Prevention Vs Performance: Managing Demands of Elite Athletes

shutterstock_30117232.jpgDespite the large amount of knowledge we now have regarding injury prevention of athletes, the shear amount of non-contact injuries that occur each year can be alarming. The balancing act between allowing an athlete to perform at an elite level and keeping them in a rehabilitation program for an extra couple of days can be a decision that keeps the medical team up at night. There are many factors which can contribute to a decision such as this and being pain free is not always a necessity. It has been found that an athlete’s performance will increase with volume and intensity increases, however, with these factors also comes the increased risk of injury. It has been found that an athlete is
seventy times more likely to suffer injury if they exceed their individual weekly training threshold. The following article looks to answer some questions in how the medical team may deal with the manipulation and interpretation of an athlete’s load during the during pre, inter and post season.

Pre-season training for elite clubs, is the strength and conditioning programs designed to prepare athletes for an entire competitive season and not just an individual event. For amateur clubs the pre-season may be used for maintenance of fitness in the post season.
The development of a well-planned pre-season training program can lead to a decrease in injury risk, increase in mental strength and condition the body for the cues and contacts of a game. The old adage of “train smarter not harder” has changed with the recent evidence produced by Tim Gabbett and Peter Blanche, with the new spin stating: “Train Smarter, Train Hard”.
The premise being that completing short hard training sessions is more beneficial to athletes than those of a longer duration which has the potential to increase injury risk. Training hard with a vehicle like High Speed Running helps to protect physical qualities of an athlete. However, a well-planned pre-season can only be as well planned as the measurement of the athletes load during that pre-season.

Measuring Loads
There are a number of different ways that load can be measured both subjectively and objectively and all with their own pros and cons.

One such way of measuring an athletes training load is through the use of the Acute: Chronic Workload Ratio. The chronic workload is measured over a four week rolling average, while an acute workload can be anything from one training session to one week, depending on the fatigue level of the athlete. The ratio known as the “sweet spot” is between 0.8 and 1.3, this is further supported by the rule of “10% volume increase” which would produce a 1.1. The “Danger Zone” in the Acute: Chronic Ratio is any workload exceeding 1.5, however, there is increased risk for any ratio above a 1.

Another way of measuring athlete load is through Rate of Perceived Exhaustion (RPE) times the duration of the session (minutes). Using this measurement tool allows for not only physical load to be recognized but the mental load being placed on an athlete. If a shutterstock_95683375.jpgprogrammed session is expected to rate a 7 on the RPE scale but the athlete scores the session as 12 then there may be something else worth exploring within the athletes life.

It is suggested that you have 7 days to manage an injury risk for a non-contact presentation. If an athlete is seen to be in the danger zone for too long a period the use of more recovery sessions or complete rest may be required to decrease the physical and mental stressors affecting the athlete. The load variables that have potential to affect the load felt by the athlete are sport specific and can be both intrinsic and extrinsic in nature.

Contributors to Load
There are a large number of factors which can contribute to load accumulation in an athlete and how that load accumulation is attenuated by the tissues of the body. Past injuries are one of the biggest contributors to future injury whether within the same region of tissues or in a separate region as a result of detraining. What was originally an ankle injury which saw an athlete reduce training load for two weeks, can easily lead a vortex of injury in other regions due to deconditioning associated with the reduced game readiness.
Additionally, the biomechanics of an athlete cannot be directly correlated to an injury which has not occurred yet – in other words, you cannot predict a specific injury based on biomechanical factors that you may visualize. Yes, those biomechanical factors can be seen as risk factor for injury but not specifically tied to an individual athlete and the injury they may incur.
Moment in time injuries (ankle sprains/ACLs) and contact injuries of varying degrees will lead to weakness within those tissues and an increase of further injury in the future. This may be a result of “overloaded” tissues relative to their current ability to handle loads – therefore the question is posed again, is it an Overuse Injury, Overload Injury or Training Error which should be the primary umbrella term used to describe these conditions.
The rehabilitation process which has been used to see the athlete return to sport is also important in the contribution to athlete load.
Did the athlete stop all physical activity over the time of injury?
Did the athlete return to training before returning to sport?
Was the athlete returned to their pre-injury chronic load before returning to game play?
Was the athlete 100% ready to return?
If not is the club, player and practitioner willing to take that risk?

There are many more questions that need to be asked and many more which we have not covered here. These decisions are commonly made under pressure to get the player back to field as soon as possible. In the coming days we hope to publish our interview with a leading physiotherapist for a major sporting team to get a better insight into how some of these decisions are made.

shutterstock_140849947.jpgManaging Load
So far we have seen what may contribute to an athlete’s load as well as how we can best measure that load in both a subjective and objective format. But how good is that information if we do not have an effective way of managing those risk factors, acute physical load spikes and psychological stressors?
Load should be considered a vehicle, an objective and subjective matter that can drive an athlete towards injury or away from injury. At the end of the day your main destination is “game day performance” or “season performance”, how you reach that destination can be done via a number of routes and selecting the best one is what must be decided upon by the medical staff, athlete and the organisation.
When looking to manage load, an athlete’s activity levels should be modified but never ceased. This is to limit detraining, maintain aerobic and anaerobic fitness and continue a base level of their chronic work load. The use of increased aerobic fitness and lower limb strength has been found to reduce an athletes risk of injury. For a long term injury which requires an extensive rehabilitation program it is suggested that workload is increased by 10% per week until the patient reaches their pre-injury chronic workload and are suitable to return to full training.

In conclusion, the monitoring of an athletes load with both subjective and objective measures is essential in the preparation for the competitive season. The development of a well-structured pre-season training plan can bullet proof an athlete not only for a single event but an entire season if completed successfully. A detailed medical history, injury history and lifestyle awareness is important for understanding of how an athlete should prepare for the sporting tasks required of them; from an easy recovery run to a worst case scenario within a single game. It is important to note that an athlete should not stop activity altogether but modify their activities in a way which is most appropriate for their injury.

Until Next Time

Jackson McCosker
Director/ Chief Editor

All 4 Talking: Multi-Sport With Duathlete/ Triathlete Caleb McIness


In our first athlete interview for 2017 we catch up with Caleb McInnes Duathlon and Triathlon World Championship Competitor, Podiatrist and Director of Freedom Sports Medicine.

race1Caleb McInnes
Podiatrist /Director – Freedom Sports Medicine
Duathlete / Triathlete
4th Duathlon World Championships 2015
4th Triathlon Sprint Distance World Championship 2009
Multiple State and Australian Duathlon & Triathlon Champion

The past 2 years have seen a big change for you, starting up your own venture at Freedom Sports Medicine and qualifying for the World Duathlon Championships in Adelaide and Canada.
How have you managed to incorporate training, work and family life?

To be honest it has been had…juggling family, work and training. I am lucky in that I have a degree of flexibility around work and incorporate some of my training into my lunch breaks. The rest is done at cray hours early in the morning when the family is still sleeping.
Also doing events in with my clinic is involved has helped.
When did you begin multisport competition and what encouraged you to get involved?

I first started when I was about 20. I had previously been racing on the track, cross-country and playing basketball and a high level and was asked by a mate I rode with for fun and x-training if I would do a Triathlon with him.
I did well winning my age group…the rest is history…I pretty much stopped doing the other sports and focused on Tri’s then started Duathlon over the winter months. I loved it and haven’t looked back.
What would you classify to be your weakest leg, what have you been doing to strengthen it and what kind of improvements have you seen?

Coming from and running background the bike and swim were probably equally as bad in different ways…training for all there and being good at them in a balancing act. Focusing on one or 2 to get good at them usually means sacrificing another to a degree.
Getting a coach that could work on my weaknesses while having an appreciation and being able to program around my life was a huge key. On top of this, private stroke correction and drill work across all three sports has been a key.
I am very big on drills to help improve efficiency and load management.
In my opinion too many people focus on progressive overload and don’t focus on the things like technique and strength to enable the body to withstand the stress placed on it as an injury prevention and performance enhancement strategy. This is something in my practice at Freedom Sports Medicine I am very big on!
What would you classify as your strongest leg, does it continue to be a focus of training and do your PB’s continue to improve?

Run & possibly after lots of work almost on par is my bike leg. PB’s come from consistency and working on the little things. I don’t always get PB’s. This is partly due to the fact that conditions and course are always different.

You competed over a similar course in 2014 to qualify for this year’s event, have you developed any particular strategy for the upcoming race?race2

Not really but knowing the course and knowing where you push hard and where you can possibly conserve energy has its advantages.

What distances are you covering in each leg?
In a race:
Duathlon: 5run/20ride/3run or 10run/40ride/5run
Triathlon: 750swim/20ride/5run or 1.5km swim/40ride/10run

In Training: Swim 5-8km a week ; Bike 200-250 a week, Run 40-60 a week
What are the spec for your bike and do you where orthotics in your cycling shoes?

I am lucky enough to have bike Sponsor in WIZZ Racing bike…I have a road bike and Time Trial bike depending on what style of race it is, draft legal or non-drafting.
Yes I wear orthoses in my cycling shoes. Mechanics on the bike are totally different to that of running.
You are in a closed chain and want as stiff a foot as possible to maximise power transfer as well as distribute pressure. Most of the pressure in a cycling shoes otherwise concentrated over the ball of the foot.

What shoes are you wearing while running for both training and competition and do you wear orthotics in them?

Training: I rotate between Mizuno Rider, Sayonara and Hitogami – no I don’t wear orthotics in any of them. What I wear depends on distance and intensity

Cycling: Shimano TR9 Tri Shoe – Orthoses. Yes for the reasons stated above.

What kind of cross training and strength work have you done to prepare your body?
Keeping up with current evidence and doing it as part of an endurance athlete program is essential to maximise performance.
I am in the gym (home gym) 1-2 x week and focus on mobility though the use or foam rollers, lacrosse balls, stick and more about 4-5x/week, all on top of my 8-10 other training sessions a week when in a big training block.
Leaving 4-6hrs between a strength session and cardio is essential to maximise the benefit of both. Weights/Targeted strength work turns on certain cell signalling which has a certain effect on your body as does endurance/cardio work. The problem is that the chemicals that are released with each particular type of training will compete against each other if done too close together or at the same time and to some degree cancel out the physiological benefit of the specific type of training adaption you are trying to achieve. On top of this diet, recovery and sleep and periodisation of a training program are all equally as important.

Thanks for talking to me and all the best for the upcoming race.


Jackson McCosker
Director/ Chief Editor

Sandwiched Between The Unstable: The Influence of the Hip and Foot on the Knee During Running


The knee is a relatively complex joint considering its hinge based status and primary flexion/ extension movements. Placed between two multi-axial joints which can be quite unstable, the knee can often feel the brunt of non-contact injuries associated increase forces from poorly controlled hip and ankle joints. The most common of these injuries is ACL tears or ruptures which we touch on in the previous article: ACL Injury: No Longer a Career Ending Injury.
Identifying the areas which may be contributing to increased stress is important factor for shutterstock_277232012.jpgthe rehabilitation process and patient management. In many cases the question asked “but which do address first, the foot or the hip?” My initial answer to this question is to address the feet first. This is not a decision I chose because I am a podiatrist but more so on the fact that the issue surrounding the feet and ankles can be addressed in a faster amount of time initially, leaving you and your patient more time to focus on the exercised based rehabilitation program of the hips.

The evaluation of an individual’s biomechanics during running has the potential to identify risk factors, which may contribute to running injuries. However, any injury as a result of biomechanical movements is not solely based on the action itself, but the body’s ability to cope with the forces placed upon that tissue.
The transition from walking to running may bring increased ground reaction forces, rotation moments and impacts upon the knee due to the nature of the activity and its single leg stance. For this reason, it is important to be aware of where the activity of walking finishes and running/jogging begins. The change of walking to running occurs when double support (both legs in contact with the ground) stance phase during the gait cycle ends and two phases of double legged float begins (NOVACHECK, 1998).

At the moment of ground contact when the foot becomes fixed to the underlying surface, a moment of dorsiflexion begins to take place at the ankle. This moment induces internal tibial rotation and pronation around the oblique axis of the sub-talar joint. That pronatory moment is responsible for the “unlocking” of the once stable foot to act as a better absorber. However, due to this moment, rotational torques are transmitted through the tibia with potential for forces to be felt more proximal at the knee joint.
As the foot enters an its propulsive stage of gait the foot will supinate, regaining its stability or “locked” position to act as an effective lever before toe-off.

A number of studies have looked at the motion at the hip during running. At the time the foot makes contact with the ground the hip is in an adducted position which then progressively becomes more adducted as the foot enters the shock absorbing stance phase.  Then from stance through to toe-off the hip becomes more abducted as it looks to aid in the “triple extension” moment.

And this is where we look at the impact of both those structures on the knee. Both the ankle joint and the hip joint are multi-axil structures designed for mobility. Our knee on the other hand is perceived as a joint for stability, a hinge joint with the two primary movements of flexion and extension, a joint that has specific anatomical structures in place for the limitation of movements such as adduction/abduction and internal/external rotation.
Now imagine if that poor knee joint was unlucky enough to have a runner who had not only poor pelvic/hip control but also chronic instability at the ankle joint as well, and the amount of force attenuation required to cope with those moments that occur simultaneously.

This is where my previous statement comes into play regarding the use of orthotics for knee pain associated with both the foot and the knee. In an ideal world a patient would be given a minimum of three exercises for each area of concern to improve activation, control and strength of those areas so no offloading or bracing is necessary. However, in being able to truly achieve that outcome, there is a large amount of confidence required in the patient’s compliance to the prescribed tasks, their ability to complete these tasks with the correct technique and will be able to maintain these assets over an extended period of time.
Or alternatively, an offloading device is used to help with the attenuation of forces which are occurring at the foot, while exercises related to the larger proximal muscles are prescribed. As activation and control at the hip reaches an appropriate level, orthotics can be weaned from the patient and foot/ankle exercises deployed, potentially returning a patient to sport earlier than may have previously be possible with the previously defined ideals.

Until Next Time

Jackson McCosker


Bisesti, B., Lawrence, M., Koch, A., & Carlson, L. (2015). Comparison Of Knee Moments And Landing Patterns During A Lateral Cutting Maneuver: Shod Vs Barefoot. Journal Of Strength And Conditioning, 3075 – 3078.

Freedman Silvernail, J., Boyer, K., Rohr, E., Bruggemann, G., & Hamill, J. (2015). Running Mechanics And Variability With Aging. Medicine & Science In Sports & Exercise, 2175 – 2180.

Novacheck, T. (1998). The Biomechanics Of Running. Gait And Posture, 77 – 95.

Paterson, K., Hinman, R., Hunter, D., Wrigley, T., & Bennell, K. (2015). Impact Of Cocurrent Foot Pain On Health And Functional Status In People With Knee Osteoarthritis: Data From The Osteoarthritis Iniative. Arthritis Care & Research, 989 – 995.

Peeler, J., Christian, M., Cooper, J., Leiter, J., & Macdonald, P. (2015). Managing Knee Osteoarthritis: The Effects Of Body Weight Supported Physical Activity On Joint Pain, Function And Thigh Muscle Strength. Clinical Journal Of Sports Medicine, 518 – 523.

Schache, A., Bennell, K., Blanch, P., & Wrigley, T. (1999). The Coordinated Movement Of The Lumbo-Pelvic-Hip Complex During Running: A Literature Review. Gait And Posture, 30 – 47.

Vannatta, C., & Kernozek, T. (2014). Patellofemoral Joint Stress During Running With Alterations In Foot Strike Pattern. Medicine And Science In Sports & Exercises, 1001 – 1008.


Pigeon Toed: Intoeing in Kids and Adults


Believe it or not, it’s a pretty common issue. Being pigeon toed or In-toeing during gait commonly begins during childhood and may continue into adult life if not addressed appropriately. There are a number of anatomical, physiological and biomechanical factors which may contribute to the visual appearance of an intoed foot. Additionally, being shutterstock_2723551.jpg“pigeon toed” does not necessarily lead to injury or pain and this is why it may go untreated in some children and follow them into adulthood. That being said being able to educate a patient about the potential risks and benefits is an important factor in developing a management plan for the presenting complaint.
Although neurological conditions should not be completely ruled out, people who in-toe are commonly identified to have one of the three following conditions;

Internal Femoral Torsion: is where the thigh bone rotates inwards which then continued throughout the rest of the lower leg. The condition is common among young children and in most cases will correct itself however, exercises, much of which are designed to be a part of play can be used in an attempt to speed up the recovery from the pathology. Additionally, specialized shoes or orthotics can be used in an attempt to alter gait.

Internal Tibial Torsion: is where the “shin bone” rotates between the knee and ankle joint leading to inward turning of the foot. The condition commonly corrects itself without treatment by ten years of age.

Metatarsus Adductus: is the curving of the foot inwards as opposed to the naturally straight position. It is believed that this in-ward curving of the foot occurs as a result of the position of the child in the uterus. The condition is commonly treated with gentle massage but does sometimes require the use of casting to straighten the foot.

Pelvic Control: with an increased sedentary lifestyle becoming the norm, pelvic control and stability are quickly becoming a common cause of in-toeing in adults. From the day we begin kindergarten we are taught to be in a seated position (legs crossed) which can increase laxity within the ligaments of the hips. Additionally, as we move through school and then enter the work force, remaining seated becomes a significant part of life, reducing activation ability of the gluteal muscles.
Specific rehabilitation exercises can be used to develop activation, control and motor patterns of the gluteal muscles responsible for extension and external rotation of the hip.

Molloy, et al (2015) found that during unsuspected movement tasks a greater hip external-rotator strength lead to reduced frontal plane hip excursion and transverse plane knee excursion in female soccer players. The article gives moderate support to the theory that external-rotator strength contributes to the dynamic control of the lower limb. However, to date very little evidence has fully supported the theory and therefore it remains just that, a theory.

Dependent on the reason for the in-toed gait a number of interventions can be put in place to address the issue. The use of in-shoe devices such as functional orthotics to address biomechanical contributors to the presenting gait complaint. Additionally, exercises or games which aim to increase activation, control and strength of external rotators of the hips can be beneficial if the complaint is believed to be of proximal origin. In many cases it is not enough to address the issue from one place and a multidisciplinary approach is recommended.

Until Next Time,

Jackson McCosker
Director/ Chief Editor


Malloy, P., Morgan, A., Meinerz, C., Geiser, C., & Kipp, K. (2015). Hip External Rotator Strength Is Associated With Better Dynamic Control Of The Lower Extremity During Landing Tasks. Journal Of Strength And Conditioning Research, 282 – 291.

Wegener, C., Hunt, A., Vanwanseele, B., Burns, J., & Rm, S. (2011). Effect Of Children’s Shoes On Gait: A Systematic Review And Meta-Analysis. Journal Of Foot And Ankle Research, 1 – 11.


ACL Injury: No Longer the End of a Career

The most commonly injured ligament within the knee is the Anterior Cruciate Ligament. The ACL attaches on the anterior intercondylar of the tibia and ascends posteriorly to the lateral area of the femur, crossing with the Posterior Crucial Ligament (PCL) in the intercondylar region with the role of preventing anterior displacement of the tibia relative to the femur.
ACL injury can occur as a result of both contact and non-contact injuries during shutterstock_195284591acceleration of deceleration while twisting. An ACL injury was once considered to be a career ending injury with athletes struggling to return to the same level of play they were previously competing. Although we have come a long way in developing rehabilitation and return to sport programs for ACL injuries there is currently no consensus on what is considered the “ideal program” with individual intrinsic and extrinsic factors strongly influencing decisions.

Nearly two-thirds of ACL injury is the result of a non-contact moment with majority of those occurring due to a “knee-in and toe-out” dynamic where the athlete attempts a direction change while the foot stays firmly planted to the surface. Contact injuries will result from the knee suffering valgus stress and typically occur in sports such as rugby, football, basketball and skiing. These types of injuries will coincide with bone bruising and meniscus trauma in 66% – 92% of cases.

As mentioned above, an ACL injury will occur with a pivoting moment at the time of accelerating or decelerating. Additionally, a patient may hear a popping or clicking at the time of the injury. Swelling will occur around the knee and clinically will display a positive pivot shift test with the loss of knee extension and Lachman’s Test. It is highly suggested that the use of MRI be used for a diagnosis of the extent of the injury to aid in the future management of the condition.

The aim of pre-operative rehabilitation is to develop full pre-injury range of motion, increase proprioception at the knee joint, neuromuscular activation patterns and of course the reduction of swelling, bruising and pain.
This is primarily achieved by a well-designed and implemented physiotherapy based rehabilitation program. Strengthening the muscles which cross the knee through basic activation and control exercises will help to stabilize the knee and reduce the possibility of early onset arthritis.
A cross-sectional study by Mikkelsen et al, 2016, found that patients who completed a 10-repetition maximum load knee extension exercise for a single set until muscular contraction failure were shown to have increases in the voluntary activation of the quadriceps muscle. This is seen as an imperative neuromuscular adaption for the enhanced recovery of functional performance. Additionally, developing this ability post-surgical intervention is also necessary due to the inhibited motor units from the surgical trauma and its physiological impact.
The evidence for rehabilitation pre-surgery has become stronger over the last eight years as it can physically and mentally prepare a patient for the impact of ACL reconstruction.

With the stronger evidence for pre-operative rehabilitation also came the development of more aggressive post-operative rehabilitation as opposed to the previous conservative approaches. Similar to the aims of the pre-operative rehabilitation programs, post-op programs aim to strengthen the knee joint and improve the proprioception around the joint. The most successful rehabilitation programs have been those which in compass home based activities and clinical setting elements. As well as the utilization of both open and closed chain activities specific to the muscles cross the knee joint.

There are multiple intrinsic and extrinsic factor which may impact an athletes return to sports however; most are expected to return to training in 6 -12months. A phased physiotherapy ACL program my look similar to the following:
PART ONE: Reduce swelling, return to full weight bearing and increase passive knee range of motion.

PART TWO: Improve proprioception, increase muscle strength in the quads and hamstrings while increasing passive knee extension.

PART THREE: Achieve better neuromuscular control and optimal strength within the lower limb.

PART FOUR: Return to sport specific exercises, movement patterns and multi-tasking activities while maintaining and improving stability of the knee through proprioceptive exercises.

All rehabilitative programs should be supported by as much education on the condition as possible so the patient is fully informed and on-board with their prescribed activities. This also helps to develop and personalize realistic goals which can maintain patient motivation and continue their compliance beyond their pre-injury physical state.

Until Next Time

Jackson McCosker
Director/ Chief Editor