Managing training load is crucial in injury prevention and treatment. A graphic in Tom Goon’s recent blog visualises how training load outweighs all other factors.

Historically we have advised that training loads shouldn’t increase by more than 10% a week. I’m not sure where this number comes from. I’ve got no problem with it, it seems reasonable, and I’ve quoted it hundreds of times.

There’s a 2015 BJSM podcast interview with Tim Gabbett on load management for injury prevention. Specifically Tim talks about this paper:

Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers 
- Billy T Hulin, Tim J Gabbett, Peter Blanch, Paul Chapman, David Bailey, John W Orchard, 2013.

It is research into fast bowlers, but I think the principles apply just as well to any athlete.  

The authors measured the acute workload of the last 7 days (and call it “fatigue”) and compare that to the chronic workload of the previous 4 weeks (which they call “fitness”).

For runners, if the training is reasonably homogenous, we could most simply measure the workload as the total kms/week.  

Or we could be more accurate and account for a mixed training program that may include a variety of hills / sprints / cross training etc, by giving each session a rate of perceived exertion (RPE) out of 10, and multiply that score by the number of training minutes:

Training load = session RPE x duration (minutes)

This is called a Foster’s Score, and provides a simple method for quantifying training loads from a variety of different training modalities.

The research subtracted the current one-week average from the previous 4-week average and called this number the “training-stress balance”.

A negative training-stress balance increases the risk of injury by 4 times.

So:

[Last 7 days’ session RPE x duration (minutes)] - ([Last 4 weeks’ session RPE x duration (minutes)] / 4) = TRAINING-STRESS BALANCE

Negative balance = 4 times risk of injury

Essentially this formula means you shouldn’t increase your training load by more than 25% a week.

For people that may be more vulnerable to injury I would change the 4-week average to a 6-week average, therefore, bringing the increase in load each week down from 25% to 16%.  

This more cautious group could include: 

• Pre-season training
• Kids going through growth spurts
• Athletes returning from injury
• Known history of over training injuries
• People without any training history
• Novel exercise modality

This is a very common presentation, and having an arthroscopic debridement is a very popular decision. 75,000 knee arthroscopies are performed in Australia each year. Therefore, you would imagine there is good evidence to support having one. Unfortunately it depends on who you speak to…

A change has been in the air since a 2002 randomised controlled study allocated 180 patients with osteoarthritis to either an arthroscopic “tidy up”, or sham surgery (where the patient was given an anaesthetic, incisions were made, but no actual “tidying up” was done) and the study concluded there was no meaningful difference in pain or function between the groups at follow up.

Since then, a number of studies have compared arthroscopic debridements and partial meniscectomy for degenerative knee injuries with exercise or doing nothing (Herrlin 2007, Kirkley 2008, Katz 2013, Sihvonen 2013, Yim 2013, Kise 2016) and the results have been unanimous.

A recent systematic review summarises: “these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain, with or without signs of osteoarthritis.”  

And another: “A trial of nonoperative management should be the first-line treatment for such patients.” 

“This high quality evidence dictates that meniscectomy is an ineffective treatment for symptomatic degenerative meniscal tears.”

And that…

“Arthroscopy for degenerative meniscal tears is no longer supported.” (ref)

And

“There is now overwhelming evidence that arthroscopic knee surgery offers little benefit for most patients with knee pain.” (ref)
​​

We do a lot of arthroscopes and people get better. What’s happening?

When you come and see me with degenerative knee pain and I tell you, “you need to do six to twelve weeks of strengthening exercises”, it sounds like hard work. Pffft. Understandably we want an easier option.

“Have surgery” sounds like an easier option. Someone else is doing the work for you. After the surgery, you proceed to do six to twelve weeks of strengthening exercises, but this time you’re happier to do the work because we take surgical post-op instructions seriously.

Twelve weeks later both these two groups are a lot better. Bingo-bango, “surgery” fixed me.

Two million knee arthroscopies a year globally, costing billions of dollars.
​

A pretty typical pathway goes something like:

• Sore knee
• GP says “you’re silly to have played football”, try some pain killers
• Not much better
• GP says “we better get a scan”
• MRI shows “degenerative changes / meniscal tear” which seems like a structural injury
• Who fixes structural injuries?… Surgeons
• Refer to surgeon
• Surgeon wants to help. What can he do? An arthroscope and a “bit of a tidy up”.

​I think we need to be careful at the MRI stage. MRIs are a lot cheaper and easier to get these days so it’s less of a big deal to get one. I was chatting to a mate with a sore knee and his MRI showed some degenerative changes. Rather than being told that it’s normal to see those sorts of things in knees as old as ours, and that it’s not necessarily the thing that’s giving him pain, he was told the knee is “bone on bone”. How can anyone ever expect to recover without surgery with that sort of imagery? Bone on bone seems definitive. Surely the only way to fix “bone on bone” is surgery?

But we know degenerative changes on MRI are poorly associated with symptoms, and degenerative changes are the norm in middle-aged knees (ref). 

Let’s try some strengthening. You will be surprised.
​

The people I do refer to a surgeon for cartilage surgery have suffered an acute twisting injury with mechanical “locking” symptoms (i.e., an inability to fully extend the painful knee because of a meniscus tear lodged between the articular surfaces).
​

I had Osgood Schlatter's Disease myself in both knees as a kid. Mum entered some fun-runs in the 80's and we used to go running together. I was training more than I should have for cross-country in years 5, 6, and 7, and suffered terribly. Terrible night pain. I used to cry. Mum took me to a GP who confirmed the diagnosis with an x-ray and told me to stop running. Crazy sounding diagnosis. Absolutely bizarre to my 10 year old ears.

I ran less, and it eventually stopped hurting. I've still got decent bumps on my tibial tubercles to show for it.

Osgood-Schlatter's is an overuse injury of the spot where the quadriceps muscle attaches on the front of the knee (tibial tubercle). It’s the tendon where the quad anchors onto the tibia. It gets sore with too much running, jumping, and kicking. Usually 9-12 year olds. Quite often if they’re having a bit of a growth spurt while they’re doing a lot of training. The body is busy spending its resources on the growing, and so the recovery between training sessions doesn’t keep up.

It’s usually sore after training when you cool down. It can ache in bed at night.

We say that it is self-limiting, which means it eventually gets better when you stop growing, but who wants to wait that long?

There’s no long-term problems from it. Once it stops hurting it’s all OK.

It doesn’t need an x-ray or a scan, or any injections or surgery. It's an easy clinical diagnosis and simple conservative management.

DO:

• Try and get to bed earlier. The knee hurts more if you've stayed up a bit later this week.
• Recover after training with a Sustagen or similar.
• Ice pack 20mins, 3/day, particularly when it's sore after training.
• The exercise for it is: hang on for balance > single leg squat (chest up, not leaning forwards) down to where it starts to be sore > stay there for 30 seconds > 3 reps of a 30 sec hold, 2/day (so 6/day).

DON’T:

• When it’s sore you’ve got to cut back on running / hopping / jumping / kicking. So that might mean drop 30mins from a training session. Or do a session or two less this week. Or avoid the sprint work and long kicks in a session - just jog around.

It’s really a matter of adjusting the running load day-to-day depending on how sore it is. If it’s sore - do less.

It's an injury that needs managing through the season. I try and get kids to do a bit less running at training and save it for game day.  If it's sore on game day and you need to keep playing, it's safe, in that, it's not going to snap or pop. But it will hurt more for longer if you push through, which is what just has to be done some times.

​Funny sounding name. Not funny at all when it's sore.

​Research Summary:

The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning (Barton et al, 2015).

Patellofemoral pain (PFP) is a common cause for knee pain in general practice and sports settings.  Pain is aggravated by running, stairs, and squatting.  The majority of sufferers report an onset of pain in early adolescence and chronic ongoing pain for up to 20 years.

A number of high-quality reviews covering conservative interventions for PFP provide greater guidance for research and clinical practice.

Four key principles to ensure effective management include:
(1) PFP is a multifactorial condition requiring an individually tailored multimodal approach. 
(2) Immediate pain relief should be a priority to gain patient trust. 
(3) Patient empowerment by emphasising active over passive interventions is important. 
(4) Good patient education and activity modification is essential.

Research supports a multimodal treatment approach including:

• Exercise to strengthen the gluteal and quadriceps muscles 
• Patellar taping
• Emphasis on education and activity modification

The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’ has been based on a combination of contemporary level 1 evidence and the analysis of international experts’ clinical reasoning:

A recently published article by Haroy et al, in the British Journal of Sports Medicine, described a simple exercise routine that decreased the number of groin injuries in male footballers by 41%.
​
Groin injuries are very common in football. Research shows that weaker groin muscles are associated with an increased risk of groin muscle injury. So strengthening groin muscles can potentially prevent injury.

The paper studied the Copenhagen Adduction exercise, which has previously been shown to strongly recruit adductor longus.

​Haroy et al, offered the Copenhagen at three levels of resistance, based on the players’ pain. Players started with Level 3. If the exercise gave them more than 3/10 pain, they were instructed to do the exercise level below instead: 3 > 2 > 1.

​The training protocol is shown in the following table:

Being only one, quick exercise, compliance was high. They found performing the Copenhagens decreased the risk of groin injury by 41%.

The full article is HERE.

Copenhagens are definitely worth adding to your training. The concept is similar to strengthening hamstrings with the Nordic Hamstring Curl which has been shown to prevent 70%-85% of hamstring strain injuries.

Sever’s is most common in 9 - 12 year olds. It’s sore to squeeze the bone at the base of the Achilles where it attaches onto the heel. It’s not something that can be seen - it never seems to look red or swollen. It’s worse after sprinting, jumping, and hopping. It settles with rest. It is an overuse injury so it’s common in pre-season, or anytime training loads increase too quickly. My kids get it when they do extra sessions in running spikes or footy boots, without the normal heel support of their running shoes.  It’s an overuse injury from excessive loads.
​

When we talk about excessive loads it can be “external” load such as:

• number of sessions
• length of sessions
• pace of running
• hills
• novel activity
• footware
• ground surface

I think the running pace is the more powerful multiplier in this list. Extra sprint sessions will do it. My kids got sore once when we did a boot-camp session with a novel plyometric exercise - split jumps.

There are also “internal” variables that determine our ability to cope with the training load:

• nutrition
• stress
• sleep
• growth spurts

My kids definitely are more prone to Sever’s if they’ve had a couple of late nights that week. And, if they’re having a growth spurt, their bodies are busy spending resources on growing rather than recovering from the stress of a training session.
​

Text books say that Sever’s disease is self-limiting because the growth plate eventually fuses by the age of 15 or 16. But I don’t think there’s anyone who would be happy to just let it run its course until then. It is usually sore enough to stop you participating in sport, so it needs treatment.
​

I used to put kids with heel pain in orthotics, until I read this research which confirms that a simple heel wedge is more effective than orthotics for Sever’s disease. 

I get them to do an isometric Achilles strengthening program which also helps with pain control.

But ultimately recovery comes down to load management.

Load management means reducing the excessive loads. So this could be:

• less sessions/week
• shorter sessions
• less sprint work
• run in joggers rather than spikes or footy boots
• less hills
• heel wedges in shoes
• stay in shoes - no bare feet / thongs / flats. I really like them to stay in some sort of shoe with a heel all the time. Even if they’re getting up to use the bathroom I want them to slip their joggers on.

And aid recovery with:

• plenty of sleep
• massage calf muscles
• ice and Ibuprofen for pain relief when sore

With these type of overuse injuries, I interpret "soreness" as essentially the same thing as "tiredness". If they've been training more, sleeping less, or growing more, we would expect some "tiredness". If they were tired what would be the treatment?... Sleep more and train a bit less.

Summary of: 
FOOTBALL RECOVERY STRATEGIES 
(Grégory Dupont, Mathieu Nédélec, Alan McCall, Serge Berthoin and Nicola A. Maffiuletti, 2015)

• High intensity exercise leads to fatigue.  
  
• Fatigue causes a decline in performance.  
  
• A high percentage of injuries occur late in each half of a game, suggesting that fatigue is a risk factor for injury.

• Combination of central and peripheral factors.
  
• Central fatigue = decreased maximal voluntary muscle contraction and sprinting ability.
  
• Peripheral fatigue = muscle soreness, damage, and inflammation.
  
• Depletion of glycogen stores.
  
• Dehydration.
  
• Muscle damage / stiffness / swelling.
  
• Mental fatigue / motivation.
  
• Jet lag / disrupted body clock / stress / poor sleep.

• Immediately after a match, 20M sprint time, quadriceps strength, and vertical jump height are decreased by about 10%.  
  
• Full recovery can take between two and four days.  
  
• Injury rates are increased when there are less than 6 days between matches.

"When playing two matches per week, the 3-day recovery time between two successive matches may consequently be insufficient to fully recover."

Immediately after a match, players should drink a large volume of fluid (about 150% of the sweat loss) with a high concentration of sodium (about 500 to 700 mg/L of water), flavoured milk, and tart cherry or berry juice. Then, they should eat a meal containing high-glycaemic index carbohydrate and protein within the hour following play.

Rehydration and consumption of carbohydrates and protein are effective techniques for optimising repair of muscle damage.  The addition of sodium at 500-700mg/L promotes fluid retention, stimulates thirst, delays urine production, and increases glucose absorption.  It is recommended to drink a large volume of fluid after the match instead of small quantities gradually.

It is recommended to take 1.2g of carbohydrate per kilogram of bodyweight per hour for up to 5 hours after a match to enable maximum re-synthesis of muscle glycogen stores.

20g of milk protein during the first 2 hours of post-exercise recovery stimulates muscle protein synthesis.  Flavoured milk is an effective beverage for post-exercise recovery. It contains carbohydrate and proteins in similar amounts to those used in studies demonstrating improved post-exercise recovery.

Juices such as tart cherry juice, tomato juice, or berry juice are also recommended to enhancing the recovery process. These juices are loaded with a high antioxidant capacity, which reduce oxidative stress and inflammation.

Alcohol delays recovery as it is a diuretic, increases urine output, impairs sleep, delays the muscular recovery process, and decreases maximal strength.

• Sleep is an essential part of recovery management.
  
• Lost sleep reduces endurance performance, maximal strength, cognitive performance, and the immune system.  
  
• Less than 7 hours sleep per night triples the risk of infections and double the risk of musculoskeletal injuries.
  

• Several meta-analyses confirm the benefits of cold-water immersion for recovery.
  
• The recommended regime of cold-water immersion is: whole-body immersion lasting 10 to 20 minutes at a temperature of 12 to 15°C immediately after the match.
  

• Active recovery performed after a match does not present any benefit for physical performance.
  

• Most studies fail to find a significant beneficial effect of massage for recovery.
  
• Psychological benefits: decreased subjective symptoms of soreness / improved perceptions of recovery.
  

• There is no substantial scientific evidence to support the use of stretching to enhance post-exercise recovery.
  
• Stretching is not clinically worthwhile in reducing muscle soreness in the days following exercise. 
  
• Recovery of physical performance is not improved after stretching.
  

• Meta-analysis on the effects of compression garments on recovery following damaging exercise indicated that the use of compression garments had a moderate effect on recovery of muscle strength, muscle power, creatine kinase and in reducing the severity of delayed onset muscle soreness.  
  
• A placebo effect due to wearing the garments could not be excluded.
  

1. The first step is hydration; the mass of the players should be measured and compared to the pre-match body mass in order to propose the appropriate quantity of fluid to drink (150% of body mass lost). The fluid should contain a combination of water and a large amount of sodium (500 to 700 mg/L of water).
   
2. The second step consists in drinking a tart cherry juice and chocolate milk in order to restore glycogen, to reduce oxidative stress and inflammation, to stimulate muscle repair and to promote quality and quantity of sleep.
   
3. The third step is the cold bath. The players should immerse themselves up to the neck at a temperature between 12 and 15°C for 10 to 20 minutes to accelerate the recovery process.
   
4. The fourth step is to wear a compression garment until bedtime.
   
5. The fifth step is to eat a meal high in carbohydrate with a high-glycaemic index and protein within 1 hour after the match (for example soup, well-cooked white pasta or mashed potatoes, chicken or fish, yogurts or cake).
   
6. The final step is to have a good night’s sleep.
   

WATCH DR DUPONT'S PRESENTATION AT ASPETAR'S POST-EXERCISE RECOVERY CONFERENCE: