Summary of:
FOOTBALL RECOVERY STRATEGIES (Grégory Dupont, Mathieu Nédélec, Alan McCall, Serge Berthoin and Nicola A. Maffiuletti, 2015) Does Fatigue Cause injury?
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Often when I’m talking to my patient about their injury and why it has happened, they guiltily report that they don’t stretch enough. We’ve all grown up being told how important is it to stretch:
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Interestingly, health professionals have changed our tune about the importance of stretching. Research over the last 15 years has suggested static stretching is not as beneficial as was once thought. I’ve been having conversations about the reasons to stretch (or not) for at least the last 15 years, but the current science on stretching just isn’t catching on with the general public.
So, what do we know?…
DOES STRETCHING PREVENT INJURIES?
There is a lot of evidence that stretching does not reduce the risk of injury. This systematic review and meta-analysis of randomised controlled trials found stretching does not prevent injuries, whether done before or after training. This randomised controlled trial, and this systematic review concluded stretching before exercising only reduces the risk of injury by less than 1%.
Therefore, in practical terms the average athlete would need to continuously stretch for 23 years to prevent one injury. Definitely not worth it.
DOES STRETCHING HELP MUSCLE SORENESS?
A systematic review concluded that stretching before or after exercising does not confer protection from muscle soreness (ref). Stretching was found to reduce muscle soreness by a trivially small amount - less than 2%.
DOES STRETCHING INCREASE RANGE OF MOVEMENT?
DOES STRETCHING HELP PERFORMANCE?
A substantial body of research has shown that sustained static stretching acutely decreases muscle strength and power (ref). Stretching before an endurance event lowers endurance performance and increases the energy cost of running (ref). Cycling efficiency and time to exhaustion are reduced after static stretching (ref).
Pretty much any measure of performance is made worse by stretching. Static stretching impairs:
- strength
- maximal voluntary contraction
- isometric force
- isokinetic torque
- one repetition maximum lifts
- power
- vertical jump
- sprint times
- running economy
- agility
- balance
A comprehensive review (ref) from 2011 concludes:
WHAT ABOUT DYNAMIC STRETCHING?
SO WHY STRETCH?
SO SHOULD WE STOP STRETCHING?
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Osteoarthritis is a structural change to the cartilage and boney surfaces in a synovial joint. Most of the joints in our skeletal system are synovial joints, which is where two opposing bones articulate in a joint capsule filled with synovial fluid. The synovial fluid is a lubricant to help the joint move, as well as a source of nutrition for the cartilage that lines the joint surfaces. The articulating surfaces in synovial joints are lined with articular cartilage, which is a smooth, glossy surface to decrease the friction in the joint (as opposed to fibrous cartilage, which is the rubbery type cartilage that plays a more structural role, found in the meniscus in knees and the rubbery part of your ribs, nose, and ears).
The fleshy parts of muscles and organs is pink because it is full of blood, which brings oxygen and nutrition, and is important for healing damage. Cartilage looks white because it doesn’t have a blood supply, so articular cartilage relies of the synovial fluid for its nutrition. This isn’t as effective as having a blood supply, so when cartilage is damaged it doesn’t heal well. Nanna damages the cartilage in her knees and it never really repairs.
Once articular cartilage is damaged, the joint tries to reinforce and repair the damaged area by laying down new tissue. It would be great if cartilage repaired itself with new cartilage cells, but the joint wants to make itself even stronger than the obviously insufficient cartilage, so it lays down a stronger building block - bone cells. So when we say that Nanna has “worn away” her knee to the point where it’s “bone on bone”, it’s not just that she’s worn away the cartilage, but actually there’s also a build up of “extra” bone, as the knee tries to make itself stronger than cartilage. Rather than being a nice smooth, glossy surface, the extra bone is now a bit rough, so we might hear and feel some gravely crunching and creaking in an osteoarthritic joint.
Osteoarthritis occurs most frequently in the knees, hips, hands, and spine and is more common the older we get. 59% of people with OA have knee OA. Osteoarthritis is diagnosed with an X-ray that shows the changes to the bony profile in the joint.
When we look at what causes osteoarthritis:
- The biggest contributor is a previous traumatic injury that has physically damaged the cartilage. This can be a landing/twisting injury or sprain, where the trauma of knocking one bone against the other, takes a “divot” or tear in the cartilage, or bruises the cartilage and underlying bone.
- The second biggest cause of osteoarthritis is genetic - the way our joints age, based on our family history. Nanna had a hip replacement and so will I.
- The third biggest contributor to osteoarthritis is BMI. Every 5 kg of weight gain, confers a 36% increase in the risk of OA. Interestingly, it isn’t the extra pressure through the joints of being heavy that causes a problem - fat people have a higher rate of hand osteoarthritis too (which are non weight-bearing joints). The problem with BMI is the systemic inflammatory effect of cytokines produced by fat tissue. Being fat causes inflammation that irritates joints, so fat people get osteoarthritis (and have heart attacks from the scarring/hardening of coronary arteries, also as a reaction to systemic inflammation caused by adipose tissue).
Osteoarthritis isn't painful most of the time. At a certain age, essentially everyone will have arthritic changes in their joints without knowing about it. When we X-ray the joint, it doesn’t look as good as it used to, but it doesn’t hurt. It’s a bit like my grey hair and wrinkles - they don’t look great anymore, and it's a sign that I’m getting older, but I don’t expect them to be painful.
If an arthritic joint is painful, it tends to go through phases of being sore and not being sore at all. It can be sore for a day, a week, a month, or a year, but then will be fine again. Whether or not it is sore is not determined by the severity of the changes we see on the X-ray. We can see nasty looking joints that have never been sore, and we see very sore joints that look fine on the X-ray. There isn’t much of a correlation.
What determines whether or not the osteoarthritis hurts is the body’s perception of "vulnerability" in that joint - essentially whether or not it feels strong or weak. Pain is an alarm system “software”, employed to defend against damage to the "hardware”. We can have different levels of sensitivity of how easily the alarm is triggered. Very commonly, an arthritic joint starts to hurt more after a period of rest, as the body looses some fitness, muscles loose some strength, an arthritic joint gets less support from the external scaffolding of the muscles, it feels more vulnerable, and communicates that by being painful, as a way of saying “be careful”.
So that gives us some treatment options for arthritis:
WEIGHT LOSS (Adipose)
- We know that a 5kg reduction in weight over a 10-year period decreased the likelihood of symptomatic knee OA by 50%.
- Losing 5% of body weight has been shown to provide some pain relief, and 10% provides significant reductions in pain.
EXERCISE
- Stay as active as possible. Rest doesn’t help. Improve muscle mass and strength so the joint is more supported and feels less vulnerable.
- Both aerobic walking and quadriceps' strengthening exercises have been shown to reduce pain and disability in subjects with knee OA.
PAIN RELIEF
- Paracetamol.
- Hot packs.
- Taping.
- Sleeves.
SURGERY
- There’s a lot of research showing that “tidy up” operations, or arthroscopic surgery for osteoarthritis is no better than an exercise program. It’s the exercise you do after the surgery that provides more benefit than the surgery itself.
- For people that never get on top of their arthritis with weight loss and exercise, the pain can get so severe that they end up needing a total joint replacement, where the bones are replaced with a metal and plastic joint.
How do you decide when it’s time to have a joint replacement?
I suggest it’s time when you really can’t walk anymore because of the pain, and/or the pain is stopping you sleeping at night. Joint replacements last for about 25 years on average, so don’t rush into doing it too early. The rehab after surgery is 3-12 months before the leg completely feels like it’s yours. The joint replacements are good for relieving pain, but unfortunately we don’t see improvements in patients’ activity levels after surgery. Total hip replacements are easier all around than total knee replacements.
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The Standard relates to care that patients aged 45 years and over should receive when they present with knee pain and are suspected of having knee osteoarthritis.
The Standard was revised and updated in August 2024. The Clinical Care Standard has been endorsed by 22 organisations, including The Australian Physiotherapy Association.
The Clinical Care Standard considers new evidence and expanded priorities so that people with knee osteoarthritis receive consistent care.
The Clinical Care Standard comprises of eight quality statements focussed on comprehensive assessment and diagnosis, appropriate use of imaging, education and self-management, physical activity and exercise, weight management and nutrition, medicines used to manage pain and mobility, patient review, and surgery, in line with contemporary evidence and international guidelines.
1) COMPREHENSIVE ASSESSMENT AND DIAGNOSIS
A patient with suspected knee osteoarthritis receives a comprehensive assessment, including a detailed history, a physical examination, and evaluation of factors affecting quality of life and participation in activities. A diagnosis of knee osteoarthritis can be confidently made based on this assessment
2) APPROPRIATE USE OF IMAGING
Imaging is not routinely used to diagnose knee osteoarthritis and is not offered to a patient with suspected knee osteoarthritis as there is a poor correlation between radiological evidence of osteoarthritis and symptom severity.
3) EDUCATION AND SELF-MANAGEMENT
Information about knee osteoarthritis and treatment options is discussed with the patient, including:
- Strategies to support increased physical activity
- Strategies to improve comfort and mobility
- Weight management guidance
- Strategies to optimise overall health
- Discussion of non-pharmacological pain management
- Referral to other clinicians
- Adjusting the management plan as needed
- Involvement of the patient’s family / support team as appropriate
4) PHYSICAL ACTIVITY AND EXERCISE
A patient with knee osteoarthritis is advised that being active can help manage knee pain and improve function. Exercise will not cause damage and is not a risky activity.
5) WEIGHT MANAGEMENT AND NUTRITION
A patient with knee osteoarthritis is advised of the impact of body weight on symptoms. Loss of excess weight can reduce knee pain and improve function, reducing the need for medicines and surgery. A 5-10% weight loss over 20 weeks is associated with reduced pain and improved quality of life.
6) MEDICINES USED TO MANAGE PAIN AND MOBILITY
Patients should speak with their GP and pharmacist regarding the management of their medicines, any possible side effects, and any potential interactions. Patients are not offered opioid analgesics for knee osteoarthritis because the risk of harm outweighs the benefits.
7) PATIENT REVIEW
A patient with knee osteoarthritis receives planned clinical review at agreed intervals, and management is adjusted for any changing needs.
8) SURGERY
A patient with knee osteoarthritis who has severe functional impairment despite optimal non-surgical management is considered for timely joint replacement surgery or joint-conserving surgery. Arthroscopic procedures are not offered to treat uncomplicated knee osteoarthritis.
www.safetyandquality.gov.au/standards/clinical-care-standards/osteoarthritis-knee-clinical-care-standard
INJURY PREVENTION IS IMPORTANT FOR RESULTS
In team sports, research shows a strong link between player availability and the success of the team, and that injuries and illness are the most common reasons for athlete unavailability in training and matches (REF). Research in team sports demonstrates an inverse relationship between injury burden and success of the team. Lower player availability is associated with failure to achieve key performance indicators. Injuries detrimentally affect the final ranking position in team sports (REF). And, research from professional European football shows lower season injury rates results in more successful seasons (REF).
Injuries and illnesses also affect success in individual sports. In elite track and field athletics, injuries and illness and their influence on training availability during preparation are major determinants of an athlete's chance of performance goal success or failure. Research shows the likelihood of achieving a performance goal increases by 7-times in athletes who complete >80% of planned training weeks. And, training availability accounts for 86% of successful seasons (REF).
So, injuries can determine success of failure in team and individual sports. Therefore, injury prevention strategies should be a focus for success-driven athletes and teams.
INJURY PREVENTION PROGRAMS
FOOTBALL
The warm-up program “FIFA11+” is an injury prevention program designed by the Federation Internationale Football Association (FIFA) Medical and Research Centre (F-MARC) in 2006. It was designed to reduce the occurrence of injuries associated with playing football.
The FIFA11+ consists of three parts and 15 exercises in total:
- The first part of the program involves running exercises and active stretching.
- The second part of the FIFA11+ program introduces six sets of exercises designed to work on the athlete’s core strength, leg strength, balance as well as their agility and plyometric ability.
- The third and final part of the FIFA11+ includes moderate to high speed running with planting/cutting movements.
The FIFA11+ program has been studied extensively over the last ten years to determine its effectiveness on injury prevention and physical performance measures, across a variety of populations. The FIFA11+ program has been shown to significantly reduce the risk of injuries in football (REF). This includes a 77% decrease in ACL injuries (REF), a 48% reduction in lower limb injuries (REF), and an overall injury reduction of 35% per 1000 hours (REF).
In 2020, Football Australia developed "Perform+" as the primary injury prevention program for football in Australia. The Football Australia Perform+ is an updated version of the FIFA11+ program with more flexibility for coaches and new content targeting hip and groin injury prevention.
PERFORM+ INJURY PREVENTION PROGRAM and more resources for injury prevention in football are available here: footballnsw.com.au/protection-and-safety/injury-prevention/
NETBALL
Knee and ankle injuries are common in netball, making up three quarters of all injuries. Devastating ACL injuries are unfortunately common in netball, making up 25% of the serious injuries.
The KNEE program offers a range of warm-up exercises that help prevent injury. There are a range of age and experience appropriate exercises for junior, through to elite netballers. They are easily understood by players and coaches, with a number of options offering variability and progression.
It would be great for the KNEE program to be widely adopted by Australia's largest participation sport for females.
KNEE Program resources are available at: https://knee.netball.com.au
AUSTRALIAN RULES FOOTBALL
FootyFirst begins with a warm-up, followed by leg strengthening and conditioning exercises, and training to improve balance, landing and side-stepping skills. It requires only standard training equipment and can replace the traditional warm-up. Once players and coaches are familiar with the exercises, the warm-up should take about 5 minutes, and the strength and conditioning exercises and jumping, landing and changing direction activities about 15 minutes.
Performed correctly and frequently, FootyFirst will improve performance and reduce injury risk. FootyFirst has been shown to decrease knee injuries by 50% and all leg injuries by 22% (REF). It will improve players’ leg strength and control – from their hip to hamstring, groin to thigh, lower leg, knee, ankle and foot.
Resources include the FootyFirst Coaches’ Manual, a series of posters illustrating the exercises at each level, and the FootyFirst Coaches DVD is available at: aflcommunityclub.com.au/index.php?id=906
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Pain originates in the gluteus medius and minimus tendons, and less frequently, the associated bursae. It was previously thought the primary source of pain was inflammation of the trochanteric bursa, and thus called “bursitis", however it has more recently been shown that true bursitis is rarely present. Sonographic research identified 8% of GTPS patients presented with isolated bursitis, compared with 41% with gluteal tendon pathology.
Risk factors for developing greater trochanteric pain syndrome include older age, reduced oestrogen levels, and excessive or sudden changes in load. GTPS is seen in both men and women across the lifespan, although women are more likely to suffer from GTPS due to biomechanical forces of having a wider pelvis and greater body adiposity. Post-menopausal women are most burdened by the condition due to hormonal changes.
ASSESSMENT AND DIAGNOSIS
Greater trochanteric pain syndrome is a clinical diagnosis and imaging is not required. There is poor correlation between pathology on imaging and symptoms. History commonly includes a change in load (eg, starting a walking program or new exercise routine) and pain in positions where the tendons may be compressed (eg, sitting with legs crossed and lying on (either) side). Other common reports include pain with sit-to-stand, after a period of sitting, and walking up and down stairs or slopes. Asking patients about their ability to manipulate shoes and socks can differentiate between GTPS and hip osteoarthritis (OA). Those with GTPS typically are not restricted in functional range of motion, so are not impaired when putting on shoes and socks.
A battery of clinical tests are recommended to diagnose greater trochanteric pain syndrome. The most sensitive objective measure is palpation over and around the greater trochanter. Other valuable pain provocation tests include: FABER, resisted hip abduction, and Trendelenburg sign.
TREATMENT
Corticosteroid injection (CSI) can have an adverse effect on tendon health and is not recommended. Benefits of CSI are short-term only, with high rates of recurrence. A single, ultrasound-guided, intratendinous platelet-rich plasma (PRP) injection is better than CSI, but no better than placebo injection.
Robust evidence demonstrates that exercise and education on avoiding gluteal tendon compression is better than injections in the longterm.
Strength based exercise prescribed in conjunction with education about avoiding gluteal tendon compression, and advice regarding load management, provides the most benefit. Education involves instruction to avoid positions of hip adduction, including:
- Avoid sitting in a position with legs crossed.
- Stand evenly on both feet and hip width apart.
- Avoid lying on either side, but if side lying is the only option, then place a pillow between the legs to avoid the top leg falling into a position of adduction.
- Avoid stairs in the short term.
- Gluteal stretching is not recommended and will delay recovery due to compression of the gluteal tendons.
Isometric loading has been advocated over dynamic strengthening.
In post-menopausal women with GTPS, a randomised control trial investigating menopausal hormone therapy (MHT) and exercise as interventions found that transdermal MHT is better than placebo when BMI<25.
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Load Management For Injury Prevention
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:
- 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”).
Measuring Training Load
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:
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:
Negative balance = 4 times risk of injury
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
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A change has been in the air since a 2002 randomised controlled study allocated 180 patients with knee pain 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.”
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)
SO WHY DID THE ARTHROSCOPE WORK FOR ME?
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 isn't quick and easy. Understandably we want there there to be a better option. “Have surgery” doesn't sound too bad.
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.
WHY DO PEOPLE HAVE SURGERY?
- 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
- GP refers 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.
SO WHO SHOULD HAVE SURGERY ON THEIR CARTILAGE?
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I ran less, and it eventually stopped hurting. I've still got decent bumps on my tibial tubercles to show for it.
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.
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Sugar
Supplements
Surgery
Sweat
Tendinopathy
Tendinosis
Tendonitis
Tmj
Treatment
Vertigo
Walking
Warm-Up
Weight Loss
Wheezing
Whiplash
Wrist
Yoga