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Basketball Sports Medicine Conference 2016

Simon Kellett the new CEO of Basketball England kicked off this year’s conference with some good visions for the future. He highlighted the need for Basketball England to aim high so as not to fall into a habit of accepting sub-standard. I like that a lot and I feel it is going to be an exciting time to be a part of Basketball England and Great Britain going forwards.

The next lecture was one I wasn’t particularly looking forward to and that was our safeguarding training. However credit to Melissa Hague (@Ass1lem) who made it interesting and relevant. One thing that really stuck with me is that load and loading plays a part in safeguarding. For example continually overloading a player to the point of breakdown. This further highlights the importance of monitoring a players load and wellbeing which gets touched on later.

So that was done for another year, it was time for Ben Rosenblatt (@ben_rosenblatt). Ben is the lead Strength and Conditioning coach at GB Hockey and a very good speaker. He has some really nice lines which stuck with me and took us through some nice views on how we can train for function, always asking the question – what is a specific exercise? And this brings me to his first line – What you train for is what you get? Hit a good note for me particularly with the last blog post I wrote discussing differences in functional and non-functional exercises. We had a look at some research by Smart et al (2014) which looked at the relationship between physical qualities and how players perform a task during a game of Rugby Union and found very little correlation between things like squatting and game tasks. We also looked at a paper (which I didn’t jot down!) which looked at 8 Welsh Rugby players sprinting, which demonstrated that each player had a unique loading strategy through gait – for the same exercise!

So with this in mind is the replication of the biomechanics of a skill practical or possible?

He went on to discuss how the biomechanics of a skill is dependent on the task demand; movement patterns and total power output are achieved using task dependent biomechanics so how can we mimic that….we break it down – “An effective exercise is one that overloads the bio mechanical determinants of performance”

For example Spiteri et al (2013) showed that stronger athletes turn faster. Being stronger you can generate more force, if muscles are firing harder and earlier then you can turn faster. Strength training, plyometrics and pre-activation all can play a part then.

A nice saying he had when discussing turning was “kill momentum”. To turn an individual needs to decelerate, stop and turn…this is kill momentum. Are they able to lean body, flex hips and knees and control their trunk. Where is there foot in relation to their centre of mass. If we want to reduce injury risk through this motion then we need to control posture alignment through the task and ensure good landing mechanics. To do this we can adopt a deterministic approach:

Change of direction determinants:

  • Kill momentum
  • Propulsive impulse
  • Control posture and trunk

Perception also plays key role in biomechanics and action of task. Take a defensive basketball player. The defender who will win against the attacker more frequently will display:

  • Same initiation time
  • Match medio-leteral velocity
  • Better preparatory unweighting

To ensure our players are reaching this level:

  • Has training overloaded physical capability to improve action
  • Is there relevant perceptual input – decision making cues

If we can match up the perception with the action and overload the physical capability then we can start to transfer into sports performance.

And that was talk one from Ben. A very thought provoking talk and really made me think of the stimuli I may add to my rehab routines before return to play. I have always been big on capacity testing and strength testing before allowing athletes to progress to more dynamic activities but I will certainly now include a lot more perceptual and reactive input into my rehab programmes.

Part 2 from Ben moved into the practice of sports specific training with the focus on improving the ability of an athlete to kill momentum. Some great videos of rehab sessions were included (when they worked J) but the key points from this were:

  • Can they train better:
    • Better hormonal response if individualised to way they train
    • Short bouts they train well to
    • Priming exercises
  • There’s a role for heavy squats – can break earlier
  • Need to be considerate of periodisation, what has athlete been doing, what have they got to do
    • Can still overload strength 6 weeks before game
      • 3 week block of eccentric training, leg press, 2 legs up, 1 down
    • Change muscle architecture, muscle inhibition – Improved kill momentum
    • Plyometrics can help, include perceptual input e.g. 1 v 1 where 1 has to react
    • Olympic lift variations can help – catch
    • Single leg hops landing as low as can to absorb load
    • Fire harder and faster – can use surface variability to improve this
    • Practice variability is better way to attain skills

Mikel Perry (@MikelPerrySandC) of the Institute of Sport, Exercise and Health (@TheISEH) was next up and had done a really interesting study on the rate of injuries across the academy level groups. No surprises that the most common time loss injury was the ankle at 45%. Knee injuries came second at 34%.

 

It was then the turn of Seth O’Neill. Now for me as a physio in the crowd, with no disrespect to any of the other speakers, this was the big event for me. I had previously followed Seth on Twitter, exchanged conversation and emails, so it was a pleasure to meet him, and a nice bloke as well! But let’s get down to business. One thing you really did get from Seth was he had a nice way of explaining everything that made it feel so easy. So tendinopathy is primarily a degenerative process caused by an imbalance in wear and repair. Chemical reaction occurs, you get an increase in protein molecules which suck fluid in causing the tendon to swell, this triggers cell molecules to react and the tendon goes mushy…like wet paper.  You can see in the image to the right the differences in structure between healthy tendon (left) and pathological tendon (right).

In the Achilles tendon, most of the structural breakdown is at the fibres of the soleus. When a tendon heats up (hysteresis) it affects the tenocytes which repair tendons.

There are some inflammatory pathways are linked to pain, but not inflammation as we may think it. More like that of delayed onset of muscle soreness (DOMs). A chemical cascade to trigger adaptation.

Assessment wise, key diagnosis criteria was finger point test and linked to loading. Patella tendon (inferior pole) the most affected in basketball, however the Achilles has a high risk of rupture. Strength below a certain level is predictive of Achilles tendinopathy. Decline squat is provocative test for patella. Also watch out for altered landing mechanics – they may have less knee flexion / be stiffer…is this chicken or egg though?

Rehabilitation of a tendinopathy needs to be structured and graded and must go heavy. Rehab doesn’t resolve the deficits as this graph nicely shows. We also cannot rely on the healthy not affected limb to give us our baseline! After you have gone heavy, that is when you can move on to the stretch shortening cycle stuff.

Rehab:

  • Isolate muscle and tendon fascicles (e.g. Achilles flexed and extended knee)
  • Reduce muscle tremor (fasciculation’s)
  • Combine endurance elements and strength
  • Pain monitoring model – running / walking day
  • Strength work – Heavy ASAP 8-12RM
  • Progress to very health strength work 6-8RM (external load)
  • Progress walking / running distance

Check out Beyer et al (2015) and Kongsgaard et al (2009) for heavy slow resistance training.

Neuromuscular control is key. With tendinopathy you get changes such as increased inhibition, excitation, reduced strength, tendon oscillations (where the tendon doesn’t move smoothly – judders – meaning more stretch shortening cycles) and altered gait patterns.

Woman seem to respond worse to rehab, sedentary even worse still and active men the best. Likely due to testosterone and epigenetics leading to quicker muscle growth. Don’t forget the other factors also – stress controls the immune system which controls your recovery rates.

A word on stretching – don’t do it!

It doesn’t make changes to the soft tissue (you must achieve sarcomeregenesis for this) and it only really stretches tendon. It may be helpful in the morning. If we consider the build-up of fluid in the tendon, stretching the tendon may force the fluid out. Otherwise it is just scratching an itch.

Seth finished off with an interesting look at isometrics. Now I have been a big advocate of isometrics, I must admit I have found them far more useful in the upper limb than lower limb, but as a low level entry exercise with an analgesic affect…brilliant. And when Ebonie Rio’s research came out, even better. Now I don’t know if it was because it was what we wanted to see, or from where it came from but as Seth quite rightly pointed out some of the key failings of the research were somewhat overlooked such as the number of participants (6!) and the fact that the isotonic group did a very different loading programme. Certainly by me anyway if not anyone else. Seth went on to explain how he saw no difference between the results of isometrics and isotonics. However, if we think graded exposure and reducing a patients fear then actually isometrics may still play an important part as that entry level exercise. There is also the argument for in-season use, that big heavy loads and high tendon stress can trigger adaptation which is a good approach as it should not make the patient sore as not energy storage. However thinking of Ben’s talk above and his 6 week eccentric programme prior to competition we may be able to get away with more than we think.

We then closed the day with the Mark Williams and Andy Howse of the GB Senior Woman’s Medical Team. I really enjoyed this talk and it gave me lots of ideas for working with my team through tournaments and training camps. They focused on load management which we know is vital in the performance world these days, with a few nods to Tim Gabbett’s excellent work. They do this by using HR monitoring, GPS, RPE, wellness scores (soreness, mood, sleep, stress, fatigue) and daily physical markers of knee-to-wall, adductor squeeze and straight leg raise. Now I don’t have access to the heart rate monitoring and GPS but can certainly make better use of RPE and wellness scores. Especially in highly intensive camps or tournaments, because as well as being good information for the medical team, it is also excellent information for the coaching team as well. RPE has been shown to have a good correlation between HR and blood lactate scores (Coutts et al, 2009)

They finished by touching on the warm up and the key message that came out of that, and what we all strive for is the players need to feel good! Find out what the key message is for the session, do what is necessary to prepare the players but make sure they feel good.

And now I feel good for writing that all up. A great day, thanks to Paul Fisher for organising and I look forward to next year.

 

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