Co-Kinetic Journal Issue 77 - July 2018 by Co-Kinetic

ISSUE 77 JULY 2018 ISSN 2397-138X

Formerly published as....

medicine & dynamics

whatâ&#x20AC;&#x2122;s inside 44-47 25 WAYS TO GROW YOUR

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MANUAL THERAPY & PHYSICAL THERAPY INFOGRAPHICS

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14-24 UNDERSTANDING THE ROLE OF

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MALALIGNMENT SYNDROME IN THE MANAGEMENT OF RUNNING INJURIES

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STRUCTURE AND FUNCTION

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LONG JULY 2018 ISSUE 77 ISSN 2397-138X

Publisher/Founder TOR DAVIES tor@co-kinetic.com Business Support SHEENA MOUNTFORD sheena@co-kinetic.com Technical Editor KATHRYN TOMAS BSC MPhil Art Editor DEBBIE ASHER Sub-Editor ALISON SLEIGH PHD Journal Watch Editor BOB BRAMAH MCSP Subscriptions & Advertising info@co-kinetic.com

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ISSUE 77 JULY 2018 ISSN 2397-138X

Formerly published as....

medicine & dynamics

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DISCLAIMER While every effort has been made to ensure that all information and data in this magazine is correct and compatible with national standards generally accepted at the time of publication, this magazine and any articles published in it are intended as general guidance and information for use by healthcare professionals only, and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissible by law, the publisher, editors and contributors to this magazine accept no liability to any person for any loss, injury or damage howsoever incurred (including by negligence) as a consequence, whether directly or indirectly, of the use by any person of any of the contents of the magazine. Copyright subsists in all material in the publication. Centor Publishing Limited consents to certain features contained in this magazine marked (*) being copied for personal use or information only (including distribution to appropriate patients) provided a full reference to the source is shown. No other unauthorised reproduction, transmission or storage in any electronic retrieval system is permitted of any material contained in this publication in any form. The publishers give no endorsement for and accept no liability (howsoever arising) in connection with the supply or use of any goods or services purchased as a result of any advertisement appearing in this magazine.

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT From 2012 to 2014, data on the injured population were collected by physicians in on-mountain clinics in 30 French ski resorts, and interviews were conducted on the slope to sample a non-injured control population. Two sets of patients [1,425 participants with traumatic brain injuries (TBI) and 1,386 with other head injuries (OTHI)] were compared with two sets of controls (2,145 participants without injury and 40,288 with an injury to a body part other than the head). The effect of helmet use on the risk of TBI and OTHI was evaluated with a multivariate The ‘usual suspect’ databases were searched looking for randomised controlled trials (RTCs), non-RCTs that included a comparison group, before and after study designs and qualitative methods. Studies were required to outline specific unimodal or multimodal psychological interventions used in relation to injury prevention in the real-world setting. The initial search resulted in 6,308 records that were whittled down to 13 papers (incorporating 14 studies) to consider. Studies reported on 1,380 athletes, aged 10–33 years (mean, 18.6 years; SD, 2.8). Participants’ level of competition ranged from international to regional levels in floorball (54.1%),

Forty percent of 289 neurologists attending the Texas Neurological Society 20th Annual Winter Conference continuing medical education meeting in 2017 completed a survey. The majority of respondents agree with the following: post-concussion syndrome (PCS) is a clearly defined syndrome with a solid basis for determining prognosis with an organic basis; accept the authenticity of patients’ reports of symptoms; effective treatment is available for headaches lasting 3 months or more; headaches 4

EFFECT OF HELMET USE ON TRAUMATIC BRAIN INJURIES AND OTHER HEAD INJURIES IN ALPINE SPORT. Bailly N, Laporte JD, Afquir S et al. Wilderness & Environmental Medicine 2018;29(2):151–158 logistic regression adjusted for age, sex, sport, skill level, crash type, and crash location. Using participants without injury as control, helmet wearers were less likely to sustain any head injury. When considering participants with an injury to another body part as control, the risk of OTHI was lower among helmet wearers. However, no significant effect was found for the risk of TBI. Participants with low skill levels, those aged <26 and >50 years, snowboarders, and those involved

in collision and in snowpark accidents were at higher risk of head injury.

Co-Kinetic comment No pun intended but this is a no brainer. Anyone skiing without a helmet is taking the piste. Head injury is the leading cause of death and catastrophic injury among skiers and snowboarders and accounts for 3–15% of winter sportsrelated injuries yet there have had to be several helmetwearing campaigns to get people to wear helmets. As of 2014, 3% of kids and 41% of adults don’t. Madness.

PSYCHOLOGICAL INTERVENTIONS USED TO REDUCE SPORTS INJURIES: A SYSTEMATIC REVIEW OF REAL-WORLD EFFECTIVENESS. Gledhill A, Forsdyke D, Murray E. British Journal of Sports Medicine 2018;doi:http://dx.doi.org/10.1136/bjsports-2017-097694 football (32.4%), rugby union and rugby league (3.5%), gymnastics (3.2%), rowing (2.5%), ballet (2.5%) and swimming (1.8%). Interventions were Intervention techniques were imagery, goal setting, mindfulness-acceptancecommitment (MAC) training, attribution training, self-confidence training, autogenic training, self-talk, thought stopping, abdominal breathing, control of emotions, concentration skills and video clips. Video-based training was also used as a stand-alone awareness training programme. The

duration of interventions ranged from 4 weeks to 8 months (mean, 15.6 weeks; SD, 10.75). Ninety-three percent of the studies (13/14) reported a decrease in injury rates following psychological interventions. There was a dominance of stress managementbased interventions in literature owing to the prominence of the model of stress and athletic injury within the area.

Co-Kinetic comment It’s all in the mind. The psychology of illness/injury and rehabilitation should be standard teaching in any therapy programme.

A SURVEY OF NEUROLOGISTS ON POST-CONCUSSION SYNDROME. Evans RW, Ghosh K. Headache: The Journal of Head and Face Pain 2018;doi:https://doi.org/10.1111/head.13272 persist in over 20% 1 year after injury; and cognitive rehabilitation is effective. The majority of the respondents do not agree with the following: symptoms improve in a relatively short period of time and quickly resolve once litigation is settled; effective treatment is available for PCS; and return to play guidelines are strongly evidence based. 68.4% disagree with the following: I would support my son or grandson (or if you do not have one, a relative’s or friend’s)

playing (American) football.

Co-Kinetic comment You may have been following the concussion debate in USA sport but if you haven’t you need to watch the Will Smith film, ‘Concussion’. It’s a game changer for American Football and this is reflected in the fact that 68% of neurosurgeons are not happy with the idea of kids playing the game. You can’t take the moral high ground of being a ‘real’ football fan (soccer for our US readers). There are some growing concerns about the long-term effects of heading the ball. Co-Kinetic Journal 2018;77(July):4-7

RESEARCH INTO PRACTICE

Physical Therapy

Journal Watch EXISTING EVIDENCE ON ULTRASOUND-GUIDED INJECTIONS IN SPORTS MEDICINE. Daniels EW, Cole D, Jacobs B et al. Orthopaedic Journal of Sports Medicine 2018;6(2):2325967118756576 OPEN A Cochrane review published in 2012 stated there was not enough evidence to recommend ultrasoundguided injections over landmark-guided injections at the shoulder. A 2015 meta-analysis, showed that ultrasoundguided glenohumeral and biceps tendon injections were not only more accurate but also more efficacious in providing relief. So what is the state of play in 2018? This paper summarises the current evidence. In the upper extremity, ultrasound-guided injections have been shown to provide superior benefit to landmark-guided injections at the glenohumeral joint, the subacromial space, the biceps tendon sheath, and the joints of the hand and wrist. Ultrasound-guided injections of the acromioclavicular and the elbow joints have not been shown to be more efficacious. In the lower extremity, ultrasound-guided injections at the knee, ankle, and foot have superior efficacy to landmarkguided injections. Conclusive evidence is not available regarding improved During the Dutch 2015–2016 season, 80 players answered a baseline questionnaire and were subsequently followed up every 2 weeks to report the hours spent on training/competition and experienced injuries, which were registered using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems. Of the 74 players included in the analysis, 52 (70%) reported 112 injuries. Eighty-seven injuries (78%) received medical attention and 56 (50%) led to training/competition timeCo-Kinetic.com

efficacy of ultrasound-guided injections of the hip, although landmark-guided injection is performed less commonly at the hip joint. Although current studies indicate that ultrasound guidance improves efficacy and cost-effectiveness of many injections, these studies are limited and more research is needed.

Co-Kinetic comment Did you know that the first paper on ultrasonography was published in 1958? The term sports ultrasound was introduced in 2015 by the American Medical Society of Sports Medicine and includes the diagnosis and treatment of both musculoskeletal and non-musculoskeletal conditions applicable to the field of sports medicine. The conclusion here is that ultrasound-guided injections are overall more accurate than landmark-guided injections, which is a bit obvious really considering it allows you to see where you are going.

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HIGH INJURY BURDEN IN ELITE ADOLESCENT ATHLETES: A 52WEEK PROSPECTIVE STUDY. von Rosen P, Heijne A, Frohm A et al. Journal of Athletic Training 2018;53(3):262–270

The participants were 284 elite adolescent athletes (147 boys, 137 girls, median age 17 years) competing at a high national level for their age in athletics (track and field), cross-country skiing, downhill skiing, freestyle skiing, handball, orienteering, or ski orienteering. They were monitored weekly over 52 weeks, using a validated online questionnaire to identify injury type, location, prevalence or incidence, and severity grade; time to first injury; and prevalence of illness. At least 1 new injury was reported by 57.4% athletes. The overall injury incidence was 4.1/1,000h of exposure to sport, and every week, on average, 3 of 10 (30.8%) reported being injured. Not unsurprisingly the injury incidence rate was higher during competition than during training (23.8/1,000h of competition). Of all injuries from which athletes recovered, 22.2% (n =35) resulted in absence from normal training for at least 2 months. Female athletes reported higher average weekly injury prevalence and substantial injury prevalence (injuries leading to a moderate or severe reduction in sport performance or participation or time loss) than male athletes. Handball had the highest number of injuries. The majority of injuries affected the lower extremity (69.0%, n =225), defined as all body parts from the hip to the toes. The highest injury incidence was in the foot (24.5%, n =80), followed by the knee (15.6%, n =51) and lower back (11.7%,n =38).

Co-Kinetic comment At the top level sport is a gory business. These young athletes push themselves. It is not surprising that a large number get hurt. It would be interesting to find out how many play on while carrying an injury.

INJURIES IN DUTCH ELITE FIELD HOCKEY PLAYERS: A PROSPECTIVE COHORT STUDY. Delfino Barboza S, Nauta J, van der Pols MJ et al. Scandinavian Journal of Medicine & Science in Sports 2018;28:1708–1714 loss. Thirty-four injuries (30%) hampered players’ availability to train and compete. Most of the injuries (74%) were not caused by any contact. The mean prevalence of injury was 29% for all, 9% for acute, and 14% for overuse injuries. Players sustained 3.5 new acute injuries per 1,000 hours of training and 12.3 per 1,000 hours of competition.

OPEN

Co-Kinetic comment What always strikes us about injury statistics studies such as this is how many injuries there are. Teams should have an army of therapists but sadly it’s often the post that gets the job when a team gets relegated. There is also a question for coaches. Seventy-four percent of those reported injuries were not caused by contact. Can these ones be prevented? 5

The data for this study comes from 151 patients with no prior knee surgery who underwent primary anterior cruciate ligament reconstruction by a single surgeon between 2010 and 2014. Based on arthroscopic diagnosis, that at the time of surgery, 33 (22%) patients had no concomitant lesions and served as the control group, 63 (42%) patients had isolated meniscal lesions, 21 (14%) patients had isolated chondral lesions, and 34 (22%) patients had both chondral and meniscal lesions. Various patient outcome protocols were recorded over 2 years from surgery. There was significant improvement in all outcome scores postoperatively

INFLUENCE OF MENISCAL AND CHONDRAL LESIONS ON PATIENTREPORTED OUTCOMES AFTER PRIMARY ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION AT 2-YEAR FOLLOW-UP. OPEN Cinque ME, Chahla J, Mitchell JJ et al. Orthopaedic Journal of Sports Medicine 2018;6(2):doi:10.1177/2325967117754189 for all three groups. The presence of a meniscal tear and laterality of the meniscal lesion did not have a negative effect on any postoperative outcome scores. Patients with isolated chondral lesions had significantly lower postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), scores compared with patients without chondral lesions. No significant differences were found for all other scores. Patients with

A REVIEW OF SHOULDER INJURIES IN YOUNG ATHLETES. Solomon D, Cong GT, Cagle P. Annals of Joint 2018;doi:10.21037/aoj.2018.02.04 OPEN This starts with a stunning statistic that there are an estimated 2 million sports injuries annually in USA High School sports and that among throwing athletes 30% of the injuries involve the shoulder and elbow. Highlighted here are proximal humeral epiphysiolysis, aka little league shoulder (LLS), although it is found in tennis players, swimmers, gymnasts, volleyball players and cricket players. Glenohumeral internal rotation deficit, the effects of various pitch types, monitoring pitch counts, general shoulder injuries in volleyball, dislocation, quadrilateral space syndrome (QSS) and hypomobility. For each there is a brief discussion on aetiology, pathology, presentation, injury prevention and treatment.

Co-Kinetic comment This paper has two things going for it. First, it is not quite in the category of, ‘all you need to know about’ studies that we really like but it is close. Second, it’s open access. We like free stuff. It’s a tad USA biased but you can easily relate all the baseball-throw stuff to cricket. The data for this study came from an international populationbased prospective trauma database (TraumaRegister DGU®) with information from Germany, Austria, Switzerland, Finland, Slovenia, Belgium, Luxembourg and The Netherlands. The registry was screened for sport-related injuries, and only patients with major injuries (Injury Severity Score (ISS)≥≥9 points) related to extreme or contact sports activities were included with a time scale of 1 January 2002 to 31 December 2012). A total of 278 athletes were identified within the study period and classified into four groups: airborne sports 6

patellofemoral chondral lesions had significantly lower postoperative Short Form–12 Lysholm scores than patients with tibiofemoral chondral lesions.

Co-Kinetic comment Really these results are not much of a surprise. Chondral lesions don’t really heal without a lot of help so if you have been unlucky enough to injure the hyaline cartilage at the same time as the anterior cruciate ligament you are not going to do as well as if you didn’t.

MUSCLE INJURIES IN THE ACADEMY OF A SPANISH PROFESSIONAL FOOTBALL CLUB: A ONE-YEAR PROSPECTIVE STUDY. Raya-González J, Suarez-Arrones L, Larruskain J et al. Apunts. Medicina de l’Esport 2018;53(197):3–9 The statistics for this study were taken from the academy of a Spanish professional first division football team during the 2015–2016 season. Timeloss injuries and exposure time were recorded following the UEFA consensus in 139 elite young football players from four levels (Senior, U19, U16 and U14). A total of 118 injuries were recorded. Overall injury incidence was 1.47 muscle injuries/1,000h, with a lower incidence in younger players. Nevertheless, injury burden (days lost/1,000h) was similar between levels. The injuries with the highest incidence and burden were hamstring and adductor injuries in Senior (50 and 58 days respectively), hamstring injuries in U19 and U16 (109

OPEN

vs 89), and adductor injuries in U14 (175 days). Regarding the severity of injuries, it was observed that moderate injuries were the most common injuries and muscle injuries during competition had a higher incidence towards the end of the matches (75–90min).

Co-Kinetic comment As we said in the hockey injury incidence study there are some questions to ask the coaches. Do they have a hamstring injury prevention programme? Do the injuries in the last 15min suggest that fatigue/fitness levels need to be looked at? Answers on a postcard please.

EVALUATION OF SEVERE AND FATAL INJURIES IN EXTREME AND CONTACT SPORTS: AN INTERNATIONAL MULTICENTER ANALYSIS. Weber CD, Horst K, Nguyen AR et al. Archives of Orthopaedic and Trauma Surgery. 2018:doi:https://doi.org/10.1007/s00402-018-2935-8 (n =105) were associated with the highest injury severity, followed by climbing (n =35), skating (n=67) and contact sports (n=71). Especially high falls resulted in a significant rate of spinal injuries in airborne activities (68.6%) and in climbing accidents (45.7%). Skating was associated with the highest rate of loss of consciousness at scene (27.1%), the highest pre-hospital intubation

rate (33.3%), and also the highest in-hospital mortality (15.2%) related to major head injuries.

Co-Kinetic comment Who said sport was good for you? The ISS rates injuries on a scale of 1 (minor) to 6 (currently untreatable). It gets over 6 and up to 75 by combing injury location scores. Co-Kinetic Journal 2018;77(July):4-7

RESEARCH INTO PRACTICE

CAVERNOUS HEMANGIOMA OF THE KNEE – CASE REPORT. Weiss M, Dolata T, Weiss W et al. OPEN Journal of Education, Health and Sport 2018;28(4):318–325 This is a case study about a 21-year-old single Polish woman who presented with persistent knee pain and swelling. She had a previous similar problem some years ago that had been managed by treating the symptoms. Her knee flexion was limited to 60° and intra-articular effusion without inflammatory signs. There was slight wasting of the thigh and calf. Laboratory tests, including a complete coagulation profile, a hemogram and a blood cholesterol were normal. Plain radiographs demonstrated diffuse articular plucking with subchondral geodes. Echography of the knee showed isoechogenic mass with a posterior intensification and a venous signal inside. MRI revealed hyperplasia of the synovium especially within the sub quadricipital pouch and arthroscopic findings show a synovial lesion in the suprapatellar pouch embedded in synovium. A histological result objectified a cavernous hemangioma, which is a type of blood vessel malformation or hemangioma where a collection of dilated blood vessels form a benign tumour. Because of this malformation, blood flow through the cavities, or caverns, is slow. Further surgery found that a diffuse cavernous hemangioma was found bulging into the suprapatellar pouch and holding the patella away from the femur. Since the operation the patient has been free from symptoms.

Co-Kinetic comment Get past the radiology speak and what you have is a patient with knee pain. The cause turns out to be a tumour, which just goes to show that items from the ‘Book of rare clinical presentations’ can sometimes walk through your door.

Resistance exercise is typically performed to increase both muscle size and strength and is regularly incorporated into training programmes for sports performance. But is there any evidence that it makes a difference. This paper challenges two assumptions. Assumption 1: An increase in muscle size will produce an increase in muscle strength. Assumption 2: A stronger muscle will increase sports performance. The problem is that although both are widely accepted, few studies are designed to examine sport-related benefits of resistance exercise while including a proper control group to account for adaptations to simply Co-Kinetic.com

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REVIEW OF ASSESSMENT SCALES FOR DIAGNOSING AND MONITORING SPORTS-RELATED CONCUSSION. Dessy AM, Yuk, FJ, Maniya AY et al. Cureus 2017;9(12):e1922 The most commonly used tools for evaluating individuals with concussion are the Post-Concussion Symptom Scale (PCSS), Standard Assessment of Concussion (SAC), Standard Concussion Assessment Tool (SCAT3), and the most recognised computerised neurocognitive test, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The strengths and limitations of each of these tools, and the Concussion Resolution Index, CogSport, and King-Devick tests were evaluated in this paper basically by listing the pros and cons of each. Based on this the authors concluded that the most sensitive and specific of these is the ImPACT test. Additionally, the King-Devick test is an effective adjunct owing to its ability to test eye

movements and brainstem function.

Co-Kinetic comment This is a nice companion piece to the neurologist’s survey we reported. There are a lot of tests and they become a bit of an alphabet soup. They are all available online if you dig a bit. This paper may recommend a couple but they may not fit your particular sporting population. You may for example be involved with children, for whom different versions of the tests are available. Your sport’s governing body may also have a favourite or even have adapted a favourite to suit their needs. Best to check just in case someone asks hard questions about why you were not following the party line.

RESISTANCE EXERCISE AND SPORTS PERFORMANCE: THE MINORITY REPORT. Buckner SL, Jessee MB, Dankel SJ et al. Medical Hypotheses 2018;113:1–5 performing the sport-related task. Much of our knowledge of resistance exercise for sport is based on crosssectional work showing that stronger athletes tend to perform at the highest level, along with cross-sectional work demonstrating that higher levels of strength are associated with various performance related parameters. However, there is a lack of evidence to support these assumptions. The weight of evidence suggests that resistance exercise may indirectly impact sports performance through injury prevention, as opposed to directly improving sportrelated abilities.

Co-Kinetic comment Controversy. Strength and conditioning coaches the world over are revolting (but that’s just what the physios say!). What you have to remember with this paper is that it appears designed to start the debate and that the lack of supposedly high quality evidence does not mean that the assumptions are wrong. It just means that researchers have not necessarily been asking the right questions. 7

CLICK ON RESEARCH TITLES TO GO TO ABSTRACT DRY NEEDLING: A CASE STUDY IN TREATING TENNIS ELBOW. Wymore MA, Blackington D. Journal of Hand Therapy 2018;31(1):153

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This is a case study about a 61-year-old African American female with a history of left non-dominant lateral elbow pain for 5 months. The pain started slowly and progressively got worse. The individual worked a stationary desk job for 8h a day and did martial arts as her primary hobby. She reported that her condition was getting worse. She was seen in traditional occupational therapy services for nine visits. At the start she had the following markers: n 8/10 pain at the lateral epicondyle with activity n full active/passive elbow range of motion n grip R: 55.1# L: 45.7# n Quickdash-9: 27.5 n positive tenderness for palpation at the lateral epicondyle region n positive for resisted middle finger and wrist extension tests. Over a 2-month period she was treated with the following: 1. activity modification 2. ECRB stretching 3. cross frictional manual therapy 4. forearm muscle mobilisation 5. eccentric loading 6. elbow counterforce bracing. After the nine visits her markers showed some improvement: n Dash: 25.83 n 6/10 for pain n grip (position 2) with elbow at 0° R: 44.7# L: 33# n positive middle finger and wrist extension resisted tests. At this point the treatment protocol was changed and during a further six visits over 55 days she had dry needling plus she continued with the stretches and activity moderation given earlier. She had six further treatments. Her final markers were: n Dash: 0 n 1/10 pain n grip (position 2) with elbow at 0 degrees R: 47.3# L: 45.7#.

Co-Kinetic comment She was getting better, albeit very slowly. The dry needling appears to have been the extra push that was needed. One can’t help wondering what would have happened over the extra 2 months without the dry needling. 8

THE PASSIVE STRETCHING, MASSAGE, AND MUSCLE ENERGY TECHNIQUE EFFECTS ON RANGE OF MOTION, STRENGTH, AND PRESSURE PAIN THRESHOLD IN MUSCULOSKELETAL NECK PAIN OF YOUNG ADULTS. Jeong HM, Shim JH, Suh HR. OPEN Physical Therapy Rehabilitation Science 2017;6(4),196–201 Thirty subjects (13 male, 17 female) aged in their early 20s were randomly assigned to the following groups: passive stretching (PS) group (n =10), massage (MASS) group (n =10), and muscle energy technique (MET) group (n =10). The treatments were applied bilaterally on the upper trapezius. The PS was applied 3 times for 30s each time. The MASS was applied using two different techniques for 2min per technique. For MET, the subjects performed 2 sets of 3 repetitions of isometric resistance exercise that was maintained for 10s, followed by 10s of rest. Range of motion (ROM), strength and pressure pain threshold (PPT) parameters were measured after intervention. In the MASS group, there was a significant improvement in all

Seventeen collegiate male (n =9) and female (n =8) track and field athletes were assigned to a counterbalanced, repeated measures designed experiment testing four treatment conditions of a pre-competition massage, dynamic warm-up, combination of a massage and warm-up, and a placebo ultrasound. The massage protocol was a short, 10–15min stimulatory massage consisting of the techniques frequently used in a clinical setting, such as effleurage, petrissage, tapotement, circular friction and jostle. The warm-up

outcomes except for muscle strength. In the MET group, ROM and strength significantly improved compared to the pre-treatment results. As result of measuring the amount of change in each group, there was a significant difference in ROM (flexion) in the PS group compared with the MASS and MET group, a significant difference in strength in the MET group compared with the PS and MASS groups, and a significant difference in PPT in the MASS groups compared with the PS and MET groups.

Co-Kinetic comment There are people who promote ‘hands off therapy’. They are wrong. How many studies such as this do we need to bring you to prove it?

began with active stretching using a standard stretching strap to stretch the quadriceps and hamstrings for 4 to 5 repetitions each. This routine was then performed on the opposite leg and leg swings were executed in a side-to-side manner and a forward-to-backward movement. Next, the participant lifted their legs as high into the air as possible and performed alternating scissor kicks and splits. With the legs still in the air, the participant moved his/her legs as if he/she was running followed by a short burst of running. Upon completion, the participant performed activity drills consisting of heel walks, toe walks,

Co-Kinetic Journal 2018;77(July):8-11

RESEARCH INTO PRACTICE

Manual Therapy

Journal Watch PAIN AND MASSAGE THERAPY: A NARRATIVE REVIEW. Field T. Current Research in Complementary & Alternative Medicine 2018;doi:10.29011/ OPEN CRCAM-125/100025

ACUPOINT APPLICATION COMBINED WITH ACUPOINT MASSAGE FOR ANKLE SPRAIN OF BASKETBALL PLAYERS. Song C, Wang Y, Long P. Biomedical Research 2017;28(22):10076–10079 This research took place in a Chinese Hospital where 1,200 cases of basketball players with ankle sprain admitted between August 2014 – November 2015. After 24h the Jiexit, Kunlun, Yanglingquan and Xuanzhong acupoints (which are in the legs) were massaged, 2 times/ day, for 2min each time. Depth was from light to heavy within the patient’s tolerance. Massage was also given to the Yongquan acupoint in the foot to aid sleep. Another 1,200 athletes with ankle sprains acted as a control group and

didn’t receive the acupoint massage. The results showed that the acupoint group had a shortened hospital stay, reported less pain and an increased patient satisfaction rate.

PubMed and PsycINFO were searched with the terms ‘pain’ and ‘massage therapy’ to identify publications from the last 10 years. Co-Kinetic comment Inclusion criteria were randomised This suffers a bit from a poor translation into English. controlled trials that focused on We should also comment on the fact that 2,400 ankle injuries chronic pain conditions, systematic with an overnight hospital stay seems a very large number. reviews and meta-analyses that were Scepticism aside, it is worth repeating this treatment on your peer-reviewed and published in English. injured ankle patients. It is not going to do them The chronic pain conditions include any harm and might just do them some good. back pain (the most frequently studied THE EFFICACY OF ELASTIC THERAPEUTIC TAPE VARIATIONS ON condition), joints in the lower limb MEASURES OF ANKLE FUNCTION AND PERFORMANCE. Brogden CM, (focused most often on the knees), Marrin K, Page RM et al. Physical Therapy in Sport 2018;32:74–79 and the upper body (primarily the shoulders and neck) and arthritis and Twelve professional male soccer improved mid-range joint position sense fibromyalgia. These studies showed players completed three experimental at 15°, and time to complete a drop landing positive effects of massage therapy trials: no tape (NT), RockTape™ (RT), task. No significant differences were on pain, especially when compared and Kinesio™ Tape (KT) applied to the observed for measures of postural stability to standard treatment. In contrast, ankle complex. Clinical and functional nor ground reaction force variables. when massage therapy was compared ankle screening tests were used to other physical activities such as to assess the effects. KT and RT Co-Kinetic comment demonstrated significant improvements Tape turns you into a super athlete. Buy more of it. Better physical therapy or exercise, the data are less conclusive. Reasons for in end range joint position sense. still, incorporate balance and proprioception training the pain reduction were speculated When compared to NT, RT significantly into every training session from kindergarten onwards. as enhanced vagal activity, reduced pro-inflammatory processes and decreased substance P. Stimulating THE EFFECT OF MASSAGE ON ACCELERATION AND SPRINT OPEN pressure receptors would enhance PERFORMANCE IN TRACK & FIELD ATHLETES. Moran NR, Hauth JM, vagal activity and the other underlying Rabena R. Complementary Therapies in Clinical Practice 2018;30:1–5 mechanisms would follow including pro-inflammatory effects and comparison to the traditional warmtoe-in walks, toe-out walks and walking decreased substance P. up, although the combination of the on the outside edges of the feet. Lastly, massage and warm-up appeared to skipping was performed along with butt have no greater difference than the kicks and 2 sets of fast twitch leg and Co-Kinetic comment warm-up alone. then alternating fast twitch running. The The paper doesn’t say how combination protocol consisted of both many hits their search got or how of the treatment conditions described they narrowed it down. A Google Co-Kinetic comment above. The placebo was a 10min Scholar search with the same This is similar to earlier work. Preultrasound treatment. There were no terms gives 14,000 hits from event massage, especially if applied deeply significant differences between the four 2017 alone. However, it does give does absolutely nothing for sprint-type treatments and performance. Massage examples of massage being good activities. In fact, it can be detrimental. By decreased 60m sprint performance in for pain management for the way, ‘jostle’ appears to mean shaking. the stated body areas.

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OCCUPATIONAL HAND INJURIES: A CURRENT REVIEW OF THE PREVALENCE AND PROPOSED PREVENTION STRATEGIES FOR PHYSICAL THERAPISTS AND SIMILAR HEALTHCARE PROFESSIONALS. Gyer G, Michael J, Inklebarger J. Journal of Integrative Medicine 2018;16(2):84–89

Hand injury is the second most common work-related musculoskeletal injury among physical therapists (PTs) and other manual therapy professionals such as osteopaths, physiotherapists, chiropractors, acupuncturists and massage therapists. Therefore, the objective of this study was to review the existing literature published on the prevalence, risk factors, consequences, and prevention of hand injuries among PTs and similar healthcare professionals. The lifetime prevalence of hand injuries was about 15–46%, and the annual prevalence was reported as 5–30%. Thumb injuries were found to be the most prevalent of all injuries, accounting more than 50% of all hand-related problems. The most significant risk factors for job-related hand injuries were performing manual therapy techniques, repetitive workloads, treating

many patients per day, continued work while injured or hurt, weakness of the thumb muscles, thumb hypermobility, and instability at the thumb joints. PTs reported modifying treatment technique, taking time off on sick leave, seeking intervention, shifting the specialty area, and decreasing patient contact hours as the major consequences of these injuries.

Co-Kinetic comment Every reader of this publication should have the take-home message of this study imprinted on the back of their hands: ‘Look after yourself’. Vary techniques, vary the way you use your hands and look for aids and equipment to reduce the risk of an unnecessary injury. Thumbs are lonely. They should never be left to work on their own.

The data for this study came from a self-reported 4-page internet survey on tapering practices completed by 454 strongman athletes. They were aged 33.2 ± 8.0 years, weighed in at 108.6 ± 27.9kg, stood 178.1 ± 10.6cm tall and had 12.6 ± 8.9 years of general resistance training, 5.3 ± 5.0 years of strongman implement training. Eighty-seven percent (n=396) reported that they used a taper. The typical taper length was 8.6 ± 5.0 days with the step taper the most commonly performed (52%). Training volume decreased during the taper by 45.5 ± 12.9%, and all training ceased 3.9 ± 1.8 days out from competition. Typically, athletes reported that training frequency and training duration stayed the same or decreased and training intensity decreased to around 50% in the last week. Athletes

THE EFFECT OF CORE STABILITY TRAINING ON FUNCTIONAL MOVEMENT PATTERNS IN COLLEGIATE ATHLETE. Bagherian S, Ghasempoor K, Rahnama N et al. Journal of Sport Rehabilitation 2018;doi:https://doi.org/10.1123/jsr.2017-0107 One-hundred collegiate athletes completed the functional movement screen (FMS), lateral step down (LSD) and Y balance test (YBT). They were assigned to either a training group (60 males) who completed a core stability training programme that met 3 times per week for 8 weeks or a control group (40 males) who didn’t. Pre- and post-test results revealed significant improvements in FMS, LSD and YBT scores were seen in the experimental group relative to the control group. Change scores indicated that larger improvements in FMS total score and Hurdle step were observed in athletes with poor baseline movement quality.

Co-Kinetic comment There are some doubters about the role of core stability: see Lederman E. The myth of core stability. Journal of Bodywork and Movement Therapies. 2010;14(1):84–98 (https://spxj.nl/2IULE3o). Professor Lederman states, “The division of the trunk into core and global muscle system is a reductionist fantasy”. We are keeping out of the argument. Read both these papers and make your own mind up.

TAPERING PRACTICES OF STRONGMAN ATHLETES. Winwood PW, Dudson MK, Wison D et al. Journal of Strength and Conditioning Research 2018;32(5):1181–1196 generally stated that tapering was performed to achieve recovery, rest, and peak performance; the deadlift, yoke walk, and stone lifts/work took longer to recover from than other lifts; assistance exercises were reduced or removed in the taper; massage, foam rolling, nutritional changes and static stretching were strategies used in the taper; and poor tapering occurred when athletes trained too heavy/hard or had too short a taper.

Co-Kinetic comment If you want to see spectacular feats of strength check out the World’s

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Strongest Man competition at http://theworldsstrongestman.com/ These guys are seriously good at lifting heavy things that don’t need lifting. The current world’s strongest man is the Mountain that Rides, Ser Gregor Clegane of House Clegane who you may know from ‘Game of Thrones’. When not in Westeros he is known as Hafthor Júlíus Björnsson from Iceland. You won’t be surprised to know that as he stands 6’ 9” tall he is a former pro basketballer. His PBs are 440kg for a squat and 230kg for a bench press. Considering he weighs 192kg, that is serious lifting.

Co-Kinetic Journal 2018;77(July):8-11

RESEARCH INTO PRACTICE

EFFECTIVENESS OF SOFT TISSUE MOBILISATION AS AN ADJUNCT TO CONVENTIONAL THERAPY IN PATIENTS WITH ANKYLOSING SPONDYLITIS. Mohanty P. Journal of Novel Physiotherapy and Rehabilitation 2018;2:1–14 Forty subjects (38 males, 2 females) diagnosed with ankylosing spondylitis (AS) were randomly assigned in an experimental group (n=20) who received conventional exercises along with soft tissue mobilisations and a conventional group (n=20) who received only conventional exercises (aerobic exercise and breathing exercise) for a period of 4 weeks, 5 days/ week. The exercises were flexibility and ROM, 30min of cycling 3 times a week and a deep breathing routine. The soft tissue protocol was massage to the periscapular and paravertebral muscles. No duration was given for

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this. The results revealed that both groups improved significantly in stiffness, pain and physical function. However, the experimental group had a greater change compared to the conventional group.

A TRUNK STABILIZATION EXERCISE WARM-UP MAY REDUCE ANKLE INJURIES IN JUNIOR SOCCER PLAYERS. Imai A, Imai T, Iizuki S et al. International Journal of Sports Medicine 2018;39(04):270–274

Co-Kinetic comment AS is not strictly speaking the sort of sport-related condition that we usually cover but we have included this study to prove (yet again) that there is plenty of evidence for the efficacy of various forms of soft tissue therapy. If you are interested in exercise for AS see Pécourneau V et al. Effectiveness of exercise programs in ankylosing spondylitis: a meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation 2018;99(2):383–389 (https://spxj.nl/2IXjeSb).

THE “SEQUENCE OF PREVENTION” FOR MUSCULOSKELETAL INJURIES AMONG ADULT RECREATIONAL FOOTBALLERS: A SYSTEMATIC REVIEW OF THE SCIENTIFIC LITERATURE. Kilic O, Kemler E, Gouttebarge V. Physical Therapy in Sport 2018;doi:https://doi.org/10.1016/j.ptsp.2018.01.007 A search of MEDLINE resulted in 33 relevant original studies which were included in this systematic review. The results revealed that the incidence of musculoskeletal injuries among recreational adult football players ranged from 9.6 to 15.8 injuries per 1,000 exposure hours. These injuries are especially located in the ankle, knee, groin and hamstring, being associated with previous injury and match

This was an electronic search of the PubMed, OVID, CENTRAL, and CINAHL databases for studies investigating manual therapy (MT) for individuals with patellofemoral pain (PFP). Studies comparing the provision of MT (local or remote to the knee), either used alone or in combination with other interventions, to control or sham interventions through August 2017 were included. Data for pain and patient self-reported outcomes were collected and synthesised. Trials were assessed via the Cochrane risk-of-bias tool, and a meta-analysis of the evidence was performed. Nine studies were included in the review, with five rated as having a low risk-of-bias. The use of MT, Co-Kinetic.com

exposure. The FIFA11 + injury prevention programme and the Nordic Hamstring Exercise (NHE) were found to be effective for the reduction or prevention of musculoskeletal injuries among adult recreational football players.

Co-Kinetic comment Fate is when you ask about hamstring injury prevention for footballers and the next paper that comes across the desk is about that very thing. If only the lottery numbers came up so easily!

EFFECTIVENESS OF MANUAL THERAPY FOR PAIN AND SELF-REPORTED FUNCTION IN INDIVIDUALS WITH PATELLOFEMORAL PAIN: SYSTEMATIC REVIEW AND META-ANALYSIS. Eckenrode BJ, Kietrys DM, Parrott JS. Journal of Orthopaedic & Sports Physical Therapy 2018;48(5)358–371 applied to the local knee structure, was associated with favourable shortterm changes in self-reported function and pain in individuals with PFP when compared to a comparison (control or sham) intervention, but the changes were clinically meaningful only for pain (defined as a 2cm or 2-point improvement on the visual analogue scale or numeric pain rating scale). The evidence regarding lumbo-pelvic manipulation was inconclusive for pain improvement in individuals with PFP based on three studies.

Co-Kinetic comment The authors cautiously suggest that MT may be helpful in the shortterm for decreasing pain in patients with PFP. That will do for us. Throw caution to the wind and get on with it.

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UNDERSTANDING THE ROLE OF MALALIGNMENT SYNDROME IN THE MANAGEMENT OF RUNNING INJURIES BY KATHRYN THOMAS BSC MPHIL

BACKGROUND Running is an asymmetric sport in that it requires bearing weight alternately on the right and left lower extremities and absorbing the resulting unilateral forces as best as possible as these are transmitted upward through the knee, hip, pelvis and lumbosacral region to the spine. The knowledge of motion dynamics during running activity is crucial to enhance the development of rehabilitation techniques and injury prevention programmes. Considering that running injuries are associated with altered joint movement, a thorough understanding of the complex nature of functional movements is important and could improve prevention, training and rehabilitation. Joint interaction pattern behaviour, mainly the direction of the influence during running, can highlight normal and pathological movement, which subsequently develops into musculoskeletal injury. In theory, abnormal motions of the lower extremity joints could be influenced from the ground and ankle up (ie. distal to proximal influence) and from the trunk and hip down (ie. proximal to distal influence). Research has shown a far greater proximal to distal influence among the four joints, from trunk, hip, knee to ankle. The findings highlight the necessity of managing proximal joint movements, in addition to motor control and core strength training of the lumbar spine, hip and pelvis in injury prevention

Pelvic malalignment is common in runners but often goes undiagnosed, which can result in inadequate treatment for the patient’s injury. This article, with the aid of 11 videos, will enable you to correctly assess your patients and to diagnose and treat any malalignment problems. This will allow your patients to achieve their maximum performance potential while reducing injury risk. We’ve also included three patient advice leaflets at the back of the journal for running injuries commonly caused by pelvic malalignment. Read this article online https://spxj.nl/2JgqZmz

11 YouTube Videos for the Assessment and Rehabilitation of Pelvic Malalignment (Courtesy of Physiotutors) https://spxj.nl/2JgqZmz

and rehabilitation programmes (1*). Acknowledging the importance of the pelvis and its influence on the entire lower limb while running, it would seem negligent not to assess and manage the pelvis with any running injury, be it a knee, foot or hip complaint (2). The term ‘malalignment’ refers to any change or minimal displacement from the normal alignment of the bones that are part of the lower extremity kinetic chain particularly the pelvis. It results in abnormal biomechanical stresses that can compromise the body’s ability to cope with the impact forces sustained during running (2). In summary, this article will revise pelvic malalignment specific to runners and how you can identify the problem and address it through treatment and rehabilitation. Every runner presenting for treatment should be assessed for pelvic malalignment regardless of their primary complaint. It will become evident that small changes in pelvic alignment can have detrimental effects at those joints but also anywhere along the lower limb, which could predispose or contribute to the runners injury.

Pack of Running Injury Patient Advice Leaflets https://spxj.nl/2JgqZmz

A ‘NORMAL’ PELVIC RING

All references marked with an asterisk are open access and links are provided in the reference list

RUNNING | LOWER LIMB | LOWER BODY | 18-07-COKINETIC FORMATS WEB MOBILE PRINT

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The sacroiliac (SI) joint is an intricate 14

joint that depends largely on its configuration and its supporting structures including ligaments, individual muscles, inner and outer core muscles as well as myofascial slings to: 1. allow the smooth transfer of weight upward or downward through the lumbo-pelvic hip complex; 2. to ensure stability of the joint during weight-bearing activities such as running, walking and jumping; and 3. to allow motion and rotation (albeit 2–4mm) around all three axes. The motion of the SI joint is essential for mobility but also assists in the absorption of stress and energy storage. During the gait cycle for example, (a) in the frontal plane there is upward motion on the weight-bearing side, (b) in the sagittal plane anterior rotation during the stance phase and posterior rotation during the swing phase, (c) in the transverse plane an outflaring during the stand phase and inflaring with swing through (2). Excessive rotation of an innominate relative to the sacrum, however, can result in one or both sides literally getting ’stuck’. Susceptibility of this occurring is attributed in part to the configuration of the SI joint, which: Co-Kinetic Journal 2018;77(July):14-24

PHYSICAL THERAPY

1. is L-shaped with the two main arms of the articular surfaces being oriented along different planes; and 2. has intimate moulding of the joint surfaces, small convexities matching concavities, and fine crescent shaped ridges sitting in matching depressions. These features enhance the stability of the joint, especially on weightbearing, and allow for a small degree of movement through the joint. However, abnormal loading resulting in minimal displacement of the joint in any of the planes of movement can cause it to become ‘stuck’ as the surfaces no longer match up. If the surfaces become locked in an abnormal position major consequences can result, including dysfunctional SI joint mobility, disturbance of lumbo-pelvic hip complex, weight transference, shock absorption and alteration of gait pattern (2). Malalignment with abnormal locking of the SI joint can be caused by: (a) an awkward lifting with reaching or torqueing motion, (b) trauma with force transmitted up through the limb to the pelvis (eg. motor vehicle accident, missing a step, landing hard on a straight leg such as a jump while running cross-country), (c) increased tension or spasm in a muscle that attaches to the pelvic ring or laxity on those that stabilise it (2). However, for the majority of malalignment cases there is no obvious cause; one theory being that malalignment is an outcome of persistent asymmetry of muscle tension throughout the body caused by asymmetrical signals being generated at the segmental level, brain stem or cortex (2,3).

Presentation with ‘Normal’ Pelvic Alignment Only approximately 10–15% of the population present with the pelvis in alignment and no history of any recent adjustments (eg. manipulation, mobilisation) (2). There are two common things to note in these patients regarding assessment and leg length:

anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS) are equidistant from the midline. The malleoli lie at the same level and move together, downward on sitting and upward on lying down. 2. Pelvis aligned, right anatomic (true) leg-length difference is present Compared with the left side the right iliac crest is, and all other right pelvic landmarks are, higher in standing but are level and equidistant from the midline in sitting and lying. The right malleoli will appear to be displaced downward relative to the left by the same amount in sitting and lying (reflective of a true leg-length difference) and the legs move together on changing from one position to the other. The diagnosis of pelvic malalignment can usually be made by looking for characteristic asymmetry of major landmarks specific to each presentation (discussed below) by comparing the position of one thumb to the other (Videos 1 & 2). One can detect a relative downward or upward displacement (upslip) or a displacement from the midline (inflare or outflare). The sittinglying test, with the examiner’s thumbs placed on the malleoli will demonstrate any movement discrepancies and relative shifts indicative of a locked joint.

MORE THAN 80% OF RUNNERS PRESENT WITH SOME FORM OF MALALIGNMENT SYNDROME 2. rotational malalignment – noted in 80–85% of cases 3. an upslip – noted in 20% of cases. Bear in mind that these alterations often don’t occur in isolation and there can be a combination of one or more of these common malalignments. Together they make up more than 90% of the 80–90% of pelvic malalignments seen in the population. The remaining 5–10% of presentations include a sacral torsion or downslip, which are far less common and will, therefore, not be discussed further (2).

1. Outflare and Inflare The right or left innominate becomes fixed in excessive inward or outward rotation in the horizontal plane. The contralateral innominate, although it may be found to lie in a normal position, usually becomes fixed in the opposite direction.

In 80–90% of the general population the pelvis is not in alignment (2). There are several ways the pelvis can go out of alignment; however, this article will focus on the three most common: 1. o utflare and inflare – noted in 40–50% of cases

Key Points on Examination Using the example of a right outflare and left inflare, key points on examination include (2): n The right ASIS has moved away from midline of the abdomen, the left toward it. Findings are reversed for the PSIS, where the right moves toward the midline and the left PSIS away from the midline demarcated by the gluteal cleft or spinous processes.

Video 1: What Single Leg Stance Assessment can tell you (Courtesy of YouTube user Physiotutors) https://youtu.be/A9pi7_JRgwQ

Video 2: The Gillet Test for SI-Joint Dysfunction (Courtesy of YouTube user Physiotutors) https://youtu.be/dvhvKXnXAac

COMMON PRESENTATIONS OF PELVIC MALALIGNMENT

1. Pelvis aligned, leg length is equal All the pelvic landmarks are level with their counterpart on the left in standing, sitting and lying. The right and left Co-Kinetic.com

FAILURE TO ACHIEVE CORRECT ALIGNMENT MAY IMPAIR THE RUNNER’S TRAINING, RECOVERY FROM INJURY AND THEIR ABILITY TO ADVANCE TO THEIR MAXIMUM PERFORMANCE n T he left ASIS will appear to have moved forward and the right backward, where in standing or sitting the left will appear to protrude compared to the right. The left will also appear to be displaced upward (ie. higher) and the right downward (ie. lower) when the runner lies supine. Barring a coexisting true leg-length discrepancy, leg lengths will present as equal in sitting and lying. Corrective Treatment Procedure When a right outflare, left inflare is present, on lying supine: 1. T he right ASIS is lOwer and displaced Outward, away from midline (2). Remember the mnemonic of the 4 O’s: n The lOw side is the ‘O’ or ‘Outflare’ side n Correction is achieved by resisting Outward movement of the knee (2) The treatment method referred to here is manual therapy, such as muscle energy technique (MET) (4–8). METs are a manipulative treatment in which the patient’s muscles are actively used on request from a precisely controlled position, in a specific direction, and against a distinctly executed counterforce (8). Therefore, the runner can harness the energy in the muscles that are positioned in a way that enables them to effect change. Resisting abduction and external rotation of the right femur, by blocking outward movement of the knee in a partially flexed position, works the piriformis and gluteus maximus. The force from these contracting muscles on their attachments on the innominate can rotate it forward in the horizontal plane such that it comes to lie in its normal position. The repeated contraction-relaxation of these muscles can decrease tone and increase relaxation and lengthening often allowing the bones to slot back into their proper position (5–7). 16

2. The left ASIS is hIgher and displaced Inward, toward the midline (2). Remember the mnemonic of the 4 I’s: n The hIgher side is the ‘I’ or ‘Inflare’ side n Correction is achieved by resisting Inward movement of the knee (2) Blocking adduction of the left leg reverses the origin and insertion of the left gracilis and adductor longus. The force generated on their attachments on the left pubic tubercle can rotate the innominate outward and back into alignment (5–7). Clinical Relevance to Runners An outflare strains the anterior SI joint ligaments/capsule and compresses the posterior joint margins, an inflare doing the opposite. Both can result in discomfort and pain, especially under stress, from the joint as well as referred pain down the buttock and leg. On the side of the outflare, the acetabulum faces progressively posterolaterally and the superior rim comes to lie more anteriorly over the femoral head. As the innominate becomes fixed, during the swing phase the hip joint is required to flex to a greater extent, to compensate for a lack of movement in the SI joint which frequently results in impingement. The runner can complain of a literal feeling of a block in the hip joint. Discomfort and pain can develop, often presenting as hip and groin pain. As the swing through (on the outflare side) is blocked, the runner may compensate by trying to rotate their acetabulum forward by increasing trunk and arm rotation. They also shorten their stride length and increase stride frequency to maintain the same speed. Either hip impingement or compensationaltering gait pattern can prove costly in decreased efficiency and increased energy demands as well as injury to the lower extremity.

2. Rotational Malalignment Innominate rotation is the most frequently seen of all the malalignments. An innominate can become fixed relative to its SI joint in a position of excessive rotation in the sagittal plane, either forward (anterior) or backward (posterior). Usually, but not necessarily, the contralateral innominate becomes fixed in rotation in the other direction. Some 80–85% of cases there is a right anterior and left posterior rotation, and in the remaining 15–20% of cases a left anterior and right posterior rotation (2). The SI joint may be locked on one side so that on the kinetic rotational (Gillet) test, the innominate is locked with little or no movement (Video 2). Key Points on Examination Using the most common example of right anterior and left posterior rotation, key points on examination include (2): n The right ASIS ends up lower than the ipsilateral PSIS and left ASIS. n The right pubic ramus is displaced downward and rotated forward in the sagittal plane, the left undergoes displacement in the opposite direction. n There is pubic obliquity where the right iliac crest and ischial tuberosity ends up higher than the left side. n A leg-length difference is noted in the sitting-lying test. Which leg appears to be longer or shorter is all relative and of little importance. What matters is that there is a shift in leg length on the test, with the right malleoli moving upward in sitting up and downward in lying down relative to the left malleoli. It would be the opposite if the rotations were reversed with a left anterior and right posterior rotation. Corrective Treatment Procedure There are several different manual therapy techniques to correct rotational malalignments; however, MET, leverage or a combination of the two can be useful for the runner, as he/she can be taught the techniques and can selfcorrect between treatments (4–7). Remember the mnemonic of the 5 L’s to help determine the side of the anterior rotation (2): n Leg Lengthens Lying, Landmarks Lower (2) Co-Kinetic Journal 2018;77(July):14-24

PHYSICAL THERAPY

So, in the case of the common right anterior, left posterior rotation, the landmarks on the right would appear lower relative to the left and the right leg would appear to lengthen on lying down. To correct: 1. Right anterior rotation (5–7) a. Blocking movement of the right thigh away from the trunk, ie. hip extension, will activate the gluteus maximus. Contraction will allow it to rotate the right innominate in a posterior direction by way of its attachments on the posterosuperior aspect of the ilium. b. Passively moving the right femur into increasing flexion, creates leverage and simultaneously tightens some posterior structures including the sacrotuberous ligament. The combined effect is a posterior rotational force on the right innominate. 2. Left posterior rotation (5–7) a. Blocking movement of the thigh toward the trunk, ie. hip flexion, activates the left iliacus and rectus femoris which exert an anterior rotational force by way of their attachments on the anterosuperior part of the ilium and the pubic bone respectively. b. Passively extending the femur created leverage, an anterior rotational force on the left innominate. Clinical Relevance to Runners Runners should be discouraged from routinely doing unilateral stretches of iliopsoas, rectus femoris, gluteal muscles and hamstrings, especially when the pelvis is free to move (ie. in standing). Unilateral stretching manoeuvres can create leverage and torsion the pelvis into rotational malalignment (2). Bilateral stretches or stretching in sitting or lying should be encouraged to avoid this. For example, standing and doing the popular one-sided quadriceps stretch can cause or aggravate an anterior rotation or the unilateral standing hamstring stretch causing or aggravating a posterior rotation; however, the same manoeuvre may be effective in correcting an anterior rotation (2)! Nonetheless, unilateral stretches can be helpful for a runner who knows Co-Kinetic.com

which way their pelvis is malaligned and can facilitate correction through stretching. For example, the common right anterior rotation can respond to a runner placing their right foot up on a chair and then gradually leaning forward, bending the trunk down toward the floor, arms swinging loosely by their sides (a type of hamstring stretch). The progressive passive flexion of the femur creates leverage and may correct the anterior rotation. Specific unilateral stretches may be prescribed following realignment where muscles may have undergone contracture or shortening during their misaligned state. Some muscles fail to relax after correction, and show increased tone or actual spasm, whereby specific stretching may be beneficial (2).

3. Upslip Of the three most common malalignments, the upslip is the least common. It presents in isolation about 10% of the time and in combination with a flare or rotation the other 10%. The innominate on one side ends up displaced straight upward relative to the adjacent sacrum and becomes fixed. Often no obvious cause is evident, although obvious ones would include (a) having a force or impact transmitted straight upward, missing a step/jumping and landing on a straight leg; (b) upward force on the innominate itself, falling and landing on the ischial tuberosity; (c) and upward traction on the innominate by chronic muscle spasm in quadratus lumborum, psoas major/minor. Key Points on Examination Key points on examination include (2): n The anterior and posterior pelvic landmarks are all displaced upward relative to the opposite innominate and sacrum. n The ipsilateral leg is moved upward passively with the innominate, resulting in an apparent leg-length difference. Relative to the opposite leg it seems shortened in both sitting and lying and the malleolus moves downward and upward, respectively, together with that on the other side. n A pelvic obliquity is evident in standing, sitting and lying.

Corrective Treatment Procedure With the runner lying supine, applying gentle and repetitive traction to the leg on the upslip side usually suffices. Often working to release tense muscles around the hip and pelvis on the upslip side (those muscles mentioned earlier) will allow the innominate to correct its upslip position. If that fails, a manipulation using a quick downward pull on the leg once or twice may prove successful (5–7). The runner may be instructed in selfcorrection (2): 1. Simply let the leg hang down while standing on a step or stool (using gravity to traction the leg). 2. Progressively increasing the time in the position or the weight of traction, by adding ankle weights, may help with correction. Clinical Relevance to Runners The apparent leg-length difference, pelvic obliquity and compensatory scoliosis combined result in unwanted stress, and change in running style which may include leaning into the weight-bearing low side to help clear the ‘longer’ leg for swing through and adjustments for side-toside differences in stride length. Dysfunction of the SI joint on the side of the upslip increases stress in the joint and the lumbo-pelvic-hip complex bilaterally, potentially resulting in discomfort and pain from stress, loading and inflammation of the joints. A coexisting rotational malalignment can hide an upslip hence it is important to check and re-check the runner after correction of one malalignment and another may become evident. If the runner is not responding to treatment for the upslip, keep in mind the rare downslip potentially on the other side. 17

MALALIGNMENT SYNDROME As mentioned earlier, the Malalignment Syndrome (MS) is a combination of any one or more of the pelvic malalignments discussed above. Frequently seen together are a rotational malalignment with an upslip, typically causing biomechanical changes and with it symptoms that can affect the runner. Displacement of the pelvic ring results in changes in the joints of the lumbopelvic-hip complex stressing the joint capsule and ligaments causing disturbance in weight transfer, irritation of neural receptors causing localised and referred pain, paraesthesia, degeneration in the joints especially the discs and facets joints, and an apparent leg-length difference. Runners who alternately bear all weight on one extremity will develop compensatory mechanisms to counter the biomechanical changes seen with MS, including the following (2). 1. Spine The patient might: n land more on the forefoot and midfoot to shift weight-bearing and impact off the heel; n tend to pronation and increasing dorsiflexion to improve shock absorption and decrease forces being transmitted upward; n offload the painful side by shortening stance phase on that side and often shifting centre of gravity/leaning to the opposite side; and n also lean toward the side of an unstable SI joint to approximate the joint surfaces and increase stability. Compensatory curvature/scoliosis of the spine can develop resulting in back pain due to compression or distraction of facet joints as well as increased disc pressure. A runner may even present with cervicothoracic complaints, uneven shoulders, neck pain due to muscle tightening manifesting from poor alignment of the spine originating from the pelvis upward.

nW eight-bearing shifts to the left side. n Rotation of the lower limbs and feet outward from the midline on the right and toward the midline on the left. n Right foot has a tendency toward pronation, as the right heel impacts more posterolaterally. The pronation increases knee valgus angulation and Q-angle and pressure on the lateral compartment of the knee. Excessive pronation can result in forced upward movement of the fibular head, jamming onto the proximal tibiofibular joint causing lateral knee pain. n Left foot has a tendency toward supination relative to the right, resulting in varus knee angulation decreasing Q-angle and increasing pressure on the medial compartment of the knee. n When not weight-bearing the right foot rests in increased varus angulation compared with the left.

catching their left big toe on the back of the right heel or ankle.

These changes in foot biomechanics causes stress to the soft tissue structures of the feet, but also muscles, nerves, ligaments and joints from the foot upward to the groin. There can be increased stress on the right medial collateral ligament of the knee and patellofemoral compartment/patellar tendon. As well as increased strain on the left lateral collateral ligaments, and iliotibial band (ITB) insertion. These stresses are increased by activities such as running on a slope declined to the left. The runner may complain that they trip or hit their one foot on the other leg. The combination of the right pronation and outward rotation of the leg makes it likely that the runner can hit the right heel against the left ankle or inner calf; similarly on the left inwardly rotated leg, they can lose their balance or trip by

3. Muscle Tone Paired muscles show tone to be increased/facilitated on one side and decreased/inhibited on the other side. The changes in tone seem to be mediated by the autonomic nervous system secondary to a mechanism, segmental or cortical, that affects the muscle spindle. Asymmetrical differences in muscle tone often exist between quadratus lumborum, iliopsoas, hip abductors/tensor fascia latae (TFL) (Video 3), triceps surae, piriformis and biceps femoris. Malalignment causes a chronic increase in tone, resulting in tenderness and trigger point development in muscles and myofascial slings. n Increasing the distance between the origin and insertion (lengthened) typically affects the paravertebral muscles, left hip abductors and peroneus longus with the tendency for left supination and right hip adductors and tibialis anterior/ posterior with right pronation. The hamstrings on the side of an anterior rotation, rectus femoris and iliopsoas on the side of posterior rotation. n Muscles being constantly in some degree of contraction (shortened) to splint a painful area or stabilise a joint typically include the paravertebral muscles in the thoracolumbar region, key muscles around the SI joint – piriformis, gluteus maximus and iliopsoas (Videos 4 & 5) and the myofascial slings that stabilise the pelvis and spine. These include the anterior oblique system formed by anterior abdominal fascia connected with internal and external obliques

Video 3: Ober’s Test – Iliotibial Band Tightness (Courtesy of YouTube user Physiotutors) https://youtu.be/Amjv6FzDeLE

Video 4: Thomas Test – Iliopsoas Tightness (Courtesy of YouTube user Physiotutors) https://youtu.be/NMDd-4NspHs

2. Feet In all those presenting with an upslip and more than 90% combined with a rotational malalignment (right anterior rotation being the most common), these changes will be evident (2): 18

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and rectus abdominus and posterior oblique system in part by latissimus dorsi on one side connected by thoracolumbar fascia and gluteus maximus on the opposite side. A runner can suffer from tension myalgia as trigger points develop in these muscles as well as pain and inflammation at the myo-tendinous junction and fibro-osseous junctions. Inhibition or alteration of movement patterns and referred pain can develop. 4. Muscle Strength and Bulk Muscle strength is affected in a typical asymmetrical pattern. This asymmetrical pattern of weakness (described below) is consistently seen with either a right or left upslip and the common rotational malalignment of right anterior, left posterior rotation. n On the right: Ankle invertors (tibialis anterior/ posterior), hip flexors (iliopsoas, quadriceps) and extensors [gluteus maximus (Video 6)], hip adductors and extensor hallucis longus are weak compared with the opposite side. n On the left: Ankle evertors (peroneus longus/ brevis), hip abductors [gluteus medius (Video 7)/minimus, TFL], hip external/ internal rotators and hamstrings are weak relative to the opposite side.

may reflect a reorientation of muscle fibres due to increased demand on one side relative to the opposite side, an apparent increase in muscle girth. Or a wasting of muscle due to disuse as the runner alters their biomechanics to accommodate the malalignment or offload a painful structure, and minimise the use of a painful muscle. A runner may complain of weakness or a feeling of instability on the weaker side, with impaired balance and recovery; or one leg feeling more fatigued than the other (2). Following realignment, the power of the weakened muscle can return almost immediately or within a matter of 2–3 weeks where the problem has been present for longer. Muscle bulk usually recovers over 2–3 months following formal rehabilitation (2).

their normal length. Pain transmitting C fibres within ligaments can neither stretch as quickly nor as much as the elastic components, making them vulnerable to irritation, inflammation and even disruption. They can become a source of localised or referred pain and paraesthesia. Ligaments that are placed in a slackened position (essentially the opposite of those listed above) gradually undergo shortening or contracture and may limit range of motion (ROM). They can be a cause of post-realignment pain.

On manual testing, some of these muscles typically meant to be weak appear to have full strength. This may reflect the inherent strength of the muscle, but remember it is the functional disparity in strength and endurance that is critical for the runner. As the malalignment persists there may be evidence of changes in muscle bulk. This

5. Ligament Tension As a result of the biomechanical changes seen with MS, ligaments are placed under increased tension. These commonly include the medial collateral ligament of the knee (on the pronating foot side) and lateral collateral ligament of the knee (on the supinating foot side); posterior and interosseous SI joint ligaments with sacrotuberous and sacrospinous ligaments on the posterior rotation side; long dorsal sacroiliac ligament on the upslip or anterior rotation side; and medial ankle ligaments and flexor retinaculum on pronating side and lateral ligaments on the supinating side (2). Ligaments that are constantly under tension gradually lengthen, decreasing their ability to support the joint. On realignment, laxity of these ligaments predisposes to recurrence of the malalignment until finally they regain

6. ROM Side-by-side comparison will show asymmetry in ROM attainable at any joint from the neck down to the big toe. Differences of 10–15% are not uncommon in MS. Obviously, there may be equal ROM through one line of movement at a single joint, but it is the combination or total range seen through a functional movement pattern that is key to the runner. Changes in ROM will affect the runner’s technique and gait pattern, decrease efficiency and increase energy costs. Decreased ROM may be due to a physical obstruction (such as a locked SI joint/bony impact) or increased muscle tone restricting motion or contracture of soft tissues (such as fascia or ligaments). Note that areas to focus on include the left pelvic or trunk rotation in the anticlockwise direction, which is commonly limited, and runners will cheat in testing compensating with entire legs and thoracic spine rotation due to restricted pelvic motion. This can also affect their stride length. Any limitation of hip flexion or extension will affect swing through and stance phase as well as stride length. Limitation of left dorsiflexion and right plantarflexion, and restricted

Video 5: Piriformis Test – Piriformis Syndrome or Tightness (Courtesy of YouTube user Physiotutors) https://youtu.be/zha5jIv4_44

Video 6: Top 5 Gluteus Maximus Exercises (Courtesy of YouTube user Physiotutors) https://youtu.be/WHDdm0Yxh-o

Video 7: Top 5 Gluteus Medius Exercises (Courtesy of YouTube user Physiotutors) https://youtu.be/GwPe0JwYbrA

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ROM in the foot can make for a rigid foot and poor shock absorber; however, too much mobility can also aggravate plantar fasciitis or Achilles tendinopathy. 7. Leg-Length Difference The most common finding that the right iliac crest ends up higher relative to the left in standing may highlight a longer right leg. A pelvic obliquity that persists when sitting (unlike someone with a true anatomical leg-length difference where it would disappear) is indicative of a MS. So, remember to assess the runner in different positions of standing, sitting and lying to determine if it is a true or apparent leglength difference. Differences in leg length as much as 2–4cm can be attributed to MS. Where 80–85% of the adult population present with malalignment, only 6–12% have a true anatomical leg-length difference (2). These runners may benefit from a heel wedge once their alignment has been corrected. 8. Balance and Recovery Balance and recovery is a problem with the asymmetry of MS and may not be evident until kinetic testing and functional movements are included. In single-leg standing, swaying of the pelvis or trunk from side to side, a wobbling ankle and foot and clawing of toes may be noticeable on one side compared to the other (Video 1). This will become even more obvious on single-leg hopping, and toe walking. This is a consequence of pelvic malalignment with an instability in joints on one side, muscle weakness and misfiring of muscle sequences. Single-leg stability is crucial for a runner who spends their entire time on one or the other leg. Poor balance and recovery can predispose the patient to falls, sprained ankles, 20

joints giving way and pain. This needs to be a component of assessment and rehabilitation following realignment.

Implications for Treating the Runner with Malalignment Syndrome The signs and symptoms seen with pelvic malalignment and the MS may cause confusion and misdiagnosis resulting in inappropriate investigations and treatment. Recognition of malalignment is significant as one can see the impact it has on the entire lower limb, predisposing joints and soft tissues to injury. Running injuries are disorders that primarily involve the neuro-musculoskeletal system; and problems are in large, part the result of the associated shift in weightbearing, instability of the pelvic ring and asymmetry in muscle strength and tension found with an underlying malalignment. Below are common running injuries where one should consider an underlying, overlapping, aggravating, precipitating MS (2). 1. Back Pain A runner may have a pre-existing condition such as a bulging or protruding disc, facet joint degeneration, spondylolisthesis or idiopathic scoliosis and be asymptomatic. Superimposing the stresses of MS with pelvic obliquity and compensatory curves may tip the balance and the runner becomes symptomatic. Note: standard back assessment often doesn’t fully address malalignment. One can use standard SI joint differentiation tests to help but remember to look for the common landmark alignment issues as discussed earlier (Video 8). 2. Hip and Knee Joint Osteoarthritis Pelvic malalignment that results in a functional leg-length difference can cause abnormal loading and wearing on joint surfaces. Degeneration and pain are likely to involve the hip joint on the long leg side and the knee joint on the short leg side. 3. ITB Syndrome This problem is likely to develop on the left with the common left posterior rotation of the innominate resulting in

supination of the foot, genu varum and separation of the origin and insertion of the ITB increasing tension and resulting in friction, irritation of the band (See the pack of running injury Patient Advice Leaflets). 4. Patellofemoral Knee Pain This may be caused by or aggravated by a right anterior rotation malalignment. With pronation, increased genu valgum and Q-angle resulting in lateral displacement of the patella, with outward rotation of the femur. Functional weakness, reorientation and early fatiguing of the right quadriceps will contribute to patellofemoral pain (9) (Link 1). 5. Plantar Fasciitis and Achilles Tendinopathy This may develop on the side that tends to pronate excessively, commonly the right foot, as these structures increases tension to support and stabilise the foot as it rolls inward (See the pack of running injury Patient Advice Leaflets). 6. Shin Splints/Stress Fracture A runner may be at increased risk of developing this on the tibia/fibula and lateral metatarsals, commonly on the left side. This is due to the decreased shock absorbing ability of the foot as it tends to supinate with increased plantarflexion and lateral shifting of weight onto the fourth and fifth metatarsal heads (See the pack of running injury Patient Advice Leaflets). 7. Compartment Syndrome Repetitive overloading with abnormal biomechanics can result in increased traction and swelling within the right anterior or medial compartments and the left lateral compartment. 8. Metatarsalgia, Hallux Valgus and Medial Bunion Formation The tendency of the right to pronate and medial shifting of weight-bearing increases pressure on the medial aspects of the first toe. Formation of a secondary Morton’s toe can develop in chronic cases. 9. Peripheral Nerve Involvement As a result of the medial or lateral shifting associated with pelvic Co-Kinetic Journal 2018;77(July):14-24

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malalignment, not just the sciatic nerve can be irritated but also the peroneal, sural, saphenous, posterior tibial nerves, for example, are all at risk of irritation, compression or entrapment. The can subsequently result in pain, localised or referred, and paraesthesia.

EVERY RUNNER PRESENTING FOR TREATMENT SHOULD BE ASSESSED FOR PELVIC MALALIGNMENT REGARDLESS OF THEIR PRIMARY COMPLAINT

10. Pelvic Floor Dysfunction The pelvic floor musculature forms part of the ‘inner core’ that, along with the ‘outer core’ muscles stabilise the pelvis and trunk when walking, running, lifting, jumping etc. Overloading, added stress or tension to these muscles or lack of support from weakened surrounding muscles can result from malalignment, ultimately causing dysfunction for example stress incontinence, dyspareunia and vaginal wall pain. Runners may present with one of these above conditions or simply pain in the thoracic spine, groin, buttock, central pubic region (osteitis pubis) for example. With any of these, pelvic alignment should be assessed as an underlying cause or contributing factor (2).

Manual Therapy Manipulation, mobilisation and METs are indicated in the presentation of pelvic malalignment (4–7). Complementary treatment measures, such as acupuncture and massage, may be beneficial in decreasing persistent pain, releasing a tight muscle and trigger point release (2). Manual therapy remains the key to achieving long-term results in realigning the pelvic bones. METs are ideal for self-treatment by the runner. Teaching them how to perform these at home (specific to his/her malalignment) will aid in selfcorrection and maintaining correction between treatment sessions (5–7). Pain and paraesthesia can be experienced in the initial 2–4 weeks following realignment. Some runners experience pain or paraesthesia in places where they never had a problem when the malalignment was present. Typically, these symptoms, which may be mistaken for an entirely new problem, arise from muscle, ligaments and joint capsules that have undergone shortening and are now subject to tension or realignment. Symptoms, which may remain localised or refer, usually abate spontaneously as structures regain normal length and strength (2,4–7).

Treatment Correction of pelvic malalignment can be achieved in most runners; however, the goal is to achieve and maintain the alignment such that the runner can continue a normal pain-free, injury-free lifestyle and continue with running. Most respond to appropriate treatment within 3–4 months, whereas others can take up to a year or more to resolve symptoms and allow for their body to adapt and strengthen to maintain correct alignment (2). A progressive treatment programme that includes the runner is most likely to achieve lasting results.

Video 8: Patrick’s/Faber/ Figure Four Test (Courtesy of YouTube user Physiotutors) https://youtu.be/89Qiht82zmg

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regaining stability of the pelvis and spine (10). Emphasis is also on ensuring the muscle is contracting in the first place and in the proper sequence/coordination with other muscles (Videos 9 & 10) (10). Strengthening the specific weak, lengthened muscles and stretching tight, shortened structures (discussed earlier) will ultimately ensure maintenance of correct alignment. Once alignment is being maintained the runner may gradually return to general strengthening and cardiovascular fitness training, with a graduated walking-to-running programme. Pool running is an excellent option to consider at early stages of rehabilitation (2).

Importance of the Core in Runners

Rehabilitation Programme Initial strengthening of the inner and outer core muscles is essential for

The core or lumbo-pelvic hip complex of the body includes the spine, hips and pelvis, proximal lower limbs and abdominal structures. The principal function of this complex is to create stability for the generation of force and motion in the distal joints. Core muscles also distribute impact forces and allow controlled and efficient body movements. Therefore, when the system works efficiently, the result is appropriate distribution of forces, optimal control and efficiency of movement, and functional movement through the kinetic chain. Imbalances or deficiencies in the core muscles can result in increased fatigue, decreased endurance, and injury in runners (10).

Video 9: Luomajoki Lumbar Movement Control Dysfunction Screening (Courtesy of YouTube user Physiotutors) https://youtu.be/A4gU0YD6HS4

Video 10: Lumbar Movement Control Exercises – Motor Control Impairment (Courtesy of YouTube user Physiotutors) https://youtu.be/x6mRy22eYkA

MAINTAINING PELVIC ALIGNMENT OF THE LUMBO-PELVIC HIP COMPLEX IS CRUCIAL FOR MAINTAINING OPTIMAL BIOMECHANICS AND PROTECTING THE RUNNER AGAINST INJURY Core stability has been defined as:

“the ability to control the position and motion of the trunk over the pelvis and leg to allow optimum production, transfer and control of force and motion to the terminal segment in integrated kinetic chain activities.” (11) As discussed earlier, the importance of maintaining pelvic alignment of the lumbo-pelvic hip complex is crucial for maintaining optimal biomechanics and protecting the runner against injury. This alignment is dependent on the core and its three subsystems to work together (12,13): 1. passive subsystem of ligaments, vertebral bodies, discs and pelvis 2. active subsystem of muscles and tendons 3. neural subsystem including nerves and the central nervous system. When rehabilitating the core one needs to consider all aspects of strength, flexibility, balance and endurance. Interestingly, research by Tong et al. (14) showed that a high-intensity maximal run may induce core muscle fatigue in runners. Running endurance may be limited by core muscle fatigue which is partly attributed to the corresponding respiratory work. Inspiratory muscles, while simultaneously increasing the demand for breathing, may also share Video 11: Hip Strengthening Protocol for PFPS – Patellofemoral Pain Syndrome (Courtesy of YouTube user Physiotutors) (https://youtu.be/Q0YztOTafe8)

the work of core stabilisation during intense exercise. Inspiratory muscle training incorporated into a runningspecific core training regimen potentially enhances the training effect on the core muscles in a functional manner to deal with the challenges of intense exercise. Maximise Flexibility Flexibility should include stretches in three-dimensional patterns to simulate functional activities. Note, as discussed earlier, depending on the malalignment syndrome present bilateral stretching may be more beneficial for the runner; or specific stretches for each side (left or right) so as not to exacerbate a malalignment. Neural mobility is also an important component of flexibility through the lumbo-pelvic hip complex and should be included in rehabilitation. Foam rollers and regular massage can be added to the runners routine (10). Maximise Strengthening There are multiple exercises that can be used to strengthen the core and lumbo-pelvic hip complex. Each runner’s malalignment may be different and require specific strengthening where there are underlying weaknesses; however, strengthening the core will become essential to maintain good alignment and a stable base for the future. Advancing to side-leg exercises where applicable, while maintaining good alignment and pelvic stability, is the ideal as this would replicate the single-leg activity for loading response during running. Some examples of exercises include (10): n 4-point kneeling bird/dog, progressed to Superman over a Swiss ball n plank with progressions to one arm/ one leg n side plank with progressions to side plank with rotations n eccentric retraining of the abdominals against a wall n curl-up/Pilates n clam

n hip abduction in side lying n bridging/single-leg bridging/bridging on a swiss ball n squats/single-leg squats/pistol squat/ squats on BOSU ball n lunges/walking lunges/side lunges/ lunges with rotation n power runner n step-ups. Using kettle bells, straps, balls and cables are all tools to add resistance and increase hip power and core strength. Exercises that target multiple joints, such as kettle bells swings, double-stand squats, deadlifts or woodchop action are helpful in developing maximal overall strength through functional movements. Increases in strength can improve running times and overall performance (15,16). Research has shown that after just 6 weeks (3 times a week) of strength training of the hip abductors, adductors, extensors, core and pelvic musculature, race times were significantly decreased compared with controls who had no additional strength training (17,18). Strength training including low- to high-intensity resistance exercises and plyometric exercises can also improve running economy in middleand long-distance runners (19). Weak hip muscles have been associated with running injuries including the common patellofemoral knee pain and ITB syndrome (9*,20–23). Hip strengthening exercises focusing on abduction and external rotation (Videos 6 & 7), as well as neuromuscular exercise have shown to be beneficial in reducing pain and improving function in individuals with patellofemoral knee pain (Video 11) and ITB syndrome (9*,21–23). Clinical improvements have also been shown with hip strengthening routines in runners with medial tibial stress syndrome, plantar fasciitis and Achilles tendinopathy, albeit not of the strongest methodological rigor (20). Recent studies have shown hip abductor weakness to predispose to ankle injury (non-contact) in running sports such as soccer (24), making hip strength an intrinsic risk factor to lateral ankle sprains (25*). These studies all highlight the importance of the hip and pelvis on the function of the kinetic chain of the lower limb. Hip strength, an essential component to pelvic stability, is therefore crucial Co-Kinetic Journal 2018;77(July):14-24

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in injury prevention and treatment for runners.

CONCLUSION Pelvic malalignment is common, with more than 80% of runners presenting with some form of malalignment syndrome (2). It is often not diagnosed or treated as it is frequently missed in a standard back assessment, or the therapist fails to assess the entire lower limb (starting at the top, being the pelvis) when treating a foot, knee, calf or thigh injury. Awareness of the malalignment syndrome is essential to provide the runner with thorough care. The abnormal biomechanics and any associated discomfort can result in compensatory measures resulting in reduced efficiency, increased energy expenditure and potential injury. Failure to achieve correct alignment may impair the runner’s training, recovery from a specific problem/injury, and impair their ability to advance and achieve their maximum performance. Core muscles are integral to a successful running programme. They provide the stability required to allow efficient running, increase endurance and decrease injury rate. Core strengthening regimes should consider all facets of core function and exercises should be chosen with an emphasis on maximal core efficiency. Remember the core not only includes the inner and outer core abdominal muscles, but also the muscles around the lower back, hips, gluteals and upper thigh region. Strengthening these muscles – working from the top down – either in prehab or rehab will not only improve running performance but potentially maintain correct pelvic alignment and prevent injury in runners. References 1. Nakashima G, Nakagawa T, dos Santos A, Serrão F, Bessani M, Maciel C. Identification of directed interactions in kinematic data during running. Frontiers in Bioengineering and Biotechnology 2017;5;67. Open access https://spxj.nl/2rSMYIG 2. Schamberger W. Malalignment syndrome in runners. Physical Medicine and Rehabilitation Clinics of North America 2016;27(1):237–317 3. Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity

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and motor activity. Manual Therapy 2001;6(2):72–81 4. Sahrman SA. Diagnosis and treatment of movement impairment syndromes. Mosby 2001. ISBN 978-0801672057 (Kindle £43.67 Print £59.99). Buy from Amazon https://amzn.to/2s0nvgj 5. Chaitow I. Muscle energy techniques, 3rd edn Churchill Livingstone 2013. ISBN 9780702046537 (Kindle £29.96 Print £49.34). Buy from Amazon https://amzn.to/2rVDcFE 6. Lee DC, Walsh MC. Workbook of manual therapy techniques for the vertebral column and pelvic girdle, 2nd edn. Friesen Printers 1996. ISBN 978-1550564297 ($34.95). Buy from Amazon https://spxj.nl/2wODKTC 7. Mitchell FL, Mitchell PKG. The muscle energy manual, vol 3: Evaluation and treatment of the pelvis and sacrum. MET Press 1999. ISBN 978-0964725034 (£868.79). Buy from Amazon https://amzn.to/2IysiRe 8. Fryer G. Muscle energy technique: An evidence-informed approach. International Journal of Osteopathic Medicine 2011;14(1):3–9 9. Petersen W, Rembitzki I, Liebau C. Patellofemoral pain in athletes. Open Access Journal of Sports Medicine. 2017;8:143– 154. Open access https://spxj.nl/2Lbz9h4 10. Rivera C. Core and lumbopelvic stabilization in runners. Physical Medicine and Rehabilitation Clinics of North America 2016;27(1):319–337 11. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Medicine 2006;36(3):189–198 12. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders 1992;5:383–389 13. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders 1992;5:390–397 14. Tong TK, Wu S, Nie, J et al. The occurrence of core muscle fatigue during high-intensity running exercise and its limitation to performance: the role of respiratory work. Journal of Sports Science & Medicine 2014;13:244–251 15. Beattie K, Kenny IC, Lyons M, et al. The effect of strength training on performance in endurance athletes. Sports Medicine 2014;44(6):845–865. Open access https://spxj.nl/2xIfS4x 16. Mikkola J, Vesterinen V, Taipale R, et al. Effect of resistance training regimens on treadmill running and neuromuscular performance in recreational endurance runners. Journal of Sports Sciences 2011;29(13):1359–1371 17. Clark AW, Goedeke MK, Cunningham SR, et al. Effects of pelvic and core strength training on high school crosscountry race times. Journal of Strength

and Conditioning Research 2017;31(8):2289–2295 18. Karsten B, Stevens L, Colpus M, et al. The effects of a sportspecific maximal strength and conditioning training on critical velocity, anaerobic running distance, and 5-km race performance. International Journal of Sports Physiology and Performance 2016;11(1):80–85 19. Balsalobre-Fernández C, Santos-Concejero J, Grivas GV. Effects of strength training on running economy in highly

trained runners: a systematic review with meta-analysis of controlled trials. Journal of Strength and Conditioning Research 2016;30(8):2361–2368 20. Mucha MD, Caldwell W, Schlueter EL, et al. Hip abductor strength and lower extremity running related injury in distance runners: a systematic review. Journal of Science and Medicine in Sport 2017;20(4):349–355 21. Thomson C, Krouwel O, Kuisma R, Hebron C. The outcome of hip exercise in

LINKS Link 1: A thorough, open access paper on patellofemoral knee pain in runners. Petersen W, Rembitzki I, Liebau C. Patellofemoral pain in athletes. Open Access Journal of Sports Medicine. 2017;8:143–154 (9). (https://spxj.nl/2Lbz9h4)

RELATED CONTENT I liotibial Band Syndrome in Runners https://spxj.nl/2M5y0s0 on’t Run into Trouble: A Marketing Campaign for D Therapists - https://spxj.nl/2LwsJIW F emoroacetabular Impingement (FAI): Management and Rehabilitation using Postural Restoration Techniques https://spxj.nl/2JhLVNU THE AUTHOR Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Masters degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners. Email: kittyjoythomas@gmail.com

patellofemoral pain: a systematic review. Manual Therapy 2016;26:1–30 22. Neal BS, Barton CJ, Gallie R, et al. Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: a systematic review and meta-analysis. Gait & Posture 2016;45:69–82 23. Foch E, Reinbolt JA, Zhang S, et al. Associations between iliotibial band injury status and running biomechanics in women. Gait & Posture 2015;41(2):706–710

24. Powers CM, Ghoddosi N, Straub RK, Khayambashi K. Hip strength as a predictor of ankle sprains in male soccer players: a prospective study. Journal of Athletic Training 2017;52(11):1048–1055 25. De Ridder R, Witvrouw E, Dolphens M, et al. Hip strength as an intrinsic risk factor for lateral ankle sprains in youth soccer players: a 3-season prospective study. The American Journal of Sports Medicine 2017;45(2):410–416. Open access https://spxj.nl/2GthcqI.

DISCUSSIONS aving read this article, would your approach to assessing and identifying H a malalignment syndrome in runners differ now, and if so how? Is there scope in your practice to include pelvic assessment in all runners who present with a lower limb injury? What techniques would you use to manage the realignment? Do you agree that core strengthening should be an integral part of prehab and rehab to improve running performance, manage pelvic alignment and prevent injury?

KEY POINTS n There is a far greater proximal to distal influence among the joints, from pelvis/trunk to hip, knee and ankle in running. nA pproximately 80% of runners have some form of malalignment syndrome. n Malalignment syndrome includes the biomechanical changes, abnormal stresses and resulting signs/symptoms seen with an upslip, rotational malalignment and/or flare. n Understanding and identifying malalignment is essential to runners as it can mimic, hide, overlap with, trigger or aggravate other injuries. n Pelvic malalignment is often missed with a standard back assessment, or not even considered with a lower limb injury. n Management should combine realignment using manual therapy techniques, core strengthening and re-establishing movement patterns. n Core muscles provide stability around the lumbo-pelvic hip complex to generate force and propulsion while running as well as absorb and distribute impact forces. n Strengthening of the core includes the core abdominal structures but also the lower back, hip, pelvis and proximal thigh muscles. n Imbalances or deficiencies in the core muscles can result in fatigue, decreased endurance and injury in runners. n Management should include instruction in self-treatment using muscle energy techniques to maintain realignment on a day-to-day basis.

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: Small changes in pelvic alignment can have detrimental effects anywhere along the lower limb https://spxj.nl/2JgqZmz Tweet this: Pelvic malalignment usually presents as outflare/inflare, rotational malalignment and upslip https://spxj.nl/2JgqZmz Tweet this: Manual therapy remains the key to achieving long-term results in realigning the pelvic bones https://spxj.nl/2JgqZmz Tweet this: Strengthening of the core muscles is essential for regaining stability of the pelvis and spine https://spxj.nl/2JgqZmz

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TENDON PAIN A mainstay of treatment for tendinopathy is exercise and load management but pain can make patients reluctant to thoroughly attempt their rehabilitation programmes. Although massage is not a cure for tendinopathy, it can play a valuable analgesic role and allow your patient to perform their loading exercises. This article explains the evidence for the role of massage in treating tendinopathy and describes in detail how to perform it at different tendon sites. This allows you to provide the best passive support for your patients so that they can be effective with their exercise regime. This article has been adapted from a chapter in the author’s book Lower Limb Tendinopathy. Read this article online https://spxj.nl/2xHIquV BY DANIEL LAWRENCE BSC, MCSP

INTRODUCTION

All references marked with an asterisk are open access and links are provided in the reference list.

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In the 1990s Dr Hakan Alfredson was troubled by chronic Achilles pain but was denied surgery. Therefore, he decided to load his Achilles aggressively and repeatedly in an attempt to rupture the tendon and so to become a candidate for surgery. The result was not as expected, the Achilles pain didn’t worsen, the tendon did not rupture – it reduced and seemingly improved. This experience triggered Alfredson’s ground-breaking study and planted the seed that has seen load management become the focus of tendinopathy management. Since the 1990s, therapists and rehabilitation professionals have also become more aware of the evidence base for exercise interventions for a multitude of musculoskeletal conditions ranging from shoulder pathologies to degenerative joint disease. Indeed, on a more global scale, the benefits of exercise continue to be scientifically championed for our general physical and mental health. As for tendons, much has been written about loading programmes but little has been written about how passive modalities can support a patient’s more active efforts. This article focuses on massage and soft tissue treatment options.

18-07-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Tendinopathy Continuum Explained (Courtesy of YouTube user The Physio Channel) https://spxj.nl/2x7K8W3 Achilles Tendinopathy Differentiation Tests (Courtesy of YouTube user The Physio Channel) https://spxj.nl/2kn412d

ROLE OF MASSAGE IN TREATING TENDINOPATHY Massage is an ancient treatment and a natural reaction to pain (eg. rubbing a sore elbow). Massage has been accepted in the clinical setting without question, although the evidence of its effectiveness is principally anecdotal and largely undocumented. The significance of therapeutic touch and the value of simple ‘handson’ treatment for tendinopathy have become overshadowed by our changing approach to the pathology and treatment. Increasingly sophisticated equipment is being used for assessment and treatment and specific exercise protocols often negate the patient’s chief concern – pain. Pain hinders the management of tendinopathy because patients 25

RESEARCH SUPPORTS THE USE OF MASSAGE FOR PAIN REDUCTION IN MUSCULOSKELETAL CONDITIONS are often reluctant to perform loading exercises when in pain, even following patient education. There are many ways to reduce pain from musculoskeletal conditions and whereas massage has received some bad press from academia for its overall lack of evidence, one thing research supports is massage as a tool for pain reduction for musculoskeletal conditions, although not specifically tendon-related pain (1–3*). There is evidence to support the use of direct deep transverse friction massage (DTFM) on tendons to reduce pain (4*), but this needs to be approached with caution against the backdrop of the tendinopathy continuum pathology model (Video 1). In my opinion, DTFM might aggravate reactive tendons and cause an unhelpful increase in protein production. However, DTFM often leads to a period of analgesia and a reduction in the size of any tendon thickening; thus, some therapists continue to use this treatment method. Based on current information, I recommend DTFM as a treatment option only for refractory degenerative tendinopathies, so please avoid the temptation to directly rub sore acute tendons. Massage has multiple alternative names that describe the style of the massage, the teaching school from which it originated, and the philosophy on which it is based. You may know, practise, or have Video 1: Tendinopathy Continuum Explained (Courtesy of YouTube user The Physio Channel) https://spxj.nl/2x7K8W3

(a)

heard of some of the following: n sports massage n soft tissue release n myofascial release n fascial manipulation n trigger point release n transverse friction n instrument-assisted massage. In terms of tendinopathy management, you need to experiment to find which massage method(s) help to reduce your patient’s pain and appreciate that these may be different between individuals. An important point to reiterate before we look at massage options, is the poor pain-to-pathology correlation. Massage treatment is solely for pain relief and the reduced pain should encourage improved exercise adherence and load management, but it is not a cure.

EFFECTS OF MASSAGE The effects of massage are well known but fundamentally unproven. There are many debatable points that could form a lengthy discussion. To keep things brief, it is unlikely that massage increases blood flow, and even if so, not in a way significant to benefit a tendon. It is most likely that the benefits of direct massage of a tendon are through desensitisation from a short period of hyperstimulation. Direct tendon massage may irritate the pathology in the acute stages, so most Video 2: Achilles Tendinopathy Differentiation Tests (Courtesy of YouTube user The Physio Channel) https://spxj.nl/2kn412d

(b)

Figure 1: Calf massage and focal pressure

of the techniques in this article target regional musculature. The benefits of massage are most likely to occur from an initial pain gating; this is followed by descending inhibition influencing the ‘volume’ of the noxious input and a more global relaxation of muscular tone. Massage causes movement of the underlying tissue and fascia, which may improve the slide and glide between different layers and influence fluid flow and hydration between the tissues. Research has also shown alterations in the following hormones: cortisol, serotonin, and dopamine (5), and oxytocin (6). This hormonal mix helps regulate many processes within the body, including immunity, pain perception and injury recovery. There is undoubtedly a placebo effect as well as the building of rapport and trust with the patient that is vital to any successful management programme. The following techniques are some of the recommended massage treatments for the lower limbs.

TESTING Before performing a treatment, it is very useful to pretest a painful movement and then retest it after a massage treatment. This also allows you to determine how long the benefits of massage last and when further treatment ceases to improve the outcome. As a result, you should then

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Action Begin with a dynamic massage using your preferred techniques (Fig. 1a) before directing sustained pressure onto any specific tender points for a short period of time (Fig. 1b).

be able to select the most effective massage options for each individual patient.

ACHILLES TENDONRELATED TECHNIQUES About 10 years ago I was treating a patient who had sustained a partial rupture of his Achilles tendon (See Video 2 for more advice on Achilles tendinopathy differentiation); our aim was to restore his plantarflexion strength. Massage would not improve his strength and massage was not an â&#x20AC;&#x2DC;evidence-basedâ&#x20AC;&#x2122; treatment. He did, however, receive a massage from a good massage therapist and reported reduced pain, increased flexibility and an improved gait following the treatment. Since then I have learnt to routinely include some form of soft tissue work for all of my tendinopathy patients. Even if the effects are short lasting it can give patients a positive start to their rehabilitation.

Calf Massage and Focal Pressure Aims Provide a moderate-to-firm massage stimulus over the gastrocnemius-soleus complex to reduce the pain from the Achilles region. Position Your patient should be prone with their feet off the end of the couch to allow relaxed dorsiflexion (Fig. 1). (a)

Note Working above the tendon often reduces the pain, tension and discomfort from the tendon region; you do not need to massage the tendon directly.

Flossing for the Calf Region Aims Improve pain-free range and reduce the sensation of muscle tension. Position Apply the compression (floss) band around the lower limb from above the ankle with moderate pressure and a 50/50 overlap (Fig. 2). Action With the compression band in place, ask your patient to complete 10 fullrange dorsiflexion stretches while standing. Tips Stretch with the knee straight (Fig. 2a) and bent (Fig. 2b) to target the gastrocnemius and soleus fibres. Note Flossing is like a pin-and-stretch massage technique. It is quick and easy to do and often yields great results.

Rolling the Calf Aims Provide a self-massage option for individuals and groups.

(b)

Figure 2: Flossing for the calf region

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Figure 3: Rolling the calf

BEFORE PERFORMING A TREATMENT, IT IS VERY USEFUL TO PRE-TEST A PAINFUL MOVEMENT AND THEN RE-TEST IT AFTER A MASSAGE TREATMENT 27

PAIN HINDERS THE MANAGEMENT OF TENDINOPATHY BECAUSE PATIENTS ARE OFTEN RELUCTANT TO PERFORM LOADING EXERCISES WHEN IN PAIN Position Long sitting, with one leg resting on the roller in a relaxed state (Fig. 3). Action Ask your patient to lift their torso up using the arms and allow the leg to roll up and down over the roller. Tips Instruct your patient to apply moderate pressure; the exercise should not be painful, but some discomfort is acceptable. Tell your patient to angle the leg to target the medial and lateral sides of the calf.

In terms of research, one interesting study is detailed below and, even if you are unsure about the proposed mechanisms of action, I would again encourage you to try it â&#x20AC;&#x201C; based on my clinical experience, it usually works.

Plantar Fascia Roll

Fascial Manipulation

Aims Self-massage the plantar fascia region using a small, firm ball. This often reduces posterior tension and sensitivity through the Achilles region.

According to a pilot study by Pedrelli, Stecco and Day (7), who reported the pain outcomes of 18 patients following fascial manipulation of the thigh, the following treatment approach proved to be successful at reducing patellar tendon pain immediately and in the short term for most of the group. The key area to treat was referred to as the centre of coordination (CC), while the patellar tendon was referred to as the centre of perception. The CC is located on the mid-thigh over the vastus intermedius muscle, which interestingly overlaps with acupuncture point ST22 and with one of the known trigger points of the quadriceps group (8). The treatment consisted of a sustained deep manual pressure between the rectus femoris and vastus lateralis muscles on the mediolateral thigh, followed by an intermittent friction massage for a total of approximately 5 minutes. Pedrelli, Stecco and Day suggested that the positive outcomes may be due to improved fascial mobility reducing the stimulation of the free nerve endings (7). Corrected quadriceps coordination may allow the correct deposition of new collagen fibres according to the forces placed on them.

Position Seated, ball under foot (Fig. 4). Action Very slow rolling with moderate pressure. Tips Experiment with different ball sizes and textures.

PATELLAR-RELATED TECHNIQUES Clinically I find that a vigorous massage of the quadriceps often provides symptom relief from pain associated with patellar tendinopathy. Although no specific studies empirically support this, I would encourage the reader to try this if they have not already done so.

Figure 4: Plantar fascia roll

(a)

(b)

Figure 5: Quadriceps massage and focal pressure

Figure 6: Quadriceps roller and massage stick

Figure 7: Flossing the knee joint

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Quadriceps Massage and Focal Pressure Aims Apply a moderate-to-firm massage stimulus over the quadriceps muscle group, with the option of using sustained pressure over a specific region of the lateral thigh (Fig. 5). Position Patient long sitting or with their knee bent. Action Begin with a dynamic massage using your preferred techniques (Fig. 5a) before directing sustained pressure onto a specific tender point commonly located on the mid-thigh, slightly lateral from the centre (Fig. 5b). Tips Once the tender spot has been located, apply a tolerable pressure with your elbow or a massage tool to save your thumbs from fatigue.

ask your patient to complete 10 squats within a pain-free range.

(a)

Tips This technique can be used to control pain during specific loading programmes. Note Flossing is like a pin-and-stretch massage technique. It is quick and easy to do and often yields great results.

(b)

HAMSTRING-RELATED TECHNIQUES I find upper hamstring tendinopathy is the slowest responder to load management when compared to the other three main lower limb tendinopathies. Although massaging the hamstrings wonâ&#x20AC;&#x2122;t send patients singing your praises from the rooftops it can be a valid method of controlling symptoms alongside activity modification such as reduced hill walking and running, and other pain reducing aids. Patients can

(c)

(a)

Rolling the Quadriceps Aims Provide a self-massage option for individuals and groups (Fig. 6).

(d)

Position Lying on the floor with one thigh on the roller and the other leg out to the side to stabilise the body. (b) Action Roll forward and back so the roller stays between the knee and hip (Fig. 6a).

(e)

Tips If this technique is difficult, try the stick option as shown in Figure 6b.

Flossing the Knee Aims Improve the pain-free range and reduce the sensation of muscle tension (Fig. 7).

Figure 8: Hamstring massage and pin and stretch

Position Apply the compression (floss) band around the knee joint with moderate pressure and a 50/50 overlap. Action With the compression band in place,

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Figure 9: Hamstring roller

Figure 10: Gluteal massage techniques

MASSAGE IS AN ANCIENT AND NATURAL REACTION TO PAIN 29

also find considerable relief using a pressure cushion, the kind used in care homes or by wheelchair users.

Hamstring Massage with Pin and Stretch Aims Apply a moderate-to-firm massage stimulus over the hamstring muscle group with the option of using sustained pressure over a specific region of the muscle while extending the knee to mobilise the underlying tissue. Position Patient lying face down with the legs straight or the knees bent (Fig. 8). Action Begin with a dynamic massage using your preferred techniques (Fig. 8a) before applying sustained pressure over a specific area of the posterior thigh, followed by a passive straightening of the knee (pin and stretch) (Fig. 8b).

Hamstring Roller Aims Provide a self-massage option for individuals and groups. Position Sitting on the floor with one leg resting on the roller behind the knee (Fig. 9). Action Instruct your patient to roll forward and backwards, so that the roller stays between their knee and hip.

GLUTEAL-RELATED TECHNIQUES Gluteal Massage Techniques Gluteal tendinopathy often leads to some associated focal muscular tender

Figure 11: Iliotibial roll

points, which commonly desensitise after sustained pressure treatments. Aim Provide sustained pressure to desensitise focal regions and reduce pain with movement. Position Lying and standing, as shown in Figure 10. Action Apply light to moderate pressure for a sustained period until the region is reported to be less tender (Fig. 10a, b).

CONCLUSION Massage is one of the oldest treatment modalities with a proven anecdotal track record. More recent evidence has disputed many of its historic claims, but its ability to reduce pain from a variety of causes is well documented. Based on what we currently know, massage can confidently be used as an analgesic tool for tendinopathy-related pain; a positive outcome from massage can hopefully improve patient rapport and exercise adherence. References

Tips Try these techniques with guidance first, then consider suggesting them as home management tasks (Fig. 10c–d).

Rolling the Iliotibial Band For most people, rolling the iliotibial band (ITB) (Fig. 11) is very painful. This is unnecessary and the therapeutic benefits of rolling the lateral thigh are disputed. Rolling the quadriceps and hamstring group may prove helpful as an alternative. These two muscle groups connect laterally at the lateral intermuscular septum of the thigh, whose superficial fibres are continuous with the ITB. In addition, reducing the tone of the ITB tensioners, gluteus maximus and tensor fasciae latae with the ball methods described previously is likely to reduce the tension through the ITB.

MYOFASCIAL ANATOMY This article forms a small, but important part of successful tendinopathy management and treatment. The techniques described predominantly focus on the adjoining muscle groups for each tendon. To expand on this idea of myofascial continuity, many therapists have reported the benefits of performing soft tissue work along the length of the myofascial continuities rather than maintaining the massage near the tendon. An example of this for gluteal tendinopathy would be to massage the lateral line of tissue or to massage the whole back line for an Achilles or hamstring tendon problem.

1. Cherkin DC, Sherman KJ, Deyo RA et al. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine 2003;138:898– 906 2. Frey Law LA, Evans S, Knudtson J et al. Massage reduces pain perception and hyperalgesia in experimental muscle pain: a randomized, controlled trial. The Journal of Pain 2008;9:714–721 3. Sherman KJ, Cherkin DC, Hawkes RJ et al. Randomized trial of therapeutic massage for chronic neck pain. The Clinical Journal of Pain 2009;25:233–238 Open access https://spxj.nl/2s63wOd 4. Joseph MF, Taft K, Moskwa M et al. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Journal of Sport Rehabilitation 2012;21:343– 353 Open access https://spxj.nl/2IHaK5t 5. Field T, Hernandez-Reif M, Diego M et al. Cortisol decreases and serotonin and dopamine increase following massage therapy. The International Journal of Neuroscience 2005;115:1397–1413 6. Morhenn V, Beavin LE, Zak PJ. Massage increases oxytocin and reduces adrenocorticotropin hormone in humans. Alternative Therapies in Health and Medicine 2012;18(6):11–18. 7. Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with fascial manipulation. Journal of Bodywork and Movement Therapies 2009;13(1):73– 80 8. Travell JG, Simons DG, Simons LS. Travell & Simons’ Myofascial pain and dysfunction: the trigger point manual. Volume 1. Upper half of body. Lippincott Williams and Wilkins 1998. ISBN 978-0683083637 (£73.00). Buy from Amazon https://amzn.to/2GLUN8n.

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THE AUTHOR Daniel Lawrence BSc, MCSP is a UK Chartered Physiotherapist, published author and international lecturer. Daniel holds separate post-graduate qualifications in musculoskeletal medicine and education. Having completed 10 years as a University lecturer for Plymouth University based in Truro, Daniel now combines teaching and writing with running an NHS funded clinic in his local area. Daniel is also on the board of directors for RockTape UK, StickMobility UK and PhysioBooks Ltd. He has delivered lectures and workshops on tendonrelated subjects throughout the UK including, Therapy Expo, COPA, private physio groups, the Shoulder Symposium, South West Seminars and the British Fascia Symposium 2018. Daniel frequently attends conferences as a guest lecturer and delivers bespoke training to professional groups. Email: daniel@rocktape.net YouTube: The Physio Channel Instagram: ThePhysioChannel

KEY POINTS nM assage is an ancient treatment and a natural reaction to pain. n Pain hinders the management of tendinopathy. n Massage is a tool for pain reduction. n DTFM might aggravate reactive tendons. n Reduced pain should encourage improved exercise adherence. n Different patients might benefit from different massage methods – experiment to find the one best-suited to individual clients. n The effects of massage might be short but they create a positive start to a patient’s rehabilitation. n Vigorous massage of the quadriceps often provides relief from pain associated with patellar tendinopathy.

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RELATED CONTENT atellar Tendon Pain: A Massage Therapist’s Game Plan P - http://spxj.nl/2twvPHS oft Tissue Treatments with Stuart Hinds: ITB Syndrome S Video Masterclass - http://spxj.nl/2gvdF0U I liotibial Band Syndrome (ITBS) and Transverse Soft Tissue Release: A Case Study - http://spxj.nl/2t8TFsL

DISCUSSIONS hat are the potential mechanisms for reducing W tendon pain with massage of the attached contractile tissue and what potential positive outcomes might occur in addition to less reported pain? How would you explain the use of massage to the patient, what might it do and what will it not achieve? If massaging tender muscles around a painful tendon is helpful then why is it ill-advised to massage directly over the tendon? Can massage and its associated pain relief improve long-term exercise adherence?

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SPINAL MOTIONS: STRUCTURE AND FUNCTION In order for an effective manual therapy treatment programme to be chosen and instigated there has to be accurate clinical assessment of the patient’s condition or injury. This article discusses how the spine functions according to its structure, enabling the therapist to visualise the normal movement processes as well as how dysfunction can lead to injury. This better understanding of the living spine allows a more accurate clinical assessment of any spine-associated impairments, permitting creation of an individually tailored treatment plan. This article has been adapted from chapter 6 ‘Spinal motions: structure and function’ from the author’s book Clinical Assessment For Massage Therapy: A Practical Guide. Read this article online https://spxj.nl/2JfyVV7 BY DAVID ZULAK MA, RMT SPINE - TRUNK 18-07-COKINETIC FORMATS WEB MOBILE PRINT

THE LIVING SPINE Although the subject of the spine can be an enormous topic, my purpose in this article is to provide a general overall picture of the living spine, that is, the spine in motion. I want to describe some of the ways in which the spine functions according to the nature of its structure, and also show how its structure and function can become impaired or dysfunctional. What follows must by necessity be general in nature. Further, I will skip details of pathological changes that may occur over time or those due to disease processes. The usefulness of looking at the spine in this way is that it helps the therapist to imagine or visualise those structures intrinsic to the spine and how they function. I call this type of exercise thinking anatomy, that is, thinking through the implications of

THE UNCOMPRESSIBLE NUCLEUS PULPOSUS OF THE INTERVERTEBRAL DISCS ACT AS A SELF-RIGHTING MECHANISM FOR THE SPINE 32

the structure and function of the musculoskeletal system. Structure (anatomy) permits and informs function, and function (physiology) shapes structure. With this perspective we can envision how the body seeks balance, successfully or unsuccessfully.

SPINAL CURVES, DISCS AND FACETS The spine acts as a spring or shock absorber for the trunk and head. Looking at the spine in profile, we see the familiar curves. These curves allow the spine to act as an S-spring. Pressure from above or below compresses the structure, but not like the loading of a solid column. Rather, the curves become exaggerated; absorbing the stress from the load, while the springiness inherent in it (via intervertebral discs, ligaments, muscles, living bone, etc.) pushes back. When the load is removed, the spine can lift itself back into its original shape, even without muscular action. This assumes that the load was not so great as to deform inert tissue or injure and impair Co-Kinetic Journal 2018;77(July):32-37

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THORACIC VERTEBRAE

other words, because the lumbar’s anterior (lordotic) curve puts more mechanical stress on the posterior portion of the disc, the nucleus, being slightly posterior to centre, is better able to provide support. Therefore, as the lumbar curve exaggerates under load, the posterior-positioned nucleus provides protective support. However, with flexion of the lumbar spine the compression of the anterior portion of the disc pushes the nucleus even more posteriorly. If the posterior cartilaginous layers are weakening (losing their integrity) then the nucleus will begin to shift even more posteriorly, causing the weakened layers to bulge, or herniate. The posterior longitudinal ligament (which is quite narrow at the lumbar spine) often helps sustain the integrity of the most posterior fibres of the disc, and so the bulging nucleus often rolls out around this ligament and moves to the side, moving in a posterior lateral direction. This puts it on a collision course with the neural foramen and the spinal nerve at that level. In the cervical spine, C2 to C7, the nucleus pulposus is also slightly posterior within the IVD, and, therefore, functions – or dysfunctions – much like the lumbar spine. The thoracic vertebrae have their nucleus pulposus generally more centred within the IVD. The lowest thoracic vertebrae, being slightly extended (beginning the lordotic curve in the low back), can have the nucleus slightly posterior; the flexed vertebrae of the thoracic kyphosis have it more centred. We have talked mostly about flexing and extending portions of the spine. Side-bending functions in much the same way, with the nucleus acting as an axis over which side-flexion occurs. These three motions, of course, do not only move in a seesaw fashion; there is, in addition, some shearing occurring as the vertebra above slides in the direction of flexing, extending or side-bending. This shearing action can cause more stress to the annular fibres than compression alone.

LUMBAR VERTEBRAE

muscle function. Some of this absorption of forces comes from the intervertebral discs (IVDs). The intervertebral disc is a polyaxial joint. It can accommodate any direction of motion, including shear forces, as well as compression and decompression. The ball-shaped nucleus pulposus at the interior of the IVD is a gel contained within numerous layers or bands of cartilaginous tissue. This makes it uncompressible, and it cannot lose volume as long as those surrounding layers remain intact. When under pressure it pushes back, acting as a self-righting mechanism for the spine, and this ability also allows the annular fibres around it (which can deform) to reinflate. Further, the nucleus, as uncompressible, acts as the axis of motion between vertebrae, as a swiveltype joint. It remains gel-like until middle age, when it then becomes fibrosed. As a result, it loses its capacity to recoil to pressure, and so the cartilaginous layers can more easily lose their height. The annular fibres, being cartilaginous, can lose water when under pressure and can, therefore, be compressed with a resulting change in shape. This compressibility provides some of the give within the spine, so that it can work as a shock absorber that helps accommodate the compressive forces exerted on the disc. Therefore, the fibrous portion of the IVD, as compressible, can have its shape altered when under stress. When the load or stress is removed these annular fibres reabsorb water, reinflating. The principle motor driving this reinflation is the nucleus pulposus. However, if the layers are put continually or forcibly under stress their integrity can begin to break down. Constant or frequently recurring compression or stress will prevent the annular fibres from taking back their water, leaving them dry and brittle. Then the gel-state nucleus itself will flatten as it begins to push its way outward through the cracks and breaks in the annular fibres and force the layers in front of it to bulge, or herniate. In the lumbar spine, the nucleus is not in the centre of the disc, but is positioned slightly posterior in order to better accommodate the compressive force when the spine is in neutral. In

CERVICAL VERTEBRAE

MANUAL THERAPY

However, rotation is even more stressful on the IVD’s annular fibres. As the layers of annular fibres run (in general) in alternating diagonal directions, the stress/tension running through the fibres during rotation will be resisted by some, while others are actually made lax. With fewer fibres resisting the forces, they are more likely to break down. Further, rotation also pulls the vertebral bodies closer together. This also reduces their ability to be shock-absorbers. Facet (zygapophyseal) joints are meant to be slightly gapped or minimally weight-bearing when the spine is in neutral (or, as some say, the facet joints idle, as the engine of a motor vehicle idles, neither engaged nor in use but ready to be used). This slight gapping occurs the closer the curves of the spine are to being ideal. The structures involved in facet joints (bone, articular cartilage, synovial fluid, joint capsules, ligaments, muscle) all contribute to the weight-bearing ability through the area; yet the articular surfaces can remain gapped in the thoracic and lumbar spine. The weight is distributed throughout the structure, where even the fluid in the joint can hold the joint surfaces apart, with the fluid playing a supporting role as forces move through the joint structures. However, as the curves exaggerate, the lordotic curves (normal in the cervical and lumbar portions of the spine) go into extension and the facet joint surfaces approximate and become weight-bearing. These stresses going into the articular cartilage, similar to the cartilaginous annular fibres, lose fluid – it is literally squashed out of them. This fluid mixes with the free synovial fluid within the capsule, making the capsule balloon, which still helps the joint, as a whole, resist the forces that are pressing through the bony facet process. However, the internal pressure of the fluid in this weight-bearing situation will stress

FRYETTE’S THIRD RULE OF SPINAL MOTION IS IMPORTANT FOR UNDERSTANDING HOW INJURIES OCCUR 33

THE RULES OF SPINAL MOVEMENT HELP EXPLAIN COMMON CLINICAL FINDINGS, BUT ANY LESION MAY PRESENT AS UNIQUE the synovial and fibrous capsules and prevent nutrients from entering the synovial cavity. Therefore, the longer this hyperlordosis persists, or the more extreme and forceful the extension: (1) the more quickly the articular surfaces will begin to break down and suffer other osteoarthritic changes; (2) the more likely it is that an injury can occur to the capsules; (3) the greater the chance for injury to occur to the intrinsic spinal ligaments and (fourth layer) musculature, with some overstretched and some left shortened; and (4) the poorer the nutrition within the joint. Now, when the spine moves from neutral into extension, sidebending/flexing, and rotating the facet surfaces not only compress but are also going to glide one over the other. This glide, or skating, also stretches the capsules, and will lengthen some supportive joint tissues while making others lax. Flexing the spine gaps the joints but generally stretches most of the facet joint tissues. Therefore, adding rotation or side-bending to a flexed spine can take ligaments and joint

capsules past their tolerance and they will begin to sprain or tear these tissues, while deep intervertebral muscles will undergo strain.

identical. Each has at least some small, possibly trivial, differences, whereas others can be shaped quite differently and so function differently, all to varying degrees. Even the adjoining facet joint surfaces can have different shapes (eg. one may have a slightly convex surface although its partner may be basically flat), be of differing sizes, or even differ in orientation one to another.

FRYETTE’S RULES OF SPINAL MOTION

DEFINITIONS AND OBSERVATIONS

I would now like to discuss what are commonly referred to as Fryette’s rules of spinal motion. The first two were formulated by Harrison Fryette D.O., whereas a third was added by C.R. Nelson D.O. They have also been call Fryette’s laws or principles (1). I like to use the term ‘rules’, as they really should be taken as rules of thumb. They are informative about how the spine can move, but, as is common with many living things, the spine does have a tendency to appear not to know the rules, or to choose at times to ignore them. Remember too that every individual person’s spine is itself individual and unique. No two facet joints are absolutely identical from one person to another, nor are any individual’s two facet joints in their spine exactly

We first need a couple of definitions and observations. A motion segment of the spine is defined as two adjacent vertebrae and all the joints between them. Between the typical spinal segment there is the IVD joint and two facet joints. When the motion under observation is between two vertebrae we are talking about segmental motion. When we are discussing several vertebrae moving we speak of group motions: these are clarified in Fryette’s rules of spinal movements. Those rules were meant to specifically apply to both the thoracic and lumbar spine, but not the cervical. A couple of observations: 1. Spinal movements are coupled. This means that any motion of the spine impacts on any other motion and, further, that some motions generally accompany each other. With respect to the last point, it has been proposed that side-bending and rotation are always coupled in the spine.

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2. The motions are named from the perspective of the vertebra above, with reference to the one below. Therefore, to say that a vertebra is side-bent and rotated is to say that relative to the vertebra below, the vertebra above is side-bent and rotated.

FRYETTE’S RULES These rules have been shown to be especially valid for the lumbar spine (1–3).

1. Fryette’s First Rule of Spinal Motion “When moving from neutral, the spine side-bends first and then rotates in the opposite direction” Comments Neutral here means the spine is neither flexed nor extended. Side-bending occurs in the frontal or coronal plane. Rotation happens in the transverse plane. When speaking of motions in neutral, side-bending occurs before rotation. Kapandji (4) says the following, to explain how this coupled movement in opposite directions occurs:

“This automatic rotation of the vertebrae … [when sidebending/lateral flexion occurs] … depends on two mechanisms – compression of intervertebral discs and the stretching of ligaments. The effect of disc compression is easily displayed on a simple mechanical model… If the model is flexed to one side, contralateral rotation of the vertebrae is shown by the displacement of the various segments off the central line. Lateral flexion increases the internal pressure of the disc on the side of movement; as the disc is wedge-shaped its compressed substance tends to escape toward the zone of lower pressure, to rotation, ie. contralaterally… Conversely, lateral flexion stretches the contralateral ligaments, which tend to move toward the mid-line so as to minimise their lengths… It is remarkable that these two processes are synergistic and in their own way contribute to Co-Kinetic.com

rotation of the vertebrae.” (4) 2. Fryette’s Second Rule of Spinal Motion “When the spine is non-neutral – when in flexion or extension – rotation happens first, and then side-bending, both in the same direction”. Comments When the spine is working normally in flexion or extension, rotation precedes side-bending. As these occur in the same direction we do not get the synergistic (compensating) motions we get when the spine is in neutral; thus, the stresses of lengthening of some supportive tissue and the amount of compression on others are greater. If we then add in rotation/side-bending it is not surprising that the tissue may exceed their tolerances and become injured. However, even when having started in neutral lumbar spine, impairments, when they do occur, are likely if the order of vertebral motion is not synchronised. For example, if the spine is first in neutral and the patient sidebends and rotates and then flexes or extends the chances of an impairment or dysfunction increase substantially as each additional plane of motion occurs. Knowing the order of movements that produced the patient’s injury helps the therapist understand how the injury occurred. This information comes from taking a thorough case history if the patient can remember the motion or even the final position they got into when their impairments were caused..

3. Fryette’s Third Rule of Spinal Motion “Introducing motion to a vertebral joint in one plane automatically reduces its mobility in the other two planes” Comments This rule is fairly self-evident. It is important, however, for understanding how injuries occur. Again, if the patient’s spine is moved following the second rule as the vertebrae are flexed, some degree of motion is no longer available for side-bending and rotation. If, however, the person moves the

spine into extremes in any of the three planes, as we noted above, this greatly increases the chances of injury. If the IVD and facet joints are driven too far, then injuries to the joint structures themselves and/or to the intrinsic muscles of the spine are likely to occur. The first rule is often referred to as type I motion. Type I dysfunctions usually occur as a group (as in a scoliosis, for example). Therefore, they are referred to as a group or neutral dysfunction, where a number of vertebrae side-bend one way and rotate in the opposite direction. A functional scoliosis means that the scoliosis may disappear when the patient flexes or extends the spine (ie. the scoliosis will decrease or disappear in moving in one direction, while it may exaggerate when moving in the other – which one happens in flexion or extension depends on several issues). However, in a bony (or pathological) scoliosis the vertebrae can be rotated and side-bent either to opposite sides or to the same side; they will not be following Fryette’s rules, and this scoliosis usually does not change significantly. The second rule is type II motion. Type II dysfunctions occur most often when the spine is already flexed or extended and then side-bending and rotation are added. These dysfunctions usually occur in isolation, in a single segment strain, with lifting and twisting, as an example. In other words, they are often segmental dysfunctions, generally not in several segments in a row (as a group). However, it is quite possible to have several segmental dysfunctions, one on top of the other, but each should be treated as individual motion segments. Again, this will help us to understand how to test for these types of lesions, and to understand the results of such testing. Note that when the spine seems to be in neutral, if the person has hyperlordosis or hyperkyphosis (excessive curves), or flattened curves (hypolordosis/hypokyphosis), then that portion of the spine is not in neutral and will function as type II motion, leading to type II impairments. So, for example, if a patient with a lumbar lordosis due to an anterior pelvic tilt 35

now rotates or side-bends, the joints involved will follow the second rule (type II motion) rather than the first rule (type I motion).

CONSIDERATIONS Of special note: The spine is a continuum. Though we refer to portions of it as the lumbar, thoracic and cervical spine, many structures undergo graduated changes as we progress up the spine from the sacrum to the occiput. It is true that there are transition points, predominately where the ribs come into play: the cervicothoracic (C7-T1) and thoracolumbar (T12-L1) junctions. (We are ignoring the lumbosacral and occipital-atlantal junctions, as we are removing the spine from its context of the body as a whole.) The ribs have real impact, but we will also get to that later. The point here is that the rules apply fairly consistently to the lumbar spine, and up into the lower thoracic spine. However, as the facet joints slowly but progressively change their orientation as they move up the spine, these rules are going to become less consistent as we move into the upper half of the thoracic spine, until the point where they no longer apply to the cervical spine at all. Gradation in spinal structure (shape) results in a gradation of function, and a graduation of how predictive these rules of Fryette’s are. The cervical spine, from C2 to C3, tends to move usually with side-bending and rotation occurring to the same side, either in neutral or when the cervical spine is flexed or extended. This is due to the orientation of the facet joint surfaces. However, these vertebrae can be made to move opposite to each other under special circumstances. Hence, Fryette’s rules just do not apply to them. Further, the unique shapes of C1 and C2 means they move in their own unique way. There, structure informs their function, and vice versa.

Do All Spinal Lesions Occur in These Ways? No. Lesions, by nature, may show patterns, but unusual traumas, severe blows or an unusual structuring or shape to the vertebrae can result in atypical patterns. The rules of spinal 36

movement are meant to help explain common clinical findings. However, because everyone is unique, joint shapes differ from person to person. Any lesion may present as unique. You may, on a rare occasion, find a group dysfunction where the lumbar or lower thoracic vertebrae seem rotated and side-bent to the same side, for example. Alternatively, a segmental dysfunction could have the motion segment rotating and side-bending in opposite directions. After all, lesions are lesions because things have gone wrong! Lesions know no rules. The joints in the spine can be forced into moving (functioning) in ways that do not conform to their shape (structure). Thus, we need to know how to accurately palpate and test the joints of the spine and, more importantly, not make assumptions about how things should be and, thus, forgo the testing. We need to be open-minded enough in order to be prepared to find the unexpected.

How the Spine Contributes to Holding the Body Upright Let us look at how the spine contributes to holding the body upright, how it bears the weight of the trunk, head, and upper limbs. Often the spine is still thought of, or described, as a column (hence the classic name spinal column) that works mechanically, like a pillar, supporting all this weight. However, this is no longer considered an appropriate model. This is where one of the many important jobs that the ribs perform comes into play. Rather than only transferring weight and other stresses onto the spine, the ribs can distribute a lot of the weight of the upper body outward, to the body wall. This transfer of weight and forces outward is referred to in the concept of tensegrity. The term tensegrity was coined by architect, engineer and scientist R. Buckminster Fuller, who was the original designer of the geodesic dome. He said his inspiration for that design came from the structures within the living cell, its cytoskeleton. The word tensegrity is a contraction of the phrase ‘tensional integrity’. Tensegrity describes the forces at work in a structure that is formed by a network of compressive, rigid elements

interconnected through tensile or elastic elements, which give the structure its overall integrity. As a result of the elastic property of the interconnections, when one element of the tensegrity structure is shifted (moved and/or loaded), this shift is spread throughout the whole structure. All the other elements shift as well, adapting and compensating by morphing into a new configuration. By yielding in this way to these shifts such a structure is more accepting of the forces or loads applied, without breaking. Acting in this way, the ribs, and all the other tissues and structures of the spine working together, disperse stresses and strains that would cause them to snap if they were a rigid structure. Therefore, the ribs also help the body absorb the forces of walking, running, weight-bearing, reaching, pulling, etc. This is in addition to their duties of being the bellows for breathing and fluid movement (as part of circulatory system, especially for venous and lymph flow through the trunk). The qualities of tensegrity also help the ribs, and their related tissues, be even more effective in nurturing and protecting the organs within the trunk. By looking at the spine in this way, by seeing its function as guided by its structure, and how its function can shape structure, the therapist is better equipped to understand how the spine works and how it gets into trouble. We can only see this way if we are looking at the spine as a living, changing and adaptive system. References 1. Chila AG. Foundations of osteopathic medicine, 3rd edn. Lippincott Williams and Wilkins 2010. ISBN 978-0781766715 (Kindle £86.45 Print £91.00). Buy from Amazon https://amzn.to/2IAzfS2 2. Bogduk N. Clinical and radiological anatomy of the lumbar spine and the sacrum, 5th edn. Churchill Livingstone 2012. ISBN 978-0702043420 (Kindle £28.26 Print £39.59). Buy from Amazon https://amzn.to/2IDedC7 3. Mitchell FL. The muscle energy manual. Volume 2: Evaluation and treatment of the thoracic spine, lumbar spine, and rib cage, 2nd edn. MET Press 2004. ASIN B0006SC5N6. 4. Kapandji IA. The physiology of the joints: the trunk and the vertebral column, volume 3, 2nd edn. Churchill Livingstone 1974. ISBN 978-0443012099. Co-Kinetic Journal 2018;77(July):32-37

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Clinical Assessment For Massage Therapy: A Practical Guide By David Zulak Handspring Publishing 2018; ISBN: 978-1909141377 Buy it from Handspring https://handspringpublishing.com/product/a-manual-ofclinical-assessment-for-massage-therapy/ Chapter 6

: Spinal motions structure and function

Clinical Assessment for Massage Therapy: A Practical Guide brings together a range of examination and assessment techniques which are otherwise only found in a variety of different places. The author presents them in a way which is specifically relevant to massage therapists. The ability to accurately assess a client’s condition is crucial if massage therapy is to be given safely, appropriately and effectively. Students of massage therapy will find the book to be a valuable source of useful and relevant material to support their learning and understanding for their new profession. More experienced therapists will use it to enhance, update and extend their skills in this key area of their practice.

THE AUTHOR David Zulak MA, RMT has been a massage therapist since 1994, and an instructor since 1996. He has worked in the past as an instructor, program director and curriculum writer for several massage therapy schools in Ontario, Canada. Over his teaching career, he has taught almost every course given at a school of massage. However, his focus and interest has always remained anatomy, treatments, techniques and orthopaedic assessment skills. A specific passion of his has been emphasising and promoting the need for all massage therapists to have a good solid understanding of and facility with the skills involved in clinical assessment. David has written over a dozen articles for the column ‘Essentials of Assessment’ in the magazine Massage Therapy Canada, and has recently been writing a column called ‘The Learning Curve’, discussing issues and trends in massage therapy education. Currently David primarily teaches seminars across Canada for practising massage therapists, along with sustaining a busy clinical practice in Brantford, Ontario. Email: dzulak@hotmail.com LinkedIn: https://www.linkedin.com/in/david-zulak-97a78a86/

DISCUSSIONS nderstand and learn Fryette’s rules of spinal motion. U Discuss how type I and type II dysfunctions occur. Discuss why the concept of the spine as a column is no longer considered as an appropriate model.

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THE UNCOMPRESSIBLE NUCLEUS PULPOSUS OF THE INTERVERTEBRAL DISCS ACT AS A SELF-RIGHTING MECHANISM FOR THE SPINE KEY POINTS n ‘ Thinking anatomy’ is an exercise that helps the therapist to visualise the intrinsic structures and imagine how they function and, hence, what goes wrong in dysfunction. n The curves of the spine allow it to act as an S-spring. nT he intervertebral discs are crucial for absorbing pressure, returning the spine to its original shape when the load is removed as well as acting as the axis of motion between vertebrae. nT he facet joints are gapped and ‘idle’ when the spine is in neutral but become weight-bearing during movement, which they help to guide and limit. nT he three movements associated with the spine are flexion/extension, side-bending and rotation. nA motion segment of the spine is defined as two adjacent vertebrae and all the joints between them. n F ryette’s rules of spinal motion are useful but it should be remembered that each person’s spine is individual and unique. n F ryette’s rules apply well to the lumbar and lower thoracic spine but apply less well to the upper thoracic spine and do not apply to the cervical spine. nU nderstanding Fryette’s rules allows the therapist, in conjunction with an accurate history, to understand how an injury has occurred. nT he ribs play an important role in the tensegrity of the human body allowing forces to be spread throughout the whole structure.

RELATED CONTENT anual Therapy Student Handbook: Assessment and Treatment of the M Cervical Spine Part 11 - http://spxj.nl/2AUo7aO anual Therapy Student Handbook: Assessment and Treatment of the M Lumbar Spine Part 12 - https://spxj.nl/2sC89jf anual Therapy Student Handbook: Assessment and Treatment of the M Thoracic Spine Part 13 - https://spxj.nl/2JjLBKl

Want to share on Twitter? HERE ARE SOME SUGGESTIONS Tweet this: A motion segment of the spine is defined as two adjacent vertebrae and all the joints between them https://spxj.nl/2JfyVV7 Tweet this: Spinal movements are coupled; ie. any motion of the spine impacts on any other motion of the spine https://spxj.nl/2JfyVV7 Tweet this: Spinal motions are named from the view point of the vertebra above, with reference to the one below https://spxj.nl/2JfyVV7

MARKETING MISTAKES AND HOW TO AVOID THEM

WARNING: SOME READERS MAY FIND THE FOLLOWING BULLET POINTS A LITTLE UPSETTING… When I talk to people about marketing this is what I hear: n I know don’t know what to do… B*llsh*t, here’s a strategy that works – http://spxj.nl/2haSVyW. n I’m crap at technology… No excuse these days when just about every piece of software you need to use comes with step-by-step videos that you just follow along with. n I just don’t have enough time… Total rubbish, that’s because you’re focusing on the wrong things. n It’s just too hard to find new customers… This has got to be the worst excuse of them all, more about that later. n Nothing I do ever works…. That’s because you don’t have a plan, and if you do, you don’t follow it through to the finish.

Each one of these marketing mistakes at the very least will cost us money as well as time, combine several together and you have a recipe for marketing disaster and yet each one can be avoided when you know what to look for. This article not only discusses each of the mistakes but provides practical advice on how to address them head first and give yourself the opportunity to not only succeed with your marketing, but also how to turn it into something you can actually enjoy. Read this article online https://spxj.nl/2LrtX8e BY TOR DAVIES, CO-KINETIC FOUNDER

Basically, all the above excuses boil down to: I don’t like doing it, so I’m just going to make excuses for myself.

MARKETING ACTIVITIES ONLY BECOME EFFECTIVE WHEN BASED ON A COHERENT STRATEGY 18-07-COKINETIC FORMATS WEB MOBILE

MEDIA CONTENTS Five Go on a Patient Journey https://spxj.nl/2xGwrOe A Crash Course in Marketing for Physical and Manual Therapists: The Quickest Way to Get BusinessChanging Marketing Results for the Least Amount of Effort https://spxj.nl/2JcHJza

Sorry if that offends you, but it’s the truth and those of you who know me, know I’m not one to sit on the fence!

THE PARABLE OF THE PATIENT AND THE PRACTITIONER You know when a patient comes to you for help? You go through the steps to diagnose the problem and you probably know quite soon what needs to happen to help the patient get better. But it involves the patient going home and doing some exercises in between your sessions, so you give them all the information they need to do this successfully. But guess what … despite being in pain all week, they arrive for their next appointment and there’s little or no improvement. You ask whether they managed to do their exercises and they reply, “sort of”, “once or twice”,

“yes, maybe a couple of times but it was really busy week”. We’ve all been there! So they continue to have their life compromised, and they continue to come back to their next appointment and pay money, and even though there is an almost guaranteed solution right in front of them – they just won’t do what needs to be done to achieve that goal. It seems illogical, right? Depending on how passionate you are about your job, you may just accept it as part of what you do, or it might make you want to scream with frustration because you know that if they just followed your instructions, their pain would disappear, their quality of life would improve dramatically and they’d be able to start living their dreams. So why does this happen?

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nB ecause people are lazy and not prepared to put the work in to get what they want? n Maybe they’re lonely and just want the care and attention? n Because they want to make the problem someone else’s, instead of dealing with it themselves? n Maybe they don’t actually want a solution, they just want to show that they’ve tried so it gives them an excuse to keep on living the way they are living? As we know, human psychology is intriguing and deeply complex but that’s not the topic of this article. I told this story, because I faced it once as a physio. Today I face it as a marketer FOR physios! Read that story again and think of you and your marketing. If you’re prepared to be honest with yourself, probably most of you can find some parallels. Unless the patient has a genuine desire and commitment to heal their pain, you are more or less powerless to help your patient. And unless YOU have a genuine desire and commitment to change your business, I’m more or less powerless to help you. I KNOW how you can turn your business into something you’ve always dreamt of, but I’ll never be able to help you do that unless you are truly driven and committed to achieve that outcome. Just as you can solve most problems a patient could throw at you, unless they are truly driven to achieve that goal, your expertise and skills are, to some extent, wasted on them.

THE 10 BIGGEST MARKETING MISTAKES THAT SMALL BUSINESS OWNERS MAKE Here are my top 10 most common marketing ‘injuries’.

No Strategy

This is right at the top of my list and it’s a bit like altered biomechanics. It doesn’t stop you walking, running or cycling (or marketing) but it does substantially

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increase your risk of suffering from a whole bunch of injuries such as: n spending too much money on one thing, with no strategic approach or any proof that this one thing actually works; n flurries of marketing activity that very rarely generate much outcome compared with a steady, little-andoften approach that wins every time; and/or n confusing a tactic with a strategy – for example running ads to collect new prospective email leads is a tactic, but if you don’t have a strategy in place to bring those new leads through the journey, they’re completed wasted. In fact, a lack of strategy pretty much accounts for every issue on this injury list. See the link to ‘A Crash Course in Marketing for Physical Therapists’ at the end of the article, and make sure this is a mistake you won’t repeat in the future.

Excessive Focus on One Thing at the Expense of Everything Else

Oh this is one of my biggest bugbears! Two things particularly occur to me here.

system link back to a high value piece of content (lead magnet) which can only be accessed in exchange for an email address through a landing page, which we host for our subscribers. Which at least means the social media is being used to build that customer’s email list ready for nurturing towards a paying customer. In other words, it’s part of the bigger picture strategy. But how many of you reading this article, are spending precious time posting to your social networks in the hope that you’ll pick up a few more page followers or fans, or attract a bit more engagement, with little or no additional strategy to your social media activities? And even worse, if you’re paying to boost these posts, with the same desired outcome, STOP NOW, PLEASE!!! There are so many better ways to spend your money. Think about how much time you or one of your team is spending on this. Are you getting a return on your investment? Do you know how to get a return on your investment? Is it feeding into another part of your marketing strategy, if so how? Social media is not going to change your business. It is certainly a piece

Social Media is the Marketing Cure-All The first is a blind faith that social media is the marketing cure-all. When people sign up to my marketing system, the first thing they rush to do is to set up their social media campaigns. They’re just itching to get the social media posts that we create as part of the campaigns onto their social network pages. Why? Well, admittedly they are awesome and they do look sexy, but the main reason is that everyone is obsessed with social media. Unfortunately, this obsession rarely has any strategy behind it (there we go, we’re back to strategy again). Thankfully my system forces some strategy into the equation, because nearly all of our social media posts that are posted from within the Co-Kinetic

of the jigsaw, but that is ALL it is. In isolation it achieves nothing and means nothing, just like a piece of a jigsaw. 2. Over-Investment in Websites My second bugbear is that generally people spend too much money and time on their website. Yes, a website is important, it’s an online brochure. It needs to be functional so they can easily get in contact with you and find maps and directions on getting to their appointment and parking (if relevant). It needs to profile you and your team – don’t hide behind a ‘contact us’ form, put a real face to your business. And it absolutely must have an active blog area. There are SO many benefits to publishing good quality content on your website. Here are a few: n Publishing video content boosts your search findability. n Blog posts can dramatically increase your search engine optimisation and findability. n Educational content helps you establish authority and reputation. n Publishing content about your team, your clinic and your services can help a customer get to know you and develop the all-important trust, before they commit to booking an appointment. n If you use blog posts and valueadded content (lead magnets) with lead capture pages it can also become a source of new prospective customer leads. But there are really only five pages you need on your website: 1. home page – read my article on home page essentials: http://spxj.nl/2seLPuS a. include videos b. links to new blog posts c. and/or publish the new posts on your social network and embed

a feed from the social networks onto your home page (see EmbedSocial.com) about us page – qualifications, credentials, include videos if you can contact us page – with maps, directions, contact details, sign up to newsletter button, etc. services – what you and your team can do/offer; focus on pains and problems you can solve, ie. benefits, not features blog area featuring regular educational, value-added content and particularly videos.

And make sure testimonials feature wherever possible – embed Facebook and Google Reviews on any page of your website using this resource: https://spxj.nl/2kJsLls. Do those 5 pages well and don’t go overboard with loads of extra superfluous stuff. Oh and you absolutely MUST make sure your website is mobile-friendly, ie. it rearranges itself in layout to accommodate mobile phones and tablets.

Make Excuses: “Can’t Market, Won’t Market”

This is your classic malingerer! They make excuses and then end up doing nothing, not a scrap of marketing. But boy do they moan about not having enough customers. It’s everyone else’s problem but their own. This is arguably the worst presentation of all of them. They talk themselves into failure without even realising it and it’s arguable that this person shouldn’t even be in business in the first place.

Leaky Customer Journeys/Marketing Funnels

This is how you take someone from first coming across you or your

NOT DOING YOUR MARKETING IS LIKE YOUR PATIENTS NOT DOING THEIR PRESCRIBED EXERCISES

business, through to building trust, authority and becoming liked, and then through to converting an individual into a paying customer. To do this, you NEED a customer journey or ‘funnel’ strategy in place. But then you need to make sure that customer journey is smooth, consistent and watertight, ie. they don’t fall through any cracks or holes. So once you’ve collected new prospective customer leads, don’t just leave them sitting in your email list while you ponder what to do with them! That’s a waste. You need to strike while the iron’s hot. In practical terms you can do this with regular nurture emails which both offer value-added information, help, advice, support and education but also opportunities to take the next step in a customer journey, such as getting face-to-face with you and attending some sort of conversion event like a mini-assessment, free workshop or presentation. The emails we write as part of our marketing content follow up with additional information based on the topic of the campaign that prompted you to give your email address in exchange for some value-added content. So, if for example someone signed up because they wanted to access the advice leaflets on the 8 most common cycling injuries, the follow-up email we’d write for that campaign, would offer additional value on that same topic. In our case for the cycling campaign, it was a professionally designed newsletter we’d produced as part of the kit covering cycling injuries and accompanied by a cheat sheet on some tips you can do to prevent common cycling injuries. We then suggest conversion opportunities that you can run to take that customer to the next level and provide you with all the information you need to promote these events. If they don’t convert, that’s fine. But next month, you’ll send them a new email with value-added information on that month’s topic, along with details of your next freebie session (if you’ve decided to run one). If you do this each month, each

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person on your email list is receiving regular value-added information that they’ve very unlikely to unsubscribe from, and which keeps you at the forefront of their minds. And they may well forward your email to someone they know who might also be interested (especially if you ask them to, which we always do in our email templates we write for you – you’d be surprised how a simple call to action can generate responses). Email nurture is a hugely powerful marketing tactic that practitioners could do really well and without it eating up a huge amount of your time (especially if you use our content). This to me is one of the leakiest (if not non-existent) parts of most marketing funnels, and the one that presents with the most opportunity to make a difference to therapy businesses.

Using the Wrong Channels

Before you commit time and money to promoting your business in a particular channel, MAKE SURE YOUR TARGET CUSTOMER IS ON THERE!!! I’ve had so many people ask me about running Instagram stories or using Snapchat to market their businesses and my answer is always the same – if your target client is under 35 and female, then Instagram could work for you. If that’s not your target audience, there are other platforms that you should be focusing on. Moral of the story? Do your research before taking action.

Not Addressing Your Client’s Pain You’ve probably heard the

Co-Kinetic.com

saying “focus on benefits, not features”. We’re all at fault of doing this and me as much as anyone. I love what my marketing campaigns consist of, because there’s so much value packed into one little campaign. So when I create my marketing material, I leap straight into: “Every kit contains: 25 social media posts; 6 videos; pre-built lead collection pages, posters, leaflets, adverts, email templates, blah, blah, blah.” Well, every kit DOES contain all those things but so what? They’re features, not benefits. They don’t solve any problems for you. So I have another crack at it! Each campaign helps you to: n collect new prospective customer email leads n increase awareness of your business n nurture these leads towards becoming a paying customer n build trust and engagement n convert those leads into paying customers n become more findable on Google. Better, but still it takes a bit of a stretch for the reader to really drill down to what it’s going to do to change their lives or help them achieve their dreams. Again I say, so what and have another go at it. How about: n never again worry about not having enough customers n build the business you’ve always dreamt of n h ave access to a never-ending supply tap of clients that you can turn on and off when you want to

SOCIAL MEDIA IS NOT A MARKETING CURE-ALL n b e able to hire admin help or bring more team members on board n move into your own clinic premises n take your family on their dream holiday, etc. These are more powerful benefits that speak to anyone who aspires to achieve those goals. As Andy Byrne talks about in his brilliant presentation “Grow Your Business By Making Your Patient’s WANT to Come Back” (which you can access at this link: https://spxj.nl/2xGwrOe) – you’ve got to get right down the nitty gritty, and understand how your client’s pain is affecting their life and what they will be able to do once you’ve fixed the current problem, that they’re unable to do now. It could be things like “being able to play with my grandkids when they come round”, or “being able to walk up Kilimanjaro”, or “getting a great night’s sleep and waking up feeling awesome, because my back pain didn’t wake me up at an ungodly hour”. As a business owner, what are your pains? They’re probably more likely to be things like: n tossing and turning at night worrying about not having enough money coming in or enough patients on your books; n a new competitor who’s moved into your area and is nabbing all your patients; n feeling pressure to market yourself,

41 4i

but not knowing how to; or n worrying you don’t have the skills that you need to keep your business afloat, let alone help it thrive. Those are the problems I’m looking to solve for you. So, think about the problems that your clients need solving and market your services in those terms.

Spending Too Much Time on Creating Content and Not Enough Time on Promoting It

OK, I totally get this one, even though it’s my job to promote my content! How often have you spent ages writing a blog post that you then publish on your website, and promptly forget about? It’s like you’ve ticked off the task, and now you can move on. Old is boring! But every marketing expert will tell you, you need to spend 20% of the time creating content and 80% of the

time promoting it. I’m SO guilty on this count. Basically, if you spend an hour writing an advice leaflet or an article on back pain, you should spend 5 hours promoting the existence of that content. (If you use my content, however, you don’t have to spend any time creating it, but you can spend the hour that you would have spent creating it, promoting it!)

Viewing Marketing as Sales Instead of Building Relationships

If we reframe our heads and instead of thinking about marketing as a function of our business and sales, think of it more as a process of meeting more people (online or offline) and building relationships with them, then it takes a completely different direction. We’re ‘people people’. This stuff is second nature to most of us, which means we should excel at it.

The problem is that historically our ‘marketing’ has been orientated around ‘pushing’ our businesses instead of trying to build on relationships and help support our communities. When you look reframe it like this, everything else will fall into place.

Not Being Focused About Your Target Customer

I have a slide that I use frequently in my marketing presentations. The Perfect Prospect is: someone with the highest probability that they’ll require your services and soon, the motivation to seek your services and the means to pay for them. Probability, motivation and means. Think carefully about who those people are, and focus your efforts specifically on that group, you can always add additional target groups as you get going.

Hiring People to do Your Marketing, Who Don’t Know Your Business or Industry

This is one of the biggest war cries I hear from people who join up to our marketing platform. Often, they’ve paid someone else to do their social media and write blog posts for them, but because those people are usually marketing experts rather than practitioners, the content has either not been up to scratch, but even on occasion has been clinically inaccurate, which (as every one of us can appreciate) in our industry in particular, this looks pretty bad. So make sure the source of your marketing material, particularly if you’re using a content-marketing approach, is technically correct and accurate. I would add another caveat here around hiring people to do your marketing for you. Only do this when you have some understanding of what needs to be done. There’s nothing more destructive to a business relationship, than people offloading responsibility for something when they don’t understand it, and therefore have

Co-Kinetic Journal 2018;77(July)38-43

ENTREPRENEUR THERAPIST

unrealistic expectations of what can be achieved. It doesn’t matter if it’s your Facebook advertising, or your lead collection processes or the impact blog posts will have on your search engine optimisation. Take a bit of time to do a bit of research and get some sort of understanding at the very least of what can be achieved. It’s all too easy to watch all these Facebook ads making huge claims and then expecting the same to happen overnight for you. It just doesn’t work like that, whatever promises those presenters make!

ON A FINAL NOTE At the end of the day, everyone is selling something. Yes, I’m selling content and a marketing platform, but test things out, read up on stuff, do your research, talk to people, read reviews and whatever you do DON’T LOOK FOR A MAGIC BULLET, BECAUSE IT DOESN’T EXIST! You’re not going to increase your return on investment by 300% overnight, you have to be prepared to put the work in. Marketing does take time and it does take effort and you might think that you don’t like it because you’re thinking about it in terms of sales. Switch that to building

relationships, offering value, giving advice and suddenly everything takes a very different and much happier direction. Here are some related resources you might like A heads up: some of the resources may require you to enter your email address to access them, this is just so I can ensure I’m GDPR compliant when I send you the info. n F ive Go on a Patient Journey https://spxj.nl/2xGwrOe This is a brilliant video series with loads of strategies for building your business and delivering an amazing customer experience. It’s based on five presentations that I and another four practitioners did at COPA 2018 (don’t worry we re-recorded them in the quiet of our own houses). n A Crash Course in Marketing for Physical and Manual Therapists:

KEY POINTS nS ocial media is not your marketing panacea. n Paid advertising on Facebook can be a phenomenally powerful tool in your marketing tool kit, but only if based on a good strategy. n A lack of a sound strategy is the biggest single reason for marketing failure. n Marketing is like a treatment plan, you have to complete all the components to give you the best chance of a successful outcome. n Social media (for marketing purposes) is only one part of the jigsaw. In isolation it’s meaningless, it only becomes effective when it’s part of a bigger picture. n Successful marketing is a ‘little-and-often’ process, not a ‘shit-or-bust’ process. n Just as patients can’t delegate responsibility for their rehabilitation to you, you can’t delegate responsibility of your marketing to someone else. n Decide on your perfect patient prospect and then get focused about your marketing. n Make sure your marketing content focuses on aspirations and life goals. Think benefits, not features. n Stop thinking about marketing as part of a sales process. Marketing is all about building relationships, offering value with no strings attached, and developing trust.

Co-Kinetic.com

The Quickest Way to Get BusinessChanging Marketing Results for the Least Amount of Effort https://spxj.nl/2JcHJza. It literally does what it says on the tin – it consists of 3 videos of 45 mins in total.

RELATED CONTENT “Ready-To-Go” Marketing Strategy for Therapists A http://spxj.nl/2haSVyW Crash Course in Marketing for Physical and Manual A Therapists: The Quickest Way to Get Business-Changing Marketing Results For the Least Amount of Effort https://spxj.nl/2J6KotP hy nobody ever engages with your Facebook posts, W why it’s impossible to ‘bombard’ your page followers with too many posts, and what the Jan 2018 Facebook news feed changes mean to your business Facebook page - http://spxj.nl/2CQqcc5 THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Twitter: @CoKinetic Facebook: https://www.facebook.com/sportex.tor

TO GROW YOUR (GDPR-DECIMATED) WAYS EMAIL LIST Email list-building is everything to your business. And if it’s not, it should be. In fact, if you’re interested in conversions and business growth in general, the number one thing you should be working on right now is how to grow your email list. Why? Because email is almost universally used. It’s more popular than social media for communication, it gets far more conversions than any other platform and it’s a direct line to your audience that works, especially when you have engaged, interested readers. Here’s a list of 25 proven ways to grow your email newsletter list and harness the power of email to turn readers into paying clients. Read this article online https://spxj.nl/2Iq8oE9

BY TOR DAVIES, CO-KINETIC FOUNDER 18-07-COKINETIC FORMATS

WEB

MOBILE

Collecting and nurturing your email contacts is one of, if not THE, most important aspects of marketing yourself and your business. Unfortunately, it’s one of the areas people tend to neglect the most … sharp intake of breath … which is a crazy waste of opportunity. Even if you don’t need new customers right now, what harm is there in delighting them with loads of great-value content while you wait for the time to come when they may need your help? It’s not like it takes any longer to send an email to 10 people, as it does to send to 2,000 if you use a dedicated email marketing platform like Mailchimp (which is also free for up to 2,000 contacts). But I can already hear the negative self-talk starting up … but I hate sending emails, I never know what to write in them, I’m crap at writing anyway and I hate feeling like I’m selling. Well, luckily for you there’s a solution to all those problems.

FOCUS ON PROVIDING VALUE You need to focus your efforts on something that’s known as ‘inbound marketing’. What is inbound marketing? Here’s a definition from Hubspot, one of the most highly respected digital marketing authorities: 44

“Inbound marketing is focused on attracting customers through relevant and helpful content and adding value at every stage in your customer’s buying journey. With inbound marketing, potential customers find you through channels like blogs, search engines, and social media. Unlike outbound marketing, inbound marketing does not need to fight for potential customers’ attention. By creating content designed to address the problems and needs of your ideal customers, you attract qualified prospects and build trust and credibility for your business.” Inbound marketing is also commonly referred to as content or educationbased marketing which you will have heard me talk about in many of the presentations I deliver and articles I write. That’s because it’s the central strategy behind the marketing content that I create for therapists.

MARKETING IS RELATIONSHIPS Here’s a suggestion: in future, stop thinking about marketing as a part of a promotional or sales process, and instead think about it in terms of building relationships and getting to know people. See, it already feels better doesn’t it? Co-Kinetic Journal 2018;77(July):44-47

ENTREPRENEUR THERAPIST

Instead of trying to shove your business in people’s faces, just offer them valuable content instead and let them come to you. It takes all the pressure off you and it sets you free to do what you do best. Help. What do I mean by valuable content? n blog posts on topics that are common issues among your patients n email newsletters with key tips or helpful resources that lead to your blog posts for more information n advice handouts and rehabilitation leaflets n newsletters and cheat sheets. Basically, all the same sort of content that we create in our marketing campaign kits. Every piece of content has the same purpose, to educate, inform and where possible inspire. And email is an awesome way to get this content in front of people and add this value to their lives. There’s not a sales pitch in site and that’s exactly how it should be. If you want to ask them to like you on Facebook or share their newsletter with their mates who they think would find it useful, then that’s fine, but draw the line there. Don’t be tempted to put in any sales pushes, and if you do, keep it seriously low key. Maybe a PS. at the end with this month’s offer but equally if you don’t want to then don’t do it. This is all about building relationships, offering value and building authority and trust. I’ve written a more detailed article about using the power of email to nurture relationships at this link (http://spxj.nl/2BU2UO3). There’s nothing to stop you sending out a more sales-orientated offer as a one-off email as long as they’re the exception rather than the rule and the rest of the time, the reader is getting value. There are some great advantages to taking this approach: 1. a more engaged readership 2. higher open and click rates 3. better deliverability (high open and click rates help the various internet algorithms work out what should get priority over what) 4. increased sharing 5. lower opt-out rates. Co-Kinetic.com

THINK ABOUT MARKETING IN TERMS OF BUILDING RELATIONSHIPS As you probably already know, a copywriter and I write a brand new nurture email, which is exactly what I’ve described above, with every marketing campaign we create. If you have a Mailchimp account it’s a oneclick import into your own account; or you can copy and paste the text and images I provide if you use another email programme. It takes less than 5–10 minutes a month and is an absolute no-brainer. Even if you don’t subscribe to our system or content, I really would recommend that this is one part of your marketing that ANYONE and EVERYONE should be doing. Pick an educational topic and write a short 400–800 word email or blog post on that topic. You could publish the full version on your blog and link to it from the email which you use to publish a teaser/taster version (giving them a strong benefit to go to the blog post itself). Just make sure the email contains valuable useful information in its own right.

TO BUILD 25WAYS YOUR EMAIL LIST

Here are some ideas for building your email newsletter list.

Run regular events: For example, a monthly education session – and make sure you collect email addresses for everyone (preferably by asking them to register online – this saves you time from doing data entry) and allows you to send automated event reminders.

Do special promotions: These could be in honour of national events, or for significant dates such as Valentine’s Day, the start of the summer holidays, celebrate “kids go back to school”, Royal weddings, local or national sports events – anything you can think of and offer an incentive to sign up: for example, “Take the weight off your feet now the kids have gone back to school, and treat yourself to a massage with our 20% discount offer”. Gift of

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Send out a postcard or postal promotion: Our mis sion is to Ask for email information educate in and give them a reason form an , d inspire to sign up. In a recent Email Newsletter SignUp campaign that we produced as part of our marketing system, we created artwork for postcards, posters and leaflets that encouraged people to sign up to our subscribers’ newsletters. P

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Take email sign-up forms everywhere you go: And I mean wherever you go, whether it’s a sports event, or local community meeting, take a simple print out signup sheet that asks for first name and email address – and which provides some sort of offer/incentive for people to sign up. Or describes what benefit they’ll get for being part of your list.

Use business cards to encourage email sign-ups: Often under-utilised, put a bowl on your reception desk or entry to your clinic where people can leave cards (again offer an incentive that’s worth having) and make sure that you include info on your business card with a quick link to where they can sign up for your email newsletter (this is an ideal use of the back of the card).

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Have a prominent home page sign-up button: We provide a newsletter sign-up page as part of our marketing subscription which you can create a simple sign-up button for OR you can use a sign-up form from the email provider you use. Mailchimp has embeddable sign-up forms that you can add to your website.

Use your blog posts: Anyone who uses our marketing content knows this is one of the best ways of collecting new email leads. Publish 45

a blog post on your website on, for example, cycling injuries, and then offer a value-added content upgrade which could be patient advice leaflets on the most common injuries, which they need to give their email address to access. This is a major feature of the lead collection aspect of the marketing content we create.

Use your social networks: Again this is a key part of our marketing content at level 1 (the lead collection phase). Publish social media posts to your social networks which lead back to a content upgrade where they can get more valueadded content on the same topic, in exchange for giving you their email address. All it requires is to have a really powerful ‘content upgrade’ offer which sits behind a lead collection/ sign-up page. But an important note, do not expect organic (unpaid) social posts to achieve this because the Facebook algorithm changes mean that very few people will ever even see your organic posts. Paid promotion of lead collecting posts is the only way to go here.

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Offer downloadable freebies (also known as lead magnets): Again, similar to the point above, offer ebooks or educational articles or newsletters in exchange for email addresses (we also produce these as part of our marketing campaigns).

ting Secrets to Preven ry Hamstring Inju

how to and mastering injuries in sport medicine. most dreaded Grails of sports are one of the one of the Holy amstring strains first is they are dreaded, the injuries has become hamstring injuries prevent hamstring reason is that of reasons why and the second to There are a couple ing injury to rehabilitate, a particularly important injury and time-consum them are a very frustrating they frequently recur. This makes treatment. physical therapy and once they’ve occurred, generally does require proper in the first place, and a hamstring injury below. be preventing rehabilitate properly, that we’ve outlined of course would few simple tricks The ultimate prize if you follow a do to possible this is completely

some of these H TELLS US in hamstring strains, unchangeable. factors involved WHAT THE RESEARC because they’re us about the risk data tells some you can’t Here’s what the risk of injury, but to reduce your you can address These risk factors

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Given that PREVENTING back muscles. together with your other for depend on each YOUR these muscles that a healthy 1 INCREASE it makes sense Y normal function, BACK MOBILIT for good hamstring lower back is critical suffer from that If you frequently is where the nerves performance. therapist for The lower back lot see a physical come from. A or back problems and exercises, control the hamstrings hamstring strains develop more specific treatment at work. of people that and ergonomics posture back symptoms on lower advice have co-existing as may be as simple GLUTES or problems. This back with 2 RELEASE YOUR tightness in the a sensation of or may be as significant a pre-season certain activities training hard in al disc. Either way, If you have been activity as a bulging intervertebr back increasing your and flexible lower INJURY build up or simply is often a a well-functioning SIGNS & to work (gluteal muscles) t! SYMPTOMS your hamstrings load, tight glutes Knee Pain not a complimen it vital to allow ergonomics at e. Now, this is and COMMO ● Pain in/under posture consequenc the N CAUSES all properly. Poor the kneecap workload increases, a desk or driving ● Worse As intensity and even sitting at knots (known and ● Poor going up and TIP work alignment the hip develop of your back. Your down and tracking hills/stairs muscles around referred pain affect the mobility ofcan day kneecap This can cause ● Address together with your due towork ● Worse muscle as trigger points). muscles muscle after prolonge weaknesses hamstring in turn work d andmuscles strengthening imbalances with tightneswhich sitting ●gluteal (buttock) s Increase and stretchin d training ● Vary your intensity, seat pedal cadence g exercises too low, riding ● Raise seat too long in height gears big Back Pain ● Use insert in shoe to ● Cleat too ● Deep ache stabilise foot near inside across lower HT TO strain on knee of shoe and reduce BROUG lumbar area ● Mechan ● Move cleat with stiffness ical factors outwards ● Can refer YOU BY: like poor bike posture, into buttocks ● Improve hunching , groin and flexibility over handlebars hip ● Core strength ● Worse ● Lack of after prolonge ening flexibility ● Alternate d sitting and postures whilst ● Weak core on getting muscles riding to up in reduce load the morning on spine Neck Pain ● Check leg length ● Pain along discrepancy back and sides of neck ● Poor bike posture ● Can refer hyperextension – excessive pain to shoulder ● Strength (looking up) and down tips en deep neck the neck between shoulder of flexors (stabilise ● Lengthe blades n trapezius ● Weak stabilisin r muscles) muscles by ● Shorten g muscles stretching your reach of neck on bike Iliotibial Band ● Raise handleb ● Pain and ars ITB) Pain ● Vary hand tenderness positions whilst on outside of ● Repetitiv change neck riding to knee e rubbing postures ● Occasio of band over nally swelling bony condyles ● Raise seat ● Pain walking ● Exacerb height up and down ated by poor ● If you pronate stairs flexibility of thigh, hip (flat-footed and buttock ) get a wedge/orthotic ● Stiffness after inactivity muscles ● Don’t tuck ● Weak pelvic your knees in too close stabiliser muscles this increase to stem as ● Cleat too s tension on near outside Achilles ● Move cleat ITB of shoe inwards ● Pain at Tendon Pain back of ankle ● Strength en weak pelvic ● Pain during ● Increase stabilisers ITB, thigh riding and d training and stretch and buttock afterwards intensity, hill muscles training ● Strength ● Pain and en Achilles ● Lack of tightness after tendon and flexibility in ● Improve inactivity or calf muscles calf muscle flexibility on rising in ● Lower the morning saddle to avoid cycling Hip Pain this loads on ‘tippy toes’ the tendon ● Deep pain as in the hip, thigh, groin and ● Overtrai buttock areas. ning, pushing ● Can refer high gears pain into ● Strength possible numbne leg with en underlyin ● Muscle imbalances g muscle imbalanc ss ● Improve and/tingling in flexibility hip/pelvic e Hand Pain region ● Gear back and increase ● Numbne ‘Handlebar cadence ss, tingling Palsy’ and weakness ● Wrist extende over outside d on handleb of hand, little for prolonge ars finger and ● d outer Alternate periods, weight half of ring hand positions of rider pushing finger ● Shorten during ride ● Clumsin stem and ess in hand and vibration through wrist sit up more Burning Feet s from road on wrists to reduce applies pressure to ● Painful weight ‘Metatarsalgia’ burning feet ● Gel padded ulnar nerve IATION WITH IN ASSOC gloves CED and padded ● Long hilly PRODU reduce handlebars pressure rides, hot weather ● Tight shoes ● Wider – compres shoes sing nerves and ● Move cleats impeding circulation closer to the heel to reduce on forefoot pressure ● Larger platform pedal ● Support ive inner soles and thermo-r socks egulating s on D should progresis not SPEE ION speed you Progression you on the PROGRESS programme. it correctly, with t will advise ent control ance to do Your therapis E s hening/movem the exercise but poor perform PROGRAMM strengthen muscle leads to the strengt to do or practice being able feel pain BILITATIONspecific exercises to and flexibility in ber poor just about time you is me has YOUR REHA control. 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Use pop-up lead collection boxes (also known as light boxes) on your website: This is really simple to do using tools such as the LeadPages pop-up forms, or free tools produced by companies such as Sumo Me (http://page.sumo.com/gosumo). The key to it is having the right sign-up incentives. It doesn’t always have to be discounts or prizes. It could be free information resources such as cheat sheets or rehabilitation leaflets.

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Team up with complimentary businesses: Ask them to include an offer in their newsletter and you include one in yours for them. Give them a link where they sign up and then set up an automated email to trigger

when they sign up, giving them details on how to redeem the offer.

email sign-ups). All the time focus on offering value.

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Do email newsletter specials: So only people on your email newsletter receive the offers or special information.

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Make sure every email you send out has a link or button to a sign-up form: It’s always good practice to include a ‘call to action’ asking people to share your email with other people who might be interested, especially if your email is on a specific topic like running or cycling, or headaches, etc. And then

Use posters outside your clinic: As I mentioned earlier, our Newsletter Sign-Up campaign included posters advertising your monthly newsletter and telling people how to sign up.

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Add sign-up details to any paperwork: Things such as receipts or letterheads or even your business cards should feature a short link where they can sign up for your newsletter with a mention of the

n Our missio is to educate,

inform and inspire make sure there’s a button or link where the recipient can sign up to future newsletters.

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you a higher lot faster the ‘mirror key. If race a time , reach is essentially of injuries. for some YOUR REHABILITATION PROGRAMME GUIDANCE FOR STRETCHING EXERCISES revention risks or causes ultimately, consistently then you treatment of – and those, image’ This exercise programme has specific exercises to strengthen muscles Hold all the stretches for 20 seconds each and repeat them five times rehabilitation has ‘healed’. Weak workouts understand injury If you on each side. It is important to stretch the uninjured muscles so that around your shoulder, upper back and scapula. The exercises will and less TRAINING: is an after the to start. to injury glycogen where prone you are well balanced. improve your rotator cuff strength and shoulder girdle control as well Muscle exercise, of running. 7 STRENGTH Overloading are more stores. forces strenuous and of as stretch and mobilise tight structures. In order to achieve proper exercises. muscles ERRORS: impact glycogen fatigue to the strength key. fuel during repetition TRAINING is rehabilitation of your injury it is important to ensure the exercises are PROGRESSION SPEED resilient fundamental essential constant of it causesglycogen stores your mileage, on due to If leg strengthnever on start Watch Focus performed with good technique. Poor practice may place potential strain Your therapist will advise you on the speed you should progress. tissues the depletion single you will action. your weekly you are performance. replaced, For runners, running, state, Progression is not just about being able to do the exercise but to on your shoulder. Before starting each exercise ensure you have good the running aim to increase5-10%. Include inhibits Each leg the you’re effectively same time. to absorb When you should no more than are not a semi-depleted do it correctly, with appropriate control. If at any time you feel pain or posture - straight upper back with scapula back and down and chin Run on at the and therefore run in by enough are about cross train. fatigue both feet mileage the next discomfort stop the exercises and consult your therapist. slightly tucked in. The following leaflet includes some exercises to help which same may days and surfaces (including the to be strong potential and forces, needs during and recovery causing injury risk. The in your rehabilitation. nature and fluid reaction routes weight, ground different also increased of dehydration the repetitive your body true to vary You should 2.5-3 times grass) also be after exercise. phase. your body. pairs of different for PENDULUM WITH TRACTION ISOMETRIC SHOULDER landing 2-3 load on great replacement – or the AND runs are between a full Mobility INTERNAL ROTATION WALL Hold a weight in your hand. Lean over rotate Group but ensure IMBALANCE with through shoes. move company the group holding on to a chair or table, let your Stand with your side to a wall or a door frame. 8 FLEXIBILITY: (like being running 5 MUSCLE This overlaps fun and to a healthy within factors to effectively We – is key tissue and WEAKNESS: ability motivation, at your pace on long, or Tuck your elbow into your body. Push your arm arm hang down by your side, and swing scar run off of motion and anatomicalknock knees). reduce range causes you can get dragged posture inwards across your chest, into the wall. Keep your your arm gently in circles. Try to let which or having daily, particularly ready Running to form, body. in muscles and don’t if you are not ‘flat footed’ postures elbow tucked in to your side as you perform the momentum and gravity move your arm. adhesions negatively impact stressful The imbalances for of nonmuscle hilly, runs and adopt held where movement. This will cause a contraction of the Go anti-clockwise and clockwise. This sitting, CAL FACTORS:is very positions lead to your mobilityA large proportion when ‘style’ Static stem from shoulder muscles. Hold the contraction, and relax. exercise is a great way to passively may BIOMECHANI people your stride.running injuries to restricted your running can develop. or jobs that muscles, 2 you Repeat as required. mobilise a stiff shoulder. run, or that some dreadful. leading create nt of some traumatic know in running way long periods, look We all tightness alterations to of others, if you muscle tight and and relevant. an overdevelopme ent while others not relate daily, even SETS REPS SETS REPS underdevelopm abnormally long look does action is. general biomechanics stretches look fantastic and for you between weak and your how are great These gait. Dynamic However inbalances muscles, or patterns or efficient that day, stability. even impossible or a don’t run flexibility and how ‘stressful’difficult or STANDING SCAPULAR shortened will alter movement a coach and squats. ISOMETRIC SHOULDER can increase be with This which or ADDUCTION TOWEL strength, swings, lunges teeth balance Style can so always consult ones. STRENGTHENING control of working leg A physical and your include help in to change and postural for injury. Stand up tall, with good posture. Place your brushing core strength Stand up and place a large rolled up towel with experience a great and Even when to improve can be therapist the potential arms just out from your side, and palms facing regularly, under your arm pit. Bend your elbow to leg therapist places on one foam roller can. Prioritise runners. manual 90 degrees. Gently contract your arm inwards forwards. Squeeze your shoulder blades Use a Running if you TIME: stability. this situation. adequate pressing into the towel. This will cause a massages “trigger points” the strongest together as you draw your arms back. Let regular One of RECOVERYbody. If given will act tight injury moving get 3 contraction of the shoulder muscles. Hold the INJURY: your chest and rib cage expand. You should previous on the especially supple. Keep and stresses those desk, these to adapt stresses and 6 PRIOR for injury is aIdeally thereforenot, contraction, and relax. Repeat as required. at your loose feel a tightening of the muscles at the recover the body tter and If stretch in your draw to stay time to risk factors 12 months. injury! causing it fi the day, bottom of your shoulder blades. This ball past the first whilst during or golf as a stimulus manner makingis inadequate in the treated, REPS your feet SETS to prevent tennis is fully exercise will strengthen your lower start if there soles of keep a the body in a positive you want your injury before you out the However, a sessions damage trapezius muscle and rhomboid muscles, and help with posture. and roll to avoid stronger. then ensure rehabilitated training and and minor into to running pain from working. time between recover healed return ISOMETRIC SHOULDER develop feel fully your SETS REPS does not can consequently a progressive if you don’t continue EXTERNAL ROTATION WALL to Even to tissues re-injury. you may need Stand with your side to a wall or a door Hard an injury. the injury, frame. Tuck your elbow into your body. Push CHICKEN WINGS NUTRITION: of muscle’s your arm outwards away from your body, Place your hands on your hips, and depletion 4 INADEQUATE causes into the wall. Keep your elbow tucked in to pull your elbows backwards, and then posture, bad training other from your side as you perform the movement. forwards, as if you were making Click for strain stress and video This will cause a contraction of the shoulder chicken wing movements. This is on by alcohol just positions, brought muscles. Hold the contraction, and relax. a useful mobility exercise for your nutrition, name often to sleeping poor Repeat as required. shoulders. awkwardhabits like weight gain, spent lifestyle you on and with use pain, SETS REPS SETS REPS have along back can consumpti nights with you to get strategies that nights Video: a few. ow manyand turning possible morning are 6 Here ying exercises, sleeplessup feeling This information position the next http://youtu.be/1iZJ_r8_QeA went tossing those wake up you is intended every as general banish you to accompan trying getting than when you guidancemedical The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual and information le and or as a substitute to help and allow for action. feeling only and day care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2017 exhausted for specialist all comfortab medical adviceshould not be relied for good, and ready more cycle the next in each individual upon as a basis feeling spend repeat the RIGHT N refreshed case. ©Co-Kinetic for planning individual you to THE still, it’s something to bed? only medical care 2017 POSITIO Well, at some Worse weary, for Back night? 1 ADOPT G and PRODUCED Positions pick a SLEEPIN the next us experience irritable and BY: of again “Sleeping during over you. pain in three leaflet ying videos, le for back one often to our life. that with Refer accompancomfortab on their in our dealing this pain the for with lying point most as if that Pain” enough, throughsleep not that’s And find le positionknees hard intensity of isn’t position people lack the in your is Many most comfortab under pillow the day increase resulting function and to to the in The a pillow is the anxiety tends ability Place back neutral. that curve meaningon your cause pain. spine also night, to keep back your impacts but can you works keep only is relentless, day, When . and state — it cycle help? evenly followingdepression pain emotional ess is important back. position back to our lower this weight widest lead chronic a toll on , and sleeplessn your your does the spiral. 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What’s pillow isn’t pressure of your that comfortab pain use a find and like cancer back body alignment don’t side your of your If you on your conditions to adjust you’ve knees the alignment try sleeping once your back between and improve your this causes onto and to positionIf you roll side, back of Being Loss your active . on your less spine. fitness,muscle behind asleep weakness, backwardssame joint fallen a pillow on the muscle tuck from rolling stiffness pain, you make sleeping lead to prevent and avoid this can try and off as pain, Try Timemoney time on work, all the and increased equally.Sleeping worries, sides side s a relationship help? better. on both concerns Create list feel imbalance ‘no go’ to sleep this position you knees that’s of things sure do does won’t make your pelvis, can’t THE How hips, alone between your OF side your the pillow will keep CYCLE IC the fetal It’s using The pillow alignment. then le disc the trick. in better CHRON comfortab a herniated toward most spine Negative fear PAIN and have knees toward be the thinking, future, If you likely to your BACK of the is depression in. 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Slee ping Flat Position On Back

Social sharing options: Similar to the topic above, make sure you include some options for your readers to share your email to their social networks. You’d be surprised how effective this can be if the content is either useful or there’s a value attached to what they’re sharing.

benefits of doing so. Or include a leaflet in anything you post out.

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Check in on Facebook: This isn’t technically an email sign-up tactic but it does mean more people see your brand and offer your clients a reward for doing this (you could also ask them to review you at the same time).

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Get involved on blogs and Facebook groups: This is a great way of marketing yourself without actually marketing yourself. Share useful information and links back to blog posts on your website (which in turn feature content upgrades in return for

gies rers ffe Strate Sleep ck Pain Su For Ba

Getting In and Out of Bed

gn ebsite to si Visit our w er tt e sl w e n l mai up to our e

TIME-SAVING RESOURCES FOR PHYSICAL

journal AND MANUAL THERAPISTS

gain loss

Stress, anxiety, and anger frustration

Include a PS. as part of your email signature or clinic email system: Which gives people a link to sign up to your email newsletter – always include a mention of the benefits of signing up and remember it doesn’t always have to be money-orientated, it could be value-added information and content.

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Give them information options on your sign-up form: For example the sign-up form I created for my subscribers to collect newsletter sign-ups included two Co-Kinetic Journal 2018;77(July):44-47

ENTREPRENEUR THERAPIST

different tick-box opt-in options – one was for educational resources and the other was for clinic news and offers. Then they have the choice which to opt in for (90% of people are opting in for both at the time of writing).

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Create an online course: This is much easier than it sounds if you set up simple automated emails. For example you might give people who sign up, a new exercise each day for 5 days, or 5 different pieces of information relating to the topic in question, for example do they have trouble sleeping at night because of their back pain? All you have to do is create 4–5 emails in a simple autoresponder series. When someone signs up for that series, it then triggers one email each day. It’s really simple to do in email platforms like Mailchimp (here’s a link to a help post (http://eepurl.com/cZlrnf))

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Surveys and quizzes: These can serve a number of different purposes. We’ve all seen the fun Buzzfeed ones which incorporate an element of personality testing in them but other things you could ask people to get involved in might be a report on back pain. Not only do you collect useful information about the prevalence of injury or musculoskeletal issues among your customer base, but you can also use it to ‘lead score’ people and get a sense of how likely they are to need your help or on what topics you could give them additional information. Just make sure it doesn’t come across as a salesy way of finding out how injured somebody is and then pitching at them as this will turn them off very quickly. Take a cycling quiz for example, you could ask what sort of cyclist they would say they were (ie. commuter, keen amateur, etc.) and then might go on to ask which out of the following injuries or conditions have they experienced and then list the 8 most common cycling issues. This gives you an idea of how many miles they put in, what topics Co-Kinetic.com

they might be interested in in the future, the sorts of injuries they’ve suffered (and you could give them advice handouts as a follow-up). Your imagination is the limit here and this is definitely a topic we’ll be discussing in much more detail in the future.

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Competitions: This is a really effective lead generation method. Generally speaking, the greater the chancing of winning, the more effective a lead generator it will be. You could team up with other local businesses providing complementary services to put a really powerful prize package together. This has the added benefit that these partners could also help you promote the event.

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Facebook lead ads: These are awesome ways of collecting new leads. It’s basically a native form that Facebook creates and pre-populates for the person who clicks on the ‘More Info’ button. So for example, say you’ve created a resource like a stretching leaflet or resource for people who suffer from sleepless nights due to back pain. Use Facebook ads to promote this resource as a free download for anyone who clicks and submits the More Info form. It’s super-simple to set up and you can collect leads for as little as 25p a lead.

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Chatbots: This is the marketer’s favourite topic at the moment and there are a growing number of tools that are cheap and easy to use (ManyChat, ChatFuel, MobileMonkey, etc). A chatbot is a computer programme that conducts a conversation via text or messenger. The most common ones are those that integrate with the Facebook Messenger app. For example, a chatbot might pop up when someone visits your home page, or a specific page on your site, and ask a series of questions. You can also programme them to deliver answers and obviously it can also be programmed to collect email

addresses to which you can then send additional helpful resources.

THE WRAP-UP Regardless of how many or how few of the above techniques you use, there’s one thing to constantly keep in mind, make sure that your primary focus is always on adding value. DO NOT be tempted to fall into the trap of pitching something salesy. Regularly check in with yourself and ask yourself if you’d be happy to receive, and would find value in, the content you’re creating or sending. Think about how you can serve your prospective customers better. Focus on developing your relationships with them and on building trust, and you’ll find that your email list will start to not only grow quite rapidly, but you’ll also experience vastly improved engagement too which is a win-win for everyone.

THE AUTHOR Tor Davies began her professional life training as a physiotherapist at Addenbrookes Hospital, Cambridge, UK. She went on to complete a BSc in Sport & Exercise Science at the University of Birmingham while also achieving a WTA international tennis ranking. After graduation she worked in marketing with a London agency and then moved into medical journalism where her passion for publishing was born. At 27 she established sportEX medicine, a quarterly journal for physical and manual therapists. With a passion for technology as well as publishing, Tor’s leadership grew sportEX into the Co-Kinetic journal and website which included a more collaborative, royalty-based form of publishing as well as a wider content remit. Tor’s focus is on providing resources to help therapists develop their professional authority and brand, and grow their own businesses while working more efficiently and effectively, a topic that she speaks regularly on at global conferences. Twitter: @CoKinetic Facebook: https://www.facebook.com/sportex.tor

RELATED CONTENT urning Email Leads into Paying Customers: Using the T Powerful Hidden Influences of Nurture Emails [Article] - http://spxj.nl/2BU2UO3 ow to Get More Patients Without Being Salesy [Article] H - https://spxj.nl/2LpsFuj “Ready-To-Go” Marketing Strategy for Therapists A [Article] - https://spxj.nl/2LXBCwa

ADVICE HANDOUT

ACHILLES TENDINOPATHY INJURIES IN RUNNERS THE INJURY The Achilles tendon and plantar fascia are energy-absorbing and energy-releasing structures that are working throughout each stride. They absorb the load as your foot impacts the ground (loads are often 3 times your body weight) and convert the energy to propel yourself during the push-off phase of a stride (where forces are as high as 7 times your body weight). The Achilles tendon and calf muscle are therefore an essential unit, critical for efficient and effective running. The Achilles tendon is prone to overuse purely by the nature of its function. Pain occurs because of weakness or dysfunction in the tendon rather than what was previously thought to be an inflammatory reaction. This can be a challenging area to treat due to the tendon’s poor perfusion (blood flow), which may need longer recovery periods, so it’s best to tackle this injury at the earliest point possible.

THE SYMPTOMS nP ain close to the heel, which is often sharp, poking and incapacitating. n Pain along the Achilles tendon, at the back of the lower leg. n Occasionally there can be mild swelling at the base of the tendon (near the heel) and redness. n If you pinch the Achilles and it’s very sore, then the source of the problem is likely to be the tendon. n Pain during and after running (Stop! This is not an injury you can run through) n In chronic cases there can be thickening or a thickened ‘lump’ along the tendon, especially when compared to the uninjured leg.

THE CAUSE The Achilles tendon is the extension of the calf muscles, gastrocnemius and soleus, where it attaches to the back of the heel and is responsible for plantarflexion (pointing your

toes). Sometimes excessively tight, weak calves are the culprit. Tight lower legs put added strain on the Achilles tendon, and over the course of many months of hard training, this overuse injury can develop. A weak posterior chain (the muscles that work together along the back of your body including the back extensors, gluteus muscles, hamstrings, calves) can also be a cause of Achilles tendinopathy. Constantly running on hard surfaces like concrete or asphalt can contribute to developing Achilles tendinopathy as the loads absorbed by the tendon are greater than running on grass or dirt roads. Unsupportive footwear can overburden the Achilles tendon with time, as it must work even harder to control ankle movement whilst running. Worn out shoes or shoes with inadequate cushioning can exacerbate Achilles tendon issues as they add no benefit in absorbing load during heel strike. Rapid increase in volume and/or intensity or training can have the same effect much more quickly, so it’s important to pay attention to both your feet and your sessions—especially when you’re training hard. Severe pronation, foot instability, a leglength discrepancy and muscle asymmetries can also contribute to Achilles pain.

THE FIX Rest, icing, and strapping can relieve symptoms in the early/acute stages. Reducing training intensity and volume may be required, possibly even complete rest for a few weeks depending on pain and the severity of the injury. The earlier you get treatment the shorter your time off running in the ‘long run’. Soft tissue massage can be used to release tight structures throughout the lower limb and back. Physical therapy treatment will mobilise tight structures, possibly use acupuncture and prescribe rehab

exercises to strengthen your calves, hamstrings, glutes and core. Stretching is also a key component to rehab. Eccentric heel drop exercises (lengthening under load), taught by your physical therapist, will be an essential part of your recovery. Advice about your shoes, orthotics and running technique can help. Importantly, keep an eye on your training. Don’t do too much, or go too hard, too quickly.

THE PREVENTION When people experience Achilles tendinopathy, it often starts as a simple feeling of stiffness in the tendon. If you take steps to increase flexibility, strengthen the ankle and calf muscles and decrease stress on the tendon at the first sign of stiffness, it’s possible to prevent the problem from escalating. One of the easiest ways to prevent Achilles tendinopathy is to keep the tendon strong and flexible. Regular strengthening of the calf, especially eccentric exercises will be beneficial, along with a regular stretching programme. It is important to strengthen the entire limb from the pelvis, core, hip, gluteus muscles and hamstrings as these will all ensure the entire kinematic chain is working efficiently and minimising overload of the Achilles tendon. Then address any underlying risk factors (like shoes, orthotics) and finally a key prevention strategy is monitoring your training capacity. Slow and steady wins the race!

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. ©Co-Kinetic 2017

PRODUCED BY:

TIME-SAVING RESOURCES FOR PHYSICAL journal AND MANUAL THERAPISTS

ADVICE HANDOUT

MEDIAL TIBIAL STRESS SYNDROME (SHIN SPLINTS) IN RUNNERS THE INJURY

THE FIX

Shin splints or shin pain is clinically referred to as medial-tibial stress syndrome (MTSS). It is an umbrella term that often refers to a number of issues involving pain in the shin area. At their worst, shin splints can turn into a stress fracture along the tibia, and searing pain will be felt with every stride. In less severe cases, the muscles and tendons in the shin area may be tender and inflamed, or even develop micro tears near their attachment to the tibia (shin bone); often pain lessens a few miles into the run and builds up again towards the end of a run or afterwards. Either way, shin pain is a sure-fire way to make your running experience markedly unenjoyable and accounts for approximately 15% of running injuries.

When the first twinges of pain strike, reduce your running to a comfortable level for a few days to a week, then slowly increase your mileage using the 5-10% rule (no more than a 10% increase per week). Cross train with cycling, pool running, and swimming. Include: 1. Rest, ice, and ibuprofen (non-steroidal antiinflammatories) to ease the pain. 2. Taping the shin can relieve pain and speed healing. Taping or bracing provides compression to aid relief, but also stabilises the ankle so the shin muscles don’t have to work so hard to support your leg. 3. Physical therapy including mobilisation, massage, and acupuncture can all promote tissue healing and mobilise surrounding tight structures. 4. Provided you are pain free when performing exercises, you should do flexibility/mobility activities for your ankle, calf and hip. Followed by strengthening exercises for the entire leg which may include squats, bridging and balance activities.

THE SYMPTOMS 1. Pain along the front and medial (inner) side of the tibia (shin bone). 2. Mild cases - pain after running. 3. Moderate cases – pain on impact as foot strikes the ground. 4. Severe cases - pain standing or just walking without any impact. 5. Pain on palpation along the inside edge of the tibia. Pain when squeezing/compressing the calf muscle and anterior shin together.

THE CAUSES Shin pain can most often be traced back to a sudden spike in training volume and intensity. Recent studies indicate the trauma isn’t caused by the direct contact of muscles attaching to the bone. Instead it happens from the slight bend that occurs during activity in a stress-loaded bone. As your tibia and surrounding muscles strengthen with repeated high-impact activity, the chance of shin splints lessens. Hence why shin splints are more common in those just starting or returning to a running programme. They are also a sign you could be wearing the wrong shoe or worn out shoes. Running on hard surfaces also increases your risk of developing shin splints. A high BMI and being female are added risk factors for shin splints.

THE PREVENTION The easiest and best way to avoid shin splints is to increase mileage gradually, and mix your training surfaces from concrete or asphalt to grass or trails. If you have high arches and a rigid foot then you may need shoes with added support and cushioning. Work towards having good mobility and stability, not just throughout your ankle and lower leg, but in your entire body. Strength with mobility means the entire kinetic chain can work together for maximum running

efficiency, so take the time to do strengthening exercises daily. Remember a dynamic warm up before a run may prepare better your body for the impact of running.

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ADVICE HANDOUT

PLANTAR FASCIITIS FOR RUNNERS THE INJURY It’s not surprising that about 15% of all running injuries strike the foot. With each step your feet absorb a force several times your body weight. While the foot is in motion during running, the plantar fascia, a thick elastic tissue that stretches from the heel to the base of the toes, works with the Achilles tendon to store and return energy. Because of this powerful attachment, the plantar fascia stabilises the inner forefoot as forces peak during push-off at the end of a stride. Unlike bone spurs and stress fractures of the heel, plantar fasciitis tends to produce pain during the push-off phase while running, and not during initial contact when the foot lands on the ground. Recent research has shown it to be similar to a tendinopathy, where there is a degenerative process involved, including features of collagen breakdown, calcification, nerve and vascular ingrowth. This is why it can sometimes be referred to as plantar fasciopathy.

THE SYMPTOMS nA sharp stabbing pain or deep ache in the arch of your foot or in the middle of the bottom of your heel. n Stiffness or pain first thing in the morning (especially when you first get out of bed) that tends to lessen a bit with a few steps, but also tends to worsen as the day progresses and your body fatigues. n Pain that worsens when climbing the stairs or standing on one’s toes. n It is a notoriously nagging injury, and running through it, while possible, can delay healing. Often once you have warmed up and started running the pain eases only to return towards the end of a long run or later that day. Take care, this can become a vicious cycle.

THE CAUSE Plantar fasciitis may result from a variety of factors, such as overtraining, doing vigorous repeated hill workouts or speed work, neglecting to stretch tight calf muscles, wearing unsupportive shoes, starting a running programme too aggressively or a general lack of foot strength.

It can also be attributed to biomechanical factors such as fallen arches. The excessive lowering of the arch in flat-footed runners increases tension in the plantar fascia and overloads the attachment of the plantar fascia to the heel bone, leading to eventual inflammation. Other biomechanical factors include an inward twisting or rolling of the foot (pronation) and tight tendons at the back of the heel (Achilles tendon), with reduced ankle dorsiflexion (upward movement of the ankle) and poor foot flexion and eversion (twisting ankle outwards) strength.

THE FIX Plantar fasciitis is considered a self-limiting condition of variable duration. With treatment, symptoms usually improve over 3-6 months. However, patients performing prolonged standing and painful loading of the tissue may require longer, up to 9 or 12 months. Treatment includes mobilising tight structures and fascia and strengthening the foot muscles: 1. Lightly stretching and mobilising the fascia throughout the day by, rolling your foot over a golf ball or over a frozen water bottle. Manually stretching your foot by pulling your toes back is particularly useful first thing in the morning. 2. Wear supportive footwear with enough shock-absorbing cushioning through the day and avoid prolonged standing, especially on hard surfaces. 3. Physical therapy to mobilise and release tightened fascia on the foot, as well as the ankle joint, calf and Achilles tendon. 4. Massage therapy to release tight structures of the lower limb and foot. 5. Night splints (including the Strassburg Sock), which holds the foot with the toes pointed up and the ankle at a 90-degree angle, can reduce morning symptoms 6. Performing prescribed stretching and strengthening exercise for the foot and the hip/pelvis and your core.

7. Cross train with water running, swimming, elliptical and cycling. 8. For severe cases surgery may be required to release the fascia, but this is needed in less than 5% of cases.

THE PREVENTION Run on a variety of surfaces, especially softer surfaces such as dirt paths, grass or trails, rather than concrete or asphalt. Make sure your running shoes are the right fit and support for your gait by going to a speciality running store and getting a properly fitted pair. Ensure your training programme is right for your ability. Lastly, foot-strengthening exercises can go a long way to reducing future injuries. Tight hip flexors, a weak core and a history of low back pain can all contribute to injury – any of these issues can lead to subtle changes in your stride that you’ll feel in your feet. Have these issues addressed with physical therapy and a rehabilitation programme.

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TIME-SAVING RESOURCES FOR PHYSICAL journal AND MANUAL THERAPISTS

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