This blog is a review of the Pacey Performance Podcast Episode 383 – James Moore
James is the leader of the specialist physiotherapy team at the Centre for Health and Human Performance (CHHP) in Harley Street. James has 25 years of experience in physio, graduating with an honours degree in physiotherapy from Kings College London. He was Clinical Lead Physiotherapist to the English Institute of Sport, with a special affiliation to UK Athletics. He spent a period of time working as Head of Medicine for Saracens RFC, before moving on to manage the intensive rehabilitation unit (IRU) at Bisham Abbey for British Olympic Association and was Head of Performance Services for the British Olympic Association and Deputy Chef de Mission for the Rio 2016 Olympics and beyond. He is currently in clinic two days a week and also has a number of consultancies including with Andy Murray.
? Listen to the full episode here
”Would you be able to talk to us about Andy Murray’s progress, is he on track for where he wants to be at this point in the rehab and the return to performance journey?
”From a physical point of view we are in a really really good place. He played nearly 12-13 weeks in a row last year at the end of the season off the back of having some pretty major niggles and came through that without any issues. He has come through the Australian Open including a 4 hour match. Andy’s expectation is super super high and rightly so – he’s still got the talent, he’s still got the skills, he’s still got the tennis IQ to play at the highest level.
There is no substitute for what is in essence four years of competitive play, if you go back to 2016 I think he played 87 matches when he was world number 1 and last year we played about 40, so we are at about 50% and so you need to build that tolerance up and that 10% top end fitness.
His V02max is low 60s which is great, but at his best he was low 70s (ml/kg/min). He’s strong, he’s deadlifting 270 kg, quarter squatting 260 kg at 84 kg and can produce 1500 W on a Watt bike so physically we are in a good place and what we need to do now is transfer that into the consistency on the tennis court. That just takes time, good coaching and continuity from the rest of the team to help him deliver.”
”Why do athletes get hip and groin pain in the first place?”
”I don’t know that we have all of the answers yet. Do we have the exact aetiology? [MEDICINE- the cause, set of causes, or manner of causation of a disease or condition.] I don’t think we do. I think we have strong indicators, for example, we know that if you play a kicking sport (football, rugby, Aussie rules, Gaelic etc) you have a much higher percentage chance (you’re probably 3 x more likely to overload your pubic joint and your adductors) than you are in any other sport.
However, when you start to shift from a kicking sport to twisting/turning sports (non primary based running sports so badminton, squash, tennis, ice hockey, short track speed skating), yes you might run as part of your conditioning to supplement the sport but it’s not a primary requirement of what you have to do in the sport. Yes, you’re sprinting on the Tennis court but you may be covering 3 km in a two-three hour match, and we know that when you twist you increase your risk of hip related injuries.
We also know that if you run in a straight line you also really increase your risk of hip related injuries and a lot of that comes down to the cumulative repetitive force within the joint and what we know is that bones don’t like reciprocal movement- the same movement over and over again, so running in a straight line is generally one of the worse things you can do for bones.
We also know that women as a rule will have a lot higher risk of running related injuries in the hip and men as a rule will have a much higher risk of groin related injuries. So when you put all that together, I think it’s really hard to find a place to hide on the sports field.
The lumbo-pelvic-hip complex as a unit is the hub for power creation in speed and power based athletes. Yes, the soleus might be one of the strongest muscles in the body, if not the strongest, but when you’re really looking at peak torque in high level sprinting and running and kicking, you’re talking way over 9 x bodyweight of impact loading and in the triple jump it is 15 x bodyweight going through the hip! So the forces are just huge and then it just comes down to capacity, tolerance and how much you can build up. I would just call it supply and demand – there is a huge demand from the sport, and then you have got to build up the supply for the individual.
If you don’t get that right, in terms of training capacity and/or individual capacity, that’s when you’re potentially going to get an overload and injury.”
”So why are the sites of injury for males and females different, it is purely anatomical?”
”No, I don’t think it is, for a number of different reasons, although the reason why I hesitate is because there is more evidence coming out more recently starting to look at that (anatomical differences). Around 15-20 years ago we were talking about width of pelvis and angles of muscles going into the groin, like you would talk about the Q angle of the knee and patella-femoral load, and really there was no evidence around it. So the morphological (structure of the body) may not make a difference. Certainly the muscle mass and the forces being produced may make a difference.
There are also a number of other factors such as line of force (males tend to be more straight down and females tend to be more diagonal), angles at the pubic joint, and the anterior pubic ligaments being significantly stronger in the female, as well as hormonal profile and elasticity of ligaments in females.”
”How can we differentiate who needs surgery and who doesn’t’?’
”The decision making process around surgery becomes multi-factorial, and we certainly have advised surgery for a number of different reasons. Certainly from a clinical point of view, there has been a anecdotal significant reduction in groin surgeries as there has been an improvement in core stability in terms of the functional load transfer across the anterior pelvis.
In football we typically see 15-20% of footballers having a groin related injury, so 1 in every 5. The game is faster, the players are bigger, stronger, the ball is moving faster on the pitch, and it’s in play for longer, which increases your exposure. So while we are seeing this transition we are still playing catch up with the demands of the sport.
The key really is that the physical signs should match up with the subjective complaint of pain.
If the pain is disproportionate to the physical signs then you have probably got tissue damage beyond the point of repair. When we start to look at groin surgery, whether we are talking about abdominal or adductor surgery, with abdominals they can produce force but it’s painful and you’ve got palpable gaps or issues with the inguinal canal, and they fail a period of rehab (2-6 weeks) where there they just can’t put enough load the tissues without provoking symptoms.
You’ll genuinely know whether they are going to succeed in a programme of rehab. We’ve looked at them and we’ve said ”this is surgery,” but they want to go down a conservative route but at 2 weeks, 4 weeks, 6 weeks they fail their markers, and so you then go through that. That’s a really good process psychologically to let the player adapt as well as tick the box in terms of doing your strength work before you go down that route; and then there’ll be certain people who will have been told that they need surgery, but there will be some obvious deficits and when they start to load the pain subsides but the pain is usually fairly consistent with their physical signs.”
”Do athletes have to stop playing in order to recover from these kind of injuries?”
”Most groin overload injuries don’t stop you from playing but they just limit your performance. So we will have lots of people who will just feel like they are at 60 or 80%, I can pass the ball, I can run but I can’t put some shape on the ball, and put my foot through the ball. Everything has to be controlled, and if I do try and push it I get sharp pain, I’m a bit incapacitated for a few minutes but then it settles and I’m able to go again.
It’s very easy to manage people and keep them ticking over and then it comes to the bigger question of the relevance to the individual- if they are 80% fit are they better than the next individual coming in?
As a medic part of our job is to protect the athlete from themselves and protect them generally, but then also as a performance scientist is to push them to that red line and get them as close to that red line as possible and keep them there for as long as possible. It’s easy to stop injuries, you just don’t train very hard, but if I want to win stuff I need to go right to that top end and push my body and that’s a difficult balance to strike.
With overload load related injuries, if we want to strip that back we need the reduce the load and then build it back up in a progressive overload manner and then you can build capacity. So it would mean dropping them out of training, whether that means complete reduction of training or modified training (allow them to run but don’t allow them to kick) to reduce some of the markers. So they can do part of the training but not all of the training, and it depends on the demands of the training.”
”How do we decide how to structure the rehab programme, are there some key approaches that need to go in no matter what?”
”Does the tissue that is the source of pain need to be loaded or unloaded? I get a lot of people coming in with adductor related groin problems, and they’ve been loaded but the adductors are the strongest part of the chain when you assess it, and their abdominals and/or hamstrings are not functioning well. So in that case, you want to reduce the adductor/adduction load and increase the abdominal/hip flexor load and maybe hamstring. A lot of that comes down to asking where are we from a capacity and/or strength point of view which requires a little bit more investigation away from just the pathology point of view. And that’s part of the trick of examining the individual from a pathology/pain source point of view and also examining them from a function perspective.
The adductors bring the leg across your body but they are also a significant hip flexor- and there is an argument that the adductor longus is the second most important hip flexor behind iliopsoas but they are also significant hip extensor, so once you go above 45 degrees of hip flexion they become your most significant hip extensors (and adductor longus decelerates hip extension in running mechanics).
The adductors are the main muscles that bring you out of a deep squat and they the are the main muscles of hip flexion and the adductor magnus off loads the hamstring, so maybe the adductors are over working because the hip flexor complex is not good enough, so maybe we need to bring up iliopsoas (which has an adduction moment arm). Or maybe the hamstring and the glutes are not doing their jobs properly so we need to increase the hip extension function to take some pressure off the adductors.
So what makes it a little more complex is that your abdominals also aid in hip flexion and control hip extension moment arm, and your obliques also control side flexion which your psoas also controls, so my right side psoas is a controller of left side flexion. So that becomes quite critical in terms of how the adductors, abdominals and hip flexors work as a unit to get a balance across the anterior pelvis.”
For every adductor load you give someone, you should give them an abdominal load to balance the pelvis.
For every abdominal and adductor load you give someone, you should give them a glute load to balance the pelvis.
- Hamstrings first – as they produce extension moment and adduction moment at the hip and help to control the pelvis, and if the hamstrings are inefficient the adductor load will go up.
- Abdominal load – in particular oblique bias including CSA of tissue not just control
- Hip flexor load
- Muscle capacity of running muscles – calves, quads and glute function as it relates to muscle capacity, and what does normal running look like technically, as if we can’t run then we are always going to struggle to kick or twist on the run?
It’s all about quads and calves
”So it’s about addressing the whole kinetic chain. Also be cautious about having the philosophy of it’s all about posterior chain and hamstrings and glutes and a posterior bias. If you just look at elite track & field athletes they have huge quads! So the first point is you have to produce vertical force in order to start running and that’s all quads and calves which you need to get that right first to produce your stride length. Then once you’ve got your stride length, it’s all about hip torque to produce your stride frequency. Stride length gets you up to 7 m/s and hip torque gets you beyond that!”
”Would attention on running mechanics help with this return to performance following groin injuries?”
”I think we need to start with what do we think is the minimal dose that we need to apply to the individual to try and reduce the risk, and if that comes in the form of a running mechanics or another stimulus. If the goal of a running stimulus is to improve the running mechanics and get them to move more like a sprinter I think that is really really difficult.
An elite 400 m sprinter will probably do near enough 2000 m of high quality speed work three times a week plus of all the drills which will probably be about 500-1000 m of work at the beginning of every session. So we are then talking about 7,500-9000 m per week of high quality speed work and that’s done week in week out for about 9 months before you get to race season. So the dosage to really get good mechanics and to really condition the tissues to that kind of load are really really high.
So maybe a footballer or rugby player is doing 1000 m of high quality speed work per match so I’m not sure you’ll necessarily see them get the same amount of dosage. But with that being said, if our goal is to condition the tissues to increase limb speed, shorter foot contact and a cognitive stimulus to get the patterning from a central nervous system or Frans Bosch decentralised spinal reflex point of view, that is reasonable. We’re not trying to turn them into runners, we are just trying to condition the tissue and not necessarily trying to hit the ”right positions’ from an elite sprinting point of view, but we are trying to get quick limb movement and short foot contact, where the outcome and the coaching cues will look different which is a very different coaching approach to coaching an elite sprinter on a track with spikes where you want a high knee, I want you to increase your stride length and that sort of thing.”
”Are there any key positions that you are looking for when you are observing a change of direction?”
”Different sports will have different strategies- e’g a rugby player may use muscle forces (concentric/eccentric) vs a basketball player using elastic/reactive (isometric forces). A change of direction also looks very different if you are moving over 5-10 m and getting up to 6 m/s versus a winger bombing down the pitch at 9-10 m/s.
Look at it with a coaching eye. Does it look efficient? Does it look effortless and free and I’d almost go back to coaching the individual and the way the individual moves and what feels right rather than getting into a very specific criteria for this is how you change direction.”
”Are there are any particular markers that you would look at as part of this return to performance following groin injuries?”
”We have different markers for different stages of rehab.
Early stage – start with clinical markers and reduction of pain such as squeeze test, abdominal load test and then can I get the abdominal to adductor ratios right (see next stage)? Markers need to move away from pain/pathology to function around the groin so 20 kg HHD or 2 Newtons/kg force across the groin and progressing to 25 kg HHD.
Next stage – progress to running specific markers, and balancing the pelvis, looking at ratios of adductor/abdominal and adductor/hip flexor and hamstring/hip flexor ratio, so you can start to see where the weak link is. Most elite level athletes get injured where they are strongest not where they are weakest, because they compensate to their strongest area which is the path of least resistance. Most of the aspiring athletes get injured where they are weak because they are trying to produce force and they just don’t have the capacity to do it and don’t have the compensatory strategies.
We might also have a functional test such as split squat for indication of capacity across the pelvis. When we get to return to running we can look at vertical force qualities, what’s their isometric squat like, peak plantar flexion force like, have they got some RSI markers we can look at? As well as looking at the balance between flexion/extension ratios.”
ADDUCTORS – 30-35 kg, and should be 60% of hip flexion, and 80% of extension.
ABDUCTORS – a little bit less than adductors- 20% behind adduction, and 60% of extension.
EXTENSION – should be primary torque producing force and FLEXION should be about 10% behind extension. Adduction should be 20% behind extension. You should be 40% stronger into extension than you are into abduction as a general ratio across the hip.
Look at those numbers relative to performance. In order for the way you run and/or kick, what do we know is your norm or what is the ideal we need to get you to? It’s about ratios around the hip rather than absolute numbers and it’s about the relative number relative to the numbers the athlete can produce in the demands of their sport demands.
Top 5 Take Away Points:
- Surgery decision process – The key really is that the physical signs should match up with the subjective complaint of pain.
- Rehab process – Does the tissue that is the source of pain need to be loaded or unloaded?
- Muscle balance – For every abdominal and adductor load you give someone, you should give them a glute load to balance the pelvis.
- It’s not all about posterior chain – you have to produce vertical force in order to start running and that’s all quads and calves which you need to get that right first to produce your stride length.
- Use your coaching eye -Does it look efficient? Does it look effortless and free and I’d almost go back to coaching the individual and the way the individual moves
Want more info on the stuff we have spoken about?
You may also like from PPP:
Episode 217, 51 Derek Evely
Episode 207, 3 Mike Young
Episode 192 Sprint Masterclass
Episode 87 Dan Pfaff
Episode 55 Jonas Dodoo
Episode 15 Carl Valle
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