNZ). Members and readers are advised that SMNZ cannot be held responsible for INVITED ARTICLE the accuracy of statements made in Athletes with limb deficiency: Physiotherapy-specific issues 18 advertisements nor the quality of the goods or services advertised. All materials Megan Munro, Justin Ralph copyright. On acceptance of an article for publication, copyright passes to the publisher. No portion(s) of the work(s) may CONFERENCE REPORTS be reproduced without written consent New Zealand Reflections on the IOC World Conference on the 20 from the publisher. Prevention of Injury and Illness in Sport PUBLISHER Monaco, 10-12 April 2014 SPORTS MEDICINE NEW ZEALAND Ginny Rutledge, Tony Page, Judith May, Jake Pearson, Duncan Reid, PO Box 6398, Dunedin NEW ZEALAND Chris Milne, Sharon Kearney, Sarah Beable Tel: +64-3-477-7887 Fax: +64-3-477-7882 Health, Wellbeing and Success, Sochi 2014 27 Email: [email protected] Nat Anglem Web: www.sportsmedicine.co.nz

ISSN 0110-6384 (Print) ISSN 1175-6063 (On-Line) SELECTED ABSTRACTS FROM THE 2013 PARTNERS IN PERFORMANCE 28 EDITOR CONFERENCE, WELLINGTON, NZ Dr Bruce Hamilton

ASSOCIATE EDITOR Dr Chris Whatman Contributors

David Gerrard Greg Usherwood aspects of endurance exercise. He has worked with David Gerrard is a sports physician and Greg Usherwood is a physiotherapist at the many major sports teams including the Crusaders, Professor of Sports Medicine at the Dunedin School of Physiotherapy, University of Otago. He Canterbury RFC and Collingwood Australian Rules School of Medicine, University of Otago. He is a maintains a clinical caseload, as well as working FC. former Olympic team physician, a New Zealand as a clinical educator for both under-graduate and Judith May Chef de Mission, an Olympic swimmer and post-graduate students. He has a master’s degree Judith May is a sports physician who is currently a gold medallist. He in manipulative physiotherapy. His interests lie in working at Grace Sports Medicine in Tauranga. is currently Chair of the WADA TUE Expert sports physiotherapy and has worked with a variety Her interests include female issues in sport and Group, Vice-Chair of the FINA Sports Medicine of different sports and teams ranging from amateur endurance sports. She is currently the Medical Committee, Chair of the NZ Drowning Prevention to professional sport. Director for New Zealand. She is a Council and former Chair of Drug-Free Sport NZ. Steve Williams Professional Practice fellow with Otago University teaching the Women in Sport paper for the Lynley Anderson Steve Williams is a general practitioner based at the postgraduate diploma in sport and exercise Lynley Anderson is a senior lecturer at the Bioethics Musselburgh Medical Centre in Dunedin. He has medicine. Centre, University of Otago. She teaches ethics and been team doctor for a number of Otago and New professional issues to medical, physiotherapy, and Zealand sport teams and is the current team doctor Duncan Reid other health professional students as well as post- for the Otago Volts cricket team. Duncan Reid is Associate Professor of Physiotherapy and Associate Dean of Health, Faculty of Health graduate students at the University of Otago. As a Megan Munro result of her PhD research, Lynley was invited to and Environmental Science, Auckland University Megan Munro, originally from Scotland, is very write the Australasian College of Sports Physician’s of Technology. Duncan has had 32 years of clinical passionate about and has great experience in para- Code of Ethics. Since then she has written the NZ experience in musculoskeletal physiotherapy. sport. She worked as a physiotherapist for the British Physiotherapy Code of Ethics, and the NZ Sports His main areas of interest are in manual and Military for a number of years, was physiotherapist Physiotherapy Code of Conduct. manipulative therapy especially manipulation to the at the London 2012 Olympic and cervical spine. Peter Burt and was appointed Lead Physio with Paralympics Peter Burt is a graduate of the University of Otago New Zealand in August 2013. She has Chris Milne in physical education (in kinesiology) and medicine. an MSc in Sports and Exercise Medicine where Chris Milne is a sports physician in private pradtice He worked for several years in general practice and she wrote her thesis in amputee rehabilitation in at Anglesea Sports Medicine in Hamilton. He with sports teams including Hawkes Bay rugby a military setting. Megan’s experience within elite has been Team Doctor for the NZ Olympic and and , and various other teams including para-sport is a great advantage to New Zealand as Commonwealth Games teams from 1990 to the the Tall Blacks, NZ Maori rugby, NZ Bike, and she understands athlete’s needs and what it takes to present and was Team Doctor for the Chiefs Super Commonwealth and Olympic teams in 2006 and succeed. Rugby team from 1997 to 2003. A past President 2008. Peter is currently working in the Department Justin Ralph of the Australasian College of Sports Physicians he of Sport and Exercise Medicine as a researcher has also served as National Chairman of Sports Justin is a physiotherapist at Sports Med in general practice and is studying towards a Medicine New Zealand. Physiotherapy in Hamilton. He has completed PhD examining sites of potential vulnerability to his postgraduate diploma in musculoskeletal Sharon Kearney professional integrity in sports medicine. physiotherapy at AUT and is the lead physiotherapist Sharon Kearney is a physiotherapist based in Angela Cadogan for the NZ Paralympic Bike Team. Christchurch. She is one of the directors of Angela Cadogan is a registered physiotherapy Jake Pearson Performance Physio along with partner Kevin. specialist (musculoskeletal) based in Christchurch. Sharon is the physiotherapist for the Silver Ferns Jake Pearson is a sports physician based at Capital Angela has a PhD in musculoskeletal diagnostics Team and is the Lead Physiotherapist for Sports Medicine in Wellington and in his training (shoulder pain) and works in private practice High Performance Sport NZ (HPSNZ). spent time at both UniSports in Auckland and the focusing on the diagnosis and management of AIS in Canberra. He is the Medical Director for Sarah Beable shoulder disorders and athletic back and groin Paralympics NZ, doctor for the Wellington Phoenix Sarah Beable is currently a registrar training pain. Angela was the physiotherapist for the NZ Club and Medical Lead for the annual towards the ACSP Fellowship in sports and White Ferns women’s cricket team for eight years, Wellington tournament. exercise medicine. She currently works out of and continues to work on a consulting basis for NZ Unisports Sports Medicine in Auckland and also Cricket. Ginny Rutledge the Avantidrome HPSNZ centre in Cambridge in Ginny Rutledge is prinicipal physiotherapist at Michael Borich her role as Medical Director for Bike New Zealand. Wanaka Physiotherapy. She is a provider for High Michael Borich is Vice President and Secretary Sarah has been involved with the Silver Ferns as Performance Sport NZ and is Physio/ Medical of Sports Physiotherapy New Zealand and is the touring doctor in recent years and part of the NZ Coordinator to the NZ Winter Performance current NZ representative to the International Medical Team for the upcoming Commonwealth Programme. She was lead physiotherapist to the Salt Federation of Sports Physical Therapy. He has 34 Games in Glasgow. Lake 2002, Torino 2006, Vancouver 2010 and Sochi years physiotherapy experience in private practice 2014 Winter Olympics. Her special interests involve Nat Anglem along with sports physiotherapy involvement minimising injury risk in winter sport athletes Nat Anglem is a sports physician in Christchurch. (principally in the sport of rugby) both within NZ who participate in Alpine Ski Racing, Free Ski and His aim is to use models of high performance sport and overseas. Snowboarding. to improve the health and well-being of his patients, Anthony Schneiders Tony Page as well as their athletic success. He works for Anthony (Tony) Schneiders is Professor and High Performance Sport New Zealand within the Tony Page, based at SportsMed in Christchurch, has Discipline Lead-Physiotherapy at Central Wintersport programme. just recently returned to NZ following three years at Queensland University, Australia. He is an the world renowned Olympic Park Sports Medicine executive member of the International Federation Centre in Melbourne. Shortly after returning to of Sports Physical Therapy, Associate Editor NZ he was appointed All Blacks team doctor. Tony (Australasia) for the journal Physical Therapy has a specific interest in stem cell and autologous in Sport and has taught Sports Physiotherapy at injection therapies, diagnostic ultrasound for guided postgraduate level since 1999. injections, acute football trauma and medical OBITUARY

Norris Roy (Norrie) JeffersonOBE KStJ MBChB (Otago) DMRD FRACR FSMNZ 1914-2013

he recent sad loss of Dr Norrie Jefferson post-War period, there was a serendipitous in his 100th year, brought to a close a meeting between Norrie Jefferson and a staff unique era that spanned the first 50 years surgeon named Arthur Porritt. Dr Porritt, Tof sports medicine in New Zealand. Described also an Otago medical alumnus, was a general as the “Father of New Zealand Sports Medicine” surgeon, who as a Rhodes scholar at Oxford, Norrie Jefferson was a pioneer and modest competed for New Zealand at the 1924 luminary who guided the early relationship Paris Olympics, winning bronze in the 100 between sport, exercise and medicine, today a metres, the track event immortalised by the discrete area of specialist clinical practice. movie and music of “Chariots of Fire”. Later, In 1963, Norrie Jefferson, a consultant radiologist a distinguished member of the International at Dunedin Hospital, chaired the first meeting of Olympic Committee, Arthur Porritt was a fledgling group of like-minded clinicians who knighted for his services to medicine and in formed the New Zealand Federation of Sports 1967 returned to New Zealand as our first Medicine (NZFSM). This meeting was convened “home-grown” Governor-General. It had been in the Red Lecture Theatre in the Scott Building much earlier that Sir Arthur aroused sufficient of the Otago Medical School. A commemorative interest in sports medicine circles, to create the British Association of Sport and Medicine, with plaque records that historic meeting. It also Norrie receiving his Sports Medicine New records the attendance of colleague doctors Jack strong encouragement for Norrie Jefferson to do Zealand Foundation Fellow Award, Dunedin, Kilpatrick and John Heslop who, together with the same in New Zealand. The rest, as we say, is 1996. history. Professor Sandy Macalister, constituted the first (1966), Israel (1970) and Germany (1972) and national executive committee of the NZFSM. Norrie Jefferson by his own admission was a in 1979 he was awarded an OBE for services They were soon to be joined by Professor modest athlete who joined the Leith Harrier to disability sport. Public recognition of his Phillip Smithells, inaugural Dean of the School Club in 1936. He went on to become President extraordinary services to the wider community of Physical Education, who thereby added the of Otago Athletics in 1955 and President of came when he was made a Knight of the first element of sport science to this interesting Athletics New Zealand in 1960. His life-long Order of St John, reflective of many years of mix of minds. These individuals established the interest in was acknowledged outstanding service to that organisation. fundamentals that have since guided the growth when was made Patron of Athletics Otago and As our Foundation Chairman, Dr Norrie of Sports Medicine New Zealand (SMNZ), later accorded Life Membership. It was during Jefferson maintained an interest in the activities and we owe them each, but their Chairman in this period that Norrie gave considerable of SMNZ until health limited his physical particular, a debt of sincere gratitude. support to the iconic coach Arthur Lydiard, capacity to attend meetings. His presence at whose stable of athletes including Sir Murray Dr Norrie Jefferson, the son of a Methodist the 2008 Annual Conference in Dunedin was Halberg and Sir Peter Snell was rewriting minister, attended Wellington College before appropriately acknowledged and he delighted the world middle-distance record books. entering the Otago Medical School for his in astute, active dialogue with many conference Norrie provided Arthur Lydiard with medical undergraduate years. He followed this with attendees, reflecting on the continuing guidance that enabled Lydiard to establish the postgraduate experience at St Mary’s Hospital contribution of medicine to contemporary foundations of what was subsequently described London, gaining specialist qualifications in professional sport and public health awareness. diagnostic radiology. While working at St as the “jogging phenomenon”. This premise, In Norrie Jefferson we have lost a man whose Mary’s Hospital, Norrie worked closely with that sustained aerobic activity had value in vision was fundamental to the genesis of our another young New Zealand doctor, Mayne cardiac rehabilitation, was fundamental to sports medicine culture, an individual who Smeeton, who was following a chosen career the establishment of health through physical quietly espoused its values and someone in anaesthetics. Both Doctors Jefferson and activity, a forerunner to the established who displayed a passion for sport across the Smeeton were to become influential in the contemporary concept of exercise prescription. community. His founding philosophy is no less development of sports medicine in this Those privileged to know and work with Norrie applicable today as it was in 1963 and remains country and serve us at the highest level. recognised his love of sport and enthusiasm an example to us all. Norrie Jefferson returned to New Zealand in for the place of clinical practice in the care and 1950 to take up a consultant post in radiology welfare of athletes. He managed the athletics at Dunedin Hospital where he remained section of the 1962 Empire Games team to Perth Farewell dear friend and colleague. until 1956 before a period in private practice where, as a neophyte international swimmer, and then a decade at Southland Hospital as I was privileged to meet Norrie for the very Professor David Gerrard Director of Diagnostic Radiology, after which first time. Little did I know then, that this OBE CNZM MB ChB(Otago) FACSP FSMNZ he returned to Dunedin Hospital practice in the relationship would span the next 50 years. (with acknowledgement to Alistair McMurran) early 1980s. Dr Norrie Jefferson also travelled extensively At St Mary’s Hospital London, in the immediate with New Zealand Paraplegic Teams to Jamaica

new zealand journal of sports medicine - 1 Editorial bruce hamilton The man who knew too much

June 2014 3 billion DNA base pairs and a genome What makes the perfect Athlete”, a book on of a running mad father, it is part of 20,000 genes, that selecting a few will somewhat ironically promoted by gene of our family folklore that when I accurately predict one’s athletic potential. To testing companies in support of their cause) was just a lad, the ground-breaking use one “simple” example to illustrate this: concluded that “consumer genetic testing for Srunning coach Arthur Lydiard visited our it is well known that psychological factors athleticism is nearly worthless” (p156).17 Gisborne home. Lydiard was allegedly heard play a significant role in successful athletic Presumably based on a range of variable to say that “due to my [gangly] legs, there performance, and while many psychological quality association studies in limited was no way I was ever going to be a runner”. traits may be genetically determined, they are population groups, numerous companies For many years I wondered if this was true, typically not assessed in any genetic screen are marketing the concept of genetic testing but with the benefits of age and time, it for performance potential. individuals to assist in choosing both “best seems he was probably right. These days, One of the best known and comprehensively suited” sports and developing specific training companies selling genetic tests of athletic researched “athletic genes” is the ACTN3 approaches based on a genomic profile.3 ability would contend that you don’t have to gene found on chromosome 11. The ACTN3 Using ACTN3 as an example, the simplistic wonder anymore, or waste time with a sport gene is known to code for alpha-actinin-3, rationale appears to be that since (in some you are not “designed” for. In 2014, without a structural protein found in some muscle populations) the ACTN3 RR allele has a talking to a doctor, geneticist, coach or even sarcomeres (typically fast muscle fibres), and higher prevalence in power athletes, if you a parent, you can buy a genetic test on-line which is thought to play a role in optimising want to be (or think you might be) a power and confirm what sort of an athlete, you may force transmission. It is recognised that athlete, then you should check your status or may not potentially be. Genetic screening variations in the R577X polymorphism before you start. This rationale, of course, for athletic performance … is it really the way of this gene result in variable expression seems fundamentally flawed - as a statistically of the future? of alpha-actinin-34 and more recently significant association between genes and A news article recently claimed that a British with variations in testosterone levels in proportions of athletes competing in different Athlete was using a “revolutionary DNA athletes, indicating possible mechanisms by events does not translate into an ability to test designed to prevent injury and improve which it may impact upon performance.5 predict performance for a specific individual. her performance”,1 and at least one country Subsequently, a consistent association Just as not all individuals with the “optimal” is already reportedly using genetic testing between polymorphisms in the ACTN3 RR combination of ACTN3 alleles will either to assist in its talent identification.2 In the gene (RR Allele) and power performance have the potential to be high level sprinters world of High Performance and not-so-high has been demonstrated6 - however evidence (they may have some other significant genetic performance sport, this is exactly the sort for a relationship between the ACTN3 gene or environmental limitation), or ultimately go of article that catches the eye of athletes, (XX Allele) and endurance performance is on to be a high level sprinter, the absence of coaches, performance staff and occasionally not as impressive.6-13 Somewhat surprisingly, the gene does not mean you cannot become medical teams. Whilst not wanting to cast given the observed associations, the ACTN3 just as good a sprinter as someone with the aspersions on claims of a revolution, the polymorphism was unable to differentiate “right” gene mix.18 To illustrate this - while a technical ability to evaluate one’s genetic between the endurance athletes of East significantly greater proportion of sprinters make-up has been available for some time – Africa, and the sprinters of West Africa.11 than controls were found to have the “ideal” essentially since the completion of the human Furthermore, it is now apparent that ACTN3 RR genotype in one large European genome project in 2003. There is however, significant variations exist in the genotype study, only 50% of elite sprinters actually no denying that over the last few years there : phenotype associations observed between had that genotype – meaning that half of the are increasing numbers of companies selling genders, ethnicities11, 14 and between elite sprinters (who were just as good) did not genetic tests of athletic potential (perhaps this and “normal” individuals,8 such that any have the “preferred” genotype.19 While for is the revolution?) – some of the questions we association observed in one group cannot any particular population group it may be of face as practitioners are whether the scientific reliably be extrapolated beyond that significant academic interest to know what a evidence supports the claims made by these population. To further complicate this particular gene distribution is, with current companies and do we risk doing more harm field, it is well recognised that studies of levels of understanding, there appears to be than good by using genetics to potentially athletic gene associations are often under- no predictive value for a specific individual. guide our sporting habits?3 powered and encumbered with significant This lack of predictability is in stark contrast 15 The heritability of individual physical methodological limitations (for example, to the less frequently cited midi-chlorian traits is well recognised and increasingly a published study on the genetic profile of count, which can be tested for in a simple 16 understood. However, less well understood seven Turkish windsurfers ). While studies blood test and which is known to directly is the relative importance of the myriad of assessing the relationship between genetics reflect the power of the Force in individual elements involved in athletic performance, and performance variables are academically Jedi Masters (Qui-Gon Jinn tests this in and as a result of this complexity it seems interesting and scientifically valuable, when it Anakin Skywalker, who along with his son intuitively unlikely that from approximately comes to using genes to predict performance Luke recorded the highest known values). David Epstein, (author of “The Sports Gene: While this is of course science fiction, the editorial underlying principle is identical and the Unfortunately, editorial deadlines and word performance with ACE and ACTN3 genetic evidence levels for prediction of individual counts prevent the full publication of results, polymorphisms: a systematic review and potential seemingly similar. which will be presented in the next journal. meta-analysis. PLoS One, 2013. 8(1): p. e54685. In addition to the current inability to At this stage however, I can highlight that accurately predict performance potential one of our subjects was found to have a 7 Grealy, R., et al., The genetics of endurance: frequency of the ACTN3 R577X variant in with genetic profiling, there are “innate” risks predominantly endurance potential, with Ironman World Championship athletes. J Sci with performing this testing. An individual a medium V02 max potential, a medium Med Sport, 2013. 16(4): p. 365-71. without the “right” genotype may cease recovery profile and a high risk of personal training for their chosen sport, become injury. 8 Hanson, E.D., et al., ACTN3 genotype does not influence muscle power. Int J Sports Med, frustrated and disillusioned. An incorrect In 1956 Doris Day starred in an Alfred 2010. 31(11): p. 834-8. genotype provides the perfect stable negative Hitchcock thriller, singing “Que Sera Sera”, attribute for poor performance, and this has containing the classic lyrics “what-ever will 9 Rodriguez-Romo, G., et al., No association a poor prognosis for future performance be, will be … the future’s not ours to see”. between ACTN3 R577X polymorphism and elite judo athletic status. Int J Sports Physiol – essentially establishing a self-fulfilling While commercial companies using genetic Perform, 2013. 8(5): p. 579-81. prophecy. screening for athletic purposes believe they 10 Ruiz, J.R., et al., ACTN3 R577X Why then, given the vast array of factors can challenge the scientific accuracy of this polymorphism does not influence explosive involved in elite athletic performance, the lyric, the reality is that there remains a lack leg muscle power in elite players. lack of individual predictability and the risks of evidence to support claims that genetic Scand J Med Sci Sports, 2011. 21(6): p. e34- screening can accurately predict performance that genetic testing carries, would anyone pay 41. to perform this testing? capability. While genetics remains an 11 Yang, N., et al., The ACTN3 R577X exciting area for the future, until further data Succumbing to self-interest, but not- polymorphism in East and West African and understanding of the relative importance so-subtly disguised in the interests of athletes. Med Sci Sports Exerc, 2007. 39(11): of the multitude of factors and the genetic scientific endeavour, I have undertaken a p. 1985-8. determinants of those factors involved in comprehensive retrospective cohort study 12 Lucia, A., et al., ACTN3 genotype in performance is available, there seems no of this topic. Enrolling an extensive cohort professional endurance cyclists. Int J Sports indication for genetic testing young athletes. of two (purists may argue that this is an Med, 2006. 27(11): p. 880-4. The name of the Hitchcock thriller, “The Man underpowered investigation, but it is not 13 Saunders, C.J., et al., No association of Who Knew Too Much”, is a prescient title far below some published studies), I have the ACTN3 gene R577X polymorphism given today’s commercial possibilities. looked to evaluate the merits of the genetic with endurance performance in Ironman determination of athletic potential from References . Ann Hum Genet, 2007. 71(Pt 6): a commercial company, readily available 1 DNA Secrets Helping Athletes Improve, in p. 777-81. 3 News.com. 2014. on-line. The demographics and athletic 14 Eynon, N., et al., The ACTN3 R577X achievements of the two individuals involved 2 Synovitz, R. and Z. Eshanova, Uzbekistan polymorphism across three groups of elite in this study are illustrated in Table One. is using genetic testing to find future male European athletes. PLoS One, 2012. Both subjects completed the informed Olympians, in The Atlantic. 2014. 7(8): p. e43132. consent required by the company involved 3 Roth, S., Critical Overview of Applications of 15 Rankinen, T., et al., Advances in exercise, in the genetic testing (subjects were not Gentic Testing in Sport Talent Identification. fitness, and performance genomics. Med Sci required to talk to anyone in particular), Recent Patents on DNA and Gene Sequences, Sports Exerc, 2010. 42(5): p. 835-46. 2012. 6: p. 247-255. the company was blinded to the athletic 16 Ulucan, K., et al., Preliminary Findings of backgrounds (as they did not ask for it), but 4 Norman, B., et al., ACTN3 genotype and alpha -Actinin-3 Gene Distribution in Elite the subjects completed the date of birth such modulation of skeletal muscle response to Turkish Wind Surfers. Balkan J Med Genet, that both were deemed 18 years old at the exercise in human subjects. J Appl Physiol 2013. 16(1): p. 69-72. (1985), 2014. 116(9): p. 1197-1203. time of testing. 17 Epstein, D., The Sports Gene: What makes 5 Ahmetov, II, A.E. Donnikov, and D.Y. the perfect athlete. 2013, London: Yellow Trofimov, Actn3 genotype is associated with Both subjects consented to the publication Jersey Press. 338. testosterone levels of athletes. Biol Sport, of their data in this editorial, but no formal 18 Lucia, A., et al., Citius and longius (faster and 2014. 31(2): p. 105-8. ethical approval was obtained. No funding longer) with no alpha-actinin-3 in skeletal support was provided for the completion of this 6 Ma, F., et al., The association of sport muscles? Br J Sports Med, 2007. 41(9): p. 616- “study”. 7. Table 1: Demographics of Subjects 19 Yang, N., et al., ACTN3 Genotype is Subject One Subject Two associated with human elite athletic Age 50 48 performance. American Journal of Human Highest Athletic Performance Double Olympic Gold Medal University Road Relay Team Member Genetics, 2003. 73: p. 627-631. Region of Birth Northern Hemisphere Southern Hemisphere Injury History Low Injury rate High Injury Rate Current Fitness High Level Age Group Hack

new zealand journal of sports medicine - 3 EDITORIAL chris whatman Are we promoting the right attitude to injury in sport?

’m writing this editorial at the last looked after in this space but injuries in elite A recent report by the Australian sports injury minute, partly because I’ve been sport are in the minority and there needs prevention task force noted a key strategy for watching too much of the football to be a focus on injury management and injury prevention was to maximise the role Iworld cup and with the recent addition prevention in amateur sport – especially and influence of the coach to create a positive of Wimbledon highlights – it’s proving a junior sport as the best way to increase your culture around sports injury prevention and tough month to be a sports fan. Although risk of injury is to get injured in the first place. management – this obviously relies on the FIFA undoubtedly put on a great show, High performance athletes have vast resources coach being educated and having the right the beautiful game does suffer from a high at their disposal to manage injuries and attitude. A recent study reported that the incidence of what appear to be horrific implement injury prevention strategies – and attitudes of netball coaches can influence the injuries (the recoveries from which are often the great work done at the high performance success of an injury prevention programme4 nothing short of a sports medicine miracle!). level possibly gives those in the amateur and another highlighted a lack of player/ I think the term FIFA uses is “simulation” or game unrealistic expectations. In amateur coach knowledge of knee injury prevention more commonly described in our household sport the coach is often the sole resource strategies in female soccer.5 More needs to be as a Hollywood! It’s probably summed up and depending on the sport and the level done in this area and it would be interesting best by a post online, pointed out to me by a of competition the quality of this resource to see how the attitudes and knowledge of our colleague this morning, “What’s the difference could vary massively. In New Zealand we rely local amateur coaches (especially in junior between footballers and rugby players? heavily on volunteer coaches and evidence sport) stack up. With this in mind colleagues Footballers spend 90 minutes pretending suggests many of these coaches are exposed and I are about to undertake a small pilot to be injured and rugby players spend 80 to very little training/education. This includes study looking at attitudes and knowledge minutes pretending not to be injured”. training related to technical aspects of the of injury in secondary school coaches, with Similarities do also exist - both games seem to sport as well as management of injuries. the hope of extending to a bigger study in have the odd problem with the bite injury – The importance of the coach in injury the near future – so watch this space. In enough said! prevention and management in amateur the meantime if you have any strategies Either way neither attitude to injury seems sport, especially at the junior level, has been for preventing simulation or reducing the to be a great look for our budding amateurs highlighted in several recent studies.1 There incidence of biting injuries in football let FIFA (especially juniors) running around on the is evidence it is often coaches who emphasise know – they might have to adapt the 11 plus a weekend and one wonders at the influence early sports specialisation and this has little further! it has on them and their coaches. When my been linked in increased overuse injuries in References 2 youngest first started playing football (soccer youth athletes. The influence of the coach 1 Saunders, N., et al., Coaches’ perspectives on to be clear) his main concern pre game was on developing the ability of the player is implementing an evidence-informed injury whether or not he had to hug all his team possibly matched by the influence the coaches prevention programme in junior community mates if he scored! I also remember being attitude to injury has on the player. We netball. British Journal of Sports Medicine, amazed at the number of expert simulations are fortunate that there are many excellent 2010. 44(15): p. 1128-1132. I witnessed in an under 11 game of football resources available to amateur coaches in 2 Nyland, J., Coming to terms with early sports when working briefly for the Fulham football this country – many made available by the specialization and athletic injuries. Journal of academy in the UK – youngsters certainly pay sports themselves and/or ACC – the rugby Orthopaedic & Sports Physical Therapy, 2014. attention to what their idols are up to. So what and netballsmart programmes come to mind. 44(6): p. 389-390. impact on amateur sport the recent stories of However the buzz term currently seems to be 3 Richmond, S., C. McKay, and C. Emery, All Blacks playing on with fractured ribs and “knowledge translation” – the need for real Knowledge translation in sport injury the follow up story in the NZ Herald recalling world implementation of injury prevention orevention research: an example in youth ice in Canada. British Journal of Sports all the tough All Blacks that have played on research – obviously key being the acceptance Medicine, 2014. 48(12): p. 941-942. injured over the years – the torn scrotum of and adopting of key practices by coaches.3 4 White, P.E., et al., Ensuring implementation one All Black captain likely the most famous/ Given the important role of coaches in success: How should coach injury prevention infamous! These stories are obviously mostly training players and delivering safety education be improved if we want coaches to media hype, especially these days given the initiatives to players it has been noted that deliver safety programmes during training expert sports medicine advice available to the very few studies have investigated coach sessions? British Journal of Sports Medicine, elite – but maybe that’s missed by average Joe injury prevention practices and safety 2014. 48: p. 402-403. amateur? 1 promotion attitudes. Coaches are in a unique 5 Orr, B., et al., Female soccer knee injury: The attitude towards injury and injury position to teach safe playing techniques/ Observed knowledge gaps in injury prevention in elite sport has certainly strategies, promote injury prevention and prevention among players/parents/coaches been a focus of attention recently with the guide appropriate injury management. For and current evidence (the KNOW study). appearance in the papers and on television this reason several authors have emphasised Scandinavian Journal of Medicine & Science in of stories discussing the possible long term coach education is fundamental to sports Sports, 2013. 23(3): p. 271-280. impact of concussion. Again I have no doubt injury prevention and risk management.1 the elite (in this country anyway) are well

4 - new zealand journal of sports medicine best of british chris milne

JANUARY - JUNE 2014 chronic sequelae of concussion. Nevertheless, to explore YouTube as a medium for the Starting with the January issue which was an it would appear that chronic traumatic dissemination of quality controlled information IOC sponsored Injury Prevention and Health encephalopathy is a relatively uncommon on sports concussion. Protection issue concentrating on the Sochi condition. The best systematic review was Early in this issue were three editorials Winter Olympics. In the opening editorial published in this issue by Gardner, Iveson and specifically addressing the issue of concussion entitled ‘The importance of sports medicine Paul McCrory. They examined the data from in . Each of these is well worth at the Sochi Games’, Catherine Stefan and 158 published case studies and found critical a read and the final response from Martin Lars Ingebretson commented that snowboard differences between the older descriptions of Raftery on behalf of the International Rugby and freestyle skiing would be under close CTE (the classic syndrome) and more recent Board lends support from the IRB to provide scrutiny given their relatively high injury rate descriptions (i.e. the modern syndrome). a unified, consistent collision sport approach. compared with other winter sports. Later in These differences in the age of onset, natural There will be plenty more in this area, so watch the same issue there was an excellent article history, natural features, pathological findings this space. on head injuries amongst World Cup alpine and diagnostic criteria suggest that modern The next issue was devoted to Exercise freestyle skiers and snowboarders. This was a CTE is a different is Medicine and started with an editorial seven year cohort study from syndrome. They documenting how exercise is medicine was Norway. The authors found that advise caution in incorporated into the health system in South the majority of head and face reading too much Carolina. The authors, Trilk and Philip, injuries were concussions and into the data from commented that in 2002 whilst the deans of that one in four of these injuries the earlier studies 64% of medical schools reported that it was the was severe. Freestyle skiers were and recommend responsibility of medical schools to educate the most at risk and women had a further research students about physical activity, only 6% of higher injury incidence than men to clearly define medical school leaders reported having a core across all disciplines. The authors the clinical course or required curriculum addressing comment that future prevention phenotype of this issue. Having just returned from a 30+ strategies should address severe the modern year reunion of our old medical school class, injuries, promote adequate CTE syndrome anecdotally I can comment that many of my recognition and medical attention and establish classmates have taken up exercise or developed for all head injuries, and target the underlying an interest in exercise prescription since leaving freestyle and snowboarding athletes aetiology. the academic environment. This bodes well for in particular. In the same the future. Later in the same issue was an article issue was a further article Exercise is not only useful for physical entitled ‘The role of sports physiotherapy at entitled ‘Chronic traumatic encephalopathy: disorders but for mental illness. An article by the London 2012 ’. Written how serious a problem is it?’ Written by Jaya Kody and colleagues explored exercise by Marie-Elaine Grant and colleagues, Charles Tator, a neurosurgeon from Toronto, for anxiety disorders. Their systematic review this article comprehensively reviewed the the overwhelming impression is that we are, included eight RCTs. They found that exercise role of sports physiotherapy at the London in Tator’s words, “just at the beginning of our appeared to reduce anxiety symptoms in Olympics. They categorised 1778 encounters appreciation of this entity due to the paucity panic disorders but was less effective than and muscle injuries made up 33% of these, of research and the inability to diagnose CTE antidepressant medication. Also, exercise with joint injuries contributing a further during life”. There may well a role for the more combined with occupational therapy and 25%. Therapeutic techniques used included advanced imaging, e.g. MR spectroscopy, but lifestyle changes reduced the Beck Anxiety soft tissue techniques in 23%, mobilisation the field is still widely open for debate, and not Inventory outcome. For social phobias, exercise techniques in 22%, taping in 9%, cryotherapy in the open and shut situation as the media would provides additional benefits when combined 7% and exercise prescription in a further 6%. have us believe. with group cognitive behavioural therapy. They commented that the most common cause Further on in the same issue was an article Screen time is a big concern of health of athletes’ injuries was overuse, which was entitled ‘Big hits on the small screen: an researchers, and a paper by van de Laar and responsible for 44% of the presentations. evaluation of concussion related videos on colleagues from Maastricht in the Netherlands Issue 2 for 2014 could be called the CTE YouTube’. This article had contributions from found that self-reported time spent watching issue. Chronic traumatic encephalopathy, an John Sullivan and Tony Schneiders of the Otago television was associated with increased arterial uncommon sequela of concussion, is much in School of Physiotherapy and Paul McCrory was stiffness in young adults in their 30s. Later in the news these days. As I write this, Kieran a co-author. This observational study found the same issue, Yildirim and colleagues looked Reid has been ruled out of the first All Black 434 videos meeting the inclusion criteria and at what helps children move more during test of the year on account of concussion, evaluated the 100 with the largest view counts. breaks and at lunchtime at school. They found and Craig Clark, former Chiefs captain, has The authors commented that there was a need that the perceived school play environment announced his retirement on account of for healthcare and education organisations (whatever that is) and perceived social support

new zealand journal of sports medicine - 5 best of british from teachers was associated with higher that it is potentially less hazardous in those In addition, they comment on the need for moderate to vigorous physical activity during of light bodyweight and with normal or near blinding of assessors and adequate follow break time. normal biomechanics. However, for a lot of up. These comments could equally apply to The fourth issue was dedicated to care of heavier individuals or those with abnormal medical articles on musculoskeletal injury, the female athlete and included a consensus biomechanics, footwear has a definite role to play. where the number of participants enrolled is statement on the Female Athlete Triad. This Czuppon and colleagues examined the variables usually less than 100 and we are often left with statement by De Souza and colleagues follows associated with return to sport following ACL extrapolating data from similar injuries where on from earlier consensus meetings on the reconstruction. Their systematic review looked no RCTs exist. Female Athlete Triad and was intended to at 16 articles and found weak evidence of the Issue 6 was devoted largely to patellofemoral serve as a supplement to the ACSM revised following variables being important: Higher pain. In September 2013 a Third International position stand published in 2007. From my quadriceps strength, less effusion, less pain, Patellofemoral Pain Research Retreat was held perspective, a lot of its recommendations would greater tibial rotation, higher Marx activity in Vancouver. The authors were Witvrouw and appear to have been supplanted by a subsequent score, higher athletic confidence, higher pre- colleagues, including Jenny McConnell and Kay statement on relative energy deficiency in sport operative knee self-efficacy, lower kinesiophobia Crossley. The statement included issues such as published under the auspices of the IOC in and higher pre-operative self-motivation. the natural history of patellofemoral pain, trunk Issue 7 of BJSM in April (see below). These findings are hardly surprising but help us and distal factors that influence patellofemoral Labral tears of the hip are a diagnostic challenge in giving a prognosis to people. pain, innovations and rehabilitation including and examination features were reviewed Lateral ankle sprains are amongst the hip muscle retraining and movement retraining. by Michael Reiman and colleagues from commonest injuries we see and manual joint Also since 2011, the date of the last research North Carolina. As one would expect from mobilisation is frequently carried out. Loudon retreat, a randomised clinical trial has identified an American group, the emphasis is largely and colleagues carried out a systematic review that conservative intervention including on imaging, although they do mention the and found that manual joint mobilisation therapeutic exercises may prevent development contribution of the impingement position of diminished pain and increased dorsiflexion of patellofemoral pain in an active population. hip flexion, adduction and internal rotation. range of motion in acute injuries. For subacute This is potentially the most important They comment that only when patient history, or chronic injuries these techniques improved development, as patellofemoral pain is about objective testing, clinical examination, special ankle range of motion, decreased pain and 10% of all sports medicine practice. testing and imaging are combined can a increased function. Later in the same issue there is an article clinician elucidate the multidimensional Whilst on the subject of physiotherapy research, entitled ‘Is patellofemoral osteoarthritis a diagnosis of ALT (acetabular labrum it is worth commenting that clinical trials in common sequela of patellofemoral pain?’ From tears). One cannot help but think that if an sports physiotherapy have been less commonly previously published data, it would appear Australasian group was writing this article there performed than in medicine. This is hardly that patellofemoral pain and patellofemoral would have been more emphasis on the clinical surprising given the funding constraints. osteoarthritis exist along the continuum of and less on the imaging findings, given Kamper disease. Particularly in our older patients that in some studies as many as 30% of and with anterior knee pain, we need to avoid athletes have been shown to have labral colleagues expectations of a “cure” and educate patients tears and their clinical significance is wrote an to recognise and monitor their joint health often unclear. editorial status and actively manage their joint loading Issue 5 mainly concentrated on looking and symptoms. Traditional teaching is that running injuries. Barefoot running at five patellofemoral OA is common following is an activity that has attracted much decades of patellar tendon ACL reconstruction. However, recent study following the article by research and a paper by Culvenor and colleagues found Lieberman several years ago. Many provide tips evidence of significant patellofemoral OA runners have been advised to run to improve following hamstring reconstruction as well. barefoot as a treatment mode for the evidence This cross sectional study was based on 70 injuries, strength and conditioning. generated by participants who had undergone hamstring However these authors, including clinical trials in reconstruction 5-10 years previously and is the well-known Tim Noakes and physiotherapy. worth bearing in mind, as it tends to challenge his group from the University In particular, the traditional dogma. of Cape Town, state that, crucially, they emphasise Issue 7 published in April 2014 in conjunction long term prospective studies have yet to be rigorous research methods, particular attention with the IOC World Conference on Prevention conducted. The link between barefoot running to eligibility criteria, source of participants and of Injury and Illness in Sport in Monaco was and injury or performance remains tenuous and similarity of groups at baseline plus concealed the largest ever issue of the journal. Running to speculative. From my perspective as a runner allocation and intention to treat analysis nearly 200 pages, most of it, i.e. over 100 pages, of 40+ years’ experience, I would comment would enhance the quality of publications. was devoted to abstracts from this conference.

6 - new zealand journal of sports medicine best of british

However, there were also some must-read that tendons respond to load on a daily basis almost all of the action. As a digital dinosaur, articles in this issue. The first of these was and waiting for tendon pain as an indication of even I can appreciate how social media can aid from athletics and included illness and injury overload may be a dance with the devil. For the in our mission. definition plus data collection procedures for symptomatic athlete they recommend actively Cricket has been much in the news recently use in epidemiological studies. reducing tendon pain with for all the wrong reasons. An article by Sarah This consensus medications such as NSAIDs Morton and colleagues looked at risk factors statement written by and occasional doxycycline, and successful interventions for cricket-related Juan-Manuel Alonso, green tea or omega-3, low back pain. They looked at 12 studies and Medical Director although the evidence found that the presence of acute MRI bone for the IAAF, and for these interventions is stress was a risk factor for developing lumbar colleagues, provides an relatively limited. Surgical stress fractures. Additionally, they found excellent framework intervention is usually moderate evidence for increased shoulder for epidemiological carried out in the off counterrotation (associated with a mixed studies in athletics. The season but occasional action) and decreased anterior formula can easily be reports describe a abdominal fascial slide to be associated with extrapolated over to other rehabilitation period of as low back pain in cricketers. sports and should be read short as six weeks post- The first dictum of medicine is primum by all of those people who operatively. non nocere, i.e. firstly do no harm. Ionising contemplate performing Finally in this issue radiation has been used to clarify the diagnosis epidemiological studies in was a superb article in various injuries, but John Orchard and the sporting population. entitled ‘Managing colleagues report on three game-changing Secondly in the same issue was the the health of the elite athlete: a new integrated studies for imaging in sports medicine. These IOC Consensus Statement entitled ‘Beyond performance health management and coaching were published in the Lancet and BMJ and the Female Athlete Triad: Relative Energy model’. Written by Dijkstra and colleagues, it the authors comment that these papers should Deficiency in Sport (RED:S)’. This paper by uses the programme adopted by UK Athletics result in a review of imaging guidelines by Margo Mountjoy and colleagues looks beyond in preparation for the London Olympic clinicians and advisory bodies. A good the standard Female Athlete Triad and defines and Paralympic Games. The medical and clinician should be weighing up the risks of this new syndrome of relative energy deficiency coaching teams are managed by qualified ionising radiation in imaging referral decisions. in sport. It encompasses a constellation of and experienced individuals operating in This is, in fact, what we have been doing for physiological impairments including metabolic synergy towards a common performance many years. In particular, the evaluation of rate, menstrual function, bone health, goal. These people are accountable to the low back pain in young gymnasts in a high immunity, protein synthesis plus cardiovascular Performance Director and, ultimately, to the performance environment resulted in many health caused by relative energy deficiency. Board of Directors. In essence, this is what we bone scans and CT scans being performed. The vast majority of athletes affected by the have adopted and modified for New Zealand Today’s young gymnasts are more appropriately condition are female but in certain sports, e.g. conditions under the able leadership of Bruce imaged by MRI scan, which does not expose cycling, ski jumping and weight class sports, Hamilton, your editor, who was appointed them to any ionising radiation. Nevertheless, significant numbers of male athletes are also Medical Director for High Performance there will still be clinical scenarios in which affected. The authors propose a traffic light Sport New Zealand just over a year ago. In a combination of a bone scan followed by a system and make recommendations for sport that time our systems have got demonstrably CT scan is associated with greater sensitivity participation and training based on where the better under his guidance and leadership. The and specificity. This point is made by Bruce athlete sits within the spectrum. Later in the programme will be further strengthened with Forster, consultant radiologist from UBC in same issue was a position statement on youth the appointment of a fulltime Rehabilitation Vancouver. Both of these articles should be resistance training. These authors support the Director in the coming months. read in conjunction with one another to get a use of resistance training on the proviso that Issue 8 was concerned with implementation good appreciation of the issues involved. qualified professionals design and supervise science and harnessing digital technology to My pick for most valuable article in this training programmes that are consistent achieve better outcomes in sport. This was particular series would be that relating to with the needs, goals and abilities of younger exemplified by an article by Evert Verhagen and managing the health of the elite athlete. It is a populations. colleagues entitled ‘How BJSM embraces the tour de force of this topic and shows just how Also in the same issue, Jill Cook and Craig power of social media to disseminate research’. far we have come since I graduated in 1980, Purdam wrote an excellent article on the This was the topic of a major seminar at the where many of my senior medical teachers management of tendinopathy in competing Monaco conference. The authors comment regarded any medical intervention in elite athletes. Tendinopathy is a condition which that in most online communities, 90% of users athlete care as being rather an indulgence and takes many months to settle and in-season are lurkers who never contribute, 9% of users taking away from our true medical mission. management is a challenge. They comment contribute a little and 1% of users account for This is indeed a sign of progress.

new zealand journal of sports medicine - 7 CASE STUDY LYNLEY ANDERSON AND PETER BURT Metal Bars: A Case Study Lynley Anderson1 while he has refused to take part and has lack the cues present in traditional clinical 3 Peter Burt2 informed the coach and manager, we ask practice. A strong sense of camaraderie whether he has an obligation to do more to may develop between the clinician and prevent harm to others. athlete due the time spent travelling, 11 1 Senior Lecturer, Bioethics Centre, Because the coach and manager are eating, and socialising together and may University of Otago disinterested in what the physiotherapist encourage the adoption of behaviours they might otherwise reject.15,18,19,13,24,23,26,6 There 2 Researcher, Department of Sport and reports, to prevent the activity, the may also be a lack of professional support Exercise Medicine, University of Otago physiotherapist will have to take this information to someone outside of the in the sporting environment leaving sports team. Taking action beyond the team clinicians professionally isolated. Instead, ports clinicians can face ethically may have negative implications for the the clinician is surrounded by sporting challenging situations in their clinical physiotherapist, including a break down administration and team personnel who practice. At times, what they consider in his employment relationship and may make the health and wellbeing of Sto be clinically and ethically appropriate 25 his ongoing role with the team, club or players a priority. The features described may not match with what their patient, team franchise. Although the physiotherapist’s can make it difficult for a professional or coach would agree with. In the real-life fears are personally significant, the to hold onto his or her professional and case that follows, a sports physiotherapist implications associated with this action personal integrity, and may encourage them refuses to comply with a player request going ahead cannot be ignored. While we to adopt behaviours they might otherwise that could result in harm to opposition consider the physiotherapist has made reject. players. We discuss any further action that the right choice, we recognise that taking may be required to prevent such harm, Sport Violence Ethics and the Law such a stand is not straight forward due but recognise this action may affect the The player request involves the potential to the influences present in the sporting physiotherapist’s ongoing role with the for serious harm to opposition players, and environment. team. We also present a range of resources some might argue that the physiotherapist’s that might assist a sports clinician to make Influences of the Environment responsibilities should be limited to his own robust decisions. While from the outside it might appear team members and not to the welfare of obvious that the physiotherapist should the opposition. We do not agree. There is The Case decline to get involved, there are a number a general obligation on all of us to prevent A physiotherapist (working with a team of characteristics within the sporting harm to others. There are examples specific playing a contact sport) is approached by environment that may make it difficult to health care where a health professional a player to ask if he will strap metal bars to do so. These characteristics have the has become aware that a patient is onto his forearm. The player does not potential to influence clinical decision threatening to harm another individual. In have an injury and the only purpose of the making as was evidenced by the actions those circumstances we consider there is a bars is to enable the player to inflict harm of the physiotherapist and doctor in the duty to take some kind of action to prevent on members of the opposing team. The “Bloodgate” scandal.10,21,6,4 In the Bloodgate that harm from occurring. We therefore physiotherapist is asked to do the strapping case, a physiotherapist and a doctor, both consider that the physiotherapist has a duty so that the addition of the bars will have the of high standing, actively participated in to act to prevent the potential harm. appearance of a legitimate treatment of an cheating to help their team win a rugby Legal academic Paul Farrugia1 writes on injury and therefore attract little attention. game. Speculation centred on whether sporting violence and the law. He states The physiotherapist refuses to have any part their actions were the result of their that sport frequently involves a level of in this activity but the player says he will personal flaws, or a product of the sporting violence that would not be tolerated in get someone else to do it. The player asks environment that places a high priority on the rest of the community. This tolerance the physiotherapist to keep quiet about it. team success. Sociologist Eliot Friedson is predicated on the benefits of sport to The physiotherapist informs the coach and (1970) suggests that the environment society, and the implied consent that each manager, but they shrug it off and ignore the in which a professional practices is the player has given. For example, if a player physiotherapist’s concerns. most important factor in determining signs up to play rugby, he or she signs up Introduction their professional standards.8 This is not to all that sport entails including the rough Setting out to deliberately harm others to say that their professional training is and tumble that is part of rugby. Breaches through the use of metal bars hidden in unimportant, rather the environment of the rules, such as punches and illegal strapping is probably one of the most in which they practice has the greatest tackles are generally dealt with internally by egregious forms of premeditated violence potential to distort a clinician’s objectivity the sport. However, this does not preclude in sport. The physiotherapist in this case and clinical decision making. When action in the courts, although within New has refused to comply with the request, considered separately, many characteristics Zealand and Australia referral to the courts and we strongly support his position. might appear insignificant, however it is is uncommon. Nevertheless, Farrugia The physiotherapist has been asked to be their cumulative effect that is concerning. states that ‘participation in contact sport complicit in an activity that has the potential For example, the physical settings for is not a licence to abandon the restraints to cause significant harm to others, and clinical practice in sport (on sidelines, of civilisation’ and some actions, he states, airports, and in hotel rooms) commonly cannot be consented to. Actions that are

8 - new zealand journal of sports medicine case study so violent or egregious and which would be the matter on to the Health Practitioner’s have the authority to check that players considered to lie beyond the rules should Disciplinary Tribunal, who has the power clothing complies with the rules of the ‘be accountable before a court of law’. That to impose similar limitations but can also sport. Basketball, rugby league and rugby threshold may well have been met if injury impose fines and costs). (HPCA Act 81-82) all prohibit the use of clothing that could occurred as a result of metal bars strapped It appears that a physiotherapist who assists harm players and they allow the referee to to a players forearm. While the player took a player to strap metal bars to his forearm to check for and exclude such clothing (FIBA the action, a physiotherapist who assisted cause harm to opposition players may well be 2012; IRB 2013; RLIF 2013). By informing the player may also face charges. However, putting his professional livelihood at risk. the referee of the offending activity, the even if legal action did not ensue, if caught, physiotherapist could be said to have the player and physiotherapist may face Responding to the Initial Request discharged his duty to protect others. Prior disciplinary action by the sporting code and As stated earlier, the physiotherapist in this to any disclosure, advice may be sought that may or may not include some sort of ban scenario refused to be part of this action, from senior colleagues and others. Such from future involvement in the sport. however there are some immediate steps the discussions should be documented. physiotherapist might consider taking. At Professional Obligations the point of request, the physiotherapist has Viability of Ongoing Role as Team The physiotherapist also has professional an opportunity to educate the player about Physiotherapist obligations spelled out in within his the rules and integrity of the sport, and the Informing outside parties, and in particular, professional ethical codes. There are two potential of harm to others, with the hope going over the coach’s head potentially poses particular documents that guide clinical that this discussion might lead the player to a threat to the physiotherapist’s ongoing practice for sports physiotherapists in New abandon his plan. While this approach may relationship with team management. Known Zealand; The Physiotherapy Board of New not achieve the desired outcome, it does as ‘whistleblowing’, the activity of informing Zealand’s Code of Ethics (2011), and the model behaviour that encourages fair play, others may lead to negative outcomes for the 2014 Sports Physiotherapy Code of Conduct. respect for the opposition, and regard for the whistleblower, and the physiotherapist would A review of both indicates that complying rules and integrity of the sport. If the player, need to be prepared for this especially, as in with the action requested by the patient despite being told of the implications, still this case, where the coach and manager do 5,14 would be considered unacceptable. The plans to proceed, the physiotherapist should not share his concerns. relevant clause in the Physiotherapy Board of inform the player that he has now been When a health professional is being asked New Zealand Code of Ethics states that: placed in a difficult position, and will need to be complicit in activities that will harm ‘Physiotherapists must: to consider his obligations. This may also others, and where management and coaching • act with honesty and integrity in all discourage the player from going ahead with staff accept this, is indicative of a problem professional activities’ his plans. with team culture. The ongoing provision of physiotherapy services may no longer be (Physiotherapy Board 2011) Confidentiality of the Physiotherapist-Patient Relationship realistic or tenable after this event and the The new Sports Physiotherapy Code of physiotherapist will need to decide whether Some might argue that if this discussion Conduct states that: this is a team with which they want to be between physiotherapist and athlete occurred ‘Physiotherapists will: associated. in the context of a therapeutic relationship, • Act with honesty and integrity and this it should be kept confidential. This is Recommendations and Support promote fair play in sport. generally true - what is discussed within This case highlights the importance of setting • Not violate the rules of a particular sport a therapeutic relationship should be kept and maintaining professional standards in order to obtain an unfair advantage’ confidential as expressed in the Health and boundaries when establishing a new (Sports Physiotherapy New Zealand Information Privacy Code (HIPC). However, relationship between a health professional 2014) the HIPC also allows for situations where and team members. Attempting to re- confidentiality may be broken including establish higher professional standards after These statements indicate that the where the patient poses a serious threat to previously demonstrating a willingness to physiotherapy professional body would, themselves or others (HIPC Rule 11). In breach them may be difficult, therefore a in all likelihood, not react favourably to a these cases any disclosure must be made clinician engaging with a team will need to physiotherapist who assisted in this kind of to someone who can do something about consider where to place their limits. activity. If the action of a physiotherapist that threat. The HIPC goes on to state that came to the attention of the Physiotherapy Requests that challenge professional ‘even if disclosure is warranted, it should Board, under the Health Practitioner’s standards may occur at any time, including only be to the extent necessary to prevent Competency Assurance Act (2003), 65(2), in the ‘heat of battle’ where there is little or lessen the threat.’ Ordinarily the coach the Board may refer this action to its warning or opportunity to consider or might be identified as such a person who Professional Conduct Committee. If the discuss. It is important that the health is able to meet both of those aims, but this Professional Conduct Committee finds a professional has established a range of option has not proven to be successful so breach, they may choose from a range of supports to assist in such a situation. the physiotherapist may decide to speak to responses including requiring competency Prior to beginning with the team we someone else. reviews, restrictions on practice, through recommend the physiotherapist (or indeed to suspension or cancellation of an annual The referee is an obvious person who any health professional) talk with senior practicing certificate. They may also refer can act immediately to prevent harm management about expectations and coming to opposition players. Referees

new zealand journal of sports medicine - 9 case study boundaries. The physiotherapist would be will be able to navigate such requests with 17 Sports Physiotherapy New Zealand, 2014. to advised to remind team management of confidence. be updated their professional obligations as expressed in Acknowledgements 18 Pipe, A. Reviving ethics in sports: time their code of ethics and conduct. A similar for physicians to act. The Physician and Dr Jeanne Snelling, Dr Neil Pickering, Sandy discussion could also be held with team Sportsmedicine, 1998; 26. Elkin members. 19 Polsky, S. Winning medicine: professional For sports physiotherapists facing a similar References sports team doctors’ conflicts of interest. The Journal of Contemporary Health Law and situation, we suggest the following four tools 1 Farrugia, Paul J. “Consent Defence: Sports Violence, Sadomasochism, and the Criminal Policy, 1998; 14, 503-29. as a way of encouraging sound and robust L aw.” Auckland UL Rev. 8 (1996): 472. ethical decisions. These include: 20 Privacy Act. Wellington: New Zealand 2 Ackford, P. Quins scandal opens the door Government Print, 1993. 1 Knowledge of the expectations expressed to world of sinister practices. The Sunday 21 Union. 2009. image of the within professional codes of ethics and Telegraph, 2009; p.Newspaper Article. game report [Online]. Available: http:// conduct. 3 Australasian College of Sports Physicians, www.rfu.com/News/2009/September/News 2 Consideration of potential areas of 2008. Code of ethics http://www.acsp.org.au/ Articles/300909_Image_of_game_report. conflict and where their own limits are 4 Anderson, L. Bloodgate: were the aspx. (in association with expectations set out punishments fair? British Journal of Sports 22 Rugby League International Federation, 2013. in professional standards). Medicine, 2011. http://rlifmedia.dyndns.org/docs/Rugby 3 Having a close group of sports health 5 Brown, J. & Olsen, J. “6. Whistleblower League International Laws of the Game - Sept 2013.pdf [Accessed 09.03.14]. professional colleagues who are willing mistreatment: identifying the risks.” to discuss ethically challenging cases Whistleblowing in the Australian public sector 23 Salkeld, L. R. Ethics and the pitchside openly. The discussions need to be 2008; 137. physician. Journal of Medical Ethics, 2008; 34, 456-7. reflective and thoughtful and that the 6 Devitt, B. M. & Mccarthy, C. ‘I am in blood group must respect confidentiality. Stepp’d in so far...’: ethical dilemmas and the 24 Stovitz, S. D. & Satin, D. J. Professionalism sports team doctor. British Journal of Sports and the ethics of the sideline physician. 4 Have a working knowledge of the Medicine, 2010; 44, 175-178. Current Sports Medicine Reports, 2006; 5, support structures within Sports 7 Fédération Internationale de 120-4. Physiotherapy New Zealand, and Basketball Amateur, 2012. http://www. 25 Waddington, I. 2010. Client control and the Physiotherapy New Zealand and know .com/downloads/Rules/2012/ limits of professional autonomy: the case of how to access that support when OfficialBasketballRules2012.pdf [Accessed sports medicine and the use of performance- required. 09.03.14]. enhancing drugs. Playthegame.org [Online]. 5 Have an effective working relationship 8 Freidson, E. Profession of medicine: a study Available: http://www.playthegame.org/ with the team doctor. of the sociology of applied knowledge. knowledge-bank/articles/client-control-and- the-limits-of-professional-autonomy-the- Conclusion University of Chicago Press 1988. case-of-sports-medicine-and-the-use-of-p. 9 Health Information Privacy Code. Wellington: The present case highlights the html. New Zealand Government Print, 1994. complexity of the setting in which the 26 Waddington, I., Smith, A. An Introduction to 10 Holm, S. & Mcnamee, M. Ethics in sports sports physiotherapist practices and the Drugs in Sport : Addicted to Winning?, 2008; medicine. BMJ, 2009; 339, b3898. compromising position they can be placed in Hoboken, Taylor & Francis. when such requests are made. We consider 11 Huizenga, R. 1994. You’re okay, it’s just a that the physiotherapist in this situation bruise: a doctor’s sideline secrets about pro football’s most outrageous team, New York, St. has made the right decision, but while it Martin’s Griffin. looks like a cut and dried case, in reality these cases are far from straightforward. The 12 International Rugby Board, 2013. http://www. irblaws.com/index.php?law=4 [Accessed physiotherapist must decide what further 09.03.14]. action to take, who to inform and whether any on-going relationship with the team is 13 Johnson, R. The unique ethics of sports medicine. Clinics in Sports Medicine, 2004; 23, feasible. 175-82. Having a clear role and establishing 14 Mansbach, A., Ziedenberg, H., & Bachner, expectations with the team management Y. “Nursing students’ willingness to blow the and players at the beginning of the working whistle.” Nurse Education Today, 2013; 33.1 relationship may assist the physiotherapist in 69-72. creating a culture where his role is respected. 15 Opie, H. The team/doctor/athlete legal However, in spite of these efforts, demands relationship. Sports Medicine, Training and may still be placed on the physiotherapist Rehabilitation, 1991; 2, 287-299. that he finds difficult to deal with. In these 16 Physiotherapy Board New Zealand, 2011. circumstances the physiotherapist who has http://www.physioboard.org.nz/docs/ good resources ready and available and NZ_Physiotherapy_Code_of_Ethics_final.pdf strategies in place for such eventualities [Accessed 09.03.14].

10 - new zealand journal of sports medicine LYNLEY ANDERSON, ANGELA CADOGAN, COMMENTARY MICHAEL BORICH, ANTHONY SCHNEIDERS A Code of Conduct for Sports Physiotherapists in New Zealand

he Sports Physiotherapy special writers to take action. The Bloodgate saga The SPCC document gains its status through interest group of Physiotherapy New in the UK – where a highly regarded sports endorsement by Physiotherapy New Zealand. Zealand has recently developed and physiotherapist got involved in cheating Status is also gained via the Code of Health Treleased the Sports Physiotherapy Code by providing blood capsules to fake a and Disability Services Consumers’ Rights of Conduct (SPCC). The SPCC is unique blood injury in rugby, and then falsified (Code of Rights). Right 4 of the Code of both nationally and internationally. Within documents – demonstrated that even top Rights states that ‘Every consumer has the New Zealand this is the first physiotherapy level physiotherapists are vulnerable to the right to have services provided that comply special interest group to have such a challenges of the sporting environment. This with legal, professional, ethical and other code written and adopted specifically for was concerning – a senior physiotherapist relevant standards’. This means that if a their particular area. The SPCC does not at the pinnacle of his career had been struck complaint has been received by the Health displace the overarching code of ethics off for poor behaviour (later reinstated). and Disability Commissioner about the for all physiotherapists in New Zealand; This raises questions about how others – actions of a sports physiotherapist, then the cornerstone for ethical guidance for particularly those at the beginning of their the Commissioner may use the SPCC to physiotherapists will always remain the career – are able to negotiate this complex determine if a breach has been made by the Aotearoa New Zealand Physiotherapy area. physiotherapist. Code of Ethics and Professional Conduct. In response to the concerns of the sports As with any code, the SPCC will require However the SPCC seeks to explain and physiotherapy community, and with the regular review in order for it to remain apply the principles found in that code to support of Physiotherapy New Zealand, a current and to meet the needs of this group the sports area. The SPCC document may decision was made to develop the SPCC. of practitioners. We hope that the code will also be unique in the world, because as far A working party was set up that included standardise behaviour across the group, as we understand, this is the first document senior sports physiotherapy people, express the values held by this community providing ethical guidance for sports Angela Cadogan, Tony Schneiders and of physiotherapists, and guide and support physiotherapists internationally. Michael Borich, and the primary author them in their everyday work. Sports physiotherapy, like sports medicine, Lynley Anderson, and this group met on The SPCC is available to all on the website of is a complex area of clinical practice. The a regular basis. The SPCC was informed Physiotherapy New Zealand. involvement of coaches, managers, sponsors by data and experience gathered as part References and fans can place expectations and demands of the development of the Aotearoa New ‘Bloodgate’ physio Stephen Brennan struck off’. on physiotherapists that are not always easy Zealand Physiotherapy Code of Ethics and (2010) http://www.bbc.co.uk/news/uk- to respond to. For example, coaches may Professional Conduct and the Australasian england-london-11302876 insist on returning players before they are College of Sports Physician’s Code of Ethics Anderson, L., & Jackson, S. (2013). Competing ready, sponsors may insist on the use of both of which had Lynley Anderson as the loyalties in sports medicine: Threats to products that do not meet player’s needs, primary author. The SPCC was written by medical professionalism in elite, commercial and for their sponsored players to be seen the working party, with legal input provided sport. International Review for the Sociology on the field or court, and athletes themselves by Jeanne Snelling. of Sport, 48(2), 238-256. can place pressure on physiotherapists to The first draft was then sent out to Anderson, L., & Bowyer, L. (2012). Engaging the take shortcuts in clinical care. At times the stakeholders for consultation. Stakeholders professional community: rewriting a code objectives of the team may conflict with included all sports physiotherapy special of ethics for NZ physiotherapists. Physical the health and wellbeing of the athletes and interest group members, other special Therapy Reviews, 17(3), 190-196. sports physiotherapists may find themselves interest group chairs, the Executive of Health and Disability Commission. (1996). Code in complex situations with little guidance. Physiotherapy New Zealand, the New of health and disability services consumers’ rights. Wellington: Health and Disability While some of these ethical concerns Zealand Physiotherapy Board, Heads Commission. will be present in other clinical areas of of Physiotherapy Schools, Accident Aotearoa New Zealand Physiotherapy Code of physiotherapy practice, it is the nature of the Compensation Corporation, Sports Ethics and Professional Conduct (2011) sports setting that can make this a fraught Physicians and doctors, and sporting http://www.physioboard.org.nz/docs/ place to work. There are also some particular organisations. Feedback was provided Australasian College of Sports Physicians Code of concerns such as fair play, and the use of electronically, and the working party met to Ethics (2008) http://www.acsp.org.au performance enhancing drugs that are collate the responses, and make changes to exclusive to sport and so require attention the document in response to that feedback. within a specific code. The final document was adopted earlier this Events overseas also spurred the code year.

new zealand journal of sports medicine - 11 CODE OF CONDUCT Sports Physiotherapy Code of Conduct Reprinted with the Permission of Sports Physiotherapy New Zealand

AUTHORS Lynley Anderson (University of Otago), Angela Cadogan (Sports Physiotherapy New Zealand), Michael Borich (Sports Physiotherapy New Zealand), Anthony Schneiders (Sports Physiotherapy New Zealand), Jeanne Snelling (Law Faculty, University of Otago)

PREAMBLE This code is not intended to vary the legal obligations and duties of sports The objective of the Sports Physiotherapy Code of Conduct (SPCC) is to physiotherapists. It is the responsibility of the sports physiotherapist to provide a comprehensive set of guidelines for the professional behaviour identify the particular legal obligations and responsibilities applicable to expected of physiotherapists providing sports physiotherapy services. their work situation. The SPCC applies to any physiotherapist providing sports physiotherapy FORMAT AND STYLE services including immediate care, injury assessment and management, The term ‘will’ is used to indicate that the associated statement sets a rehabilitation, exercise prescription, injury prevention or enhancement minimum standard that sports physiotherapists will achieve. The term of sporting performance in individuals involved in any level of exercise or ‘should’ reflects a standard that sports physiotherapists aim to promote and sport. nurture. The SPCC acknowledges the varied work environments of a sports 1. GOOD PATIENT CARE physiotherapist. Sports physiotherapists work in recreational sports and Commentary: Good patient care in sport requires a range of clinical, leisure industries, as physiotherapists working with athletes at all levels, interpersonal and management skills. The nature of the physiotherapy- within sporting organisations as a physiotherapy/medical coordinator, or in patient relationship is critical to achieving positive outcomes. Sports physiotherapy clinics. physiotherapists should be aware of how the environment in sport A patient/client in this setting is the individual receiving sports may impact upon the ability to provide quality care. Sports health care physiotherapy services, or, the group of people for whom the sports sometimes requires balancing the health and welfare of the patient with physiotherapist is contracted or otherwise engaged to provide sports the desire for sporting success. An understanding of the special physical physiotherapy services. and mental demands placed on patients through their participation in RELATIONSHIP BETWEEN THE “Aotearoa New Zealand sporting activities is required. Physiotherapy Code of Ethics and Professional Conduct” AND Standard of Clinical Practice THE SPCC. The sports physiotherapist will: The same ethical principles that apply to the practice of all physiotherapists i. Acknowledge the best interest of the patient as the underlying value in New Zealand also apply to those physiotherapists who provide sports that should guide management in the sporting environment. health care. ii. Provide a standard of clinical care that is consistent with the current The Aotearoa New Zealand Physiotherapy Code of Ethics and Professional best practice in sports physiotherapy, within the resource and systems Conduct produced by the New Zealand Physiotherapy Board (NZPB) and constraints of the sporting environment. Physiotherapy New Zealand (PNZ), is the code for all physiotherapists in iii. Be aware that he or she is not obliged to provide treatment if, in his or New Zealand (see www.physioboard.org.nz). her professional judgement, the treatment would either not benefit or would harm the patient, or is considered unethical (assist the patient to Aotearoa New Zealand Physiotherapy Code of Ethics and seek a second opinion if requested). Professional Conduct iv. in an emergency, be prepared to assist in the care of others if required. 1. Physiotherapists respect patients/clients and their whanau and v. when providing physiotherapy services at sports events, hold up-to- families. date competencies in basic life support (including use of Automated 2. Physiotherapists act to promote the health and wellbeing of the External Defibrillator, Cardiopulmonary resuscitation and airway patient/client, while acknowledging, respecting and facilitating patient/client autonomy. management) and first aid. 3. Physiotherapists respect confidentiality, privacy and security of vi. Provide appropriate handover of patient information to relevant patient/client information. medical personnel to ensure continuity of care. 4. Physiotherapists treat people fairly. vii. Recognise the particular vulnerabilities and physiological and 5. Physiotherapists practice in a safe, competent and accountable developmental characteristics of children in sport, and the short and manner. long-term risks (physical and psychological) of training regimes and 6. Physiotherapists act with integrity in all dealings. competition on children. 7. Physiotherapists strive for excellence in physiotherapy standards. 8. Physiotherapists communicate effectively and cooperate with viii Recognise the particular needs and vulnerabilities of athletes with colleagues, other health professionals and agencies, for the benefit disabilities. of their patients/clients and the wider community. The sports physiotherapist should: 9. Physiotherapists take responsibility to maintain their own health and ix. Advocate for children if children are being placed at high risk of harm wellbeing. from their participation in sport. 10. Physiotherapists accept responsibility to uphold the integrity of the profession. x. Be aware of the psychological and emotional aspects of sport including: training, competition, sporting success/failure, injury (and recovery from injury) and retirement. Have baseline knowledge of the key warning signs of depression, significant anxieties and eating The SPCC does not alter the Aotearoa New Zealand Physiotherapy Code disorders and, refer patients appropriately. of Ethics and Professional Conduct, but interprets and explains these principles as they relate to the sporting environment. Commentary: Sports physiotherapists may be the first person to observe mental health issues in a patient. Depression and significant anxieties A SPORTS PHYSIOTHERAPIST’S LEGAL OBLIGATIONS may first present with sleep problems, extreme fatigue, loss of motivation The SPCC should be read in conjunction with all legislation, standards and and energy, anger and/or sadness, over-thinking, withdrawal from sport codes relevant to the provision of physiotherapy services in New Zealand. and life. Eating disorders may include anorexia, bulimia, binge eating,

12 - new zealand journal of sports medicine code of conduct purging, abuse of laxatives and or diuretics, or other inappropriate physiotherapist is employed or otherwise engaged by a team or sporting compensatory behaviour including excessive exercise. Eating disorders are franchise. Employment contracts may require physiotherapists to share more common in sports that emphasise the athletes’ appearance, or those health information, in particular injury and injury treatment information sports with weight classes. Patients identified as having eating disorders with the coach or management. In these situations a sports physiotherapist or mental health issues or should be referred to their GP or, within a team may face a dilemma, either to share health information in accordance with environment, to the appropriate health professional. contractual obligations (and employer expectations) but against the wishes 2. RELATIONSHIPS WITH PATIENTS of the athlete, or, respect the wishes of the athlete, but be in breach of contractual obligations. Sports physiotherapists will: Failure to respect confidentiality of personal health information about i. Communicate effectively with patients (including parents and a patient may result in unintended consequences including a patient guardians of minors) about the nature, prognosis, and implications deciding not to disclose relevant information to the sports physiotherapist, of an injury on training and competition, the risks of continued creating unnecessary risk to the health of the individual or others. Sports participation and possible consequences for recovery, the treatment physiotherapists should take particular care to protect confidentiality when options and any relevant injury prevention strategies. using social media. ii. Not exploit any patient/client whether physically, sexually, emotionally, The sports physiotherapist will: or financially. Sexual contact of any kind with any patients/clients is unacceptable. i. Maintain patient confidentiality, except where legal requirements direct otherwise, or a strong ethical justification exists. Commentary: Sexual contact of any kind with athlete-patients is unacceptable. If a sports physiotherapist has an existing relationship with ii. Seek permission from the patient prior to each disclosure of health an athlete or team management prior to taking on the physiotherapy role, information to a third party (unless it is believed on reasonable he or she should be aware that this relationship may create a conflict of grounds that such disclosure is one of the purposes for which the interest. (see PNZ, Clear sexual boundaries in the patient-physiotherapist information was obtained and the patient is aware of the intended relationship) recipient(s)). Inform the patient of the advantage of sharing health information with coaches and team management to promote effective iii. Act in a considered and professional manner during all team social injury management and return to play. activities, especially where alcohol is consumed. iii. where necessary, educate coaches, trainers, team management and Commentary: A sports physiotherapist is part of the team by virtue of their sports governing bodies of the need for confidentiality between the professional role. As a health professional within that team, the sports sports physiotherapist and the patient. physiotherapist should consider how their individual actions in a team social setting reflects on themselves and the physiotherapy profession, and Commentary: Sports teams or sporting bodies commonly require athletes to impacts on future physiotherapy patient relationships and may endorse sign a health information release form at the beginning of the season or on particular team behaviours. Insofar as a sports physiotherapist has a role in joining a team. A health information release form signed by an athlete does ensuring patient health and welfare, the abuse of any substances should be not discharge the sports physiotherapist from the responsibility for seeking discouraged. permission to each disclosure of health information about the patient to a third party. In complex situations a sports physiotherapist should seek 3. EMPLOYMENT STRUCTURE AND RELATIONSHIPS advice from other health professionals associated with that patient’s care, Commentary: Where a sports physiotherapist is employed or otherwise or other appropriate sources. engaged by a team or sports governing body, multiple responsibilities and iv. Be sensitive to and respect the cultural and personal values of patients, obligations may result. Particular duties or responsibilities may be specified especially where carrying out assessment or treatment in shared facilities. within an employment contract that will conflict with the ethical obligations expected of physiotherapists. A problem can arise where meeting one v. where assessment or treatment must be carried out in a public obligation will result in the neglect of others. The most common divided environment, patient privacy will be maintained to the level it can be loyalty for a sports physiotherapist is where the needs of the employer reasonably achieved. conflicts with the health needs of the patient. Before agreeing to provide Commentary: The nature of some sports settings may make it difficult to services to a team the sports physiotherapist should be aware of whom they provide privacy for the patient. will be expected to provide care for. vi. Not provide health information about a patient to the media without When employed/engaged by a sports organisation the sports the consent of the patient (and/or team management where required) physiotherapist will: and will consider how information provided might impact on the i. Act with honesty and integrity in all professional activities and act in athlete or team. good faith with their employer/contractor. 5. SCOPE OF PRACTICE ii. Recognise his or her duty of care to the patient as the first concern and Sports physiotherapists will: that contractual or other responsibilities are of secondary importance. i. Be aware of the limits of their clinical competence and sports-specific iii. Not be party to an employment contract that forces or encourages him knowledge at varying levels of competition and refer to, or seek advice or her to abandon a commitment to patient welfare. from an appropriately skilled professional as required. iv. Be aware of the contractual and regulatory requirements of funding ii. work within their scope of practice, and ensure that they maintain authorities in the provision of sports physiotherapy services. their knowledge and skills through regular continuing professional The sports physiotherapist should: development. v. Seek legal advice prior to signing an employment contract. Commentary: In some situations, sports physiotherapists may be expected to work, outside the usual scope of practice generally understood to be that vi. Ensure that decisions regarding the supply of health products to of a physiotherapist. These situations may include suturing, fracture and the patient or team are, where possible, evidence based. Advocate dislocation care, and administering medications. Sports physiotherapists constructively for patients where sponsors’ demands or products must be aware of their legal obligations, and the regulations of the New negatively impact on patient welfare. Zealand Physiotherapy Board. It is the responsibility of individual sports vii. Discourage sponsorship of the sports medical team that is in conflict physiotherapist to ensure they have received relevant training and education with good health (e.g. alcohol or tobacco sponsorship) and have obtained the necessary competencies to work at this level. 4. CONFIDENTIALITY AND PRIVACY Providing Medications in the Absence of a Doctor (Standing Orders) Commentary: Confidentiality of health information about athletes is Commentary: Patient safety and wellbeing are of utmost importance when an area of concern for sports physiotherapists, particularly when the receiving physiotherapy services. Prescription and dispensing medications

new zealand journal of sports medicine - 13 code of conduct is not within the scope of practice of a physiotherapist, however a sports ii. Not engage in any activity that encourages or enables the use or physiotherapist may, under certain formal structures, supply or administer administration of any prohibited substance or doping method (as medications under instruction from a doctor in that doctor’s absence. This defined by theW orld Anti-Doping Code) unless an athlete has a current activity is set out in the Medicines (Standing Orders) Regulations, 2002, and Therapeutic Use Exemption (TUE). is further explained in the NZ Ministry of Health document entitled ‘Standing iii. Cooperate fully with the athlete testing programme and not impede Orders Guidelines, 2012’. Sports physiotherapists wishing to supply or doping control officials, or encourage/assist athletes to impede or administer medications must familiarise themselves and comply with the evade doping control procedures and processes. Discourage the requirements specified in these documents. Standing orders must not be an potential use of banned performance enhancing substances and activity of first choice if better options are available (e.g. travelling with a banned doping methods. doctor or using a doctor in another centre). A relationship of trust with the Honesty and Integrity: prescribing doctor is necessary to ensure safe patient care. Sports physiotherapists will: When working under ‘standing orders’ i. Act with honesty and integrity and promote fair play in sport. Sports physiotherapists will: ii Not violate the rules of a particular sport in order to obtain an unfair • Be aware of and comply with all legal obligations. advantage. • Maintain appropriate competencies (including those specified by the iii. Not fix or attempt to fix a match (or any part of a match), or use of issuer) for this work. reveal inside information for the purposes of betting. • Ensure patient safety is paramount, if in doubt – seek assistance. Any referrals to other services must be documented and the prescribing 9. EFFECTIVE RELATIONSHIPS doctor informed. Commentary: Good quality care for patients often requires collaboration • Recognise that any deviations from the standing order are not with a health care team. permitted (this includes providing medication to those not specified Sports physiotherapists will: within the standing order). • Keep contemporaneous documentation of care and advice given. i. Maintain effective, collaborative and professional relationships with • Debrief with the prescribing doctor on return other medical/healthcare professionals (including physiotherapists, • Understand that over the counter medications must be included sports physicians, sports doctors, GP’s) involved in the patient’s care. in a standing order. If no standing order exists direct the patient to ii. Maintain respectful relationships and behave in a professional manner consult a pharmacist or doctor. with non-medical/health care personnel (including coaches, managers, support and administration staff, match officials etc.). iii. Not undermine relationships between another sports health care 6. RISK TAKING provider and their patient. Commentary: Risk-taking in sport is the responsibility of the patient where REFERENCES that patient understands the nature and extent of the risk, is competent to • Physiotherapy New Zealand: physiotherapy.org.nz make a decision, and the decision is freely made. • New Zealand Physiotherapy Board: physioboard.org.nz The sports physiotherapist will: • New Zealand Physiotherapy Board: Aotearoa New Zealand i. inform the patient (as far as possible) of the potential harm associated Physiotherapy Code of Ethics and Professional Conduct, 2011. with returning to sport following injury including the likelihood and • Medicines (Standing Orders) Regulations, 2002 http://www.legislation. severity of further injury and the implications of injury on quality of life govt.nz/regulation/public/2002/0373/latest/DLM170107.html and future career. Advocate for the patient where the patient is being pressured into taking high levels of risk. • Standing Order Guidelines 2012. http://www.health.govt.nz/ publication/standing-order-guidelines ii. when advising athletes about return to sport following injury, discourage choices to participate in sport where a patient’s condition • World Anti-Doping Code, 2009: wada-ama.org/en/World-Anti-Doping- creates a high likelihood of a severe outcome (loss of life or severe Program/Sports-and-Anti-Doping-Organizations/The-Code/ incapacity). This advice should be documented. • Therapeutic Use Exemption, 2011: wada-ama.org/en/Science-Medicine/ iii. Not knowingly facilitate a return to sport following injury where there TUE/ is a high likelihood of a severe outcome for the patient (loss of life or • PNZ, Clear sexual boundaries in the patient-physiotherapist severe incapacity). A sports physiotherapist is under no obligation relationship (2012) to assist a patient to return to sport following an injury if the sports • Health Information Privacy Code (HIPC) physiotherapist considers the risk is unacceptable. FUNDING 7. MAINTENANCE OF PATIENT RECORDS The Sports Physiotherapy Code of Conduct was developed with the support Commentary: Maintenance of patient records can be difficult during training of Physiotherapy New Zealand. or games, however for reasons of patient safety and to meet professional expectations the sports physiotherapist will: ACKNOWLEDGEMENTS Physiotherapy New Zealand i. Ensure maintenance of accurate, legible and contemporaneous records of treatment provided, advice given, and the results of investigations. Physiotherapy Board of New Zealand (PNZ position statement) International Federation of Sports Physical Therapy ii. Be aware of legal requirements about collection, storage, and Sports Physiotherapy Australia disclosure of personal health information about patients, and ensure High Performance Sport New Zealand appropriate transfer or storage of patient’s records upon completion of care. [See the Health Information Privacy Code] Karen Nimmo (Clinical Psychologist) 8. Fair play in sport Banned Performance Enhancing Substances: Thanks also to the many athletes, physiotherapists, medical professionals and sporting organisations who provided feedback during the consultation The sports physiotherapist will: process. i. Be familiar with current anti-doping policies (including the current list of banned substances) and the rules of the WADC (World Anti-Doping Code). 30th December 2013

14 - new zealand journal of sports medicine 2014 NZ Sports Medicine and Science Conference 14-15 November • Shed 6, Wellington, New Zealand

Keynote Speakers

THOMAS BEST Dr Thomas Best is a professor of Family Medicine, OSU College of Medicine and a professor in the department of Biomedical Engineering. He serves as the team physician Columbus’ professional dance troupe BalletMet. Prior to joining the OSU Sports Medicine staff in 2005, Thomas spent ten years on the faculty of the University of Wisconsin College of Medicine as well as team physician for the Wisconsin athletic department. Thomas’ clinical interests include muscle/tendon injuries, osteoarthritis, concussion, endurance athletes and evidence-based medicine. STUART PHILLIPS Prof Stuart Phillips is a Professor of Kinesiology from McMaster University, Canada. Stuart has BSc and MSc degrees from McMaster. He graduated with a PhD from the University of Waterloo in Human Physiology in 1995. He returned to McMaster in 1997 to assume a faculty position and is now a Professor in the Department of Kinesiology and an Adjunct Professor in the School of Medicine at McMaster University. HANS TOL Dr Hans Tol is a Dutch trained Sports Medicine Physician specialising in medical management of tendon and muscle injuries. Currently he is a Sports Medicine Physician and Coordinator of Clinical Research at Aspetar, Qatar Orthopaedic and Sports Medicine Hospital. Hans is a senior associate editor of the British Journal of Sports Medicine and has published extensively in international peer-reviewed journals. ERIK WITVROUW Dr Witvrouw is a researcher and senior physiotherapist at Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar. His research focuses on musculoskeletal injuries in general, and knee problems in sports medicine in particular.

For further information, please go to:

www.sportsmedicine.co.nz

or contact

[email protected]

new zealand journal of sports medicine - 15 CASE REPORT GREG USHERWOOD, STEVE WILLIAMS Teres Major Strain: Not a minor

Greg Usherwood1 noticeable at ball release when bowling. strain of the triceps or teres major, or a Steve Williams2 Pain was also experienced when posterior labral injury. Given the failed throwing and when doing “lat pull return to bowling and the ongoing downs” at the gym. On examination he symptoms, he was referred for non- 1 Physiotherapist, School of Physiotherapy, had a full range of shoulder movement, arthrogram MRI of the shoulder. University of Otago there was no painful arc and no 2 General Practitioner, Dunedin MRI revealed a grade II strain of the glenohumeral laxity was noted. On TM/latissimus dorsi (LD) muscles. palpation there With the MRI findings Introduction was no tenderness Teres Major Muscle and ongoing symptoms, he teres major (TM) muscle is over the AC Origin Dorsal surface of inferior angle part of the posterior shoulder and lower third of lateral border we instigated a joint or bicipitial of scapula musculature and acts to medially further period of groove, however Trotate, adduct and extend the arm.1 TM Insertion Crest of lesser tubercle of humerus relative rest. After he was tender in muscle strains are uncommon injuries Action Medially rotates, adducts and one week he resumed the region of the and there are very few reported cases extends the glenohumeral joint strengthening exercises proximal triceps. in the literature.4,6,7,8,9,10,11,12 Of reported Innervation Lower subscapular C5, 6, 7 consisting of scapular But he had no cases, pitchers appears to stabilising exercises and pain with resisted be the most frequently cited in the progressing to incorporate strengthening 6,8,10,11 triceps testing. Rotator cuff testing was literature, although there have of internal rotators, adductors and normal as were O’Brien’s and Crank test. also been documented reports in sports progressive rotator cuff exercises. Over 4 12 The presentation appeared somewhat such as , tennis and water a two week period plyometric and skiing.7,9 To our knowledge there have atypical but indicated injury of the functional sport specific exercises were been no cases of TM strains reported in posterior structures possibly a muscle introduced. The athlete’s progress was cricket players. We present a case study of a professional cricket player with a strain to his TM muscle. Case Report A 25 year old male right arm medium pace first class cricketer presented with acute onset right posterior shoulder pain which developed after bowling a delivery. The pain was such that he did no further bowling in the match, but he was able to bat with some discomfort. He was initially treated by the team physiotherapist for a sprain of the subscapularis muscle. Four weeks later he attempted to return to bowling but the right posterior shoulder pain was still present. Figure One: Sagittal T2 MRI image of the right shoulder revealing increased signal intensity and fluid collection in theT M and LD muscles. The pain was most

16 - new zealand journal of sports medicine case report assessed with his ability to complete literature with regards upper limb muscle 5 Jobe FW, Moynes DR, Tibone JE, Perry J. An sports specific exercises without activation during the bowling action.2 emg analysis of the shoulder in pitching. Am J Sports Med. 1984; 12:218-220. shoulder pain and he returned initially to Likely factors involved in the 6 Leland MJ, Ciccotti MG, Cohen SB, Zoga throwing followed by graduated levels of development of this injury were that AC, Fredrick RJ. Teres major injuries in two bowling. Nine weeks from the original the athlete had a greater bowling and professional baseball pitchers. J Shoulder onset of symptoms he returned to throwing workload than normal, and Elbow Surg 2009; 18:e1-e5. competitive cricket and bowled pain free. was perhaps not conditioned for this. 7. Lester JD, Boselli KJ, Kim PD, Ahmed CS. He remained pain free although six The athlete was a fringe first class player Isolated rupture of the teres major tendon: A months later he was attending an out of so was not getting regular 4 days cricket case report and literature review. Orthopedics season training camp in Australia which games. Therefor the amount of bowling 2012; 33:1-5. involved increased volumes and intensity that he was doing in this game was much 8. Malcolm PN, Reinus WR, London SL. Magnetic resonance imaging appearance of throwing and bowling. He completed greater than what he was used to playing of teres major tendon injury in a baseball the camp but noticed the gradual onset in club cricket. This case highlights the pitcher. Am J Sports Med 1999; 27:98-100. of similar right posterior shoulder pain. need for monitoring of bowling and 9 Maldjian C, Adam R, Oxberry B, Chew F, This resolved over two weeks with no throwing loads. Kelly J. Isolated tear of the teres major: A formal treatment and there has been no To what extent throwing by the athlete waterskiing injury. J Comput Assist Tomo further recurrence. contributed to the injury is unclear. This 2000; 24:594-595. Discussion highlights an area of future research to 10 Nagada SH, Cohen SB, Noonan TJ, Raasch WG, Ciccotti MG, Yocum LA. Management Injuries to the TM muscle are study upper limb muscle activity during and outcomes of latissimus dorsi and teres uncommon, and to our knowledge there the bowling action. With an increasing major injuries in professional baseball. Am J have been no case studies involving emphasis on fielding in modern day Sports Med 2011; 39:2181-2186. cricket (with throwing a key component cricket players. Among sixteen 11 Schickendantz MS, Kaar SG, Meister K, Lund professional baseball pitchers with TM of this), consultation with throwing P, Beverley. Latissimus dorsi and teres major and/or LD injuries fifteen returned to the coaches in professional baseball may tears in professional baseball pitchers: A case same level of play. Mean time to return be beneficial for establishing correct series. Am J Sports Med 2009; 37:2016-2020. to throwing was 35 days and 62 days techniques and appropriate throwing 12 Takase K. Isolates rupture of the teres major to pitching. Nine of the sixteen injuries loads to avoid injury. muscle. JOSPT 2008; 38:439. 10 were season-ending. This cricketer Key lessons from this case include the returned to play at approximately 63 importance of an accurate diagnosis days, which may have been earlier had and clear initial management plan, the he not had an early failed return to play. identification of likely risk factors for Studies investigating muscle activity the injury and the risk of returning during throwing and baseball pitching without completing a comprehensive have not looked at the TM muscle rehabilitation programme. specifically, but have investigated the References 3,5 LD muscle. These two muscles have 1 Bartlett RM, Stockill NP, Elliott BC, Burnett a similar action, medially rotating, AF. The biomechanics of fast bowling in men’s adducting and extending the gleno- cricket: A review. J Sports Sci. 1996; 14:403- humeral joint. These muscles are 424. primarily involved in generating force in 2 Broome HL, Basmajian JV. The function of the acceleration phase of throwing, but the teres major muscle: An electromyographic study. Anat Rec 1971; 170:309-310. are also involved in decelerating the arm 3 Gowan ID, Jobe FW, Tibone JE, at the end of the cocking phase.3,5 During Perry J, Moynes DR. A comparative the ‘ball release’ phase of the bowling electromyographic analysis of the shoulder action in cricket the arm can be observed during pitching. Am J Sports Med. 1987; moving into flexion and adduction (this 15:586-590. is when most pain was experienced by 4 Grosclaude M, Najihi N, Ladermann A, the athlete). Teres major and LD are Menetrey J, Ziltener JL. Teres major muscle likely to be in action. Unfortunately, tears in two professional ice hockey players: in comparison to muscle activation case study and literature review. Orthop Traumatol Surg Res 2012; 98:122-125. studies in baseball there is a paucity of

new zealand journal of sports medicine - 17 INVITED ARTICLE MEGAN MUNRO, JUSTIN RALPH Athletes with limb deficiency: Physiotherapy-specific issues Megan Munro1 be given a different classification for periods of time in a slightly rotated Justin Ralph2 breaststroke compared to the other position. The higher the amputation strokes depending on their impairment. level, the greater the biomechanical Para swimmers are disadvantage. Lower 1 Lead Para Swimming Physiotherapist not allowed to race limb amputees may 2 Lead Para Bike Physiotherapist with prosthetic have increased lateral limbs on, even if movement of the True or False? they are adapted for pelvis so core and swimming, however gluteal strengthening some may choose to should be • Paralympic swimmers only have one train with them on. emphasised in their classification. There are various dry land program. • Amputee swimmers are not allowed to modifications/ Standing on and race wearing a prosthetic limb. equipment diving off the blocks • Lower limb amputee cyclists may ride swimmers can use or pushing off from with or without their prosthesis. to help them start the wall may also • Lower limb amputee cyclists are at according to their pose difficulties for higher risk of overuse injuries in ability. For example amputee swimmers. comparison to able-bodied athletes. for a below elbow This again can be amputee, a belt could addressed in dry be tied around the land training by ollowing on from the last article diving block for the improving balance discussing the medical issues of athlete to hook their and proprioception athletes with a limb deficiency, this limb around if they and stability muscle Farticle will focus on the physiotherapy- cannot grip the bar. activation/control. specific issues encountered when dealing Strength and with athletes with a limb deficiency, The main difference conditioning or dry specifically with regards to the events of between amputee land training should swim and bike. Swim and bike are two of and able-bodied be tailored towards the key focus Paralympic sports in New swimming is the the mechanical Zealand and physiotherapy input within asymmetry that differences in stroke. The dry land these sports is now well established exists which can lead to more strain on program should complement the with lead physiotherapy roles, and these the unaffected side or longer limb, and swimmer’s water training and consist specialised providers will share some of cause muscle imbalances and injuries. of shoulder/scapula stability, core and their specific observations and expertise The most common injuries are shoulder, gluteal exercises alongside a mobility/ in their areas. neck, and mechanical low back pain. Amputee swimmers will pull through flexibility program particularly for the Swimming freestyle, butterfly and or kick with their intact or longer limb shoulders and upper and lower back. backstroke require relatively greater more powerfully which can lead to Similar to able-bodied swimmers, upper limb strength and function overuse injuries on that side. The more amputee swimmers need to work on whilst breaststroke places relatively altered the swimming biomechanics having good scapulo-thoracic stabilisers, higher demands on the lower limb. are, the more potential there is to run avoid anterior and posterior shoulder A swimming athlete will therefore be into problems. For example, a complete capsule tightness and have optimal variably affected depending on whether amputation of an arm at shoulder thoracic mobility to ensure they don’t they have an upper or lower limb 3 level, will generally involve an athlete develop ‘swimmer’s shoulder’. Training deficiency (or both) and their preferred swimming more on their side,2 which volume should be considered if an stroke/s. This is reflected in a swimmer’s means they could spend prolonged athlete is persistently experiencing race classification where an athlete can

18 - new zealand journal of sports medicine invited article overuse problems. It is also important has been measured that up to 80% of the physiotherapy and the way in which it not to forget about optimising the work load is performed through the non- is delivered to Paralympic athletes is shorter limb because in elite races the amputee leg in an athlete riding with a no different to that provided to able- affected limb, no matter how short or prosthetic limb and in an athlete riding bodied athletes. The primary focus is to weak, could be the difference between without a prosthetic the work load of the support the athlete and coach to deliver a gold or silver medal. Working closely non-amputee side can approach 100%.1 peak performance when it matters, and with the limb centres is important as a It is also important to take into account the key to this is an understanding of good fitting limb (particularly lower) will any leg length discrepancies, such as a how each individual athlete’s disability improve day to day mobility and ability shorter femur on the amputee side. This impacts on their training and subsequent to train in the gym and pool. significantly alters the biomechanics of performance. In some cases this is of Para swimmers may not do as much dry the pedal stroke predisposing the athlete little significance but in others is can be a land strength and conditioning work to an injury again around the lumbo- major factor. Therefore it is important to compared to able-bodied athletes due pelvic and hip region. perform a detailed subjective assessment to lack of knowledge of how to adapt Although assessment and treatment prior to treating disabled athletes. These the exercises to their ability. This is principles and methods are very similar athletes will usually welcome questions something Paralympics NZ Swimming to able-bodied athletes there are some related to their disability and are very is working on as most exercises can be specific considerations to take into used to answering them. adapted to still improve strength, control account. It is important to assess the References and flexibility if you level of amputation, 1 Childers W.L, Kistenberg R & Gregor R.J. are an amputee; you function of the Pedaling asymmetry in unilateral transtibial often just need to use a amputee leg, and amputee cyclists and the effect of prosthetic little imagination and whether the athlete foot stiffness. 2007. Retrieved from http:// think outside the box. rides with or without www.smartech.gatech.edu. Bike athletes with a their prosthesis (and 2 Lecrivain G, Payton C, Slaouti A, Kennedy I. Effect of body roll amplitude and arm lower limb amputation if they ride without, rotation speed on propulsion of arm amputee can choose to either where the stump swimmers. J Biomech 2010; 19;43(6):1111-7 ride with or without is fixed to on the a prosthetic limb bike). Assessing the 3 Tovin B, Prevention and Treatment of Swimmer’s Shoulder. N Am J Sports Phys Ther. and they are then trunk stabilising 2006; 1(4):166–175. classified according musculature is of to this as well as their high importance as functional level on the it is a key element to bike. Prosthetic limbs help provide a stable used by cyclists are base for the athlete different from their in the bike saddle everyday ones and are from which they can made specifically for pedal while helping cycling within certain to compensate regulations. for the amputee side. Depending Lower limb amputees on the level of are at high risk of amputation there certain overuse injuries can be functioning primarily around the muscles or partially lumbo-pelvic and functioning muscles, hip region. This is which are prone due to an increased to overuse as they work load through attempt to assist the non-amputee leg, through a pedal altering the position of stroke. the lumbo-pelvic region and in turn the hip joint as an athlete rides the bike. It In many cases, the nature of

new zealand journal of sports medicine - 19 GINNY RUTLEDGE, TONY PAGE, JUDITH MAY, JAKE PEARSON, CONFERENCE REPORT DUNCAN REID, CHRIS MILNE, SHARON KEARNEY, SARAH BEABLE NZ Reflections on the IOC World Conference on Prevention of Injury and Illness in Sport Monaco 10-12 April 2014

Introduction hemisphere he IOC World Conference on world cup Prevention of Injury and Illness in season in Sport occurs every three years, and Alpine Ski. Tbrings together world leaders in the fields The injury of Sports Medicine and Physiotherapy to surveillance discuss the health and well-being of athletes. strategies Krosshaug of Norway to clearly demonstrate Over the past 10 years or so, it has proven include interviews and questionnaires to injury mechanism. itself to be one of the most popular Sports coaches and athletes during and post season, The most common (50%) of the ACL injures Medicine conferences, and this year was no but also included video of injuries in an are classified as” slip catch” whereby the exception, with many thousand attendees effort to gain insight into mechanisms and skier loses pressure on the outside ski with from all around the world. The range of causes of injuries. the inside edge catching and the ski sliding presentation topics was immense and the Four perceived key injury risk factors were away. This creates internal tibial rotation and most challenging aspect of the programme identified in order of perceived ranking of a valgus moment with resultant injury to the was figuring out where to be at different risk, which were presented on behalf by Jorg ACL.1 Two other ACL injury mechanisms times. Sporri, University of Salzburg , Austria) include the “landing back weighted “and Pleasingly, NZ had a strong representation • System-Ski/Plate /binding boot the “Dynamic snowplough”. Video footage at the conference, and the following is of these were presented by Tone Bere. of • Changing snow conditions a summary of personal highlights from theNorway Olso Sports Trauma Group. • Speed and course setting aspects some of those who attended. We would Due to the ski /Plate boot /binding issue • Speed in general. recommend the IOC World Conference as a as a risk factor an effort to reduce the conference to put in your diary for 2017. Alpine Ski racing has four disciplines aggressiveness of the Giant Slalom Ski and Preventing Injuries in World Downhill and Super G (Speed Disciplines) avoid the Slip catch mechanism. A prototype Cup Alpine Skiing: Research and and Giant Slalom and slalom (Technical evaluation project was carried out in Austria implementation hand in hand Discipline) The Speed Disciplines present by the Salzburg Group with three key aims Ginny Rutledge with highest rates of injury whereby Speed • Reducing the aggressiveness of the in ski HPSNZ Lead Physiotherapist Snow Sport and jumps are identified as the risk factors. –snow interaction (more skidding less lpine Ski Racing and the more recent Injuries most commonly occur to the knee, carving) of Free Ski and head, shoulder and lower back. FIS Injury A • Reducing the mechanical load-(turning Snowboard are high risk sports if performed Surveillance (ISS) reports one injury for forces) at the Elite (World Cup) Level. There are every three skiers per season with 30 percent • Reducing the turning energy (turn concerns with regard to the incidence and of these being severe. (>28 days off snow)) 60 speed) severity of injuries occurring at the elite level per cent of these injuries occur in World Cup across all three Sports as evident at the Sochi competition. While at the same time trying not to detract Winter Olympics in February 2014. from the ski ability and attractiveness of the The knee is the most commonly injured, sport Of these three disciplines Free Ski presents with the ACL accounting for the majority with the greatest risk of severe injury (>28 of the severe injuries. Interestingly there is At the beginning of the 2012/3 season days off snow) followed by Snowboard and no gender difference between males and the GS Ski was singled out by FIS and the then Alpine Skiing. (Florences et al, Scand J females, but males present with a higher specifications changed requiring the ski Sci Sports: 2014) overall risk of injury. to be longer and thinner, with a ski radius change to 35m. This essentially returned The governing body FIS (Federation of Knee ACL mechanisms that have been the Ski to “old school” long and straight Ski) and the Oslo Sports Trauma Research captured on Video have been recreated taking skiing back to the 80s. This created Group have been collecting data from 2006- via Model based imaging ( MBI) by Tron 2014 across the 5 months of the northern considerable disgruntlement amongst the

20 - new zealand journal of sports medicine conference report racing community and challenges for the Ski to successful ACL Injury prevention ligament laxity, BMI, female sex and Companies. Changes were also made to GS programs in and soccer with neuromuscular. The reasons why male and course set specifications with the distance >50% injury reduction. Some of her key females rupture may be different… between the gates shortened and the courses messages for implementation of successful These later presentations highlight that set to require more technical skiing. prevention programmes include athlete screening is difficult if we want to predict With the complex jigsaw puzzle in mind compliance, coach acceptance,changing who will get injured. However we know what including the snow conditions, course coach culture, and multivariate approaches the risk factors are, and we should focus on setting, equipment and the athlete FIS has set including education and media. Successful these to improve prevention strategies and up a FIS risk management program. Pernilla programmes should include technique prevention should be for everyone. correction- for example cutting technique Wiberg (Swedon), herself one of the more Hamstring Injuries with low knee abduction angles and toe famous World Cup Alpine Skiers presented Tony Page on behalf of this group. Safety elements such landings, Strength (core and hamstring All Blacks Sports Physician as making slalom gates thinner, looking at focus), plyometrics, as well as dynamic arl Askling presented his paper slope preparation, Helmet componentry, balance. The Norwegian prevention website ‘Acute hamstring injuries in Swedish teeth and back protection and continuing to can be found on: C elite sprinters and jumpers: a prospective work on protective knee bracing are part of http://www.klokavskade.no/no/Skadefri/ randomised controlled clinical trial their on -going projects. Tim Hewitt presented Sport research comparing two rehabilitation protocols’ (4) To date modifications to the GS Ski has not statistics showing that 67 % of athletes A more rapid return to sprinting activity influenced the rate of ACL ruptures in GS do not return to sport within a year, and in elite athletes was demonstrated when Skiing in World Cup. However, there does approximately 1/4 will re tear with a high percentage being a tear of the contralateral following a lengthening type rehabilitation appear to be a slight decrease in overall rate knee. protocol when compared to a contracting of injuries in recent seasons. (Oslo Group, type standard hamstring rehabilitation Bere et al) An interesting workshop was run by Markus protocol. Weldon (Sweden). He introduced their Anterior Cruciate Ligament soccer specific programme that is being Hamstring injury is a common injury in (ACL) Injury implemented successfully nationwide in sprinters and jumpers, with a known high Ginny Rutledge Sweden. This is a 15 min warm up program re-injury rate. This study follows similar HPSNZ Lead Physiotherapist Snow Sport with compliance and player attendance as methodology to a study done in football e were spoilt to have the World key messages. This app can be downloaded players in Sweden. Leaders in ACL Injury prevention W free on smartphone. Search: Knakontroll. It The commonest clinical “sprinting type” presenting in Monaco. Day one of the is worth viewing as it includes video clips of hamstring injury occurs when a fatigued conference started with Symposium - the exercises and progressions delivered. athlete sprinting at high speed acutely ‘The role of human movement patterns http://www.altaif.se/altaif-fotboll-f02/ grasps the proximal outer hamstring and is in predicting ACL injuries’. Amongst the nyheter/444671/app-knakontroll unable to continue exercising. The biceps lectures Lindsay Di Steano ( USA)presented The final day symposiums included femoris long head is usually injured, and less the results of the large prospective cohort “Screening for ACL injury using the drop commonly the proximal semi-tendinosis study “The Jump ACL” carried out on jump task.” Presenters debated the Drop may also be involved. The second, less 5000 military academy personnel looking Jump test as a screening tool. Tim Hewitt common hamstring strain injury is the at biomechanical risk factors. The cohort told us that knee valgus and abduction “stretching type”, when an acute “pop” is felt, was followed up over 4 years for incidental angles (>8 degrees) are a valid predictor usually with assisted stretching , often during ACL ruptures. Their biomechanical and of ACL injury in the female athlete. Darin warm up. This stretch type injury is more neuromuscular risk factors were presented Padua presenting for the “Jump ACL” Cohort severe and usually involves a proximal tear of noting that the greatest predictor of an stated that they found no support for knee the semi-membranosis tendon. ACL injury was a previous ACL injury. An kinematics (valgus collapse or reduced knee It is proposed that neuromuscular inhibition interview with Karim Kahn discussing this flexion) as a predictor of ACL injury using of voluntary hamstring contraction occurs recent study can be listened too on BJSM the drop Jump test. However they did find after injury particularly at longer muscle podcast free of charge. that hip adduction at initial ground contact tendon lengths. Therefore a rehabilitation Gerthe Myklebust and Tim Hewitt co- was a risk factor (Pelvic drop /Hip Shift) protocols involving exercises performed in a presented workshops:” Techniques for The risk factors are multivariate including lengthened position was developed, and this preventing ACL injuries”. Gerthe is well family history (4x risk if a parent has prior was compared to a standard rehabilitation known for her international contribution ACL), joint geometry and laxity, general protocol.

new zealand journal of sports medicine - 21 conference report

A general rehabilitation programme was the failure of shoe prescription on the basis Deficiency in Sport (RED-S) which was performed in both groups three times a of gait assessment, arch height and foot developed by an expert working group. Both week, consisting of stationary cycling, fast characteristic to reduce injury rates. In a statements have been published in the British foot stepping in place, 40 m short stride literature review which he presented, there Journal of Sports Medicine (2,3). jogging and forward- backward 10m was a paucity of evidence for shoe features Both groups presented their guidelines accelerations, all performed pain free. or prescribed orthotics having any effect on which highlighted some differences of Athletes then progressed to high speed reducing injury rates. opinions. Margo Mountjoy represented the running drills three times a week, consisting The “Runners World Annual Shoe Survey” IOC consensus group and introduced the of 6 x 20 m, 4 x 40 m and 2 x 60 m sprints. ranking shoes from 1 star to 5 stars on the new concept of Relative Energy Deficiency The L(lengthening )protocol intervention basis of features determined by editorial in Sport (RED-S). The authors feel this consisted of 3 exercises, performed pain free staff has driven trends in athletic foot wear terminology should replace the female from day 5; design, that have not been evidence based. athlete triad, as it allows for the inclusion of 1 “Extender”(active knee extension, lying The development of elevated heels, anti- males who are not immune to low energy supine) pronation features and differing midsole availability (EA) and its consequences. designs in the last 30 years occurred in They also feel it reflects that many other 2 “Diver”(stand on injured leg, palms a non- scientific manner. Often patented physiological and psychological processes are together, perform a forward reach, shoe design features were discontinued affected by low energy availability, not just flexing through ipsi-lateral hip, push hips once the patent period expired, suggesting a menstrual function and bone health. They backwards, slight knee flexion) precedence of marketing over science. also introduced a traffic light system for risk 3 “Glider”(weight on injured heel, grasp He cited recent prospective research showing assessment in return to sport. handrail ipsi-lateral side, slide uninjured that the provision of soft insoles, chosen by Mary Jane De Souza then presented the leg ( in a sock) backwards, causing patients (soldiers) on comfort alone, reduced Female Athlete Triad Coalition statement. flexion in ipsi-lateral hip, pull back to subsequent injury rates. In addition, injury She debated that the traditional concept of upright starting position using arms) rates appear lowest when athletes are allowed the triad should remain as the consequences The control group did hurdler position to choose shoes on comfort criteria alone. for females are more dire, and that low EA contract relax(PNF type) exercise, upright He therefore described the concept of the has a clear causal relationship with bone cable pendulum exercises and hamstring shoe acting as a sensory filter, or comfort health and menstrual dysfunction. They bridges. filter, rather than a biomechanical device. also introduced a tool for risk stratification Before return to play the Askling “H” test and return to play decision making. This Overall, the impression gained was that shoe was performed. involves a worksheet that assigns a point design needs to be simplified and focus on This is an un-validated test, but consists of value for various risk factors for the triad comfort alone, unless evidence shows that a set of 3 single leg straight leg hip flexion such as low EA, low BMI, delayed menarche, additional features actually reduce injury movements performed at high speed oligomenorrhoea/amenorrhoea, low bone rates. while lying supine. The test is positive if mineral density and past history of stress IOC Consensus Statement “Beyond apprehension is experienced and RTP is then fracture. The points are then totalled to the Triad- RED-S” and Female delayed. Athlete Triad Coalition Statement determine if the athlete is low, moderate or RTP was 49 days in the L protocol and 86 on Treatment and Return to Play. high risk. After considering various sport days in the C protocol. Judith May risk and decision modifiers e.g external Trends in athletic footwear over Medical Director Triathlon NZ pressures, competitive level and timing in season, a clearance or return to play status 30 years: Benno Nigg, Keynote n early 2014 two different groups Address can be determined. Ideveloped updated guidelines for the Tony Page Female Athlete Triad. The “2014 Female Certainly both groups have introduced new All Blacks Sports Physician Athlete Triad Coalition Consensus Statement concepts and useful tools in determining rof Nigg detailed a career in research on Treatment and Return to Play of the the risk to the athlete. It will be interesting Pwith multiple publications concerning Female Athlete Triad”: was developed by to see what evolves in the future, and which athletic foot wear and injuries. an international consortium of researchers terminology and risk stratification tools Despite in house scientific input and much in association with the American College become adopted in the literature and clinical marketing from shoe companies to the of Sports Medicine. This was soon followed practice. contrary, the rate of injury in runners has by the “IOC consensus statement: beyond not reduced over 30 years. He discussed the Female Athlete Triad-Relative Energy

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Patellar tendinopathy the deep part of the proximal patellar increased injury risk and therefore variety Jake Pearson tendon, with results comparable to the of sporting activities in injury preventative. Medical Director Paralympics NZ open technique. Children should have 1-2 days of rest per atellar tendinopathy was covered at the Current Concepts in injury week, and we should all watch for signs of Pboth the Injury and Illness Prevention prevention for young athletes: burnout and loss of interest. Time away from Conference and the Advanced Team’s do we have solutions sport is important. Duncan Reid Physician’s Course, with a dedicated session Greg Myer: Adolescent ACL knee injury HPSNZ Physiotherapy Lead National during the latter. The potential mechanisms This is a multifactorial issue. Intrinsic Training Centre of the development of patellar tendinopathy, risk factors include puberty, alterations Presenters : John Di Fiori (USA),Margo specifically reasons for the failed healing in anatomy, hormonal changes, general Mountjoy (Canada) Neeru Jayanthi (USA). response to repetitive microtrauma were ligament laxity and knee hyperextension, Greg Myer (USA), Thomas Best (USA), reviewed by Michael Kjaer. Despite plenty of and increased BMI. External risk factors Kevin Guskiewicz (USA) ongoing research on this, debate continues are a lack of trunk and hip control, reduced regarding the specific mechanisms. Front- Key messages: hamstring and quads strength increased running contenders include the potential role Margo Mountjoy: Prevention of abuse dynamic activities and the amount of knee of compression, stress-shielding, a peripheral and harassment in youth sport. A silent load. Adolescent males and female have neuronal phenotype, or other metabolic injury similar characteristic pre puberty but after or immunological factors. Karim Khan buse and harassment are as common puberty males have greater strength and reminded us of the critical role that tension in sport as in the community and reduced knee valgus moments whereas plays in maintaining tendon structure, and A have similar issues around the abuse of females lose strength and have increased suggested that while ‘there is robust evidence power. Young males and females are equally knee valgus moments with jump landing. for the efficacy of mechanotherapy’ (i.e. good vulnerable. Often starts with befriending Neuromuscular and proprioceptive training support for an exercise therapy approach) it than special rewards and time alone with programmes can alter these variables but remains unclear if there is any real difference athlete. Athletes are often embarrassed and there is still some controversy. Risk factors between eccentric and concentric loading, or withdraw, so may feign injury as they do can be identified but those actually going whether the reaction is rather instead simply not want to go to training. So as a sports forward to have an ACL rupture is not so related to the overall load imposed. medicine provider if you can’t relate the predictable. ACL injury rates in young In terms of further adjuvant treatments, a intensity of the injury to the symptoms females increases by 1.3% per year. 30% will few of the options were discussed: you may need to be suspicious. If there is have another ACL tear within one year of the 1 One speaker presented a reasonably evidence that abuse has taken place it should first tear. The long term consequence is OA well conducted RCT demonstrating the be reported to the relevant authority, either of the knee joint. efficacy of peri-tendinous high volume police or social services. It is not appropriate Heat Problems Symposium injection of corticosteroid (relatively low to let the sport or medical team deal with Dr Chris Milne dose) + sterile saline (30ml total) with this. The main thing is to support the athlete. Medical Director NZ the proposal that breaking the peri- John Di Fiori: Physeal Stress in young symposium on heat problems was held tendinous adhesions is beneficial. athletes Alate on the first day of the conference. 2 Shock-wave therapy seems effective Physeal stress injuries are well documented The initial presentation by Martin Schwellnus when there is a significant calcific in young athletes and are mainly due to two provided a state of the art update on our component to the tendinopathy risk factors, training duration and intensity, present knowledge. Following on from that, 3 PRP injections compared to ‘flipping a and rapid growth phases. Most physeal Roald Bahr provided new guidelines to coin’ but a reasonable consideration if injuries are over-use not acute trauma. manage heat stress in elite sports. These had >6 months of rehabilitation-resistant Prevention requires monitoring of training been drawn up after experience in high level symptoms volumes and care through growth phase volleyball competitions in various venues throughout the world. I believe rugby 4 The only clearly effective in 10 -14 year age range. Children should could usefully look at this work, as I vividly pharmacological treatment is IGF-1 and/ not play through pain. Parents need to be remember a Super Rugby match in Durban or growth hormone..! cautioned about children being involved in more than one sport in a season and that is in March of 2002 where players were losing 5 An arthroscopic surgical technique, OK to miss trainings for other important life up to 6kg during the course of a match. In curiously working outside the tendon, events. my view, beyond a certain temperature, 4x 20 debriding the neovessels and portion of minute quarters would be more appropriate Hoffa’s fat pad immediately adherent to Early specialisation is also associated with

new zealand journal of sports medicine - 23 conference report than 2x 40 minute halves. Union and started his sports medicine type is said to be genetically determined. The third presentation by Cristiano Eirale career with Ruth Highet in Wellington. He However, consistent studies have found that of Qatar described the challenges of playing freely acknowledges that his grounding in eastbound travel is more detrimental than football in a hot country, particularly in the New Zealand started him on the road to westbound due to the shortening of the days, context of the World Cup being awarded to his current elevated position. He gave an and any New Zealand team travelling back to Qatar in 2022. Their response has been to excellent overview of the contrast between play a home game after competing in South build high-tech stadia which can provide an Sevens and 15-man rugby. Africa can attest to this observation. indoor temperature of <30ºC, and hopefully In essence, Sevens is played at a higher pace The seminar was rounded out by Phillippe closer to 25ºC, when the outside temperature with less time for stoppages. Consequently, Decq, a French neurosurgeon, who ascribes is approaching 50ºC. This will be a major the athletes are better aerobically specific concussion issues relevant to Sevens challenge but they certainly have the conditioned, as exemplified by the players. These include multiple games per resources to do it. programme Gordon Tietjens has put in place day, the impact of international travel and The next presentation by Ron Maughan for our New Zealand squad over the year. the pairing of back to back tournaments a from the UK outlined the role of athletes Anthropometrically and physiologically week after one another. in prevention of heat illness on the day of the Sevens forwards look most like loose Overall, I found this to be an excellent competition. Recommendations include: forwards from the 15s game, and people will seminar. Rugby is a sport that, until a recall that Liam Messam and other All Black 1 Starting the day euhydrated decade or so ago, had minimal published loose forwards have indeed played Sevens literature and we are grateful to New Zealand 2 Drink according to thirst prior and at international level. By contrast, the backs colleagues such as Steve Targett, Ra Durie, during the competition look more like outside backs in 15s, and David Chalmers and Ken Quarrie for 3 Staying out of the sun where possible many of our most exciting attacking talents initiating this research. 4 Pre-cooling has a role in certain events have been unleashed in the 15-man game ACHILLES TENDON INJURIES after first being exposed by Tietjens talent 5 After the event, providing adequate fluid Sharon Kearney spotting in Sevens. and electrolyte replacement to restore HPSNZ Lead Physiotherapist body levels to normal Martin Schwellnus then gave an excellent Key Points Late in the seminar, Julien Periard of Qatar overview of the impact of travel on injury • There are few studies into biomechanical outlined research identifying athletes in Super Rugby and also Sevens rugby. He risk factors (RF). predisposed to exertional heat illness based conducted a detailed study of all Super • There are only 2 prospective studies on the heat shock response. Rugby teams in 2013 and teams averaged 5,6 1.67 time loss injuries per game. Of greater done. Overall, I would rate this seminar as relevance is the injured player proportion, • Retrospective studies highlight the average to good. I have attended many such which is very high. In any one season 55% of possibilities of these risk factors. seminars over the years and was able to graft players can expect to be injured, i.e. it is the on a little additional knowledge from this - Altered EMG pattern between soleus norm to have an injury during a Super Rugby one. However, for somebody new to the and gastrocnemius result in less season. Of these injured players, about half field, it provided an excellent overview of the shock absorption in calf and other had more than one injury. There was no issues and challenges. muscles such as rectus femoris and significant injury difference in home versus gluteus medius pre and post heel Rugby Sevens Seminar away games but illness was more common in strike so intra-tendinous loads may Dr Chris Milne away games, particularly upper respiratory be altered.7,8,9 tract illness. Medical Director Rowing NZ - Smaller knee ROM in injured The final day saw a presentation on the His presentation was accompanied by one runners result in less shock Rugby Sevens World Series and, in particular, from Ross Tucker, also from South Africa, on absorption in quadriceps muscle, the impact of injury and illness prevention strategies to maximise recovery to reduce the and therefore higher tendon loads. 7 programmes to minimise the adverse events impact of international travel and repeated • Systemic Risk factors of intercontinental travel. This was chaired same day competitions. He explained that • Increased adiposity associated with by Martin Raftery from Australia, who is the rugby players who travel have two primary tendinopathy (not likely to be case in HP ex Wallabies doctor and works for the IRB in issues: The first is jetlag and the second is athletes).10,11,12,13 Dublin. sleep deprivation. However, there is a big • Estrogen seems to be a protective factor, Simon Kemp is currently Head of Sports variation between individuals, the so-called as post-menopausal women have an Medicine for the English Rugby Football night owl versus the early morning lark

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Adequate Repair

Increased Demand on Tendon

Inadequate Repair Increased Vulnerability to Injury Tendinosis Cycle

Further Decrease in Collagen Decreased Collagen and and Matrix Matrix Production

Tenocyte Death

Figure 1: Proposed Cycle of Tendinosis

increased risk of achilles tendinopathy. • Summary re-modeling. • Hypertension seems to be a risk - Achilles tendon has substantial blood • Strength – load intensity rather than factor due to blood flow, which may supply. contraction type is stimulus.18 compromise normal metabolism and - Blood flow is dynamically regulated • Increase in strength = prevention tool? reparative maintenance of tendons.14 - Presence of Doppler effect could be Blood Flow (Alex Clarke) used as one indicator of increased • Progression in load – isometric. • A dense net of small arteries enters the risk of AT. concentric eccentric plyometric. Achilles tendonin its lower 20cm and - However in symptomatic patients • Slow speed may lesson risk of tendon seems to provide ample blood supply.15,16 Doppler is not a recommended sole injury. • Blood flow is increased by localised diagnostic criteria or indicator of Flexibility (Duncan Reid) exercise in healthy and tendinopathy. prognosis/treatment outcome. • Reduced ankle dorsiflexion is 2.5 x more • Baseline blood flow increased in Eccentrics (Scott Reid) likely to incur limb injury However too symptomatic tendinopathy or following • A gradual progression from eccentric- much range (DF >9deg) can increase acute injury. concentric to eccentric followed by faster risk.6 • Blood flow is dynamically regulated – loading may benefit patients who are • There is no evidence pre exercise therefore increased blood flow or power unable to start with Alfredson due to stretching reduced soft tissue or bone Doppler should not be referred to as pain and weakness. lower limb injury. neovascularisation. Neovascularisation • Too much or too less dorsiflexion • Eccentrics exercises may actually be a can only be confirmed histologically. is a possible risk factor for Achilles stretching activity vs strengthening. • Power and colour Doppler have tendinopathy. CARDIAC SYMPOSIUM: limited sensitivity but are useful in case • A thinner tendon (in reaction to Is it really possible to prevent management. The majority but not all eccentrics) may be a prevention tool. sudden cardiac death in sport? Achilles tendon patients demonstrate • When US is normal at the beginning Dr Sarah Beable increased Doppler effect. Power of the season, eccentric training can Bike NZ Medical Director Doppler(PD) is more sensitive but tends prevent the tendon to become abnormal. to be used less. his was an extremely informative and • When US is abnormal at the beginning highly relevant symposium regarding • Presence of PD signal had the greatest T of the season eccentric training can sudden cardiac death in the active population positive prediction of development of increase the injury risk.17 presented by an internationally recognised Achilles tendinopathy. • Oscillations – pattern of loading and panel of Whyte, Chalabi, Wilson, Borjesson, • There is no relation between blood flow unloading with force fluctuations may Papadakis, Sharma and Drezner. and prognosis or recurrence. provide an important stimulus for This two hour session involved an overview tendon re-modeling i.e. similar to bone of sudden cardiac death in young athletes,

new zealand journal of sports medicine - 25 and current perspectives on screening support in injured athletes compared 10 Gaida NE, Alfredson H, Kiss ZS et al. athletes for conditions predisposing to with a cohort of injured athletes with no Asymptomatic Achilles tendon pathology is associated with a central fat distribution sudden cardiac death. A challenge as a sports psychological support intervention and in men and a peripheral fat distribution medicine practitioner is differentiating the supported group showed this reduced in women: A cross sectional study of 298 the ‘athlete’s heart’ from pathology and the rate of injury recurrence. Although individuals. BMC Musculoskelet Disord 2010 this symposium was highly educational in very early days in terms of research, and Mar 2; 11:41 different ECG interpretations in athletes, and seemingly limited to handball, football and 11 Wendleboe AM, Hegmann KT, Gren LH et al. also those of different ethnicities. players, this an exciting, developing Associations between body mass index and surgery for rotator cuff tendinitis. J Bone Joint The importance of a thorough history asking area for injury and illness prevention Surg Am 2004 Apr; 86-A (4):743-7 about different cardiac symptomatology, research. 12 Shiri R, Vikari-Juntra E, Varonen H et al. family history, and a thorough cardiovascular References Prevalence and determinants of lateral and 1 Bere T, Florenes TW, Krosshaugh T et al. examination and was reiterated. The medial epicondylitis:a population study. Am J Events leading to ACL injury in World Cup common theme in all the informative Epidemiol 2006 Dec 1; 164(11);1065-74 Alpine Skiing: a systematic video analysis of presentations was that ECG (supported by 20 cases. Br J Sports Med 2011; 45 (16):1294- 13 Malliaras P, Cook JL, Kent PM. Antropmetric a presentation on the Seattle criteria) is an 302 risk factors for patella tendon injury among essential screening and diagnostic tool to volleyball players. Br J Sports Med 2007 Apr; 2 De Souza MJ, Nattiv A, Joy E et al. 2014 41(4):259-63 detect underlying cardiovascular conditions Female Athlete Triad Coalition Consensus that may increase the risk for sudden cardiac Statement on Treatment and Return to Play 14 Holmes GB, Lin J. Etiologic factors associated death of the Female Athlete Triad. Br J Sports Med with symptomatic Achilles tendinopathy. Foot 2014; 48:289 and Ankle Int 2006 Nov; 27(11):952-9 A stand out lecture for me was from 15 Wolff KS, Wibner AG, Binder H e al. The Jonathan Drezner from the USA on the use 3 Mountjoy M, Sundgot-Borgen, Burke L et al. The IOC consensus statement: beyond avascular plane of the Achilles tendon: A of AED in high schools, showing 71 % of the Female Athlete Triad-Relative Energy quantitative anatomic and angiographic sudden cardiac arrest patients who were Deficiency in Sport (RED-S) Br J Sports Med approach and a base for a possible new defibrillated on site survived to hospital 2014; 48:491-497 treatment option after rupture. Eur J Radiol 2012 Jun; 81(6):1211-5 discharge. This is an important piece 4 Askling CM, Tengvan M, Tarassova O et of research that confirms that AEDs are al. Acute hamstring injuries in Swedish 16 Theobold P, Benjamin M, Nokes L et al. Review of the vascularization of the essential in many community areas, schools, elite sprinters and jumpers: a prospective human Achilles tendon. Injury 2005 Nov; and sporting arenas as possible. randomised controlled clinical trial comparing two rehabilitation protocols. Br J 36(11):1267-72 Psychological Illness in Sports Med 2014; 48:532-539 17. Fredberg U, Bolvig L, Andersen NT. relation to injury in Athletes 5 Van Ginckel A, Thijs Y, Hesar NG et al. Prophylactic training in asymptomatic soccer Dr Sarah Beable Intrinsic gait-related risk factors for Achilles players with ultrasonographic abnormalities in Achilles and patellar tendons:the Danish I attended a two hour symposium lead tendinopathy in novice runners:a prospective study. Gait Posture 2009 Apr; 29(3):387-91 Superleague Study. Am J Sports Med 2008 by Johnson, Ivaarson and Tranaeus, well Mar; 36(3):451-60 published researchers on this topic. Andreas 6 Mahieu NN,Witvrouw E,Stevens V et al. Intrinsic risk factors for the development of 18 Malliaras P, Barton CJ, Reeves ND et Ivaarson et al based their research around Achilles tendon overuse injury:a prospective al. Achilles and patellar tendinopathy a baseline stress injury model (Williams study. Am J Sports Med 2006 Feb; 34(2):226- loading programmes: a systematic and Andersen 1998) that suggests the 35 review comparing clinical outcomes and identifying potential mechanism psychological state (life events, underlying 7 Azevedo CB, Lambert MI, Vaughan CL et for effectiveness. Sports Med 2013 Apr; anxiety, stress, depression, and daily hassles al. Biomechanical variables associated with 43(4):267-86 for example) increases the incidence Achilles tendinopathy in runners. Br J Sports of injury, and furthermore on injury Med 2009 Apr; 43(4):288-92 recurrence. Urban Johnson presented recent 8 Wyndow N, Cowan SM, Wrigley TV et al. research that the last 6 months of athlete life Neuromotor control of the lower limb in Achilles tendinopathy:implications for foot impacts on injury outcome; and those that orthotic therapy. Sports Med 2010 Sep 1; experienced minimal daily uplifts and had 40(9):715-27 more significant life events were more likely 9 Baur H, Muller S, Hirschmuller A et al. to get injured. Comparison in lower leg neuromuscular Ulrika Tranaeus from Sweden presented his activity between runners with unilateral mid research on a group of randomized control portion Achilles tendinopathy and healthy individuals. J Electromyogr Kinesiol 2011 Jun; trials where they introduced psychology 21(3):499-505

26 - new zealand journal of sports medicine CONFERENCE REPORT nat anglem Health, Wellbeing and Success Sochi 2014

wellbeing with performance, and that physical injuries, particularly in the holistic method of support is a good one setting of courses and events set up for to achieve health or happiness or any spectator interest, challenged skills and other objective in wellbeing. courage to the extreme. However the In these Games I enjoyed being part of athletes within the team excelled during e Taumata o Angitu, or the a very cohesive and skilled team. Such these games. To my observation, every ‘pinnacle of success’ was is the varied nature of disciplines within athlete was pushed to their absolute the name of the pounamu our Winter Olympic programme, and limit, either physically, emotionally or Tpendants prepared specifically for so varied are the cultures of individual psychologically. They achieved 5 top-ten the Winter Olympic Games team by sport, it has almost come as a surprise to placings which was our most successful Ngai Tahu. It was a perfect symbol see just how well our group united. Winter Games, with the sole exception for us, incorporating who we were of Annelise Coberger’s 1992 silver medal. representing, who had supported us and The biggest medical challenges during It might be good fortune that kept us the magnitude of the challenge ahead. the Games fell into two categories. The largely free from illness despite living in The binding cord of these taonga was first was the environment of a Games run close quarters under stress throughout a symbol for the binding together the in a nation with different language and the Games. It might also be an example team, which ultimately proved to be both culture. One of the greatest impacts for of a supportive community contributing unified and successful. me was the reporting and interpretation to overall wellbeing. We suffered very of medical imaging. We had a number Despite being involved in the Winter little sickness in our group, and the of significant injuries to manage, and Sport Programme since 2005, this management and healthcare teams were despite state of the art equipment and was my first attendance at an Olympic cohesive and productive throughout. It specialist medical services, there seemed Games. Having not qualified previously would thus be opportune to recognise frequently to be a risk of information as a Doctor (2006, Torino), or as our entire operations and support team being lost somewhere between process an athlete (2010, Vancouver), I was who worked long hours throughout the and communication. It was apparent interested to see what I had been games, some even staying on repeat the that the level of radiology service that missing, as well as wanting to assist our procedure for the paralympic team. My I am accustomed to in Christchurch is athletes whom I know work so hard. personal thanks go to them for their something to cherish. The apparent oxymoron of looking contribution to the athletes, the wider It is hard to describe the extent to which after the health of elite athletes is never team, and indeed their expert help to our wider team were affected by these more apparent than at the time of major me. Specifically I would like to recognise cultural differences, however the skills competition, when the goals of the Chef De Mission, Peter Wardell, and his within our group and a “get things done” athlete and their physical wellbeing are expert leadership of the team, and the attitude was encapsulated by our Chef sometimes at odds. Physical wellbeing physiotherapists whose specific expertise De Mission walking straight through an of course does not equate to wellbeing in management within the wintersport entourage of security personnel to grab per se, and denying opportunity can and Winter Olympic setting was President Putin by the hand and wish leave psychological and emotional scars invaluable. Thanks to Ginny Ruttledge, him greetings from New Zealand! It that heal slower than physical trauma, Sally Birchall and Sheryl Dickinson. seemed at the time to be quite a plucky thus the pinnacle of sport is in some Thanks are also due to the NZOC and manoeuvre, and more so as security ways the ultimate challenge for the HPSNZ for their ongoing support of our tensions rose. Sports Physician. I often cite models of sporting pursuit of excellence. The second difficulty was managing high performance sport to my sporting My experience of the games was thus the triad of injury, psychology and and non-sporting patients as a model a very positive one, and perhaps best performance within such extreme sports. of wellbeing. One of the things that summarised by the metaphor of the Within the Winter Sports Programme we high performance sports excels at in greenstone pendants that the team had been faced with a massive 18 months New Zealand is collaboration and received. By recognising our base of in regards to significant injury, including creating an environment of motivated support, and challenging ourselves many fractures, ligament ruptures, people to use their relative skill for a through a structured journey, we can spinal injuries and concussions, with common objective, that objective being achieve our pinnacle, te taumata o a risk profile far exceeding any other the ultimate performance of a group angitu. of individuals. In that setting, I equate sport that I have been involved in. These

new zealand journal of sports medicine - 27 Selected Abstracts FROM THE 2013 Partners in Performance Conference Handbook 20-23 November, Wellington, New Zealand

A RANDOMISED CONTROLLED TRIAL LOOKING AT A NARRATIVE REVIEW COMPRESSION SOCKS ON FUNCTIONAL RECOVERY Medical interventions in the management FOLLOWING MARATHON RUNNING of hamstring muscle injury 1 2 3 4 S A Armstrong , E S Till , S Maloney , G Harris M Robinson1 and B Hamilton2 1 Anglesea Sports Medicine Clinic, Hamilton 1Unisports, Auckland, New Zealand 2 Albury Emergency Department, Albury 2High Performance Sport New Zealand, Auckland, New Zealand 3Physiotherapy Department, Monash University 4MP Sports Physicians, Mornington Hamstring injuries remain a common problem in the sporting population. Physiotherapy-led rehabilitation remains the mainstay Introduction: Compression socks have become a popular recovery of treatment, and the physician’s input is often minimal. Anecdotally, aid for distance running athletes. Although some physiological many different topical, oral and injectable therapies are used around markers have been shown to be influenced by wearing these garments, the world in an effort to accelerate the healing of these injuries and no evidence exists on functional recovery. This research aims to shed to prevent their recurrence. There is an increasing arsenal of medical light onto whether the wearing of compression socks for 48 hours interventions available for the treatment of hamstring injury; however after marathon running can improve functional recovery as measured the majority of medical interventions lack a substantial evidence by a timed treadmill test to exhaustion 14 days following marathon base, and continue to be used on a personal experiential level only. running. Traditionally, sports medicine literature has ignored many of the Purpose: To investigate if compression socks improve functional practices being performed by practitioners working with high level recovery after marathon running athletes. As a result, the medical management of the hamstring muscle Methods: Healthy male and female athletes (n=24, age = 41 ±7yrs) injury has progressed little in the last 50 years. This article reviews participating in the 2012 Melbourne or 2013 Canberra marathons the evidence available to support some of the most commonly-used were recruited and randomised into the compression stocking (C) medical therapies and the pathophysiological basis for their use. or placebo (P) group. The compression socks used were medical It also presents the evidence behind some of the more promising grade below knee Jobst compression socks with a compressive value future treatments for muscle injury, including stem cell therapy, at the ankle of 30 – 40mmHg. A graded treadmill test to exhaustion growth factor delivery and potential novel uses of current medication was performed 2 weeks prior and 14 days following each marathon. not traditionally used in the musculoskeletal setting, such as anti- Participants were monitored for rate of perceived exertion (RPE) via fibrotic agents, which have a sound pathophysiological basis and the Borg RPE scale. Heart rate was noted every 3 minutes during the in-vitro evidence. These offer some hope to enhancing our medical treadmill. Time to exhaustion, average and maximum heart rates were management of hamstring injuries, but their value will only be recorded. Participants were asked to wear their socks for 48 hours established with further clinical trials. immediately after completion of the marathon. The treadmill was repeated 14 days following the marathon. The change in treadmill HYPOPITUITARISM SECONDARY TO TRAUMATIC times (seconds) was recorded for each participant. BRAIN INJURY: A VALID CASE FOR Results: 7 C and 9 P participants completed the treadmill protocols; TESTOSTERONE SUPPLEMENTATION? drop-out rates were similar between the groups. In C the average David F Gerrard treadmill run to exhaustion time 14 days following the marathon was OBE CNZM MB ChB FACSP FSMNZ increased by 2.4%(59 ±152s) compared to their baseline treadmill. In Professor of Sports Medicine, Dunedin School of Medicine, the placebo group the average treadmill run to exhaustion time was University of Otago decreased by 5.1% (-102s ±139s). The data was analysed using a two sample t-test and was found to be statistically significant (P<0.05). Introduction: An increasing body of literature (1,2,3,4,5,6) confirms Conclusion: The wearing of below knee compression socks with the link between chronic traumatic brain injury and a condition now a compressive value of 30-40mmHg for 48 hours after marathon widely reported as post-traumatic hypopituitarism. This has been running has been shown to improve functional recovery as measured reported in athletes including soccer players(1), boxers(4) and rugby by a graduated treadmill test to exhaustion 2 weeks following the players who have sustained low-grade, repetitive, sub-concussive event. Consequently, medical grade compression socks can be brain insults. Amongst the sequelae are increasing reports of low considered a valid recovery aid. serum testosterone. These cases raise the question of Therapeutic Use Exemption (TUE) to permit testosterone supplementation. Purpose: This paper addresses the rationale for approving supplemental testosterone in athletes, hypogonadal as the result of sub-concussive head injury.

28 - new zealand journal of sports medicine selected abstracts

Methods: A review of the recent literature linking documented 41 months. All patients had good stability post procedure. Three episodes of recurrent traumatic brain injury to hypogonadal patients had repeat operations (15%), all for on-going pain: One had hypogonadism was undertaken and tested against the current ankle arthrodesis and the other two underwent arthroscopy and scar International Standards for Therapeutic Use Exemption applied by the exploration. World Anti-Doping Agency (WADA). Conclusion: Brostrom repair is an operation that provides good Conclusions: The hypopituitarism described following repetitive stability. Re-operation is mainly due to pain. 85% of patients studied sub-concussive head injury in athletes, appears to be reversible and were able to return to normal function. thought to be consequent upon a number of possible mechanisms including compromised hypophyseal blood supply as the result of The Efficacy of a Neck Strength sudden shearing forces within the bony confines of the pituitary Intervention in Professional fossa. On the basis that this pituitary dysfunction appears transient, Rugby Union Players constituting a functional rather than organic cause for hypogonadal 1 1 2 1 hypogonadism, it is argued that the existing WADA criteria are D M Salmon , P Handcock , S J Sullivan , N J Rehrer 1 not met and that supplemental testosterone in these athletes is not School of Physical Education, Sport and Exercise Science, justified. University of Otago, Dunedin 2Centre for Health, Activity and Rehabilitation Research, References University of Otago, Dunedin 1 Auer M, Stalla GK, Athanasoulia AP. Isolated gonadotropic deficiency after multiple concussions in a professional soccer player. Dtsch Med Wochenschr. (2013) 138(16):831-3. doi: 10.1055/s-0033-1343099. Epub Introduction: Neck strengthening has been recommended for 2013 Apr 15. preventing and reducing neck injury in collision sports, but there is 2 Crooks CY, Zumsteg JM, Bell KR. Traumatic Brain Injury:Review of Practice Management & Recent Advances. Phys Med Rehab Clin N Am 18 limited research for this advice. Acute cervical spine trauma from (2007) 681–710 rugby participation is well documented.(1-3) The observed cervical 3 Dubourg J, Messerer M. Sports-related chronic repetitive head trauma as a spine pathological changes in rugby players have led many to suggest cause of pituitary dysfunction. Neurosurgical focus, (2011) 31(5): 131-144 that sufficient physical preparation of this musculature is necessary to 4 Tanriverdi F, Unluhizarci K, Karaca Z, Casanueva FF, Kelestimur F. reduce the risk of injury. (3-5) Hypopituitarism due to sports related head trauma and the effects of Purpose: To evaluate the impact of a neck exercise program over a growth hormone replacement in retired amateur boxers.Pituitary (2010) 13:111–114 season in professional rugby union players using peak isometric force 5 Dusick JR, Wang C, Cohan P, Swerdloff R, Kelly DF. Pathophysiology of and self-reported neck pain (NP) and stiffness (NS). hypopituitarism in the setting of brain injury. Pituitary (2012) 15:2–9 Methods: Isometric neck strength was measured pre- and post-season 6 Zaben M, El Ghoul, Belli A. Post-traumatic head injury pituitary for extension, flexion, left (LtFlx) and right lateral flexion (RtFlx). dysfunction. Disability & Rehabilitation. (2013); 35(6): 522–525 Testing was conducted in a unique simulated tackle stance where participants performed 1 maximal voluntary contraction (MVC) RE-OPERATION RATES FOLLOWING BROSTROM for each direction. One team was given the supervised neck exercise REPAIR (DIRECT LATERAL intervention (IG, n=28) while the other was a control group (CON, ANKLE LIGAMENT RECONSTRUCTION) n=15). The neck exercise intervention included exercises for strength E Hardy,1 N Baraza,2 M Pereira2 and endurance, muscle coordination, and impulse loading. Current, average and worst NP and NS values over the past 3 wk were recorded 1Alexandra Hospital,, Redditch, United Kingdom, using a visual analog scale. 2Alexandra Hospital,, Trauma & Orthopaedics, Redditch, United Kingdom Results: Comparison of the peak force values for the two groups revealed a significant main effect for time x group (F(1,41)=15.61, p< 0.00), indicating that for all directions the IG improved from Introduction: Brostrom repair is used to restore function in unstable 31.41 to 32.53kg while the CON decreased from 33.11 to 26.64kg. ankles post lateral ligament injury. Data on reoperation rates following Similar results were isolated for the main effect for direction x group this procedure is scarce and we conducted a study to assess this in (F(3,123)=3.07, p=0.04) and time x direction x group (F(3,123)=4.17, patients with chronic ankle injuries undergoing Brostrom repair. p=0.01). Ext revealed a decrease for both groups over the season (F(1, Purpose: Determine re-operation rates and stability of the ankle post 41)=11.64, p<0.00), with no differences between the IG and CON. Brostrom repair There was no change in time for both Flx and RtFlx (F(1, 41)=0.55, Methods: The hospital’s computerised archiving system was searched p=0.46 and F(1, 41)=2.47, p=0.12). When the groups were examined for Brostrom repairs done by a single surgeon over the past 6 years over time there was difference in the neck strength response between with a minimum follow up of 6 months. the two for Flx and RtFlx (F(1, 41)=13.03, p<0.00 and F(1, 41)=11.06, Results: 20 eligible patients were studied. Mean age at operation p<0.00), with the IG improving pre- to post-season while the CON was 30.3 months and mean time between injury and repair was decreased. LtFlx revealed a significant main effect for time and time

new zealand journal of sports medicine - 29 selected abstracts x group (F(1, 41)=10.33, p<0.00 and F(1, 41)=25.79, p<0.00). When motorised instrumented treadmill. Peak torque, angle of peak torque, neck pain scores between the two groups were examined pre- and peak horizontal force and peak vertical force were compared pre and post-season no differences were isolated for current or average neck post-rehabilitation against normative data from 14 un-injured rugby pain; however, the CON did undergo a significant increase in worst league players of the same position and similar characteristics. neck pain, t(14)= -2.18, p=0.04, while the intervention group’s scores Results: Pre to post testing: peak torque increased in the injured leg remained unchanged. during knee extension (47%), knee flexion (47%) and hip extension Conclusion: Neck specific exercises implemented over a rugby season (49%); peak torque leg asymmetry decreased 22%; angle of peak preserved neck extensor peak force and improved peak force for torque increased in the injured leg during hip extension (27%) and flexion, LtFlx, and RtFlx. The intervention decreased both the worst hip flexion (67%) reducing asymmetries by 50%; sprinting horizontal NP and average NS scores. As NP is one of the most frequently cited force increased (injured: 50%, non-injured: 19%); sprinting vertical symptoms of minor neck injuries, reductions in symptom severity force decreased (injured: 3%, non-injured: 5%); horizontal and vertical through a neck specific intervention could translate into a reduced peak force leg asymmetries decreased 18% and 13% respectively. The number or less severe minor neck injuries. return-to-play decision made by the player’s supporting health team References and coaching staff was based primarily on the sizable asymmetry 1 Fuller CW, Brooks JH, Kemp SP. Spinal injuries in professional rugby decreases and return to normative ranges for knee and hip strength union: A prospective cohort study. Clin J Sport Med. 2007; 17(1):10-6. measures. 2 Lark SD, McCarthy PW. Cervical range of motion and proprioception in Practical implications based on multi-disciplinary perspectives: rugby players versus non-rugby players. J Sports Sci. 2007; 25(8):887-94. Sports injury and performance biomechanist Patria Hume: “To 3 Peek K, Gatherer D. The rehabilitation of a professional rugby union enable return to sport at the elite level, baseline values are needed to player following a C7/T1 posterior microdiscectomy. Phys Ther Sport. 2005; 6(4):195-200. determine return-to-play levels, as well as quality normative databases 4 Pinsault N, Anxionnaz M, Vuillerme N. Cervical joint position sense in for athlete types”. Sports medic Doug King: “I use baseline values a lot rugby players versus non-rugby players. Phys Ther Sport. 2010; 11(2):66- and judge players’ return-to-sport activities based around these values. 70. I perform regular baseline assessments to ensure players can equal or 5 Sinibaldi KS, Smith DR. Prevention of spinal injuries in rugby. Strength better these values throughout the season”. Strength and conditioning Cond J. 2007; 29(4):18-24. coach Nic Gill: “The use of objective data to assess the quality of rehabilitation and to track progress back to ‘normal function’ is MULTI-DISCIPLINARY PERSPECTIVES ON THE USE valuable for all rugby code athletes”. Sports team physiotherapist OF LOWER-EXTREMITY INJURY ASSESSMENTS FOR A Hamish Craighead: “Concise programs that provide targeted RUGBY PLAYER’S RETURN-TO-PLAY exercises give medical, training staff and the athlete the opportunity S R Brown1, M Brughelli1, P A Hume1, D King1, to approach their rehabilitation with confidence”. Sports team doctor N Gill2, H Craighead3, S Kara4 Stephen Kara: “Reliable, valid and sensitive assessments ensure we 1Rugby Codes Research Group, Sports Performance Research In New have minimised the risk of recurrence prior to returning the athlete to Zealand (SPRINZ) at AUT Millennium Institute, Auckland University play”. of Technology, Auckland, NZ; Conclusions: Lower-extremity assessments are useful for an athlete’s 2New Zealand Rugby Union; 3New Zealand Warriors Rugby League; career and a team’s investment. It is recommended that coaching staff 4 Auckland Blues Rugby Union support athletic baseline and post-injury assessments for improved performance and to enable quality information on which to base Introduction: Intra and inter-limb imbalances can affect injury return-to-play decisions. risk and athletic performance in rugby1. Dynamometry and force References plate instrumented treadmills are two methods for assessing an 1 Brown SR, Griffiths PC, Cronin JB & Brughelli M. Lower-extremity athlete’s return-to-play status2. Interpretation of these data by health isokinetic strength profiling in professional rugby league and rugby union. practitioners is important to the health and longevity of the athlete. Int J Sports Physiol Perform 2013; [In press]. Purpose: To provide multi-disciplinary perspectives on how 2 Mendiguchia J & Brughelli M. A return-to-sport algorithm for acute biomechanical assessments of a rugby player’s symmetry in hamstring injuries. Phys Ther Sport 2011; 12, 2-14. lower-extremity strength pre and post-rehabilitation is useful as a determinate of the players’ return-to-play status. Methods: A professional male rugby league player (28 y, 178 cm, 98 kg) was tested pre and 10-weeks post-rehabilitation of a patellar tendon rupture. Isokinetic concentric knee and hip extensor and flexor strength on each leg at 60°·s-1 was completed using a Humac Norm dynamometer and standard protocols1. Bilateral sprint kinetics for five maximal effort sprints was completed on a Woodway self-

30 - new zealand journal of sports medicine