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Anterior Cruciate Ligament (ACL) injuries are a common sports-related injury, often requiring surgical intervention. While traditional rehabilitation focuses on physical factors like strength and range of motion, emerging research highlights the importance of neurocognitive strategies in optimising recovery. By incorporating exercises that challenge both motor and cognitive functions, clinicians can enhance neuromuscular control, proprioception, and reaction time, ultimately reducing the risk of re-injury.

The Role of Neurocognitive Training

Neurocognitive training involves exercises that simultaneously engage both motor and cognitive functions. This approach helps to:

• Enhance Neuromuscular Control: By challenging the brain and body to coordinate complex movements, neurocognitive training improves the ability to control muscles and joints.
• Improve Proprioception: This training helps the body become more aware of its position in space, leading to better balance and coordination.
• Increase Reaction Time: By responding to unexpected stimuli, neurocognitive exercises enhance the ability to react quickly to changing situations.

Incorporating Neurocognitive Strategies into ACL Rehabilitation

Pre-Operative Phase:

• Early Intervention: Initiate neurocognitive exercises immediately following injury to minimise negative neuroplastic changes.
• Dual-Tasking Exercises: Combine functional tasks (e.g., gait training) with cognitive challenges (e.g., counting, memory recall) to enhance brain activation.
• Proprioceptive Training: Exercises like closed-eye joint repositioning and balance drills on unstable surfaces can improve sensory awareness.

Immediate Post-Operative Phase:

• Neuromuscular Electrical Stimulation (NMES): Utilize NMES to facilitate quadriceps activation, but combine it with cognitive tasks to increase neural demand.
• Visual Biofeedback: Employ EMG biofeedback to enhance voluntary muscle control, while incorporating cognitive challenges to further stimulate the brain.

Acute Phase:

• External Focus of Control: Encourage patients to focus on the effects of their actions (e.g., target a specific point on the floor) to improve motor learning.
• Progressive Balance and Coordination Drills: Gradually increase the complexity of exercises by adding unstable surfaces, visual distractions, and dual-tasking components.
• Gait Training: Emphasise proper gait mechanics and incorporate cognitive challenges, such as counting or reciting a phrase, to enhance neuromuscular control.

Intermediate Phase:

• Closed Kinetic Chain Exercises: Progress to more advanced exercises like lunges and step-downs, incorporating cognitive challenges and external perturbations.
• Reactive Training: Utilize tools like BlazePods to train rapid reaction times and agility.
• Sport-Specific Drills: Gradually introduce sport-specific movements, incorporating neurocognitive challenges to simulate real-world demands.

Conclusion

By incorporating neurocognitive strategies into ACL rehabilitation, clinicians can optimise patient outcomes and reduce the risk of re-injury. A comprehensive approach that addresses both physical and cognitive factors is essential for achieving optimal recovery and return to sport.

Want to take a deep dive into this paper? Read the full text paper here

A recent study by Herrington et al (2021) examined the quadriceps strength and hop performance of professional soccer players who had undergone anterior cruciate ligament reconstruction (ACLR) and were cleared to return to play.

This study provides valuable insights into the functional limitations experienced by these athletes and highlights the importance of comprehensive rehabilitation.

Study Details:

• Participants: 15 professional soccer players (age 22.3 ± 3.1 years)
• Assessments: Isometric, eccentric, and concentric quadriceps strength, quadriceps inhibition, and single and cross-over hop performance.
• Comparison: Performance was compared between the ACLR leg and the uninjured leg.

Key Findings:

• Significant Deficits: Despite being cleared for return to play, the ACLR leg demonstrated large significant deficits in isometric, eccentric, and concentric quadriceps strength, quadriceps inhibition, and hop distance.
• LSI Scores: Over 80% of the players failed to meet the limb symmetry criteria of ≥90% for strength tests, while 75% passed the ≥90% criteria for hop tests.
• Discrepancy between Strength and Hop Tests: This finding highlights the importance of assessing both functional tests and strength when evaluating return to sport, as hop tests alone may not accurately reflect underlying deficits.
• Potential Implications: Poor quadriceps function may increase the risk of ongoing knee symptoms and future ACL injuries.

Clinical Implications:

• Comprehensive Assessment: Physiotherapists should incorporate a battery of tests, including quadriceps strength, to assess a patient's readiness for return to sport.
• Prioritise Quadriceps Rehabilitation: Re-establishing full quadriceps activation and strength should be a priority in rehabilitation programs for ACLR patients.
• Long-Term Monitoring: Ongoing monitoring of quadriceps function may be necessary to identify and address potential issues.

Future Research:

• Larger Sample Sizes: Further studies with larger cohorts are needed to confirm and generalise these findings.
• Longitudinal Studies: Investigating the long-term impact of quadriceps deficits on sporting performance and the development of comorbidities is crucial.
• Rehabilitation Strategies: Research should explore the effectiveness of specific rehabilitation techniques and exercises in improving quadriceps strength and function.

Conclusion:

This study underscores the importance of addressing quadriceps strength and function in ACLR patients, even after they are cleared for return to sport.

By incorporating comprehensive assessments and targeted rehabilitation strategies, physiotherapists can help improve outcomes and reduce the risk of long-term complications.

Want to take a deep dive into this paper? Read the full text paper here

A recent study by Bramah et al (2019) investigated the effectiveness of increasing step rate by 10% in runners with patellofemoral pain (PFP) who exhibited abnormal hip and pelvis movement.

The researchers found that this simple intervention led to significant improvements in both running kinematics and clinical outcomes.

Key findings from the study included:

• Reduced frontal-plane pelvis and hip kinematics: Participants experienced a decrease in hip adduction and pelvic drop, which are known risk factors for PFP.
• Improved clinical outcomes: Pain levels decreased significantly, and running function improved, with participants increasing their weekly running volume and longest pain-free run.
• Neuromuscular benefits: The intervention likely improved neuromuscular control of the hip and knee, leading to better stability and reduced stress on the patellofemoral joint.

Clinical implications:

• Simple and effective intervention: Increasing step rate is a relatively easy and accessible treatment option for PFP.
• Personalised approach: The study emphasises the importance of assessing individual running kinematics to tailor interventions effectively.
• Potential for home-based rehabilitation: Participants in the study successfully self-monitored their step rate using a metronome app and GPS smartwatch, suggesting that home-based rehabilitation may be feasible.

While this study provides promising results, further research is needed to confirm the long-term benefits and to investigate the optimal step rate increase for different individuals.

However, the findings suggest that increasing step rate could be a valuable tool for physiotherapists treating runners with PFP.

Want to take a deep dive into this paper? Read the full text paper here

The role of cryotherapy in post-total knee arthroplasty (TKA) rehabilitation remains a topic of debate.

While it's commonly recommended, the optimal modality and timing of its application are unclear.

This recent RCT by Quesnot et al (2024) explores the effectiveness of compressive cryotherapy (CC) versus standard cryotherapy (SC) in improving knee range of motion (ROM), pain, and functional outcomes following TKA.

Study Objectives

The primary objective of the study was to compare knee ROM after 21 days of rehabilitation post-TKA between patients who underwent rehabilitation with CC and those who had SC. Secondary objectives included comparing other trophic, pain, and functional outcomes.

Key Findings

• Knee ROM: Both CC and SC groups showed significant improvements in passive knee flexion by day 21. However, CC patients reached the "healed" thresholds for passive knee flexion significantly faster than SC patients.
• Pain: Both groups experienced pain reduction, but CC was associated with faster reduction in pain at rest and more significant improvement in pain during activity.
• Trophic Parameters: CC group demonstrated more significant improvements in knee circumference measurements and joint effusion compared to SC group.
• Functional Outcomes: Both groups showed improvements in functional parameters (6MWT and KOOS), with CC group exhibiting slightly better results.

Implications for Clinical Practice

The study's findings suggest that both CC and SC can be beneficial in post-TKA rehabilitation.

However, CC may offer some advantages in terms of faster recovery of knee ROM, pain reduction, and improved trophic parameters.

Future Research

Further research is needed to confirm these findings and explore the long-term effects of CC versus SC on post-TKA outcomes.

Additionally, investigating the optimal timing and duration of cryotherapy application would be valuable.

Conclusion

While more research is required, the evidence from this study suggests that compressive cryotherapy may be a promising adjunct to rehabilitation for patients undergoing TKA.

It offers potential benefits in terms of improving knee ROM, reducing pain, and enhancing functional recovery. Physiotherapists can consider incorporating CC into their post-TKA rehabilitation programs, especially for patients seeking faster recovery and improved outcomes.

Want to take a deep dive into this paper? Read the full text paper here

Blood Flow Restriction (BFR) has emerged as a promising technique in rehabilitation, particularly for post-ACL surgery. By reducing blood flow to the muscles, BFR can induce metabolic stress, leading to increased muscle growth and strength without the need for heavy loads.

This study by De Melo et al (2022) investigated the effectiveness of BFR in post-ACL rehabilitation, focusing on muscle strength, function, and quality of life.

The study compared patients undergoing ACL reconstruction who performed rehabilitation exercises with BFR to those who used traditional resistance training.

The results demonstrated that BFR led to significant improvements in quadriceps and hamstring muscle strength, as well as overall knee function. Patients who used BFR reported less pain and experienced faster recovery times.

Key Findings:

• Enhanced muscle strength: BFR effectively increased both quadriceps and hamstring strength, even when using lower training loads.
• Improved function: Patients using BFR showed significant improvements in knee function, as measured by various outcome measures.
• Reduced pain: BFR was associated with lower levels of pain, leading to better patient experience and adherence to the rehabilitation program.
• Faster recovery: BFR may accelerate the recovery process after ACL surgery, allowing patients to return to activities more quickly.

Implications for Clinical Practice:

• Consider BFR for post-ACL rehabilitation: The findings of this study suggest that BFR can be a valuable tool for physiotherapists working with patients undergoing ACL reconstruction.
• Combine with traditional resistance training: BFR can be used in conjunction with traditional resistance training to optimise rehabilitation outcomes.
• Individualise treatment: The appropriate BFR protocol should be tailored to the patient's individual needs and goals.
• Monitor for safety: While BFR is generally safe, it is important to monitor patients for any adverse effects and ensure proper technique.

Future Directions:

• Larger studies: Further research with larger sample sizes is needed to confirm the findings of this study.
• Long-term outcomes: Investigating the long-term effects of BFR on ACL rehabilitation is essential.
• Comparison with other techniques: Comparing BFR to other rehabilitation interventions can provide valuable insights.

Conclusion

This study provides solid evidence for the effectiveness of BFR in post-ACL rehabilitation. By enhancing muscle strength, improving function, and reducing pain, BFR can contribute to faster recovery and better long-term outcomes for patients. Physiotherapists should consider incorporating BFR into their rehabilitation programs for patients with ACL injuries.

Want to take a deep dive into this paper? Read the full text paper here

A recent study by Engeroff et al (2023) has shed light on a potentially revolutionary approach to improving running economy: daily hopping exercises.

The research, conducted on amateur runners, found that incorporating short bouts of hopping into a training routine could lead to significant improvements in running efficiency, especially at higher speeds.

The study, published in Scientific Reports, involved participants engaging in six weeks of daily hopping exercises.

The results were promising: the runners experienced enhanced running economy and increased respiratory exchange ratio at faster running paces. This suggests that the hopping exercises helped them to use oxygen more efficiently while running.

Key findings from the study include:

• Improved running economy: Hopping exercises led to a more efficient use of oxygen during running, particularly at higher speeds.
• No impact on maximal aerobic capacity: While running economy improved, the study found no negative effects on overall aerobic fitness.
• Safe and effective: The hopping protocol was well-tolerated, with minimal discomfort reported by participants.

So, how does hopping improve running economy?

The researchers believe that hopping exercises may contribute to improvements in running economy through several mechanisms:

• Tendon stiffness: Hopping may increase tendon stiffness, which can help to store and release energy more efficiently during running.
• Energy storage: Hopping could enhance the storage and use of elastic energy in the tendons and muscles.
• Metabolic adaptations: The study suggests that hopping may lead to changes in metabolic pathways, such as increased reliance on carbohydrates for energy.

Implications for clinical practice

These findings have significant implications for physiotherapists working with runners. The study demonstrates that a simple, daily hopping routine can be a valuable addition to a training program, potentially helping runners to improve performance and reduce the risk of injuries.

Key takeaways for physiotherapists:

• Incorporate hopping into training programs: Consider recommending daily hopping exercises to runners seeking to improve their performance.
• Tailor the program to individual needs: The intensity and duration of hopping exercises can be adjusted to suit the runner's fitness level and goals.
• Monitor for discomfort: While the study found hopping to be generally safe, it's important to monitor for any signs of pain or discomfort.

As with any new training approach, it's essential to consult with a healthcare professional before starting a hopping program.

By understanding the potential benefits and risks, physiotherapists can help runners safely and effectively incorporate this innovative technique into their training routines.

Want to take a deep dive into this paper? Read the full text paper here

A new study by Collings et al (2023) has shed light on the most effective exercises for targeting and strengthening the gluteal muscles.

By using motion capture, ground reaction forces, and electromyography, the research team were able to quantify the forces generated by the gluteus maximus, medius, and minimus during various hip-focused exercises.

Key Findings:

Exercise Specificity: The gluteal muscles are activated differently in various exercises, suggesting that a well-rounded routine is necessary for optimal strength and function.

External Resistance: Adding external resistance (e.g., weights, bands) can significantly increase gluteal muscle forces, making it a valuable tool for enhancing strength and performance.

Muscle Activation and Fiber Length: Peak muscle force often coincides with maximum fiber length, highlighting the importance of considering muscle mechanics in exercise selection.

Top Exercises for Gluteal Strength:

Gluteus Maximus: Loaded split squat, loaded single-leg RDL, loaded single-leg hip thrust

Gluteus Medius: Body weight side plank, loaded single-leg squat, loaded single-leg RDL

Gluteus Minimus: Loaded single-leg RDL, body weight side plank

Implications for Physiotherapy Practice:

Tailored Exercise Programs: The study's findings can help physiotherapists design more targeted and effective exercise programs for patients with gluteal weakness or dysfunction.

Injury Prevention: Strengthening the gluteal muscles can help prevent injuries such as anterior knee pain, low back pain and hip pain.

Performance Enhancement: For athletes and individuals seeking to improve performance, incorporating these exercises into their training routine can be beneficial.

By understanding the unique activation patterns of the gluteal muscles and the impact of external resistance, physiotherapists can provide their patients with evidence-based recommendations for strengthening and optimising gluteal function.

Want to take a deep dive into this paper? Read the full text paper here

Understanding Hamstring Engagement

This study by van den Tillaar et al (2017) delved into the effectiveness of various hamstring strengthening exercises compared to the demands of a maximal sprint. The primary goal was to determine the extent to which these exercises activate the hamstring muscles.

Key Findings:

• Hamstring Activation During Sprints: Maximal sprint activities resulted in the highest muscle activation for the semitendinosus and biceps femoris. For the semimembranosus, only the laying kick matched the sprint's activation level.

• Exercise Effectiveness: While the Nordic hamstring exercises and laying kick demonstrated significant hamstring activation, they generally fell short of the levels observed during sprinting.

• Exercise Variations: Modifications to the Nordic hamstring exercise, such as adding a return or bump, did not substantially increase hamstring activity.

• Joint Angles: The hip angles at which peak hamstring activity occurred varied between exercises, potentially influencing their effectiveness.

Implications for Hamstring Strengthening:

• Nordic Hamstring Exercises: Despite lower overall activation compared to sprinting, Nordic hamstring exercises remain valuable for strengthening the hamstrings, particularly the semitendinosus - which is very important for those with a past history of ACLR with a hamstring graft.

• Laying Kick: While promising, further research is needed to determine the optimal execution of the laying kick for maximum hamstring activation and potential benefits in injury prevention.

• Exercise Variation: Modifications to exercises like the Nordic hamstring may not always result in increased activation. Careful consideration of joint angles and movement patterns is crucial.

Future Research:

• Exercise Variations: Investigating additional variations of Nordic hamstring exercises, such as one-legged versions, could provide further insights into their effectiveness.

• Laying Kick Refinement: Exploring the impact of different knee angles and weight variations in the laying kick may optimize its effectiveness for hamstring strengthening.

By understanding the nuances of hamstring activation during various exercises and sprints, physiotherapists can better tailor rehabilitation and injury prevention programs for their patients.

Want to take a deep dive into this paper? Read the full text paper here

Sleep is often overlooked in the demanding world of collegiate athletics. However, it's a critical factor influencing performance, mental health, and overall well-being.

This great review by Kroshus et al (2019) delves into the importance of sleep for collegiate athletes, exploring its impact on various aspects of their lives and offering practical recommendations for improvement.

Although this review was centred around the importance of improving sleep quality and duration in college athletes, the themes and recommendations can and should be applied to the general adult population.

The Importance of Sleep for Collegiate Athletes

Physical Performance: Adequate sleep is essential for optimal athletic performance. It aids in muscle recovery, improves reaction time, and enhances overall energy levels.

Mental Health: Sleep disturbances can contribute to anxiety, depression, and mood swings. Prioritising sleep can significantly improve mental health outcomes for collegiate athletes.

Academic Performance: Sufficient sleep is linked to better academic performance, as it enhances concentration, memory, and problem-solving abilities.

Injury Prevention: Lack of sleep can increase the risk of injuries due to decreased reaction time and impaired judgment.

Challenges to Sleep in Collegiate Athletes

Demanding Schedules: The combination of academic responsibilities, athletic training, and social commitments can make it difficult for collegiate athletes to maintain consistent sleep schedules.

Poor Sleep Hygiene: Common sleep hygiene mistakes, such as excessive screen time before bed, irregular sleep patterns, and caffeine consumption late in the day, can hinder sleep quality.

Environmental Factors: Loud and crowded dorm rooms can disrupt sleep, making it challenging to achieve restful nights.

Recommendations for Improving Sleep in Collegiate Athletes

Prioritise Sleep: Establish a regular sleep schedule and stick to it as much as possible, even on weekends.

Create a Sleep-Conducive Environment: Ensure your bedroom is dark, quiet, and cool.

Limit Screen Time: Reduce exposure to electronic devices before bed, as the blue light emitted can interfere with sleep.

Establish a Relaxing Bedtime Routine: Engage in calming activities like reading or taking a warm bath before bed.

Manage Stress: Explore stress management techniques such as meditation, deep breathing, or yoga to improve sleep quality.

Limit Caffeine and Alcohol: Avoid caffeine and alcohol, especially close to bedtime, as they can disrupt sleep.

Seek Professional Help: If you're struggling with chronic sleep issues, consult a healthcare professional for advice and potential treatment options.

By prioritising sleep and implementing these recommendations, all adults and athletes can significantly improve their overall well-being, academic/work performance, and athletic abilities.

Want to take a deep dive into this paper? Read the full text paper here

Golf, like any sport, carries the risk of injury.

While warm-up programs have been shown to reduce injury risk in various sports, their effectiveness in golf remains under scrutiny.

To address this, researchers Gladdines et al (2024) developed the Golf Related Injury Prevention Program (GRIPP) and sought to optimise its implementation through effective instruction methods.

A pilot study was conducted to compare different instruction methods for GRIPP exercises: instructional cards, instructional videos, and a combination of both.

This study found that golfers who received instructional videos, either alone or with cards, performed significantly better than those who received only cards.

The Benefits of Video Instruction

• Enhanced Motor Learning: Visual cues from videos can significantly improve motor learning, helping golfers grasp complex movements more easily.
• Reduced Trial and Error: Observing a model in a video can minimize the need for trial-and-error, leading to faster and more efficient learning.
• Improved Exercise Fidelity: By providing clear visual demonstrations, video instructions can ensure that golfers perform exercises correctly, maximizing their benefits.

Implications for Physios

The findings of this study have important implications for physiotherapists working with not only golfers - but all patients and athletes!

By incorporating video instructions into injury prevention programs and rehab programs, physiotherapists can:

• Improve Patient Adherence: Engaging and informative videos can make it easier for patients and athletes to understand and follow their exercise routines.
• Enhance Treatment Outcomes: Correct exercise performance is crucial for achieving optimal results. Video instructions can help ensure that your patients and athletes are performing exercises as intended.
• Streamline the Rehabilitation Process: By providing clear guidance, video instructions can reduce the need for frequent in-person sessions, saving time and resources for both patients and therapists.

As the study demonstrates, the choice of instructional method can significantly impact the effectiveness of injury prevention programs.

By leveraging the power of video instruction, physiotherapists can help not only golfers (but all patients and athletes) stay healthy and improve their performance.

Want to take a deep dive into this paper? Read the full text paper here

Returning to sport (RTS) after an ACL reconstruction (ACLR) is a complex challenge - and Wouter Welling PhD knows very well just how challenging the ACLR rehab environment is.

Wouter has put pen to paper and written a great narrative piece of the current state of play in ACLR rehab land, and what things we need to do improve outcomes with our ACLR athletes - with the below paragraphs being an executive summary of the key recommendations that Wouter has put forward in his his 2024 paper.

• While traditional rehabilitation focuses on strength, balance, and movement, it often falls short of preparing athletes for the demands of their sport.
• On-field rehabilitation is crucial to bridge the gap between clinic and competition. Wearable technology and neurocognitive training can enhance the rehabilitation process. Understanding that ACL injury affects not just the physical body but also the brain is essential.
• Psychological factors play a significant role. Fear of reinjury and a positive rehabilitation environment are key. Treating the ACL injury as a neurological challenge alongside a physical one is a new frontier.
• The RTS journey is not linear. A dynamic, individualized approach is necessary. Monitoring progress with repeated testing and using GPS data to manage training load are essential tools.

While challenges remain, progress is being made. By combining physical, psychological, and neurological aspects of rehabilitation, we can optimise outcomes for ACLR patients.

Key takeaways:

• Traditional rehab is insufficient
• On-field rehab is crucial
• Psychological factors matter
• ACL injury affects the brain
• Individualised approach is essential

Want to take a deep dive into this paper? Read the full text paper here

Pre-op rehab, or prehab, has gained traction as a key component in optimising outcomes for patients undergoing Anterior Cruciate Ligament Reconstruction (ACLR).

Recent evidence from Giesche et al (2020) highlights both preoperative and postoperative benefits of this approach, with implications for improving functional performance, neuromuscular symmetry, and self-reported knee function.

Prehab and Functional Performance

Low to moderate quality evidence suggests that prehab positively impacts functional performance both before and after ACLR.

This approach appears to enhance self-reported knee function at multiple time points: pre-reconstruction, three months post-surgery, and even two years after the procedure.

Prehab has also been associated with higher rates of return to sport (RTS) and a trend towards a shorter time to achieve RTS.

Quadriceps Strength and Limb Symmetry

The effects of prehab on quadriceps strength and limb symmetry index (LSI) show mixed results.

Some studies report superior outcomes in quadriceps peak torque LSI preoperatively and at three months post-ACLR, suggesting that prehab can improve strength symmetry between the injured and uninjured limbs.

Conversely, other studies find no significant differences, possibly due to improvements in both limbs' strength, thereby maintaining baseline asymmetries.

Single-Leg Hop Performance

Single-leg hop tests are crucial for assessing knee function and are highly reliable for ACL-injured individuals.

Studies indicate that prehab improves single-leg hop for distance LSI at three months post-surgery compared to control groups.

This enhancement reflects better leg strength, neuromuscular control, and confidence in knee stability.

However, while prehabilitation shows promising trends, its effects on single-leg hop performance may not always reach minimal detectable change thresholds.

Self-Reported Knee Function

Prehab has shown beneficial effects on self-reported knee function, with significant improvements in Lysholm, Cincinnati, and International Knee Documentation Committee (IKDC) scores from baseline to pre-surgery and beyond.

These scores indicate better perceived knee function and quality of life post-surgery.

The association between improved preoperative neuromuscular performance and better postoperative self-reported outcomes underscores the value of prehab in preparing patients for surgery and recovery.

Return to Sport and Prehab Programs

Studies suggest that prehab may lead to higher RTS rates and a shorter time to RTS, aligning with improved functional outcomes and self-reported knee function.

Prehab programs, despite variations in frequency, intensity, and supervision, generally involve muscle control, co-contraction exercises, strength training, and advanced neuromuscular and plyometric exercises.

High compliance and low dropout rates suggest that prehab is safe and feasible for ACL-injured patients.

Clinical Implications

For physically active adults with ACL injuries awaiting reconstruction, prehab offers promising benefits. It helps in reducing the decline of postoperative neuromuscular performance, improves self-reported knee function, and may enhance RTS outcomes.

Although high-quality randomized controlled trials are needed to confirm these findings and assess the impact on re-injury rates, current evidence supports the incorporation of prehab into preoperative care strategies.

Want to take a deep dive into this paper? Read the full text paper here

Golf, despite its popularity, is associated with a significant risk of injury.

While injury prevention programs have been successful in other sports (Soccer, ALF, Netball), there's a notable gap in golf-specific research.

This thoughtful review by Thomas & Wilk (2023) introduces three progressive exercise programs designed to address this gap.

The Challenge Golfers often suffer from overuse injuries due to the repetitive nature of the swing. Traditional strength and conditioning programs may not adequately target the specific demands of golf. Moreover, there's a lack of consensus on effective injury prevention strategies for golfers.

The Solution The article presents a series of three progressively challenging exercise programs: The Golfer’s Fore, Fore+, and Advanced Fore+. These programs focus on:

• Mobility: Targeting key areas like shoulders, thoracic spine, and hips.
• Strength: Building overall strength and stability, with a particular emphasis on the core and lower body.
• Core activation: Enhancing core stability, crucial for power generation and injury prevention.

The exercises are designed to be accessible, using primarily body weight and resistance bands. They can be adapted to suit golfers of all levels and incorporated into warm-up routines or as standalone programs.

Key Benefits By implementing these programs, golfers can expect to:

• Reduce the risk of golf-related injuries
• Improve strength, mobility, and core stability
• Enhance swing efficiency and performance

Call to Action While more research is needed in this area, these exercise programs offer a valuable starting point for physiotherapists working with golfers. Consider incorporating these exercises into your patient care plans to help golfers stay healthy and improve their game.

Want to take a deep dive into this paper? Read the full text paper here

This meta-analysis by Ramirez-Campillo et al 2020 confirms that Plyometrics effectively enhances vertical jump height in volleyball players compared to control groups.

This finding aligns with previous research. However, the magnitude of improvement varied significantly across studies.

Frequency, Duration, and Volume Impact Vertical Jump Height Minimally

Surprisingly, the frequency, duration, and total volume of Plyo sessions had little impact on jump height gains.

This suggests that the content of individual sessions, rather than their frequency or duration, is more crucial. Ie. QUALITY > QUANTITY

While low to moderate Plyo volumes are effective, excessive jumps could increase injury risk, especially in females.

Intensity and Jump Type Remain Unclear

A significant limitation of this meta-analysis is the inconsistent reporting of Plyo intensity.

Optimal Plyo intensity and jump type for volleyball players remain undetermined. Future research should prioritise this area.

Practical implications:

• Plyometrics is beneficial for volleyball players: Incorporate Plyos into training programs to improve vertical jump height.
• Moderate volume and frequency are sufficient: Aim for approximately 40-160 jumps per session and 2-3 sessions per week.
• Individualize Plyos: Consider player position and load tolerance, especially for players like liberos.
• Monitor Vertical Jump Height and jumping technique: Track vertical jump height progress and assess for changes in jumping strategy to identify potential injury risks.
• Plyometrics are part of a broader training plan: Combine Plyos with other physical fitness components for optimal athlete development.

Limitations of this review:

The number of high-quality studies on Plyometrics in volleyball players is limited. Additionally, the meta-analysis relied on dichotomising continuous data, which could reduce statistical power. Future research should address these limitations by conducting more rigorous studies with detailed reporting of training parameters.

In conclusion, Plyometrics are a valuable tool for enhancing vertical jump height in volleyball players.

While further research is needed to optimize Plyo programs, the findings of this meta-analysis provide practical guidance for physiotherapists working with volleyball athletes.

Want to take a deep dive into this paper? Read the full text paper here

A new study by Dong et al (2024) has revealed the superior benefits of Jumping Interval Training (JIT) over High-Intensity Interval Training (HIIT) for young female gymnasts.

This research compared the impact of both training methods on aerobic, anaerobic, and jumping performance.

The Study

The study involved 73 young gymnasts who were divided into three groups: a control group, a JIT group, and a HIIT group.

The experimental groups engaged in two additional training sessions per week, while the control group continued their regular training.

Both JIT and HIIT sessions were designed to last 4-5 minutes and were conducted twice a week for eight weeks.

JIT focused on maximal continuous bilateral countermovement jumps, while HIIT involved running-based exercises.

See Table 2 in full text paper for JIT and HIIT programs

Key Findings

• Both JIT and HIIT significantly improved aerobic and anaerobic performance compared to the control group.
• JIT demonstrated superior results in enhancing jumping performance compared to both HIIT and the control group.
• The study suggests that JIT can be a valuable addition to the training regimen of young gymnasts to improve overall athletic performance.

Why JIT is Effective?

JIT's effectiveness in enhancing jumping performance can be attributed to its specific biomechanical and neuromuscular demands.

The exercises involved in JIT target the stretch-shortening cycle, which is crucial for explosive power and jump height.

Implications for Physiotherapists

These findings have significant implications for physiotherapists working with young gymnasts.

By incorporating JIT into training programs, physiotherapists can help athletes improve their overall physical fitness, reduce injury risk, and enhance performance.

It's important to note that while this study provides valuable insights, further research is needed to explore the long-term effects of JIT and to determine optimal training parameters for different age groups and skill levels.

Want to take a deep dive into this paper? Read the full text paper here

An important study has revealed the effectiveness of a simple, time-efficient neck-strengthening program in significantly improving neck strength among young rugby players.

Given there is growing evidence that performing neck-strengthening exercises as part of a warm-up, or within strength and conditioning sessions has been associated with fewer head and neck injuries, including concussion; and not to mention that higher neck strength has also been associated with reduced concussion in high school athletes - it makes complete sense to have a simple and effective program that is available for all rugby players to do without the need for equipment.

Attwood et al (2022) compared a group of U18 rugby players who performed three weekly sessions of self-resisted neck exercises for eight weeks with a control group.

The intervention involved holding short, maximal contractions in various neck directions (see full text paper link below for program).

The results were impressive, with the intervention group demonstrating a substantial 24% increase in overall neck strength compared to the control group.

This low-cost, easily implementable program offers a promising approach to reducing neck injury risk in athletes.

Key findings:

• Self-resisted neck exercises effectively increased neck strength in young rugby players.
• The program was simple, time-efficient, and required no specialized equipment.
• Increased neck strength has been linked to a lower risk of head and neck injuries.

Conclusion:

This study provides compelling evidence for the inclusion of neck-strengthening exercises in training regimens for athletes across various sports. By addressing a critical factor in injury prevention, physiotherapists can play a vital role in safeguarding athlete well-being.

Want to take a deep dive into this paper? Read the full text paper here

A ground-breaking study by Sammoud et al (2019) revealed that incorporating plyometric jump training (PJT) into the training regimen of young male swimmers can significantly enhance both power and swimming performance.

This research compared plyometrics + swimming training to swimming training-alone in prepubertal boys.

Participants were randomly assigned to either a plyometric group (PJT) or a control group.

Both groups undertook six training sessions per week, with the PJT group integrating two plyometric sessions into their routine (see full text link below for full PJT program).

A preparatory strength endurance phase preceded the study for all participants.

Key findings:

• Enhanced power: The PJT group exhibited substantial improvements in jump height and distance compared to the control group, demonstrating the effectiveness of plyometrics in boosting muscle power.
• Improved swimming performance: Swimmers in the PJT group showcased significant advancements in various swimming distances compared to the control group, highlighting the positive impact of plyometrics on in-water performance.

While the exact mechanisms underlying these improvements require further investigation, it is believed that plyometrics contribute to enhanced neural drive, muscle coordination, and power output.

Implications for physiotherapists:

These findings strongly support the inclusion of plyometrics in the training programs of young swimmers.

By incorporating PJT, physiotherapists can help young athletes optimise their performance and reduce the risk of injuries.

Limitations and future research:

While this study provides valuable insights, it is essential to acknowledge its limitations, including sample size and the absence of physiological measurements.

Future research should explore the long-term effects of PJT and delve deeper into the underlying mechanisms responsible for performance enhancements.

By understanding the benefits of plyometrics and addressing potential limitations, physiotherapists can effectively guide young swimmers towards achieving their full potential.

Want to take a deep dive into this paper? Read the full text paper here

This nice pilot study by Behan et al (2023) investigated the Single-leg Romanian Deadlift (SLRDL) as an alternative to the Nordic Hamstring Exercise (NHE) for preventing hamstring injuries in athletes.

Hamstring injuries are a major concern in sports, and while NHE programs have proven effective, compliance can be low.

Here's a breakdown of the key findings:

• SLRDL shows promise: Both NHE and SLRDL exercises significantly improved performance on a hamstring strength test (SLHB) after a 6-week program (performed 2x per week). This suggests SLRDL could be as effective as NHE in reducing hamstring injury risk.
• The Program: Both NHE & SLRDL started at 2sets of 5reps in week 1 and progressed to 3x12 by week 6 (See Supplementary1 at the full text paper link below).
• Remote delivery is feasible: The entire program, including exercise instruction and monitoring, was conducted remotely via video conferencing. This approach may offer greater flexibility and convenience for athletes.
• Muscle soreness not a barrier: Both exercises caused minimal muscle soreness, with no significant difference between them. This addresses a potential reason for poor compliance with NHE programs.
• Limitations: The study didn't assess other hamstring injury risk factors or future injury rates. Additionally, it lacked blinded assessment and measures of exercise intensity.

Overall, the study suggests SLRDL as a viable alternative to NHE for hamstring injury prevention.

Key Takeaways:

• SLRDL can offer a valuable tool for hamstring injury prevention programs, especially for athletes with low adherence to NHE.
• Remote delivery via video conferencing can be a practical and cost-effective approach for implementing these programs.
• Further research is needed to explore the long-term effects of SLRDL on hamstring injury rates and to compare exercise intensity between NHE and SLRDL.

Want to take a deep dive into this paper? Read the full text paper here

It's well-known that ACL injuries and subsequent surgeries significantly impact quadriceps and hamstring strength - by 10-20% at 12 months post-op in most studies.

However, the long term impact on other lower limb muscles, such as the hips and calves, is less clear.

A recent systematic review by Girdwood et al (2024) has shed new light on this topic.

Surprisingly, the research found no consistent evidence of widespread hip or calf muscle weakness following ACL reconstruction at 12 months post.

Implications for Rehab

While the findings are intriguing, it's important to note that the evidence is still developing.

The review found considerable variability in the data, and more research is needed.

Nevertheless, these results suggest that a blanket approach of intense hip and calf muscle strengthening might not be necessary for all ACL patients.

Instead, clinicians should individualise treatment and tailor rehabilitation accordingly.

For example, a young ACLR athlete who has a strong desire to return to running, jumping, pivoting and change of direction sports (and has the luxury of time); you would address calf and hip musculature in the first 6 post-op months along with quads, hams to ensure a timely and smooth transition back into running, jumping and sport specific training.

Meanwhile, an older busy mum or dad who is going through ACLR rehab, who has limited time to dedicate to rehab, you would prioritise quads and hamstrings and prescribe hip and calf strengthening as "bonus" exercises

Key Takeaways

• Hip and calf muscle weakness at 12 months post-op is not as prevalent after ACL injury as previously thought.
• Individualised assessment is crucial for determining specific rehabilitation needs.

Future Directions

Further research is needed to explore the long-term implications of these findings.

Understanding how factors like age, activity level, and the specific nature of the ACL injury impact hip and calf muscle strength is essential.

Additionally, investigating the potential benefits of targeted hip and calf muscle strengthening for specific patient populations would be valuable.

By shifting our focus and tailoring rehabilitation efforts based on individual needs, we can optimise outcomes for patients recovering from ACL injuries.

Want to take a deep dive into this paper? Read the full text paper here

This study by Warden et al (2022) investigated whether participating in multidirectional sports (MDS) during youth influences bone health in female collegiate cross-country runners. Bone stress injuries (BSIs) are a common concern for these athletes, and stronger bones could potentially reduce their risk.

The investigation:

• Female collegiate runners were divided into two groups:
• RUN: Trained/competed only in cross-country, running/jogging, swimming, or cycling.
• RUN+MDS: Had an additional history of playing soccer or basketball when younger (history of training and/or competing in either soccer or basketball twice or more per week for at least 6 months per year for ≥5 years beginning prior to 10 years of age).
• Researchers used high-resolution CT to examine bone properties at various locations in both legs and arms.
• Key areas in the legs were tibia/fibula, metatarsals and navicular
• The radius bone of the arm served as a reference point.

The findings:

• Stronger bones in RUN+MDS:
• Compared to the RUN group, runners with a history of MDS in their youth displayed:
• Stronger and thicker Tibia cortex and more internal bone (trabeculae).
• Larger and stronger Fibula.
• Larger and stronger second Metatarsal (MT) bone.
• Improved bone properties at high-risk BSI sites in the foot (base of the 2nd MT, Navicular and proximal diaphysis of the 5th MT)
• The strength enhancements ranged from an average of 11.1% at the Fibula diaphysis to 19.5% at the distal Tibia

The takeaway:

This study suggests that playing multidirectional sports like soccer or basketball when young (before and across their pubertal growth period) may contribute to stronger bones later in life for female runners. This could potentially help to reduce their risk of developing BSIs. The researchers recommend that young athletes delay specialising in just one sport (like running) and consider including MDS in their training to promote bone health.

Important to note:

• This study only looked at female athletes.
• The design doesn't prove cause-and-effect, just an association.
• The study involved a relatively small group of participants.

Want to take a deep dive into this paper? Read the full text paper here

This cohort study by Forelli et al (2023) investigated the effectiveness of incorporating Open Kinetic Chain (OKC) exercises into rehabilitation programs following Anterior Cruciate Ligament Reconstruction (ACLR), and compared a program combining closed kinetic chain (CKC) and OKC exercises with a program solely using CKC exercises.

The Study Design

• 103 recreational athletes who underwent ACLR using hamstring grafts participated.
• Patients were divided into two groups:
• Control group: CKC exercises only.
• Intervention group: Combined CKC and OKC exercises.
• OKC exercises were introduced in the intervention group 4 weeks after surgery.
• Both groups underwent rehabilitation for 6 months and were assessed at 3 and 6 months post-surgery.

Key Findings

• The intervention group showed significantly greater quadriceps and hamstring strength at 3 and 6 months compared to the control group.
• There was no significant difference in graft laxity (looseness) between the groups.
• This suggests that OKC exercises are safe and effective for improving muscle strength after ACLR.

Safety of OKC Exercises

• This study aligns with previous findings that CKC and OKC exercises produce similar strain on the ACL.
• Early introduction of OKC exercises seems safe when implemented with 60% 1RM loading protocols.

Limitations of the Study

• The control group's rehabilitation program couldn't be directly controlled by the researchers.

Conclusion

This study supports the early introduction of OKC exercises in ACLR rehabilitation programs. Combining CKC and OKC exercises led to better muscle strength recovery compared to CKC exercises alone, without compromising graft integrity. Future research could explore the psychological aspects of recovery alongside these physical interventions.

Want to take a deep dive into this paper? Read the full text paper here

This brilliant and recent article by Rush et al (2024) highlights the importance of analyzing take-off mechanics during single-leg hop tests (SLHD) for patients recovering from anterior cruciate ligament reconstruction (ACLR).

Traditionally, focus has been placed on hop distance and symmetry between limbs or LSI.

However, this study suggests that how patients generate movement during take-off provides crucial information about quadriceps function and potential compensatory strategies that may put them at risk of further injury - most commonly, their currently healthy, uninjured limb.

Key Takeaways for Physios:

• Knee Underloading: Patients with ACLR may exhibit lower peak knee flexion angles, moments, and power absorption during take-off compared to the uninvolved limb and healthy controls. This suggests the quadriceps may not be fully recovered or patients may be avoiding knee flexion to compensate for weakness.
• Quadriceps Strength Matters: Lesser quadriceps strength symmetry is associated with altered take-off mechanics, including reduced knee loading and potentially greater trunk flexion to shift the center of mass and help them jump/hop easier.

Incorporating These Findings into Practice:

• Include looking at take-off mechanics either by force plate or video analysis during single leg hop assessments for ACLR patients.
• Develop rehabilitation programs that address quadriceps weakness (especially in isolation) and any compensatory strategies identified during take-off analysis.
• Don't assume that the person has a strong quad with they can single leg squat or single leg leg press a heavy load - ACLR patients are great at cheating through the hip during "functional" tasks.
• Train patients to properly load the involved knee during single-leg exercises to prepare them for more demanding activities.

By targeting the quad in rehab and taking a more comprehensive approach to hop testing evaluation, physiotherapists can gain valuable insights into how ACLR patients generate movement and develop more effective rehabilitation strategies to optimize long-term joint health and function.

Read the full text paper here

This tremendous accumulation of work by Van Melick and colleagues that covers normative values for isokinetic quads and hamstring strengthening has now just recently been beefed up with jump and hop normative data for ACLR athletes.

If you're like me and unfortunately don't get to see many ACL patients before surgery, knowing what similar athletes at the same age, same sport and same sport level can achieve in terms of strength values and jump/hop values can at the time of their return to sport can allow us to make better clinical decisions in guiding our ACLR back to sport safely and at the right time.

For example, if you go to the ACL Reference Values website you'll see that you can click on Basketball as a pivoting sport, then you can click on female elite, then you can click on 20-35yrs of age, and then you can the normative data for ACLR patients for different isokinetic tests and speeds for quads and hamstring strength as well as normative hop test distances for a variety of hop tests.

It is so well done, and the best thing it is free to use - so get using it if you see ACL patients in the return to sport phase of their journey and you don't have pre-op data to compare their post-op results to.

Just to be clear - the ACL reference values website you need to go to is here

The study by Baektoft van Weert et al 2023 investigated the efficacy of external focus (EF) compared to internal focus of attention (IF) for improving jump-landing technique in patients who had undergone ACL reconstruction. Internal focus cues typically instruct patients to focus on specific body mechanics during movement, while external focus cues encourage them to concentrate on an external target or outcome of the movement.

The researchers divided participants into two groups. One group received instructions with an EF focus, where they were asked to focus on jumping "as high as possible" towards a target. The other group received instructions with an IF focus, where they were instructed to focus on minimizing knee valgus (collapse inward) during landing. Both groups underwent a six-week jump-landing training program.

The study found that the group receiving EF instructions demonstrated significantly better jump-landing technique compared to the IF group. Specifically, the EF group exhibited less knee valgus, reduced trunk flexion, and a more symmetrical landing pattern. These findings suggest that incorporating EF cues into rehabilitation programs may lead to improved neuromuscular control and movement patterns during jumping and landing tasks.

Practical Applications for Physiotherapists

The findings of this study suggest that physiotherapists can leverage EF cues as a valuable tool to enhance jump-landing rehabilitation programs for patients recovering from ACL reconstruction.

Here are some tips for incorporating EF into your practice:

• Shift the focus from mechanics to outcomes. Instead of instructing patients to focus on minimizing knee valgus, for example, encourage them to concentrate on jumping high or landing softly on a target.

• Use clear and concise language. Provide patients with simple and easy-to-understand instructions regarding the external target or outcome they should focus on.

• Provide visual cues. When possible, incorporate visual targets such as cones or hoops to further reinforce the EF focus.

By incorporating EF cues into rehabilitation programs, physiotherapists can potentially help patients achieve better jump-landing mechanics, improve neuromuscular control, and ultimately promote a safe and successful return to sport following ACLR

Read the full text paper here

This study by Vermeulen et al 2021 investigated whether starting hamstring lengthening exercises (eccentric strengthening) earlier during rehab improves recovery for male athletes with acute hamstring injuries.

Methods:

• 90 male athletes with MRI-confirmed hamstring injuries were split into two groups.
• One group began lengthening exercises on day 1 of rehab, while the other started after regaining 70% running speed.
• Both groups followed a standard rehab program.
• Researchers tracked time to return to full training/play (primary outcome) and reinjury rates (secondary outcome).

Results:

No significant difference in return to sport time:

• Early lengthening: 23 days (median)
• Delayed lengthening: 33 days (median)
• No difference in reinjury rates at any point within 12 months after return to sport.

Conclusion:

Adding lengthening exercises early in rehab for hamstring injuries doesn't speed up recovery or decrease reinjury risk in male athletes. But goes to show that hamstrings can tolerate more loading earlier in rehab than what was previously thought - and can be seen as a positive to maintain important eccentric strength properties of the musculature.

Read the full text paper here