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Physiotherapy in elite sport

Symmetry physio

June 2018

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Role and expectations of physiotherapists

Best-practice rehabilitation

Running assessment and interventions

Key learnings

Areas to cover

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Sports physiotherapists

Breakdown of our HP/Medical team: AFL (Eight full time staff and four are physios – doctors part time). Include P/T and VFL and VFLW: (18 staff and 9 are physios).
But what is the role. Why does the demand for sports physiotherapy really exist? ASK QUESTION.
Small groups and discuss.
For me once you get through the layers it is all about getting players back to play quicker. We could employ doctors and a medical model and have an outstanding low recurrence rate.
My expectations of them are: To provide a world class management (and know research and options). To have an ego capable of seeking outside advice when required. To be strong and open communicators (give me a minimum of surprises). To be planned and prepared. And to prepare our players/not protect them (see below):
Lead into the best rehabilitation staff – physio or otherwise focus on preparation and not protection.

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Preparation vs. protection

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Preparation

vs.

Protection

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Running (volume)

Running (max velocity)

Running (high speed volume)

COD/Agility

Accelerating/Decelerating

Jumping/landing

Kicking (volume)

Kicking (intensity)

Marking/Spoiling

Ground balls, awkward positions

Tackling, contact, bumping, wrestling

Concentration

Competitiveness

Repeated efforts

Preparation for what

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Rehab models

Medical

Physio

S+C

Coaching

Rehab coach coordinates

Medical

Physio

S+C

Coaching

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Acute:Chronic workload

How much work has an athlete has done recently?

What are they used to?
What are they prepared for?
4-wk average, 3-wk average, exponentially weighted average…

vs.

How much work are we asking them to do now?

- Today, this week…

In simple terms the acute:chronic workload is a ratio between how much an athlete is used to doing (which is the chronic workload – and in the research this is typically measured over 4 weeks), and how much work we are asking the athlete to do now in any given week or on any given day.

So, if we have a ruckman who has completed an average of 10km of running a week over the last month and we plan for him to do 10km this week then his OR HER acute:chronic workload ratio will be 1.0 or 100%. If we ask them to do 15 km then their ratio will be 1.5 or 150%. Simple.

It is worth noting that although people choose to measure it in different ways the principle remains the same. For example, at Essendon we found that the best fit for estimating our injury risk using the acute:chronic workload ratio is a chronic period of 21 days and an acute period of six days. We then calculate the ratio on a daily basis and have published our rationale for this in the British Journal of Sports Medicine.

One limitation of this method is that any work completed by an athlete more than a month ago doesn’t get considered by the model. A clever researcher from ACU called Nick Murray has recently demonstrated the effectiveness of an alternative method that uses an equation called an exponentially weighted average that treats your more recent training as more important than training that happened further back in your training history. This method has obvious advantages if you can do it but one practical disadvantage that also needs to be considered and explains why we haven’t adopted it yet.

While the method is brilliant for calculating a meaningful acute:chronic workload ratio it is poor at providing a meaningful chronic volume.

For example, when one of our coaches is asking how much training a certain player should do next week I love being able to explain to them in simple terms that the player is used to doing 15km a week over the last month and that we should pick a smart progression from there. The problem with the exponential model is that the chronic volume is an arbitrary number and can add an extra layer of complexity when explaining things to an athlete or a coach.

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What to monitor

Total running volume (GPS metres)

Amount of high speed running (GPS metres)

Workload: RPE x time

Number of high speed efforts

Time since last max speed effort

ACWR:

Other:

So, our next question is what are we actually measuring to calculate our acute:chronic worload? Most research out there focuses on GPS running volume.

However, remember that the hamstrings are most active in high speed running – so it makes sense, and the evidence supports this, to also look closely at the amount of high speed running an athlete does. The paper Dave was involved with looked at how many metres are spent running faster or equal to 24 km/hr and at Essendon we use the same running band.

But, if you don’t have GPs available or your athletes are in a non-running based sport – you can use all sorts of training load measures and the principle still stands up. Taking an athlete’s Rating of Perceived Exertion and multiplying that by the amount of time they spent training to get a measure of workload is also a very effective and accessible way to calculate workload ratios that we can all do. An advantage of this measurement is that you can also account for work completed in the gym and across different training types into your overall measure.

There are a couple of other things practitioners in running based sports can also look at that relate closely to hamstring injury risk and they are how many times an athlete reaches high speed and also how long it has been since an athlete has sprinted fast.

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At Essendon, with the help of our Data Analytics PhD student dave Carey we ran our own in-house research to come up with this injury risk table for our own group of players.

And we use this table all the time. We use it when planning our pre-season training progressions, when progressing a player out of rehab and when thinking about how we might manage our first year players differently to our senior players. A classic example is when a player is due to return to play after an injury – for the sake of the example let’s say it was a hamstring strain. We know the player has missed two matches after injuring their hamstring 3 weeks ago. They have passed all of our tests and our physios are happy for them to play except that we know that because their running has been limited during the early stages of their rehab if they play a full match on the weekend and do their normal amount of running in that game then their acute:chronic workload ratio for volume will be 180%. Whereas is they only play a half in the VFL their ratio will be 140%

I can then go into match committee and let them know that the risks associated with each of our options. For example, for a full game that is 14.8% and it is important to remember that it is only risk and that means that 17 times out of 20 a player won’t get injured from that match. However, we halve our risk for a half match to 6.7% or alternately we can rehab them for another week and play them for a full match next week at only 5% risk. Then I walk out and let match committee make an informed decision.

Also note:

AFL study (Duhig et al., 2 seasons of AFL) HSR: same as ours 24km/hr+: An acute:chronic workload ratio of >2.0 for total distance during the in-season was associated with an 8-fold greater injury risk in the current (relative risk (RR)=8.65, p=0.001) and 5 times greater injury risk in the subsequent week (RR=5.49, p=0.016).

Players with a high-speed distance acute:chronic workload ratio of greater than 2.0 were 11 times more likely to sustain an injury in the current (RR=11.62, p=0.006) and 5 times more likely in the subsequent week (RR=5.10, p=0.014).

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Acute:chronic run volume

Now I want to share with you some of the things we are looking at at Essendon on a daily basis:

This is basically a graph that works from right to left of a players acute:chronic workload. You can see the players chronic workload build throughout pre-season in blue, their acute workload fluctuate in red, and importantly their acute chronic workload ratio represented by the dotted white line. You can see over here on the left hand side of the chart the we can plug into the model what a player is planned to do over the next couple of weeks and cross-check their workload ratio. In this example form early February, the player is going to have a day off running and then run 5000m on the 5^th Feb and on this day their acute:chronic workload ratio (another term for which is TSB or training stress balance) will be 110% and their chronic weekly volume will be just under 20km.

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Complete the equivalent of a match

(when a match doesn’t sit within their chronic load)

Running volume
HSR
Max velocity

- Match-specific movements

Competitive football training
ACWR within a reasonable limit
Player believes they are ready
Coach is comfortable with skills and training performance

When are they prepared?

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Be specific to the sport

Movements and postures
Skills
Environment
Concentration
Competitiveness
Energy systems and HR demands

If necessary manipulate speed, load, ROM etc.

Coach and educate rather than blanket protection

What CAN an athlete do

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Opportunity to improve technique

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Introduction

Running is a somewhat subconscious cyclical motion

Pendular and NOT circular

Mostly reactive and elastic activity. This is the key to efficiency.

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Key points in the cycle:

Initial contact

Full weight acceptance

Toe-off

Swing

Float

Increase speed:

More strides (through coordination - metronome)
Greater stride length (through force generation)

Running cycle

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Key principles

Speed is more force in less time.

Coordination is vital.

You cannot be fast unless you are relaxed.

Avoid unnecessary force leakage.

Fundamentals of max speed running and acceleration are the same.

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What sort of running things to consider?

Body posture
Hip Drive
Hip vs. knee flexion
Ankle dorsiflexion
Pelvic control
Arm swing
Foot placement
Strength + power

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1. Body posture

Posture should be upright once high speed running.

Slight backward lean acceptable.

Forward lean leads to overstride and longitudinal rotation.

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1. Body posture

Drills to get somone upright in high speed running:

Overhead walking and drills: stick, plate, aquabag
Bullet belt
30m flying runs with stick on shoulders

Practice transition from forward lean in acceleration to HSR

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2. Hip drive

Forceful and early hip drive

Swing knee should be past stance knee at full weight acceptance.

In talented fast runners it is often further past.

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Make sure hip bends before knee.

Pendular and not circular motion.

Trail leg should bend >90⁰ after toe –off in swing

3. Hip vs. knee flexion

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2 + 3. Hip Drive

Swing knee should be past stance knee at full weight acceptance. Therefore focus on early and fast hip flexion after toe-off.

Also, make sure hip bends before knee.

Cue to snap big toe up.

Drills:

Leaning tower
Kneeling hip switch/drive
Step-up resisted from behind (hips)
Light band on knee resisted knee flexion
Use hip before knee as an attractor in weights

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2 + 3. Hip Drive

Resisted knee flexion:

Scissor movement:

Hip drive:

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4. Ankle dorsiflexion

Forefoot contact preferable in high speed running

Ankle should be neutral to dorsiflexed in stance b/n

initial contact and toe off

“Hard landing” -> maximises energy transfer.

↓ Hardness - ↑thrust duration - ↑ stance time - ↑ long. rotation

Check no active push-off: unnecessary and encourages ↓ dorsiflexion in swing

Note: Too much dorsiflexion in stance can increase time on the ground and lead to increased longitudinal rotation.

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4. Ankle dorsiflexion

Optimal ankle stiffness at ground contact is vital to efficiency and running fast.

Along with posture this should be addressed FIRST.

This is usually a coordination issue (unless ankle pathology limits.)

Ankle locks in dorsiflex early after toe-off, then if you time active plantarflex right at contact - you hit the sweet spot.

Educate athlete about coordination.

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4. Ankle dorsiflexion

Winckler ankle drills:

DL bunny hop on the spot
L/L then R/R on spot
15m DL, SL, LL/RR, run with contact focus

Cues:

Happy feet
Tap, tap, tap the ground
Slap the foot down
Aim for an audible ‘pop’ and rewarding ‘float’
Sweet spot
Don’t wait for the ground
Make things happen before contact
d/flex at toe-off then sl. pl flex timed perfectly at IC
Whip from the hip + attack the ground from above

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4. Heel contact

If runner makes initial heel contact and then gets foot back under the hip at weight acceptance not of huge consequence.

However maximal utilisation of the

elastic properties of the leg can’t be

achieved with heel contact (Bosch).

Address with barefoot running and drills.

Also, ankle contact drills are pretty useful too.

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5. Pelvic control

In frontal plane hip should only drop sl. on swing side.

Minimal longitudinal rotation is ideal.

Getting into full hip lockout in swing allows hip to recoil and maximise elastic power.

Pelvic tilt should be neutral at initial contact, then tilt posteriorally till full weight acceptance, anteriorally tilt until toe off as hip extends, and then posteriorally tilt back to neutral in float.

Important for maximising HS preloading at mid-end swing phase.

Facilitate concentric glute max in stance hip extension.

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5. Pelvic control

In frontal plane hip should only drop slightly on swing side.

Address with lockout and hip integrity exercises as well as SL stance exercise in gym.

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5. Pelvic control

Drills:

Walking lockout with object overhead
Leaning tower lockout drills
A and B drills with lockout
SL squat exercises + feedback + ext. cues
Any SL stance drills with free hip movement

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Both elbows should be alongside body at point of greatest thrust.

Front shoulder should barely get in front of body.

Poor postural control (long. rotation) may

cause the arms to need to compensate

Stance side shoulder gets sl. forward in stance = good torsion

Shoulder on opposite side to swing leg gets forward to compensate = ‘bad’ rotation

6. Arm swing

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Both elbows should be alongside body at point of greatest thrust. Front shoulder should barely get in front of body

Cue to drive elbows BACK

Drills (to address rotation):

Run without arms and then introduce
Run with wobbly pole on shoulders and stop wobble
Core exercise to control transverse rotation

6. Arm swing

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7. Foot placement

Foot should be placed directly under the hip.

Look for this at full weight acceptance.

When this is incorrect it is usually secondary to other issues such as posture or long. rotation

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7. Foot placement

Usually a secondary problem but can use B-Drills to help with understanding of this.

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8. Strength and power

Once all coordination

AND

ROM issues (hip flexion, dorsiflexion etc.)

are exhausted…

THEN consider the role of

strength and power development.

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Once technique has been addressed then power might play a role in an athletes ability to run fast.

Strength is only useful in helping get coordination right – Gary Winckler

Train fast to be fast.

Don’t lift slow and heavy in the gym.

Use light overloads in running and the gym that have don’t compromising speed/technique.

In gym also consider key ‘attractors’:

Hip before knee, pendular and not circular, contact from above, get hip under knee etc….

8. Power

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Once technique has been addressed then power might play a role in an athletes ability to run fast.

Drills:

Uphill running (3-5 degree slope)
Low incline steps
Resistance band accelerations
Bullet belt
Light sled sprints

8. Power

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Gait Correction

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Same principles as max speed.

More horizontal – forward lean first few steps.

Lead with the head and hips will follow.

Higher relevance of power.

Acceleration

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Be mindful of not reinforcing the things you don’t want

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Sometimes you have to take your medicine

Reactive tendons
Early pubic overload signs
Soleus recovery time

Running a sesion with multiple athletes

Keep them individual
Be very well planned
Listen hard

Nothing is proven to work

“This is my best advice (based off all of the research and my experience)”

Some stuff I had to learn along the way

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Questions and discussion