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)
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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
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London Paralympics 2012
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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
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Optimal Biomechanics • body maintained sagittal direction • minimal vertical displacement C.O.M • minimal frontal & transverse plane
deflection
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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
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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)
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Treadmill Test - Running
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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
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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
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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
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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
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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
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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)
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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)
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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
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Sport Case Studies
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Swimming
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Optimal Biomechanics • Equal body rotation & balance • Early catch • Early exit • Straight through pull - arm stroke
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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
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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
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Sport Case Studies
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Rowing & Sculling
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Optimal Biomechanics • Transfer physiological
performance into optimal propulsion through biomechanical efficiency
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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
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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
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Rehabilitation Exercises
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Return To Play
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Flexibility Strength Proprioception
Endurance
Motor Relearning
Return to Sport
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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
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THANK YOU