New Zealand Journal of

SPORTS MEDICINEOfficial Journal of Sports Medicine New Zealand Inc

Volume 37 • Number 1 • 2010

The use of contrast therapyrecovery within the NewZealand elite sports setting.

Photos kindly supplied by Wayne Hing (AUT)and Jude Spiers (Warriors Rugby League)

The opinions expressed throughout thisjournal are the contributors’ own and donot necessarily relfect the view or policyof Sports Medicine New Zealand (SMNZ).Members and readers are advised thatSMNZ cannot be held responsible for theaccuracy of statements made inadvertisements nor the quality of the goodsor services advertised. All materialscopyright. On acceptance of an article forpublication, copyright passes to thepublisher. No portion(s) of the work(s)may be reproduced without written consentfrom the publisher.

PUBLISHERSPORTS MEDICINE NEW ZEALANDPO Box 6398DunedinNEW ZEALANDTel: +64-3-477-7887Fax: +64-3-477-7882Email: smnznat@xtra.co.nzWeb: www.sportsmedicine.co.nz

EDITORDr Chris Milne

INFORMATION FOR AUTHORSManuscripts are to be sent to:The EditorNZ Journal of Sports MedicineSports Medicine New ZealandPO Box 6398DunedinNEW ZEALANDEmail: smnznat@xtra.co.nz

Manuscripts may be submitted inelectronic format. For full submissiondetails please contact the publisher.

Contents

EditorialRUGBY AND RODEO _____________________________________ 4Chris Milne

Best of BritishJANUARY TO JUNE 2010 __________________________________ 4Chris Milne

Original ResearchTHE USE OF CONTRAST THERAPY RECOVERY____________ 8WITHIN THE NEW ZEALAND ELITE SPORTSSETTINGWayne Hing, Steven White, Peter Lee

CHANGES TO STRAIGHT-LINE SPRINTING FOOT _________ 12POSITIONS DURING A RUGBY UNION BASEDAGILITY TASKKeane Wheeler and Mark Sayers

ArticlesREVIEW CURRENT THINKING ON THE __________________ 20MANAGEMENT OF RETROPATELLOR PAINSteven Lim

THE RELATIONSHIP BETWEEN PERSONALITY ___________ 23AND PERFORMANCE IN ENDURANCE SPORTRod Corban

Case StudiesDE QUERVAIN’S TENOSYNOVITIS ________________________ 26Chris Lawrence, Hamish Osborne

INTERSECTION SYNDROME _____________________________ 28Rachel Stewart, Hamish Osborne

Book ReviewsTHE COMPLETE GUIDE TO FOOD FOR SPORTS __________ 30PERFORMANCE 3rd EditionOPEN - AN AUTOBIOGRAPHY____________________________ 31

Patient Information SheetANTI-INFLAMMATORY DRUGS (NSAIDs) FOR _____________ 32MUSCULOSKELETAL PAIN

New Zealand Journal of

SPORTS MEDICINE

EDITORIAL

4 NZJSM

You may wonder what these two activities have incommon. The idea for this editorial arose out of adiscussion I had with Winne Meeuwisse shortly afterthe opening ceremony of the Winter Olympics inVancouver.

Winne works in Calgary, home of the famed Stampede.He therefore sees a lot of rodeo riders. It seems likethese riders have a similar mindset to plenty of ourfootball players; that is, they are relatively stoical laconictypes. They tend to downplay their problems, whichcan make history taking a real challenge for the clinician.For example, a rodeo rider saying, “I fell off and hurtmy shoulder” is rather analogous to a rugby playersaying “he went through me in the back line and I hurtmy shoulder”. This may be the only explanation givenfor what turns out to be a glenohumeral dislocation.

Full history taking may seem like dragging teeth butone should attempt it. With such patients there is atendency to move more rapidly from the general to thespecific, e.g. “did you feel a dead arm after the incident”.Usually by asking a few key questions the true severityof the condition can be ascertained; given that the historysupplies about 80% of our diagnostic information, timespent on this aspect is seldom time wasted.

In this context, the clinician will be more dependent onexamination findings. Again, you should have apractised routine and if signs are equivocal then do notbe afraid to repeat a specific test later in the course ofthe examination.

After what may well be a relatively limited history takingand focused examination, you should be in a position toformulate a working diagnosis. You should also be awareof other diagnostic possibilities which may needexclusion.

In my opinion, the role of investigations is oftenoveremphasised in today’s healthcare environment. Ingeneral, one should only order an investigation if theresult will alter patient management. For most sportinginjuries we are generally talking radiology; start withplain x-rays and use ultrasound only if there is a treatablepathology likely to be identified by that modality. High-technology imaging, (CT, MRI and bone scanning)should be reserved for those few cases where a diagnosisremains elusive despite standard modalities, or later downthe track if the patient’s clinical course has not followedexpectations.

From my 15 years in primary care, two things I learnedthat have remained are to be comfortable making aworking diagnosis even without extensive investigations,and to use time as a diagnostic aid where appropriate.

In summary, dealing with the laconic patient can haveits challenges but the rewards are many, as these patientsare usually the most grateful for any intervention whichenables them to return to their sporting endeavours.

Dr Chris MilneEDITOR

Rugby and Rodeo

BEST OF BRITISH

JanuaryThe January issue of the BritishJournal of Sports Medicineconcentrated on kids in sport. Thewarm up article by Dennis Caineasks the question, are kids having arough time of it in sports? He notesthat sport, recreational and exerciserelated injuries were the mostcommon cause of paediatric injuriesand that some of these may have longterm consequences on themusculoskeletal system. Articleslater in the same issue tackle specificpaediatric sports medicine issues.

The editorial by Steven Stovitzoutlined the pyramid of sportsmedicine and child health. This isbuilt on a foundation of promotionof physical activity, energy balance,non-violence in sports and injuryprevention. In the middle row hementions advocacy plus a voice ofreason pushing for more free playopportunities. Also, emotional andphysical wellbeing are highlightedtogether with injury treatment. Thepinnacle is the attainment of optimalchild health.

There is a useful article on heatinjury in young sportspeople.Children are known to be at higherrisk for developing heat injury thanadults. The article recommendsgradual acclimatisation of allathletes to hot conditions andreduction in activity during hot orhumid conditions. There is a furtherrecommendation to use lightcoloured clothing that absorbs heatless and careful monitoring ofathletes for signs of heat injury, plushaving resources available toimmediately and rapidly cool anyaffected athletes. Lastly, there is a

BEST OF BRITISH

plea for better education of athletes,caregivers and coaches about heatinjury in young athletes.

Nicola Maffulli and colleaguesexamined the long term healthoutcomes of young sports injuries.It is estimated that 8% of Australianadolescents drop out of recreationalsporting activities each year becauseof injury recurrence. Growth plateinjuries are associated with growthdisturbance in about 15% of cases.Most of these appear to involveAmerican football. MRI scan studiesof athletes with back pain haveshown some correlation with discdegeneration, but this is not borneout by all studies. About 50% ofyoung athletes who undergomeniscal surgery will have laterdevelopment of knee osteoarthritis.These figures are in accord with thedata in adults. ACL reconstructionin children is a complex issue.Studies have indicated that childrenmanaged non-operatively frequentlydevelop poor function comparedwith those undergoingreconstruction. There are stillpotential issues with growth platedisturbance and detailed discussionby the surgeon, athlete and theircaregivers is advised.

Weight training among youngathletes is another controversial area.Faigenbaum and Myer evaluate thisissue and conclude that resistance(weight) training can be aworthwhile and beneficial activityfor children and adolescents. Theyconclude that most injuries relatingto youth weight training are as aresult of inadequate professionalsupervision, with associated poorexercise techniques andinappropriate training loads. Theytherefore advocate supervision byappropriately qualified professionalsand, in this context, have notobserved any increased risk ofmusculoskeletal injury resultingfrom age appropriate weighttraining, weight lifting andplyometrics. This is when comparedwith other recreational activities in

which children and adolescentsregularly participate.

In my experience, in New Zealand alarge percentage of the children whoI have seen who have beenparticipating in resistance trainingprogrammes have been influencedby people with a weight trainingbackground. I remain unconvincedthat it is necessary for athletes toundergo significant weight trainingprior to attaining skeletal maturityand believe that the same gains canbe accrued by waiting until suchmaturity has occurred.

The January issue concludes withpart 5 of the reviews of nutritionalsupplements on an A to Z basis. Thisissue covers sodium bicarbonate andsodium citrate, where there isundoubted evidence of efficacy at anoptimal dose of 0.3g/kg bodyweight.Both substances function as buffers,reducing the acidosis associated withhigh level exercise. The mainlimitation to their use is GI upset, andindividual tolerances vary so usersneed to test their own response tobuffer ingestion. Beta alanine andcarnosine both function asintracellular buffers. The authorsquote two studies indicating theability to undertake strenuousbicycle exercise increases withcarnosine supplementation and afurther study indicated that betaalanine supplementation limits thefall in blood pH during high intensityexercise without affecting bloodlactate or bicarbonate concentration.Therefore, it is not surprising thatthese substances have become usedby international level athletes.Further studies are necessary toclarify their true roles.

FebruaryThe February issue included asystematic review of home basedstrength and balance programmes inpeople aged over 80 to prevent falls.Nine studies were evaluated andthree of these showed cost saving inthese older adults. The best valuefor money came from the Otago

Exercise Programme which involveda specific set of muscle strengtheningand balance retraining exercisesprescribed at home by three trainednurses supervised by aphysiotherapist. There were fivehome visits and monthly phone calls.A 30% reduction in falls wasobserved.

Later in the same issue Bell, Cusi andcolleagues in Sydney examined theuse of prolotherapy in the sacroiliacjoint. They studied a group of 25patients with SI joint pain, diagnosedby validated clinical tests, who hadnot had satisfactory improvementfollowing a previous exerciseprogramme. They were given aninjection of 0.8ml of a solutioncontaining 50% glucose,Bupivacaine 1% and radioactivecontrast material. Their subjectswere reviewed at three months, 12months and two years, and bothclinical and functional questionnairescores using the Quebec Back PainDisability Score and RolandMultiform Questionnaire showedsignificant improvement. This is asmall intervention trial and theauthors suggested further research inthis area. The data is consistent withother interventional trials where themore specific the diagnosis is in thelow back, the more likely a targetedinjection is to achieve a desirableoutcome.

Later in the same issue, GeorgeMurrell and colleagues evaluatedshoulder pain in elite swimmers andconcluded that most of this arosefrom the supraspinatus tendon. Theyfound features of tendinopathy andthis seemed most strongly correlatedby the volume of swimming training.They found that shoulder laxity perse had only a minimal associationwith shoulder impingement in eliteswimmers. They therefore proposedthat the intensity and duration of loadto tendon fibre results intendinopathy, impingement andtherefore shoulder pain. This issomewhat different from the

Vol 37 No 1 2010 5

BEST OF BRITISH

prevailing hypothesis thatglenohumeral joint instability is themajor cause of shoulder pain inswimmers. This study included 80young elite swimmers aged between13 and 25 years, of whom 73 hadreported shoulder pain.

It has long been observed that ruralAfricans have low rates of coronaryheart disease despite a diet high insaturated fat, and genetic protectionhas been postulated as the reason forthis. Mbalilaki and colleaguesperformed a cross-sectional study of985 Tanzanian men and women; 130were rural Masai, 371 rural Bantuand 484 urban Bantu with a meanage of 46 years. The most significantfinding for the rural Masai, who wereeating a high fat-low carbohydratediet, was their extremely high energyexpenditure and low bodyweight.The Masai would expend some 2565kilocalories per day over vasalrequirements on average, comparedwith 1500 kilocalories per day in therural Bantu and 891 kilocalories perday for the urban Bantu. This highenergy expenditure resulted inreduced body mass index among theMasai. In other words, they were soactive that they burnt off any excesscalories, whether these were in theform of fat or carbohydrate.

Respiratory symptoms are commonin endurance athletes. A group fromthe Australian Institute of Sportevaluated the use of Difflam throatspray in a group of 45 well-trainedhalf marathon runners in an effort toevaluate its efficacy. This study wasprompted by the observation that notall bouts of upper respiratorysymptoms in athletes have aninfectious cause. Therefore,alternative treatments may well behelpful. They found symptomseverity scores were approximately29% lower in those subjectsundergoing Difflam treatment, butpost-exercise responses in plasmainflammatory markers showed nosignificant variation. There was asubtle rise in salivary

6 NZJSM

myeloperoxidase and salivaryinterleukin 6 in the Difflam group;the significance of this remains to bedetermined. The authors concludethat anti-inflammatory basedinterventions may be useful inalleviating the severity of post-raceupper respiratory symptoms inathlete populations.

Exostoses in the external auditorycanal are common in those athleteswho exercise in or on water. A Welshgroup studied 92 kayakers andcompared their findings with 65control volunteers. They found that69.5% of the kayaker ears and 1.7%of the ears in the control group werefound to have exostoses in theexternal auditory canal. Severity ofthese exostoses was significantlyassociated with the duration andfrequency of kayaking. Oncekayakers had been active in theirsport for more than 10 years, over90% of them had such exostoses. Itis thought that the exostoses arisefrom hyperaemia after cold waterexposure of the external auditorycanal. This, in turn, stimulatesosteoblastic activity which results innarrowing of the canal. The authorsfound some evidence that earplugsmay prevent the formation andrecurrence of exostoses, but advisedfurther study in the area.

MarchThe IOC-sponsored special editionof BJSM in March focused on rugbyinjuries. Several articles within thisissue will be of interest to NewZealand readers.

The first of these assessed the injuryrisks associated with tackling inrugby union. Simon Kemp andcolleagues studied 645 players from13 English premiership clubsthrough two professional seasons.They found that high speed goinginto the tackle in association withhigh impact forces and contact witha player’s head or neck weresignificant risk factors for both theball carrier and the tackler. Midfield

backs were more prone to tacklinginjuries than other players. Videoanalysis showed that only 17% ofplayers who had sustained an injuryrelating to a tackle above the line ofthe shoulder had that tackle penalisedby the referee. The authors mademention of New Zealand’s RugbySmart injury prevention programmeplus also the Shark Smart injuryprevention programme from SouthAfrica.

Shoulder padding is being wornincreasingly by today’s players butthere is relatively little evidence forits benefit. Harris and colleaguesfrom Middlesborough in the UKanalysed the impact attenuationproperties of four commerciallyavailable shoulder pads in thelaboratory. They found that all padsreduced peak impact force and thebest performing pad was the thickestone, which is hardly surprising.However, the pads were lesseffective at higher loads and theauthors expressed disappointment inthe overall performance of pads,stating that they appeared to bottomout under higher impact loads. Myinterpretation of this would be thatthey may well induce a false senseof security for players.

Cervical spine injuries are amongstthe most catastrophic in rugby. AFrench-based study, with PeterMilburn and Ken Quarry as NewZealand-based co-authors, examinedstatic and dynamic MRI protocols inthe assessment of cervical spineabnormalities in asymptomatic adultprofessional rugby union players.The most frequent anatomicalabnormality was degenerative discdisease and, not surprisingly, thiswas seen in players aged over 21years. Those players with a highmedulla to canal ratio were at highestrisk. Interestingly, most medullarycanal ratios that were initiallyassessed as intermediate on staticMRI were subsequently assessed asabnormal with dynamic MRimaging. However, the big unknown

BEST OF BRITISH

is predicting which players with anyMR abnormalities would go on tosustain permanent functionalimpairment. In the absence of suchpredictors, clinical evaluationremains the mainstay of athletescreening.

The issue also contained an articleregarding ethical dilemmas and thesports team doctor. This arose outof the controversy following the useof a fake blood capsule by aHarlequins rugby player during amatch versus Leinster in 2009. Thedoctor was involved as she is allegedto have cut the inside of the player’smouth in order to fabricate alaceration. The ethical issues areexamined in depth and the mostimportant guideline is “do notabdicate your responsibility to theindividual player”.

The routine March issue of BJSMincluded an article on oraladministration of the probioticLactobacillus fermentum VRI-003and mucosal immunity in enduranceathletes. Twenty healthy elite maledistance runners were studied at theAustralian Institute of Sport. Adouble blind placebo-controlledcross over trial was conducted overa four month period of wintertraining. The active ingredient wasa freeze-dried powder and gelatinecapsules, with placebo capsules forthe other group. Subjects reported30 days of respiratory symptomsduring probiotic treatment comparedwith 72 days during placebotreatment. Also illness severity waslower. There were no significantdifferences in the mean change insalivary IgA and IgA1 levels, or ininterleukin 4 or 12 levels betweentreatments, however the probiotictreatment doubled the gammainterferon levels compared withplacebo. These are impressiveresults and may offer some avenueof future prophylaxis for thoseathletes who are prone to recurrentillness, especially over the winterperiod. It would be worthwhile to

see if the results are replicated inother studies before rushing out toembark on this intervention.

Also in the March issue was a studyby the Lincoln University group onhealth and fitness parameters in NewZealand children aged 10 to 14 years.Comparisons were made between agroup study in 1991 and acomparator group in 2003. Over that12 year period the average weight ofboys increased by 4.5kg and girls by3.9kg. The 550 metre runperformance declined by 1.5% peryear for boys and 1.7% per year forgirls. Most worryingly, children inthe poorest performing and fattestpercentiles showed substantiallyworse results in 2003 than in 1991.Results obtained in this studyconfirm the worrying trend seen inother countries. The major worry ishealth problems that these childrenwill face later in life and theassociated healthcare costs thatsociety and these individuals willhave to bear. The study providescompelling evidence for trying to getour least active children to be moreactive.

Whole body vibration exercise hasbecome popular in recent years. Isthere any evidence that it mayreverse age-related loss of musclemass and strength? Is seems therecould be, based on a UK study of 20individuals with an average age of70 years. They used a randomisedcross over trial design with fiveminutes of vibration exercisecharacterised by static squat with afrequency of 30Hz. There was anacute increase in the circulatinglevels of IgF1 and cortisol but nochange in growth hormone andtestosterone. It remains to be seenwhether these hormonal changes aresufficient to slow the rate offunctional decline in older people.

The regular review of dietarysupplements in the March issueconsidered the role of caffeine. Thiswas on the list of banned substances

Vol 37 No 1 2010 7

from 1980 to 2003, when it wasremoved because it was found thatthe best ergogenic effects come fromsmall to moderate doses of caffeine(2-3mg/kg). These doses are wellwithin the normal daily caffeineintake of the general population.Traditionally, caffeine was believedto enhance endurance performanceby increased utilisation of fat as anexercise fuel and relative sparing ofglycogen. However, this glycogensparing effect is now known to beshort-lived and inconsistent.Furthermore, caffeine drinkers werewarned about the diuretic effect butsmall to moderate doses of caffeinehave only minor effects on urinelosses and the authors conclude thatthe diuretic risk had been previouslyoveremphasised. All in all, a verygood update about this controversialsubstance.

As Sports Medicine New Zealand isno longer maintaining a collectivesubscription to BJSM, thesesummaries have been expanded toprovide our members with greaterdetail on the current contents of theJournal.

Chris MilneSports PhysicianHamilton

ORIGINAL RESEARCH

The use of contrast therapyrecovery within the NewZealand elite sports settingWayne Hing PhD1

Steven G White MSc(Hons)1

Peter Lee MHPrac (Hons) (Musculo), PGCert (West Acup), PGDHSc (Musculo), BHSc(Phty)2

Anousith Boouaphone PGDHSc (Musculo), BHSc(Phty)3

1 AUT University, School of Rehabilitation & Occupation Studies2 Mark Plummer Physiotherapy, Manukau City, Auckland3 Health Zone, Millennium Institute of Sport and Health, Albany, Auckland

Correspondence toDr Wayne Hing, Associate ProfessorAUT University, School of Rehabilitation & Occupation StudiesHealth & Rehabilitation Research Centre, Discipline of PhysiotherapyPrivate Bag 92006Auckland 1142, New Zealand.Telephone: +64 9 921-9999 extension 7800e-mail: wayne.hing@aut.ac.nz

ABSTRACTBackground; Contrast therapy is a recovery modality that is widely used by many athletes despite the lack of scientificevidence for its use.Aim; The purpose of this paper is to firstly survey and analyse the current utilisation of contrast therapy within the elitesports of New Zealand (NZ) and secondly, to compare the findings with current scientific research.Method; A questionnaire was developed to survey elite NZ sports teams on their use of contrast therapy. The majority ofrespondents (79%) utilised contrast therapy as a recovery modality.Results; The results indicated that contrast therapy is used immediately post exercise, utilising bins (cold cycle) and showers/spas (hot cycle). The temperatures of each cycle ranged from 4-15°C (cold) and 23-40°C(hot) with 1:1-3 minutes (cold : hot)ratio over 3 repetitions.Conclusions; This study demonstrates that contrast therapy is widely used amongst the elite athletes of NZ. There appearsto be little consensus in regard to contrast therapy and this is also reflected in the literature which does not currently reportoptimal contrast therapy parameters.

INTRODUCTION

Contrast therapy consists ofimmersion in hot/warm and coldwater baths in an alternating

sequence. The strategy was initially usedfor injury management but has beingutilised for post-exercise recovery in morerecent times.1 There are a number ofanecdotal reports from athletes andcoaches that suggest that contrast therapyhas a positive effect on both recovery postexercise and on subsequent performance

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

in sport.1 Contrast therapy may thereforebe an athlete’s preferred choice of postexercise recovery compared to otherrecovery modalities.

An earlier paper9 reported the findings ofa systemic review of the literature thatinvestigated the physiological andfunctional effects of contrast therapy inthe experimental setting. The reviewconcluded that although a number ofphysiological changes were reported

(including changes in blood flow,decreased creatine kinase levels, increasedrange of motion, decreased musclesoreness and faster recovery of power) thequality of the studies included in thereview were of limited methodologicalquality. Therefore this paper reports thefindings of a survey that investigatedcurrent utilisation of contrast therapywithin elite sports of New Zealand (NZ).The purpose of the research was todetermine if contrast therapy was being

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ORIGINAL RESEARCH

Vol 37 No 1 2010 9

Sporting Number of Number Contrast National Professional/Code Teams Returned Therapy Teams International

TeamsBasketball 3 2 2 2Cricket 2 2 2 2Hockey 2 2 2 2Netball 9 9 9 8 1Rowing 1 1 1 1Rugby 14 13 8 6 2Rugby League 2 2 2 2Soccer 3 3 3 1 2Squash 1 1 1 1Tennis 1 1 1 1Triathlon 1 1 0Softball 1 1 0Swimming 1 1 0

TOTAL 41 39 31 15 16

TABLE 1: The sports and number of teams the questionnaires were sent towith the response rate and number of teams that utilise contrast therapy.

widely used and if so, to establish whatthe normal practice in terms of protocolswas amongst this cohort. This paper alsocompares how current practice relates tothe research evaluated in the earlier paper9

with the intent of helping to provide aguide to the clinical application of contrasttherapy.

METHODSQuestionnaireA questionnaire was developed by theresearchers to collect data concerning anumber of sports recovery strategiesincluding: active recovery (light jogging,cycling), water immersions (ice baths, spa,contrast therapy), pool recovery, massage,stretching and nutrition. The data wascollected over the period. Key themesaddressed in the questionnaire includedthe type of equipment, applicationprotocols, rationale and the personnelinvolved with the prescription and theimplementation of the recovery strategy.This paper reports the findings specific tothe use of contrast therapy.

Questionnaires were coded to correspondto a particular sporting code/team toprovide the tracking of responses andsubsequent follow up of the non-respondents. Participants were asked torespond to questions for each of therecovery strategies they used. Thequestioning consisted of a mixture of openand closed ended questions. The closedended questions required the participantto answer yes/no questions or tick boxesfrom a list of available choices. Openended questions were used in relation tothe rationale for the use of a particularrecovery strategy. Questionnaires werereturned (either by a pre-paid envelope,email or fax). On receipt of the completedquestionnaire, information was enteredinto a Microsoft Access data base andExcel spreadsheet.

ParticipantsIdentification of elite national andinternational sporting teams within NZthat potentially used recovery strategieswas undertaken. The nature, purpose, andprocedures of the study were conveyed tothe participant via telephone and acovering letter attached to thequestionnaire. Informed consent wasgained in accordance with the AUTUniversity Ethics Committee guidelines.

Statistical AnalysisAnalytical reports and tables weregenerated from Microsoft access and alsofrom SPSS. For this paper, analysis anddata presented is specific to the ‘waterimmersion’ section of the questionnaire,in particular the contrast therapy section.

RESULTSResponse RateA total of 39 out of 41 completed andreturned the questionnaire providing aresponse rate of 95%. Fifteen teams werein NZ domestic (Interprovincial)competitions and 16 teams wereinternational teams or NZ basedprofessional teams playing in overseascompetitions. Of the 39 responses, 31(79%) indicated that they utilised contrasttherapy as a recovery strategy. Thenumbers of responses from the variousteams and sports are presented in Table 1and the individual protocols of each teamare presented in Table 2.

Method of DeliveryA range of equipment is used inapplication of contrast therapy includinglarge bins, showers, plunge pools, spabaths and pools, bath tubs and swimmingpools. Large bins were the mostcommonly used equipment for the coldcomponent, while showers or spas werethe most common for the hot component.There was significant variation in the timeof application following activity/competition. This ranged fromimmediately up to 30 minutes post event.

This information is incomplete howeveras 14 of the respondents (45%) did notanswer this question.

TemperatureEleven teams (35% of respondents) gavedetails about the temperature of the hotor cold water they used. The temperatureof the cold water ranged from 4 to 15°Cand between 23 and 40°C for the hotcomponent. The addition of ice to coldwater was the usual method of achievingthe desired temperature. Three teams didnot state how the water was chilled.Twenty one teams (67% of respondents)used showers as the warm/hot componentof their contrast therapy. One team used abin full of hot water and 7 teams used aspa pool.

Application TimeThe time spent in the cold varied from 20seconds to 120 seconds each cycle. Themost common was 30 seconds and usedby 19 teams (61% of respondents). Thetime spent in the hot component variedfrom 30 to 180 seconds. The mostcommon was 60 seconds and used by 15teams (48% of respondents).

Cycle Ratio / RepetitionsThe ratio of the cycle between cold andhot ranged from 1:1 to 1:4. The mostcommonly used ratios were 1:2 (13 teams/41% of respondents) and 1:1 (10 teams/32% of respondents). However, one teamappeared to spend more time in the coldcycle than hot with a ratio of 2:1. Threeteams indicated multiple options in the

ORIGINAL RESEARCH

ratio of the hot and cold cycle dependingon the intensity of the workout.

The number of contrast therapy cyclesranged between 1-5 repetitions. The mostcommon was 3 repetitions (20 teams /64% or respondents). Total time spentperforming contrast therapy ranged from2.5- 20 minutes.

DISCUSSIONThis study has demonstrated that themajority of teams (79%) and elite sportingcodes in NZ use contrast therapy.However, there appears to be littleconsensus with respect to a number ofparameters relevant to this form oftherapy. Similarly, there are significantdifferences in the method of applicationof contrast therapy ‘in the field’ comparedto that used by those who haveinvestigated the physiological andfunctional effects of this form of therapy.One of the treatment parameters that couldbe considered likely to have a significanteffect on the effects of contrast therapy isthe temperature of the water used,however, only 11 teams (35%) of the

survey respondents provided detail aboutthe temperature of the water they used.

The temperatures for the cold cycle variedbetween 4 to 15˚C from the survey whichappear similar to the 8-15˚ used in theresearch environment.9 Interestingly, themajority of the studies recently reviewedby Hing et al (2008) used temperaturesover 10˚C indicating that the temperatureof the cold cycle appears to be at thehigher end of the range.

In addition, it is clear that temperaturesare not monitored or strictly controlled asthey are in the research environment.With the repeated cycles between cold andhot water, it is likely that with subsequentuse of the ice bath there would be aprogressive increase in the temperature ofthe water. The size of the bins used andthe relative amounts of water and iceadded are also likely to affect the watertemperature.

With respect to the hot cycles, whilst theshower was the most common method ofapplication, it is largely up to the

individual to determine how hot they hadthe water. This is reflected in the responsesto the survey where the majority ofrespondents either stated that they couldnot give a temperature or left this questionblank. Ten teams (32%) usedthermostatically controlled plunge or spapools and could therefore give definitivevalues (38-40˚C). The hot watertemperatures used by these teams werevery similar to those used in the researchbased studies apart from one study thatused hot packs heated in water at 75˚C.9

It is common for the surveyed athletes tospend less than 1 minute immersed foreach cold cycle. This reflects the timingof 1 minute employed in all but one ofthe research studies12 identified in ourrecent literature review.9 There is morevariation in the duration of the hot cycle,with surveyed athletes spending between1-3 minutes and the subjects in theresearch studies spending between 3 and10 minutes.The total duration of application ofcontrast therapy also varied between theathletes represented by the survey and the

TABLE 2: Contrast therapy protocols for each sports code and individual team.

SPORT TEAM TEMPERATURE/APPLICATION CYCLE RATIO REPETITIONS WHENCOLD HOT (Cold:Hot) (secs)

Basketball Team 1 option A ice Shower 30 : 60 3 straight afterTeam 1 option B ice nil 300 in cold 1 straight afterTeam 2 4-10 o C shower/spa 60: 180 not stated not stated

Cricket Team 1 ice shower 30 : 60 3 10 - 30 mins post matchTeam 2 10 - 15 o C shower 30 : 30 3 not stated

Hockey Team 1 ice shower not stated 3 15 - 20 mins post matchTeam 2 ice shower 30 : 60 3 not stated

Netball Team 1 ice shower 30 : 60 not stated not statedTeam 2 ice shower 30 : 60 3 straight afterTeam 3 not stated shower 20 : 40 OR 30 : 60 5 not statedTeam 4 ice shower 30 : 60 OR 30 : 120 3 not statedTeam 5 10 o C shower 30 : 30 3 straight afterTeam 6 ice shower 30 : 60 3 straight afterTeam 7 ice shower not stated 2 OR 3 straight afterTeam 8 ice shower 30 : 60 3 straight afterTeam 9 10 - 12 o C shower 60 : 180 not stated straight after

Rowing Team 1 ice hot water bin 30 : 30 3 straight afterRugby Team 1 10 o C 23 o C 30 : 30fOR 60 : 180 5 straight after

Team 2 8 o C 40 o C spa 45 : 45 4 not statedTeam 3 not stated 39 - 40 o C spa 60 : 60 3 not statedTeam 4 ice shower 60 : 120 2 straight afterTeam 5 ice 38 o C spa 30 : 120 1 straight afterTeam 6 not stated 39 - 40 o C spa 60 : 60 3 not statedTeam 7 8 o C 40 o C spa 45 : 45 4 straight afterTeam 8 ice 38 o C spa 30 : 120 1 straight after

Rugby League Team 1 ice thermostat controlled spa 30 : 60 3 straight afterTeam 2 ice thermostat controlled spa 30 : 60 3 not stated

Soccer Team 1 3 - 4 bags ice shower 30 : 30 4 OR 5 straight afterTeam 2 ice shower not stated 3 not statedTeam 3 ice shower 45 : 45 3 not stated

Squash Team 1 ice shower 120 : 60 3 not statedTennis Team 1 option A ice nil 600 in cold 1 straight after

Team 1 option B ice shower 30 : 60 3 not stated

10 NZJSM

ORIGINAL RESEARCH

subjects in the research basedexperiments. The athletes from the surveyaveraged a total of 5-10 minutes, whilethe experimental subjects averaged 20minutes.9 In terms of the elite sportingenvironment, it may not be very practicalto spend a long time performing contrasttherapy as athletes may have obligationsto attend team debriefs, after matchfunctions, media interviews and the like.

As discussed previously, bins filled withcold water and ice and a hot shower arethe most common method of applicationof cold and hot respectively in the sportingsituation. This is quite different to the useof whirlpools which were the method mostcommonly employed in the researchidentified in the literature review.3,4,5,8,10,11

Practical considerations most likelydictate the type of equipment used by thesports teams. Bins and showers are costeffective and accessible, especially whiletravelling however the majority of therugby teams surveyed have plunge pools/baths at their home stadiums specificallyfor the delivery of contrast therapy.

CONCLUSIONThis study demonstrates that althoughcontrast therapy is widely used as a postexercise recovery strategy by elite sportsteams in NZ there appears to be littleconsensus in regard to the method ofapplication in terms of equipment, timingor water temperature. The survey foundthat the parameters of contrast therapyranged from 4-15˚C for the cold cycle, 23-40˚C for the hot cycle ratio of 1 minutecold to 1-3 minutes hot, repeated 3 timesand is usually performed straight after thematch.

There are also differences between themethods used by researchers investigatingthe physiological and performance relatedeffects of contrast therapy and thoseapplying this therapy in the actual sportingarena. Whilst the research hasdemonstrated a number of physiologicaleffects that might support the theory thatcontrast therapy can aid in recovery aftersport, it was concluded that the quality ofthe studies included in our recent reviewwere of limited methodological quality.9

Also, out of the twelve studies includedin that review only five investigatedcontrast therapy in an athleticpopulation.2,4,6,7,13 With the limited quality

of these studies and the inability to be ablegeneralise the findings of most of thestudies to the athletic population, it isdifficult to be able to provide evidence thatsupports the use of contrast therapy.

There is anecdotal evidence for contrasttherapy’s use with limited scientificevidence that justifies its use however, anumber of studies of limitedmethodological quality havedemonstrated physiological andfunctional effects that suggest that thetherapy may have promise. Furtherresearch is warranted although it is equallyclear that the researchers in this field needto be better informed in regard to themethodology employed by the end usersof contrast therapy. Good quality researchthat investigates the effects of contrasttherapy using techniques of applicationthat can be replicated in the sports settingis required. This research needs to providedetail regarding the optimal contrasttherapy parameters taking into account therestrictions that may face the teamsinvolved.

Similarly, those responsible foradministering contrast therapy shouldkeep abreast of the research into its effectsand do their best to employ techniques thatreflect those that have been shown toproduce physiological or functionalchanges.

Ethics StatementFull ethics approval was gained from theAUT University Ethics Committee for thisstudy. Informed consent was gained inaccordance with the AUT UniversityEthics Committee guidelines.

Ethical Approval: Ethical approvalApplication Number 05/147 Recoverystrategies in sport.

Funding: The questionnaire was fundedby the New Zealand Academy of Sport -Northern.

Conflict of Interest StatementThere is no potential conflict of interestexisting with respect to the authors of thispiece of work.

REFERENCES1 Cochrane D J. Alternating hot and cold

water immersion for athlete recovery:

A review. Physical Therapy in Sport2004; 5:26-32.

2 Coffey V, Leveritt M, & Gill N. Effectof recovery modality on 4-hour repeatedtreadmill running performance andchanges in physiological variables.Journal of Science and Medicine inSport 2004; 7(1):1-10.

3 Cote D, Prentice W, Hooker D, &Shields E. Comparison of threetreatment procedures for minimizingankle sprain swelling. Physical Therapy1988; 68(7):1072-1076.

4 Cotts B, Knight K, Myrer W, &Schulthies S. Contrast-bath therapy andsensation over the anterior talofibularligament. Sport Rehabilitation 2004;13:114-121.

5 Fiscus K, Kaminski T, & Powers M.Changes in lower-leg blood flow duringwarm-, cold-, and contrast-watertherapy. Archieves of Physical Medicineand Rehabilitation 2005; 86:1404-1410.

6 Gill N D, Beaven C M, & Cook C.Effectiveness of post-match recoverystrategies in rugby players. BritishJournal of Sports Medicine 2006;40(3):260-263.

7 Hamlin M J. The effect of contrasttemperature water therapy on repeatedsprint performance. Journal of Scienceand Medicine in Sport 2007; 10(6):398-402.

8 Higgins D, & Kaminski T. Contrasttherapy does not cause fluctuations inhuman gastrocnemius intramusculartemperature. Journal of AthleticTraining 1998; 33(4):336-340.

9 Hing W A, White S G, Lee P, &Bouaaphone, A. Contrast therapy - Asystematic review. Physical Therapy inSport 2008; 9(3), 148-161.

10 Kuligowski L, Lephart S, GiannatonioF, & Blanc R. Effects of whirlpooltherapy on the signs and symptoms ofdelayed-onset muscle soreness. Journalof Athletic Training 1998; 33(3):222-228.

11 Myrer W, Draper D, & Durrant E.Contrast therapy and intramusculartemperature in the human leg. Journalof Athletic Training 1994; 29(4):318-376.

12 Myrer W, Meason G, Durrant E, &Fellingham G. Cold- and hot-packcontrast therapy: Subcutaneous andintramuscular temperature change.Journal of Athletic Training 1997;32(3):238-241.

13 Vaile J M, Gill N D, & Blazevich A J.The effect of contrast water therapy onsymptoms of delayed onset musclesoreness. Journal of Strength andConditioning Research / NationalStrength & Conditioning Association2007; 21(3):697-702.

Vol 37 No 1 2010 11

ORIGINAL RESEARCH

Changes to straight-linesprinting foot positionsduring a rugby union basedagility taskKeane W Wheeler BAppSci(Hons), PhD1

Mark G L Sayers BAppSci, MAppSci, PhD2

1 University of Canberra, Australia2 University of Sunshine Coast, Australia

Correspondence to:Dr Keane W WheelerUniversity of CanberraACT 2601AUSTRALIATel +61 2 6201 2122Mobile +61 0407 236 157Fax +61 2 6201 5615Email keane.wheeler@canberra.edu.au

ABSTRACTAim: To determine the changes to straight-line sprinting foot positions during a rugby union based agility task.Study Design: 3D kinematic analyses examined maximal effort straight-line sprinting (20 m) and agility performances. Theagility course involved an initial change of direction followed by a subsequent straightening in the running line, withparticipants required to complete six successful side-stepping trials, through both right and left running lines.Setting: Testing was conducted on a dry, grassed rugby playing surface.Subjects: 8 highly trained rugby union players.Outcome Measures: Anteroposterior and mediolateral foot displacement relative to the centre of mass and as a percentage ofleg length. Running speed (anteroposterior) and lateral movement speed (mediolateral) measured as the velocity of thecentre of mass in these directions.Results: Agility technique was based on different foot positions (% leg length) than straight-line sprinting. The lateral(41.35 ±5.85 %, p< .001) and anterior (46.24 ±11.19 %, p < .001) foot positions during the change of direction step wasgreater than straight-line sprinting (8.06 ±3.17 % and 14.90 ±8.90 %, respectively). This meant that the initial side-step wascharacterised by the deceleration of running speed and the development of lateral movement. Following this, agilitymanoeuvres were characterised by a redirection of residual lateral movement to promote forward progression. The footpositions reflected this desire to accelerate, with the anterior foot position at the straighten (-0.91 ±15.43 %, p < .001) andre-acceleration (11.84 ±11.22 %, p < .001) steps less than straight-line sprinting (14.90 ± 8.90 %).Conclusions: The characteristics of agility are unique to straight-line sprinting. Running programs in rugby union shouldfocus on effective foot positions when rapidly changing directions.Keywords: locomotion, stability, movement control, biomechanics, sprinting

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INTRODUCTION

The ability to evade defenders usingchange of direction (agility)manoeuvres is a fundamental

determinant of effective attackingstrategies in rugby union.8,25,26 Despitethis, there is a severe lack ofcomprehensive scientific research that hasdescribed the key determinants of suchagility performance.6,10,12 Importantly,running technique during agilitymanoeuvres in rugby union remainsrelatively undefined throughout thepublished literature. Consequently,confusion exists regarding the specifictechnical attributes of agility duringattacking ball carries in rugby union. Afact particularly evident when consideringthe training programs in rugby union,where running technique is trainedcommonly using models of performancederived from straight-line sprinting (e.g.training athletes to display upright bodypostures that would be counter-productiveduring contact with defensiveopponents).19,20 Clearly, themultidirectional nature of rugby meansthat such models may not be appropriate.

Previous research has demonstrated thatstraight-line sprinting speed has limitedtransfer with the speed of agilityperformance.11,13,28 This could be because

ORIGINAL RESEARCH

the running mechanics associated withagility require significant alterations tostraight-line sprinting gait.29 Forexample, track sprinters demonstratepurposeful increases to stride length andconcurrent decreases in stride rate.1 Incontrast, excessively long strides(characterised by considerable flightperiods) reduces the effectiveness ofagility performance during attacking ballcarries in rugby union (attacking ballcarriers have no stable base of support toresist defenders when in flight).3,19,20

Beyond this, there is a limitedunderstanding regarding the changes tostraight-line sprinting technique duringagility manoeuvres in rugby union.

The complexity of agility during attackingmanoeuvres in rugby union indicates thatit is important to divide the skill into therespective performance phases (agilitygait cycle). It would no doubt be a mistaketo describe the agility gait cycle(multidirectional motion) using straight-line sprinting models of performance(unidirectional motion in the sagittalplane).18,22 A comprehensive model ofagility needs to consider the events before,during and after direction change.25

Accordingly, it is proposed that the agilitygait cycle display five distinct phases,

consisting of the pre-change of direction,change of direction, transition, straightenand re-acceleration phases (Figure 1).

The open skilled nature of field sportssuch as rugby union means that agilitymovement patterns are expressed in anumber of ways.25 A side-step andstraighten agility manoeuvre (completeagility cycle) would be observed when anattacking ball carrier executes an initialside-step to outmanoeuvre an opponentand then straightens the running directionto advance the ball beyond the defensiveline (Figure 1). In contrast, a slightlydifferent pattern of movement would beobserved when an attacking ball carrierdisplays an initial lateral running line andthen side-steps to challenge the defence(Figure 2). It should be noted thatbiomechanical analyses of agilityperformance have been limited to adirection change and continuation throughthe adjusted running line.5,15,16,23

Additional analysis of the agility cycle(e.g. side-step then straighten) would nodoubt provide a vital understanding ofagility running technique during variousattacking strategies in rugby union andother similar sports (e.g. rugby league).Accordingly, this study explores thecharacteristics of a complete agility cyclebased on evasive attacking ball carries inrugby and compared this to conventionalstraight-line sprinting technique.

Change of direction step

Straighten step

Transition

Re-acceleration step

Pre-change of direction step

Change of direction step

Pre-change of direction step

Re-acceleration step

FIGURE 1: Transverse plane representation of the completeagility cycle.

FIGURE 2: Transverse plane representation of a modifiedagility cycle.

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ORIGINAL RESEARCH

METHODSParticipantsEight male rugby union playersvolunteered to participate in this study(age 23 ± 4 yr, height 183 4 cm, mass 9811 kg). The participants were from highlevel rugby union teams, such as thosecompeting in international provincialcompetitions. All testing procedures wereapproved by the University HumanResearch Ethics Committee, and informedconsent was obtained before testing.

Study DesignThree dimensional kinematic analysesexamined maximal effort straight-linesprinting and agility performances (fullrecovery between each straight-linerunning and agility trial). Participantscompleted three 20 m straight-line sprints.Agility course design was based on thecharacteristics of attacking ball carries inrugby union.14,21,25 Participants ran atmaximal effort through an agility coursewith an initial change of directionfollowed by a subsequent straightening inthe running line (Figure 3). Measures ofagility were recorded for six successfulside-stepping trials, through both right andleft running lines. Testing was conductedon a dry, grassed playing surface.Participants were required to carry a rugbyball and wear rugby footwear as well asany other necessary protective equipment,as regulated by the International RugbyBoard. Participants received descriptionsand demonstrations of the assessmenttasks (straight-line running and agilityconditions) and completed non-measurable performances as part of theirstandardised warm-up.

Performances were filmed by 4 PALdigital video cameras (Panasonic Nv-GS180GN, Matsushita Electric IndustrialCo., Ltd., Japan) operating at 50 Hz andthe shutter speed at 1/2000th s (Figure 3).Twenty anatomical landmarks forming afull body model (Figure 4) were nextdigitised using the Ariel PerformanceAnalysis System (Ariel Dynamics, Inc.,USA), with 3D transformation usingstandard Direct Linear Transfer (DLT)procedures (25 stationary control pointsdigitised on a calibration frame (2 m wide,2 m high and 6 m long)) and smoothedwith a 5 Hz digital filter. The choice ofcut-off frequency was based on a residualanalysis27 and a visual inspection of the

Right direction change

1.86 m

7.00 m 7.00 m

Camcorder

Slalom pole

Marker cone

1.00 m

4.80 m

1.86 m

0.93 m

5.00 m

3.72 m

1.86 m

3.72 m

Left direction change

7.70 m 7.70 m

Start Point

FIGURE 3: Diagram of the agility course design.

coordinate and displacement dataconsistent with Wakai and Linthorne.24

Digitising was completed by a singleanalyst and the raw position of randomlyselected landmarks and jointdisplacements were used to assessreliability. Coefficient of variation (CV)and typical error of measurement (TEM)demonstrated high reliability for jointlandmarks in the anteroposterior (CV =3.12 %, TEM = 1 cm); mediolateral (CV= 0.42 %, TEM = 1 cm) and vertical (CV= 0.87 %, TEM = 1 cm) planes, inaccordance with Menz et al.17

Statistical AnalysisThe SPSS software package (Version 17.0for Windows, SPSS, Inc., USA) was usedto present descriptive statistics ( x ±SD)and compare performances using t-test (t(df) = 000, p = .000) and Chi-squared (2)measures of relationship (2 (df) = 000, p =.000). A significance level of p < .05 wasused for all analyses. Independentvariables included; performance condition(straight-line sprinting and agility), speedof agility performance (fast, moderate andslow) and the number of transition steps(0, 1 and 2). It should be noted that thespeed of performance was categorised

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ORIGINAL RESEARCH

1 12 2

3

4

5

6 7

8

9

10

11

13

14

15 16

17

18

19

20

X

1 Right toes 11 Left posterior calcaneal point2 Right posterior calcaneal point 12 Left toes3 Right lateral malleolus of the fibula 13 Right distal lateral radius4 Right femoral lateral epicondyle 14 Right humoral lateral epicondyle5 Right femoral greater tronchanter 15 Right acromion process6 Right iliac crest 16 Left acromion process7 Left iliac crest 17 Left humoral lateral epicondyle8 Left femoral greater tronchanter 18 Left distal lateral radius9 Left femoral lateral epicondyle 19 Anterior mandible10 Left lateral malleolus of the fibula 20 Anterior frontal bone

X Centre of Mass (CM)

FIGURE 4: Representation of the full body model achieved by linking anatomicallandmarks.

based on fast (0.5 SD below the meanperformance time), moderate (between0.5 SD above and below the meanperformance time) and slow (0.5 SDabove the mean performance time) foragility and straight-line sprinting.Dependant variables included speed(running and lateral movement) and footpositions (anteroposterior andmediolateral). Running speed and lateralmovement speed were determined usingkinematic measures of the velocity of thecentre of mass (CM). Changes to runningspeed and lateral movement speedbetween foot-strike and toe-off were thencalculated for each agility phase as wellas averaged over multiple stance phasesof straight-line sprinting. Displacementof the foot in the anteroposterior andmediolateral planes at foot-strike and toe-off was measured relative to the CM andas a percentage of leg length (Figure 5).

RESULTSPre-change of Direction PhaseComparison of the spatiotemporalcharacteristics between straight-linesprinting and agility tasks showed thatrunning speed decreased during the pre-change direction phase (-0.64 ±0.43 m.s-

1) compared to an increase during stanceof straight-line sprinting (0.27 ±0.17 m.s-

1, t (67.91) = 12.759, p < .001). Theanterior foot displacement at foot-strikewas then greater at the pre-changedirection step (41.68 ±14.78 %) comparedto straight-line sprinting (14.90 ±8.90 %,t (67.405) = -9.556, p < .001) (Figure 6).

(a)

Lateral foot displacement (negative values)

(b)

Centre of mass (CM)

Lateral foot displacement (positive values)

Posterior foot displacement (negative values)

Anterior foot displacement (positive values)

FIGURE 5: Representation of a foot displacement values (a) frontal plane view oflateral foot displacement (b) sagittal plane view of anteroposterior foot displacement.

FIGURE 6: Sagittal plane representation of the anterior foot displacement at foot-strike (a) straight-line sprinting (b) pre-change direction step.

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ORIGINAL RESEARCH

FIGURE 7: Transverse plane representation of the anterior and lateral footdisplacement at foot-strike (a) straight-line sprinting (b) change of direction step.

FIGURE 8: Transverse plane representation of the posterior anterior and lateral footdisplacement at toe-off (a) straight-line sprinting (b) change of direction step.

greater lateral foot displacement observedat the change of direction foot-strike(41.35 ±5.85 %) (Figure 7) and toe-off(74.69 ±8.34 %) (Figure 8) whencompared to the foot-strike (8.06 ±3.17%, t (56.451) = -31.273, p < .001) and toe-off (-17.69 ±2.82 %, t (64.134) = -68.751,p < .001) positions of straight-linesprinting.

Transition PhaseOur results then explored the transitionstep patterns during the agility task.Differing transition step strategies wereobserved with athletes exhibiting no stepsthrough the transition phase or onetransition step or two transition steps.Moreover, analysis examined thetransition step strategies between speedsof agility performance. A significantrelationship was observed where fastperformances favoured no transition steps,whilst moderate performances oftendemonstrated a single transition step andslow performers were more likely todisplay two steps through the transitionphase (2(4) = 103.403, p < .001).

Straighten PhaseFurther comparison of straight-linesprinting to agility tasks showed thatgreater acceleration to running speed

FIGURE 9: Transverse plane representation of the anterior and lateral footdisplacement at foot-strike (a) straight-line sprinting (b) straighten step.

FIGURE 10: Transverse plane representation of the posterior and lateral footdisplacement at toe-off (a) straight-line sprinting (b) straighten step.

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Change of Direction PhaseDuring the change direction phase, it wasshown that running speed decreasedmarkedly (-1.18 ±0.41 m.s-1) which is instark contrast to the acceleration thatoccurred with straight-line sprinting(0.27 ±0.17 m.s-1, t (68.586) = 20.998, p< .001). The trend for anterior footdisplacement at foot-strike continuedduring this agility phase, with greatervalues recorded at the change of directionstep (46.24 ±11.19 %) compared tostraight-line sprinting foot-strike (14.90±8.90 %, t (70) = -11.944, p < .001)(Figure 7). Conversely, posterior footdisplacement at toe-off was less duringchange of direction (-22.92 ±15.52 %)compared to straight-line sprinting (-43.36 ±2.94 %, t (53.430) = -8.816, p <.001) (Figure 8). Results then showedthat lateral movement increased duringthe change of direction phase (1.64 ±0.28m.s-1) compared to straight-line sprinting(-0.43 ±0.29 m.s-1, t (70) = -28.835, p <.001). This was no doubt related to the

ORIGINAL RESEARCH

occurred during the straighten phase ofagility trials, with increases in runningspeed of 0.77 ±0.35 m.s-1 compared to just0.27 ±0.17 m.s-1 for straight-line sprinting(t (69.996) = -8.208, p < .001). It was thenshown that the foot was positionedposterior to the CM at foot-strike of thestraighten step (-0.91 ±15.43 %)compared to the anterior placement of thefoot during straight-line sprinting (14.90±8.90 %, t (68.426) = 5.501, p < .001)(Figure 9) and that posterior footdisplacement at toe-off was greater at thestraighten step (-81.02 ±7.35 %)compared to straight-line sprinting (-43.36±2.94 %, t (67.773) = 30.896, p < .001)(Figure 10). In addition, the straightenphase was characterised by having a largereduction in lateral movement (-1.51±0.57 m.s-1) compared to straight-linesprinting (-0.43 ±0.29 m.s-1, t (69.934) =10.660, p < .001). Lateral foot positionsthen followed similar patterns to thechange of direction step, with greatervalues recorded during the straightenphase (foot-strike = 46.14 ±11.42 % andtoe-off = 28.40 ±15.56 %) compared tostraight-line sprinting (foot-strike = 8.06±3.17 %, t (59.722) = -21.494, p < .001)and toe-off (-17.69 ±2.82 %, t (54.926) =-19.887, p < .001) (Figures 9 and 10).

Re-acceleration PhaseThe spatiotemporal characteristics of there-acceleration phase were similar to thatreported for the straighten phase. Greateracceleration to running speed againoccurred during this phase for agilitytrials, with increases to running speed of0.50 ±0.49 m.s-1 compared to a smallerincrease in running speed for straight-linesprinting (0.27 ±0.17 m.s-1, t (64.922) = -2.910, p < .001). In addition, this phasewas also characterised by smaller anteriorfoot displacement at foot-strike (11.84±11.22 %) compared to straight-linesprinting (14.90 ±8.90 %, t (68.426) =5.501, p < .001) (Figure 11) and greaterposterior foot displacement at toe-off (-68.33 ±12.72 %) compared to straight-linesprinting (-43.36 ±2.94 %, t (56.272) =12.923,p < .001) (Figure 12). Thepreviously reported reduction in lateralmovement continued through this phase(-0.97 ±0.32 m.s-1), which was greaterthan the changes to these values forstraight-line sprinting (-0.43 ±0.29 m.s-1,t (70) = 6.871, p < .001). Further analysisshowed that lateral foot displacement atfoot-strike of the re-acceleration step (-

FIGURE 11: Transverse plane representation of the anterior and lateral footdisplacement at foot-strike (a) straight-line sprinting (b) re-acceleration step.

FIGURE 12: Transverse plane representation of the posterior and lateral footdisplacement at toe-off (a) straight-line sprinting (b) re-acceleration step.

39.50 ±8.64 %) had crossed the line ofthe CM and was greater than recordedduring straight-line sprinting (8.06 ±3.17%, t (65.968) = 33.840, p < .001) (Figure11). Finally, lateral foot displacement attoe-off was also greater at the re-acceleration step (-32.00 ±10.52 %)compared to straight-line sprinting (-17.69±2.82 %, t (59.012) = 8.811, p < .001)(Figure 12).

DISCUSSIONPre-change of Direction PhaseWe demonstrated that the pre-changedirection phase is characterised by areduction to running speed which is nodoubt crucial to maintain movementcontrol during the subsequent change ofdirection.2 It appears that the main avenuefor reducing / controlling running speedis by increasing anterior foot displacementat foot-strike, which has been associatedwith braking forces that deceleraterunning speed.4,9 We propose that a trade-off exists between running speed andcontrolled agility movements (dynamicstability), where excess running speedswhen attempting to evade (changedirections) defenders during attacking ball

carries may promote instability and asresult, greatly diminish the ability tomaintain movement control.

Change of Direction PhaseThe change of direction phase wascharacterised by continued reduction torunning speed achieved with increases toanterior foot displacement at foot-strike.Similarly, it was shown that an increaseto anterior foot positions occurred withgreater running speed at change ofdirection foot-strike. This furtheremphasises the role that increases toanterior foot positions have in reducingrunning speed prior to direction change.7

There is no doubt that the reduction torunning speed with purposeful increasesto anterior foot displacement at foot-strikerepresents a fundamental element of thechange of direction phase during agilitymanoeuvres.

We also demonstrated that the change ofdirection phase provides the criticalcomponent eliciting the desired directionchange during agility manoeuvres.Consequently, a substantial increase tolateral movement was associated with

Vol 37 No 1 2010 17

greater lateral foot positions, whereincreases to lateral foot displacementduring the change of direction phaseincreased lateral movement. In rugbyunion, the ability to execute rapid changeof directions (lateral movements)represent a fundamental component ofevasive (agility manoeuvres) attackingstrategies.21,25 It is recommended thatrugby union coaches focus on the footplacement patterns of players in order toimprove their rapid lateral movementduring attacking ball carries.

Transition PhaseWe observed that the transition phase ischaracterised by the transmission of lateralmovement whilst seeking to controlforward motion. Importantly, the steppatterns exhibited during the transitionphase altered the properties of lateralmovement and provided differentiationbetween speeds of agility performance.Clear variations to the transition stepspatterns occurred during agility skillexecution, such that enhanced speed ofperformance was achieved with lesstransition steps and subsequent increasesto the percent transition flight. It wasconcluded that the inverse relationshipbetween the speed of performance and thenumber of transition steps represents a keydeterminant to the speed of evasive agilitymanoeuvres during attacking ball carriesin rugby union. Clearly, further researchexamining running technique during thisagility phase is warranted.

Straighten PhaseThe straighten phase was characterised bea redirection of lateral movement topromote forward motion. Accordingly,increases to running speed in conjunctionwith a reduction to lateral movement wereobserved during the straighten phase. Anincrease to lateral foot positions no doubtassisted this redirection of lateralmovement, which coupled with aconcurrent decrease to anterior footpositions promoted the acceleration ofrunning speed.9 Interestingly, the foot waspositioned posterior to the CM at foot-strike of this phase, a characteristic ofacceleration based running techniques4,9

In rugby union, rapid acceleration offorward motion during the straightenphase would no doubt enhance the abilityto exploit breaks in the defensive line

created from the initial evasive directionchange. The ability to evade defenders andadvance the ball beyond the advantageline is a crucial component of runningability in rugby union.14,25,26 Therefore,the properties of forward propulsionduring the straighten phase represent a keydeterminant of agility performance inrugby union.14,25

Re-acceleration PhaseThe re-acceleration phase refers to theconcluding events of the agilitymanoeuvre, where a considerable increaseto running speed is a desirable feature ofperformance. In rugby union, the re-acceleration phase allows the attackingball carrier to advance the ball beyond thedefensive line.14,21,25 We demonstratedthat a reduction to anterior footplacements, that more closely resembledstraight-line sprinting patterns, promotedacceleration of running speed during there-acceleration phase.4,9

In contrast, the lateral foot placementsobserved during the re-acceleration phasewere distinctive to straight-line sprinting.The negative lateral foot positions, wherethe foot crossed the line of CM indicatedthat a residual amount of lateral movementremained following the straighten phase,and that the foot position likely produceda blocking force to counter thismovement. In addition, the presence ofresidual lateral movement during the re-acceleration phase no doubt represents adestabilising component that wouldreduce the effectiveness of running abilityin rugby union and would therefore notbe a characteristic of effectiveperformance.

CONCLUSIONThe phases of the agility gait cycle exhibitcharacteristics that make it a unique skillto that of straight-line sprinting. The initialside-step was characterised by thedeceleration of running speed and thedevelopment of lateral movement towardsthe intended direction change. Followingdirection change, the agility gait cycle wascharacterised by a redirection of residuallateral movement to promote forwardprogression. Our findings present anessential understanding of agility runningtechnique throughout multidirectionalsports and specifically rugby union.

Clearly, training programs that emphasisestraight-line sprinting techniques areinappropriate in rugby union because ofthe multidirectional nature of this sport.It is then recommended that agilitydevelopment programs, that are moresuited to the requirements of rugby union,focus on the effectiveness of footplacement patterns and consider theability to control movements when rapidlychanging directions.

ACKNOWLEDGEMENTSThis project received financial assistancefrom the New Zealand Rugby Union. Thisorganisation and its members received noincentives, financial or commercialbenefits from this arrangement. There areno conflicts of interest directly relevantto the content of this manuscript.

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15 McLean S et al. Sagittal planebiomechanics cannot injure the ACLduring sidestep cutting. Clin Biomech2004; 19:828-838.

16 McLean S et al. Knee joint kinematicsduring the sidestep cutting maneuver:potential for injury in women. MedSci Sports and Exerc 1999; 31:959-968.

17 Menz H B et al. Reliability of theGAITRite walkway system for thequantification of temporo-spatialparameters of gait in young and olderpeople. Gait Posture 2004; 20:20-25.

18 Ounpuu S. The biomechanics ofwalking and running Clin Sport Med1994; 13:843-863.

19 Sayers M. Running techniques forrunning rugby. New Zealand Coach1999; 20-23.

20 Sayers M. Running techniques forfield sport players. Sports Coach2000; 23:26-27.

21 Sayers MGL and Washington-King J.Characteristics of effective ballcarries in Super 12 rugby. Int J PerfAnal Sport 2005; 5:92-106.

22 Schache, A.G., et al. A comparison ofoverground and treadmill running formeasuring the three-dimensionalkinematics of the lumbo-pelvic-hipcomplex. Clin Biomech. 2001 16:667-680.

23 Schot P, Dart J and Schuh M.Biomechanical analysis of twochange-of-direction maneuvers whilerunning. J Orthop Sports Physl Ther1995; 22:254-258.

24 Wakai M and Linthorne N P.Optimum take-off angle in thestanding long jump. Hum MovementSci 2005; 24:81-96.

25 Wheeler K W, Askew C D and SayersMGL. Effective attacking strategiesin rugby union. Eur J Sport Sci 2010;10:237-242.

26 Wheeler K W and Sayers MGL.Contact skills predicting tackle-breaks in rugby union. Int J Sports SciCoach 2009; 4:535-544.

27 Winter D A. Biomechanics and motorcontrol of human movement. NewYork: John Wiley, 2009.

28 Young W, Hawken M and McDonaldL. Relationship between speed, agilityand strength qualities in AustralianRules football. Strength Cond Coach1996; 4:3-6.

29 Young W B, McDowell M H andScarlett B J. Specificity of sprint andagility training methods. J StrengthCond Res 2001; 15:315-319.

ORIGINAL RESEARCH

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Review current thinking on themanagement of retropatellor painSteven Lim MBChBGeneral PractitionerChristchurch

INTRODUCTION

Retropatella pain is the mostcommon diagnosis madeamongst runners in sports

medicine centres.10 It contributes up to25% of all knee injuries in sports medicalcentres and constitutes between 16 and25% of all injuries in runners.3,15

It is more commonly known aspatellofemoral pain syndrome (PFPS),runner’s knee or movie-goer’s knee.Generally other intraarticular andperiarticular pathologies such as, plicasyndromes, apophysitis, and inflamedbursa are excluded.1 The diagnosis ofPFPS is usually a clinical one as imagingis usually normal. The pain can be difficultto manage, but often improves with a welldesigned conservative treatment protocol.

PATHOPHYSIOLOGYThe patellofemoral joint is comprised ofthe patella and femoral trochlear. Thefunction of the patella contained in thisjoint is to act as a lever and increase thepower generated by the extensormechanism. The patella contacts with thetrochlear at 20 degrees with maximalcontact at 90 degrees.11 The stability ofthe patellofemoral joint is controlled byboth static and dynamic stabilisers.Together these help to control themovement of the patella throughout itsrange of motion and this is referred to as“patella tracking”. Forces through thepatella which can be transferred onto thejoint can range from a third of one’s bodyweight during walking to seven timesduring squatting.12 Abnormalities ofpatella tracking can change thepatellofemoral joint contact pressures andlead to pain stimulation. This is thoughtto be the key to determining possiblecauses of PFPS and help to identify thefocus of treatment.3

RISK FACTORSSeveral factors may increase the risk indevelopment of PFPS. Overuse, traumaanatomical and dynamic biomechanicalforces and their effect on patella trackingappear to be the main contributors.3

Static malalignment of the patellofemoraljoint such as an increased standing Qangle, pes planus and subtalar pronationhave thought to have been contributors inthe development of PFPS.3 However,there is limited evidence of a causalrelationship for this.5,13,22 Kinematicanalysis during the stance phase has beenperformed with runners with PFPSshowing higher resultant abduction andexternal rotation movements and lowerresultant extension moments at the kneethan those without symptoms of PFPS.13

Larger studies are needed to confirm thisfinding.

HISTORYA patient will typically describe painbehind and around the patella that isdifficult to localise. Pain is usuallydescribed over the anterior aspect of theknee but often patients will draw a circlearound the patella.3 Symptoms are usuallyof gradual onset and can be bilateral. Painis often exacerbated by prolonged sittingand pain on activities that increasepressures over the patellofemoral jointsuch as running, jumping and squatting.3

Patients may also complain of instability,however this does not usually representtrue patella instability but rather transientinhibition of the quadriceps because ofpain or deconditioning.16

PFPS is described as an overuse typeinjury so a recent training or occupationalhistory should also be sought. Othersignificant contributors can includeinappropriately worn footwear, exercisessuch as squats and lunges and otherconditioning exercises.3

CLINICAL FINDINGSThe reliability of clinical tests for PFPSis either low or untested and thereforemultiple evaluations are needed to helpgive a diagnosis of PFPS.8 These arediscussed below. They may also be helpfulin revealing factors contributing to PFPSand patellofemoral malalignment. Anysignificant effusion or swelling of anteriorstructures such as fat pads or bursa areunusual and would suggest an alternativediagnosis.

Q-angleThe Q angle is the angle formed by theline formed by the quadriceps relative tothe patella tendon as it intersects in thecentre of the patella.17 Changing the Q-angle can change the location of contactand pressure at the patellofemoral jointresulting in areas experiencing excessivestresses that are not physiologicallymanageable.18

By increasing the Q-angle the patella ismore likely to tract laterally as thequadriceps is contracted.8 This mayincrease lateral contact pressures and alsoinstability.5 Decreasing the Q-angle willnot change the patella position but willincrease the tibiofemoral contact pressuresthrough increasing varus orientation of theknee.19 Numerous studies have been doneto determine whether the Q-angle iscorrelated with PFPS with conflictingresults.5 Grossly larger Q angles such asthose greater than 20 degrees may be asignificant risk factor.20

Mediolateral GlideThis test is performed with the knee flexedat 20 degrees. The midpoint of the patellais measured (usually by tape measure) andshould be equidistant (+/- 5mm) betweenthe two femoral epicondyles. Dataappears to be inconclusive in the relevanceof this test. Correlation appears to be poor

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with both comparison MRI measurementsat the 20 degree angle and clinicalsymptoms of PFPS.5

Patella TiltingExcessive patellar tilting laterally canrestrict medial motion and increase thestress between the lateral facet of thepatella and the lateral trochlea. It isconsidered pathological when the tilt isgreater than 20 degrees in knee extensionwhen measured by CT.5 It has beenreported in one study that a positive patellatilt was significant for PFPS compared tocontrols with 92% specificity and 43%sensitivity.14

Patella Compression TestThis test is performed by compression ofthe patella in the trochlear groove whilemoving the patella up and down, with painindicating a positive test. It has been notedthat patients with PFPS have a highprobability of a positive result in theaffected knee, but also in the unaffectedknee21 and so the reliability for this test isuncertain.

Dynamic Patellar TrackingThis can be assessed by having the patientperform a single leg squat and stand.Imbalance between the medial and lateralpatella forces such as vastus medialisobliquus (VMO) dysfunction and tightlateral structures can be manifested by anabrupt deviation of the patella as itengages the trochlea in early flexion. Thisis known as the “J sign”.3

Neuro-Motor Dysfunction has also beenmeasured using EMG studies. One studyhas demonstrated a significantly fastercombined VMO and vastus lateralus (VL)response as well as a delayed response ofthe VMO compared to the VL comparedto controls in PFPS.22 However althoughthe later finding would support the theoryof maltracking of the patella contributingto symptoms to PFPS it was small and notsignificant.

Foot AbnormalitiesStatic measurements of genu varum, genuvalgum, pes cavus and pes planus havenot been found to contribute to PFPS.5,13,22

MANAGEMENTNumerous strategies can help to alleviateand better manage the pain associated withPFPS, usually best in combination.

EducationEducation about the pathophysiology tothe patient is important for both patientunderstanding and may help withcompliance to any rehabilitation program.Positive effects on the muscular systemwith modification and training takes timeand so patients need patience and plentyof encouragement.1,2

Relative Rest and ModificationReduction of exacerbating factors andloading to the patellofemoral joint is thefirst step to reduce pain. If certainexercises such as lunges or squat arecontributing, these should be stopped.Runners should reduce their mileage to alevel that does not provoke pain duringthe exercise and over the 24 hours postexercise.

Symptoms usually abate with thesemodifying measures however furthertreatment as described below is oftenneeded to prevent recurrence.1,2

Physical TherapyThere is conflicting data regarding theeffectiveness of physical treatments inPFPS.

Some authors have suggested that part ofthe reason for this is that PFPS has failedto be and needs to be categorised intosubgroups that describe an underlyingcause for PFPS such as tightness ormuscular weakness.6 Physical therapythen needs to be focused on theseunderlying factors. For example, inwomen with weak hip external rotatormuscles a focused strengtheningprogramme can improve patella trackingin patients with PFPS.9 Tight structuresshould be mobilised and the kinetic chainbalanced. Specific factors to work on ina training programme are: strength,flexibility, proprioception, endurance,functional training and a gradualprogression of the exercise load.26 Thiscan be done with manipulative therapysuch as stretching combined withproprioceptive and strengtheningexercises. The efficacy of this can beassessed by watching patella tracking withsingle leg squats with heavier or higherfrequency loads.

The general recommended treatment forPFPS is with an exercise programme as

described above, however one of the maindifficulties is with compliance. One studyby Yates who followed up 64 patients withPFPS over 15 months revealed 42 noncompliant, 17 partially compliant and only5 compliant with the prescribedrehabilitation programme.27 Despite this,numerous studies have shown goodresults. In a long term study of 48 patientsgiven advice about PFPS and isometricexercise over a mean period of 11 years,results were found to be good to excellentin 85% of patients.28 This agrees withfindings from other studies.1

There is inconclusive evidence to supportthe superiority of specific physiotherapyinterventions1,4 however eccentricquadriceps strengthening programmesappear to result in a better treatmentresponse than other forms ofstrengthening when comparing functionalimpairment measures.4

AnalgesiaNSAIDs and paracetamol are oftenprescribed for patients with PFPS,however there is little evidence supportingtheir effectiveness.23 They may be usefulfor patients with symptoms during theirdaily activities at the initiation oftreatment when other measures such as iceare ineffective.3

TapingPatella taping has been suggested as ameasure in improving patella tracking andquadriceps function. Howeverrandomised clinical trials have failed toshow consistent benefit when added overphysical therapy. It has also not beenshown to improve symptomatic relief inthe long term.3

Foot OrthosisAs mentioned above static measurementshave failed to show a relationship betweenlower extremity malalignment and PFPS.However in a patient with significant footpronation corrective footwear can be areasonable option.3 In patients withrearfoot varus there is some evidence froma non blinded study that correctivefootwear may be useful in reducing painin PFPS activities after a period of 8weeks.24

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Progressive Resistance BraceHigh volume quadriceps strengtheninghas been monitored using a progressiveresistance brace which showed significantimprovement in pain, radiological patellaralignment and function.25 Althoughbenefit was observed, this was notcompared with any equivalent treatmentarm and also given the expense of thedevice further comparative study isneeded.

SurgerySurgical consultation may be consideredfor patients whose symptoms persistdespite a thorough rehabilitation programfor at least 1 month and whom othercauses of anterior knee pain has beenexcluded.3 Most studies for surgicaltreatment are uncontrolled case studiesand therefore have not been fullyevaluated.

Options include release of the lateralretinaculum and proximal realignment forthose with tight lateral structures.9 Distalrealignment with anteromedialisation ofthe tibial tubercle may benefit those withlateral compression and associate articularcartilage injury.

CONCLUSIONThe pathophysiology of PFPS is not fullyunderstood but there are probably multiplefactors contributing to pain in the anteriorknee. The underlying principle is thoughtto be excessive or abnormal forces overthe patellofemoral joint as the knee isflexed.

Generally improvement is expected overa long period with modification ofactivities. Physical therapy is the mainstayof treatment but this needs to beindividualised to the patient and focusedon the underlying factors that may becontributing to patella maltracking.Patients need to be strongly encouragedto be compliant with any rehabilitationprogramme. Other forms of treatmentshave not been fully evaluated, howevermay be useful in certain circumstances.

REFERENCES1 Thomeé R, Augustsson J, Karlsson J.

Patellofemoral Pain Syndrome, SportsMed 1999 Oct; 28 (4):245-262.

2 Juhn M, Patellofemoral Pain Syndrome:A Review and Guidelines for Treatment.Am Fam Physician. 1999 Nov

3 Dixit S, Difiori P, Burtion M, MD, MinesB, Management of Patellofemoral PainSyndrome. Am Fam Physician. 2007 Jan15;75(2):204.

4 Crossley K, Bennell K,Green S,McConnell J. A Systematic Review ofPhysical Interventions for PatellofemoralPain Syndrome. Clin J Sport Med,11:103–110

5 Waryasz G R, McDermott A Y.Patellofemoral pain syndrome (PFPS): asystematic review of anatomy andpotential risk factors. Dynamic Medicine2008, 7:9 (26 June 2008)

6 Witvrouw E, Werner S, Mikkelsen C, VanTiggelen D, Vanden Berghe L, Cerulli G.Clinical classification of patellofemoralpain syndrome: guidelines for non-operative treatment. Knee Surg SportsTraumatol Arthrosc 2005; 13:122–130

7 Brushøj C, Hölmich P, Nielsen MB,Albrecht-Beste E. Acute patellofemoralpain: aggravating activities, clinicalexamination, MRI and ultrasound findings.Br J Sports Med 2008 Jan; 42(1):64-7;discussion 67. Epub 2007 Jun 11

8 Fredericson M, Yoon K. Physicalexamination and patellofemoral painsyndrome. Am J Phys Med Rehabil 2006Mar; 85(3):234-43.

9 Fulkerson J P. Diagnosis and treatmentof patients with patellofemoral pain AmJ Sports Med 2002 May-Jun; 30(3):447-56. Review.

10 Taunton J E, Ryan M B, Clement D B,McKenzie D C, Lloyd-Smith D R, ZumboB D. A retrospective case-control analysisof 2002 running injuries. Br J Sports Med2002; 36:95-101.

11 Fu F H, Seel M J, Berger R A.Patellofemoral biomechanics. In: Fox JM, DelPizzo W, eds. The PatellofemoralJoint. New York, NY: McGraw-Hill,1993:49. Sited by 3.

12 Reilly D T, Martens M. Experimentalanalysis of the quadriceps muscle forceand patello-femoral joint reaction forcefor various activities. Acta Orthop Scand1972; 43:126-37. Sited by 3.

13 Lun V, Meeuwisse W H, Stergiou P,Stefanyshyn D. Relation between runninginjury and static lower limb alignment inrecreational runners. Br J Sports Med2004; 38:576-80.

14 Haim A, Yaniv M, Dekel S, Amir H:Patellofemoral pain syndrome:validity ofclinical and radiological features. ClinicalOrthopaedics & Related Research 2006Oct 451:223-228.

15 Baquie P, Brukner P: Injuries presentingto an Australian sports medicine centre:A 12-month study. Clin J Sport Med 1997;7:28–31

16 Post W R. Clinical evaluation of patientswith patellofemoral disorders.Arthroscopy 1999; 15:841-51.

17 Brattstrom B: Shape of the intercondylargroove normally and in recurrentdislocation of patella. Acta Orthop ScandSuppl 1964; 68:1–44. (Cited by:Fredericson M, Yoon K. Physicalexamination and patellofemoral painsyndrome. Am J Phys Med Rehabil 2006Mar; 85(3):234-43)

18 Duffey M J, Martin D F, Cannon D W,Craven T, Messier S P: Etiologic factorsassociated with anterior knee pain indistance runners. Med Sci Sports Exerc2000; 32(11):1825-1832.

19 Mizuno Y, Kumagai M, Mattessich S M,Elias J J, Ramrattan N, Cosgarea A J,Chao E Y: Q-angle influencestibiofemoral and patellofemoralkinematics. J Orthop Research 2001;19(5):834-840. (Cited by: Patellofemoralpain syndrome (PFPS): a systematicreview of anatomy and potential riskfactors Gregory R Waryasz, Ann YMcDermott Dynamic Medicine 2008, 7:9)

20 Haim A, Yaniv M, Dekel S, Amir H:Patellofemoral pain syndrome: validity ofclinical and radiological features. ClinicalOrthopaedics & Related Research 2006;223-228.

21 Hand C J, Spalding T J: Associationbetween anatomical features and anteriorknee pain in a “fit” service population. JR Nav Med Serv 2004; 90:125–34. (Citedby: Fredericson M, Yoon K. Physicalexamination and patellofemoral painsyndrome. Am J Phys Med Rehabil 2006Mar; 85(3):234-43)

22 Witvrouw E, Lysens R, Bellemans J,Cambier D, Vanderstraeten G: Intrinsicrisk factors for the development ofanterior knee pain in an athleticpopulation. A two-year prospective study.Am J Sports Med 2000; 28(4):480-489.

23 Heintjes E, Berger M Y, Bierma-ZeinstraS M, Bernsen R M, Verhaar J A, Koes BW. Pharmacotherapy for patellofemoralpain syndrome. Cochrane Database SystRev 2004; (3):CD003470

24 Eng J J, Pierrynowski M R. Evaluationof soft foot orthotics in the treatment ofpatellofemoral pain syndrome. Phys Ther1993; 73:62–70

25 Timm K E. Randomized controlled trialof protonics on patellar pain, position, andfunction. Med Sci Sports Exerc 1998;30:665–670.he treatment of patellofemoralpain syndrome. Phys Ther 1993; 73:62–70 (Cited by: Crossley K, Bennell K,Green S, McConnell J. A SystematicReview of Physical Interventions forPatellofemoral Pain Syndrome. ClinicalJournal of Sport Medicine, 11:103–110)

26 Shelton G L, Thigpen L K. Rehabilitationof patellofemoral dysfunction: a reviewof literature. J Orthop Sports Phys Ther1991; 14: 243-9, J Sports Med 2002;30:447-56.

27 Yates C, Grana W A. Patellofemoral pain:a prospective study. Orthopaedics 1986;9:663-7 (Cited by: Thomeé R, AugustssonJ, Karlsson J. Patellofemoral PainSyndrome Sports Med 1999 Oct; 28 (4):245-262)

28 Karlsson J, Thomeé R, Swärd L. Elevenyear follow-up of patellofemoral painsyndrome. Clin J Sports Med 1996; 6:22-6

29 Collin N, Bisset L, Crossley K, VicenzinoB. New evidence for physical therapiesfor anterior knee pain presented at sportsphysiotherapy symposium: a systematicreview and meta-analysis APA ConferenceWeek 2009, Sydney.

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The relationship betweenpersonality and performance inendurance sport

Rod Corban PhDNew Zealand Academy of Sport

There have been numerousstudies that have attempted toelucidate the relationship

between expert performance in sportand the personality traits of athletes.The popularity of this research topicwas perhaps at its zenith in the early1980s with the work of Morgan beingparticularly influential (Morgan,1980). Early studies tended to focuson the difference between athletes andnon athletes with findings suggestingdifferences on such dimensions asmotivation, social confidence,aggressiveness (Cooper, 1969),conscientiousness and self control(Garland and Barry, 1990). Howevermany of these studies were based uponteam contact sports which mayaccount for these particulardifferences. Furthermore, these earlystudies aimed at exploring personalityand sporting performance suffer froma lack of theoretical basis ofpersonality and have been referred toas a “Blunderbuss” approach: if wethrow enough personalityquestionnaires at athletes something isbound to hit the mark (Shaw, Gorley& Corban, 2003). Even the work byMorgan cited earlier, and which isoften seen as a seminal work in thearea, suffers from a fatal flaw. Morgandeveloped what he termed the Ice BergProfile of successful athletes. Thisprofile was obtained by measuring themood state of athletes using the sixdimensional Profile of Mood States(POMs). Clearly mood states are notequivalent to personality traits,something often overlooked by sportpsychologists and sport scientists.

Given the inconsistent findings ofearly research and some of the issuesaround personality and itsmeasurement, research in the areaseemed to come to a halt by the end ofthe 1980s and little of any realsubstance has appeared in theliterature in the subsequent 10 to 15years.

Perhaps one of the major issues aroundthe measurement of personality wasthe lack of a clear theoretical modelof personality. Specifically, it hadbeen suggested that one of the reasonsfor the equivocal results relatingperformance in a variety of areas (job,academic and sporting performance)was the lack of a consistent use ofmethodologies and theoreticalapproaches to the study of personalityand performance (De Raad &Schouwenburg, Hogan & Roberts,2001;Guion & Gottier, 1965;, 1996;Piedmeont, Hill Blanco, 1999).Eysenk, Nias and Cox (1982)suggested that the application of afactorial model of personality mayprovide a more fruitful avenue forexploring the relationship betweenpersonality and performance. Theseauthors demonstrated how theapplication of a theoreticallyconsistent well established, broadspectrum dimension approach topersonality could be applied to highlevel ability athletes in specific sportsto identify the relationship betweenpersonality and performance. Eysenket al (1982) supported the use of athree factor model of personality,although more recent views of broad

factorial models of personality haveproposed a five factor model.Specifically, an individual’spersonality can be described within thecontext of five broad domains ofbehavior:

Openness (inventive/curious vscautious/conservative)Conscientiousness (efficient/organised vs easy-going/careless)Extroversion (outgoing/energeticvs shy/withdrawn)Agreeableness (friendly/compassionate vs competitive/outspoken), andNeuroticism (sensitive/nervous vssecure/confident).

Moreover, this “Big Five” approach topersonality theory has shown toprovide a broader description ofpersonality than Eysenk’s originalthree factor model (Costa and McCrae,1995).

In terms of the application of the “Big5” within a sporting context the studyconducted by Piedemont, Hill andBlanco (1999) employed the fivefactor model of personality to attemptto predict sporting performance incollegiate female soccer players. Thismore recent study was able to putsome of the earlier inconsistentfindings in the context of the “Big 5”model and obtain some agreementwith their own findings. Specifically,in combination with earlier studies,including Eysenk et al. (1982), itwould appear from the Piedmont et

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al’s (1999) study successful athletestend to be more focused and goaldriven and score low on Neuroticism(high self control, self esteem andemotional control). In summary theseauthors concluded that high achieversin sport, just like in other behaviouraldomains, are emotionally stable,capable, have a heightened sense ofcompetence and a drive to succeed.This appears to be the only existingapplication of the Five Factor Model(FFM) of personality applied to theinvestigation of the relationshipbetween personality and sportperformance. However, examinationof the literature drawing on otherperformance domains such asacademic and occupationalperformance would tend to support thesport findings. In particular, thisresearch suggesting that those whoperform well academically and inoccupational settings score highly onthe Conscientiousness domain and lowon Neuroticism domain (Hurtz &Donovan, 2000; Judge & Ilies, 2002;Poropat, 2009; Sackett, Gruys,Ellingson 2006). However, on closerexamination of these findings it is notthe scores on the domains themselvesthat are predictive but rather some ofthe facets that sit “below” thesedomains. What seems to be consistentacross these studies is that the facetsof Achievement Striving and Selfdiscipline are better predictors thantheir global domain ofConscientiousness. The only otherFFM domain that seems to beconsistently related to performance isthat of Neuroticism. Furtherexamination of the findings wouldappear to suggest that there is a generalnegative relationship between thefacets of impulsivity and anxiety. Insupport of this view in sport are therecent findings by Stoeber et al. (2008)that suggests successful eliteendurance athletes require high levelsof perfectionism and achievementstriving and low levels of what can belikened to behaviours associated withthe FFM of neuroticism.

Thus there appears to be someevidence that some facets of the big 5personality factor model are predictiveof performance at least in collegiate

athletes. Additionally, this seems to beconsistent with findings in otherperformance areas outside of sport.The danger of course is that peoplewith a lack of understanding ofpersonality theory and itspsychometric assessment assume thatwe should, from the results above, beable to “profile” athletes to predictthose that will be successful. Muchof this misguided ideology comesfrom the Human Resource practice ofthe use of personality tests to screenpotential employees. In thesesituations the tests used are notexposed to rigorous peer review andare “sold” to clients as a robustprocess. In practice of course thesepsychometric tests are not as reliableor valid as one would like, and aretreated with caution by thoseprofessionals that do posses thenecessary knowledge and expertise intheir use. Even if we do take theresults of Peidemont et al. (1999) andothers applying the FFM to profilesuccessful athletes we must considerthat the population assessed were nottrue elite athletes and in Peidemont etal’s study were collegiate athletesparticipating in a closed skill teamsport (ie, soccer). Even the resultsprovided by Stroebe et al (2008) donot specifically utilise the FFM ofpersonality and in addition theirdefinition of elite was based on hoursof training rather than level ofperformance. Thus it is possible thatdifferent results would be obtained byan examination of true elite athletes(those that have competed in eliteWorld Championships and OlympicGames) participating in endurancebased sports.

One further interesting developmenthas been the recent emergence fromthe positive psychology literature thatoptimism (or hope) plays an importantrole in how successful one is. Forexample, Seligman (1998) suggestedfrom a study using inter collegiateswimmers that those high in optimismwere more successful compared tothose scoring high on pessimism.Other prominent sport researchershave also suggested that dispositionalhope and high levels of optimism maybe predictive of successful

performance (Gould, Dieffenbach &Moffett, 2002). This positivepsychology approach has receivedsome popular support in the modernsporting world – particularly in NZ.It also appears that high levels ofoptimism also predicts successfulperformance in other areas such as thework place (Peterson and Byron,2008).

To this end and with the cooperationof Rowing NZ and Bike NZ membersof NZ national teams since the AthensOlympics were asked to complete anonline personality assessmentmeasuring the facets of AchievementStriving, Self Discipline, Hope(Optimism), Impulsivity and Anxiety.These facets were chosen due to theirconsistent relationship withperformance in sport and otherperformance domains as noted in theabove. Specifically, successfulathletes score high on the first threefacets and lower on the lattermaladaptive two. Those individualswho had won medals at a WorldChampionship (not a World Cup) oran Olympic Games (n = 21) werecompared to those who had not (n =28). Surprisingly, on averagesuccessful athletes scored significantlylower on the adaptive personality traitsof achievement striving, selfdetermination and optimism, althoughthey did score significantly lower onthe neurotic facet of anxiety.However, of more interest, whenexamined individually the successfulathletes varied markedly in terms oftheir personality profile. Indeed anexamination of the variability of thescores on the personality facetsshowed that “champions” were quitedifferent from each other and more sothan the non-champions particularlywith respect to the more adaptivepersonality traits (see Figure 1). Forthose of us who work with elitesuccessful athletes this is of nosurprise: these athletes are extremelydifferent in terms of their personality.Anecdotally one just has to think ofthe differences in personality of JohnMcEnroe and Bjorn Borg; two verysuccessful tennis players of the sameera and yet with clearly differentpersonalities. Moreover the results

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FIGURE 1: Comparison of the variability of scores on the personality facets measured between champion athletes and non-champion athletes.

NoteObviously this is a very abridged reportof the aforementioned study. For moreinformation you should contact RodCorban (rodc@nzasni.org.nz)

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suggest there is very little point inlooking for athletes that have aparticular personality type to predictwho will be successful at the elitelevel. Rather these results suggest thatsuccessful athletes come in differentshapes and sizes (psychologically andphysically) and that coaches,administrators and support serviceproviders should perhaps pay moreattention to the different individual needsof these athletes.

“The author acknowledges the input ofProfessor Michael O’Driscoll Departmentof Psychology, University of Waikato”.

CASE STUDY

INTRODUCTION

De Quervain’s tenosynovitis isa stenosing tenosynovitis ofthe first dorsal compartment of

the wrist at the radial styloid.5 It iscaused by impaired gliding of thetendons of the abductor pollicis longus(APL) and extensor pollicis brevis(EPB) muscles, caused by thickeningof the extensor retinaculum.6

Although the term tenosynovitis iscommonly used, histopathologicalstudies indicate that thepathophysiology involvesdegenerative changes2 and the absenceof inflammation. Few treatments havebeen shown to lead to favourableoutcome. However corticosteroidinjection has been proven to beeffective, with surgery reserved forthose patients who fail to respondconservatively. This case studyoutlines a patient successfully treatedfor De Quervain’s tenosynovitis.

CASE STUDYA 34 year old woman was referred forphysiotherapy with right thumb andwrist pain, of insidious onset. Her painhad began two weeks earlier and hadbeen progressively increasing. Shewas having discomfort playingbadminton, lifting her children andwith any lifting or gripping activitiesof daily living. The pain was notenough to stop her doing any of theseactivities, however, she was worriedthat the pain was going to stop her

lifting her children. She had seen herGeneral Practitioner (GP) whoprescribed her non-steroidal anti-inflammatories and referred her forphysiotherapy. She was a mother oftwo, and a regular badminton player.

She described an intermittent sharppain along the radial aspect of her right(dominant) wrist during activity. Shecomplained of no pain at rest, and nonight pain. She had no pins andneedles or numbness.

She was otherwise fit and healthy, withno previous complaints affecting thethumb, hand, wrist, shoulder or neck.

Her examination findings showed herto be swollen over the distal radiusnear the radial styloid. She was tenderon palpation over radial styloidprocess and the tendons of APL andEPB muscles. There was no loss ofrange of motion of the thumb, wrist,forearm or elbow joints. She had painwith resisted abduction of thumb.There was no crepitus present withmovement. Finklestein’s test waspositive (pain reproduced at end ofrange ulnar deviation/thumb flexion).Her neck examination wasunremarkable.

X-rays of her wrist requested by herGP were normal.

De Quervain’s TenosynovitisChris B Lawrence BHSc(Physiotherapy)1

Hamish R Osborne MBChB, MMedSci, FACSP2

1 Division of Health Sciences, University of Otago2 Department of Medicine, Dunedin School of Medicine, University of Otago

Correspondence toDr Hamish OsborneDepartment of MedicinePO Box 913DUNEDINTel +64 3 474 7007 Ext 8556Fax +64 3 474 7461Email hamish.osborne@otago.ac.nz

Based on the very typical history andexamination findings a diagnosis ofDe Quervain’s Tenosynovitis wasmade. It seemed unlikely to beintersection syndrome or osteoarthritisof the 1st carpometacarpal joint.

After initial assessment, treatmentoptions were discussed with thepatient. It was decided that the initialcourse of action would be provisionof a splint to support and rest both thethumb and wrist and referral for acorticosteroid injection to the tendonsheath. The splint was provided andfour days later she had thecorticosteroid injection. Within 3 daysof having the injection she was ableto stop using the splint, and 8 days laterfelt no further pain with lifting orplaying badminton.

DISCUSSIONThere is good evidence for the efficacyof cortisone injection1,6 early on in thetreatment phase and later surgery forpatients with De Quervain’s who failto respond to surgical treatment. Othertreatment options include non-steroidal anti-inflammatories,splinting,4 and eccentric training.

Splinting has also been used as aconservative treatment. Lane et al4

studied 300 patients with DeQuervain’s and categorised thesymptoms into minimal, mild orsevere. The combination of splinting

26 NZJSM

CASE STUDY

and NSAID’s were found to be veryeffective in mild cases (88% had reliefof symptoms) but less effective inmoderate (35%) and severe (25%)cases. On the basis of this study, thereis potential to encourage the use ofsplinting in mild cases of DeQuervain’s, but no evidence to supportthe use of it in moderate or severecases.

Corticosteroid injection has beenshown to be curative for DeQuervain’s. Most patients aresymptom free after a single injection.The effectiveness is attributed to theanti-inflammatory effects of thecortisone, but the exact mechanismremains unclear.6 A study by Avci etal1 of 18 pregnant or lactating womencompared steroid injection to splintingwith thumb spica. All nine patients inthe injection group achieved completerelief of pain, compared to 0 out of 9in the thumb spica group. Howeveronly a small number of participantswere used, and were all from onesubset of society.

A systematic review by Ritchie &Briner7 included seven observationalstudies with 459 wrists. They authorsfound that 83% of the 226 wrists thatreceived injection alone were cured,61% of the 101 wrists that receivedinjection and splint immobilisationwere cured and only 14% of thosetreated with splint only were cured.

This literature provides a basis fortreatment options. Only the verymildest cases seem to respond wellwithout early corticosteroid injection.It seems reasonable to provide a splintas it gives early and yet functional painrelief, but to abandon it as soon as thecorticosteroid injection has beenperformed and its effects felt.

A small, pilot study researching acombination of sclerosing therapy andeccentric training led to encouragingresults in terms of pain reduction andfunctional improvement.3 However,there were only three subjects in thestudy, and as the intervention was bothsclerosing therapy and eccentrictraining, it is impossible to attribute theimprovements to one single

intervention and further researchshould be done in this area.

Surgery has been identified as thetreatment of choice after conservativetreatment has failed. It has beenreported to have success rates of 91%in non-controlled studies6 but isassociated with higher costs and therisk of possible surgicalcomplications. In a long-term followup study,8 94 patients with DeQuervain’s tenosynovitis weresurgically treated. Subjects wereconsidered for surgery if they haddisease duration of longer than threemonths and unsuccessful treatmentwith one or two corticosteroidinjections. A successful outcome wasdefined as absence of triggering andpain, and was achieved in all cases.The authors concluded that due to nocomplications affecting either tendon,that simple decompression of bothtendons and partial resection of theextensor ligament could berecommended for excellent long termresults in patients who fail to respondto conservative treatment.

REFERENCES1 Avci S, Yilmaz C, Sayli U.

Comparison of nonsurgical treatmentmeasures for de Quervain’s disease ofpregnancy and lactation. J Hand SurgAm 2002; 27(2):322-4

2 Clarke M T, Lyall H A, Grant J W,Matthewson MH. The histopathologyof De Quervain’s disease. J HandSurg Br 1998; 23(6):732-4

3 Knobloch K, Gohritz A, Spies M,Vogt PM. Neovascularisation in deQuervain’s disease of the wrist: novelcombined therapy using sclerosingtherapy with polidocanol andeccentric training of the forearms andwrists-a pilot report. Knee Surg SportsTraumatol Arthrosc 2008; 16(8):803-5

4 Lane L B, Boretz R S, Stuchin S A.Treatment of De Quervain’sdisease:role of conservativemanagement. J Hand Surg Br 2001;26(3):258-60

5 Paynter M. Identifying De Quervain’stenosynovitis. Emerg Nurse 2006;14(1):27-9

6 Peters-Veluthamaningal C, van derWindt DA, Winters JC, Meyboom-deJong B. Corticosteroid injection forDe Quervain’s tenosynovitis.Cochrane Database Syst Rev 2009;8(3):CD005616.

Vol 37 No 1 2010 27

7 Richie C A, 3rd, Briner W W, Jr.Corticosteroid injection for treatmentof De Quervain’s tenosynovitis: apooled quantitative literatureevaluation. J Am Board Fam Pract2003; 16(2):102-6

8 Scheller A, Schuh R, Honle W, SchuhA. Long-term results of surgicalrelease of De Quervain’s stenosingtenosynovitis. Int Orthop 2009;33(5):1301-3, 2009.

CASE STUDY

Intersection SyndromeRachel E Stewart BHSc(Physiotherapy)1

Hamish R Osborne MBChB, MMedSci, FACSP2

1 Division of Health Sciences, University of Otago2 Department of Medicine, Dunedin School of Medicine, University of Otago

Correspondence toDr Hamish OsborneDepartment of MedicinePO Box 913DUNEDINTel +64 3 474 7007 Ext 8556Fax +64 3 474 7461Email hamish.osborne@otago.ac.nz

INTRODUCTION

Intersection syndrome is anoveruse, inflammatory conditionof the distal forearm, located at the

intersection of the first and seconddorsal extensor tendon compartments,in the dorso-radial aspect. Itcommonly occurs with the onset of anew sport or work activity thatinvolves repetitive wrist flexion andextension. It is important to distinguishfrom de Quervain’s Tenosynovitis.4

The pathophysiology remains unclear.It was generally thought to be due tounaccustomed friction between thetwo tendon compartments, but morerecently was demonstrated astenosynovitis of the secondcompartment, with adjacent swellingoccurring subsequently.1 We present acase study of a patient withintersection syndrome and reviewtreatment recommendations.

CASE REPORTA 33 year old male marketing managerand social rower presented with a oneweek history of pain in his right dorsalforearm and wrist. His pain occurredinitially while racing on the water,with strong winds. He felt a twingeinitially and then the pain became deepand ached for the last 500 m. Over thenext week his pain intensified, becamemore frequent and his distal forearmbecame increasingly swollen. Hecontinued to row and in windy or cold

conditions he began getting pain intohis thumb and felt a “creaking” in hisforearm. He had no pain with otheractivities or while ergometer training.He only began rowing at the beginningof the current season and he had beentraining four times per week and racedin regattas at the weekends. He hadhad no recent trauma to the area, orprevious wrist injuries. He had noneural symptoms. No medication hadbeen taken prior to the initialconsultation.

On examination it was noted there wasswelling on the radio-dorsal aspect ofthe forearm 4 cm proximal to the radialstyloid. There was tenderness,minimal warmth and crepitus onpalpation over the above area. He wasnot tender along the line of the thumbabductors at the radial styloid. Therewas full active and passive movementof wrist joint but with pain and audiblecrepitus felt in dorsal wrist 4 cm fromradial styloid with wrist flexion,extension and ulnar deviation.

Weakness associated with pain wasnoted with grip and pinch strength ofthe right hand. There was a negativeFinkelstein’s Test, negative Tinel signof radial sensory nerve at exit of deepfascia and normal neck and shoulderexaminations.

Further investigation was notnecessary as a clear diagnosis ofIntersection Syndrome was madebased on the clinical history andexamination. The differentialdiagnosis included de Quervain’stenosynovitis, entrapment of dorsalradial sensory nerve and tenosynovitisof the wrist extensors - “Sculler’sThumb”.

Treatment was commenced andinitially relative rest was indicated forthe first week where he only trainedon the ergometer. During this time hewas instructed on modification of hisrowing technique including:

- increasing use of palm and fingerswhile relaxing grip

- relaxing at end of each stroke- correcting pull through phase- controlling oar while feathering

and squaring - fleece grips worn in cold weather

Anti-inflammatories were prescribedby his general practitioner (diclofenac75 mg bd).

He gradually returned to full trainingon the water over the subsequent twoweeks where the modified/correctedtechnique was adopted.

He was pain-free and in full training,without the use of anti-inflammatories

28 NZJSM

CASE STUDY

after three weeks of conservativetreatment.

DISCUSSIONThere have been limited studiesevaluating the effectiveness oftreatment options for intersectionsyndrome. It is however, widelysuggested that it responds positivelyto cessation and modification ofprovocative activities and anti-inflammatories, within two to threeweeks in majority of cases.4 Rumballet al10 explains that among rowers thisinjury is usually due to excessive wristmotion, and is generally traced backto fatigue or poor technique.Inexperienced rowers are more likelyto suffer due to their inability to relaxat the end of strokes and improperinitiation of their pull through. Furtherthey suggest ERG training initially tolimit wrist motion and continuetraining, as it is the ‘feathering’ actionon the water which generally causesexcessive movement. It has beenfound that high winds and improperuse of the wrist contributes totenosynovitis in canoeists.2 Coldconditions were also shown to increaseoar gripping. Nowak et al6 showedthat cold conditions decrease sensoryfeedback from the hands, increasinggrip forces, leading to excessiveforearm and wrist movement. The useof ‘fleece pogies’ are recommended toprevent this in colder weather.10

There is strong evidence supportingthe inclusion of anti-inflammatories aspart of initial treatment for thiscondition. Pantukosit et al7 carried outa prospective study with 30 patientswith intersection syndrome, with allbut 1 patient having dominant forearmpain. Patients were prescribed nonsteroidal anti-inflammatorymedication, and advised to modifytheir aggravating activity. All patientsat follow-up one week later hadfavourable responses. At 12-18months post-treatment, 14 werefollowed-up and there was nosymptom recurrence. Caution shouldhowever be used with topical anti-inflammatory agents as there is asuggestion the patients do worse withtheir use.5

There has been no research evaluatingthe effectiveness of splinting forintersection syndrome, but it is widelysuggested that splinting is another wayof resting the muscles involved ifappropriate. A thumb spica splint with15 degrees of wrist extension, for twoweeks is generally prescribed.7,8

The majority of patients have anexcellent response with conservativetreatment but if this fails after two tothree weeks, a corticosteroid injectionat the site of swelling or the seconddorsal compartment has provedsuccessful.1 Hanlon et al3 reported acase of a 35 year old landscaper withintersection syndrome. He wasinitially treated with a thumb spicasplint and anti-inflammatories. At twoweeks he had minimal improvement.He received a corticosteroid injectionadjacent to the area of maximalswelling. After 10 days he was pain-free and showed no recurrence of painafter six months.

It is very rare for good conservativemanagement, as outlined here, to fail.If the patient isn’t responding toconservative treatment after six weeks,it may be appropriate to operate,releasing the second dorsalcompartment and debriding of theinflamed tissues.9

REFERENCES1 de Lima J E, Kim H J, Albertotti F,

Resnick D. Intersection syndrome:MR imaging with anatomiccomparison of the distal forearm.Skeletal Radiol 2004; 33(11):627-31

2 du Toit P, Sole G, Bowerbank P,Noakes T D. Incidence and causes oftenosynovitis of the wrist extensorsin long distance paddle canoeists. BrJ Sports Med 1999; 33(2):105-9

3 Hanlon D P, Luellen J R. Intersectionsyndrome: a case report and reviewof the literature. J Emerg Med 1999;17(6):969-71

4 Lee R P, Hatem S F, Recht M P.Extended MRI findings ofintersection syndrome. SkeletalRadiol 2009; 38(2):157-63

5 May J J, Lovell G, Hopkins W G.Effectiveness of 1% diclofenac gel inthe treatment of wrist extensortenosynovitis in long distancekayakers. J Sci Med Sport 2007;10(1):59-65

6 Nowak D A, Hermsdorfer J. Digitcooling influences grasp efficiencyduring manipulative tasks. Eur J ApplPhysiol 2003; 89(2):127-33

7 Pantukosit S, Petchkrua W, Stiens SA. Intersection syndrome in BuriramHospital: a 4-yr prospective study. AmJ Phys Med Rehabil 2001; 80(9):656-61

8 Parmelee-Peters K, Eathorne SW. Thewrist: common injuries andmanagement. Prim Care 2005;32(1):35-70

9 Rettig AC. Wrist and hand overusesyndromes. Clin Sports Med 2001;20(3):591-611

10 Rumball J S, Lebrun C M, Di CiaccaS R, Orlando K. Rowing injuries.Sports Med 2005; 35(6):537-55

Vol 37 No 1 2010 29

BOOK REVIEW

30 NZJSM

The Complete Guide to Food for SportsPerformance 3rd EditionAuthors: Dr Louise Burke and Greg CoxPublisher: Allen and Unwin, Sydney 2010Price: $40.99

I picked this book up at the airportwhilst waiting for my children toarrive on a delayed flight. Having

previously owned the first edition, Iwas aware of the strengths of that workand was curious to see how much hadchanged - in essence, a lot.

The principal author is Dr LouiseBurke, who is head of the SportsNutrition Programme at the AustralianInstitute of Sport. She is joined forthis edition by Greg Cox, who isanother member of the sports nutritionteam at the same institution. Togetherthey have put together a highlyreadable and comprehensive guide tonutritional issues facing athletes.

The book is divided into two parts.The first half goes through theprinciples of sports nutrition in asystematic fashion, and the second halfis concerned with the practicalapplication of those principles in aseries of about 20 sports; all of themajor sports are included.

The authors start with the big picture,including trends away from traditionalfood prepared from scratch and eatingin a family setting with the socialattributes that provides, to the all-too-familiar situation of rapidly preparedor reheated meals eaten “on the run”.In other words, a move towards justfeeding rather than the other attributesof other food consumption.

They cover the big trends followingreports of superior sports performanceby athletes consuming highcarbohydrate diets. The food industryresponse was to provide large portionsof low fat, high carbohydrateprocessed foods. Not surprisingly, thishas led to a rise in obesity throughoutthe population. Not all athletes have

high fuel requirements and a largeenergy budget and many need to focuson weight control with only low tomoderate fuel needs.

The second issue is that of fluidbalance. Following the publication ofa study years ago showing the adverseeffects of dehydration, today’s athletesoften appear welded to a drink bottle.In competition some obsessionalathletes who rigidly follow previoushydration guidelines have died ofhyponatremia, hence the currentadvice to drink according to thirst.Another issue they touch on is that ofsugary drinks, which not onlycontribute to extra energyconsumption but also can eat away atdental enamel. They explain that theadmonition to drink eight glasses ofwater per day is folklore rather thanbeing evidence-based.

The first half of the text follows aconsistent pattern, with checklistsfollowing at the end of each chapter.These are excellent bullet point listswhich can be readily applied to mostathletes.

There is an excellent section on dietarysupplements based on material fromthe AIS’s Sports SupplementationProgram. This groups supplementsinto categories A to D, depending onthe evidence for their efficacy and alsotheir potential for harm. Category A,which includes substances with themost benefit and the least risk,includes only three substances:caffeine, bicarbonate and creatine.

The second half of the book examinesthe dietary challenges for individualsports and the strategies that can beused to overcome them. Once again,there are useful checklists covering

such issues as eating well in a cafeteriastyle dining hall and making weightfor specific events.

Overall, I would rate this book veryhighly. It is a tour de force of theavailable information regarding sportsnutrition and is presented in an easyto read format. The current editionruns to about 500 pages, which is anindication of how much knowledgehas been accumulated in the past fewdecades. The challenge for today’sathletes, and those who advise them,is to incorporate this knowledge intotheir daily routine. This book certainlyprovides the tools to do that.

Chris MilneSports PhysicianHamilton

BOOK REVIEW

Vol 37 No 1 2010 31

Open: An AutobiographyAuthors: Andre AgassiPublisher: Harper Collins, London 2009Price: $35.00

Andre Agassi is one of the great tennisplayers of the modern era - also oneof the most colourful. Therefore, hisautobiography was eagerly awaitedand it does not disappoint.

The book opens with him on thethreshold of retirement at the age of36 at the US Open in 2006. Herequired a cortisone injection to helphim play and the description of that issomething that will interest allclinicians.

His early life was dominated by hisfather, who corralled him into playingtennis. Born in Iran, his fatherexhorted him to hit harder and “verkyour volley”. He hit 2500 balls perday as a youngster, most flung at himby a custom-made ball machine. Ashe put it “no one ever asked me if Iwanted to play tennis, let alone makeit my life”. He grew up on the outskirtsof Las Vegas and when he was agedfour was hitting balls with tennisgreats such as Jimmy Connors. Hisfather strung Jimmy’s racquets.

At the age of 10 he played at theNational Championships and enteredNick Bollittieri’s tennis academy. Herebelled against the conformityrequired here and this was a harbingerof his later flamboyant behaviour. Thebook details his close relationship withGil, his trainer. He won his first GrandSlam in 1992 at Wimbledon, beatingGoran Ivanisevic, and describes anearly crush on Steffi Graf, thewomen’s champion that year. He wasdisappointed not to get to dance withher at the post-Championship ball.

Growing up as an American he wasvery conscious of image and hisobsession with his hair, or lack of it,crops up repeatedly in the book. Hewas introduced to the actress BrookeShields via the wife of Kenny G, themusician, and ended up marrying her.

His volatile behaviour is welldescribed in the book and on oneoccasion he broke all his trophies in afit of despair. The highs are included,such as the Olympic final where hewon a gold medal in Atlanta in 1996.These contrast markedly with thelows, with his well publiciseddalliance with crystalmethamphetamine.

After the breakdown of hisrelationship with Brooke Shields heacquired a new coach in Brad Gilbertand he proved to be a wonderfulmentor. Agassi describes meetingNelson Mandela as one of thehighlights of his life.

His dogged pursuing of Steffi Graf isa story well told. He meets her after apractice session and is clearlylovestruck and sends her a birthdaycard made from the first class menuon the plane. Stefanie, for that is herpreferred name, sees his good side andthe love story that develops is welltold. Peter Graf, her father, is asobsessional as Andre’s father and thedescription of their first meeting isexcellent. In particular, Peter Graf wasobsessed by the ball machine.

In his later competitive years, he couldsee the value of setting standards andbecame a supporter of Wimbledon’s“all whites” dress policy. He describesthe retirement of his contemporarieslike Michael Chang and Jim Courierand regards himself as the last of the1980s Mohicans.

He donates a substantial portion of hiswealth to the founding of the AndreAgassi College Preparatory Academyon the outskirts of Las Vegas. There,he brings in sports stars to meetstudents, and he sees the irony of howhe tried to skip school as a child butnow sees the value in education.

In essence, this is a great book. It isdefinitely from the heart and is a wartsand all description of his life. Theprose is crisp and clear. I am no sportspsychologist but at times thedescriptions appear over-dramatic,however this is what one might wellexpect in a book with its emphasis onthe highs and lows. If you haven’t readthis book already and you are any fanof sporting autobiograpies, get hold ofa copy.

Chris MilneSports PhysicianHamilton

PATIENT ADVICE SHEET

ANTI-INFLAMMATORY DRUGS (NSAIDs) FOR MUSCULOSKELETAL PAIN

1 What are they?They are medicines that are used extensively to treat injuries and joint pain. The first such drug was aspirin,developed in 1898. All the newer drugs are designed to provide the same benefit, with less frequent dosing andfewer side effects.

2 How do they help in musculoskeletal pain?In many cases, pain is caused by inflammation. Anti-inflammatory drugs block prostaglandins that causeinflammation. In this way, they reduce pain and swelling.

3 Are there side effects?Yes, there are common side effects:

a Burning stomach pain. Some NSAIDs can damage the protective mucous lining of the stomach. Thisaffects about 10% of people who take NSAIDs, and can be dangerous in older people who are on cortisonetablets or have heart disease. If you vomit up coffee ground material, this is serious and you should see adoctor the same day.

b Fluid accumulation. You may notice swollen ankles — this is more common in older people. NSAIDsreduce blood flow to the kidneys. In people who are dehydrated (e.g. athletes on hot days) this can causeacute kidney failure, so keep up your fluid intake, especially in hot weather.

c In rare cases, people with asthma who take NSAIDs may notice wheezy breathing. This is serious andshould be reported to your doctor.

d Pregnant women should not take NSAIDs, as they can affect the blood circulation in the unborn child.

4 Which types of anti-inflammatory tablets are there?There are two main types, as listed below:

Traditional (non-selective) NSAID, eg: Selective (COX -2) Agents, eg:Aspirin (Disprin) Celecoxib (Celebrex)Ibuprofen (Nurofen, Brufen) Etoricoxib (Arcoxia)Diclofenac (Voltaren, Diclax) Lumiracoxib (Prexige)Naproxen (Naprosyn, Synflex) Meloxicam (Mobic)

The selective (COX -2) agents were developed for use by people who either:

a Had burning stomach pain when taking traditional NSAIDs (ie, a sensitive gut); orb Were on cortisone tablets, or otherwise at high risk of stomach bleeding on traditional NSAIDs.

They are no stronger than traditional NSAIDs, but cause much less burning stomach pain in those with asensitive gut.

5 Who can benefit from use of NSAIDs and COX -2 agents?Anyone with injury or joint pain, where inflammation is present. They are of particular use where there isinflammation in a nearby joint (eg, water on the knee) that may affect muscle function.

6 What are the options for those people who have a sensitive gut? Either:a Use a selective (COX -2) agent — these agents do tend to cost more, though; orb Use a traditional NSAID, with the addition of Omeprazole (Losec) or Pantoprazole (Sumac); orc Avoid anti-inflammatories drugs altogether and use Paracetamol (Panadol).

7 How are these drugs best taken?To minimise the risk of gut upset, you should take all anti-inflammatory drugs with food.

Dr Chris MilneSports Physician

March 2007Revised July 2008

New Zealand Journal ofSPORTS MEDICINE

Change of address advice and business correspondence to:

Sports Medicine New Zealand IncPO Box 6398, Dunedin, New Zealand

Phone +64-3-477-7887 • Fax +64-3-477-7882 • Email smnznat@xtra.co.nzWebsite www.sportsmedicine.co.nz