osteopathy in sport osteopathy_in... · 2017-10-01 · medial tibial stress syndrome 44...

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OSTEOPATHY IN SPORT Clive D Lathey D.O MSc (Sports Medicine)

My Background In Elite Sport

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Professional Triathletes- 2012-2017

Rio Olympics- Saudi Arabian Team- 2016

London Olympics- iOC Clinic Village-2012

Liverpool FC- 2009-2010

Chrissie Wellington- 4 x World Ironman (Triathlete) 2008-2011

Benita Johnson- World cross country champion 2003-2005

Colin Montgomerie- PGA Golfer- 2000-2005

Thomas Johansson- Tennis (No7) 2000-2002

Wayne Ferreira – Tennis (No6) 1998-2000

Bimal Physiotherapy- England Rugby, Uk Athletics, Football 1990-1998

www.theputneyclinic.com

London Paralympics 2012

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www.theputneyclinic.com 4


Rio Olympics 2016

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Types of Sport

• 800 World Wide

• 23 Professional

• 16 Categories- Collision, Contact, Bat + Club, Net Based, Racket

Based, Running, Weightlifting ,Combat, Board Sports, Ski Based,

Skating, Water Sports, Swim Related, Cycling, Equestrian +

Extreme Sports.

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Sports Medicine Medical Team

Dentist Sports Psychologist

Sports Physician

Podiatrist Nutritional Therapist

Radiologist Performance Coach

Massage Therapist

Physiotherapist

Strength + Conditioning Coach

Orthopaedic Surgeon

Osteopath

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Sports Medicine Team • Dr Carl Todd - England + Chelsea FC

• David Millard- Tottenham FC

• Dave Lewis- Swiss Olympic Team

• Ed Barry- Georgia Rugby Team

• Rob Hill – UK Athletics

• Parah Singh- UK Athletics

• Daniel Trussler- Worcester RFC

• Roy Knightbridge-PGA Golf

• Daniel Clearfield- USA Judo + Wrestling

• Luke Fuller-ATP Tennis

• Simeon Milton, Tim Allardyce, Rosie Hyman et al- iOC-Olympics.

Registered Osteopaths in Elite Sport.

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Force and Load

Non Contact Contact

• Gravitational • Tension, • Friction, • Compression • Shear • Torsion

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Runner

Skeleton Skeleton

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Tennis player

Skeleton

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Snow Boarder

Mogul or Jump

Skeleton

Skeleton

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Gymnast

SOMERSAULT

Skeleton

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Gymnast

Skeleton

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Sports Injury- Extrinsic Risk Factors

Extrinsic Risk Factors

1. Exposure

• Type of sports

• Exposure time

• Position in the team

• Level of competition

2. Training

• Type

• Amount

• Frequency

• Intensity

3. Environment

• Type of playing surface

• Indoor vs outdoor

• Weather conditions

• Time of season

• Human factors (team mates, opponent, referee, coach, spectators)

4. Equipment

• Protective equipment

• Playing equipment (e.g. racket, stock etc.)

• Footwear, clothing

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Sports Injury- Intrinsic Risk Factors

• Age

• Gender

• Somatotype

• Previous injury

• Physical fitness

• Sports specific skills

• Motor abilities

Intrinsic risk factors

Physical characteristics

Psychological profile

• Joint mobility

• Muscle tightness, weaknesses

• Ligamentous instability

• Anatomic abnormalities (malalignment)

• Motivation

• Risk taking

• Stress coping

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Posture And Joint Loading

• Neutral posture

• Even distribution of forces

• Alignment of body segments

• Reduce excessive loading

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Mechanical Properties Of Soft Tissues

Stress-strain curve Wang et al (2006)

Composition • Extracellular matrix

• Collagen (28 types)

• Elastin

• Ground substance

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A Review Of The Anatomy

Local muscles – Type 1 (slow twitch)

• Transversus abdominus • Multifidi • Internal oblique

Global muscles – Type 2 (fast twitch)

• Erector spinae • External oblique • Rectus abdominus • Quadratus lumborum • Psoas

“Stabilisers & Mobilisers” Comerford and Mottram (2000)

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Lumbopelvic Hip Complex

Roof Diaphragm

Front Abdominal muscles

Back Paraspinals & gluteal muscles

Floor Pelvic floor muscles

TA & multifidus - contract - 30ms before shoulder

contract - 110ms before leg

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Fascia & Tensegrity Structure

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Fascia & Tensegrity Structure

Anatomy Trains. T.Myers (2014)

Fascia

• Superficial front & back • Lateral line • Spiral line • Deep front line

Triangulated tensegrity structure. ( Continuous tensional behaviour )

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Pillars of Functional Stability

• Functional mobility

• Balance

• Posture

• Optimal functional motor pattern

• Neuromuscular control

• Movement symmetry

Elphinston J (2008).

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Model Of Movement Dysfunction

Kinetic Control 2001

Continued Global Imbalance And Tissue

Overload

Non Mechanical Pain Cumulative Micro-inflammation Trauma Or Injury

Pain And Pathology

Motor Control Deficit Of The Local Stability System

Predisposition For Recurrence

Degenerative Changes Within The Movement

System

Poor Movement Habits Or Poor Postural Alignment

Inhibition Or Functional Weakness Of The Global Stability Muscles

Increased Stiffness Or Shortening Of The Global Stability Muscles

Imbalance In The Global Stability System And Loss Of Global Control

Direction Specific Mechanical Stress And Strain Of: Articular, Myo-fascial, Neuro Meningeal And Connective Tissue

Abnormal Neuro Dynamic Sensitivity

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• Body is a unit

• Structure & function reciprocally related

• Body possesses self - regulatory mechanisms

• Body capacity to defend & repair itself

• Fluid movement essential to health

• Nerves play crucial role fluid movement.

• Visceral, physic and somatic components to

disease

Dr. Andrew Taylor-Still ( 1874 )

Osteopathic Philosophy

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Sport Case Studies

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Running


Optimal Biomechanics • body maintained sagittal direction • minimal vertical displacement C.O.M • minimal frontal & transverse plane

deflection


Sport Case Studies

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Running

Injuries • Stress fractures • Compartment syndrome (shin splints) • Chondromalacia patellae • Iliotibial band syndrome & trochanteric bursitis • Gluteus medius tendinopathy • Achilles tendinopathy • Plantar fasciitis

Causes • Training frequency/duration & equipment

• Anatomical - foot type, leg length, excessive pronation,

alignment lower extremity

• Lack cross training - Core training - keep VGRF & HGRF

within normal limits


Sport Case Studies

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Running

Female • Aged 33 • 2 children 1 & 3 years old • 6 month history pain- lateral left knee • History mechanical low back pain • Abnormal muscle performance • Movement deviation

Diagnosis - Clinical & U/S scan - Iliotibial band syndrome (ITBS)


Treadmill Test - Running



Athlete Profile

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• Abdullah X

• 100 + 200 metre runner

• Aged 19

• Height - 1.72 (5 foot 8 inches)

• Weight - 73Kg

• 100 metre PB - 10.04 Sec ( 15.4.16 – wind ass )

• 100 metre - Rio Olympics - 10.26 - Round 1

• IAAF Ranking - 43


History + Examination

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History

• 7 month history – Left sided lower Tibia pain-More acute last 3/12

• Aggravated - Running, hopping and long walks

• MRI – Periosteal + Endostal oedema distal tibial diaphysis

• Treatment - Physical therapy, PRP, Pulsed Electromagnetic - USA

• Past history - Acute left sided low back pain - resolved 3/52

• Grade 1 tear Rectus Femoris - Left thigh - 9/12 ago


History + Examination

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Examination

• Mild functional scoliosis - short left lower ext-<6cm

• Hypomobile + tender left L5/S1 - S/B + Ext dec

• Joint Assessment - Hip ROM - normal, Knee - normal, Left-Superior

Tib/Fib-hypomobile + Left Subtalar + Talonavicular

• Bilateral pes planus feet + Genu Varus

• Reduced dorsiflexion left calf


Medial Tibial Stress Syndrome

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• Exercise-induced pain and specific overuse injury to posteromedial,

distal 2/3 tibia

• Bone stress + marrow oedema + periosteal inflammation

• Increased Osteoclast cell activity / Decreased Osteoblast = Local Tibial

Osteopenia - potential precursor - Stress fracture

• Long recovery time - 100-300 days

• Incidence rate - 20-34% athletes


Risk Factors MTSS

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• R.OM- Hip, Knee, Ankle, Rear + Forefoot + Hallux

• Muscle Length - Hamstring, Gastrocnemius + Soleus

• Leg Length

• Q Angle

• Navicular Drop Test + ve

• Hip Abduction Strength

• Training Loads - Volume + Intensity


Risk Factors MTSS

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• Previous history MTSS

• Irregular menstrual cycle

• BMI

• Gender - Greater female - ratio 1.7: 1

• Dynamic over pronation - related max velocity

• Lower extremity alignment

Newman (2013)


Treatment Modalities

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• Low energy lazer - poor outcome

• Periosteal pecking - poor outcome

• Pulsed Electromagnetic field - poor outcome

• Extracorporeal shockwave therapy - medium outcome

• Physiotherapy + Osteopathy - unknown

• Rehabilitation programme – fair - medium outcome

• PRP (Platelet rich plasma) - poor outcome

• Exogen Treatment- medium outcome

Winter et al ( 2013)


Recommendations

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• Physical therapy – Osteopathic - Lumbar spine, Soft tissue myofascial

• Biomechanical + Kinematic assessment

• Core stability programme - Gluteal strength + pelvis

• Lower extremity - eccentric + concentric – soleus, Tib Ant +

• Hydrotherapy programme + gradual progression to load

• Stretching + mobilisation

• Possible orthotics ( leg length correction?)

• Diet – Vitamin D levels very low

• Rest


Sport Case Studies

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Swimming


Optimal Biomechanics • Equal body rotation & balance • Early catch • Early exit • Straight through pull - arm stroke


Sport Case Studies

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Injuries

• Rotator cuff tendinopathy

• Impingement syndrome

• Joint laxity A/P

• Cervical spine

Swimming

Causes

• Muscle imbalance

• Scapular kinematics

• Poor spinal core stability

• Thoracic spine stiffness

• Myriad of stroke flaws


Sport Case Studies

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Swimming

• Female

• Aged 27

• 11 month history – Pain anterior & lateral - right shoulder

• Sedentary employment

• Kypho - lordotic posture & scapular dyskinesis

• Club swimmer - Training 4 times / week

Diagnosis - Clinical & MRI - Supraspinatus & Long head bicep -

tendinopathy


Sport Case Studies

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Rowing & Sculling


Optimal Biomechanics • Transfer physiological

performance into optimal propulsion through biomechanical efficiency


Sport Case Studies

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Rowing & Sculling

Injuries

• Low back

• Shoulder, elbow & wrist tendinopathy

• Knee - patellofemoral + ITB

• Ribs

Causes

• Poor core stability & endurance

• Poor technical skills

• Incorrect equipment & ergonomics

• Overuse


Sport Case Studies

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• Female

• Aged 31

• Sedentary- IT expert

• Club level – Sculling – Training 6 days / week

( 2 in gym)

• Kypholordotic posture

• 7 month history left Elbow pain & forearm cramp

Diagnosis - Clinical & MRI – Lateral epicondylitis

Rowing & Sculling


Rehabilitation Exercises

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Return To Play

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Flexibility Strength Proprioception

Endurance

Motor Relearning

Return to Sport


Summary

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Patients

• Cross train endurance & strength in all planes of motion

• Maintain good posture and flexibility

• Have an appropriate balance of exercise & rest days

• Have intermittent assessment & preventative treatment

• Instruction & coaching & appropriate equipment

Practioners

• Examine the kinetic chain

• Patient management - eliminate pain & restore mobility & regain stability

THANK YOU

osteopathy in sport osteopathy_in... · 2017-10-01 · medial tibial stress syndrome 44...

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