- Are we addressing intrinsic/extrinsic factors that may influence injury risk?
- Are we putting in injury prevention programmes that have been proven to reduce rate of injuries?
- Do we use the most up to date methods of preparing our players for their performance demands?
- Are we continually up-skilling and increasing our knowledge?
- Are we educating the people who make the important decisions on best practices?
Hip pain is a very topical issue within GAA players at the moment. In the past year there has been some high profile articles within the media, with often misleading information and scaremongering being circulated, confusing the patients that we see in our clinic.
So what is it?
For years there has been a poor establishment of diagnostic criteria and management of this injury, however the Warwick Agreement on Femoroacetabular Impingement Syndrome has outlined the consensus of world experts. Femoroacetabular syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum. The main symptoms that people present with in the clinic is hip or groin pain during certain movements or positions e.g. changing direction or cutting during training/match. Pain may also be felt in the buttock and thigh.
Patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.
In clinic, GAA players often report an increase in training load, playing with multiple teams and multiple age groups, general increase in stiffness in the hips and groin over a sustained period.
Diagnosis of FAI syndrome does not depend on a single clinical sign. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion. There will be strength deficits around the joint on testing, especially in Hip Abduction and Hip Flexion. Hip flexion deficits were associated with a decrease in function as shown by the association with the greater loss in range of motion and patient reported outcomes. It is well established that large strength deficits are found in people who have chronic hip pain, leading to weakness of the hip rotators and hip abductors. There is suggestion of impairments in hip frontal, sagittal and transverse plane ROM during gait, squatting and stair climbing. A recent research paper showed that during a squat movement, participants with FAI had decreased hip internal rotation and increased anterior pelvic tilt compared to a normal group. The study also showed the FAI group had decreased gluteal and hamstring strength compared to the normal group. In theory, decreased activation of the gluteus maximus and/or hamstring muscles may contribute to the lack of posterior pelvis tilt. Hypothetically, relative posterior tilt of the pelvis during this phase of squatting would limit the potential for impingement in the presence of cam morphology.
The average age of symptomatic hip pain in this group is about 28 years, with nearly a 50/50 split in male and females, however this is a North American population,
with very little research been done in GAA. Studies of adolescents have made it apparent that the development of FAI may also be due to developmental adaptations during skeletal maturation as a result of activities that involve repetitive hip motion, such as field based sports. Recent research demonstrates an increased prevalence of FAI type-deformities in elite adolescent athletes compared to their age-matched non-athletic controls.
This suggests that the morphological changes of FAI may be a response to repetitive stress at the hip joint secondary to sporting activity during periods of skeletal growth.
Research has shown that in particular, adolescent males who participate in ice-hockey, basketball and to a lesser extent soccer, whilst performing a minimum of three training sessions and games per week are currently at greatest risk of developing a boney deformity in the hip and potentially progressing to symptomatic hip impingement. So from a practical point of view, parents and coaches need to be aware of the amount of training load that young adolescents are participating in, especially during times of growth spurts. While physical activity is hugely important, a 15 year old boy playing three different sports up to 9 or 10 times a week while going through a growth spurt needs to be properly managed.
Rehabilitation aims to reduce patients’ symptoms by improving hip stability, neuromuscular control and movement patterns. However, for optimal results in returning the player to pain free play it is important that all confounding variables are explored.
- Activity Modifications to reduce pain
- Training Load education
- Range of Motion deficits
- Especially Internal Rotation
- Strength deficits
- Sagittal plane
- Frontal plane
- Transverse plane
- Movement patterns
- eg. modifying squat and deadlift mechanics to prevent pain and increase glute/hamstring strength
- Correct poor mechanic mechanics
- Change of Direction
One of the most important things that patients need to understand is there is no one size fits all to these problems. Each case has different challenges and rehabilitation needs to target the presenting persons deficits so a suitable tailored programme can be prescribed.
Thomas Divilly MSc MISCP
Griffin et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. (2016). 50
Hayes et al. Persons With Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength. Journal of Orthopaedic & Sports Physical Therapy. (2014). 44 (11).
Nepple, J.J. et al. Hip Strength Deficits in Patients With Symptomatic Femoroacetabular Impingement and Labral Tears. Arthroscopy: The Journal of Arthroscopic and Related Surgery. (2015). Vol 31, No 11 ,
Diamond et al. Isometric and Isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. Journal of Science and Medicine in Sport. (2016) 696-701.
Bagwell et al. Hip kinematics and kinetics in persons with and without cam femoroacetabular impingement during a deep squat task. Clinical Biomechanics. (2016). 87-92.
de Silva et al. Does high level youth sports participation increase the risk of femoroacetabular impingement? A review of the current literature. Pediatric Rheumatology. (2016). 14:16
Running Style: Forefoot Running?
Forefoot running amongst runners at the moment is the big buzz word. When speaking to runners in the clinic, it’s viewed as the optimum foot strike. While the heel strike is now seen among recreational runners as poor mechanics.
What does the research say about forefoot striking amongst runners? Most studies that have examined the strike pattern of runners have shown that heel striking is by far the most common pattern, with up to 90% (Larson et al., 2011) adopting this pattern. So it’s very fair to say that heel-strike is a pattern adopted by the majority, even amongst the holy grail of runners, the Kenyans.
But is forefoot running more economical for the everyday runner?
Gruber et al. (2013) “When the alternative footstrike pattern was performed, Forefoot running resulted in greater rates of V̇O2 than Rearfoot running in the Rearfoot group at the slow and medium speeds and across groups at the fast speeds”. So what does this mean in layman’s terms, basically that forefoot running is not more economical than rearfoot running. However, much more research is needed in this area.
So when would I ever change foot striking pattern?
One population group that it is useful to change the strike pattern is runners who present with knee pain. Research has shown that running with a forefoot strike reduces the overall forces that are absorbed through the knee itself. It’s a useful strategy to increase the overall step rate of a runner, which has a direct implication on step length during the rehabilitation process. Increasing the step rate by 5-10% will allow this to happen, but caution must be applied to this strategy as there will be increased forces placed on the calfs and Achilles tendon.
To summarsie forefoot running?
There is no research that supports increased running economy or reduced injury risk among a running population. However, it may be a useful strategy for certain population groups.
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High Hamstring Pain
Runners and sometimes field based athletes can present with lower buttock pain in the clinic. This can reduce performance and be painful carrying out normal daily activities. After assessment, this is usually diagnosed as a proximal hamstring tendinopathy.
A proximal hamstring tendinopathy is when the tendon that inserts into the bony point of the bottom, the ischial tuberosity, gets overused and causes structural changes in the type of collagen present in the tendon. This can cause pain to the bony area, especially with sitting on hard surfaces, in cars, etc.
The main symptoms are:
- pain on running activities,
- pain when sitting down, especially on hard surfaces,
- pain when flexing the hip e.g. putting on a sock.
In a clinical setting, the main reasons behind development of the tendon issue is due to overload of the tendon i.e. the tendon has been asked to do too much work for it’s ability to recover. So the typical story of a patient who presents with high hamstring pain is how they felt great during their runs over the preceding weeks and decided to increase the volume or intensity of their runs, or sometimes both! Another factor that may cause the issue to develop is hill running, which causes the hamstring muscles to come under increased eccentric stress, leading to tightened hip flexors, which in turn will contribute to the hamstrings working harder.
It’s important to get the region properly assessed to rule out other pathologies such as: lumbar referral, bursitis of the ischial tuberosity, glute max pain, sciatic nerve irritation, referral from the hip joint.
The best solution short term is to reduce and avoid the causing factors until the pain has subsided and get a proper assessment from one of the team to get a good structured rehabilitation programme under way..
Chronic Ankle Instability
Chronic ankle instability is an encompassing term used to classify an individual who presents with both mechanical and functional instability of the ankle joint following an initial lateral ankle sprain injury.
Mechanical Instability refers to measurable laxity of the ligaments, i.e. ligaments that are less stiff following injury, with some joint restrictions and synovial changes. Functional Instability is the lingering feeling of giving way or unsteady feeling which is generally attributed to neuromuscular and proprioceptive deficits.
Research has identified a number of potential reasons for long term issues with ankle instability after a sprain. One theory is that the ankle proprioception, where the joint is in space, is impaired creating an impaired reflex arc of the muscles that help stabilise the ankle joint. Swelling of the joint can cause the feedback system of the ankle joint to also alter and cause long term neuromuscular deficits.
So clinically, what can we do to help and reduce this occurring?
- Reduce pain and swelling of the joint
- Loading in functional tasks as soon as possible e.g. walking, running, cutting
- Establish baseline strength and power
- Improve proprioception of the ankle joint
- Practice tasks that are important to your need
- Landing/jumping mechanics
How To Fix Your Push Up
The push up is one of the most basic exercises that you can do, but time and time again it is technically performed poorly.
We see issues from poor technique contribute to low back pain, knee issues, along with a number of other issues. So technique is vital to keep the body healthy.
So how do I, and the rest of the team in Sports Physio Ireland, see a push up? Simple really, think about a dynamic plank.
Quiet simply, the core should be engaged throughout the total body movement, and 9/10 in most injured or poorly trained clients this is the last thing that is thought about!
So How To Do The Perfect Push Up
• Hands directly under the shoulder, screw them into the ground.
• Squeeze the ass, tuck the tail bone under until you feel the lengthening of the abdominals
• Drive the heels to the back wall
• Slowly and controlled bring the chest to the ground, keeping the elbows close to the rib cage and drive up through the heels of the hand.
Harder than you think, but more bang for your buck!
Phase One Meniscal Tear Rehabilitation
When the knee suffers a meniscal and osteochondral fracture injury, it’s ability to absorb forces produced from stepping, running and cutting is diminshed. It’s essential to slowly and progressively load bear the joint in movements that simulate and compliment the movement patterns of the sport.
See the video of Sports Physio Ireland client, Ciaran, week one with Thomas, one of our Physiotherapists and Strength and Conditioning Specialists going through his initial rehabilitation.
Paralympic Football World Cup 2015
Back in June, SPI Physiotherapist Thomas Divilly travelled to England for two weeks to assist the Irish Paralympic Football Team at the Cerebral Palsy Football World Cup
Here’s a short piece on his experience during the tournament with the team.
‘I had the privilege of working as the Physiotherapist to the Irish Paralympic Football Team as they competed in the Cerebral Palsy Football World Cup in St. George’s Park, home of the England FA. There was a huge prize on offer for the guys. Qualification for the Paralympic Game in Rio 2016. And boy did they deliver!
It was a hugely successful campaign as the team finished 6th overall. Defeating Portugal, Australia and Argentina en route to a qualification spot. I was personally able to help keeping the guys fit and healthy throughout the tournament. We finished the competition with a strong and healthy squad, just as we had started.
Key components to achieving a fit and healthy squad throughout the two weeks of intense competition was implementing a good recovery system. This was achieved through proper nutrition & hydration, mobility work and pool sessions to keep the players in top condition.
I’m already looking forward to seeing the guys learn from this invaluable experience and push on to bigger and better things!’
The most commonly injured area that occurs in field based sports is the Hamstring. But why the hamstring? It’s an interesting question, with many different potential reasons.
Is it strong enough for the sport? Does it fatigue easy? Is it working too hard, making up for lack of support? Have you done enough sprinting in your training program?
Here is a few exercises that we have in our bag, that can help recruit better hip and hamstring strength and control.
We aim to get you strong to help prevent the possibility of injuring you Hamstring again.