Patellofemoral Pain Syndrome (PFPS) is a knee condition associated with anterior knee pain when loading the knee in movements like squatting, stair climbing, running and jumping (Ferber et al., 2015). Due to its high prevalence and running becoming an increasingly common form of exercise, it is important that high quality evidence regarding treatment and preventative strategies are made accessible to the public.

Like most soft tissue injuries, PFPS is also a multifactorial condition involving structural, sensorimotor, somatosensory, psychological, and nociceptive processing changes (Powers et al., 2017). Consequently, a consensus paper was written which outlined the current evidence-based understanding of the complex aetiology of this condition. Figure 1 shows the varied levels of scientific knowledge on the proposed mechanisms of the pathophysiology in PFPS.

To understand how best to deal with PFPS we are going to look at a question posed by Ferber et al.: what is the best form of exercise when treating PFPS? According to the most recent consensus statement on treatment regarding PFPS, there is an understanding that exercise and multimodal treatment involving knee, hip and core training is the most evidence-based approach when treating PFPS (Crossley et al., 2016). However, until 2015, there had not been research into whether, in isolation, a hip and core or knee protocol is more efficient (Feber et al., 2015).

Feber et al. (2015) included 199 individuals suffering from PFPS in the USA in a randomised control trial comparing a 6-week knee protocol (Figure 3) to a 6-week hip and core protocol (Figure 2). These programs used functional exercises to progressively overload the participants throughout the 6-weeks. Both protocols produced similar statistically significant increases in maximum isometric knee extension strength (Hip/Core – 8.04% (p<0.05); Knee – 6.37% (p<0.05)) and functional capacity measured by the Anterior Knee Pain Score (Hip/Core – 12.58% (p<0.05); Knee – 12.90% (p<0.05)) post treatment . However, the hip and core protocol had a greater reduction in VAS pain scores after 3-weeks (p<0.05) even though pain scores were equal at 6 weeks. The hip and core also produced greater hip extension (Hip/Core – 11.34%; Knee – 7.13%; p<0.05) and abduction (Hip/Core – 11.46%; Knee – 8.21%; p<0.05) maximal isometric strength post treatment (Feber et al., 2015). Both of these variables are shown to be possible risk factors for PFPS (Figure 1). Therefore, the hip and core protocol may have a greater efficiency when treating PFPS as it targets more risk factors than the knee protocol.

Six Week Hip and Core – Strengthening Protocol from Feber et al. (2015).

Six Week Knee Focused Protocol from Feber et al. (2015)

Therefore, this hip and core exercise protocol, which is time efficient and uses a shotgun approach against the risk factors relating to PFPS, may be a much sort after injury prevention program for runners wanting to avoid future anterior knee pain.

References

Crossley, K. M. et al. (2016) ‘2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions)’, British Journal of Sports Medicine, 50(14), pp. 844–852. doi: 10.1136/bjsports-2016-096268.

Ferber, R. et al. (2015) ‘Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: A multicenter randomized controlled trial’, Journal of Athletic Training, 50(4), pp. 366–377. doi: 10.4085/1062-6050-49.3.70.

Powers, C. M. et al. (2017) ‘Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: Part 3’, British Journal of Sports Medicine, 51(24), pp. 1713–1723. doi: 10.1136/bjsports-2017-098717.

by Tumelo Lethule 

Basketball has become one of the most popular sports in the world and has given us the pleasure of gushing over NBA stars such as O’neal, James, Curry and of course, the legendary Jordan. As a non-contact sport, basketball remained one of the safest sports ever played. However, as the sport seems to increase its popularity status; so did the injuries associated with the sport. Injuries most common to basketball are ankle sprains, knee injuries, lower back pains, facial and finger injuries as well as anterior cruciate ligament injuries.

In comparison with contact and other non-contact sports, basketball has been classified as one of the sports with a higher injury risk of injury and injury incidence [2]. Because basketball is a sport that requires speed, strength and power to accomplish movements such as rebounds and jump-shots, one can presume that players are likely to suffer some injuries when performing these highly dynamic movements [2].

Weiss, KJ et. al [1] used the Oslo Sports Trauma Research Questionnaire (OSTRQ) to record the onset of overuse injuries for the ankle, knee and lower back in professional male basketball players. The author assessed the prevalence and severity of overuse injuries and also determined the efficacy of the questionnaire over one season. The authors found that severe knee overuse injuries were reported more than ankle and lower back injuries [1], suggesting injury prevention strategies may need to focus on the knee.

Another study showed the prevalence of injuries in female basketball players (19.5% ankle injuries, 20.6% knee injuries) and in male basketball players (28.4% ankle, 17.5 knee injury) [3] suggesting a higher injury risk in women than men. Zuckerman and his team [4] found that during practice, males had a higher rate of ankle injury compared to females while females have higher rate of overuse knee injuries curing practice. From these findings, one can assume that females are more at risk to knee injuries and male’s ankle injuries.

While the underlying causes of injuries are yet to be fully understood, some research has emerged to understand how these injuries occur. Ankle sprains may occur as an athlete lands on an opponent’s foot. Overuse knee injuries seem to be caused by overloading and previous injury. Interestingly, knee injuries are seen mostly in centre players than any other positions, suggesting that playing positions may be a risk factor [2].

The cause of overuse knee injuries and ankle sprains is still a puzzle that seems to have little pieces, at least for now. With that said, through injury surveillance and the identification of injury risk factors and further understanding how injuries occur, better injury prevention strategies can be formulated and implemented. Until then, sprains and pains remain a concern in basketball.

References:

[1] Weiss, K.J., McGuiren, MR, Besier, T.F., Whatman, CS, 2017. Application of Simple Surveillance Method for Detecting the Prevalence and Impact of Overuse Injuries in Professional Men’s Basketball. The Journal of Strength and Condition Research, 31(10), p2734-2739.

[2] Cumps, E., Verhagen, E., and Meeusen, R. 2007. Prospective epidemiological study of basketball injuries during one competitive season: Ankle sprains and overuse knee injuries. Journal of Sports Science and Medicine, 6, p204-211.

[3] Andreoli, C.V., Chiaramonti, B.C., Biruel, E., Pochini, Andre de Castro, Ejnisman, B., Cohen, M., 2018. Epidemiology of sports injuries in basketball: integrative systematic review. BMJ Open Sport Exerc Med

[4] Zuckerman, SL, Wegner, AM, Roos, KG, et. al. 2018. Injuries sustained in National Collegiate Athletic Association men’s and women’s basketball, 2009/2010-2014/2015. British Journal Sports Medicine, 52: 261-268

by Aminah Emeran

Soccer is arguably the most popular sport globally, with an estimated 200 million players worldwide (1). There are many health benefits of playing soccer, including reducing the risk of type 2 diabetes and hypertension (2). Despite its health benefits, soccer also poses a significant risk of injury (3), particularly to areas such as the knee, ankle and thigh (4). These injuries are largely attributed to insufficient warm-ups, muscle fatigue and imbalance (5). A study conducted on the incidence of soccer injuries, showed that 15-20 injuries occurred per 1000 hours of match play, in players above 15 years old (6).

Because of the high incidence of soccer injuries worldwide, an injury prevention strategy for amateur players was developed in 2006, called the FIFA 11+. The FIFA 11+ comprises of a simple warm-up routine consisting of 15 exercises, that soccer players are to perform for a minimum of 2 times per week. The warmup requires minimal equipment, is available online and can be performed within 10-15 minutes (7).

 The FIFA 11+ prevention programme

Does the warmup reduce injury risk?

This question was answered by conducting trials that implemented the FIFA 11+ intervention into real life practice. These trials were then analysed in systematic reviews. The studies selected for review were implemented in a range of locations including North America, Europe, Asia and Africa, and tested male and female amateur players, with ages ranging from 15-45 years (7–10).

Overall results showed that implementing the FIFA 11+ warm-up for about 2 months, reduced the number of injuries in male and female amateur players between 13 and 25 years, by 30-39%. Studies also showed an improvement in motor and neuromuscular performance such as improved balance, increased quadriceps and muscle strength, speed and agility (7,8,10). The largest reduction in injury risk occurred when players adhered to performing the warm-up correctly. This was achieved with the help of supervision from coaches. Studies where little reduction in injury was seen, could be due to lack of compliance to the intervention and lack of guidance from coaches (7).

These results sound very promising. However, there are some limitations in the studies analysed. These include a risk of outcome bias that could result from the participants knowing that they were receiving the 11+ intervention, and the researcher knowing what group did and did not perform the intervention (9). Some studies also used different injury definitions, with some not even defining the type of injury analysed (8).

Despite these limitations, the warm-up has been successfully utilised in other sporting fields, such as basketball. It has also been endorsed by 20 FIFA Member Associations. Thus, given the high prevalence of soccer injuries sustained by amateur players, the FIFA 11+ intervention is recommended to reduce injury risk (7)(9).

References:

1. FIFA C. FIFA Big Count 2006: 270 million people active in football. FIFA Commun Div Inf Serv. 2007;31:1–12.
2. Krustrup P, Bangsbo J. Recreational football is effective in the treatment of non-communicable diseases. Br J Sports Med. 2015;49(22):1426–7.
3. Rahnama N, Reilly T. Injury risk associated with playing actions during competitive soccer. Br J Sport Med [Internet]. 2002;36:354–9. Available from: http://bjsm.bmj.com/
4. Price RJ, Hawkins RD, Hulse MA, Hodson A. The Football Association medical research programme: An audit of injuries in academy youth football. Br J Sports Med. 2004;38(4):466–71.
5. Ekstrand J, Hägglund M, Waldén M. Injury incidence and injury patterns in professional football: The UEFA injury study. Br J Sports Med. 2011;45(7):553–8.
6. Faude O, Rößler R, Junge A. Football injuries in children and adolescent players: Are there clues for prevention? Sport Med. 2013;43(9):819–37.
7. Barengo NC, Meneses-Echávez F, Ramírez-Vélez R, Cohen DD, Tovar G, Correa Bautista JE, et al. The Impact of the FIFA 11+ Training Program on Injury Prevention in Football Players: A Systematic Review. Int J Environ Res Public Heal [Internet]. 2014;11:11. Available from: http://www.mdpi.com/journal/ijerph
8. Thorborg K, Krommes KK, Esteve E, Clausen MB, Bartels EM, Rathleff MS. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med. 2017;51(7):562–71.
9. Sadigursky D, Braid JA, De Lira DNL, Machado BAB, Carneiro RJF, Colavolpe PO. The FIFA 11+ injury prevention program for soccer players: A systematic review. BMC Sports Sci Med Rehabil. 2017;9(1):1–8.
10. Bizzini M, Dvorak J. FIFA 11+: An effective programme to prevent football injuries in various player groups worldwide – A narrative review. Br J Sports Med. 2015;49(9):577–9.

by Jenna Bloom

When you’re watching Wimbledon, have you ever wondered how busy the doctors and physiotherapists are behind the scenes?

Well, McCirde et. al. (2016) wanted to determine the rate of injuries that occurred during Wimbledon, which could assist scientists to eventually develop measures to prevent injuries. ⁽³⁾

They study found that there were 700 injuries over the 10 years of Wimbledon (2003 to 2012), with a total of 12 212 sets played. The overall injury rate was 20.7 injuries per 1000 sets played. ⁽³⁾ McCirde et. al. (2016) observed that males had lower injury rates than females despite males playing more sets. ⁽³⁾ However, Sallis et. al. (2001) found that there was no significant difference in injury rate between females and males across seven different sports including tennis. ⁽⁶⁾ Differences in injury rates between sexes could be due to woman having higher oestrogen levels, more fat, more flexibility and less muscle mass. ⁽⁵⁾

Figure 1 indicates the percentage of each injury type sustained over the 10 years of Wimbledon. This figure shows that there was a large percentage of injuries sustained before Wimbledon, indicating the demanding nature of a professional tennis players’ season. ⁽³⁾

As seen in Figure 2 and 3, the most common injuries in both genders were in the shoulder, knee and lumbar spine. Groin, hip, heel and ankle injuries were more common in males than females, who suffered more wrist and foot injuries. From this we can see that in both genders, injuries in the lower extremities were most common. ⁽³⁾

Different tennis court surfaces have different properties. For example, on a grass court the ball bounces less and the rallies are shorter. ⁽³⁾ According to Nigg et. al. (1987) playing on various surfaces could be associated with injuries of the lower extremity. They further stated that overuse injuries have become more prevalent since the increased use of artificial surfaces. More research should be done to investigate the association between tennis court surfaces and injuries. ⁽⁴⁾

Research determining injury rates in tennis is extremely limited and often has variable outcomes. It is extremely important to determine injury rates in tennis players as it can improve knowledge regarding player care and can lead to the reduction of injuries. So next time you watch Wimbledon, remember – it’s not all just strawberries and cream!

References

1. Dharsaun, A., Dharsaun, A., Patel, N. and Patel, N., 2021. These Are The 5 Best Serve Techniques In The History Of Tennis – Playo. [online] Playo. Available at: <https://blog.playo.co/5-best-serving-techniques-tennis-history/&gt; [Accessed 10 April 2021].
2. Gordon, A., 2021. Science Explains Why Female Tennis Players Can Serve As Fast As Men. [online] Slate Magazine. Available at: <https://slate.com/culture/2014/09/sabine-lisicki-record-serve-science-explains-why-female-tennis-players-can-serve-as-fast-as-men.html&gt; [Accessed 10 April 2021].
3. McCurdie, I., Smith, S., Bell, P. and Batt, M., 2016. Tennis injury data from The Championships, Wimbledon, from 2003 to 2012. British Journal of Sports Medicine, 51(7), pp.607-611.
4. Nigg, B. and Yeadon, M., 1987. Biomechanical aspects of playing surfaces. Journal of Sports Sciences, 5(2), pp.117-145.
5. Robert H. Shmerling, M., 2021. The gender gap in sports injuries – Harvard Health Blog. [online] Harvard Health Blog. Available at: <https://www.health.harvard.edu/blog/the-gender-gap-in-sports-injuries-201512038708&gt; [Accessed 13 April 2021].
6. Sallis, R., Jones, K., Sunshine, S., Smith, G. and Simon, L., 2001. Comparing Sports Injuries in Men and Women. International Journal of Sports Medicine, 22(6), pp.420-423.

by Shana-Lee Bownes

Lockdowns that had us all cooped up in our homes for over a month seems to have sparked a greater appreciation for exercise in us all. Who can forget how ironically crowded the Cape Town beach front walkway was on the 1^st May 2020 with walking folk and runners eagerly tottering about with mask-concealed smiles.

Running is arguably one of the most accessible forms of exercise and a popular choice adopted by many trying to stay fit and get outside, especially during the hard lockdown. A survey conducted by De Jong and colleagues (2021) about running during the pandemic found a small but significant  increase in running mileage of 1,4km per week (great) but also a 1,4 times the injury risk compared to before the pandemic (not so great)(DeJong, Fish et al. 2021).

Here’s the story: We dust off out running shoes and hop on the road. The first few training sessions are rough, but then they get easier and that’s when the bug bites. Suddenly you’re up at 5am on a Saturday for your long run and posting a snap of your coffee #postrunfeels. But that little niggle in your knee that gradually builds up as you run is still there and often when niggles are ignored they have the potential to turn into more serious injuries. When looking at the studies published in running injuries van der Worp and colleagues found that injury was reported between 19,8-25% in men and 79,1-79,5% in women who run (van der Worp, ten Haaf et al. 2015).

Research on running injury prevention has unfortunately been somewhat inconclusive. Messier and colleagues have undertaken a very important step to improve research in this area by unpacking all of the different factors that contribute to developing running injuries. Over a two year period they followed 300 runners, testing running specific, physical and psychological characteristics. During the study 66% of participants sustained injuries in the two year period. Expressing more negative emotions, being a female and knee stiffness was associated with injury, this is unsurprising considering knee injuries were most commonly reported. Knee stiffness, especially in those weighing 80+ kilos, significantly increased the chances of developing one of those pesky overuse injuries (Messier, Martin et al. 2018).

So, where to from here? Hopefully with this knowledge we can focus our efforts on discovering the mechanisms by which these risk factors contribute to injury. Hopefully by addressing these risks we can come up with strong preventative measures. Measures will translate well into the running community and when implemented – will protect us against injury.

Until then in the wise words of Dean Karnazes: “Run when you can, walk if you have to, crawl if you must; just never give up.” (Meuller 2020)

References

DeJong, A. F., P. N. Fish and J. Hertel (2021). “Running behaviors, motivations, and injury risk during the COVID-19 pandemic: A survey of 1147 runners.” PLOS ONE 16(2): e0246300.

Messier, S. P., D. F. Martin, S. L. Mihalko, E. Ip, P. DeVita, D. W. Cannon, M. Love, D. Beringer, S. Saldana, R. E. Fellin and J. F. Seay (2018). “A 2-Year Prospective Cohort Study of Overuse Running Injuries: The Runners and Injury Longitudinal Study (TRAILS).” Am J Sports Med 46(9): 2211-2221.

Mueller, S (2020). “60 Inspiring and Motivating Running Quotes” [online] Planet of Success. Available at: <http://www.planetofsuccess.com/blog/2017/motivating-running-quotes/&gt; [Accessed 11 April 2021].

van der Worp, M. P., D. S. ten Haaf, R. van Cingel, A. de Wijer, M. W. Nijhuis-van der Sanden and J. B. Staal (2015). “Injuries in runners; a systematic review on risk factors and sex differences.” PLoS One 10(2): e0114937.

by Ashleigh Thomas

If you’ve heard or experienced an achilles tendon rupture, you’ll know exactly what the title is alluding to. If you don’t know, an achilles tendon rupturing sounds like a gunshot, and it’s as painful as it sounds. Researcher Gregory Hess, in his 2010 review of “Achilles Tendon Rupture” in the Foot and Ankle Specialist Journal, writes that the number of sporting injuries is increasing with the increase in sport participation. The most common injury; achilles tendon injuries. This begs the questions: how can we avoid them (and the months of no sport participation and gruelling rehab) and who is most vulnerable?

Schepsis, Jones and Haas (2002) comment that the increase in sport-related achilles tendon injuries as going from 2 to 12 cases per 100 000 in less than 10 years. Typically, this occurs in males during their 4^th and 5^th decade of life (Schepsis et al., 2002). The injury also appears to occur most commonly in racquet sports such as tennis, squash, and badminton (Schepsis et al., 2002:298). It appears that this injury is the achilles heel of middle-aged male squash players.

It is important to understand the mechanisms of this injury. Hess (2010) explains that 53% of reported cases are due to the push-off mechanism (off the weight bearing leg with the knee extended). Other mechanisms include unexpected ankle dorsiflexion and violent dorsiflexion of a plantar flexed ankle during running/jumping/agility activities/activities involving eccentric loading/explosive plyometric contractions (Hess, 2010).

Figure 1: The anatomy of the Achilles Tendon

The achilles’ structure and function are also pieces of the puzzle. The achilles is an extension of two independently moving muscles, the gastrocnemius and soleus muscles, and it attaches to the posterior heel bone. The tendon is primarily composed of collagen which forms cross-links that allow it to resist high tensile forces (Hess, 2010). Forces stretching the tendon beyond 4% result in some of these cross-links failing and stretching beyond 8% is likely to result in a rupture (Hess, 2010).

Additionally, defects in the tendon’s structure could result in a rupture as it has a poor nutrient and blood supply (Hess, 2010). A rupture is also likely if degeneration and overloading occur repeatedly over extended periods of time (Hess, 2010). Therefore, it makes sense that the proposed processes for achilles tendon degeneration and rupture are tendinosis and chronic tendinopathy because these conditions cause an imbalance between tendon degeneration and repair (Hess, 2010).

How can we identify individuals who may be at risk of experiencing such excruciating pain? Through research, a number of intrinsic and extrinsic factors which predispose individuals to sustaining a rupture have been identified. The presence of these can increase the likelihood of a rupture. These factors, as described by Hess (2010), are seen in Figure 2.

Figure 2: The extrinsic and intrinsic factors predisposing individuals to achilles tendon rupture adapted from Hess (2010).

Individuals exhibiting these factors should take extra precaution as Hess (2010) writes that a combination of these factors reduce the tensile strength of the tendon and contribute to faulty biomechanics and compensatory mechanisms which can evolve into a tendon rupture. A key factor that Schepsis et al. (2002) emphasizes, and which Hess (2010) agrees with, is the degenerative effect of natural ageing on the tendon resulting from decreased blood flow, decreased collagen tensile strength and increased tissue stiffness (Schepsis et al., 2002). These aging effects reduce the tendon’s ability to handle stress, predisposing it to injury.

All is not lost; there are things you can do to try to prevent this from happening. A rupture could be prevented by avoiding degenerative changes in the tendon by doing regular physical activity, and by allowing adequate rest following tendon injury (Hess, 2010). Eccentric strengthening of calf muscles has also been linked to prevention of rupture (Hess, 2010). However, we still have many questions to answer before we can say for certain what the best method of prevention is. This also speaks to the gap in this area and research going forward should focus on the implementation and the effectiveness of prevention programs.

References

• Hess, G., 2010. Achilles Tendon Rupture. Foot & Ankle Specialist, 3(1), pp.29-32.
• Schepsis, A., Jones, H. and Haas, A., 2002. Achilles Tendon Disorders in Athletes. The American Journal of Sports Medicine, 30(2), pp.287-305.
• de. 2021. Achilles tendon – anatomy and importance. [online] Available at: <https://www.medi.de/en/health/the-body/tendons-and-ligaments/achilles-tendon/&gt; [Accessed 9 May 2021].