Overuse Injuries: Situational Cause and Effect

Just the title of this article will have people calling it out of date and linguistically incorrect. As evidence begins to pile up with a conclusive directive toward tissue load tolerance and a particular time lapse between the period of initial pain onset and preliminary medical health consultation. There is a growing trend toward naming the once touted overuse injuries as “Training Error” injuries, and in those performing athletic or artistic feats this may just be appropriate when contact and “moment in time” incidents have been ruled out.
But what about your average punter?
What about your client who removes themselves from physical activity altogether and presents with the same conditions as those who are involved in sport at an elite level? How do you explain them that this has clearly been brought on by a “Training Error”?  Aside from saying you have this issue because you don’t train at all, and there lies your training error.

For those who are interested in the athletic side of load management a recent article which has been quite popular can be found here: https://footnotesblogging.com/2017/02/28/prevention-vs-performance-managing-demands-of-elite-athletes/

So, Jackson, if not an overuse injury and not a training error injury, and patient biomechanic abnormalities are only risk factors but not enough to predict an injury then how on earth do we explain to a patient how their issue came about and why our management is aimed at addressing areas not directly at the spot of where their pain coming from.

Quite simply with another label…. Tissue Load Intolerance. Quite simply dear patient, the load you have placed through the tissues associated with the affected area have been too much for those tissues to tolerate, and as a result you now have an injury.
The load you have placed through those tissues may have been for a number of reasons;


Biomechanics Training Technique Tissue Tolerance


Range of Motion Frequency Foot Strike Strength Weight
Kinematics Intensity Foot Placement Power Diet
Kinetics Duration Stride Length Endurance Activity Level
Distal Type Stride Rate Movement Specific Excessive Alcohol
Proximal Chronic Period Triple Extension Task Specific Drug Use
Chain Influence Acute Period Proximal Movement Medications/ Medical Condition Previous Injury History

What should be taken away from this article, or rant however you look to interpret it is that labels should be taken with a grain of salt and not used to broadly cover a group of injuries or simplify a process you as practitioner to beyond the comprehension of your client. Education of patients is important! If patients have only been shown to remember a small percentage of that verbally communicated during a consult, then make sure you have printed or electronic copies of the information available for the patient to review at their own leisure.
Otherwise, how “informed” is your informed consent?

Until Next Time

Jackson McCosker
Director/ Chief Editor



Clarsen, B., Bahr, R., Heymans, M., Engedahl, M., Rosenland, L., Thorsen, G., & Myklebust, G. (2014). The Prevalence and Impact of Overuse Injuries in Five Norweigian Sports: Application of a New Surveillance Method. Scandinavian Journal of Medicine & Science In Sports, 1 – 8.

Goossens, L., Verrelst, R., & Cardon, G. (2013). Sports Injuries in Physical Education Teacher Education Students. Scandinavian Journal of Medicine and Science in Sports.

Hawke, F., Burns, J., Radford, J., & du Toit, V. (2008). Custom- Made Foot Orthoses For The Treatment of Foot Pain (Review). Cochrane Library.

Rome, K., Handoll, H., & Ashford, R. (2005). Interventions For Preventing and Treating Stress Fractures and Stress Reactions of Bone of the Lower Limbs in Young Adults (review). Cochrane Library.

Seay, J. (2015). Biomechanics of Load Carriage – Historical Perspectives and Recent Insights. Journal of Strength and COnditioning is Research, 129 – 133.

Yeung, S., Yeung, E., & Gillespie, L. (2011). Interventions For Preventing Lower Limb Soft-Tissue Running Injuries (Review). Cochrane Library.


Changes in Tendinopathy Research Findings Since 2013: An Update of the Evidence

It’s been quite some time since we looked at tendinopathy in specifically in our FootNotes Publishing articles. Yes, there has been times where we have looked at the achilles, tibialis posterior, peroneus long all in a separate and more in-depth structure. But in that time great researchers and tendon enthusiasts alike have been producing have been producing some interesting and thought provoking pieces which have been shown to confirm but also challenge conventional thought; and in a couple of instances through a curve ball from left field. So let’s look closely at this short but interesting update.

The debate rages on, which time of muscle activation provides the greatest benefit for tendinopathy pain reduction and rehabilitation. The important thing to be aware of is all isometric, concentric and eccentric muscle activation have been found to have a positive benefit to the patient’s pain, function and strength. However, in a randomized controlled trial by Stasinopoulos et al, found a combination of concentric + isometric + eccentric activation had the greatest patient based results when compared to “concentric + eccentric” or “isometric” activation individually.

AchillesAnother finding which may add sway to this previous mentioned finding, is the newly researched and promising aspect of Tendon Neuroplastic Training, a concept discussed
recently by Tom Goom (RunningPhysio).  His recent discussion on Tendon Neuroplastic Training informs us that although eccentric rehabilitation training may still have its place in clinical management, physiological/neurological adaption to Heavy Slow Resistance may have a much larger placement as we look to place the tendon under tension through a controlled and timely range of motion. This isn’t a whole new subject with Rio et al 2015, discussing the cortical inhibition and the ability of the motor cortex to control the body tissues.

A number of articles tried to link biomechanical deficits directly to tendinopathy injury, however, most of this was speculative due to the number of external and internal factors which may add to the individual’s presentation.

“Biomechanical deficits should only be considered red/yellow flags for injury and not something which can predict injury itself.”

Offloading & Footwear
Wearing et al 2014, were able to show that peak acoustic velocity in the achilles tendon was significantly higher during shod (10mm heel) compared to barefoot treadmill walking. However, the study was not able to take into account the individual biomechanical variables during walking which may have been associated with the correlation.
Further to this article it has been shown that shoes which have a highly cushioned rearfoot has potential to encourage a rearfoot strike and initial contact with that highly cushioned heel.

More proximally at the patella tendon, research was conducted comparing biological gender neuromuscular recruitment in patella tendon loading. The finds found that although males had a slightly more favourable neuromuscular recruitment strategy for lessening patella tendon forces. Other factors such as frequency and height of jumps were more likely to significantly impact the onset of patella tendinopathy development

In two separate intervention reviews published through the Cochrane Collaboration investigation injection therapies similar conclusions were reported.

2014 – Platelet- Rich Therapies for Musculoskeletal Soft Tissue Injuries: There is currently insufficient evidence to support the use of PRT for treating musculoskeletal soft tissue injuries. More so, there needs to be the implementation of a standardization for PRP preparation methods.

2015 – General Injection Therapy for Achillies Tendinopathy: Insufficient evidence from randomized controlled trials was available to support the routine use of injection therapy for Achillies Tendinopathy.

So as you can see the evidence regarding lower limb tendon pathology, treatment and management has changes a little over the last couple of years and probably will continue to do so in the next couple of months. As a practitioner it is important to stay on top of what is being produced in the research community, identify the quality of the evidence and compare it to the previous body of literature before automatically including the suggested modality within your treatment plan. Similarly, if you are a patient and you hear about this brand new craze that is suggested to fix your ongoing pain you have had for six months, don’t assume it will work for you because a person on your TV with thick black glasses in a white lab coat and sterile looking room said it would.

Keep Your Mind Open!

Until Next Time

Jackson McCosker
Director/ Chief Editor



Davenport, K., Campos, J., Nguyen, J., Saboeiro, G., Adler, R., & Moley, P. (2015). Ultrasound Guided Intratendinous Injections With Platelet-Rich Plasma or Autologous Whole Blood for Treatment of Proximal Hamstring Tendinopathy. Journal of Ultrasound Medicine, 1455 – 1463.

Franettovich, M., Honeywill, C., Wyndow, N., Crossley, K., & Creaby, M. (2014). Neuromotor Control of Gluteal Muscles in Runners with Achilles Tendinopathy. Medicine & Science in Sports & Exercise, 594 – 603.

Janssen, I., Steele, J., Munro, B., & Brown, N. (2014). Sex Differences in Neuromuscular Recruitment Are Not Related to Patellar Tendon Load. Medicine & Science in Sports & Exercise, 1410 – 1416.

Kearney, R., Parsons, N., Mercalfe, D., & Costa, M. (2015). Injection Therapies for Achillies Tendinopathy. The Cochrane Collaberation.

Malliaras, P. (2017). Isometrics For Tendon Pain – Is the Hype Justified?

Malliaris, P. (2017). Compression in Insertional Achilles Tendinopathy: Worth Worrying About?

Malliaris, P. (2017). Is Achilles Tendon Blood Flow Related to Foot Pronation.

Masood, T., Kalliokoski, K., Magnusson, P., Bojsen-Moller, J., & Finni, T. (2014). Effects of 12-wk Eccentric Calf Muscle Training on Muscle-Tendon Glucose Uptake and SEMG in Patients with Chronic Achillies Tendon Pain. Journal of Applied Science, 105 -111.

Moraes, V., Lenza, M., Tamoki, M., Faloppa, F., & Belloti, J. (2014). Platelet-Rich Therapies For Musculoskeletal Soft Tissue Injuries. The Cochrane Collaberation.

Stecco, C., Corradin, M., Macchi, V., Porzionato, A., Biz, C., & De Caro, R. (2013). Anatomical-Radiological Study of the Plantar Fascia and Its Correlation with Achilles Tendon Pathologies. Italian Journal of Anatomy and Embyology.

Wearing, S., Reed, L., Hooper, S., Bartold, S., Smeathers, J., & Brauner, T. (2014). Running Shoes Increase Achilles Tendon Load in Walking: An Acoustic Propagation Study. Medicine & Science in Sports & Exercise, 1604 – 1609.





Wobbles, Falls, Trips and More: The Feet and Balance

Poor balance can affect anyone, from the tiny toddler learning to walk to the grey nomad climbing in and out of her RV and the middle age ressie’s footballer who has had one too many injuries, poor balance will be experienced at least once in your life time.
Balance is a complex process involving afferent and efferent principles of the central nervous system which aim to keep equilibrium by maintaining the centre of gravity over the base of support. Additionally, proprioception as a mechanism is also associated with balance as a whole in maintaining equilibrium by way of spatial and body awareness. In today’s article we look at the importance of the feet and balance and the impact poor balance may have on an individual.

WARING! The following paragraph gets a little sciencey, feel free to by-pass at will!

The body’s perception of static joint position is dependent on afferent information delivered from Golgi tendon organs, muscle spindles and joint receptors. Specific receptors known as Ruffini receptors and Pacinian corpuscles are stimulated when a joint is moved toward its end range of motion and are important in processing proprioceptive concerns in everything from day to day life, sports and occupational tasks (Paes, et al., 2013).

The ankle joint plays an important part in the process of maintaining postural stability. This can be disrupted in the case that the ankle becomes injured or losses its musculaejercicios para el equilibrio corporalr capacity to protect the joint. To that effect, people who have been identified as having chronic ankle instability have been found to be less sensitive to light touch stimuli and less effective at single-leg stance tasks.

Inefficient balance and postural control has been linked to ageing as a result of reduced somatosensory input such as vestibular, proprioceptive and visual processing; increasing the risk of falls and potential injury. Additionally, five other contributors to falls and balance have been identified; pain, polypharmacy, foot deformity, Flexor Hallucis Longus strength and Footwear. Although there is no standardized method for the prescription or construction of customized foot orthoses when looking to influences patient balance it has been acknowledged that insoles including those without medial arch support or specific padding can influence proprioception. Furthermore, the use of custom orthotics has been used to address lower limb pain and foot deformity inclusive of clawing of the toes. Footwear may affect a client’s proprioception and cutaneous stimuli processing, however, if inappropriate for the individual may act as a tripping hazard as opposed to directly being associated with a person’s postural stability.
A literature review by (Gillespie, et al., 2015), found that both group and home-based exercise programmes reduce the rate and risk of falls in older adults. Similarly, the use of a multifactorial assessment and intervention program was seen to reduce the rate of fall but not the risk of falling.

Balance issues do not only effect the elderly however. The reasons for poor postural stability in a younger age bracket however is more likely be associated directly with injury. Lateral ankle sprains occur in a variety of different activities both competitive and recreational, they have a prevalence of approximately 10% in the sporting community and sequential ankle sprains are probable leading to the development of a chronic ankle instability (Doherty, et al., 2015).
Surprisingly the mechanisms used to adjust for postural sway also differs as one ages. Donath et al; found that young adults (27 years +/- 3) increased their co-activation of both posterior and anterior muscles which cross the ankle to combat inversion actions in single leg stance. Alternately, seniors (70 years +/-) with poor postural control showed an increased tibialis anterior contribution.

Balance is a skill which is learned and can be trained and therefore improved as a result. It is a life skill required to complete even the simplest of tasks. Being aware of our actions, our surroundings and placement of our feet is one thing but there are many other variables which relate to proprioception and balance that need to be taken into consideration. Poor balance is not the only reason for falls either with; foot deformities, pain, multiple medications, footwear choices and flexor strength being highlighted as falls risks.

Until Next Time

Jackson McCosker
Director/ Chief Editor



Barbosa, C., Bertolo, M., Neto, J., Coimbra, I., Davitt, M., & Magalhaes, E. (2012). The Effect of foot orthoses on balance and foot pain and disability in elderly women with osteoporosis: A randomized Clinical Trial. Rheumatology, 515 – 522.

Bohannon, R. (2012). Impairments in static and standing balance are highly prevalent among older adults receiving home-based physical therapy. journal of gericatric physical therapy, 145 – 147.

Doherty, C., Bleakley, C., Hertel, J., Caulfield, B., Ryan, J., Sweeney, K., . . . Delahunt, E. (2015). Lower Limb Interjoint Postural Coordination One Year After First Time Lateral Ankle Sprain. Medicine and Science in Sports and Exercise, 2398 – 2405.

Donath, L., Kurz, E., Roth, R., Zahner, L., & Faude, O. (2015). Different Ankle Muscle Coordination Patterns and Co-Activation During Quiet Stance Between Young Adults and Seniors Do Not Change After a Bout of High Intensity Exercise. BMC Geriatrics, 1 – 8.

Forestier, N., Terrier, R., & Teasdale, N. (2015). Ankle Muscular Proprioceptive Signals’ Relevance for Balance Control on Various Support Surfaces. American Journal of Physical and Medicine and Rehabilitation, 20 – 27.

Gillespie, L., Robertson, M., Gillespie, W., Sherrington, C., Gates, S., Clemson, L., & Lamb, S. (2015). Interventions for Prevention falls in older people living in the community . The Cochrane Coolaboration.

Gribble, P., & Hertel, J. (2003). Considerations for Normalizing Measures of the Star Excursion Balance Test. Measurement in Physical education and excerise in science, 89 – 100.

Paes, F., da Silver, R., Freira, A., Politti, F., Chiavegato, L., Geraldes, A., & Amorim, C. (2013). Immediate Effect if Bilateral Talocrural Joint Manipulation of Postural Balance in Healthy Subjects. Ergonomics.

Powell, M., Powden, C., Houston, M., & Hoch, M. (2014). Plantar Cutaneous Sensitivity and Balance in Individuals With and Without Chronic Ankle Instability. Clinical Journal of Sports Medicine, 490 – 496.

Shim, A., Steffen, K., Hauer, P., Cross, P., & Van Ryssegem, G. (2015). The Effects of Balance Training on Stability and Proprioception Scores of the Anklein College Students. International Journal of Kinesiology and Sports Science, 16 – 20.

Wright, W., Ivanenko, Y., & Gurfinkel, V. (2012). Foot Anatomy Specialization for Postural Sensation and Control. Journal of Neurophysiology, 1513 – 1521.


The Role of Leg Stiffness During Running

“What are your legs?”
“Steel Springs!”
“What are they gunna do?”
“Hurl me down the track.”
“How fast can you run?”
“As fast as a leopard”

That scene right there is one of the only things I actually remember from my year eight English classes. Stated just before Archy jumps out of the trenches and makes a mad dash toward the enemy in the amazing 1981 story of Gallipoli.

Leg stiffness in running was not a concept I had heard of until the start of 2016 when I attended a running symposium by Dr Christopher Bishop from The Biomechanic Lab in Adelaide. Yet another variable in the paradigm of running was opened to my mind and yet another question about how the activities we participate in can lead to injury.

Leg stiffness relates to the soft tissues of the lower limb; muscles, tendons and ligaments working together to store elastic energy through a stretch and recoil process and lower the metabolic cost of movement. Leg stiffness has been shown to be vary based on stride frequency, velocity, ground force reaction and surface firmness suggesting that inherent properties of the musculoskeletal system associated with the central nervous system determine leg stiffness and not conscious intervention (Arampatzis, Bruggemann, & Metzler, 1999).

Running economy has been described as the amount of energy required to maintain a submaximal running velocity. Improved running economy has been linked to the neuromuscular benefits associated with resistance training which is believed to enhance lower limb stiffness during running and therefore the stretch-shortening reflex (Roschel, et al., 2015).
Additionally, leg spring stiffness has been found to adjust to a change stride frequency. Further information regarding stride rate and length can be explored here: https://footnotesblogging.com/2017/01/23/running-cadence-is-180bpm-right-for-you/
In contrast to this discussion, Farley et al; suggests that leg stiffness does not change with a change in stride length but stays consistent while the angle of leg sweep and time spent in ground contact changes. Further to this suggestion, in a separate paper they concede that although they’re findings suggest no change in leg stiffness with a change is stride rate, there is a change of leg stiffness with a change in surface type.midfoot strike

Surfaces with a lesser density require a runner to reduce their leg spring compression by increasing their leg stiffness. The adjustment of leg stiffness counterbalances the surface compression and maintains the athletes centre of mass despite the change in how firm a surface may be.

Leg Stiffness is important when changing various surfaces in a single run for the prevention of injury but also for enabling our legs to work like steel springs and maintain our running efficiency. The system itself is in-built but can be trained and therefore improved, the question posed is whether an individual would directly benefit from this neural training process or if there was a better use of time when looking at deficits of an athlete or their training program?

This was a tough topic to get my head around, trying not only fully understand the concept but then place that knowledge in a simpler term was a difficult task. If you wish to try to understand this topic more in-depth I suggest you follow references below and really take the time to understand what the research states.

Until Next Time

Jackson McCosker



Arampatzis, A., Bruggemann, G., & Metzler, V. (1999). The Effect of Speed on Leg Stiffness and Joint Kinetics in Human Running. Journal of Biomechanics, 1349 – 1353.

Farley, C., & Gonzalez, O. (1995). Leg Stiffness and Stride Frequency in Human Running. Pergamon, 181 – 186.

Ferris, D., Liang, K., & Farley, C. (1999). Runners Adjust Leg Stiffness for Their First Step on a New Running Surface. Journal Of Biomechanics, 787 – 794.

Ferris, D., Louie, M., & Farley, C. (1998). Running in the Real World: Adjusting Leg Stiffness For Different Surfaces. The Royal Society, 989 – 994.

Gunther, M., & Blickhan, R. (2002). Joint Stiffness of the Ankle and the Knee in Running. Journal of Biomechanics, 1459 – 1474.

Roschel, H., Barroso, R., Tricoli, V., Batista, M., Acqueta, F., Serrao, J., & Ugrinowitsch, C. (2015). Effects of Strength Training Associated With Whole-Body Vibration Training on Running Economy and Vertical Stiffness. Journal of Strength and Conditioning Research, 2215 – 2220.

Williams, D., Davis, I., Scholz, J., Hamill, J., & Buchanan, T. (2003). High-Arched Runners Exhibit Increased Leg Stiffness Compared to Low-Arched Runners. Gait & Posture, 263 – 269.



Injury in Elite Sporting Codes: Managing Our Sons and Daughters of the West – With Fiona Jacobs


fi.JPGI am an AustralianPhysiotherapy Association Titled Sports Physiotherapist, having completed both a Bachelor Degree in physiotherapy( honors ) in 2004 and a Masters in Sports Physiotherapy in 2013.

I have been fortunate to experience and work with some elite athletes and performers over the years. Highlights have included touring with Cirque du Soleil throughout South America with a big top show as head therapist of performance medicine amongst international artists and staff, and touring to Ireland with an International Rules Football Team. The icing on the cake has to have been working with the Western Bulldogs/Footscray Bulldogs during their premiership year, and holding both the VFL and AFL premiership cups!! Most recently I have had the absolute pleasure of being involved in the development of AFL Womens programs, and I am currently the head physiotherapist for the Inaugural AFL Womens Western Bulldogs team. When not at the club, I work at Melbourne Sports Physiotherapy Clinic in Essendon, treating elite athletes and weekend warriors alike!

You have just come off a history making season in 2016 with the Western Bulldogs taking out the AFL Premiership Cup over Sydney and Footscray taking the VFL Premier Cup over Casey. On top of that, the much anticipated AFL-W League has recently kicked off and your girls look to strong contenders to finish on top of the ladder. With such a rapidly growing list how do you manage and prioritise injuries when time is such a pressing factor?

Time certainly has been a constraint, as the team all have work commitments outside of football, and can be expected to train only up to 9 hours per week. To help streamline our services to those who need us most, good communication and education has been vital. We have utilised online wellness questionnaires pre training to flag concerns the players may be having with their health, and conduct weekly physical screenings across the entire group, to help identify players who may require training modifications or further assessment/treatment, to minimise risk of injury.

Preseason we conducted a thorough screening on the list, and from that we were able to identify areas that either needed work from the group as a whole, or individualised adjustments to their weights and conditioning programs. All players were also set up with individualised injury prevention programs, and as a group we integrated injury prevention strategies into our warm ups and strength programs.

We have an incredible support team of physios, doctors, strength and conditioning/performance coaches, sports science personnel including nutrition and player welfare, as well as trainers, myotherapists and coaches, who made this possible. We have a dedicated rehab team whose job is to take care of injured players and ensure a safe reintegration back into training and playing. We have all worked really hard together to provide an efficient yet all-encompassing program with the goal of elite performance and minimal injury.

 Working in a multidisciplinary team would have major benefits for both players and practitioners. Are there protocols for where one practitioner will pass on a player’s management to another practitioner or is open dialogue found to be the best practice?

I think each team you work in has its own structure. For us, we do have a dedicated rehabilitation team, who specifically take over the care of an injured player if they have an injury that affects their ability to train with the group. The process we have adopted involves the head physio and doctor working with the injured player to assess and diagnose the injury, and determine an estimated return to play timeline. From there, the rehab team take over that players care, however, there is always open dialogue amongst all the medical staff. As for the rest of the playing group, we tend to share the management of the playing group as a whole, but as all the players treated at the club, communication between therapists/trainers about players needs is easy. We have weekly meetings to review each of the players’ health and wellbeing, as well as a wrap up at the end of each session. This enables us to have a good continuum of care between everyone in the support team, including coaching.

 When managing a player at an elite level you would be required to take both team and individual sponsorship and endorsement into consideration. Have you found this to be a challenge at times?

 The main challenge that springs to mind, is with respect to the athletes footwear. There is no doubt that some brands of footwear may be better suited to some players than others. It is rare, but unfortunate, when the player’s sponsor requires a certain boot to be worn, that may not be ideal for that player’s body. Having said that, players sponsors want what’s best for their players too, and are fairly accommodating to our podiatrist’s recommendations. We were delighted to be sponsored by Birkenstock this year, so all of our players could avoid wearing dodgy flip flops throughout summer!

 With the introduction of the AFL-W League there is a risk that the type of injuries sustain by the female players will differ from that of the males, with ligament laxity and joint stability potentially being an issue. Have you noticed a difference in the way female players have prepared for the current season as opposed to the males?

 It has been identified already that female football players have a higher tendency for ACL injury, as well as concussion (and hand injuries!) (Fortington, Donaldson and Finch 2016).

 With respect to ACL injury, there have been a few predisposing factors proposed, some inheritable and genetic, and some to do with the conditioning/level of the athlete, which to be honest doesn’t really differ to the men. What does differ to the men relates to the shape of female bodies at the pelvis. Given female tend to have a wider pelvis relative to the knee, this increases the angle of loading through the knee, and can be one of the proposed risk factors of injury. Another speculation is that the collagen make up within the ligaments tends to slightly differ, and perhaps this could be a factor. However, on the whole, females’ ligaments tend to be more elastic, and one could argue that this makes them less susceptible to tissue failure compared to a stiff, inelastic ligament.

 While we can’t control anatomy or genetics, we can influence strength and neuromuscular control of the lower limb, and this is our primary focus with our injury prevention strategies. Lots and lots of landing practice!!

 The other reason we suspect female footballers have a higher incidence of ACL and concussion injury, has to do with how long they have been playing the sport, and the way this influences their neuromuscular control and peripheral awareness, or” reflex instincts” if you like. It will be fascinating to revisit the injury data in a few years’ time, once we see the first few waves of female footballers who have had a consistent pathway from juniors through to elite, coming through!

Thanks Fiona, this has given a fantastic insight into how practitioners deal with elite players. Once again congratulations for last year and all the best for the 2017 season.