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Sports Kongres 2017

Well wasn’t that just great!

I’m fairly new on the conference scene having attended only a handful but I now know where I need to be in February 2018.

Sports Kongres is without a doubt a conference at the top of its game. Leading names from all of sports medicine, quality in every presentation you struggle to pick what you want to see, and to top it off they don’t half look after you. I can’t recommend it enough.

Before I get to it I would like to thank Seth O’Neal, Brad Neal, Simon Lack, Dylan Morrisey and Jarrod Antflick. Having travelled out only knowing people through Twitter I may have found myself at a loss but such is the welcoming and friendly extent of Twitter’s physio community I was well received and looked after. Really top blokes and a pleasure to meet them.

So after having a bit of a cycle around Copenhagen, I am now waiting for my flight home and reflecting on some key content.

The main theme was treatment and prevention of sports injuries with a focus on knee injuries and return to sport. Something we as physio’s see so much of in clinic whether that be NHS, private or sports. The conference opened with Professor Willem van Mechelen, who was the one to first coin the four step injury prevention model (reference). He discussed the cost effectiveness of a sports injury prevention programme in relation to ankle sprains and had some really interesting data to start us off. Prevention programmes are effective in reducing re-injury in ankle sprains, up to 60%, but not effective for first injury. Taping / bracing and neuromuscular training are effective but surprisingly to me bracing is MORE effective than neuromuscular training and neuromuscular training and bracing combined (reference).

Next up for me was one of my favourite presentations of the conference ‘Repair of meniscis and hyaline cartilage – is that at all possible?’ In a word, no! But there was some cool pics to describe what does go on. The hyaline cartilage is formed of collagen domes and it is these that provide the absorption. Collagen is not repaired or renewed in adults, in fact beyond the age of 16/17 that is what you have (reference). However these domes are filled with glycoaminoglycogens (GAGs), which attract water, you lose these in OA which means the domes almost ‘deflate’ but these can be renewed! What was even more interesting is these GAGs can be lost with a lack of loading! Sooo, reduced loading leads to softer cartilage which could increase the risk of a mechanical injury. Load that cartilage!!

 

There are of course some surgical options but nothing that produces hyaline cartilage beyond an osteochondral autograft. Microfracture produces fibrocartilage not hyaline cartilage.

That was really interesting to me. The presentation went on to add a few nice meniscal facts; the horns are most important to transfer the load; beware lesions of the meniscotibial ligament; 85% of load is transferred through the mensicus at 90 degrees of flexion; Running can increase GAGs (it’s good to run!) and the medial mensicus can’t move as much as the lateral therefore 75% of traumatic injuries are medial. Physio is recommended as the first point for meniscal injuries, particularly of the inner portion of the meniscus which is less vascularised and not surgically appropriate for suturing; once the meniscus is taken out or damaged the degradation process is sped up. Work with the patient, create the ideal ‘scaffold’ to allow the meniscus to heal.

Another keynote followed and this was a toss-up, the PFP boys were in the main hall and Seth O’Neill was talking muscles next door. I ran with what I probably see in clinic most at the mo and went with PFP. Michael Rathleff, Simon and Brad set off to explore biases in PFP homing in on biomechanics, exercise, education and load with the point being sometimes each of these works for a patient, perhaps in isolation, so what do we do? The Cochrane review (reference) was explored, which recommends exercise, but what exercise? A lot of the research doesn’t even deliver on what they are saying in terms of sets and reps. So what are we supposed to do? And that brings us back to N=1. We can work with recommendations but we need a good assessment and targeted planning in line with the patients goals and we need to educate++. Around 60% of patients in their study reported that they were still symptomatic at 12 months, so clearly we can’t just give exercises and clearly the ‘can’t go wrong, getting strong’ mantra isn’t enough, we need to do better.

This is a good time to give a nod to JF Esculier (@JFEsculier) and his excellent presentation and cool results. He looked at 69 runners with PFP in three intervention groups; education, education and exercises and education and gait re-training, and found…..no difference in interventions!

JF came second in the oral presentation competition so congrats for that…top bloke as well!

The content continued to flow and up came one of the men of the moment in Tim Gabbett, who it was great to meet and I look forward to seeing him at our basketball conference in April as well. He has brought some really key concepts around load into the physio world and we can learn a lot from applying them to our patient’s situation. Just remember when we talk load, that means everything; What the patient does every day, their lifestyle, their nutrition, their stresses and strains, everything can be their load.

So you have to be strong enough or fit enough to do what you want to do. I have been having this conversation for years with ‘manual’ workers who think their job keeps them fit. My argument is you have to train to do what you want, so build up those chronic loads! I won’t talk too much about this one as you can read all about it here, and here, and in this cool blog here. A cool graph for the clinic room (right) demonstrated how increasing load can lead to injury. Interestedly this increase in injury risk can be for up to 4 weeks! Also make sure your players get a good preseason, the more preseason sessions completed, the less likely players are to miss games in a season (Reference). Players have a responsibility to stay injury free, just as us general population do to keep fit and healthy, just read this article with Andy Carroll.

With injury, you want to try and maintain the chronic workload as best as possible, fairly obvious for athletes but this can also be applied to the general population and how it is important when taking them through rehabilitation phases as how often do they have pain, and then that goes but they develop pain somewhere else because they have deconditioned in that period?

The day finished with some apophyseal injuries in youth soccer player. Dr Amanda Johnson led the way with a presentation jam packed full of data collected from the Aspire Academy in Doha. The overarching fact was that there is 14% prevalence of growth related injuries in youth football (lower limb 89.4%), which lead to 28% of time missed, which is huge for some of these young footballers and their dreams of competing for a living. Interestingly it was the early maturers which got injured more, but a ‘growth spurt’ was not significant. A point to make here is be wary when working with this age group as there can be a 5 year spread in the same age group between their bone age, and ossification of the pubis can continue until aged 21 so be aware of apophyseal injuries in this age bracket as well. Per Holmich finished this session of with a few points on avulsion fractures, mainly that if you have avulsion of 2-3cm then surgery should be considered as an option and pain over the iliac crest is not always related to the abdominals, consider the posterior attachments of the gluts and also the tfl.

And that was day one wrapped, just about time for a quick shower and then some superb food and lovely beer and wine with a lot of great people! #physioelement

Day 2 started off with some injury prevention in athletics and a high injury rate in track and field was acknowledged (reference) with most being gradual onset injuries which eventually lead to championship injury (reference). Whilst this was happening I had to have a little look over to the other hall where tweets were popping up on ACL grafts in reconstruction. As we know there are only minor and insignificant difference in patella tendon and hamstring tendon groups however there was some data showing a greater return to sport in the short term with hamstring grafts (reference).

On the topic of hamstring grafts and back to the athletics, attention was turned to sprinting and the role of the hamstring. Horizontal force is key in sprinting and hamstring hip flexor strength is vital to rehab (reference). One to be aware of is that athletes can return to their top speed in sprinting but still have a deficit in horizontal force production, which could be an injury risk, so vital++ to efficiently test an athletes strength.

Second of the day was a jam packed hall for Claire Adern’s ‘Current concepts on return to play after AL injury’. Claire’s work is great and her papers have been out their for all to read for the last couple of years which I would highly recommend (check her out here). So there wasn’t a great deal new but it was great to hear her talk through it. She highlighted the return to play consensus (reference) and how this starts from the time the athlete gets injured and runs through three phases, (1) return to participation (2) return to sport (3) return to performance. Some stats on RTP after primary ACL reconstruction were next and with a return to pre-injury level at 65% and return to competitive sport at 55% (reference), the question is, is this really good enough? Or are we failing our athletes somewhere?

Psychological factors were highlighted as a key component, with those who are mentally ready getting back in a more timely fashion (reference) and there is a great app (here) for measuring this (ACL-RSI), do check it out!! Along with the latest evidence we have on  conservative vs surgery, and the latest on rehab.

There was there a few oral presentations to take in. All very good and do see my twitter (@bscanes) for notes on all of them, however for purpose of length I’m going to pick my favourite and that was MB Clausen’s (@mikkelBek) ‘Conservative treatment results for subacromial impingement patients’ who concluding that we are UNDER-loading our shoulder rehab patients! Get the weights out!

The next lecture generated some good discussion on Twitter over risk factors for ACL injury, in particular knee valgus. The presentation was lead by Greg Myer of Cincinnati who explored ACL injuries in female athletes, but I still feel we can’t be sure and other factors also contribute. So maybe it is a risk factor, but as with a lot of risk factors it leads to injury when you add other risk factors into the equation. A great question from Dylan Morrisey put it in to perspective when he asked why does a player get injured in that ‘valgus’ moment when they have moved that way many times? The answer was that it is often a higher risk moment….but then is that the risk factor and not the valgus, or is it them both. I think for now I’m going to continue to get splinters and sit on that fence. The most recent study is this, which found valgus is not a risk factor.

We then headed in to the oral presentations which was good fun. They all smashed it, the winner however was Merete Moller who nicely combined a study on load and risk factors in handball and generated a real good response from the audience not at least Tim Gabbatt, who gave a nod to these combination studies as the next to be done. The study found that load and weakness / dyskinesis was a higher risk than just the two alone.

And then we were done! Kinda, I had one more workshop I wanted to attend before my better half arrived in the morning to see the sights of Copenhagen, but this would be attended with some blurry eyes after a cracking night at the gala ball. Drinking beer (and the rest), talking physio, meeting physio legends and dancing the night away. Thank you Sports Kongres.

Day 3 and the final workshop was Jarrod Antflick and Lorenzo Masci, which for someone  who has just started ultrasound scanning was great (just got to get a scanner like their’s now so I can see clearly :)). This was on tendinopathy and imaging and explored the limitations of what we have; our traditional imaging can exclude/confirm tendon disease and do some differential diagnoses which Jarrod took us through but it cannot guide rehab or monitor treatment. Could this be because our modalities are not good enough though?

There was some case / anecdotal talk of poor and detrimental results from injections and we have to ask whether we really know what it does to tissue. However have we got anything else currently when physio is failing? The plantaris was also covered and I wonder if it is more prevalent than we think (well me anyway), and you can read more here and here. And the final point, presented with some great data, is the need to combine imaging with other data.

Annnnd done! That went on a lot longer than I thought! But what a fantastic conference. Inspiring and invigorating, and it makes you want to be back their next year…it makes you want to be involved! So much it may have even got me thinking about looking into doing some research. Sorry Phoebe (my ever so understanding wife to be).

See you next year Copenhagen.

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