In this issue
SPORTS
INJURY
BULLETIN
PREVENTION • TREATMENT • REHABILITATION
From the editor
As this SIB arrives (all being well), the Turin
Winter Olympics will have come and gone,
and the Six Nations rugby internationals will
be in full roar. No doubt I shall have overcome
my normal ambivalence towards this game
of mud and guts and big men, and I’ll
momentarily be able to appreciate their skills
and fine physical tuning (and big thighs).
Nick Grantham’s research review takes
rugby as its theme this month, bringing
together some of the more interesting and
significant findings from previous tournaments
in which injury data have been collected and
analysed. As both Nick and the evidence make
Professional development
What all physiotherapists should know, but don't
There is a crucial element missing from the profession’s basic training, Sean Fyfe argues
How can a physiotherapist practise in the
musculoskeletal or sports field without a sound
knowledge of strength and conditioning
training? This question has bothered me
privately for a long time, but my recent experi-
ence of completing a Level 2 strength and condi-
tioning course with the ASCA (Australian
Strength and Conditioning Association) has
finally provoked me into asking it publicly.
Physiotherapy and strength and condi-
tioning go hand in hand. After all, it is an inte-
gral part of the physiotherapist’s role to plan
long-term rehabilitation and maintenance
programmes for acute and chronic injuries.
But I know that when I do this part of my job,
in respect of the average throughput of clients
in a physio clinic, I will be constantly drawing
upon my knowledge of strength and condi-
tioning. And this causes me to start to wonder
about my own profession.
I learned what I know about strength and
conditioning mainly as a result of my post-
graduate studies plus a lot of independent
study of this area, and my own experience as
a serious tennis player. I must emphasise that
I am in no way claiming to be unique among
physios in having such knowledge; the impor-
tant point is that those of us who have acquired
Are physios up to the job? 1
Core training menus, part IV: the super-tough 4
How to identify the weak links in core stability 6
Rugby research round-up 9
Injury update: meniscal damage to the knee 11
Issue57
clear, if you play rugby, you get hurt. So, full and
rounded fitness – and that’s a lot more than
brute strength and a bit of leg power – is the best
prophylaxis against career-threatening damage.
Sticking with the high end of sport for a
minute, we wrap up Raphael Brandon’s core
training series this month with the final two
menus, which come stamped with a big health
warning that they are intended only for the
super-tough to attempt. Just reading Menu 10
makes me wince.
Some of our other fare this month may well
prove controversial. Firstly, new contributor
Sarah Mottram explains an approach she is
pioneering to try to bring some rigour to the
assessment of core stability and weak links in
it have done so through mechanisms other
than our physiotherapy training. And I would
hazard a guess that a large proportion of
physios practise without such knowledge.
I certainly took comfort in the fact that the
physios with whom I underwent my recent
strength and conditioning course, share my
sentiments exactly. And all of us were at a loss
to explain how it was that we were never taught
the fundamentals of strength and condi-
tioning training in our undergraduate phys-
iotherapy studies.
What is strength and
conditioning?
Strength and conditioning training covers a
broad range of skills – strength, power, speed
and agility, endurance and flexibility training
and recovery methods – the significance of
each of which varies according to the athlete
being trained and their sport.
A competent trainer needs to understand
the purpose of different exercises, exercise
technique, correct programming for different
sports, phases of training and individual
circumstances, and the detail of how, when
and why to vary instructions on the perfor-
mance of sets, repetitions, speed of repetitions
March 2006
trunk function. As this is an area that many of
you have to make judgements about all the
time, it would be good to know what you think
of this kind of approach.
And for a real stir-up, look no further than
page 1: below we kick off the issue with Sean
Fyfe’s essay, which I might provocatively para-
phrase as ‘what physiotherapists think they
know but don’t really’. Sean is putting his head
above the parapet on this one, but he’s certainly
not alone in his views. Let’s have some reac-
tion, please – whether you agree or disagree!
Enjoy the rugby, and the issue.
Jane Taylor
Email: sib@electricwordplc.com
and length of rest periods.
Three key elements
It seems to me that three elements of strength
training – exercise technique, progressive over-
load and specificity – are also critical to the
competent practice of physiotherapy.
Take the example of the squat. Squatting is
a movement pattern I teach over and over in
my clinical practice, to athletes and non-athlete
clients alike who are rehabilitating lumbar
spine and/or knee injuries. Yet one of the
lecturers on my recent course tells of how, as
a tutor, he routinely encounters sports phys-
iotherapists, many with more than 10 years’
experience, who cannot teach the performance
of a basic squat. If they can’t teach a squat, it is
doubtful they could teach someone to dead-
lift. So how, for example, have they been
teaching their patients with lumbar disc
injuries to brace their low backs in neutral?
To take the point further, if they can’t teach
a double-leg squat, they surely can’t teach a
single-leg squat, so how have these physio-
therapists been rehabilitating someone with
patellofemoral dysfunction?
What I do know for sure is that I was never
taught in my undergraduate course how to
2 SPORTS INJURY BULLETIN March 2006 No 57

Table 1: Rehab programme, weeks 1-3, daily

Exercise Week 1 Week 2 Week 3
Transverse abdominis (TVA) activation in crook lie
5x10 sec hold 5x20 sec hold 5x30 sec hold
(knees bent, feet flat, supine)
Single leg bridges with inactive knee to chest 3x10 sec hold 5x10 sec hold 10x10 sec hold
each side each side each side
Plank on toes 3x30 sec hold 3x45 sec hold 3x60 sec hold
Side plank 2x20 sec hold 2x30 sec hold 2x40 sec hold
each side each side each side
Squats double-leg 3x10 3x12 3x15

squat or how to deadlift correctly, which now
seems to me a pretty incredible omission.
Here’s something else that was barely
touched on in my undergraduate studies.
The overload principle is the underpinning
principle of all training. Put simply, the body
adapts in line with the demands placed on
it. To achieve a positive training response
and thus gain strength improvements, you
must overload the relevant muscles. Too little
effort and the client will fail to make strength
gains. But too much overload at any point
will cause injury, so it is necessary to prescribe
a programme of progressive overload,
manipulating the weight, repetitions, sets,
rest periods and speed of movement.
The other key principle common to effec-
tive training and physiotherapy is specificity,
or SAID (specific adaptations to imposed
demands). Again, put simply, the body
adapts in a highly specific way to increased
demands: the precise input will determine
the precise adaptation.
To illustrate this, let’s look at how you
might use a single-leg squat in the rehab of
a sprinter versus a marathon runner, both
recovering from patellar tendinitis. The aim
of the single-leg squat is:
● to improve strength and activation through
gluteus maximus and gluteus medius
● to improve quadriceps strength and acti-
vate vastus medialis (VMO)
● to maintain neutral spine under load, and
● to improve proprioception of the lower
limb chain.
The exercise is functional for the sporting
needs of both athletes, and will be working
aspects of their lower limb chain that prob-
ably need improvement to prevent further
tensile overload to the patellar tendon. But
the 100m sprinter needs to do all of these
things fast, with maximal contraction, for
10 to 11 seconds; while the marathon runner
does them all submaximally and more slowly
– for more than two hours.
It is therefore no good prescribing exactly
the same dose of this exercise to both athletes.
The sprinter will need:
● low repetitions
● greater load to enable them to achieve
maximal contraction
● fast speed of movement, and
● longer rest periods.
And the marathon runner needs quite the
opposite.
The teaching of correct technique and
the principles of overload and SAID should
be at the forefront of a physiotherapist's
mind whenever prescribing an exercise
programme. Indeed, they should underpin
the setting of all rehabilitation programmes.
Programming in practice
The case study outlined below shows how
strength and conditioning knowledge needs
to be woven into the way a physiotherapist
treats musculoskeletal problems, in this case
a lumbar spine stress fracture which devel-
oped in this 16-year-old male tennis player
as a result of serving.

Table 2: Weeks 4-9, four times weekly

Exercise Week 4 Week 5 Week 6 Week 7 Week 8 Week 9
Squats
double-leg 2x12 2x12 2x10 2x12 2x12 2x12
(15kg load) (20kg load) (25kg load) (25kg load) (30kg load) (35kg load)
single-leg 1 1 squat 3 squat 3 squat 3 squat 3 squat
2squat 2 4 4 4 4
1x10 (bodywt) 1x12 (bodywt) 1x10 (bodywt) 1x12 (bodywt) 1x10 (10kg load) 1x12 (10kg load)
Deadlifts 2x12 (10kg) 2x12 (15kg) 2x10 (20kg) 2x12 (20kg) 2x12 (25kg) 2X12(30kg)
Supine leg extensions 2x10 2x12 2x15 2x20 3x15 3x20
(neutral spine, resting leg each leg each leg each leg each leg each leg each leg
bent, active leg raised to
just above horizontal)
Prone hip extensions 5x10 sec 5x10 sec 10x10 sec 10x10 sec 10x15 sec 10x15 sec
(neutral spine, active leg hold hold hold hold hold hold
raised to just above each leg each leg each leg each leg each leg each leg
horizontal)
Front plank 2x30 sec hold 2x30 sec hold 2x45 sec hold 3x45 sec hold 2x60 sec hold 3x60 sec hold
Side plank 1x20 sec 1x30 sec 2x20 sec 2x30 sec 3x20 sec 3x30 sec
hold each side hold each side hold each side hold each side hold each side hold each side
March 2006 No 57
Table 3: Weeks 10-18, three times weekly
Exercise Week 10 Week 11
Squats 3x10 3x10
(35kg) (40kg)
Deadlifts 3x10 3x10
(30kg) (35kg)
Curls on Swiss ball 1x10 1x15
Back extension 1x10 1x15
Seated medicine ball
passes (45-degree sit, 1x7 2x7
feet on floor) each side each side each side each side each side each side each side each side each side
Side plank with arm 2x15 sec 2x20 sec 2x25 sec 2x30 sec 2x20 sec 2x30 sec 3x20 sec 3x25 sec 3x30 sec
and leg abduction hold hold
each side each side each side each side each side each side each side each side each side
Weeks 1 to 3: The player must undergo
complete rest from tennis, and concentrate
on a daily regime of lumbopelvic muscle acti-
vation and low-level strength exercises in
neutral spine.
Weeks 4 to 9: The player is permitted to hit
forehand and backhand groundstrokes and
volleys, starting with limited court move-
ment and low-intensity strokes, and gradu-
ally building up. Exercises remain focused
on holding a neutral spine position, but now
under increasing load.
Weeks 10 to 18: The player is permitted to
start serving, beginning with low-speed and
slice serves. Over the weeks serving speed
and volume is increased and the player is
allowed to resume the kick serve, which
places more load in an extended position on
the lumbar spine. The focus of the
programme now switches to strengthening
work and movement control through exten-
sion, flexion and rotation.
The strength and conditioning schedules
for this player are summarised in Tables 1
to 3 (see above and left). To keep it simple,
I have omitted details of rest periods and
speed of performance. As a guide, 30-sec
rest periods between sets. Rest time needs
to increase as loading is introduced and
the exercises take on more of a strength-
and power-building emphasis. With this
shift, the speed of movement will also
increase and the number of repetitions
drops.
Most of the dynamic exercises would
initially be worked at 2 sec eccentric phase
and 2 sec concentric phase, to ensure control.
As the programme progresses and as tech-
nique improves, the concentric phase can
be reduced to 1 sec.
SPORTS INJURY BULLETIN 3
Week 12 Week 13 Week 14 Week 15 Week 16 Week 17 Week 18
3x8 3x8 2x8 3x8 3x10 3x8 3x6
(50kg) (55kg) (45kg) (60kg) (60kg) (65kg) (70kg)
3x8 3x8 3x10 3x8 3x10 3x8 3x6
(40kg) (45kg) (35kg) (50kg) (50kg) (55kg) (60kg)
1x20 2x15 1x15 3x15 3x20 2x25 3x25
1x20 2x15 1x15 3x15 3x20 2x25 3x25
2x9 2x11 1x9 2x12 3x9 3x11 3x12
hold hold hold hold hold hold hold
Whose job is it anyway? same – but just how likely is it that this client
It can be argued – and no doubt many phys- will even have heard of such a thing as a
iotherapy colleagues will be thinking this – strength and conditioning coach?
that this kind of exercise programme-setting
is surely the job of a professional strength Pilates is no panacea
and conditioning coach. This is a fair While the physiotherapy profession fails to
comment – up to a point. It is the job of a equip its practitioners with basic physiolog-
physiotherapist to prescribe exercises and ical knowledge, it seems we are all bending
we therefore need to know what kinds of over backwards to add clinical pilates to our
exercises should be done at which rehab skills repertoire. Pilates is without doubt a
points. That is only possible if you under- very valuable addition to the profession. But
stand properly how the movement and load this shouldn’t be at the expense of traditional
will affect the injured structures. Secondly, strength training for fundamental move-
if we don’t understand these principles, how ment patterns. Both approaches need to be
can we advise our coaching colleagues worked into rehab programming to suit the
(whose primary purpose is to train healthy needs of the individual being treated.
bodies, not injured or recovering ones)? And I am absolutely clear that to be a compe-
thirdly, how many of your clients can afford tent musculoskeletal or sports physio, you
to track down and work with a strength and need a sound understanding of strength and
conditioning coach, especially once they’ve conditioning training. And that means this
already paid out for their physiotherapy treat- knowledge must be taught at undergraduate
ment? If the client in question is not a level, not just in 10 minutes but including
talented young tennis player, but a middle- specific practical modules. From such a
aged employee with chronic lumbar spine grounding, it is hoped that practising physios
pain, the exercise principles behind what will advance their understanding further
may be a lengthy and slow rehab will be the with supplementary courses.
What do you think?
● Are you a physiotherapist or a strength and conditioning coach?
● What do you think about this issue?
● Did your own basic training cover all the necessary elements of
strength and conditioning training?
● How do you view the relative merits of clinical pilates versus strength
and conditioning in the rehab setting?
● Does the physiotherapy syllabus need an overhaul?
● Are physios in danger of duplicating the work of trainers and
coaches?
● Is the Australian experience repeated elsewhere?
Join in the debate: tell us your reactions to Sean Fyfe’s argument, your
own views, experiences and proposals.
Email sib@sportsinjurybulletin.co.uk
4 SPORTS INJURY BULLETIN
Prehabilitation
The core training menu system IV
Menus 9 to 10 of Raphael Brandon’s trunk strengthening regime
that sustains challenge and beats boredom
The core training menu system enables
athletes to follow a prophylactic or rehabili-
tative core stability and strengthening
programme, using a wide variety of move-
ments to maximise adaptations and muscle
groups trained.
The system is designed to overcome two
widespread problems that sports support
professionals encounter in setting core
stability training regimes for their clients.
The first is behavioural. Core stability exer-
cises can quickly become ‘bore stability’. It
takes self-discipline to do 20 to 30 minutes
of the same exercises three or more times a
week over a long period. As a consequence,
adherence can be an issue.
The second problem is physiological. The
principles of specificity and progression apply
to core work as for any other body training.
In my experience it is quite common for an
athlete to perform the same core routine over
a long period and get very good at four or five
Menu 9: Resistance-based
The aim of these three exercises is
to progress the loading in order to
build high-level trunk muscle
strength. These exercises can be
performed in the 5- to 10-
repetition range with a suitably
difficult weight for this number of
reps. As the athlete gets stronger
the progression should prioritise
an increase in weight rather than
an increase in the number of reps.
Overall, these exercises are very
advanced
Crunch with weight
(above right)
Overview The standard isolated
abdominal exercise with increased
load
Level Advanced
Muscles targeted
Abdominals
Technique Perform the crunch in
the usual way: knees bent, low back
flat, head up and looking forward.
movements or ‘holds’. But teach that athlete
a new core exercise and they will find it diffi-
cult, simply because it’s a new stimulus.
Progression and variety are key to optimising
benefits of a strengthening programme.
Overall the menus are aimed at athletes
who have developed basic transversus
recruitment skills and are familiar with a
number of core exercises. The scheme offers
a challenging programme, which covers all
the trunk and pelvic muscles and runs from
basic recruitment to very advanced strength
movements.
The system contains 10 exercise menus,
each using a single piece of training appa-
ratus. The first two menus (SIB 54) dealt
with floor work, static and dynamic. Menus
3 and 4, in SIB 55, covered Swiss ball exer-
cises, static and dynamic. Menus 5 to 8
appeared in SIB 56, covering work with the
weighted pulley machine and weighted
medicine balls.
Crunch with weight
Curl the shoulders up and down
using just the abdominals. The
weight (medicine ball, dumbbell or
barbell weight plate) should be held
above or behind the head. Arms
are fixed, all they do is hold the
weight in place. Do not use arms to
move the weight relative to head as
the crunch is performed. Keeping
the elbows out helps to achieve this
Perform 5 to 10 reps, 2 to 3 sets
Progression Increase weight,
maintaining the range of 5 to 10 reps
per set
March 2006 No 57
The two final menus, 9 and 10, are super-
advanced ‘high force’ trunk exercise and will
not be appropriate for all athletes, if they lack
the necessary core conditioning and strength.
They are aimed at athletes who want to
develop advanced strength – but only as part
of a broader (and generally lower-level)
regime: you simply cannot sustain working
your trunk muscles at such intensity over an
extended period.
Coaches, therapists and athletes should
set the number of sets and repetitions for each
exercise according to the usual principles.
The therapist or coach should select the
most relevant menus for the athlete to use
in rotation. Thus, if the athlete is using eight
menus and doing four units of core training
per week, over the course of a fortnight they
will perform each menu once. This will
ensure that the athlete works all the muscles
in a variety of ways, using different pieces of
equipment.
Reverse hypers
Overview An excellent hip and back
extension exercise to which it is very
simple to add load
Level Advanced
Muscles targeted
Erector spinae
Gluteals
Technique Lie on your front on a
horizontal bench, with hips just off
the end of the bench. Grasp bench
legs firmly for support. Your legs
should be straight with a dumbbell
between the ankles for resistance.
Squeezing the gluteals, extend hips
and lift legs and the dumbbell off the
floor. Stop when your back is slightly
hyper-extended and hips are fully
extended. Lower slowly until feet are
just off the floor and continue
Perform 8 to 10 reps, 2 to 3 sets
Progression Increase weight,
maintaining the range of 8-10 reps
per set
 March 2006 No 57
Reverse crunch with weight
(right)
Overview This is a great exercise, as
it requires good coordination and
strength. EMG research shows that
the obliques as well as the
abdominals work very hard during
this exercise, making it excellent
value
Level Advanced
Muscles targeted
Abdominals
Obliques
Technique Lie on back with hands
behind head and elbows out to the
sides. Knees should be bent and
heels close to buttocks. Hold
weight between your legs. Initiate
the movement by curling the pelvis
upwards (flattening the back into
the floor) and then continue to use
the abs to pull the low back and
pelvis off the floor. This is the bit
that requires good coordination, as
the temptation is to kick with the
legs and pull the hips up with the
hip flexors. Learn to focus on the
abs before you add weight, as if
you do this strictly it is very tough,
especially for women (whose
pelvises are relatively heavier)
Perform 5 to 10 reps, 2 to 3 sets
Progression Increase weight,
maintaining the range of 5 to 10 reps
per set
Menu 10: Hanging bar
The aim of these two exercises is to
work the abdominals as hard as
possible with very advanced,
gymnastic-style movements.
Reasonable upper body strength is
required for these exercises
Hanging leg lifts
Overview This exercise requires
the athlete to lift the full weight of
their legs and (if possible) their
pelvis, while hanging from a bar.
Anyone who can perform these
movements well through a good
range of motion has achieved good
strength
Reverse crunch with weight
Level Advanced
Muscles targeted
Abdominals
Obliques
Hip flexors
Technique Hang from a bar with
arms straight. Lift knees, bringing
them up as high as possible. At the
top of the movement the knees
should be near the chest and pelvis
should be curled upwards (low
back flexed). This extra curl of the
pelvis ensures that the abdominals
are working maximally. Do not kick
legs up or swing the body
excessively. Simply draw up knees,
crunching as you lift. It is
important to feel that the
abdominals are doing the lion’s
share of the work rather than the
hip flexors or quads
Perform 5 to 10 reps, 2 to 3 sets
Progression Perform the same
exercise with straight legs, lifting
them up to 90 degrees in front of
you, curling the pelvis at the top of
the movement
Windscreen wipers
Overview The ultimate abs-buster.
Anyone who can do 10 reps of this
exercise with good technique has a
very strong core!
Level Super advanced
Muscles targeted
Abdominals
Obliques
Hip flexors
SPORTS INJURY BULLETIN 5
Technique Hang from bar with
arms straight. Lift legs up in the air
until feet are at approx head
height. Maintaining the height of
the lift, take the legs from side to
side in an arc. The movement will
look like a windscreen wiper,
moving from side to side. Aim for
at least 45 degrees of movement
to each side
Perform 5 to 10 reps, 2 to 3 sets
Progression The straighter the
legs, the harder the exercise.
Increasing the range of
movement to each side also
makes it tougher
Candlesticks
Overview Another beauty! Lots of
strength required to control this
movement, only for the very strong
Level Super advanced
Muscles targeted
Abdominals
Obliques
Hip flexors
Technique Lie flat and raise
yourself up to a shoulder stand
position, holding on to a
bench/table leg/partner’s leg with
your hands above your head.
Establish a fully extended hip and
leg position and then begin to
lower your body down slowly to
the floor. The body should move
in an arc as a single unit (no
sagging in the back, or bending at
the hips or knees), lowering under
control from vertical to just
above horizontal.
Gripping firmly for stability, lift
your body back up into shoulder
stand, again keeping everything
straight and aligned in a single
unit.
Slow and controlled movement on
the way down will help, and a
maximal contraction of everything
will get you back up
Perform 3 to 5 reps, 2 to 3 sets
Progression I think that’s tough
enough
6 SPORTS INJURY BULLETIN
Functional testing
Adding rigour to core stability
Sarah Mottram outlines an assessment approach to help identify a client’s weak links
In recent years the importance of stability
training has been recognised but it remains
more art than science: to date there is a lack
of specificity in stability assessment and
retraining. Over the last 10 years much
evidence has emerged to demonstrate the
link between movement faults and muscu-
loskeletal pain(1,2). Faulty movement patterns
develop over time through the normal
stresses of life, training or sporting activi-
ties. Chronic states and recurrences of
musculoskeletal pain have been linked with
changes in strategies for motor control. In
particular, individuals in such states of pain,
according to the literature, change their
motor control strategies for their ‘low-load
function’(3,4).
Low-load functional activities include:
● maintenance and adjustments of postural
positions
● normal functional movements of the
unloaded limbs or trunk.
People with faulty movement control tend
to use high-load strategies for low-load
control(3,4). The particular movement faults
can only be identified on low-load testing.
Further research studies have shown that
correcting these faults leads to a decrease in
pain, increases in ranges of motion and
improvement in function(5,6).
Equally important in the sporting envi-
ronment is the assessment of high-load
stability, which has been more widely
described(7,8). It is essential that athletes
undergo assessment of their high-load
stability control. Therapists and coaches
therefore should ensure their athletes
undergo detailed assessment designed to
identify movement faults and to find areas
of uncontrolled movement (stability faults)
under low and high load (see Table 1 above).
It is only possible to identify deficits related
to inefficiency of low-threshold recruitment
by using specific low-load tests, based on the
accepted and extensive research on muscles
such as transversus abdominis. Some low-
load dysfunctions develop prior to the onset
of symptoms and injury and appear to be
precursors or contributing factors to the
development of injury and symptoms(9,10).
Muscle strength is measured as the ability
to pass a test of resisting or supporting a high
load. For the athlete, the objective of being
strong is to maintain or improve perfor-
mance. But strength training does not
March 2006 No 57
Table 1: Stability assessment
Low-load Helps to identify risks Related to inefficiencies in low-threshold
testing associated with: recruitment
● maintained postural Problems are identified in the deep stability
positions muscle system(9). Research has linked
● normal functional inefficiencies in low-threshold recruitment to
movements of the unloaded the recurrence of insidious pain
limbs or trunk
eg standing, walking Problems are identified in the global (more
superficial) muscle system(9). Inefficiencies in
low-threshold recruitment in the global system
are related to repetitive incidence of pain
High-load Helps to identify risks Related to deficits of multi-joint movement
testing associated with loaded Problems are identified in the global multi-
activities joint system under load
eg sprinting, throwing
resolve problems of pain and pathology or are integrated together into a training
poor low-threshold motor control function programme, it is usually assumed that there
(see Table 2 below). is a linear progression from low to high load.
From these principles it is possible to However, there is no real evidence to support
devise a protocol for assessment testing, to the concept of motor control training being
pinpoint stability dysfunctions (see Table 3 a prerequisite for strength training. Specific
opposite). The stability dysfunction or ‘weak testing can determine the appropriate
link’ is defined by the presence of inefficient retraining strategy to manage symptoms and
or uncontrolled movement. improve performance.
Based on the evidence to date: Many strength training programmes are
● high-threshold retraining (strengthening) predominately designed to train strength at
does not appear to correct motor control one joint and muscle at a time. Although
dysfunction in local stability systems sportspeople using such approaches pass
● specific low-threshold training does appear strength tests in sporting situations, they
to correct local and global motor control often get injured under load. Their training
stability dysfunction(11,6) fails to appreciate the difference between
● Low-load training does not appear to single-joint strength and multi-joint move-
correct high-threshold dysfunction or ment control (ie using two or more strong
atrophy(12). muscles together in a coordinated way under
load). And two strong muscles working badly
Different mechanisms are used to control puts more intrinsic strain on the body than
movement under low-load and high-load one weak muscle working badly.
situations. When low and high load exercises In effect, athletes need two distinct types
Table 2: Limitations of strengthening programmes
Ineffective at changing low- ● Motor control deficits that are unrelated to
load stability dysfunction strengthening
● These deficits respond to low-threshold retraining
Reinforcement of ● When a high-threshold recruitment pattern is
dysfunctional movement dominant (because of inefficiency under low load) it
patterns and strategies may be reinforced by high-load training
● Even an appropriate exercise may not be beneficial if
it encourages the recruitment of fast motor units
where the primary deficit involves slow motor unit
dysfunction
Excessive sagittal plane ● Many strength training exercises are done in the
(flexion-extension) training sagittal plane. During these exercises there is minimal
rotational control or specific training of the
deceleration of rotation
March 2006 No 57 SPORTS INJURY BULLETIN 7

Table 3: Protocol for assessment testing Case study illustration

In the following example, assessment results
Low threshold High threshold are shown for two tests on a footballer. He
complained of a recurrent right hamstring
Motor control Strength
Neural adaptation ‘strain’, which had been affecting his perfor-
mance. He’d had three severe episodes with
Inefficient low-threshold muscle Insufficient high-threshold muscle
a break in training and play. He had also
function relates to low-load motor function relates to high-load strength and
control deficiencies neural adaptation deficiencies complained of vague backache, which he had
tended to ignore.
Previous management included some
of training: strength work that targets the ‘weak link’ and move independently at the core stability training. The treatment regime
muscles of range and force potential; and adjacent joint in the direction of testing. The had always cleared the symptoms in his
motor control training for the deeper (force ability to control the weak link can be hamstring and improved his strength but
inefficient) muscles. assessed under both low-threshold (low load never prevented a gradual recurrence of
and slow) and high-threshold (high load OR symptoms two to three months after
Towards an assessment fast) conditions. resuming training.
system The ability to prevent movement at the Performance Matrix testing identified
The Performance Matrix is an assessment site of the weak link is rated as a ‘pass’ (able some weak links. Two tests are described
system developed from the latest academic to demonstrate good active control) or ‘fail’ here in detail, along with the results achieved
and clinical research to determine the ‘weak (unable to prevent uncontrolled movement). by the footballer (Tables 4 to 7).
links’ in the stability and performance chain. Where the athlete is able actively to control
These weak links are identified in terms of: ranges of movement or to make compensa- Test A: Leg rotation under a neutral pelvis
i. the site tions under both low- and high-load direction- (low load)
ii. the direction of musculoskeletal risk specific testing, that aspect is not classified as Start position
iii. the threshold (low or high) of potential a significant stability dysfunction. However, ● Stand with the heels 5-7cm away from a
performance failure. if movement cannot be controlled, the pattern wall and the back resting on the wall
is defined as a ‘weak link’. ● Stand feet under hips (10-15cm apart)
The Performance Matrix can be used as a This assessment tool makes it much ● Inside edges of the feet parallel
rehab tool, but will also help coaches and easier for the support professional to design ● Keeping heels down, bend the knees and
trainers to identify movement faults before and implement a prescriptive retraining slide down the wall
symptoms become apparent. programme, including strategies to regain ● Keep the kneecap out over the second toe
The system has 10 tests (5 low load, 5 high control of the site and direction of perfor- ● The back should be straight and vertical as
load). To test for uncontrolled movement, mance failure at the appropriate threshold if sliding down a wall
the subject is asked actively to control the of loading. ● Position the shoulders midway between
hitched up and dropped down.
Table 4: Analysis chart, leg rotation test
Test movement
Weak link ● Swing the knees fully to the left and right
L R Load Site Direction without any movement of the pelvis and
Can you reproduce the same ✔ ✔ Low Hip Rotation upper trunk
movement available on the wall, ✘ ✘ ● As the knees swing side to side allow the
moving both legs without wall
feet to roll from inside to outside edge
support?
● Move the feet one step away from the wall
Can you prevent the pelvis and ✔ ✔ Low Low back Rotation so the back is off the wall
back rotating to follow the legs? ✘ ✘ (lumbo-pelvic)
● Repeat the movement without the wall
Can you prevent side bending of ✔ ✔ Low Low back Side bend support.
the trunk or tilting or side ✘ ✘ (lumbo-pelvic)
shifting of the pelvis?
The tester notes how far the knees move side
Can you prevent the foot turning ✔ ✔ Low Lower leg Rotation to side.
in or the toes lifting? ✘ ✘
Notes on protocol
Table 5: Results for footballer First practise the test movement with the
pelvis and trunk supported against a wall.
Test A: Leg rotation under a neutral pelvis If the client can’t reach the same range off
the wall (unsupported) as they could on the
Weak link
wall, try turning one leg at a time. If the
Load Site Direction Result
range moving one leg at a time is now the
Low Low back Rotation ✘ same, there is no restriction. If the range
Side bend is still less, then there is a restriction
Hip Rotation of the foot or the knee that needs mobil-
Lower leg Rotation ising. The hip is unlikely to be the cause
of restriction.
8 SPORTS INJURY BULLETIN March 2006 No 57

Test B: Elbow push-up plus single-leg lift if inefficient, the hamstrings dominate the of retraining this high-load weak link is to
(high load) pattern of movement. train under high load and not modify to low
Start position Although the footballer’s symptoms had load (if he’d had a concurrent weak link
● Lie face down propped on elbows with fore- always been cleared with previous treat- under low load it may have been necessary
arms and hands pointing to opposite elbow ments and rehab, the weak link was to start retraining under low load). High-load
● Knees and feet together contributing to gluteal inefficiency and retraining strategies must include load, speed
● Shoulders midway between hitched and concurrent dominance of the hamstring or an unstable surface. Again he only
dropped (the synergist for the inefficient gluteals), performed the exercise if he could control
● Taking weight through the arms, lift hips which contributed to overstrain and recur- the weak link. His goal was to work up to
and knees off floor, pushing off the toes rence of symptoms. From this assessment sustaining extension for two minutes,
● Make a straight line with legs, trunk and a specific retraining strategy can be imple- working always to the point of fatigue to
head. mented to correct the faults. ensure high-load training.
In this case, the footballer retrained control He passed both tests at six weeks and
Test movement of lumbar rotation with a low-load strategy. again six months after return to full training,
● Keeping the pelvis neutral and in a straight This included retraining hip rotation (as and has not had a recurrence of symptoms
line with the legs and trunk, lift one leg to described in the test) but with wall support in the hamstring or lumbar spine.
horizontal. and kinaesthetic feedback from his hands in
his iliac crests. This was progressed away from References
The results demonstrate that this footballer the wall, to walk and then lunge. He 1. van Dillen LR, Sahrmann SA, et al ‘Effect of
has a low-load motor control rotation performed repetitions of the movement, stop- active limb movements on symptoms in
dysfunction of the low back and a high-load ping when he could no longer control it. When patients with low back pain’ J Orthop Sports
strength dysfunction controlling extension. he passed the test he could perform the move- Phys Ther 2001 Aug; 31(8):402-13
This weak link into extension is often asso- ment for four minutes, demonstrating good 2. O’Sullivan PB, Beales DJ, et al ‘Altered motor
ciated with recurrent hamstring problems. low threshold lumbopelvic control. control strategies in subjects with sacroiliac
This is linked with inefficiencies in the The lumbar extension weak link was joint pain during the active straight leg raise
stability muscles (obliques and gluteals) from retrained with high-load strategies. The test test’ Spine 2002; 27(1):E1-E8
controlling lumbar extension and rotation position was modified to start with more 3. Falla D, Bilenkij G, et al ‘Patients with chronic
(under both low and high load). The gluteals thorax support (hip extension with the neck pain demonstrate altered patterns of
also contribute to active hip extension and, thoracic spine on gym ball). The importance muscle activation during performance of a
functional upper limb task’ Spine 2004;
Table 6: Analysis chart, elbow push-up plus leg lift test 29(13):1436-40
4. van Dieen JH, Cholewicki J, et al ‘Trunk
Weak link muscle recruitment patterns in patients with
L R Load Site Direction low back pain enhance the stability of the
Can you prevent the back from ✔ ✔ High Low back Extension lumbar spine’ Spine 2003; 15, 28(8):834-841
arching and the pelvis from ✘ ✘ (lumbo-pelvic) 5.O’Sullivan PB, Twomey L, et al ‘Evaluation of
dropping? specific stabilising exercises in the treatment of
Can you prevent the back and ✔ ✔ High Low back Rotation chronic low back pain with radiological diagnosis
pelvis from rotating? ✘ ✘ (lumbo-pelvic) of spondylosis or spondylolisthesis’ Spine1997;
Can you prevent the hips from ✔ ✔ High Hip Flexion 22(24):2959-67
flexing and lifting? ✘ ✘ 6. Jull G, Trott P, et al ‘A randomized controlled
trial of exercise and manipulative therapy for
Can you prevent the shoulder ✔ ✔ High Shoulder Rotation
blade from winging? ✘ ✘ blade (scapula) cervicogenic headache’ Spine 2002;
27(17):1835-43
Can you prevent forward tilt of ✔ ✔ High Shoulder Tilt
7. Chek P www.chekinstitute.com
the shoulder blade? ✘ ✘ blade (scapula)
8. McGill S (2002) Low Back Disorders: Evidence
Can you prevent the upper back ✔ ✔ High Upper back Flexion based prevention and rehabilitation Human
flexing up or rounding out? ✘ ✘
Kinetics
9.Comerford MJ, Mottram SL ‘Movement and
Table 7: Results for footballer stability dysfunction – contemporary
developments’ Manual Therapy2001; 6(1):15-26
Test B: Elbow push-up plus single-leg lift 10. Sahrmann SA (2002) Diagnosis & Treatment
of Movement Impairment Syndrome (Ist ed)
Weak link
Mosby USA
Load Site Direction Result
11.Hides JA, Jull GA, et al ‘Long term effects of
High Upper back Flexion specific stabilizing exercises for first episode low
Shoulder blade Winging back pain’ Spine2001; 26(11):243-8
Tilt 12. Danneels LA, Vanderstraeten GG, et al
Low back Extension ✘ ‘Effects of the three different training modalities
Rotation on the cross sectional area of the lumbar
Hip Flexion multifidus muscles in patients with chronic low
back pain’ British J Sports Med 2001; 35:186-9
March 2006 No 57
Research Review
Rugby injuries
Hookers beware
Rugby (union and league) is one of the most popular
professional team sports in the world, and whether you
are watching the Six Nations or a Super League play-off,
it will come as no surprise that it also has one of the
highest rates of injury. In 2005 three different studies
were published looking at the incidence of match injuries
sustained by professional rugby players in domestic and
international competition.
In the first study researchers from the Rugby Football
Union and University of Leicester, UK, examined players
from 12 clubs competing in the English Premiership
over 98 weeks during the 2002/03 and 2003/04
seasons (‘Epidemiology of Injuries in English
professional rugby union: part 1 – match injuries’,
British Journal of Sports Medicine 2005; 39:757-
766). This research is of particular interest because
prior to this only a handful of studies had investigated
injury rates in the professional game, and their findings
were restricted because of the small size of the study
samples (49 to 145 players). By comparison this study
is huge, with 546 players taking part.
Team clinicians reported all match injuries on a weekly
basis and provided details of the location, diagnosis,
severity and mechanism of each injury. The study counted
all injuries that forced players to refrain from normal
training or match play for more than one day after
sustaining their injury.
The researchers discovered that the overall incidence
of injuries was 91 per 1,000 player-hours, and each injury
resulted on average in 18 days’ lost time. Recurrences,
which accounted for 18% of injuries, were significantly
more severe (27 days lost) than new injuries (16 days).
Forwards and backs most commonly sustained thigh
haematomas, but the longest absences from play
resulted from ACL damage for forwards and hamstring
injuries for backs. Contact accounted for 72% of
injuries, but foul play was implicated in 6% of injuries
(unlike soccer where foul tackles have been shown to
be responsible for 44% of all injuries).
Losers beware
The above research provides useful information about the
incidence of injury in top class domestic rugby. But what
happens during major international events? Do we see
similar patterns and are the underlying contributory factors
the same? Just over two years ago a team from the
Australian Rugby Union and the School of Safety Science at
the University of New South Wales, Australia, examined
injury patterns during the 2003 Rugby World Cup (‘Rugby
World Cup 2003 injury surveillance project’, British
Journal of Sports Medicine 2005; 39:812-817).
As with the English study the team physicians recorded
all injuries and this information was then submitted to the
tournament medical officer. This study defined an injury
as ‘any injury or medical condition related to a game
SPORTS INJURY BULLETIN 9
by Nick Grantham
Not surprisingly the ruck and maul elements of the
game caused the most injuries to forwards; being tackled
caused most injuries to the backs. Prizes for the most
dangerous positions on the field are reserved for hookers
and the outside centre, who were shown to be at the
greatest risk of injury.
The appliance of science
Practical implications for SIB readers
For attention of
Therapists
Strength and conditioning coaches
Sports coaches
PE teachers
Significance
Cutting edge
Confirms best practice
Too early to say
How to use it
One way to reduce the overall incidence of contact-
related injuries is to develop injury prevention
strategies as part of an ongoing strength and
conditioning programme(1). These should incorporate
exercises for:
● Lower extremity: hamstring and hip extensors
strength; improve ankle stability and proprioception
● Upper body: shoulders are main point of contact
during collision phases and preventive measures
should look at strengthening the rotator cuff and the
stabilising muscles around the scapula
● Neck: development of isometric and dynamic actions
to improve the capacity to resist forces acting on the
cervical spine
1. ‘Physical preparation for elite level rugby union football’
Strength and Conditioning Journal 2004; 26(4):10-23
event that caused a player to leave the field during a
game and/or to miss a subsequent game’.
During the tournament 189 injuries were recorded
over 48 matches. The overall incidence was 97.9
injuries per 1,000 player-hours. As seen in the English
domestic competition, player position had an impact
on the incidence of injury, although this time the open
side flanker, inside centre and number 8 were the
most frequently injured players.
Of particular interest is the fact that the tournament
pool (elimination stage) matches yielded a higher injury
rate than non-pool matches and the 12 non-finalist teams
sustained significantly higher injury rates than the eight
finalist teams. The non-finalist teams also recorded a
higher rate of recurrent injuries. One possible 10
10 SPORTS INJURY BULLETIN March 2006 No 57

Research Review (continued) by Nick Grantham

9 explanation is that the pro rugby playing field is less appropriate injury prevention and management
not level: smaller teams are likely to have a smaller pool strategies, and a combination of these factors may well
of talented players, lack of adequate physical preparation, result in their players being at greater risk of injury.

The appliance of science influenced by how well a team is prepared. The authors
noted that a lack of physical preparation could be one
Practical implications for SIB readers of several risk factors. The team that is in best physical
For attention of condition is less likely to pick up injuries.
Therapists Recent research from Australia(2) supports the use of
Strength and conditioning coaches supervised strength and conditioning programmes in
young athletes.
Sports coaches
If all this sounds too obvious, Iet me assure you the
PE teachers message is still not getting through. If you play rugby,
Significance you need to be in great physical condition… get
Cutting edge yourself a trainer and don’t leave this crucial aspect of
Confirms best practice your training to chance.
Too early to say 2. ‘Effect of direct supervision of a strength coach on
measures of muscular strength and power in young rugby
How to use it league players’ Journal of Strength and Conditioning Research
Risk of injury during a tournament situation could be 2004; 18(2):316-323

Beware of tackles there are clear similarities in the mechanism of injury. All
We can’t have a round-up of research into rugby related three studies found that the tackle (either tackling or
injuries without looking at the incidence of injuries in being tackled) was the highest-risk injury mechanism.
rugby league. Rugby league has similar rules and
movement patterns to rugby union; however, it does not
have line outs, has 13 players per team instead of 15, and The appliance of science
involves the immediate play of the ball after every tackle.
Just like rugby union, the league games are intense, with Practical implications for SIB readers
a high number of physical collisions throughout a match, For attention of
making musculoskeletal injuries commonplace. Therapists
At the end of 2005 Tim Gabbett from the Athlete and
Strength and conditioning coaches
Coach Support Services at the Queensland Academy of
Sport, Australia, investigated whether playing position Sports coaches
influenced the site, nature and cause of injuries to rugby PE teachers
league players (‘Influence of playing position on the Significance
nature and cause of rugby league injuries’, Journal of Cutting edge
Strength and Conditioning Research 2005; 19(4):749-
755). The two studies above have highlighted how Confirms best practice
playing position can predispose players to injury in rugby Too early to say
union. Is the same true for league players? How to use it
During two consecutive seasons (2000 and 2001) the Most injuries occur during the tackle. Researchers
researchers studied 156 semi-professional rugby league suggest:
players: 77 in the first season, 79 in the second (39 ● Appropriate time should be spent developing correct
players competed in both seasons). A single recorder tackling technique
collected injury data from 137 matches. In this study an ● Position-specific training is warranted for rugby league
injury was defined as ‘any pain or disability suffered by a players. Those playing high-risk positions (hooker, prop)
player during a match that resulted in the player missing should also have position-specific injury prevention
a subsequent match’. Gabbett found the overall incidence programmes
to be 68 injuries per 1,000 player-hours, but that the rate ● Introduce skills into conditioning programme to
was significantly higher among forwards than backs. challenge the player in a fatigued state and improve their
Although the overall incidence of injuries was lower aerobic endurance
than that seen in the two rugby union studies above,

The bottom line: All three studies clearly show that rugby is code, chances are you are going to pick up an injury during
an extremely demanding sport that carries a relatively high the course of a season. Working with a rugby player presents
injury risk. If you play rugby, irrespective of your chosen a significant challenge for medical and support personnel.
March 2006 No 57
Basic briefing notes
Meniscal damage to the knee
An update by Sam Oussedik and Fares Haddad
The menisci are two crescent-shaped pieces
of cartilage present in both knees, one in the
medial tibiofemoral compartment – the
medial meniscus – and the other in the lateral
tibiofemoral compartment – the lateral
meniscus. Together these structures act in
four different ways to improve knee function:
● They transmit load across the joint. In
extension, this is up to 50% of axial load; in
flexion it increases to 90%
● They improve joint congruency or stability
● They increase the contact surface area of
tibia and femur, helping to spread axial load
across a greater area of articular cartilage
● They help to circulate synovial fluid around
the knee(1).
To carry out these functions, the menisci have
a complex structure. They are composed of
a specialised type of fibrocartilage the high
water content of which allows them to resist
the forces they must withstand.
They have a limited healing potential.
Their blood supply only reaches the outer-
most 10% to 30% of each meniscus; within
this region tears may heal. More centrally
placed tears have very little chance of healing.
Meniscal injuries are relatively common,
with the medial meniscus most often injured.
The posterior part of the medial meniscus
also supplements the anterior cruciate liga-
ment (ACL) in restraining anterior tibial trans-
lation, helping to stop the tibia from sliding
forwards against the femur. This puts the
meniscus at risk from injury in any trauma
that disrupts the ACL. It also means that ACL
deficiency can lead to tears in the meniscus.
More commonly, the menisci are
damaged from a twisting injury to the knee,
with the foot usually anchored on the ground.
These traumatic injuries should be differ-
entiated from degenerative tears, which
occur in an older age group, although some-
times in patients as young as their late 20s,
often in association with early degenerative
changes in the knee.
Typically a client with a traumatic
meniscal tear will have a history of recent
trauma, swelling of the knee, and a restricted
range of motion. If there is a ‘bucket-handle’
tear, where a mobile segment of torn
meniscus can lodge in the joint, the client
may feel frequent locking of the knee, or the
inability to fully extend. More frequently
symptoms may simply be of discomfort over
one side of the knee, particularly in deep
flexion. The client may not be able to kneel
or squat, and may not ‘trust’ that knee.
Joint line tenderness is a common feature
and restricted range of motion may be the
result of effusion or mechanical block by a
mobile segment of meniscus. Pain is elicited
on deep squatting.
McMurray’s test is diagnostic: the knee is
placed into full flexion and the tibia is inter-
nally and externally rotated as the knee is
brought into extension. This test is positive if
pain is elicited in the presence of a palpable or
audible clicking.
Meniscal injuries can be diagnosed on
magnetic resonance imaging (MRI), but this
is not necessary for the isolated injury,
although it may yield valuable information
if a more complex injury is suspected.
Arthroscopy is also diagnostic, with direct
visualisation of the injury. However, clinical
diagnosis is preferable prior to any proce-
dure being undertaken.
Management
Non-operative
While a relatively asymptomatic client with
low functional demands may do very well
with non-operative management, where
the tear is symptomatic or the patient has
a high functional demand, an orthopaedic
surgeon should assess the case for a
possible operation.
Symptomatic tears may result in further
damage to the articular surfaces of the femur
and tibia. The added stress on the torn
meniscus associated with greater sporting
activity may also result in degeneration of
the torn segment, such that meniscal repair
may not be possible. Early assessment is
therefore required, before secondary damage
is caused.
Non-operative management is usually
reserved for those patients with few or no
symptoms who are able to carry out a full range
of physical activities. This group is usually
made up of older patients with degenerative
tears in the presence of significant degenerate
changes in the knee. Physiotherapy helps to
regain range of motion and strengthen muscle
groups. This is also an important part of post-
operative management.
If there is doubt and the patient has a
combination, for example, of patellofemoral
pain and a borderline meniscal pathology, clin-
ically and on MRI, non-operative treatment
of the patellofemoral symptoms and knee
SPORTS INJURY BULLETIN 11
control may sometimes be sufficient to keep
symptoms at bay. Careful review is necessary.
Operative
Patients with recurrent mechanical symp-
toms and/or significant pain require opera-
tive management. Nowadays this means an
arthroscopy. Depending on the location of
the tear, several options are available.
Partial meniscectomy is indicated for
those tears which are degenerate, or outside
the vascularised zone. During this procedure,
specialised instruments are introduced
through an arthroscopy portal to remove the
torn piece of cartilage, leaving a stable rim of
tissue behind. The least possible amount of
tissue is removed, so as to leave behind the
largest amount of healthy, stable tissue to
continue protecting the articular cartilage
from increased stress.
In those tears that lie within the vascu-
larised zone, repair can be attempted by fixing
the damaged part to the meniscus behind it
and the joint capsule. Tears repaired at the
time of cruciate ligament reconstruction have
a better prognosis. We believe this is related
to the fact that these are traumatic tears in
healthy menisci with good healing potential
rather than degenerate ‘predetermined’ tears,
which have poor healing potential.
Results for meniscal repair are very good,
especially when carried out during ACL
reconstruction. Boyd and Myers(2) estimate
a re-tear rate of less than 10%. The long-term
effects on articular cartilage are not yet well
understood, but we believe that meniscal
preservation offers the best hope of avoiding
further damage. In functional terms, most
patients will recover all but the final(3) degrees
of flexion, which is inconsequential for most
sporting needs. It is important that the patient
is pre-warned about this likelihood.
Shelbourne et al(4) looked at rehabilitation
following isolated meniscal repair. They
found that an accelerated programme,
allowing a full range of motion and weight
bearing as tolerated, had similar results in
terms of meniscal healing to a more conven-
tional restrictive regime.
New developments
While peripheral meniscal tears may be
amenable to repair, those within the
avascular zone have traditionally had to be cut
out. Tissue engineering techniques are being
developed to address this problem. One
possible solution is to deliver cells to a tear
together with the specific growth factors
necessary for repair to take place. So far animal
work has focused on discovering which mate-
rials are needed to effect a repair. This type of
approach may well yield clinically significant
12 SPORTS INJURY BULLETIN March 2006 No 57

results in the not too distant future.
Meniscal transplant is an option for the
treatment of severe meniscal damage.
Indications for this form of treatment vary
among researchers. Some believe that persis-
tent pain in a compartment that has lost its
meniscus is good enough to attempt implan-
tation; others argue some degree of chon-
dral damage is a prerequisite. Preserved
meniscal tissue from cadavers is used. As
yet results for this are mixed(5); associated
problems include: the availability of meniscal
tissue for graft, its preservation, possible
transfer of disease, shaping of the graft and
potential immunological reactions to it.
In trying to overcome some of these
concerns, attention has turned to alternative
sources of graft material. One such alterna-
tive is the use of bovine-derived collagen.
However, in order for tissue ingrowth to occur,
a rim of the patient’s own meniscus must be
present. Again, results for this technique are
rather poor(3).
The purpose of all of these procedures
should be to prevent chondral damage while
restoring knee function. As yet this has
proved to be a difficult target to attain. No
research published to date shows such
results. This has led some to believe that the
procedure itself may be to blame for some
of the chondral damage seen. Work is there-
fore focusing on more minimally invasive
techniques to implant material.
References
1. Alford JW, Cole BJ ‘Cartilage restoration
part I: basic science, historical perspective,
patient evaluation, and treatment options’
Am J Sports Med 2005 Feb; 33(2):295-306
2. Boyd KT, Myers PT ‘Meniscus preservation;
rationale, repair techniques and results’ The
Knee 2003; 10:1-11
3. Stone KR, Steadman JR, et al
‘Regeneration of meniscal cartilage with use
of a collagen scaffold. Analysis of preliminary
data’ J Bone Joint Surg (Am) 1997; 79:1770-7
4. Shelbourne KD, Patel DV, et al
‘Rehabilitation after meniscal repair’ Clin
Sports Med’ 1996 Jul; 15(3):595-612
5. Rijk PC ‘Meniscal allograft transplantation
– part I: background, results, graft selection
and preservation, and surgical
considerations’ Arthroscopy 2004 Sep;
20(7):728-43

Contributors to this issue

Raphael Brandon MSc is a sports conditioning and
fitness specialist, working as the London region
strength and conditioning coach for the English
Institute of Sport
Sean Fyfe is a physiotherapist, tennis coach and
director of TFP (Tennis Fitness Physio), a Queensland
based company specialising in sports medicine, elite
tennis player development, strength and conditioning
and childhood motor learning programmes
Nick Grantham is a lead strength and conditioning
coach with the English Institute of Sport. Previously he
worked with the England netball team and the British
gymnastics team
Fares Haddad BSc MCh (Orth) FRCS (Orth) is a
consultant orthopaedic surgeon at University College
London Hospital and editorial consultant to Sports
Injury Bulletin
Sarah Mottram is a director of Performance Stability,
which delivers training courses to professionals in the
sports, exercise and medical industries, and which has
developed the Performance Matrix stability assessment
system. For information, visit: www.performance-
stability.com or call 01584 877987
Sam Oussedik is clinical and research fellow in
orthopaedics at University College London Hospital.
His primary interest is football
Illustrations by Viv Mullett
SPORTS INJURY BULLETIN
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