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HVOLUME 33 ISSUE E 3 2015 A LT H FOOT ISSUE Running shoe selection Diagnosing heel pain Analysing the foot during running Obesity and foot pain

• Ankle taping • Impacting running economy • Rising through the ranks • Sport and exercise medicine in Japan • Working in Olympic sports medicine Victor SportS

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1263_Victor_SMA_A4advert.indd 1 23/09/2014 9:57 am CONTENTS

CONTENTS Volume 33 Issue 3, 2015

REGULARS

02 From the Chairman: Information overload How the sheer volume of information available in sports medicine can affect decision making. Peter Nathan

03 From the CEO: Building a solid foundation How problems with the feet takes 20 36 a toll on other parts of the body. Anthony Merrilees INTERVIEWS 34 The countdown to Rio A look at the role of physiotherapist for Analysis of the foot and ankle 07 04 5 minutes with… Kent Sweeting, the Australian Olympic Headquarters during running: Simplifying the Podiatrist and Australasian Academy medical team. complicated to make informed of Podiatric Sports Medicine (AAPSM) clinical decisions President Kylie Holt A look at how we can better understand Obesity and foot pain: How do foot and ankle movement by studying 36 they impact on physical activity? how people run. FEATURES Chris Bishop How foot pain caused by obesity can 15 Running shoe selection: make it harder for overweight individuals more art, less science? 30 The Journal of Science and to lose weight. Medicine in Sport: Rising in the A look at how the scientific benefits Thomas Walsh ranks with our impact shouldn’t outweigh comfort when choosing a running shoe. A republished JSAMS editorial 40 Heel pain: a simple diagnosis? John Arnold (Volume 18, Issue 5, September 2015) How the many causes of foot and heel Gregory S. Kolt, PhD. pain can make diagnosing the issue 20 Running economy: Can running quite problematic. shoes affect performance? 44 Sport Trainers Guide: Karl Landorf Ankle taping A look at the most important features of a running shoe and how they impact People who have shaped SMA: Advice on the most effective way on performance. 46 to tape an ankle. Peter Duras Joel Fuller

NEWS 32 Sport and exercise medicine in Japan 24 SMA Member News A look at the strengths and weaknesses 26 ASICS Sports Medicine of the sport and exercise medicine Australia Conference 2015 recap system in Japan. Toru Okuwaki, Michiko Dohi, Takashi Ono 48 Council of Discipline news

Opinions expressed throughout the Editor magazine are the contributors’ own and do Chris Bishop not necessarily reflect the views or policy of Managing Editor/Advertising Manager Sports Medicine Australia (SMA). Members Declan Boffa and readers are advised that SMA cannot be held responsible for the accuracy of Publisher Design/Typesetting statements made in advertisements nor Sports Medicine Australia Perry Watson Design the quality of goods or services advertised. PO Box 78 Mitchell ACT 2911 Cover photograph All materials copyright. On acceptance of an sma.org.au www.thinkstockphotos.com.au article for publication, copyright passes to ISSN No. 1032-5662 Content photographs the publisher. PP No. 226480/00028 Author supplied; www.thinkstockphotos.com.au

VOLUME 33 • ISSUE 3 2015 1 FROM THE CHAIRMAN FROM THE CHAIRMAN INFORMATION OVERLOAD

SMA CHAIRMAN, PETER NATHAN DISCUSSES THE CHALLENGES OF SIFTING THROUGH THE MASS OF RESEARCH CURRENTLY AVAILABLE IN SPORTS MEDICINE.

he foot and ankle are the most “we need milk”. The broad range of milk common regions of the body products available does nothing to assist to be injured during sporting the consumer and in fact hinders them as activity, so it is appropriate they now have to filter through groups, Tthat this edition is dedicated to the subgroups and subsets of products, even management of foot and ankle problems. if subconsciously, to choose one of life’s One of the great challenges in managing basic essentials. or preventing injuries is keeping abreast Peter Nathan of the current body of relevant research If “life is like a box of chocolates” then [email protected] and evidence that will drive decision “Sports Medicine Information is like a making. It is not so much the lack of supermarket shelf”, there are copious information which is the problem, but amounts of information available but rather the information overload. filtering out the irrelevant information and identifying the material that will We receive so much information that it guide your decision making processes is often irrelevant so it can be difficult to can be overwhelmingly difficult and make sense of it all. Information has to be time consuming. filtered out so much that in the end we have to ignore most of the information This has always been a key strength directed at us completely. This is a of a publication like Sport Health which We receive so common problem not only in our industry condenses research and evidence into much information but in all industries. interesting, relevant and practical articles that offer gems of wisdom which the that it is often If we consider a product like “milk” as an reader can take and apply immediately. example, the supermarket shelves carry irrelevant so it can over 45-plain milk products at any one This edition is no exception with a be difficult to make time, meaning the next time you ask focus on foot and ankle issues which someone to buy some milk from the many of us would deal with on a regular sense of it all. supermarket you are going to need basis. No filtering required. to be a whole lot more specific than,

2 VOLUME 33 • ISSUE 3 2015 FROM THE CEO

FROM THE BUILDING CEO A SOLID FOUNDATION NEW SMA CEO, ANTHONY MERRILEES RECITES A STORY OF HOW IMPACTFUL THE FOOT CAN BE ON THE REST OF THE BODY.

oming from a business consulting the result of some poor footwear background one of my most choices over time by mum and dad. used homilies for my clients over The toe problem was of course easy to the years is that every good spot visually. However, it was the factors Cbusiness is built upon solid foundations. that I couldn’t readily visualise which were As a parent, like most others, I want the having the most effect. Specifically, how best for my children and like most typical the poor architecture and gait of his feet parents this consists of providing them were the actual cause of other issues with a good education, opportunity and affecting my son such as bad posture, Anthony Merrilees keeping them healthy and happy. sore knees and sore hamstrings. [email protected]

Perhaps the furthest thought from my It wasn’t until the podiatrist put him mind while changing their nappies, through a series of tests on a treadmill or helping them with their homework, that were filmed and then subsequently was that one of the most important analysed that I became aware that his bad things that might have a future impact posture, sore knees and sore hamstrings on their health and happiness was the were actually the result of some fairly state of their feet. A chance trip to my significant deficits in his feet, which in local podiatrist with my teenage son turn caused him to walk with a poor gait. changed my view forever. Untreated, his prognosis was for ongoing It wasn’t until the Growing up and participating in problems due largely to what was little podiatrist put him many sports, I was armed with a basic more than poor foundations. Happily, understanding of the importance of treatment via specially designed orthotics through a series of biomechanics and was certainly aware was available and with the right amount that core strength, fitness and flexibility of cajoling and reminding, he stuck to the tests on a treadmill were key aspects for achieving optimal regime of treatment prescribed by his that were filmed and performance. However, the connection podiatrist. between feet and posture is not then subsequently something that I ever recall receiving The end result for him was that his poor much attention at all. posture had resolved, as did the pain in his analysed that I became knees and hamstrings, and he now enjoys aware that his bad Initially, the trip to the podiatrist was few if any of the symptoms he once had largely about my sons “clawed and because of his bad feet. posture, sore knees and misaligned toes” which was no doubt sore hamstrings were actually the result of some fairly significant deficits in his feet.

VOLUME 33 • ISSUE 3 2015 3 5 MINUTES WITH INTERVIEW 5 MINUTES WITH KENT SWEETING PODIATRIST AND AUSTRALASIAN ACADEMY OF PODIATRIC SPORTS MEDICINE (AAPSM) PRESIDENT

Tell me a little about your sports medicine background.

I’ve always been involved in sport, as one of four boys there were plenty of passionate games of cricket and soccer (and the odd boxing match) in the backyard growing up. I always wanted to get into a profession which combined my love of sport with the ability to help people. I always thought I’d study physiotherapy but after spending some time with my podiatrist who I’d seen through my high school years I changed my mind. I won the sports medicine award in my final year of university and got a job working at a running injury clinic. Like anyone straight out of university, you learn a lot. For me, I learnt a lot about runners, particularly the mindset of a runner and athletes in general. It was during this time that I also started working on a randomised clinical trial on Achilles tendinopathy with Professor Michael Yelland in the Medical School at Griffith University. I presented our findings at the National SMA Conference in 2008 and was lucky enough to win the Best New Investigator Award and travel to Seattle in 2009 to present at the American College of Sports Medicine (ACSM) conference. During this time I was also lecturing in sports medicine to podiatry students at Queensland University of Technology. Clinically I’ve been lucky enough to treat elite and amateur athletes in a range of sports but I get just as much satisfaction out of treating a patient with a challenging pathology.

What does a typical day for you consist of?

I’m in my clinic (Performance Podiatry & Physiotherapy) three days a week. We have a fairly small clinic consisting of three podiatrists, a sports physiotherapist, sports dietitian and Pilates instructor. My brother Ben and minutes5 I set up the clinic about eight years ago. I’ll typically see a number of runners and triathletes of varying abilities as well as people of varying ages just walking or running to keep fit and healthy. I also consult to the Queensland Ballet so I’ll either go to the studio or they’ll come and see me in the clinic. The other two days, I’m at Queensland Orthotic Laboratory, which Ben and I also own and is one of the country’s biggest orthotic laboratories. We really act as the link between the podiatrist and our production staff to ensure a high quality product. I get a lot of satisfaction out of helping other podiatrists to effectively treat their patients and I also enjoy the variety it brings me in the working week.

What is your favourite aspect of your job?

Meeting so many different people each day, hearing their stories and helping them to stay active. It’s nice treating people who are motivated to get better and want to get back to full training and achieve their goals.

What has been the highlight of your career?

It’s hard to single out one but I’d have to say that winning the prize at the SMA Conference in 2008, getting published in the British Journal of Sports Medicine and making a very small contribution to Brukner & Khan’s Clinical Sports Medicine textbook are all hard to beat.

4 VOLUME 33 • ISSUE 3 2015 5 MINUTES WITH INTERVIEW

How did you become involved with SMA?

My first employer told me that I need to join up to SMA and AAPSM which I did straight away. I needed to learn from the best across a range of sports medicine disciplines and SMA was the best way to do that. I’ve been a member ever since.

What do you think the benefit of being a SMA member provides especially within the podiatry field? It’s really about being in a multidisciplinary team and learning from people outside of podiatry. It’s great going to conferences and learning from physios, exercise physiologists, biomechanists, psychologists, dietitians and sports doctors. Where else would you get that?

Describe your role with AAPSM, how did you come to be in this role?

I started off as the Queensland board member for AAPSM in 2012 and then was voted in as the National president in 2013. AAPSM is our national sports podiatry body and also a discipline group of SMA. Our role is primarily education of podiatrists in sports podiatry. We hold regular professional development (PD) events across the country and provide speakers and content for the Australasian Podiatry Council (APodC) & SMA Conferences. My role is to oversee the organization as a whole and work with our key stakeholders – SMA, APodC and ASICS to deliver high quality education for our members. When I came into the role as president, I really wanted to achieve a couple of things – to improve member services for podiatrists in regional areas and also to develop a career pathway in sports podiatry. I’m pleased to say that this year we are starting to record some of our PD sessions so members all over the country can view them. Our board is also working on developing a career pathway in sports podiatry in minutes5 conjunction with the APodC to deliver a structured pathway for podiatrists who want to develop their skills and be recognised by their colleagues and the FAVOURITES community as being expert clinicians in sports podiatry. Travel destination: Besides from sports medicine, what are you passionate about? Stradbroke Island. My family. My kids are at a really nice age where they want to kick the footy Sport to play/watch: with me and play together. I love my Aussie rules and cricket. I’m a Geelong Play – soccer, watch – AFL. supporter in the AFL so I’ll try to watch them play as much as I can and my kids both love sitting down with me and watching some footy together. Cuisine: Japanese. What’s the best piece of advice anyone has ever given to you? Movie: Old School. Don’t stress about things that you can’t control. My grandfather also always TV program: Game of Thrones told me never to go to bed without resolving an argument. or Curb Your Enthusiasm.

Song: Everlong by the Name four people, living or not, you would invite for a dinner party Foo Fighters. and why?

Book: The latest edition of BJSM. Kerry O’Keefe – to tell a few good cricket stories. Leigh Mathews – to talk footy. Gadget: My corkscrew. Ricky Gervais – for a few laughs. My wife – to share it all with.

VOLUME 33 • ISSUE 3 2015 5 FINISH WITH FLYING COLOURS IN THE GEL-NOOSA TRI 11 The latest GEL-Noosa Tri features a new upper with minimal seams, delivering superior fit and comfort. A full length Guidance Line helps improve gait efficiency, while front and rear GEL units alleviate stress on the lower limbs, making this an ideal training or racing option for over pronators. Also available in men’s colour way.

ASICSaustralia IT’S A BIG WORLD. GO RUN IT VV28307A

28307 A v1F.indd 1 8/10/2015 3:00 pm FEATURE ANALYSIS OF THE FOOT AND ANKLE

ANALYSIS OF THE

FOOTA N D

ANKLEDURING RUNNING

SIMPLIFYING THE COMPLICATED TO MAKE INFORMED CLINICAL DECISIONS

PODIATRIST CHRIS BISHOP DISCUSSES THE MOST RELIABLE WAYS TO STUDY A PERSON’S GAIT AND THE BENEFITS ASSOCIATED WITH THOROUGH ANALYSIS.

VOLUME 33 • ISSUE 3 2015 7 FEATURE ANALYSIS OF THE FOOT AND ANKLE

ANALYSIS OF THE

FOOTA N D

Despite the detail of these studies, it is highly infrequent, in a Western ANKLE society, that activities of daily living features are small, and non-systematic. DURING RUNNING would be undertaken barefoot. Despite Further, any changes to the foot inside the barefoot debate, and the noted the shoe as a result of footwear and/or differences between running barefoot orthotics certainly cannot be seen with he movement of the foot and and shod, in reality, most people run with the naked eye as research shows that ankle underpins everything our shoes on (of some form)6. This presents analyzing the motion of the shoe upper patients do. We put all of our a unique set of challenges in terms of not is not the same as the foot inside the body mass through it every step only understanding the motion of the shoe7. There is large variability between Twe take – one foot in front of the other. foot inside the shoe, but the effect that individual’s response to footwear, and When we walk and run, up to three times footwear design and in-shoe inserts (i.e. if anything, this supports the range of our body weight is applied through our orthotics) have on the foot at the level of footwear present in most retail stores. ankle to the ground, with the same force the foot-shoe interface. In contrast to The commercial reality is that all shoes, applied directly back on the body1. what many footwear companies will no matter their design, work for This puts potentially damaging forces have you believe, our understanding of someone. This has direct implications through our bones, ligaments and in-shoe foot interaction and footwear for transforming the way we analyse tendons, and it is our job to be able to biomechanics is extremely limited7. gait – with less emphasis on quantifying analyse someone’s movement profile to Understanding the true mechanisms motion control and more emphasis on determine if this is likely to be a problem. of the effect of footwear technologies how ‘comfortable’ interventions can has largely been restricted by both the begin to work with the foot to restore Research using gold standard motion inability of human eyes to see through optimal function. capture techniques has directly informed the shoe upper, as well as a lack of our understanding of foot and ankle accurate methods to analyse foot motion So the question remains though – how motion during gait. The kinematics inside the shoe during gait. Based on best to replicate such detailed analytical (i.e. motion) of the foot during barefoot current evidence demonstrating small methods in a clinical environment where tasks have been studied in detail, giving effect, the concepts that manipulating we don’t have access to half a million insights into the motion at the level of midsole geometry (e.g. dual density) or dollars’ worth of motion capture the foot during walking and running2-3. inserting a rigid heel counter to stop the equipment. Do we need to? These Previous efforts have stemmed right foot pronating is unsubstantiated8. questions are all answered with a true from simple rigid segment models to Likewise, the concepts relating to understanding of the role of gait analysis describe idealized foot motion, through increased cushioning as a result of shock in a clinical context – to provide to bone pin work describing the attenuating systems of responsive foams information about movement profiles of movement of the individual bones of to reduce loading rates of force remains individuals back into the clinical decision the foot2-5. This research has identified questionable, especially given that there making matrix. I have spent a great deal that motion occurs at multiple areas of is minimal evidence to suggest high of time advocating to other therapists the the foot and that it is inappropriate to loading rates are a predictor of a lower need to be able to effectively analyse gait consider the foot as one segment. limb injury9. This has led to the proposal patterns in a clinical environment. This is The current trend in the literature is to of new theories, all of which focus on specifically important for running – I just model the foot as at least three (if not individual responses10-11. The take home don’t understand the concept of treating four) individual segments to represent message from the literature is that any running injuries without an ability to the hindfoot, midfoot, forefoot changes as a result of shoe design analyse running biomechanics. We walk (metatarsals) and the toes. The research differently to how we run1-12. How people is conclusive that most motion at the level run is arguably more variable to how of the foot and ankle occurs in the sagittal plane, yet with large variability between subjects2-3. Research efforts have also given us new appreciation for the amount of motion occurring at the level of the midfoot (talonavicular and medial cuneiform-navicular joints). Overall the data in the literature demonstrates the complexity of the foot and ankle, and specifically the importance of the joints distal to the rearfoot in its overall dynamic function.

8 VOLUME 33 • ISSUE 3 2015 FEATURE ANALYSIS OF THE FOOT AND ANKLE

people walk and this requires thorough analysis. To ensure our analysis is as accurate as possible, we must optimise setup, as well as the analytical processes we use. In terms of logistics, the most cost effective method to do this in a clinical environment is with the use of treadmills.

Before we argue whether treadmills can replicate overground running, let’s first understand what a treadmill does. The motor accelerates your centre of mass (COM) instead of you having to do this over-ground. Also, when running indoors on a treadmill, we also don’t have the same effects of climate (i.e. heat, wind etc.) that can influence the physiological In contrast to what many expenditure of the run. In terms of footwear companies will biomechanics, research has suggested small differences exist when running have you believe, our overground vs. on a treadmill (even though it is argued that results are understanding of in-shoe generalizable13-15). I acknowledge this foot interaction and may be the case, yet the larger issue is the physical effort running on a treadmill footwear biomechanics vs. over-ground outdoors is likely to be is extremely limited. less. In saying this, it can be controlled for with a number of setup considerations that if we get right, improve the representativeness of the gait pattern seen. Firstly, the treadmill needs to be as stiff as the ground to ensure we don’t introduce compliance into the system. Think those bouncy treadmills we have all ran on – these will increase the displacement of the COM and have consequent effects on increasing joint and increased braking forces. Thirdly, motion16. Secondly, the treadmill motor and most importantly, is matching needs to be more powerful (ideally > 2.5 physiological cost and lower limb changes in biomechanics are likely to HP) than the force the runner applies to biomechanics. Research has suggested be within measurement error of 3D it when they land to prevent belt slippage that raising the incline of the treadmill motion systems). Further, appropriate to 1% mimics the economic cost of acclimatisation of the treadmill for up to over-ground running, yet this will change six minutes has been shown to reduce the biomechanics17. It is plausible to think that variability in stride-to-stride fluctuations18. if we set someone’s analytical running And if we want to really go to the next speed based on their perceived level of level, we can place a large fan in front of exertion (i.e. BORG’s scale RPE) rather the treadmill to create wind resistance. than speed (yes this has them run faster By taking a moment to think about the on a treadmill), we may get a more logistics of our analytical environment, representative gait pattern that minimises we come out the other end with an the differences in biomechanics (and incredibly controlled environment that has large benefits in terms of being able

VOLUME 33 • ISSUE 3 2015 9 FEATURE ANALYSIS OF THE FOOT AND ANKLE

ANALYSIS OF THE

Will it: FOOTA N D • Alter the treatment that the patient is given? • Improve the outcome for the patient? • Simply provide a marketing avenue for the business? ANKLEDURING RUNNING If it’s the latter, you are wasting your time and going about it the wrong way. Although it may look good, it takes time and considerable expertise and the appropriate utilization of gait analysis to describe multiple foot falls, have our that gives inferences to underlying must always have the intention of patients run at any speed (training vs. mechanics at play. What I do see the need improvement in technique or treatment tempo vs. race pace), and for as long for though is the addition of video gait prescription. It has to directly benefit the as they want (induce fatigue). With the analysis (or a method to slow down and patient. We have to be able to report setup now right, we lend our attention replay movements). meaningful clinical outcomes, whether to the analytical component they be simply the visualization of applied of gait analysis. For years, clinicians and I constantly get questioned as to what interventions (think different shoes, scientists have been fascinated by the it adds to my practice and it’s a research taping techniques, orthotics etc.) or way humans move and the analysis of only tool. Although I believe this is wrong, the success of suggested retraining gait has formed a large part of clinical the argument that video analysis does protocols. It is not designed as a practice for many practitioners. With the not identify anything that a trained eye quantitative process in a clinical context development of technology, we are cannot is complete rubbish, and is – drawing lines to infer calcaneal eversion constantly being inundated with different often a sign of a practitioner who is incredibly inaccurate and offers little to options to conduct this rather complex does not know when and how to utilise the overall clinical management in terms task. But do we need it? Can we analyse this technology. The human eye simply that A) abnormal pronation cannot be gait without technology? What can we cannot see all the complex interactions quantified, B) pronation is not a risk factor see with our own two eyes and what does of the foot and ankle during gait. for injury and C) interventions have a the addition of video feedback provide? It can’t break down the movement of the small and negligible effect on changing Firstly, we need to appreciate what we hindfoot, midfoot, forefoot and toes in biomechanics. If anything, it’s a sign can’t see with our own two eyes. Think real time, which research has indicated is of being preoccupied with previous forces, muscle activity, in-shoe foot required information2. It cannot play side paradigms of motion control, and perhaps movement when wearing shoes. by side movement profiles of barefoot we need to shift our thinking towards We need to accept that without gold and shod motion, or multiple shoes effect more of qualitative point of view in standard techniques, we can’t infer this on the foot and ankle. Yet, before you terms of quality of movement occurring11. level of detail. In saying this, it is likely that even get the patient in the clinic, you What is most important, and where the subjective feedback (i.e. self-perceived must be comfortable within your own benefit of 2D analysis lies is in the quick comfort, stability etc.) from our patients assessment protocol as to what is the description of gross movement changes, is going to provide a level of information purpose of gait analysis. especially in the sagittal plane. This is

10 VOLUME 33 • ISSUE 3 2015 FEATURE ANALYSIS OF THE FOOT AND ANKLE

Comparing a patient’s running gait profile to a theoretical or population So with this discussion, where should we be heading? How should we be using gait norm has one large issue analysis to analyse foot and ankle function – that there is such a in a clinical environment? Can we simplify our approach? To answer this, we are thing that is normal. likely to benefit from reviewing our understanding of biomechanical theory, Each person has their foot and ankle function during gait, the own unique DNA role of gait analysis in our assessment, and where gait analysis fits into the sequence, their own diagnostic matrix. To effectively analyse foot and ankle motion during running, biological passport and we need to have: therefore their own risk

1. An understanding of all the foot and factors for injury. assisted with one of the many pieces ankle biomechanical theories so that of software available on the market we can apply the most relevant theory (be careful – not all are both MAC to the clinical presentation at hand. necessarily normal for someone and PC compatible). Forward trunk lean, else. There is large variability in how anterior pelvic tilt, knee flexion, ankle 2. An understanding of what clinical tests individual patients move and respond plantarflexion, arch deformation and can be conducted to provide value as to different conditions, leading to the hallux dorsiflexion can all clearly be seen, an input to the dynamic gait evaluation. need for a more individualized with the later outcomes giving good Although static tests do not dictate approach to the assessment of insight in terms of the natural mechanism dynamic function, they certainly uman movement of our patients. of shock attenuation as well as can provide valuable insight into quantification of foot strike patterns. restrictions in range of motion that 6. An appreciation that the foot moves Of course this implies that the camera are likely to cause compensatory inside the shoe and we can’t infer is sampling at an appropriate rate (ideally patterns when analysing gait. in-shoe foot motion when analysing > 100Hz / 100 frames per second) to be shod gait. Inferences can be made able to visualise/capture an appreciation 3. An understanding of the differences from the analysis of barefoot gait, of the movement of each joint through between walking and running gait, assuming that temporal-spatial each phase of gait (initial contact, loading and the appropriate facilities to parameters do not change. response, midstance, propulsion, swing). describe both gait patterns. The addition of a second camera in the 7. An understanding that the foot-shoe coronal plane has benefits for visualising 4. An understanding that the human eye complex in a clinical context is a black foot progression angle and hindfoot cannot observe, process and interpret box (a template), whereby we can add motion, yet caution needs to be taken all of the complex movements of the elements of design and/or technology when inferring the magnitude of eversion human body. We need high speed to influence the way the foot functions (i.e. pronation) occurring as the visual video to assist us in seeing the intricate and/or to modulate the load applied appearance could be masking some movements of the foot and ankle that at the foot-shoe interface. influence of transverse plane foot motion may be contributing towards (i.e. over- or under-estimating the amount someone’s pathology. 8. Force dictates motion. When we run, of eversion really occurring). Regardless a force is applied to our body that the setup, it is important that the 5. An appreciation that each individual causes us to move in a particular outcomes get fed back into the clinical is unique and requires personalised manner. In a perfect world, our decision making matrix. Gait analysis attention. Comparing a patient’s muscles are strong enough to is not prospective in this environment – running gait profile to a theoretical or counteract this force and provide it does not infer why the problem is population norm has one large issue – a stabilizing effect, but often this present. What it does provide in a clinical that there is such a thing that is normal. isn’t the case and we get an imbalance environment is a visualisation strategy Each person has their own unique between the external forces acting to assist in making decisions on how best DNA sequence, their own biological on our body and the internal forces to reduce the load on pathological passport and therefore their own risk trying to stabilise the body. This is structures of the foot and ankle to factors for injury. Therefore what is when we likely experience pain restore asymptomatic function. normal for one person is not and injury.

VOLUME 33 • ISSUE 3 2015 11 FEATURE ANALYSIS OF THE FOOT AND ANKLE

internal forces of the intrinsic muscles We now have broad applications of ANALYSIS that are required to effectively offload technology at the grasps of our finger OF THE the tissue. tips, many of them free of charge and accessible right in the palms of our hands. The technology of gait analysis is We are slowly running out of excuses. moving rapidly, and as a sports medicine The key to effective clinical management profession, we must embrace this to of lower limb pathology likely lies in taking FOOTA N D assist us in the diagnostic and/or the time to understand your patient’s assessment process. The way humans biomechanical profile and the intricate move is extremely complex. The foot interactions not just at the level of the and ankle, through simply being the foot, but how the foot can influence weight-bearing joint of interest, underpins proximal mechanics. This is simply not everything we do. Add to this the unique possible without being able to analyse ANKLE demands of individual sports, different your patient run. DURING RUNNING surface terrains, variability in footwear designs and the increased in orthotic 9. An appreciation that biomechanical and/or bracing use, and we have a effects can be applied without a situation which requires careful thought change in visual appearance to the and consideration. Clinical examination ABOUT THE AUTHOR foot. Therefore, just because the and experience are no longer sufficient appearance of foot motion (i.e. the to analyse the complexities of the foot Chris Bishop is a clinical podiatrist kinematics of the foot) does not and ankle during gait – we need to and Biomechanics Research Fellow change with orthotics (i.e. the foot is embrace technology to better describe at the University of South Australia still everted), does not mean that the complex anatomical function. Yet we focusing on footwear biomechanics orthotic is not or cannot be applying don’t necessarily need expensive motion and human movement. a force that is sufficient to alter the analysis setups to analyse most runners.

12 VOLUME 33 • ISSUE 3 2015 MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE MELBOURNE

NationalConference_2016_Advert-v2a.indd 1 8/10/2015 6:58:32 PM

FEATURE RUNNING SHOE SELECTION

RUNNING SHOE SELECTION MORE ART, LESS SCIENCE?

PODIATRIST JOHN ARNOLD It only takes a short visit into any sports us to an injury rather than the finish line. store to become perplexed by the range With such anxiety created by having to PROPOSES THAT WHEN of running shoes lining the shelves. Not choose from the plethora of potential CHOOSING A RUNNING SHOE, only do we have to contend with the running shoes comes one critical growing number of brands, but also the question: what’s important for ATHLETES SHOULD FAVOUR cornucopia of gels, foams and rubbers determining which running shoe COMFORT AND FEEL adorning the walls from floor to ceiling. is right for us, and our patients? This makes finding the ‘right’ pair of OVER ANY SUGGESTED running shoes a seemingly Current running shoe selection habits are SCIENTIFIC BENEFITS. insurmountable task. Our conundrum centred on the practice of matching foot is further complicated by our fear that type and footwear. The classification of choosing the wrong shoe will fast track footwear is based on the features it

VOLUME 33 • ISSUE 3 2015 15 FEATURE RUNNING SHOE SELECTION RUNNING SHOE SELECTION MORE ART, LESS SCIENCE? possesses that presumably match up the foot ‘type’ of the wearer, ranging from ‘stability’ shoes (for pronated feet) to ‘neutral’ shoes (for supinated feet). It is logical that the structural features of the foot and footwear are compatible to prevent fitting issues, such as rubbing and slipping. The dynamic function of the foot is also frequently taken into account, evidenced by the growing number of gait analysis style services offered in the retail environment.

Despite enhanced efforts to personalise the fitting of running footwear, the evidence to support this practice is surprisingly weak. A randomised trial that allocated 81 female runners of varying foot types (pronated, neutral and supinated) to shoes with different levels of stability found no difference in injury rates during a 13-week training program1. So how can we interpret these findings in the current state of uncertainty we face when trying to select the right running shoes?

Firstly, these findings suggest running shoe selection based on foot type may not confer an advantage to prevent running related injuries. Secondly, we must question the underlying premise of considering foot type in running shoe selection, given that multiple systematic literature reviews have found only weak evidence that foot type or function are risk factors for developing running related injuries2-4. Practices that aim to improve the biomechanical profile of the runner, such as matching foot type to footwear, may not provide benefit for injury prevention. This raises the important possibility that other approaches to running shoe selection may be more superior than matching foot type to footwear for preventing running related injuries.

WALKING ON AIR?

Over the past four decades we have witnessed the evolution of running shoes, from the humble beginnings of the original waffle-soled Nike ‘Moon Shoe’ of the early 1970s to the expensive feature- packed models of today (and ironically, back again). In the search for improved performance, comfort (and sales), the consumer was introduced in the late

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1970s to the concept of ‘cushioning’, pioneered by the introduction of air-bag systems in the heel of Nike running shoes. Indeed, since then the pursuit of improved cushioning to prevent running related injuries has sat at the epicentre of Comfort has long been the development of footwear technology. known to be an The premise underpinning this approach is that high impact forces cause injury important factor in selling and must be dampened.

running shoes, however, Unfortunately, this approach seems only more recently are we flawed as the evidence linking high impact forces to the development of running beginning to understand related injuries is ambiguous5. We have a lack of well-designed prospective studies that shoe comfort may in this area, and without these the picture also be a key factor for won’t get any clearer. There is also limited evidence from randomised trials, improving performance although one recent study which and reducing running allocated 247-runners to wear either hard or soft soled running shoes found related injuries. no difference in injury rates between the two groups over a five-month period6. So neither foot type nor midsole hardness appear like strong candidates for guiding our selection of running shoes. This leaves us wondering what factors should inform our decision making. Interestingly, the most important factor could lie not in the information gleaned from our observations – but that of our patients.

COMFORT

At first thought having the power taken out of our hands during the running shoe selection process is a daunting prospect. It is certainly counterintuitive to trust the intuition of our patients over our own clinical experience. Comfort has long been known to be an important factor in selling running shoes, however, only more recently are we beginning to understand that shoe comfort may also be a key factor for improving performance and reducing running related injuries. So when it comes to running shoes, what exactly is ‘comfort’ and why does it matter?

WHAT IS COMFORT?

Comfort is an inherently difficult concept to define. It is highly subjective and person-specific7. Descriptors of comfort often relate to perceptions of ‘well-being’ and ‘satisfaction’, highlighting to the contribution of physical, psychosocial and contextual factors8. Discomfort is more easily defined as it is more strongly influenced by physical factors, with common descriptors including reference to ‘cushioning’, ‘cramping’ or ‘numbness’. After all, when trying to determine which shoe we prefer, it is often easier to put our finger on what we don’t like, compared to what we do like.

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Despite comfort being an imprecise RUNNING SHOE concept, it is obvious that improving footwear comfort can only be a good SELECTION thing, but why? MORE ART, LESS SCIENCE? WHY DOES IT MATTER? There is no doubt that comfort is high on our priority list when searching for a new pair of running shoes. What is less known is that improved footwear comfort is also associated with improved markers of running performance and a reduced frequency of running related injuries. More comfortable footwear reduces oxygen cost during running9, and while this is not of importance to all runners, it suggests the effects of comfortable shoes may reach further than just feelings of well-being and satisfaction. Ratings of comfort are also explained by differences in biomechanical parameters during running, such as muscle activity, joint kinetics and kinematics10. Unsurprisingly, biomechanical variables during running only contribute a modest amount to comfort, with the rest explained by a range of psychological, aesthetic and contextual factors. Of more importance is evidence linking more comfortable footwear conditions to a lower frequency of injuries (up to 13%) than when footwear is standardised, without any optimisation of comfort11. These studies suggest that comfort can be an influential factor in modifying injury risk and performance.

Whilst it could be seen as disheartening that our patients’ intuition might rival our own when selecting running shoes, we should be capitalising on the opportunity to empower our patients in this process. It might take some time to accept that the selection of running shoes may be more about ‘art’ and less about ‘science’, but if this can translate into less injuries and improved performance for our patients, I don’t think we can complain.

ABOUT THE AUTHORS John Arnold is a Lecturer in Exercise Science in the School of Health Sciences at the University of South Australia. His research focus is in the area of musculoskeletal biomechanics with applications in the fields of rheumatology, orthopaedics and sports medicine.

18 VOLUME 33 • ISSUE 3 2015 SMA Online Store Do you need strapping tape? or a first aid kit?

Together with our partner, Victor Sports, Sports Medicine Australia has opened an online store to purchase strapping tape and first aid supplies at special wholesale prices. There is an extensive range of tape in various sizes and quantities, as well as featuring new products from time to time.

If you need some new on-field equipment or your club needs to replenish the first aid kit, visit www.smaonlinestore.com.au

Complete an SMA First Aid or Sports Trainers course for a special discount.

Contact your SMA state branch for more details.

www.smaonlinestore.com.au

A4-flyer.indd 1 6/08/2015 11:37:49 AM FEATURE RUNNING ECONOMY

20 VOLUME 33 • ISSUE 3 2015 FEATURE RUNNING ECONOMY RUNNING ECONOMY CAN RUNNING SHOES AFFECT PERFORMANCE?

PHYSIOTHERAPIST JOEL unning shoes are often purchased based on foot type as a means FULLER LOOKS AT SOME for preventing injury. What is the IMPORTANT FACTORS TO next most important reason for Rpurchasing a new pair of running shoes? CONSIDER WHEN CHOOSING Improved race performance. However, A RUNNING SHOE AND HOW does your selection of running shoe really influence how well you will THEY CAN AFFECT perform in a race? PERFORMANCE AND To answer this question, we are limited RUNNING ECONOMY. to research that has compared running economy between shoes, because of a lack of studies that have assessed race times in different shoes. Running economy refers to the amount of energy required to support running at a given speed. Running economy, along with lactate threshold, is a good predictor of running performance in a long distance race. Lower energy cost (improved

VOLUME 33 • ISSUE 3 2015 21 FEATURE RUNNING ECONOMY RUNNING ECONOMY CAN RUNNING SHOES AFFECT PERFORMANCE?

running economy) means that a faster race pace can be achieved without exceeding the lactate threshold and this should lead to improved performance over longer race distances.

In 2015, my colleagues and I published a meta-analysis that reviewed 19 studies of running economy that included over 30 different pairs of running shoes.1 We were interested to know what features of running shoes were important for optimising running economy. Among the shoe features we considered were shoe mass, cushioning, comfort, bending stiffness and motion control.

The effect of shoe mass on running economy is the most commonly studied shoe feature. Across studies we found that reducing shoe mass by only 100 grams improved running economy by approximately 2%. Over the course of a marathon this improvement in running economy is estimated to save a runner approximately six minutes! So does this mean that running barefoot with zero shoe mass is the most economical way to run?

Yes… if shoe mass was the only shoe feature that influenced running economy. However, we found no difference in running economy between running barefoot and running in shoes weighing 220 grams. This lack of difference was observed even though theoretically the 220- gram shoe should have impaired running economy by 4%. Based on this finding, we can conclude that shoe features other than shoe mass are also important for optimal running economy.

Shoe cushioning is one shoe feature that has often been suggested as important for running economy. The human foot is a remarkable structure

22 VOLUME 33 • ISSUE 3 2015 FEATURE RUNNING ECONOMY capable of cushioning the impacts of 3 running using the ligaments and muscles that traverse the large number of joints 2 that comprise the foot-ankle complex. However, there is a metabolic cost 1 associated with using the foot to absorb impacts and appropriately cushioned 0 shoes can be used to minimise this cost. The appropriate amount of cushioning -1 varies for each individual and for experienced runners is approximately -2 10 mm of foam cushioning. This level of Shoe Mass Cushioning Bending Sti
ness Motion Control Comfort

Eect on running economy (%) on running economy Eect (100g Reduction) (10mm) (doubled) (medial posting) (most comfortable) cushioning improves running economy economy / Improved economy Decreased by approximately 2%. Figure 1: The effect of different shoe features on running economy. In addition to functioning as an absorber of energy, the foot also has the potential to contribute energy for forward propulsion. The longitudinal and With cushioning and longitudinal bending Although it is possible to influence transverse arches of the foot have been stiffness having variable effects on running economy using different shown to store and recover mechanical running economy for each runner, it is footwear features (Fig. 1), these features energy in ex vivo studies and it has been potentially difficult to determine which should never be altered at the expense of hypothesised that these ligaments can running shoe will be optimal for improving safety. Forced time off from training due perform the same function during the running performance of an individual to injury has a much greater effect on running gait. In order to improve this runner. However, importantly running race performance than any effects elastic potential of the foot, studies shoe comfort appears to provide a strong derived from different running shoe have investigated whether increasing indication of which shoe will suit which designs. A typical running injury will the longitudinal bending stiffness of runner the best. When choosing between interrupt training for an average of six running shoes improves running shoes with differing amounts of weeks and running performance will economy. Interestingly, doubling cushioning, bending stiffness and motion regress considerably during this time. longitudinal bending stiffness improves control (but with the same shoe mass), However, if running shoes can be altered running economy by approximately 1% runners will improve running economy to improve running economy without an but tripling longitudinal bending stiffness by approximately 1% if they select increase in injury risk than the available has no effect on running economy. Similar whichever shoe is most comfortable. evidence suggests that this will facilitate to shoe cushioning the optimal amount of As a result, runners can rely on their improved race performance. longitudinal bending stiffness varies for subjective assessment of shoe comfort each individual. to help them identify the shoe that will help improve their race times the most.

Much less research has considered the ABOUT THE AUTHOR effect of motion control shoes on running economy. It has been hypothesised that, Joel Fuller is a respected by preventing excessive foot pronation physiotherapist who works at the and compensatory motion at the knee, University of South Australia in the motion control shoes may help to Alliance for Research in Exercise, improve running economy. However, early Nutrition and Activity (ARENA). work in this area suggests that motion He has an extensive knowledge in Over the course of a control features in shoes (e.g. external the field of sports science, including marathon this improvement heel counter and additional medial the topics of running performance posting) have no effect or a possible and injury. in running economy is negative effect (approximately 1%) on estimated to save a runner running economy even when controlling for the additional mass these features approximately six minutes! add to shoes.

VOLUME 33 • ISSUE 3 2015 23 SMA MEMBER NEWS

MEMBER SMA NEWS

SMA BOARD CHANGES Sport Medicine Australia has made three changes to its National Board structure as three National Director positions were vacated for new candidates at the recent AGM during the 2015 ASICS SMA Conference. Andrew Jowett and Caroline Finch became two new additions to the National Board, while Peter Nathan was re-elected. SMA would like to thank Kerri Lee Sinclair, Fabio Egitto and Wendy Brown for their contributions to SMA.

SMA RESEARCH FOUNDATION GRANTS The SMA Research Foundation has been established to provide support to young postgraduate researchers engaged in sports medicine and disease prevention research.

The SMA Research Grants are designed to support research conducted by postgraduate students and postgraduate practitioners for the purpose of advancing research in sports medicine and its relationship with disease prevention.

Congratulations to the following five applications that were recently awarded SMA Research Grants of $2,000 each for 2015. • Joshua Denham, University of New England • Luke Heales, University of Queensland • Natalie Lander, Deakin University • Margaret Perrott, La Trobe University • Rhiannon Snipe, Monash University

Further congratulations goes to Margaret Perrott who was also recently awarded the 2015 Brian Sando Clinical Sports Medicine Research Award.

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CONCUSSION POSITION STATEMENT

Sports Medicine Australia has released its official position statement on concussion for 2015. The purpose of the position statement is to provide an evidence-based, best practice summary to assist SMA members, coaches, parents, officials and administrators to recognise and manage sport-related concussion.

SMA ONLINE STORE Remember to visit the SMA online store. It has everything you need for first aid, including the full range of Victor sports taping equipment. Click here to start shopping!

ASISCS SMA CONFERENCE PROGRAM AND BOOK OF ABSTRACTS For anyone who missed out on the 2015 ASISCS SMA Conference on the Gold Coast, the program and book of abstracts detailing the full list of presenters can be downloaded from the SMA website. The booklets feature the complete list of speakers and researchers with their chosen field of research. Click here for all the details.

VISIT US ON SOCIAL MEDIA  @SMACEO @sma_news @SMA_Events @_JSAMS @SMAChairman  Search Sports Medicine Australia  Search Sports Medicine Australia

VOLUME 33 • ISSUE 3 2015 25 2015 ASICS SMA CONFERENCE 2015 ASICS SPORTS MEDICINE AUSTRALIA CONFERENCE CONFERENCE MANAGER ERIN WALSH GIVES YOU ALL THE HIGHLIGHTS FROM THIS YEAR’S ASICS SMA CONFERENCE. The Intercontinental Sanctuary Cove Our popular social calendar once again provided the perfect location for the didn’t disappoint, with delegates enjoying 2015 ASICS Sports Medicine Australia catching up with old and new friends over Conference from October 21st-24th, many drinks throughout the week, with everyone embracing this biannual including “Drinks with Deek”! We were conference and the casual atmosphere honoured to have Rob De Castella join it is becoming renowned for! us at Sanctuary Cove and had the delegates enthralled as he provided tales With just on 500-delegates in of his career and also gave an insight into attendance, the support for the his Indigenous Marathon Foundation. conference well and truly exceeded our expectations and they were all Sports Medicine Australia would like to treated to an amazing array of high thank all conference partners and trade calibre presentations and presenters. exhibitors for their involvement in the 2015 ASICS Sports Medicine Australia The conference was officially opened Conference, most notably the naming with the Refshauge Lecture by Dr Peter rights partner ASICS for their continued Brukner, providing everyone with an support of the conference and help insight of the lessons he has learnt over shaping it into what it is becoming the past 30-years in sports medicine. today. SMA also owes its thanks to the His engaging presentation kept the Conference Chair Ms Kay Copeland and delegates glued to their seats even after the committee consisting of Professor the presentation went 30-minutes over Garry Allison, Professor Andrew Cresswell, the scheduled allotted time! Dr Anita Green and Dr Luke Kelly.

Dr Brukner was joined by other high All Conference abstracts will be published calibre and insightful keynotes and online as a supplement to the Journal invited speakers including Professor of Science and Medicine in Sport. Jens Bangsbo, Professor Joseph Hamill, More details about this journal, including Professor Ylva Hellsten, Mr Alex subscription information can be found Kountouris and Ms Susan Mayes. at www.jsams.org

While being blessed with such high We hope that all those who attended quality presentations, it made it very hard the 2015 ASICS SMA Conference were on our judges when it came time to award encouraged by the research being time! Congratulations to Ryan Timmins undertaken in the industry and we from the Australian Catholic University, look forward to seeing you all back who took out the ASICS Medal for 2015 in Melbourne at the MCG for the 2016 for his research on hamstring injuries in Sports Medicine Australia Conference, Australian soccer. 12th-15th October!

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AWARDS We would like to congratulate the ASICS Award for Best New fantastic 2015 ASICS SMA Conference Investigator – Physical Activity Award Winners. and Health Promotion Dr Carol Maher ASICS Medal – Best Paper Overall An online social networking physical Mr Ryan Timmins activity intervention delivered via Strength and architectural risk factors for Facebook: a randomised controlled trial. hamstring strain injury in elite Australian soccer: A prospective cohort study. Wendy Ey, Women in Sport Award Dr Toby Pavey BEST PAPER AWARDS Is the recommendation of 300 minutes of physical activity a week achievable? ASICS Best Paper – Clinical Sports Medicine POSTER AWARDS Dr Natalie Collins Prevalence and factors associated ASICS Best Poster – Clinical Sports with radiographic Patellofemoral joint Medicine osteoarthritis (PFJ OA) in young to Miss Stephanie Filbay middle-aged adults with chronic Quality of life in anterior cruciate ligament patellofemoral pain. deficient individuals: A systematic review.

ASICS Best Paper – Exercise and ASICS Best Poster – Exercise and Sports Science Sports Science Professor David Lubans Mr Craig McNulty Improving muscular fitness enhances New method for processing and psychological well-being in low-income quantifying VO2 kinetics: linear VO2 adolescent boys: findings from the onset kinetics. ATLAS Cluster RCT. ASCIS Best Poster – Physical Activity ASICS Best Paper – Physical Activity and Health Promotion and Health Promotion Associate Professor Rochelle Eime Professor Philip Morgan Participation in modified sports Engaging dads to increase physical programs: A longitudinal study of activity and well-being in girls: The children’s transition to club sport DADEE (Dads And Daughters Exercising participation. and Empowered) RCT. AMSF FELLOWS ASICS Ken Maguire Award for Best New Investigator – Clinical Sports During the 2015 ASICS SMA Conference Medicine the ASMF Fellows enjoyed an Miss Joyce Ramos entertaining evening at the ASMF Fellows Cardiorespiratory fitness and not body Dinner, held at The Fireplace at the fat is independently associated with beta Intercontinental Sanctuary Cove Resort. cell function in individuals with metabolic syndrome: Fitness versus Fatness. Congratulations to the following two SMA members who were awarded John Sutton Award for Best New Fellowships: Investigator – Exercise and Sports • Dr David Bolzonello Science • Mr Peter Garbutt Mr Ryan Timmins Strength and architectural risk factors for These inductees now join an esteemed hamstring strain injury in elite Australian group of Professional members that have soccer: A prospective cohort study. made a great contribution to SMA and the sports medicine industry. ASICS Award for Best New Investigator – Injury Prevention Miss Gillian Weir Injury prevention and athletic performance are not mutually exclusive: An anterior cruciate ligament injury prevention training program.

VOLUME 33 • ISSUE 3 2015 27 ACT SYMPOSIUM

2016 SPORTS MEDICINE AUSTRALIA ACT SYMPOSIUM

SPORTS MEDICINE AUSTRALIA-ACT AND THE AUSTRALIAN research focuses on innovation in sport science and coaching practice INSTITUTE OF SPORT (AIS) ARE PROUD TO JOINTLY HOST to enhance the performance of people THE 2016 SYMPOSIUM “SILENT CONTRIBUTORS TO INJURY, and organisations across the sport participation spectrum. His work is ILLNESS AND PERFORMANCE” AT THE AIS FACILITY IN multidisciplinary and includes athlete monitoring, performance management CANBERRA. THE ORGANISING COMMITTEE IS EXCITED and sport system development. Focus BY THE LINE-UP OF SPEAKERS AS THEY ALL HAVE areas include assessment methods to quantify load and the monitoring of OUTSTANDING SCIENTIFIC ACHIEVEMENTS AND athlete responses to training and KNOWLEDGE THAT HAS BEEN RECOGNISED BOTH competition. In addition to his work in academia, Paul worked in Olympic/ DOMESTICALLY AND WORLDWIDE. Paralympic and professional sport in Australia and overseas over many years holding senior positions in leading organisations such as the Victorian SILENT CONTRIBUTORS TO PERIODISATION Institute of Sport, the UK Sports Institute INJURY / ILLNESS / and UK Sport. He is an Exercise and PERFORMANCE Periodisation is an accepted method Sports Science Australia (ESSA) of structuring training programmes to accredited sport scientist. Injury and illness can be catastrophic to produce maximum performance at the athletic performance. These conditions right time. However, emerging evidence PATHOLOGY SPECIFIC not only place pressure on the individual shows that the way we periodise an athlete but also the coach, support staff, athletic plan may expose athletes to Stress can have detrimental effects on national sporting organisation and the increased susceptibility to injury; a silent the body and is closely related to pain, health care system. But how much do contributor to injury and illness. This sub injury, and illness. Stress in other aspects we really know about the contributors theme will address topics such as training of life can affect training, lead to injury/ to these conditions? Are we missing errors, planning for performance and the illness and negatively affect performance something? And are we doing the simple management of training loads to minimise and mental health. Poor stress things well enough. The 2016 symposium the risk of injury and illness while management and higher injury rates are will focus on the Silent Contributors to maximising performance. associated. Not only can the body and Injury and Illness and ultimately immunity become weaker, but muscles performance. Dr Paul Gastin is an associate professor are tense, concentration is poor, and in the Centre for Exercise and Sport self-confidence is down. When designing Four sub-themes of the symposium have Science and Associate Head of School an injury and illness prevention program been chosen, given their potential to both (Teaching and Learning) in the School of do you consider mental health in its enhance and interrupt performance. Exercise and Nutrition Sciences at Deakin design? If not, this may be silently University, Australia. Paul’s teaching and contributing to injuries and illnesses.

28 VOLUME 33 • ISSUE 3 2015 ACT SYMPOSIUM

This section will also cover pathology equally as detrimental as injuries. It’s important to make sure your overall specific topics of pain, tendinopathy To illustrate this, AFL clubs can expect caloric intake matches your activity level. and muscle injuries. Pain is contextual 2.4 illnesses per season, a number almost Mismatched energy can lead to weight and subjective. In the last decade pain equal to calf strains and groin strains and gain or loss and alter an athletes resting research has increased but these have the fifth highest incidence when metabolic rate. The female triad of finding do not always translate to compared to injury data. Think to inadequate energy, poor bone health sports medicine/science practice. yourself, how long would you take to and altered menstruation is well This section is aimed to give an updated get back to training following being ill? understood, but what about male understanding of pain science, muscle For muscle injuries we have risk factor athletes? Men too can have insufficient physiology and best practice muscle studies, prevention and rehabilitation energy intake, with equal but gender and tendon injury treatment. programs yet comparatively little specific consequences. This has been research is available for medical acknowledged now as “relative energy Prof. Per Aagaard was a keynote at the conditions that affect athletes. deficiency” where an individual is eating 2013 SMA Conference in Thailand and insufficient energy for the amount of was so good he has been invited back. If physical performance is depressed for activity. Athletes tend to eat a lot but how Per is a Professor in Biomechanics and extended periods of time the situation do you know if they are eating enough? appointed Head of the Muscle Physiology may result in a decreased desire to What are the consequences? And what and Biomechanics Research Unit (MoB) exercise and may also increase the risk can we do about this silent contributor? at the Institute of Sports Science and of illness or injury. There may even be Clinical Biomechanics, University of phases of training where an individual Dr Anna Melin is a Swedish dietician with Southern Denmark. He also holds a experiences short-term performance a PhD from the Department of Nutrition, position as Guest Professor at the decrements that are easily recovered Exercise and Sports, University of Institute of Neuroscience and Physiology, from with several days of decreased Copenhagen. She has 20 years of Department of Clinical Neuroscience exercise stress, but how does one experience as a sports nutritionist; the and Rehabilitation, Sahlgrenska Academy, recognise this? The presenter line first 15 years at Team Denmark and now University of Gothenburg, Sweden. His up is yet to be finalised for this section at the Swedish Olympic Committee. research covers the adaptive change in but you are promised an engaging and She is specialised in disordered eating neuromuscular function and muscle informative session from some of behaviour and has developed and morphology/architecture induced by Australia’s leading sport physicians implemented a national prevention training and detraining/inactivity, and researchers. and multidisciplinary treatment strategy including aging and immobilisation. for eating disorders in elite athletes in His research has focused on the effect PHYSICAL: SLEEP/BODY Denmark. Her research area is energy of resistance training on musculoskeletal COMPOSITION deficiency in athletes and the impact health and neuromuscular function in on health and performance. young and old adults, myogenic stem The cause of a bad workout week cell activation with acute exercise and might be as simple as not getting enough Sports Medicine ACT and the Australian long-term training, antagonist muscle sleep. Sleep is sometimes called a legal Institute of Sport are proud to jointly host coactivation, spinal motor function performance aid because of its ability the 2016 Symposium “Silent Contributors during walking and running, in vivo to promote recovery. Research also to Injury, Illness and Performance” at the muscle-aponeurosis-tendon function, suggests sleep helps embed a task or skill. AIS facility in Canberra. The organising knee ligament (ACL) injury, muscle- Equally, poor sleep hygiene is associated committee is excited by the line-up of tendon injury, tendinopathy, and exercise/ with increased injury and illness, but what speakers as they all have outstanding training/biomechanical analysis in elite is good sleep? How do we assess if an scientific achievements and knowledge sports including aging master athletes. athlete is getting enough sleep? that has been recognised both What do we do if we know they are domestically and worldwide. MEDICAL not? Dr Shona Halson is the Head of Performance Recovery at the Australian See you in Canberra, March 18-19 2016. Medical conditions too affect Institute of Sport. Dr Halson will touch performance. In sport, there are few on how important sleep is to the athlete, prospective studies looking at medical its assessment and treatment options. conditions. They are under-reported but

VOLUME 33 • ISSUE 3 2015 29 THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT RISING IN THE

RANKSWITH OUR IMPACT

THE FOLLOWING IS A REPUBLISHED EDITORIAL WHICH FEATURES IN THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT (VOLUME 18, ISSUE 5, SEPTEMBER 2015) WRITTEN BY EDITOR-IN-CHIEF, GREGORY S. KOLT, PHD.

he message is simple – the total number of papers published the Journal of Science and in that same 2-year period. Medicine in Sport has again been recognised internationally for We are proud to announce that in 2014 Tthe quality and impact of the papers we the Journal of Science and Medicine in publish. What I am referring to is the Sport achieved its highest ever impact recent release of the Journal Impact factor, a score of 3.194. This resulted in Factors for 2014. Impact Factors are our rise in the journal rankings to 7th out essentially a metric that describes the of 81 journals in the category where all journal’s citation influence, and tend to the sports medicine and sports science be used vigorously by journals and their journals are included. We can all be very publishers to indicate esteem and to proud of this, as it places us in good attract further high-quality papers. company that includes the other leading The impact factor is calculated by sports medicine and sports science counting all the citations in a given year journals including British Journal of (in this case 2014) of the papers that Sports Medicine (ranked 2nd), American were published in that journal in the Journal of Sports Medicine (ranked 3rd), previous two years (in this case, 2012 and Medicine and Science in Sports and and 2013), and then dividing this by Exercise (ranked 6th). In 2014, the

30 VOLUME 33 • ISSUE 3 2015 THE JOURNAL OF SCIENCE AND MEDICINE IN SPORT RISING IN THE

This overall result, once again, truly acknowledges our journal as one of the leading and well-respected RANKS journals internationally. WITH OUR IMPACT As readers and contributors to the journal you can all be proud.

Journal of Science and Medicine in Sport practitioner readers to take away was one of only four journals in the top 10 evidence around new approaches for that increased their impact factor on their clinical application. We will continue 2013 results. This overall result, once to do this, as the multidisciplinarity is a again, truly acknowledges our journal key feature of our journal. My thanks go as one of the leading and well-respected to the members of the editorial team who journals internationally. As readers and work so tirelessly in contributing to the contributors to the journal you can all journal’s achievements. be proud. The Journal of Science and Medicine The editorial team will continue to in Sport, published by Sports A particular challenge we face, is ensuring provide you with a high quality journal Medicine Australia (SMA), is the that we provide a very balanced group that maintains its place among the most major refereed research publication of papers in each of our issues that esteemed journals internationally. on sports science and medicine in collectively cover areas of sports and Australia. The Journal provides high exercise medicine, sports injury, physical quality, original research papers to activity and health, and sports and keep members and subscribers exercise science. As a multidisciplinary informed of developments in sports journal, unlike many others, we need to science and medicine. Produced for ensure that each issue offers papers of SMA six times a year by Elsevier interest to our very broad reader-ship. Australia, it reflects SMA’s While research in certain areas comes ABOUT THE AUTHOR commitment to encouraging world- in and out of vogue, it is the responsibility class research within the industry, of the entire editorial team to provide Gregory S. Kolt is the Editor-in- and its commitment to the continuing you with papers that are of a high quality, Chief of The Journal of Science education of its members. Journal that demonstrate scientific and academic and Medicine in Sport. articles can be found at jsams.org rigour, and that allow our many

VOLUME 33 • ISSUE 3 2015 31 FEATURE SPORT AND EXERCISE MEDICINE JAPAN SPORT AND EXERCISE MEDICINE INJAPAN

THIS ARTICLE, WRITTEN BY Which types of practitioners Unfortunately, the epidemiological data TORU OKUWAKI, MICHIKO typically look after athletes and on sports injury that covers all ages and what training do they require? sports categories has not been obtained. DOHI, AND TAKASHI ONO The School Safety Department of Japan In Japan, medical doctors and Sports Council has conducted research FORMS PART OF A SERIES physiotherapists working at medical on injuries and accidents that occur to PUBLISHED IN SPORT HEALTH institutions mainly look after athletes, school children whilst under school as well as practitioners in private or supervision, and has reported the data TO LOOK AT THE STRENGTHS alternative medical areas, such as every year since 1980. The Department AND WEAKNESSES OF oriental medicine (Kampo) doctors, has also provided a medical expenses acupuncturists, masseurs, Judo- system (Injury and Accident Mutual Aid THE SPORT AND EXERCISE therapists, or chiropractors who are Benefit System) for school children and MEDICINE (SEM) SYSTEMS also in charge of paramedical care for 99 per cent of school children nationwide athletes. The license for medical doctors subscribe to the system. IN VARIOUS COUNTRIES, and physiotherapists is the national PROVIDING IDEAS AND qualification, however some other According to their research results, practitioners in alternative medical during 2009-2013, the occurrence of INSPIRATION FOR ALL areas are allowed to practice medicine. sports injury (within the sports of soccer, COUNTRIES ON HOW TO baseball, volleyball, basketball, rugby, On the other hand, in the sports field, tennis, kendo, judo, gymnastics, IMPROVE INFRASTRUCTURE ‘sports doctors’ and ‘athletic trainers’ swimming, and track and field) was are in charge of medical and paramedical approximately 260,000 cases per year IN THIS EMERGING SPECIALTY. care for athletes. ‘Sports doctors’ have and the frequency was approximately been certified by three organisations; the 9,300 cases per 100,000 per year. VIEW PAST ARTICLES HERE. Japan Sports Association (JASA, 1982-), In terms of gender, the number of the Japanese Orthopaedic Association occurrences in men was more than twice VIEW PAST SPORT AND EXERCISE (JOA, 1986-), and the Japan Medical that in woman (180,000 cases per year MEDICINE AROUND THE WORLD Association (JMA, 1991-), in chronological in men > 80,000 cases per year in EDITORIAL HERE. order. There are 5,596 doctors currently women), but hardly differed in the registered as JASA-certified sports frequency of occurrence (about 9,000 doctors (current as of 01/10/2014). cases per 100,000 per year). In terms There are 2,324 athletic trainers currently of age, the occurrence rate was largest registered as JASA-certified athletic in 14 year olds, where the frequency trainers (current as of 01/10/2014). was highest in 17 year olds. Looking at the number of occurrences each month, What are the main sports played injuries occurred most often at the beginning of the new school year, in Japan and which injuries are especially in May (in Japan the new school most common? year starts in April). For the site of injury, the ankle joint suffered most (21 per cent According to the statistical data provided of all injuries), followed by the hand and by the Ministry of Internal Affairs and fingers, head, and knee joint. Sprain was Communications (2011), walking is the the most observed in terms of ankle most popular activity in Japan (40 million injury, fracture and sprain for the hand people, 35 per cent of all those who are and fingers, and bruises for the head active), followed by bowling (15 million, (including face, especially eyes or teeth). 13 per cent), swimming (12 million, When viewed by pathology, fracture 11 per cent), training and exercise with occurred most, followed by sprain and a machine, jogging, climbing and hiking, bruise, with these three injury types cycling, fishing, and golf. Baseball, which accounting for 75 per cent of the whole is one of the nation’s popular sports, is injuries (about 200,000 cases per year). played by eight million people (seven per In terms of sports category, the most cent), and soccer by 6.4 million people injuries were recorded in basketball (six per cent). (about 68,000 cases per year) followed

32 VOLUME 33 • ISSUE 3 2015 FEATURE SPORT AND EXERCISE MEDICINE JAPAN by soccer and baseball, however, rugby education or the testing of doping has have also taken place in various was the most at risk of injury (about been entrusted to each sports association competitions, such as the FIFA soccer 33,000 cases per 100,000 per year) which has resulted in a difference of World Cup co-sponsored by the when viewed by occurrence frequency consciousness between each association. Korea Republic in 2002. Within each in relation to participation, with the sport competition, the medical committee being more than twice that of basketball With the establishment of JADA, anti- organised as part of the central (about 14,000 cases per 100,000 per doping activities in Japan have been committee has prepared a venue doctor, year). In the autumn of 2015, a nationwide implemented however it was not a an emergency system and hospital epidemiological research project smooth transition. Triggered by the arrangements. At the IAAF World for sports injury is expected to be Japanese Government’s conclusion to the Championships in Athletics (Osaka, established by the National Sports Agency. UNESCO International Covenant in 2006 2007), care booths for all athletes and the Tokyo Olympics bid activities for were installed and paramedical services How are athlete treatment visits 2016 and 2020, anti-doping activities in were provided. Japan have begun to accelerate, and now, funded at the professional, 78 organisations are currently members What kind of medical support do university and amateur level of JADA (current as of 09/01/2015). (public, private, insurance)? Since 2009, JADA has started to we expect in anticipation of the cooperate with the Japan Pharmaceutical Tokyo Olympic and Paralympic In Japan currently, there is no division Association for certifying the ‘Sports Games in 2020? of insurance due to competition level. Pharmacist’ and has been involved in Typical insurance targeting all competitive anti-doping activities such as providing Looking towards the Tokyo Olympic and categories is done via the National Health accurate information on drugs for Paralympic Games in 2020, the medical Insurance System, which is intended for athletes and preventing athletes from the committee of each sport association and use by the entire nation. Via this system, unauthorised use of drugs. Since 2013, each prefecture unit have commenced people can visit medical institutions and the Japan Ministry of Education, Science medical and scientific support in the access medical services at 30 per cent and Culture has incorporated descriptions form of workshops (topics on injury of the actual costs. This is the same even about doping in the government course prevention/medical checks) for athletes. in top athletes. At the Medical Center of guidelines for high school students with In regards to a nationwide effort, Japan Institute of Sports Science (JISS), the aim of preventing not only athletes polyclinics are being planned for and the athletes pay 30 per cent of the actual but all young people from drug abuse. ‘Multi-Support House’ (newly established cost for any medical services they have since the London Olympic Games in sought. In some universities and Doping tests are regularly done with 2012) is planned to be installed for the companies, athletes can access services 2,300 done in 2005, 4,000 in 2006, Tokyo 2020 Games. for free or low-cost provided they are and more than 6,000 in 2013. Among done by their own health management the 6,145 cases tested in 2013, only six The Multi-Support House will be center or medical office. In regards to were positive (0.1 per cent positive rate) entrusted to the Japan Sports Promotion the compensation system when receiving and most were a result of ‘careless Center for all planning and management. medical treatment, there is a disaster doping’. Since 2008, the highest positive Specific duties of MSH are to provide mutual aid benefit plan for school rate has been 0.2 per cent per year. information support (video analysis, children, general life insurance, or provision of information strategy or failure solatium system for each The Japan Olympic Committee (JOC) meeting space), or medical support sports association. It is expected that a and JISS have also been integral in (self-care [stretching or cooling bathing], nationwide insurance system for sports providing anti-doping education for recovery [meals, contrast baths, or dry injury is to be established by the National athletes and in checking what drugs/ CO2 baths], condition checks, medical/ Sports Agency in the autumn of 2015. supplements have been taken prior to psychological counseling, medical care, international tournaments, such as the and relaxation/refreshment). At the Are anti-doping measures Olympic or Asian Games. The Japan Tokyo Games the MSH is planned to be National Team has never had a doping installed as a strengthening base outside seemingly effective in Japan? violation at an Olympics, and this the village for the Japanese team. cleanliness is considered to be one of Since it was established in 2001, the the factors that led to the success of the Japan Anti-Doping Agency (JADA) 2020 Tokyo Olympic bid. In summary, ABOUT THE AUTHORS has actively provided information in Japan, the anti-doping activities and and guidance on doping in sports measures developed by various Toru Okuwaki and Michiko Dohi competitions held in Japan, not only organisations in various forms can be are from the Japan Institute of at the international level, but also at said to be effective. Sports Sciences. a domestic level ranging from junior Takashi Ono is from Kitasato tournaments to the National Sports How did sports medicine University. Festival, and has conducted educational activities even for sports-related medical services work in any recent affiliates. However, in spite of the anti- major international events doping activities of the Japan Sports held in Japan? Association Sports Science Committee, people engaged in sports are not so The international multi-sport event most interested in doping control at present. recently to have taken place in Japan was Furthermore, before the establishment the Nagano Winter Olympics in 1998. of JADA, implementation for providing World Championships or the World Cup,

VOLUME 33 • ISSUE 3 2015 33 THE COUNTDOWN TO RIO

THETHE COUNTDOWNCOUNTDOWN TOTO

SPORT HEALTH CONTINUES RIORIOITS SERIES OF ARTICLES CHATTING TO SPORTS MEDICINE PROFESSIONALS IN THE LEAD UP TO THE 2016 RIO OLYMPIC GAMES. THIS ISSUE FOCUSES ON KYLIE HOLT, PHYSIOTHERAPIST FOR THE AUSTRALIAN HEADQUARTERS MEDICAL TEAM.

rowing up I participated in As my athletic career was cut short I finally achieved my Olympic goal by many sports including athletics, due to injury, I knew I wanted to help attending the 2012 London Olympics gymnastics and netball. Being other athletes avoid my misfortune, so as the appointed physiotherapist with the sporty I wasn’t sure whether I my sports physiotherapy career began. Australian Women’s Artistic gymnastics Gwanted to be a physical education To this day I still laugh with Kay as to how team. It was very surreal that with all the teacher or a physiotherapist. It wasn’t little I saw in my half hour appointments hard work and sacrifice, I had gone from until I competed for Australia at the 1992 every few days. I was ignorant to the long watching in the stands at the Sydney World Junior Athletics Championships days of treatment, meetings and what 2000 Olympics to the competition floor that I saw what being a sports carrying the kit and physio table around wearing the green and gold. As a mother physiotherapist involved – travelling the the world really involved! Since graduating of three young kids, I would not have world! The team physiotherapist at those I was extremely lucky to have amazing achieved this without the amazing championships was Professor Kay mentors at South Sydney Sports support of my husband, family and Crossley, who made being a team Medicine and Sydney Sports Medicine the AIS. physiotherapist look fun and exciting. centres for 10-years, with the past seven My decision was made. 12-years later my years working at the Australian Institute After being part of the Australian very first international appointment was of Sport (AIS). Since becoming an APA Headquarters medical team for the the Australian team physiotherapist at Sports physiotherapist in 2006, I have 2010 and 2014 Commonwealth Games, the very same World Junior Track and been lucky enough to travel I applied to be part of the Australian Field Championships. internationally with athletics, Headquarters team for the 2016 Olympic gymnastics, netball and swimming. Games in Rio de Janeiro. To be selected

34 VOLUME 33 • ISSUE 3 2015 THE COUNTDOWN TO RIO

be completed. At the end of the games we are also required to help pack up the headquarters area; this includes boxing up equipment to be freighted back to Australia and cleaning the area. Any unused consumables are usually donated to a local hospital.

In comparison to the above role, attending London 2012 with gymnastics came with different experiences and challenges. I had worked closely with the gymnasts and staff for the three years prior to the games attending camps and travelling to international competitions, so I had developed strong relationships. The team had been together at the AIS for a training camp for the six weeks for this position, you need to be area as homely as possible by decorating prior to the games and once in the village, working closely with national sporting it with flags, posters, and of course some I lived in an apartment with the girls and organisations that compete at the big boxing kangaroos! If possible some coaches so was on call 24-hours a day. Olympics as you require a nomination televisions are setup to allow staff and I also attended every training as well as from these sports to the Australian athletes to cheer on their fellow team being on the competition floor for all Olympic Committee. For me this included members whilst receiving treatment. sessions. The week prior to heading over gymnastics, athletics and swimming, and As a member of the Australian team to London, we had two significant injuries I was appointed to be one of seven sports we also receive our own team gear in that required extensive treatment and physiotherapists for the Rio headquarters these first few days. management of training loads. in June this year. With these injuries it was great to have In the first week while athlete numbers access to medical and headquarters As part of the Headquarters team, we are are low, the physiotherapists will each physiotherapists for additional support. responsible for servicing the sports with travel out to the different venues of the smaller numbers that are unable to get sports they are assigned with, to check I am looking forward to attending my accreditation to take their own team out crucial details such as travel times second Olympic Games in a different role. physiotherapist. Such sports include and what medical rooms, staff and Being a member of the headquarters triathlon, diving, synchronised swimming, facilities are available at these venues. team is a great honour, and I love archery, shooting, badminton, table This information will be important as one working closely with highly experienced tennis, beach volleyball, weightlifting of the challenges in Rio will be servicing practitioners. It is extremely rewarding and all the combat sports. Twelve months the three sub sites away from the main working with the different sports that out from Rio 2016 each physio has been village. Generally, the medical area will be access headquarters. Many of these given a liaison role for 4-5 sports each. open from 7am to 10pm with the physio’s athletes have been travelling the world This is to provide a point of contact for working a 10-hour roster in the clinic, for the months leading into the Olympics the different sports in the lead up to the which may also include going out to without medical support and are so Games, to give us any information that the venues with a sport when required. appreciative of the support that we the sport has or needs regarding HQ There will be a booking system for provide them. To be able to assist them in physiotherapy services and physiotherapy athletes to book in treatment times achieving their goals is a fantastic feeling coverage during the Games. As we get in advance around their training and and our ultimate reason for being there. closer to the Olympics, when athletes competition schedules. Working with gain selection, further information will be a few different sports at once requires Post Rio, it will be back to work at the gathered such as screening results and you to be extremely flexible with your AIS and focusing on completing my injury histories. schedule throughout the two weeks training to become a Specialist Sports of competition. Inevitably when injuries Physiotherapist through the Australian During the Olympics the full Australian occur you may be required for strapping College of Physiotherapists. I have also Headquarters medical team (medicine, or treatment at the venue before, during been heavily involved in research with physiotherapy, soft tissue therapists, or after competition rounds. This is where Swimming Australia so will aim to nutrition, psychology, recovery, sports the headquarters team step in to cover complete those projects for publication. science and medical administration) will your other athletes back at the village. arrive at the village as soon as it opens to setup the medical area. This area will As part of my role it is important to be ABOUT THE AUTHOR be in the heart of the Australian team constantly liaising with the sport coaches residence for easy access by the athletes. and management teams as to athlete Kylie Holt will be a member of the Setup includes unpacking the numerous injury status, management and potential Australian Headquarters Medical pre sent freight boxes of treatment tables implications for competition. Being at team at the Rio 2016 Olympic and consumables (tape, braces, cream, the games does not mean the paper Games. Kylie was also an appointed dry needling equipment, theraband, etc.) work is ignored – treatment notes must physio for the women’s artistic as well as packing individual kits to be be written and at the end of the games gymnastics team at the London taken by each physio to the venues when ongoing management, rehabilitation 2012 Olympic Games. required. We try and make the medical plans, follow up and handovers must

VOLUME 33 • ISSUE 3 2015 35 FEATURE OBESITY & FOOT PAIN OBESITY & FOOT PAIN WHAT’S THE LINK AND DO THEY IMPACT ON PHYSICAL ACTIVITY?

36 VOLUME 33 • ISSUE 3 2015 FEATURE OBESITY & FOOT PAIN OBESITY & FOOT PAIN WHAT’S THE LINK AND DO THEY IMPACT ON PHYSICAL ACTIVITY?

PODIATRIST THOMAS WALSH t last count, 68% and 56% of The most preferred treatment for Australian men and women were excessive weight is to modify diet and LOOKS AT THE VICIOUS either overweight or obese, increase physical activity. But the idea CYCLE OF HOW FOOT PAIN respectively. Excessive weight of performing physical activity when you Abrings with it an increased risk of various have painful joints is probably something ASSOCIATED WITH BEING comorbidities including diabetes and only a masochistic would enjoy and most OVERWEIGHT OR OBESE cardiovascular disease. People are often people are not this way inclined. So how warned against gaining excessive weight, do we keep people that are carrying MAY STOP PEOPLE FROM as it will increase their risk for these excessive weight active, despite their EXERCISING AND TRYING conditions however, many ignore this risk pain? How do we square that circle? because related symptoms may be mild To tackle this we need to know, (1) Is TO LOSE WEIGHT. or possibly non-existent. But, excessive foot pain caused by excessive loading? weight also increases the risk for pain, (2) Should people remain physically something that is easily ignored. active when they have foot pain? Pain is experienced in the present, it is depressive and from all accounts it is OBESITY AND FOOT PAIN not much fun. Despite what your average B-grade football coach will tell you, pain Overweight and obese people get sore probably isn’t weakness literally leaving feet. This seems logical, an open and shut the body and it should be listened to. case. The more weight someone has to

VOLUME 33 • ISSUE 3 2015 37 FEATURE OBESITY & FOOT PAIN OBESITY & FOOT PAIN carry the more mechanical stress is Body composition can be measured using pain in univariable analysis, bore by the feet and musculoskeletal techniques such as dual-energy X-ray when FMI was considered pain ensues. This premise is supported absorptiometry (DXA). This provides in the same model BMI by a systematic review in 2012 that found measures of fat, lean soft tissue and bone became non-significant for an increased body mass index (BMI) was mass (lean soft tissue mass and bone both prevalent and future strongly associated with non-specific mass are often combined to calculate foot pain. One of the most foot pain in the general community and ‘fat-free mass’). It can also provide details compelling studies chronic plantar heel pain in a non-athletic on location of these tissues and has regarding a metabolic link population1. A study published in 2014 allowed investigators to determine if the to musculoskeletal pain was found that over a five-year period that as type and location of tissue is associated published this year6, which BMI increased, the risk of developing foot with pain. It turns out that fat mass is found the number of painful pain also increased even after adjusting routinely associated with pain, whereas sites in the lower limb for age2. Whilst there is no doubt that fat-free mass is not, particularly when increased as FMI, increasing your BMI will increase your both of these measures are normalised but not FFMI, chances of developing foot pain, it may for height (giving fat mass index [FMI] and increased be a bit more complicated than simply fat-free mass index [FFMI]) and adjusted following an overloading issue. for each other respectively. To make this a bit clearer, using quite rudimentary The beauty of the BMI is that it requires mathematics if BMI = FMI + FFMI and minimal equipment (no equipment if you both BMI and FMI are associated with have an honest patient) and can be pain, but FFMI is not, then it is not immediately calculated. One of the unreasonable to conclude there may be problems with using the BMI is that it something about fat that makes it a bit is an arbitrary measure of weight/height more than an aesthetic nuisance. and cannot account for body composition, namely fat mass and lean Of the investigations exploring body soft tissue mass nor can it account for composition and foot pain, all have found the location or activity of these tissues. that fat mass, but not fat-free mass, was There has been much debate as to the associated with pain after normalising usefulness of the BMI as a risk factor for height3-5. The largest study5, for pain and disease given it can found that despite BMI being underestimate the prevalence of significantly associated adiposity and because of the known with foot differences in body composition across age, gender and race.

38 VOLUME 33 • ISSUE 3 2015 FEATURE OBESITY & FOOT PAIN

their body and realise all this extra weight can’t be good. Secondly, the majority of weight loss is achieved through a change in diet and only supplemented with exercise – you can’t outrun a bad diet. Finally, a reduction in pain does not necessarily mean people will lose weight or do more exercise. “I know I need to lose As clinicians, it is important that we weight, but I can’t provide some empathy, but we do exercise because my need to stress that foot pain does not preclude a change in diet and should foot hurts and now I’m not limit physical activity per se. It may, however limit activities performed whilst in a vicious cycle of weight bearing. Podiatrists can address weight gain and more local factors, but in order to tackle the difficulties of being overweight or obese, pain.” Patients will patients may require advice from a dietician regarding what to eat and often recognise that when. Patients may also benefit from their weight is probably consultation with an exercise physiologist who are great at explaining how to a factor, but all too maintain muscle mass, continue to frequently will exercise and remain motivated. Given the association between depression, pain blame their pain and obesity, physical activity may not only be useful in using calories, it may have a for the inability positive effect on depressive symptoms to lose weight. – reducing the perception of pain. Is foot pain in overweight or obese individuals caused by metabolic or mechanical factors? Probably both, appropriate adjustment. but fat does seem to be a major player. It may not be considered As seductive as the BMI is, it does have politically correct, but people its limitations and if we are going to with chronic joint pain may be provide sound advice to people too fat, not heavy. regarding foot pain, then we have to start considering body composition, FOOT PAIN, OBESITY fat in particular. Physical inactivity AND PHYSICAL should be discouraged and we need to ACTIVITY stress that there are many activities that can be performed that don’t stress a “I know I need to lose weight, painful foot. There is much research to but I can’t exercise because my be done on understanding the underlying foot hurts and now I’m in a vicious mechanisms and potential management cycle of weight gain and more strategies for foot pain, but we are pain.” Patients will often recognise now starting to address the elephant that their weight is probably a factor, in the room. but all too frequently will blame their pain for the inability to lose weight. Implying that if a clinician can help them ABOUT THE AUTHOR resolve their pain, they can get on with Thomas Walsh is a podiatrist and their weight loss program. There are a current Director at the Adelaide few problems here. Firstly, people are Podiatry Clinic and also works for not generally on a weight loss program SA Health. He is completing his PhD and then develop disabling foot pain, they at Flinders University. generally get foot pain and then look at

VOLUME 33 • ISSUE 3 2015 39 FEATURE HEEL PAIN HEEL

DOCTOR KARL LANDORF HIGHLIGHTS THE MANY PAIN CAUSES OF HEEL PAIN A SIMPLE AND THE DIFFICULTIES FACED WHEN TRYING TO IDENTIFY THE DIAGNOSIS? PROBLEM.

“There is a condition worse than When the foot hurts it is hard to rest. blindness, and that is, seeing Who really wants to sit down and take the something that isn’t there.” daily weight-bearing grind away from it? — Thomas Hardy No-one. Because of this, people with foot and foot-related problems rightly want While the context of Thomas Hardy’s to relieve themselves of the pain and quote above would have been get back to doing what they want to do. substantially different to the one I am Frequently, this means heading off to using in this article, it nonetheless serves a sports physician, physiotherapist or as an appropriate opening. Foot and podiatrist to be diagnosed and then foot-related problems in sport and treated appropriately. But how certain exercise are a curse to most that are is the diagnosis, and by default, how not couch potatoes. Even if one is a appropriate then is the treatment? couch potato – a heavy couch potato, Are clinicians truly clear-sighted with that is – foot and ankle problems can their diagnosis or are they blind? be a curse. The problem is, whether we Or maybe worse, do they see something place excessive demands on our feet that isn’t there? With these questions from over-doing it on the sporting arena in mind, are patients really receiving or over-doing it on the calorie arena, the appropriate treatment? humble foot takes a pounding!

40 VOLUME 33 • ISSUE 3 2015 FEATURE HEEL PAIN

VOLUME 33 • ISSUE 3 2015 41 FEATURE HEEL PAIN

Many clinicians dealing with regional problems from low back pain, to shoulder pain, to foot pain grapple with this issue on a daily basis. How do clinicians act with clear sight rather than act as if they were blind? How do they see what is really there and not see something that isn’t HEEL there? Some conditions are relatively easy to diagnose – a frank fracture of a metatarsal is one such entity. However, others are more difficult. Take plantar fasciitis as an example. For many, the term ‘plantar fasciitis’ has been used to describe most cases of pain under the PAIN heel; a common condition in people trying A SIMPLE to walk or run, whether that is starting a walking program to benefit general health or running long distances to compete in running events. The term implies that the DIAGNOSIS? plantar fascia is the culprit, but do we really know if it is just the plantar fascia that is affected? Could other structures, such as the plantar fat pad or the calcaneus be contributing to the problem? Could there be alterations in the stiffness of the plantar fascia or plantar fat pad? Could there be other conditions, such as a soft tissue tumour or a nerve entrapment? Without appropriate investigation, do clinicians really know what they are dealing with? Without really knowing what they are If I were a patient dealing with, are they treating the with this condition, symptoms appropriately? If I were a patient with this condition, I would want I would want to know to know what structures were causing the problem before I began an expensive what structures were course of treatment. But I would also causing the problem want to know if the medical imaging I was being referred for was going to benefit before I began an me. This balancing act is challenging, and expensive course it needs to be guided with good evidence. Consideration of the evidence for the of treatment. benefits (or otherwise) of medical

42 VOLUME 33 • ISSUE 3 2015 FEATURE HEEL PAIN

imaging cannot be understated and is a referred to as a case-control study) So, next time a patient comes in with hot topic in relation to public expenditure of those with and without plantar heel plantar heel pain, do you know for certain on health care. pain, is evaluating the role of imaging if it is ‘just’ plantar fasciitis? Should you in this common condition. Utilising this refer the patient for medical imaging to Sports medicine has been at the forefront methodology is important because it will find out more? Do you know if the results of many investigative tests, including lead to more valid findings. Not using of the imaging will truly be diagnostic of medical imaging. From early bone scan appropriate methodology, for example what is causing the symptoms? More investigations, where for the first time, just investigating people with plantar questions than answers? Yes, but to some of the more nebulous heel pain, may lead us to believe that some extent this is the nature of research. manifestations of bone pathology could certain imaging findings only occur However, these small steps not only cure be detected, sports medicine clinicians in people with this condition. Indeed, our blindness, but hopefully stop us have been keen to image. The value of many imaging findings (i.e. supposed seeing stuff that isn’t there! medical imaging cannot be pathologies) have been detected in underestimated. It is one of the people with plantar heel pain, including cornerstones of modern medicine and fractured calcaneal spurs, partial tears of it has relatively quickly changed the way the plantar fascia, bone marrow oedema we practice. But, don’t just assume that in the calcaneus, oedema in the plantar imaging prevents blindness…it may still fat pad and space occupying soft tissue make you see something that isn’t there. tumours. However, these same imaging Like many components of health and findings may also be present in people ABOUT THE AUTHOR medicine, medical imaging requires without plantar heel pain. Accordingly, Dr Karl Landorf is an Associate robust evaluation prior to being used in we need studies that compare the Professor and Research a binary manner (‘yes, they have this on findings to a control group. We also need Coordinator in the Discipline of the MRI, therefore this is the problem’). the study to be appropriately powered to Podiatry and a member of the provide meaningful estimates of the odds La Trobe Sport and Exercise In one of our most recent studies, the of having these findings. Until we have Medicine Research Centre at La Trobe University Heel Pain Imaging this data, we don’t know if we are really La Trobe University in Melbourne. Study, we are attempting to do this. seeing something of importance, or we Karl is also the deputy editor for the This cross-sectional observational are just seeing something that isn’t there Journal of Foot and Ankle Research. study (commonly, but erroneously, (or isn’t really a problem).

VOLUME 33 • ISSUE 3 2015 43 SPORT TRAINERS GUIDE SPORT TRAINERS GUIDE ANKLE

SPORTS MEDICINE AUSTRALIA PROVIDES SPORTS TRAINERS TAPINGWITH ADVICE ON HOW TO TAPE AN ANKLE EFFECTIVELY.

The ankle is probably the most commonly Apply 2-3 stirrups (depending on the Heel locks (two complete sets) sprained joint during sporting activity. It is size of the foot/ankle) 1. Commence at the front of the ankle important for the sports trainer to have a 1. Begin from the ankle on the medial and lay the tape diagonally across good understanding of the anatomy and side, cover half the malleoli (bony part the top of the foot towards the functioning of the ankle to manage of the ankle), hook underneath the medial side of the calcaneus: injuries effectively. heel and finish at the anchor on the a) Across the malleoli. lateral side. b) Around the back of the calcaneus. TAPING AN ANKLE 2. The second and third stirrup should c) Under the calcaneus. be applied as for the first stirrup but d) Across the front of the foot. Ankle taping applied directly to the should overlap the first by half the 2. Repeat this sequence from the athlete’s skin affords the greatest width of the tape. lateral side. support. The aim of taping an ankle is to: • Provide protection. Apply a figure of 6. Closing down • Prevent injury. Begin from the anchor on the medial side, Lay a piece of tape gently around • Decrease the severity of the injury follow the stirrup under the heel and the midfoot, covering the extreme if an injury does occur. return across the front of the ankle to edges of the heel locks. Check: where the tape commenced. • Distal capillary refill. TECHNIQUE FOR TAPING • Movement and sensation. AN ANKLE Closing down of stirrups • Restriction. 1. Start above the ankle and work 1. Ensure the ankle and lower leg down the leg. Want to learn more on taping? are clean and dry. 2. Apply separate strips of tape, each Sports Medicine Australia runs 2. Position the foot at 90 degrees. overlapping their predecessor by half the following sports taping courses: 3. Apply protective padding and cover the width of the tape until the stirrups Advanced Sports Taping, Introduction any existing wounds. are covered. to Sports Taping and Introduction 4. Apply two anchor strips around the 3. Finish at the malleoli. to Kinesiology Taping. Visit base of the calf muscle: sma.org.au for more information. a) The first strip at the base of the calf. b) The second strip overlapping the first by half the width of the tape.

44 VOLUME 33 • ISSUE 3 2015 SPORT TRAINERS GUIDE

VOLUME 33 • ISSUE 3 2015 45 PEOPLE WHO SHAPED SMA

PEOPLE WHO SHAPED SMA PETER DURAS eter Duras was always destined first decade, ASMA morphed into the committees. These included ethics, for a career in sports medicine. ASMF in 1963 and later into the SMA. education, coverage, course The son of a distinguished sports establishment and conference groups. medicine pioneer, he grew up, in As a youngster Peter shared his father’s He also represented SMA on several Phis own words “with SMA in my DNA”. love of sport, trailed along with him while State Government health and education he covered athletic events at Olympic committees. More recently he served on His father Dr Fritz Duras had an illustrious Park, and sat with him to witness some SMA’s National Board and the Fellows career in sports medicine and physical of the unforgettable performances at National Council. education. He was Director of the Sports the 1956 Olympic Games. It’s hardly Medicine Institute at Freiburg University surprising that he was drawn towards He watched, and was part of the in Germany from 1929 – 1933. Though sports medicine when he graduated in evolution of SMA. As he puts it, “initially a highly respected lecturer, researcher, physiotherapy some years later. all activities, including training, coverage clinician and administrator he was and administration were carried out on a removed from that post by virtue of his Peter joined SMA in 1971 while working voluntary basis by skilled, highly dedicated Jewish ancestry. In 1937 he was recruited at Toronto General Hospital in Canada. but unpaid health professionals. The by Melbourne University to establish After opening a private practice in the addition of professional administrators Australia’s first tertiary course in Physical sports orientated Melbourne suburb of and the proliferation of formal education Education. He was one of a small group Essendon, he began his lengthy career allowed SMA and its associated groups to of medicos who established the as a valued member of SMA. Over more grow into the highly advanced network Australian Sports Medicine Association than two-decades on the Victorian that is Australian sports medicine today”. (ASMA) in 1955. Several of those early Branch Council he served in a number meetings were held in the Duras home of roles including treasurer, newsletter Peter’s biggest contribution to that in Canterbury. Despite a tumultuous editor and member of a host of sub- change fell just outside SMA. In the mid

46 VOLUME 33 • ISSUE 3 2015 PEOPLE WHO SHAPED SMA

A MOMENT WITH PETER

What was your career highlight?

My first overseas trip as an athletics team physio in 1981. I worked hard, but it was incredibly satisfying to see every athlete compete well at the main international event despite a number of injuries on tour.

I’ve also had the opportunity to meet and sometimes work with many of the quiet achievers and some of the colourful characters that have made such a contribution to sports medicine. It’s quite amazing how many larger than life personalities emerge in this field. I would start with Howard Toyne, Izzy Zimmerman and Fred Better and then the list would go on and on. Great people.

What is your advice to those starting out in their career?

Sports medicine is very rewarding, but it’s tough right now. It’s crowded, so you’ll need to be smart, dedicated, confident and look for opportunities. Work with as many sports as you can and then find a niche. Volunteer at the 2018 Commonwealth Games on the Gold Coast; it will be a life changing experience. Become active in SMA and your own professional association. Attend their courses and National Conferences. They will be a rich source of knowledge, inspiration and networks. Work with a mentor. Participate in a sport or active recreation in order to stay fit and engage with your sporting clientele. Finally, aim to balance pleasure and achievement.

Do you have any career regrets? PETER DURAS See my last piece of advice. I never got the work – life – family balance right. 1970’s it became clear that neither What is your next challenge? SMA nor the Australian Physiotherapy Association (APA) at the time could At 75, survival and maintaining synapses between the few remaining neurons. service all the needs of a rapidly growing group of physiotherapists wanting to expand their knowledge and opportunities in the sports medicine area. In response he chaired the newly formed Football Club and three years at Sports Physiotherapy Group (SPG) in Essendon Football Club. He toured Victoria and in 1982 was Foundation with a host of Athletics Australia and Chairman of the National SPG. The need Commonwealth Games teams between was there and membership rapidly grew 1981 and 2002. After retiring from his to 1800. His belief has always been that private practice, he worked for a number cooperation, communication and joint of years as a volunteer physiotherapist membership of SMA and APASPG have at the Asylum Seekers Resource Centre, added great strength to both and later worked as a project manager on organisations. the demolition and refit of their massive new headquarters. He believes he’s the Outside of SMA Peter has had an active only sports physio with a current fork career in physiotherapy. With his wife lift licence. He is also a member of the Sue he operated a busy private practice Australian Society of Sports Historians for over 30 years. He spent five years as and a volunteer guide at the National physiotherapist at Western Bulldogs Sports Museum.

VOLUME 33 • ISSUE 3 2015 47 COUNCIL OF DISCIPLINE NEWS AND EVENTS

COUNCIL OF DISCIPLINE NEWS AND EVENTS

Sports Dietitians Australia (SDA)

An Accredited Sports Dietitian (AccSD) can help you & your clients: • Eat better, without dieting • Stay fit, healthy and strong • Avoid injuries and help promote faster recovery • Get educated on safe legal effective use of supplements

Find your nearest AccSD here: www.sportsdietitians.com.au

Wishing all our SMA friends a safe holiday season.

Australian Physiotherapy Australia (APA)

The 2015 APA Connect Conference was run on the Gold Coast in October. Key sports topics included the hip and groin, injury prevention, exercise strength and condition and the latest tendinopathy update.

Sports Physiotherapy Australia (SPA)

SPA has signed along with Sports Medicine Australia as a stakeholder in the Youth Sports Injury Prevention Program.

48 VOLUME 33 • ISSUE 3 2015 COUNCIL OF DISCIPLINE NEWS AND EVENTS

CALENDAR

JANUARY 2016 12

The popular joint SMA and SPA lecture evenings will continue in 2016. The next lecture will be held on Tuesday the 12th of January. There are also three other planned joint events between SMA and SPA in 2016.

Watch this space for future dates.

FEBRUARY 2016 12-16

Australasian College of Sports Physicians (ACSP) Annual Scientific Conference – Treating the Elite Athlete

Surfers Paradise, Marriott Hotel, Gold Coast

• Registrar Conference: 12 • MOST Course: 15 – 16 • ACSP Scientific Conference: 12 – 16 • MSK USS Course: 15 – 16

Please refer to the ACSP website for registration www.acsp.org.au or contact [email protected]

VOLUME 33 • ISSUE 3 2015 49 Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028