Professor Nicola Maffulli Centre Lead and Professor of Sports and Exercise Medicine at Barts and the London School of Medicine and Dentistry who chaired the Foot and Ankle session in the morning.
This milestone meeting marked the second anniversary of the series, and was heavily oversubscribed, demonstrating the increased popularity and the value of education at a high level. After introducing the event, the series organiser, Professor Nicola Maffulli, Centre Lead and Professor of Sports and Exercise Medicine at Barts and the London School of Medicine and Dentistry, began the morning session describing a unique approach to Achilles tendinopathies developed by a team of multi-disciplinary experts. “We do not know where the pain originates from, therefore, we do not know why and how any therapeutic modality, including surgery, works,” stated Professor Maffulli. He also described tendinopathy as the clinical syndrome, where diagnosis is clinical, and the Achilles tendon pathology maybe used as a paradigm for all other tendinopathies. Professor Maffulli discussed various approaches to the surgical management of tendinopathies, including minimally invasive approaches, with the overall aim of promoting repair and returning the patient to pre-activity levels. It is difficult to judge the “best treatment” from the literature, this is due to the outcomes being difficult to compare between studies, an inverse relation between the rigour of the trial and claimed results, and the lack of randomised controlled trials. Professor Maffulli concluded that there is still a mountain to climb, but progress is being made.
The second presentation in the morning by Dr David Perry, Emeritus Consultant Rheumatologist and Examiner in Sports and Exercise Medicine at QMUL, tackled the topic of uncommon foot and ankle problems in sport. A series of interesting case studies was used to show the symptoms and treatment of a number of problems. These included some tropical conditions such as Ainhum, a constricting groove encircling the base of the toe, and Loa loa filariasis, a worm inhabitation of the soft tissues. These were followed by studies of a rare adnexal tumour of the hallux, psoriatic synovitis and symphisitis in sport. Dr Perry was also Medical Officer on the Everest Marathon in 1995 and described the most common problem in the team as “gastrointestinal”!
Professor Maffulli’s second presentation, entitled “Posterior Ankle Endoscopy”, showed the history and development of ankle arthroscopy, and the main indications of hindfoot endoscopy including osteochondral defects, loose bodies, ossicles, chondromatosis and avulsion fragments. He described the operative position for the patient, detailed anatomy and the various portals used in the approaches. Professor Maffulli also said that “Two postero-medial endoscopic approaches make it possible to visualise and treat pathologies of the posterior ankle and of the hindfoot, without prolonging the operation through the need to reposition the patient in the prone position”. This technique has been shown to be beneficial in the treatment of, for example, posterior impingement syndrome.
As a reflection on ankle arthroscopy, Mr Rhidian Thomas, Consultant Orthopaedic Surgeon, Charing Cross Hospital, and Foundation Fellow in the Faculty of Sports and Exercise Medicine, described indications for Anterior Ankle Arthroscopy. Several interesting case studies were presented to the group.
After the break, Dr Manuela Angioi gave the meeting an update on Foot Stress Fractures in Ballet and training related causes. The most common site of a stress fracture in ballet is the base of the 2nd metatarsal, with the cause being extreme plantar flexion of the foot in the on pointe position, and also the locking configuration of the 2nd metatarsal and cuneiforms. An analysis of how these can be prevented highlighted better understanding of the foot position and forces on pointe, and other associated risk factors, such as nutrition and the “female triad”.
“All the World’s a Stage and The Seven Ages of the Dancer” was the title of the session by Professor Bill Ribbans, Consultant Orthopaedic Surgeon and Professor of Sports Medicine. Professor Ribbans described the role of the orthopaedic surgeon with the English National Ballet and the importance of being available to support the dancers. He described the orthopaedic ages of the dancer from baby dance class through to Corps de Ballet, teacher and retirement and linked these ‘ages’ to the various pathologies that may present during the dancer’s lifespan, and afterwards. A number of case studies were discussed relevant to the “seven ages” and some of the difficult issues, such as the dance ending injury. Professor Ribbans concluded that top flight ballet dancers and top flight rugby players are similar in that that they are both as “tough as old boots”!
Dr Zoe Hudson, Honorary Clinical Senior Lecturer, QMUL, concluded the morning session discussing Foot and Ankle Rehabilitation. Dr Hudson cited current research stating “An accelerated exercise protocol during the first week (20 minutes, three times a day) after ankle sprain improved ankle function”. In the pathway to predict future injury, she highlighted dorsiflexion as the main predictor for potential injury in several sports, and also as a risk factor for developing patella tendinopathy.
Dr Dylan Morrissey Consultant Physiotherapist and Senior Clinical Lecturer in Sports and Musculoskeletal Physiotherapy who chaired the afternoon session on Core Stability.
The afternoon session, Core Stability, commenced with an introduction by Dr Dylan Morrissey, Consultant Physiotherapist and Senior Clinical Lecturer in Sports and Musculoskeletal Physiotherapy. Dr Morrissey also chaired the session that led to a series of informative debates and discussions.
Sarah Mottram, founding director of Kinetic Control and Research Fellow at Southampton University, shared some insights from her own research and development on ‘Latest Advances in Core Stability Research’. She used this as a basis to develop ideas around exploring impairments in movement control, and revealed some recent developments concerning the Performance Matrix, which is a novel tool for injury prevention. Sarah concluded that core stability is a difficult term to define. She stated that “Changes in the control of movement can be identified where there is pain, or a history of pain, and there is evidence to support changes in the control of movement linked to the risk of injury.”
Claire Small, Clinical Director at Pure Sports Medicine, then shared some recent research findings discovered in conjunction with QMUL. In a presentation entitled ‘Lumbo-pelvic Muscle Activation in Chronic Adductor Related Groin Pain – A Research Report”, Claire illustrated how coronal plane muscle control is compromised in footballers with groin pain. This demonstrated some novel data showing a significant reduction in gluteus medius activity relative to adductor longus activity in those with chronic groin pain. The findings of the research report will have implications in the rehabilitation of these patients.
Following the afternoon break, Mr James Moore, Consultant Physiotherapist at UK Athletics and the Rugby Football Union, presented “Core Stability Related to Common Sporting Hip and Groin Injuries”. Mr Moore addressed the issue of functional load transfer across the pelvis with respect to injury. In this provocative presentation, many suggestions about the role of, for example, adductor magnus and gluteus maximus in athletic function were made. A schematic approach to the conservative treatment algorithm for all groin pain management was also outlined.
Dr Nicki Phillips, Fellow of the Chartered Society of Physiotherapy and President of the International Federation of Sports Physical Therapy, addressed the issue of pre-competition trunk stability enhancement immediately prior to competition using motor control principles mainly through manual techniques, range enhancement, neural modulation and pain reduction. Dr Phillips showed some illuminating use of technique videos and balanced them with cautionary notes about the timescale needed to alter musculoskeletal presentations while respecting the fragility of an expert’s technique.
One delegate commented: “It was a delight to be welcomed by coffee, a selection of Danish pastries, and even fruit salad in the glorious anteroom of Chandos House. We were gently ushered into the main room, to comfortable seating, to hear seven speakers talk knowledgeably and enthusiastically on their chosen topics. I either had my understanding soundly confirmed or learnt new things at an agreeable pace. I shall keep track of future events run by DJO Education/Queen Mary.”
Another added: “It was a great day and looking forward to coming to future meetings. Great line up, great content.”
The next meetings are 16th March 2012 (Muscle Problems and Pathology) and 15th June 2012 (Hip & Groin and Respiratory Medicine)
For a booking form email Barry Hill at barryghill@hotmail.com or visit www.djoglobal.co.uk/DJOeducation.
Delegates from the Foot and Ankle and Core Stability session held in December
