If you've been paying attention to the Gait Guys' blog, you may have noticed a string of running posts lately. They have ranged in topics from injuries to examination to training techniques. Two of the posts focused on potential causes for injury. The first post discussed the issue of running only one direction on a track. Turning one direction leads to asymmetries in muscle strength and stresses placed on the body. It's not a surprise that people get injured from this! The second post was about banking your head during turns. The authors review the importance of the cervical region's role in preparing the rest of the body for movement. This further emphasizes the need to look at the entire body when we are evaluating our patients!

The third post isn't necessarily restricted to runners. It's an examination technique called the standing tripod test. The tripod is formed by the calcaneus and heads of the 1st & 5th metatarsals. As expected, the patient stands on one LE at a time, while the examiner observes the entire body for any reactions. This is a more intricate test than the standing trendelenburg test, because we should be looking at more than the hip. The authors present a case in this post that demonstrates the relationship between forearm pronation/supination and foot/ankle adjustments in maintaining balance. Very cool! The final article we wanted to include is not from the Gait Guys. Triathlete presents 5 training drills with the purpose of improving running form. While the reasoning behind them is theoretically plausible, it is by no means a scientific study. But definitely still interesting to consider and potentially a research idea!

     This systematic review helps explain some of the evidence behind lower extremity tools that can predict injuries in the athletic population.  Injury prevention is a hot topic in sports. With tools like FMS becoming popular it is important for physical therapists to understand which tools provide the best evidence for future injury.  This review broke down the lower extremity into multiple muscular and ligamentous injuries: ACL, knee injuries, hamstring strains, groin injuries, and ankle sprains.   

     The authors found that for ACL-injured athletes, there was a knee abduction moment 2.5x greater during the drop vertical jump.  Furthermore, knee abduction moments predisposed the occurrence of an ACL injury with 73% specificity and 78% sensitivity.  When predictive tools for knee injury were reviewed, the authors were unable to find any measured factors that could predict acute knee injuries.  
     Predictive tools for hamstring strains were less conclusive.  The authors noted that while a decrease in flexibility of the hamstrings was predictive for football players older than age 23, flexibility of the hamstrings in soccer players was not significant.  However, the hamstring to quadriceps ratio was a significant predictive factor for hamstring strains in football players.  
     Additionally, groin injuries were analyzed in soccer, football, and hockey players.  It was found that hip adduction to hip abduction strength ratio was a significant predictive tool for a future adductor strain when hip adduction is less that 80% of hip abductor strength.  Additionally, a decreased ROM of hip abduction for groin strains was found to be significant.  
     Ankle sprain predictive tools were conflicting and the authors described BMI, age, and postural sway as predictors for future ankle sprains in athletes.  
     What is important to consider from this systematic review is that these tools only scratch the surface of predicting lower extremity injuries in athletes.  Considering the athlete's full history, specific sport, and current level of conditioning is necessary whenever assessing injury risk.  

For those of you who have performed pre-participation screenings or have seen screenings done, which tools do you use and/or find beneficial? What are your thoughts on FMS in comparison? 

    Many dedicated athletes utilize an exhausting training program to enhance their skill level. Occasionally, athletes push their bodies beyond a healthy threshold that leads to under-performance and sickness. This study takes a look at the management of overtraining syndrome. There are three terms that, while similar, are quite different in describing the state of the athlete: functional overreaching, nonfunctional overreaching, and overtraining syndrome. Symptoms commonly seen in these disorders include:
    -fatigue                           -hypertension
    -depression                     -restlessness
    -bradycardia                    -anorexia
    -loss of motivation           -weight loss
    -insomnia                        -lack of mental concentration
    -irritability                        -heavy, sore, stiff muscles
    -agitation                         -anxiety
    -tachycardia                    -awakening unrefreshed

    Functional overreaching involves training at a higher intensity, so that performance decreases for a limited time and is improved following a rest period. This is commonly seen in training methods everywhere. Nonfunctional overreaching is similar to functional overreaching, except a longer period of rest is required for recovery. Sometimes there are psychologic and/or neuroendocrinologic symptoms experienced as well. Overtraining syndrome is differentiated from nonfunctional overreaching with an even longer period of time with decreased performance, usually greater than 2 months. It is associated with psychologic, neurologic, endocrinologic, and immunologic symptoms and another stressor that cannot be explained by another disease. The article examines many possibilities that could potentially explain these disorders: glycogen hypothesis, central fatigue hypothesis, glutamine hypothesis, oxidative stress hypothesis, autonomic nervous system hypothesis, hypothalamic hypothesis, and cytokine hypothesis.
    Patients typically have a history that involves decreased performance even with a lengthy rest period, changes in mood, and no indication of another cause to the symptoms. Some people state that nonfunctional overreaching is diagnosed if symptoms disappear following less than 21 days of rest and overtraining syndrome is diagnosed if it has been longer than 21 days of rest with symptoms persistent. Since some pathologies can present similarly as overtraining syndome, it is important to listen for cues, such as lots of mood changes or having the ability to start a workout but missing the "finishing kick." There are many lab tests that can be performed to determine the likelihood of a contribution from a non-musculoskeletal source. According to Dr. Noakes, some early signs to keep an eye out for are progressive loss of weight, an increased fluid intake (especially in the evening), a progressively later bedtime each evening, a decreased number of hours of sleep, and a persistent increase of 5-10 beats per minutes in early morning pulse rate. Dr. Noakes references a study by Waitzthat states if a positive answer to 3+ of the questions below could indicate the need to decrease training:
    -Does your normally comfortable pace leave you breathless?
    -Do your legs feel heavy for far longer than usual after a hard workout or a race?
    -Do you find it especially hard to climb steps?
    -Do you dread the thought of training?
    -Do you find it hard to get out of bed in the morning?
    -Do you have a persistent lack of appetite?
    -Are you more susceptible to colds, flu, headache, or infections?
    -Is your resting heart rate 5-10 beats higher than usual?
    -Is your heart rate during exercise higher than usual?

    Treatment recommendations are quite varied with no proven findings as of yet. Some suggest relative rest, while others suggest complete rest from the sport (Dr. Noakes suggests 6-12 weeks of rest). It is important to take a look at the motivating factors of the athlete. With decreased performance, some athletes try to compensate with increased training levels, which can worsen the problem. Additionally, with the association of mood alterations a sports psychologist consultation should be considered. Others have recommended the use of selective serotonin reuptake inhibitors to alleviate some of the symptoms. The best course of managing overtraining syndrome is prevention. Athletes should increase their training load prior to increasing their intensity, giving their bodies ample time to adjust. One of the studies referenced in this article found a decrease in "burnout" for collegiate swimmers when training levels were adjusted based on mood (lower load with low mood state).

References:
Kreher JB, Schwartz JB. "Overtraining syndrome: a practical guide." Sports Health. 2012 Mar;4(2):128-38. Web. 10/08/2012.

Noakes, Tim. Lore of Running. 4th. Southern Africa: Oxford University Press, 2001. 484-510. Print.