If you have ever debated whether to load a patient on the Leg Press or progress them immediately to a Barbell Back Squat, you are not alone.

The "Free Weights vs. Machines" debate is a classic in strength and conditioning, and it is just as relevant in the rehabilitation clinic.

A 2023 systematic review and meta-analysis by Haugen et al. analysed 13 studies (n=1016) to settle the score on maximal strength, hypertrophy, and power.

Crucially, I also unpacked the specific protocols used in these studies so you can replicate the results.

Here is the evidence for your practice.

Part 1: The Verdict: It’s a Draw (Mostly)

The researchers compared the direct effects of free-weight (FW) training against machine-based (M) training.

• Maximal Strength: The Principle of Specificity (SAID) reigns supreme. Patients who trained with free weights improved significantly more on free-weight tests, while those on machines improved more on machine tests. However, when comparing the "direct effect size", there was no significant difference in strength gains between modalities.
• Hypertrophy: There was no significant difference in muscle growth between groups. Whether using a barbell or a pin-loaded stack, the muscle grows if the stimulus is sufficient.
• Power (Jump Height): Results showed no significant difference in countermovement jump performance, though there was a non-significant trend favouring free weights.
• Experience Level: Interestingly, training status (trained vs. untrained) did not influence the results - the findings held true for both populations.

Part 2: The "Meat & Potatoes" of the Protocols

To get these results, the studies did not just prescribe "3 sets of 10" forever. They utilised specific dosing parameters that you can adapt for mid-to-late stage rehab.

• The Exercises: The studies compared biomechanically similar movements. You can view these as interchangeable "clinical substitutions"
• Knee Dominant: Barbell Squat vs. Leg Press / Hack Squat.
• Push: Bench Press vs. Machine Chest Press.
• Frequency: Most protocols required 2 to 3 sessions per week.
• Duration: Interventions lasted between 6 and 12 weeks.
• Volume: The standard dose was 3 to 4 sets per exercise
• Intensity & Periodisation: Most studies used Linear Periodisation, progressively increasing load while decreasing volume;
• Phase 1: 10–12 reps (Capacity/Hypertrophy)
• Phase 2: 6–10 reps (Strength)
• Phase 3: 4–6 reps (Max Strength)

Clinical Interpretation & Actionable Takeaways

The study highlights that mechanical tension is the primary driver of adaptation, regardless of the source.

However, stability requirements differ. In complex movements (like a squat), the brain may prioritize stability over force production, whereas machines allow for maximum output without the "balance tax".

Here is how to implement this tomorrow:

1. Prioritise Preference for Adherence: Since hypertrophy and general strength gains are similar, let the patient's preference guide the equipment choice. If they are intimidated by barbells, machines are an equally effective alternative for building tissue.
2. Use Machines for "Force First": If a patient lacks the coordination for a heavy squat but needs significant quadriceps loading (e.g., post-op hypertrophy), use machines. They lower the stability requirement, allowing the target muscle to be taken closer to failure without form breakdown.
3. Train for the Test (Specificity): If you are rehabbing an athlete who needs to return to unpredictable environments (e.g., a team sport athlete), you must use free weights eventually. Strength gains are highly specific to the modality used.
4. Rehab the Movement, Load the Tissue: Consider a hybrid approach. The authors speculate that combining modalities may yield the best results. Use free weights to build coordination and functional capacity, and machines to exhaust specific muscles safely.

Bottom line: Stop worrying that machines are "non-functional." They are potent tools for hypertrophy and force production. Match the tool to the specific rehabilitation goal.

For a complete breakdown and a deeper dive, you are encouraged to read the full paper here:

If you work with junior basketballers, you’ve probably seen your fair share of “wonky” athletes; one leg that jumps better, lands better, or cuts harder than the other.

We care about that stuff because asymmetries can affect both performance and, potentially, injury risk.

This study by Cao et al (2024) looked at a really practical question: if we add plyometric training to youth male basketballers, is it better to focus on unilateral jumps, bilateral jumps, or a mix of both?

Short answer: all three help, but unilateral work seems to give you more bang for buck, especially if you care about asymmetries.

Who Were The Athletes?

The study followed 66 male youth basketball players:

• Around 16 years old
• About 180 cm and 68 kg on average
• Training three times per week with their team plus games
• At least two years of basketball experience
• No recent injuries and no extra gym/S&C work on the side

They were randomly split into four groups:

• Unilateral plyometric group (UT)
• Bilateral plyometric group (BT)
• Combined unilateral + bilateral group (UBT)
• Control group (basketball training only)

So this is a pretty “real world” youth hoops squad scenario.

What Did The Training Actually Look Like?

All players kept doing their normal basketball training.

On top of that, the three plyometric groups did:

• Eight weeks of plyos
• Two sessions per week
• Plyos done before basketball training

Session structure:

• Session 1 each week: mostly horizontal plyos
• Session 2 each week: mostly vertical/reactive plyos

Warm-up for everyone: five minutes of light running, five minutes of dynamic leg work, five minutes of balance drills.

Examples of exercises (see full text paper link below for comprehensive plyo program):

• Unilateral group:
• Single-leg broad jumps
• Single-leg three-bounce jumps
• Single-leg pogos
• Single-leg countermovement jumps
• Single-leg drop jumps from 10 cm
• Bilateral group:
• Two-leg broad jumps
• Three consecutive bilateral horizontal jumps
• Bilateral pogos
• Bilateral countermovement jumps
• Bilateral drop jumps from 10 cm
• Combined group:
• A blend of both across the week

Volume:

• Weeks 1–4: about 100 jumps per week
• Weeks 5–8: about 150 jumps per week
• Roughly 1000 total contacts over eight weeks

Rest breaks between sets were 3mins and the focus was on high quality, maximal effort reps rather than fatigue.

How Did They Test It?

All tests were done on each leg separately, before and after:

• Isometric single-leg squat strength
• Single-leg countermovement jump (height and force)
• Isometric knee flexor strength at 30 degrees
• Single-leg land-and-hold from 30 cm (landing force)
• 5-0-5 change of direction test, cutting off each leg

They then calculated asymmetry between limbs for each test.

What Did They Find?

A few key takeaways:

• All three plyometric groups improved performance compared to baseline
• Unilateral training often produced the biggest gains in single-leg strength and power
• Unilateral and combined groups tended to reduce asymmetries
• The bilateral group, interestingly, increased asymmetry in some measures
• Change of direction times improved in all plyometric groups, with unilateral again having an edge in some conditions

So, if you’re chasing both performance and more symmetrical legs, unilateral work looks pretty handy.

What Can We Do With This Tomorrow?

If you’re working with youth basketballers (or similar COD athletes), this study supports:

• Making unilateral plyos a regular feature, two times per week for at least eight weeks
• Using simple progressions like:
• Session 1 (horizontal focus): single-leg broad jumps and three-bounce hops
• Session 2 (vertical/reactive): single-leg pogos, single-leg jumps, low box drop jumps

You don’t need fancy tech to monitor it:

• Test single-leg jump height or hop distance on each leg
• Watch their land-and-stick quality
• Time a simple 5-0-5 off left and right

The big clinical takeaway: any plyos are probably better than none, but if you’re trying to clean up side-to-side differences and sharpen COD, giving unilateral plyos top billing – with bilateral as the support act – is a very reasonable, evidence-backed place to start.

For a complete breakdown and a deeper dive, you are encouraged to read the full paper here:

Is manual therapy actually worth it after a knee replacement?

This trial from Argut et al (2020) gives us a clear nudge: yes, but when it’s gentle, targeted, and paired with smart exercise.

This randomized controlled trial compared a manual therapy + exercise program versus exercise alone in adults following primary unilateral TKA for severe OA.

Forty-two patients (mean age ~68.5 years; BMI ~34; Kellgren–Lawrence grade 3–4) were randomised during their hospital stay and followed to 2 months.

What they did:
Everyone received standard peri-op care: education, daily physio reviews, and cryotherapy 15 min × 5/day with the leg elevated.

Day 1 focused on breathing, ankle pumps, quads sets, and early ambulation.

From post-op day 2 until discharge, both groups completed a structured program (typically 3x10 program):

• active-assisted knee flexion/extension,
• straight-leg raises,
• hip/knee flexion in standing,
• hamstrings/calf stretching,
• gait training,
• transfers and stair practice

After discharge, all patients continued a daily home program (2×10 reps/exercise), logged in a diary, with weekly phone check-ins.

The manual therapy group also received 15–20 minutes/session of gentle techniques delivered by an experienced therapist:

• Patellofemoral glides (superior/inferior; medial/lateral)
• Tibiofemoral posterior glides (for flexion) and anterior glides (for terminal extension),
• Soft-tissue mobilization around medial/lateral/posterior knee, plus scar friction.
• Dosing was Grade I–II oscillations, 30 s × 3 sets per technique.

What they measured:

• Primary: pain (NPRS) and knee flexion ROM.
• Secondary: extension ROM, WOMAC total/subscales, 10-meter walk test (10MWT), 5× sit-to-stand (5SST), and SF-12 (PCS/MCS), plus Global Rating of Change for satisfaction.

Assessments were pre-op, discharge, 2 weeks, and 2 months (PROMs at pre-op, 2 w, 2 m).

Key results:

• Pain: Clear win for manual therapy. There was a significant group×time effect; the between-group change favored manual therapy by ~1.3 NPRS points at 2 months, approaching commonly cited MCIDs. Patients in the manual therapy arm also reported lower in-session pain and stiffness across treatments.
• Function: WOMAC total and 10MWT improved more with manual therapy (significant interactions). 5SST improved similarly in both groups.
• Quality of life: SF-12 mental component improved more with manual therapy; physical component improved in both with no between-group difference.
• ROM: Both groups hit ≥100° flexion and full extension by 2 months. The manual therapy group showed a larger mean flexion gain (~+12.8°), exceeding some ROM MCIDs, but the overall group×time effect for flexion/extension was not significant.
• Patient satisfaction: More patients rated themselves “much better” with manual therapy at 2 weeks (+29%) and 2 months (+25%).

How I’d bring this to the clinic tomorrow:

1. Blend gentle manual therapy into your early inpatient sessions.
   Use Grade I–II patellofemoral glides (all directions) and tibiofemoral ant/post glides to ease pain and stiffness and to facilitate early movement. Dose 30 s × 3 sets per technique, then immediately chase with task-specific exercise (heel slides → sit-to-stand → short walks).
2. Track what changes fastest: pain and walking speed.
   Add a sessional NPRS and a simple 10MWT each visit or phone check-in. Patients in the manual therapy arm walked faster and hurt less; two quick metrics your team and the patient can see and feel.
3. Keep ROM milestones realistic and functional.
   Aim for early extension to 0° and progressive flexion, targeting ≥100° by ~2 months; consistent with both groups here. Don’t oversell ROM gains from manual therapy alone; use it to enable loading and gait practice, not replace them.
4. Sweat the basics that improve experience.
   This protocol paired manual therapy with frequent cryotherapy, clear home-exercise dosing (daily, 2×10), diary compliance, and weekly phone support; likely contributors to the higher patient-reported “much better” ratings. Build these touchpoints into your pathways.

Bottom line: In the first 2 months after TKA, adding gentle, targeted manual therapy to a solid exercise pathway improves pain, perceived stiffness, walking speed, mental well-being, and satisfaction. ROM still comes with time and work; manual therapy seems to smooth the road, not teleport the knee to end-range.

For a complete breakdown and a deeper dive, you are encouraged to read the full paper here:

If you work with runners or track & field athletes, calf muscle injury (CMI) is a regular visitor.

This 8-season prospective study followed 201 elite athletes on the British Athletics World Class Programme from 2011–2019, covering 616 athlete-seasons.

The cohort included 109 men (mean age 24.4) and 92 women (mean age 25.1), typically spending ~3.1 ± 2.0 seasons on the program.

Events spanned sprints, hurdles, middle/long distance, jumps, throws, multi-events, race walking and marathon.

How common and how costly?
About 11% of athletes sustained a CMI in any given season. Nine in ten led to time loss, with a median of 19 days out (mean ~29 days). One-third were severe (>28 days). That’s real disruption - especially because cases clustered in April, right before the northern summer competition window.

Which muscle?

CMIs skewed heavily to the soleus (61%), with gastrocnemius ~31%. No surprise: the soleus is a workhorse across running speeds and acceleration, handling huge forces in knee-flexed positions.

Who’s at higher risk?
Two clear signals:

• Age: Each additional year increased the incidence of both medical-attention and time-loss CMIs (~9–11% per year).
• Previous lower-limb injury: More prior injuries = higher CMI risk.
• Sex wasn’t a factor.

Event-group flavour:
Time-loss burden (days lost per athlete-season) was highest in multi-events, hurdles, and middle distance. There was also a right-side bias in several groups (sprints, jumps, middle distance, multi-events), which likely reflects bend-running mechanics and/or take-off leg demands.

Recurrence: less than you’d think, but a soleus story. Recurrences were ~16% of all CMIs, almost entirely soleus, and tended to recur months later (median ~214 days, mean ~364). Severity at recurrence looked similar to index injuries. Translation: once they’re “better,” don’t forget about that soleus - capacity needs to be maintained long after return to full training.

What do we do with this?

1. Build and keep soleus capacity.
   Make knee-flexed plantarflexor strength non-negotiable (think seated calf raises: heavy slow resistance and isometric holds), then progress into range, velocity and RFD work. Keep some soleus loading in season, not just pre-season.
2. Coach the calendar, not just the set/rep.
   Because incidence peaks before competition, manage exposure in the 6–8 weeks beforehand. Avoid big spikes in fast running, bends, jump approaches and race-specific sessions. Sharpen, don’t surge.
3. Stratify risk and individualise.
   Older athletes and those with any lower-limb injury history deserve earlier screening, tighter load progressions, and more frequent check-ins. For hurdles/middle distance/multi-events, be explicit about bend-running exposure and monitor side-to-side capacity.

Three actionable tips for Physios (use this week)

1) Knee-flexed calf strength block (2–3 days/week):

• Seated calf raise: 4×6–8 heavy (2–3 s ecc), progress to mid-range isometric holds 3–4×30–45 s near session days.
• Add end-range plantarflexion strength (e.g., Smith machine calf raises with full ROM) and a fast-intent block (lighter loads, crisp concentrics).

2) Pre-season “calf health” screen (weekly for 6–8 weeks):

• Quick check: localized soreness map, single-leg calf-raise count/quality, low-amplitude pogo tolerance, next-day stiffness.
• If flags pop up, dial back bend volume and top up isometrics around key sessions.

3) Event-specific exposure log:

• Track bend-running minutes/reps and fast-running dose alongside gym work for hurdles/middle distance/multi-events.
• Spread bend load across the week and balance left/right calf loading in the gym (e.g., unilateral tempos, matched isometric holds both sides).

Bottom line: CMIs are common, soleus-heavy, and season-sensitive in a young, high-performance cohort (men ~24, women ~25).

Protect the calendar, prioritise knee-flexed calf capacity, and tailor exposure to the event and athlete to keep more runners on the track when it counts.

For a complete breakdown and a deeper dive, you are encouraged to read the full paper here:

Chronic low back pain in older adults takes up a huge part of our days.

And we've all seen the frustrating cycle: short-term gains fade, leaving patients feeling stuck.

This demographic is often excluded from major trials, leaving us to adapt protocols designed for younger populations while wrestling with their unique risks and needs.

A landmark randomised trial conducted by Silva et al (2025), the ESCAPE trial, offers a powerful blueprint for this exact challenge.

Researchers designed a group exercise program from the ground up for older adults, then pitted it against a waitlist control to see if a tailored approach could deliver lasting results.

The study followed participants for 8 weeks. Here’s a detailed look at what each group did.

The ESCAPE Exercise Program

This group attended one-hour group sessions three times a week. The program was comprehensive, progressed in intensity over the 8 weeks, and required minimal equipment like chairs and mats. Each session included:

• Warm-up (5 mins): Self-regulated walking.
• Aerobic (20 mins): Moderate-intensity walking, with participants aiming for a perceived effort of 3 to 4 on a 10-point Borg scale.
• Strength & Balance (30 mins): Resistance training for major muscle groups in the legs, trunk, and arms, performed to the point of volitional fatigue. This was combined with balance exercises that progressed in difficulty.
• Cool-down (5 mins): Self-regulated walking.

Crucially, the program was meticulously designed for older adults by adapting exercises for safety (eg, performing balance exercises in pairs), modifying floor exercises to standing or sitting alternatives, and fostering community through social interaction.

The Control Group

Participants in this group were placed on an 8-week waiting list. They were instructed to continue their usual daily activities and were permitted to use previous treatments like medication. The research team contacted them weekly to monitor their status.

The Results:

Outcomes were tracked for a full year, and the exercise group showed impressive, durable benefits.

• Meaningful Pain & Disability Relief: The program delivered clinically significant improvements. The Number Needed to Treat (NNT) was just 2-3 for pain and 2-4 for disability, meaning for every few patients treated, one extra person achieved a worthwhile improvement compared to no intervention. These benefits were largely sustained at 12 months.
• Lasting Global Effect: Patients in the exercise group felt significantly better, and this positive perception was maintained for the entire 12-month period.
• Likely Reduction in Falls: Over the long term, the data showed that the intervention is likely to reduce falls—a massive co-benefit for this population.
• No Change in Fear: Interestingly, the program had a negligible effect on the fear of falling, suggesting this complex issue may require a more targeted, multidisciplinary approach.

Actionable Tips for Your Practice

The clear takeaway from the ESCAPE trial is that how we deliver exercise matters as much as what we prescribe. Here are three actionable tips from their successful model:

1. Adapt, Don't Exclude. Instead of viewing an older adult's limitations as barriers, use this study as a template for adaptation. Simple modifications like chair-based alternatives for floor exercises or using a partner for balance support make programs accessible and effective.
2. Build a Community, Not Just a Class. The study's focus on social interaction was key to its success. Foster this in your groups by using paired exercises or allowing time for social chat. This builds the camaraderie and accountability that keeps people engaged.
3. Target More Than Just Pain. The program’s comprehensive nature drove its wide-ranging benefits. For your older patients with CLBP, ensure your prescription is holistic. As this study suggests, adding a dedicated balance component is crucial and may provide the life-saving co-benefit of reducing long-term fall risk.

For a complete breakdown and a deeper dive, you are encouraged to read the full paper here:

Stretching is one of those things we’ve all been taught to prescribe, whether it’s in warm-ups, cool-downs, or rehab sessions.

But let’s be honest - how often do we stop to question why we’re doing it, and whether the evidence actually supports it?

A recent international Delphi consensus paper pulled together 20 stretching experts from around the world to cut through the noise.

Their mission? Review the mountain of stretching studies, agree on definitions, and give us some clear, practical recommendations.

Here are the key take-homes you need to know.

What Stretching Does Well..

1. Improves range of motion (ROM).
Both short-term (a few bouts of 5–30 seconds) and long-term (2–3 sets of 30–120 seconds per muscle daily) stretching improve flexibility. Static and PNF work best for longer-term changes. But here’s the kicker; other methods like full-range resistance training, foam rolling, or even cycling can get you similar results.

2. Reduces muscle stiffness.
If your goal is to acutely reduce stiffness, longer holds (4+ minutes per muscle) are needed. Over weeks, regular intensive stretching (4+ minutes per muscle, 5 days per week) can make muscles more compliant. Just remember though; sometimes stiffness is helpful (e.g., in running and jumping sports).

3. May support cardiovascular health.
Static stretching of ~15 minutes per muscle, 5 days a week, has been linked to improved arterial stiffness and endothelial function. It’s early days, but it could be a useful option for people unable to do aerobic or resistance training.

What Stretching Doesn’t Really Do...

• Not great for strength or hypertrophy. Unless you’re holding stretches for 15+ minutes per muscle per day for weeks (which isn’t very practical), stretching isn’t going to build strength or size. Resistance training is still king.
• Not reliable for injury prevention. The evidence is patchy. Some signs point to fewer muscle strains with stretching, but other injuries (like bone/joint) may increase. Overall: don’t hang your hat on stretching for prevention.
• Not effective for posture correction. Stretching alone won’t fix “upper crossed syndrome” or similar. Strengthening weak muscles is far more effective.
• Not a recovery tool. Sorry, but stretching post-exercise won’t reduce DOMS or speed recovery. If athletes enjoy it, that’s fine, but don’t prescribe it as a magic fix.

The Practical Bottom Line..

Stretching isn’t useless.

But it’s also not the cure-all it’s often sold as. Think of it as one option in your toolkit, with clear strengths (ROM, stiffness, vascular health) and clear limits (strength, hypertrophy, injury prevention, posture, recovery).

Actionable Tips for Physiotherapists:

1. Be intentional with stretching prescriptions. Use static or PNF stretching if the goal is long-term flexibility, and keep holds 30–120 seconds. For warm-ups, short static or dynamic stretches are fine, but avoid prolonged static holds (>60s per muscle) before explosive tasks.
2. Don’t oversell stretching. Be upfront with patients. Stretching won’t prevent injuries or fix posture on its own. Pair it with strengthening, balance, and movement-specific training for best outcomes.
3. Consider patient context. For those who can’t (or won’t) do resistance training - like some older adults or people with health conditions - structured static stretching can provide small but meaningful benefits for strength, vascular health, and ROM.

In conclusion, stretching has a place, but it’s not a golden ticket. Use it with purpose, alongside other evidence-based strategies, and you’ll be setting your patients up for success.

For a complete breakdown and a deeper dive into this paper, you are encouraged to read the full paper here:

We've all had that athlete in the clinic, right? They've passed their return-to-play protocol, ticked all the neurological boxes, and are absolutely itching to get back on the field. But what if I told you that clearing their head might not be enough to protect their shoulders?

A cracking recent study by Roach et al (2023) suggests we might be missing a massive piece of the puzzle.

So, what did the clever folks in this study do? They took a massive group of fit, uni-aged cadets over at the United States Military Academy and got to work. They identified 316 cadets who'd recently had a concussion and matched them perfectly with another 316 who were concussion-free.

For a full 12 months after the concussed group was given the all-clear, the researchers simply watched and recorded any new upper body injuries - think shoulder dislocations, wrist fractures, you name it.

And the results?

Well, to be honest, they're pretty staggering. The findings paint a very clear picture that a knock to the head has some serious downstream effects on the rest of the body.

• Double the Trouble: The concussed group had a much rougher time. A whopping 19.3% of them picked up an arm or shoulder injury in the following year, compared to just 9.2% of the non-concussed cadets.
• The Real Risk: When you crunch the numbers, the concussed athletes were 2.25 times more likely to sustain a new upper extremity injury.
• It's Not a Fluke: Even when the researchers accounted for other things like playing at a high level or having a previous injury, the risk was still huge. The concussed group was 1.84 times more likely to get hurt. This tells us the concussion itself is a massive contributing factor.
• A Lingering Problem: This increased risk wasn't just for a few weeks. It seemed to hang around for the entire 12-month follow-up period.

So, what do we, as physios on the ground, do with this info? It's all about being smarter and more thorough in our rehab. Here are my thoughts:

1. Don't Just Clear the Head, Clear the Whole Body. This research is a powerful reminder that "asymptomatic" doesn't always mean "fully recovered". When that athlete is ready to return, we need to be doing a full-body biomechanical screen. Their brain might feel fine, but their neuromuscular control, reaction time, and proprioception might still be lagging, putting their joints at risk.
2. Beef Up the Neuromuscular Rehab. The study hints that the wiring between the brain and the muscles might be a bit fuzzy after a concussion. This is our bread and butter! Let's double down on neuromuscular training once they're cleared for activity. Think balance work, plyometrics, and reaction drills that challenge the upper body. We need to help the brain and body get back on the same page.
3. Remember the Person, Not Just the Injury. Interestingly, the study found a link between higher "somatisation" scores (where psychological stress shows up as physical symptoms) and injury risk. It’s a great reminder to check in with our athletes. How are they coping? Are they anxious about returning? A holistic approach that supports the person is always going to get a better outcome.

At the end of the day, this is a brilliant bit of research that helps us do our jobs better. It's not about bubble-wrapping our athletes, but about being more deliberate in our rehab to ensure they return to sport safer and stronger.

For a complete breakdown and a deeper dive into this paper, you are encouraged to read the full paper here:

We've all been there - an athlete gets a minor knock, a bug, or heads off on a well-earned holiday. We figure a fortnight off is no big deal, right? They come back, hit the gym, lift heavy, and everything seems fine.

But what if the strength that really matters - the high-speed, bullet-proofing kind that protects them from injury - has silently plummeted?

A cracking paper by Yamashita and colleagues (2023) should make every single one of us rethink what "a short rest" actually means for our athletes.

So, what was the point of the study?

The researchers wanted to find out how two weeks of complete training cessation affects the knee extensor (quads) and knee flexor (hamstrings) strength in highly trained sprinters.

Crucially, they didn't just look at one type of strength. They wanted to see if there were different effects on:

• Slow concentric strength (think lifting a heavy weight slowly).
• Fast concentric strength (think explosive, high-speed movements).
  
• Eccentric strength (the 'braking' force of a muscle).

They also specifically looked at knee flexion strength during the Nordic Hamstring Exercise (NHE), a clinical favourite for hamstring health.

What did they do?

The study involved13 highly-trained male sprinters. The design was pretty straightforward:

• Baseline Testing: The sprinters had their knee strength thoroughly tested using isokinetic dynamometer for slow concentric (60 deg/s), fast concentric (300 deg/s), and slow eccentric (60 deg/s) contractions.

They also measured their max torque during a bilateral NHE. Their body composition was also recorded.

The Break: The athletes then had two weeks of complete training cessation. They were told to carry on with normal daily life but do zero physical training – no running, no lifting, not even stretching! 

Post-Break Testing: After the two weeks were up, they repeated all the exact same tests.

The Key Results

This is where it gets really interesting.

Body composition didn't change: Two weeks off had virtually no impact on their body mass or muscle mass. So, the athletes looked the same.

Slow strength was maintained: There were no significant changes in slow-speed concentric strength for either the quads or the hamstrings. An athlete could likely go into the gym and lift the same heavy-and-slow weights without noticing a difference.

Fast concentric strength dropped: Strength during high-speed contractions significantly decreased for both knee extension (-5.9%) and flexion.

Eccentric strength took a big hit: This was the most dramatic finding. Eccentric strength dropped by a massive 15.0% in both the quads and hamstrings. This reduction was significantly larger than the drop in fast concentric strength.

Nordic strength also dropped: Knee flexion torque during the NHE also declined significantly (between -7.9% and -9.9% depending on the leg).

Interestingly, the size of the drop in eccentric strength measured on the dynamometer was not related to the size of the drop in NHE strength. This supports the idea that they measure different qualities of muscle function.

What does this mean for us in the clinic?

These findings have some pretty direct and actionable implications for our practice. Here are my key takeaways:

• An athlete returning from a two-week break might feel fine and still be able to push good numbers on a heavy, slow lift like a squat or leg extension. This paper shows that this can give a false sense of security. Their more explosive, speed-based strength and, most importantly, their eccentric 'braking' capacity will have taken a significant hit. This is a massive risk factor for re-injury, especially for sprint-type hamstring strains.
• When an athlete comes back, your programme needs to immediately address these specific deficits. Don't just slowly ramp up their old programme. Actively target the losses by including eccentric-focused exercises (like Nordics, RDLs) and high-speed concentric work (like jumping, fast-velocity lifting) right from the get-go.
• If you're doing return-to-play testing, don't just rely on a 1RM squat. You need to assess eccentric and high-velocity strength. The NHE is a great, accessible clinical tool, but remember it doesn't tell the whole story. If you have access to a dynamometer, great. If not, use a range of tests that challenge the muscle in different ways (e.g., NHEs, single-leg hopping for distance, etc.).
• This is a fantastic paper to share. We need to make it clear that even a short two-week period of total rest can dramatically reduce specific types of strength that are crucial for injury prevention. This should influence how we plan off-seasons or manage short breaks. Perhaps "active recovery" with a minimum dose of eccentric and high-speed work is a much better strategy than complete rest.

So, the next time an athlete takes a couple of weeks off, remember they're not coming back the same as they left, even if they look and feel strong in the weights room. The devil is in the detail, and in this case, the detail is eccentric and high-speed strength.

For a complete breakdown and a deeper dive into this paper, you are encouraged to read the full paper here:

What if your strongest, most powerful client - the one who aces every dynamometer test - lacks the endurance to perform when it truly counts?

It’s a gap in assessment that many of us might be missing.

A fascinating study by Lehecka et al. (2025) puts this very idea under the microscope using the Single-Leg Wall Squat (SLWS) test, and the results could change how you approach late-stage rehab and performance training.

A Closer Look at the SLWS Test Protocol

To ensure their results were reliable, the researchers used a highly specific and consistent protocol.

Participants first had their maximal isometric strength of the hip extensors, abductors, and knee extensors measured with a handheld dynamometer.

After a 2min rest period, the SLWS test was performed as follows:

• The participant stands with their head, shoulders, and back flat against a wall. Their feet are positioned together, precisely 30 centimeters (12 inches) away from the wall.
• One leg is lifted off the ground by extending the knee of the non-tested limb.
• The participant slowly lowers their body by flexing the hip and knee of the stance leg until their fingertips touch a pre-measured tape marker placed 15 cm (six inches) below their starting fingertip position. They then immediately return to the start.
• A metronome dictates the speed, ensuring each repetition lasts exactly two seconds (one second down, one second up).
• The test continues until volitional failure, which is defined as the inability to complete a full repetition using correct form in time with the metronome.
• Throughout the test, standardised verbal feedback is provided to maintain proper speed and form.

Key Findings: Strength ≠ Endurance

1. Isolated Strength Did Not Predict Endurance Performance

The central finding was that there was no significant correlation between HHD strength measures and the number of SLWS repetitions a person could complete. The study suggests that the SLWS test captures a more complex interplay of factors beyond just peak force production, challenging coordination, balance, and proprioceptive feedback.

2. No Significant Performance Difference Between Sexes

Despite males demonstrating significantly higher absolute strength values in every HHD test, there was no statistically significant difference in SLWS performance between males and females. Males averaged 86 reps and females averaged 63 reps.

3. It's a Demanding Test

The SLWS test elicited a high physiological strain, with an average Rate of Perceived Exertion (RPE) of 8.3 out of 10. The primary reason for stopping was gluteus maximus fatigue (41.4%), followed by quadriceps fatigue (34.5%).

Clinical Caveats and Applications

It's crucial to acknowledge that this study was conducted on a homogenous group of healthy, young university students. Therefore, we must be cautious when generalising these results directly to injured, deconditioned, or older patient populations.

However, the findings provide a valuable benchmark.

For patients in later-stage rehabilitation whose goals involve high levels of endurance - like runners or field sport athletes - these results can help inform our targets. The average performance of 76 repetitions in this healthy cohort can serve as a potential standard to aim for when returning an individual to full, resilient function.

Actionable Takeaways

• Don't just rely on the HHD. Add the SLWS test to your assessment battery to get a real-world picture of a patient's muscular endurance and neuromuscular control. It can reveal functional deficits that isolated strength testing might miss.
• A patient might have symmetrical quad strength, but can they control their body weight through dozens of single-leg squats? This test shifts the focus from pure strength to sustainable, coordinated movement.
• Use the patient's reason for termination as a diagnostic clue. Did they stop due to fatigue in the target gluteal or quad muscles, as seen in the study? Or did they stop because of poor balance, compensation, or pain (which no participants in this study reported )? This tells you where to direct your intervention.
• For athletes recovering from lower limb injuries, the SLWS can be used to track progress and set objective goals for endurance. Aiming for performance similar to that of a healthy, active population can build confidence and resilience against re-injury.

Conclusion

The single-leg wall squat test proves to be a robust tool for assessing functional lower limb endurance, offering insights that isolated strength measures cannot. This research reinforces a fundamental clinical concept: strength and endurance are distinct and separate qualities. By incorporating this simple, effective test into our practice, we can gain a more comprehensive understanding of our patients' functional capacity and better prepare them for the demands of their life and sport.

For a deeper dive into this wonderful paper, click here:

Let's talk about one of the most common questions we get in the clinic: a patient with a history of chronic low back pain (LBP) looks at you, full of hope and hesitation, and asks, "So, is it really okay for me to start running?".

For too long, the narrative around LBP has been one of fear, caution, and avoidance, leaving many of our patients (and maybe even some of us) unsure.

Well, what if I told you a brand-new randomised controlled trial by Neason et al (2025) just dropped that gives us the evidence to answer that question with a confident "YES!"?

This paper, the ASTEROID trial, gives us the data and the framework to safely get our patients with non-specific chronic LBP back on the track or trail.

The Lowdown on the Trial

The researchers took 40 adults aged 18-45 with non-specific chronic LBP (pain lasting ≥3 months) and split them into two groups.

• One group was put on a 12-week progressive run-walk interval program that was digitally delivered and remotely supported by an exercise physiologist.
• The other was a waitlist control group.

To measure success, they used a couple of key patient-reported outcomes:

• Pain Intensity: Measured using a 100-point visual analogue scale (VAS) for current, average, and worst pain.
• Disability: Assessed with the Oswestry Disability Index (ODI).

The "How": A Look at the Run-Walk Program

This wasn't just a "go out and jog" prescription. The program was brilliantly designed to be gradual and adaptable, which is key for our clinical practice.

It was a 13-stage interval program. Participants started at Stage 1, 2, or 3 based on their tolerance in a simple 2-minute run test.

To give you an idea of how gently this program builds up, here is the progression through the first six stages. Each session involved repeating these intervals 6 to 10 times.

• Stage 1: Run for 15 seconds, then walk for 120 seconds. (A very low-threat starting point).
• Stage 2: Run for 30 seconds, then walk for 120 seconds.
• Stage 3: Run for 45 seconds, then walk for 115 seconds.
• Stage 4: Run for 60 seconds, then walk for 90 seconds.
  
• Stage 5: Run for 75 seconds, then walk for 75 seconds.
• Stage 6: Run for 90 seconds, then walk for 60 seconds.

This sensible pattern of gradually increasing the run time, often by 15 seconds per stage, while decreasing the walk time continues right through to the final Stage 13, where participants run for a full 3 minutes with only a 15-second walk break.

Crucially, progression was not forced. Participants only advanced if they felt comfortable and met specific criteria. They had the option to stay at their current stage or even regress if they had a flare-up or a period of poor adherence.

What Did They Find?

The results were incredibly encouraging. The running group showed statistically significant improvements in average pain intensity and disability compared to the control group. The program was also highly acceptable: there was zero attrition , and adherence was solid at 70%.

Now, it’s vital to add a note of caution here: the study’s follow-up only extended to the 12-week (3-month) mark. We don't have data on whether these positive effects were sustained longer-term.

Nevertheless, this is a ground-breaking paper. For too long, advice has been dominated by fear and uncertainty. This trial provides robust evidence that allowing a patient to engage in a run-walk program is not harmful and is, in fact, safe and acceptable.

While there were seven instances of lower limb pain/injury, there was only one case of increased LBP , and the overall risk of an adverse event was similar to the general population starting a new running program.

This evidence helps us dismantle the fear-avoidance cycle and confidently state that running can be a suitable part of a management plan.

Actionable Tips for Your Practice

• For your patients with non-specific chronic LBP who are interested in running, this study gives us a green light. We can state that a gradual program is not only safe but likely beneficial.
• Use the run-walk method described in this study as your template. A gentle start with ample walking recovery is the perfect way to reintroduce running and build a patient's self-efficacy.
• The study protocol included educating participants on running safety, footwear, and managing setbacks. We must do the same to address our patients' fears and give them ownership over the process.
• While the risk of a major LBP flare-up appears low , it's still vital to monitor progress and be prepared to temporarily modify the program - just as they did in the trial.

In short, while we must be mindful of the 3-month follow-up, this trial provides much-needed evidence to challenge outdated narratives. It shows that for the right patient, running is not something to be feared, but an accessible and effective tool to be embraced.

For a deeper dive into this wonderful paper and it's amazing resources, click here:

A recent paper in The New England Journal of Medicine has given us some robust data to work with when it comes to treating acute Achilles tendon ruptures (ATR).

We've all seen the debates and conflicting evidence, but this large-scale, multicenter, RCT by Myhrvold et al (2022) has shed some much-needed light on the matter. They compared three treatment options: nonoperative treatment, open surgical repair, and minimally invasive surgery. And the results? Well, they might just surprise you.

Study Design

The study included adults between the ages of 18 and 60 who presented with an acute Achilles' tendon rupture.

Patients were excluded if they had a previous Achilles' tendon rupture, had received quinolone antibiotics or local glucocorticoid injections in the six months before the injury, or had other disabilities affecting their ability to walk.

A total of 554 patients were enrolled and underwent randomisation. The final analysis included 526 patients.

The characteristics of the three groups at baseline were similar, with a mean age of around 39 to 40 years and over 70% of participants being male. The trial participants' ethnic composition was also representative of the Norwegian population.

All participants, regardless of their assigned group, received a below-the-knee equinus cast within 72 hours of the injury. The cast was maintained for two weeks. After the cast was removed, patients were allowed to bear weight as tolerated using an ankle-foot orthosis with heel wedges for six weeks. This was part of a standardised rehabilitation protocol followed by all participants.

The primary outcome they measured was the change in the Achilles' tendon Total Rupture Score (ATRS) at 12 months.

Results:

What the researchers found was that there was no significant difference in ATRS outcomes between any of the three groups.

This is a massive finding.

It means that whether a patient goes for surgery or chooses the nonoperative route, their patient-reported function at one year is likely to be the same.

Now, the study didn't just stop at patient-reported outcomes. They also looked at physical performance and other secondary measures. Once again, there were no significant differences.

So, for all the talk about surgical repair leading to a "stronger" tendon or better functional outcomes, this study provides strong evidence that it just isn't the case in the long run.

But wait, there's more..

Of course, the study did highlight some important trade-offs between the treatments, and this is where we need to pay close attention.

• Rerupture Rate: Nonoperative treatment had a higher rerupture rate (6.2%) compared to both open repair (0.6%) and minimally invasive surgery (0.6%). This is a significant difference and one of the main reasons many clinicians have favoured surgery.
• Nerve Injuries: The tables turned when it came to nerve injuries. The minimally invasive surgery group had a 5.2% incidence of nerve injury, compared to 2.8% in the open repair group and a mere 0.6% in the nonoperative group. This is a crucial point to discuss with patients when weighing up the risks and benefits of surgery.

So, where do we go from here?

Here are some actionable tips for my fellow clinicians:

1. Educate your patients thoroughly: This study provides the perfect evidence base for a balanced conversation with patients. Present the data clearly: similar long-term function and ATRS scores for all three options, but with a trade-off between rerupture risk and nerve injury risk.
2. Rerupture risk is real, but a choice: A 6.2% rerupture rate is not insignificant, and it's something that needs to be factored into decision-making. However, some patients may be willing to accept that risk to avoid the potential complications and recovery of surgery, particularly the risk of nerve injury.
3. Standardised protocols are key: The study used a standardised rehabilitation protocol for all groups, including a cast for 2 weeks followed by a walking boot with heel wedges. This highlights the importance of a well-defined and consistent rehabilitation plan, regardless of the initial treatment choice, to ensure the best possible outcomes. If you're looking for rehab guidance for both non-op and tendon repair - be sure to check out our latest Achilles Tendon Practical with Cam Dyer

In conclusion, this landmark study provides compelling evidence that the long-term functional outcomes for Achilles tendon ruptures are similar whether a patient is treated surgically or nonoperatively. The decision, therefore, hinges on a careful discussion of the patient's priorities and their willingness to accept a higher risk of rerupture with conservative treatment versus the higher risk of nerve injury with surgery.

Full text reference to read more on this fascinating paper is here:

For physiotherapists, plyometric training is a go-to method for enhancing athletic power and speed. We meticulously design programs, but a crucial question often dictated by simple logistics is: does it matter when our athletes perform these exercises?

A 2020 study in the Journal of Strength and Conditioning Research provides a clear answer, demonstrating that the sequencing of plyometrics can significantly impact its effectiveness.

The Research: Before or After?

The study investigated the effects of a seven-week plyometric jump training (PJT) program on the physical fitness of 17-year-old male soccer players. Researchers divided players into three groups: one performing plyometrics before their regular soccer session (PJT-B), one performing it after (PJT-A), and a control group that only did regular soccer training.

The researchers measured changes in sprint speed, jumping ability, change-of-direction, and endurance.

The Plyo Program

The plyometric intervention was highly practical and designed to integrate into a regular season.

• Frequency & Duration: The program ran for seven weeks, with two 20-minute sessions per week.
• Load Management: Crucially, it was not an additional load. The PJT sessions replaced approximately 11% of the players' low-intensity technical drills.
• Progressive Volume: The program progressed from 104 jumps per leg in week one to a peak of 204 jumps per leg in week six, before tapering in the final week. Rest periods of 30-60 seconds were taken between sets of drills.
• Exercises: The sessions included 13 different vertical and horizontal exercises. For example, the repetitions for Squat Jumps and 20-cm Drop Jumps progressed from 5 reps in week one to 10 reps in week six (see full text paper for full program).

Key Findings

While both plyometric groups improved, the timing created significant differences.

Performing plyometrics before the main soccer practice resulted in substantially larger improvements across most measures of power and speed.

• Speed & Agility: The PJT-B group (plyo before) saw significant gains in 20-meter sprint speed (-7.4% time) and change-of-direction speed (-4.2% time). The PJT-A group (plyo after) showed no significant improvements in these areas.
• Jumping & Power: While both groups improved their standing long jump and countermovement jump, the gains were much larger in the PJT-B group. Critically, only the PJT-B group significantly improved their squat jump (+6.3%) and reactive strength in a drop jump (+19.1%).
• Endurance: Interestingly, both training groups saw equal, significant improvements in their endurance (+9.0%).

The authors suggest that the neuromuscular fatigue from a full soccer session blunted the potential adaptations for speed and power in the PJT-A group.

Actionable Tips

This study provides clear, evidence-based guidance for structuring training for young athletes.

• Prioritise for Power: When the goal is improving sprint speed and explosive strength, schedule plyometric sessions when the athlete is fresh; after a warm-up but before the main sport-specific practice.
• Substitute, Don't Just Add: This effective program replaced a small portion of low-intensity work rather than adding to the total training volume, a key strategy for managing athlete load.
• "After" is Better Than Never: If schedules make pre-session plyometrics impossible, conducting them afterwards is still beneficial for improving some jump metrics and endurance compared to no plyometrics at all.

Full text reference to read here:

For any busy health professional, staying on top of the latest evidence for complex post-operative protocols can be a challenge. This memo breaks down the key takeaways from Hsu et al (2025) from the International Journal of Sports Physical Therapy review on Medial Patellofemoral Ligament (MPFL) reconstruction rehabilitation, giving you clear, actionable steps for your patients.

The paper proposes a comprehensive, four-phase rehabilitation protocol that is criteria-driven, not just time-based. This approach integrates clinical milestones, biomechanical assessments, and psychological readiness to optimise patient outcomes.

Here's a snapshot of the phases and recommended exercises:

• Phase 1: The Protection Phase (Weeks 0-6) The initial goals are to manage pain and swelling, restore full knee extension, and achieve at least
• 110∘ of flexion. The patient should be walking without crutches and be able to perform a straight leg raise without any lag before progressing.
• Range of Motion & Stretching: Heel slides, supine wall slides, and heel propping or prone hangs are recommended.
• Strengthening & Muscle Activation: Focus on quadriceps sets and 3-way straight leg raises. Hip-focused exercises like bridges and clamshells can also be introduced. Neuromuscular electrical stimulation (NMES) can be considered to facilitate quadriceps activation.
• Conditioning: Use of an upper body ergometer or assault bike is appropriate.

• Phase 2: The Strengthening Phase (Weeks 6-12) The focus shifts to achieving full knee range of motion and building strength. Clinicians should aim for quadriceps strength to be greater than 60% of the non-surgical side and a normal gait pattern.
• Strengthening: Begin progressive lower body exercises, targeting a rating of perceived exertion (RPE) of 6-8/10. Single-leg strengthening can be initiated, but clinicians must watch for compensation.
• Balance & Proprioception: Start balance and proprioceptive exercises, incorporating tools like wobble boards or balance cushions.
• Conditioning: You can introduce cycling with resistance, a rowing ergometer, or incline walking on a treadmill. Running can commence once the patient has full ROM, pain <2/10, and a quadriceps limb symmetry index of over 70%.

• Phase 3: Advanced Strengthening & Functional Phase (Weeks 12-16) This phase prepares the patient for the demands of sport. Milestones include quadriceps and hop test limb symmetry of greater than 80%.
• Advanced Strengthening: Continue lower body exercises like leg press, squats, deadlifts, and lunge variations.
• Power-Based Training: Incorporate exercises like kettlebell swings, hang cleans, and medicine ball slams to promote rate of force development.
• Initial Agility & Plyometrics: Initiate basic agility drills and begin plyometrics with double-leg box jumps, double-leg squat jumps, and bound-and-stick exercises.

• Phase 4: Return to Sport (RTS) Phase (>16 weeks) Before returning to sport, patients should demonstrate greater than 90% limb symmetry in quadriceps strength and hop tests, and a Y-Balance test composite score of over 90%.
• Advanced Agility & Plyometrics: Progress agility to include multi-task and reactive drills. Plyometrics should emphasize single-leg and explosive activities like zig-zag cuts, pivoting, depth jumps, and single-leg lateral hops.
• Neurocognitive Drills: To simulate competitive play, consider dual-task exercises (e.g., single-leg hops while answering questions) or reactionary drills (e.g., mirroring a therapist's unplanned movements).

A crucial takeaway is that psychological readiness is a significant factor in a successful return to sport.

Fear of re-injury and a lack of confidence can be major barriers, so consider using tools like the MPFL-Return to Sport after Injury (MPFL-RSI) scale to gauge a patient's psychological state.

Ultimately, a multi-faceted approach is best. Combine your clinical judgment with objective data from strength testing, hop tests, and patient-reported outcomes to make well-informed decisions about your patient's readiness to get back in the game.

Full Text Reference to read here:

In the relentless effort to safeguard athletes from hamstring strain injuries (HSIs), are we consistently identifying all key modifiable risk factors?

Compelling new research from Bramah et al. (2025), recently published in the British Journal of Sports Medicine, sheds new light on the critical role of sprint running mechanics and introduces a practical tool that could transform your approach to HSI prevention and rehabilitation.

This pivotal study, "Sprint running mechanics are associated with hamstring strain injury: a 6-month prospective cohort study of 126 elite male footballers," investigates this very link.

The researchers utilised the Sprint Mechanics Assessment Score (S-MAS), a 12-item qualitative screening tool designed to evaluate specific kinematic features from slow-motion video analysis of an athlete's sprint.

Higher S-MAS scores denote more suboptimal, and potentially injurious, movement patterns.

Key Findings:

The study yielded several significant findings highly relevant to clinical practice:

• Athletes with a history of sprint-related HSI in the preceding 12 months exhibited significantly higher median S-MAS scores (6 out of 12) compared to their uninjured counterparts (median S-MAS 5).
• Athletes who prospectively sustained a new, MRI-confirmed sprint-related HSI during the 6-month follow-up period also demonstrated significantly higher baseline S-MAS scores (median 6/12) than those who remained injury-free (median S-MAS 4/12).
• Notably, athletes sustaining their first HSI had a median S-MAS of 7/12.
• After adjusting for potential confounders such as age and previous HSI, each one-point increment in an athlete's S-MAS score corresponded to a 33% increase in the incidence rate of new sprint-related HSIs over the follow-up period (adjusted Incidence Rate Ratio [IRR] = 1.33, 95% CI: 1.01 to 1.76).
• Receiver Operating Characteristic (ROC) curve analysis identified an S-MAS score of 5.5 (i.e., scores ≥6) as the optimal threshold for identifying athletes with suboptimal mechanics.
• This cut-off yielded a sensitivity of 78.6% and specificity of 65.4% for prospective HSI.

Clinical Implications for Physiotherapy Practice:

These findings offer several actionable insights for physiotherapists working with athletes, particularly in football:

1. The S-MAS provides a feasible, field-based method for assessing sprint running kinematics. It requires readily available technology (e.g., smartphone slow-motion video capabilities) and can be integrated into existing screening protocols.
2. S-MAS scores, particularly those ≥6, can assist in identifying athletes with suboptimal sprint mechanics. These individuals may be at an elevated risk of future HSIs and could benefit from targeted preventative interventions.
3. The study highlights the importance of assessing and addressing sprint running mechanics as an integral component of HSI rehabilitation. Persistent suboptimal mechanics post-rehabilitation may contribute to re-injury risk, suggesting a need for specific mechanical retraining.
4. The S-MAS evaluates 12 specific kinematic features. Detailed analysis of an individual's score can inform the selection of targeted running drills and conditioning exercises aimed at modifying identified biomechanical inefficiencies.
5. While the S-MAS is a valuable tool, its findings should be incorporated into a comprehensive, multifactorial HSI risk assessment. This includes considering other established risk factors such as eccentric hamstring strength, muscle architecture, training load, age, and previous injury history.

In conclusion, this study by Bramah et al. provides compelling evidence for the association between suboptimal sprint running mechanics, as measured by the S-MAS, and the incidence of HSIs in elite male footballers.

The S-MAS presents a practical tool for clinicians to screen, identify, and potentially mitigate this injury risk factor.

Full Text Reference to read here:

A really insightful paper by Bruder et al. (2021) that looks into what elite AFLW athletes think and experience when it comes to injury prevention practices (IPPs).

Given the alarmingly high rates of serious knee injuries in the AFLW – six times greater than their male counterparts – this is a conversation we absolutely need to be having.

The study, which involved interviewing 13 AFLW players, really underscores that while these athletes genuinely believe in the power of IPPs to reduce injury risk, enhance performance, and even prolong their careers, their actual experiences and understanding can vary massively.

This isn't just a simple case of telling them what to do; it's far more nuanced.

One of the key takeaways for me is the sheer diversity in how IPPs are perceived and implemented, not just between clubs but within the same team.

Players reported different types of exercises, varying durations dedicated to IPPs (from 10 to a staggering 135 minutes per session!), and inconsistent levels of education about why they were doing what they were doing.

Some felt well-informed, others received minimal explanation.

This highlights a clear gap: if the athletes don't fully grasp the "why," adherence and the quality of execution are likely to suffer.

The researchers used the Socio-Ecological Model, which is a great way to understand that IPP adoption isn't just down to the individual athlete. It’s a complex interplay of factors at multiple levels.

At the individual level, while athletes are motivated, barriers like a lack of specific knowledge or previous negative experiences can hinder them.

Interpersonally, the support and buy-in from coaching staff and teammates are crucial, as is direct supervision and feedback on exercise technique.

Organisationally, things like access to appropriate facilities, sufficient equipment, and adequate staffing levels play a big role.

And at a broader community level, the very structure of the AFLW as a semi-professional league creates significant challenges. Many players are juggling full-time work or study, limiting the time and energy they can dedicate to IPPs, training, and recovery. As one player noted, "We only have a certain amount of hours you can train". This often means IPPs can get squeezed or rushed when football-specific skills or team meetings are prioritised.

So, what can we, as health professionals working with these athletes, do?

Actionable Tips for Clinicians:

1. Don't just prescribe; explain. Athletes in the study expressed a strong desire to understand why certain exercises are important and how they reduce injury risk. Bruder et al. (2021) found that "Athletes wanted to know more about why injury prevention is important, what they can do to reduce their injury risk and individualised supervision and feedback...". Consider co-designing parts of the IPP with athletes. Giving them a voice in the process can improve ownership, motivation, and ultimately, adherence. Tailor education to different learning styles using infographics, videos, or practical demonstrations.
2. The study highlighted that athletes want IPPs that are specific to them – considering their bodies (female-specific), their sport, and even their position. Generic programs are less likely to hit the mark. Crucially, provide "individualised supervision and feedback around body movement awareness during exercise". This ensures exercises are performed effectively and builds athlete confidence.
3. Given the semi-professional nature of the league, time is a massive barrier. As clinicians, we need to be realistic and work with the athletes and clubs to integrate IPPs efficiently. This might mean advocating for IPPs to be a non-negotiable, scheduled part of training, or developing highly effective, time-efficient routines. We should also support athletes in understanding how to best use their limited time, perhaps by integrating IPP components into their warm-ups or cool-downs.

This research by Bruder et al. (2021) is a valuable reminder that the athletes themselves are critical stakeholders.

By listening to their perspectives, we can develop and implement IPPs that are not only evidence-based but also meaningful, practical, and ultimately more effective in keeping them on the park.

Full Text Reference to read here:

We all dutifully learn about injury prevention programmes (IPPs) – the Nordics, the dynamic warm-ups, the landing drills.

We know they should work.

But how many times have you introduced something at a club, only to see it fizzle out after a few weeks?

Players rush through it, coaches cut it short for time, and those potential benefits vanish into thin air.

It’s frustrating, right? Feels like a waste of everyone's time.

Well, a cracking paper on the development of the "Prep to Play PRO" programme for elite women's Aussie Rules footy caught my attention (Bruder et al., 2023). They were facing a shocking ACL injury rate – six times higher than the men! Instead of just prescribing drills, they mapped out a 7-step 'how-to' guide focused on actually getting the programme embedded and used effectively.

While it was developed for the elite level, the process is gold dust for any physio working at any level. It confirms that getting an IPP to stick is less about having the 'perfect' set of exercises and more about how you build and integrate it.

The Blueprint:

1. Get the Brass On Board: Secured partnership with the governing body (AFL) from day one.
2. Dig Deeper Than Just Exercises: Analysed real injuries in their context, alongside implementation science.
3. Consult the Experts: Spoke to physios, coaches, and players actually involved.
4. Build It Together: Co-created the programme content and delivery strategies with those end-users.
5. Test Drive It: Piloted resources and got feedback on usability and appeal.
6. Check Against Frameworks: Continuously evaluated using models like RE-AIM to ensure real-world factors were considered
7. Listen and Learn: Gathered feedback after the first season to adapt and improve.

The key takeaway? Their success (9 out of 10 clubs adopting it initially!) wasn't luck; it was down to this collaborative, context-aware process.

Making it Work at YOUR Club: Actionable Steps for Grassroots Physios

So, how can you, the busy physio at a local club with limited time and resources, apply these principles? Forget trying to replicate an elite setup. Focus on these core actions:

1. Forget the governing body for now; start with the coach and maybe a key committee member. Have a chat. Explain why prevention matters (fewer injuries = more players available = better team performance). Find out their priorities and biggest challenges (e.g., time, equipment). Get them invested with you.
2. What are the common niggles or injuries you see? When do they happen? What are the typical player skill levels and time commitments? You don't need complex surveillance; just observe and ask questions. Tailor your approach to your club's reality, not a generic template.
3. Work with the coach to integrate simple, evidence-based components. Can you build key exercises into the warm-up they already do? Focus on 2-3 core elements (e.g., landing technique, hamstring strength, change of direction control) rather than a huge list. Use language the coach and players understand. Provide simple visual aids if possible.
4. Consistency over complexity! Encourage the coach or senior players to lead the integration. Briefly check in – are players actually doing it? How does it feel? Is it too time-consuming? Be prepared to adapt based on real-world feedback. A slightly 'imperfect' programme done consistently beats a 'perfect' one that's ignored.

Building an effective IPP that lasts is a marathon, not a sprint.

It requires collaboration, understanding your specific environment, and continuous small adjustments.

By applying these principles, you massively increase the odds of your efforts actually making a difference where it counts – keeping players on the pitch and enjoying their sport.

Take a deep dive into the full text paper here

If you've ever felt like you're throwing everything but the kitchen sink at PHT, or that the standard tendinopathy playbook isn't quite cutting it, you're not alone.

This tricky customer, notorious for its persistence and potential to derail sporting ambitions, demands a sharp, evidence-informed approach.

Good news! A recent literature review by Dizon et al (2023) took a deep dive into conservative interventions for PHT, aiming to cut through the noise and give us clearer signals on what really moves the needle.

Forget just extrapolating from Achilles or patellar rehab; it's time to get specific with those proximal hamstrings.

So let's break down what they found and how it can supercharge your treatment plans.

What Did the Review Uncover?

The review synthesised findings from 13 studies, including RCTs, case reports, and case cohorts, evaluating interventions like strengthening, lumbopelvic stability, stretching, return-to-sport protocols, and modalities.

The key takeaway? A multi-modal approach focusing on progressive loading, lumbopelvic stabilization, and specific joint angle considerations seems to be the most promising path forward.

Here are the highlights:

Load is King:

• Interventions that progressively increased load intensity (aiming for a minimum RPE of 5/10) showed significant pain reduction. Some studies even allowed for a maximum of 3/10 pain during exercises, suggesting we might be underloading patients if we stick rigidly to "pain-free" loading. Heavy slow resistance training is noted for promoting collagen turnover.
• The semimembranosus tendon is often the primary culprit in PHT, especially in Type II injuries (active stretching). The review suggests that loading the hamstrings at increased length – specifically around 100 degrees of hip flexion and 45-90 degrees of knee flexion – may best target this tendon. This mimics the mechanism of injury angles seen in running.
• While eccentrics are a cornerstone, the review indicates that the intensity and progression of load might be more critical than the specific contraction type alone. Isometrics were also highlighted for their potential analgesic effects and neural adaptations.

Lumbopelvic Stability is Non-Negotiable:

• Poor trunk stability and sagittal plane dysfunction (e.g., increased anterior pelvic tilt) can increase hamstring strain.
• Programs incorporating progressive agility and trunk stabilization (PATS) demonstrated faster return to sport and lower re-injury rates compared to just stretching and strengthening or even progressive running and eccentric strengthening alone in some studies.
• Consistent lumbopelvic stabilization exercises (recommended at least 5 days/week) received a Grade B recommendation.

Return to Sport & Re-Injury:

• A combination of eccentric strengthening and lumbopelvic stabilization appeared key for faster RTS and reduced re-injury.
• A "lengthening protocol" (focusing on eccentric loading) showed a 0% re-injury rate at one year in one study, possibly due to its longer treatment duration (16 weeks) and incorporation of lumbopelvic work.

Duration and Modalities:

• Rehabilitation programs should be sustained for a minimum of eight weeks (Grade C).
• Extracorporeal Shockwave Therapy (ESWT) received a Grade C recommendation, suggesting it should be used as an adjunct to a multi-modal exercise approach, rather than a standalone treatment. The evidence for ESWT being superior to a well-structured exercise program is weak, especially when exercise programs in comparative studies were potentially under-dosed.

This review reinforces that there's no single magic bullet for PHT. However, by focusing on progressive, targeted loading, robust lumbopelvic control, and patience, we can guide our patients towards better outcomes and a successful return to the activities they love.

Take a deep dive into the full text paper here

We all see patients who've had knee surgery – ACL reconstructions, meniscectomies, you name it.

Many are keen runners, or want to take up running, but there's often a cloud of uncertainty hanging over them. Namely:

Is running okay after surgery? Will it fast-track knee OA?

This great paper by Alexander et al (2025) dug deep into the experiences of recreational runners who've been through knee surgery, exploring what helps them run, what holds them back, and what they believe about running and their long-term knee health. Let's break down the key takeaways.

What Helps Runners Get Back on Track?

Unsurprisingly, you – the health professional – play a massive role. Key enablers reported were:

1. Positive Support: This wasn't just about prescribing exercises. Runners valued clear education (especially on pain monitoring and load management), building trust and a strong therapeutic alliance, and feeling genuinely supported. Providing structured, progressive rehab plans, including walk-run programs, was crucial for building confidence.
2. Structured Strength Training: Runners felt that targeted lower-limb strengthening helped them regain confidence and was important for maintaining running and preventing injury, even if they struggled with long-term adherence.
3. Smart Load Management: Being able to "listen to their body," monitor fatigue and pain, and adjust training accordingly (self-regulation) was seen as vital for ongoing running. Some also valued guidance from coaches.

What Are the Roadblocks?

Runners also faced significant hurdles:

1. Unhelpful Health Encounters: Yep, the flip side. Being told "you shouldn't run," receiving unstructured rehab, or lacking guidance on load management were major barriers, sometimes leading runners to seek second opinions (often from other health professionals recommended by fellow runners).
2. Persistent Symptoms & Fear: Ongoing pain, weakness, and particularly the fear of re-injury (especially post-ACLR) significantly hampered attempts to run. Pushing through pain often backfired.
3. New Injuries & Life: Sustaining other running-related injuries was common, as were the practical barriers of juggling running with family and work commitments.

Beliefs About Running and Knee Health

This was a mixed bag. Most runners actually believed running was beneficial for their knee symptoms and long-term joint health, though a few worried about the future (but kept running anyway!).

• What they think helps knee health: Managing training load/recovery, strength training, appropriate footwear (fit, cushioning, age), and varying running surfaces were commonly cited.
• Knowledge of OA: Awareness was variable. Many used pathoanatomical terms like "wear and tear" or "bone on bone." They generally knew previous injury/surgery was a risk factor and believed staying active and strong was preventative/helpful.

Why Do They Really Run?

Here’s a crucial insight: While physical health benefits were acknowledged, they weren't the main driver. The overwhelming motivation was psychosocial:

• Mental health boost
• Stress relief and relaxation ("switching off")
• Pure enjoyment
• Social connections
• Sense of achievement from goals/competition

Actionable Tips for Clinicians:

Based on these findings, here’s how we can better support runners post-knee surgery:

1. Be the Positive Voice: Prioritise building rapport and trust. Provide clear, structured education on load management, pain monitoring (challenge unhelpful pain beliefs!), and the rehab process.
2. Build Confidence & Strength: Implement evidence-based, progressive strengthening programs. This directly addresses confidence issues and physical impairments.
3. Guide the Return: Use structured walk-run plans and empower patients with self-management strategies for load ("listen to your body," but give them parameters!).
4. Address the Fear: Acknowledge and validate fears of re-injury. Use graded exposure and education to rebuild confidence.
5. Educate on OA (Constructively): Move away from potentially negative "wear and tear" language. Emphasise the benefits of staying active and strong for joint health, aligning with guideline recommendations. Address footwear/surface beliefs with current evidence.
6. Promote Strength Training Adherence: Highlight potential benefits beyond just injury prevention (e.g., performance gains, symptom management) to boost motivation for sticking with it.

The Bottom Line:

Running after knee surgery is achievable and highly valued by many, primarily for its mental health benefits. As physios, our supportive guidance, structured rehab, load management advice, and confidence-building are key ingredients for success. Understanding the enablers, barriers, and powerful motivations highlighted in this study can help us tailor our approach and get more patients safely back to the activity they love.

Take a deep dive into the full text paper here

With Easter just around the corner, chocolate is definitely on the menu! But beyond the seasonal treats, could a familiar favourite – chocolate milk – or even dark chocolate actually help your muscles recover after exercise?

As physios, we know good recovery is key, whether you're a top athlete or just enjoy staying active. Getting recovery right helps muscles repair, refuels energy, and gets you ready for your next workout. So, let's look at what the science says.

Why Does Post-Exercise Recovery Matter?

Think of it like this: exercise is the work, recovery is when the body rebuilds and gets stronger. After a workout, your muscles need fuel (to restock energy stores, called glycogen) and building blocks (protein) to repair tiny muscle tears, which is how muscles adapt and grow stronger. You also need to replace fluids and salts (electrolytes) lost through sweat.

Getting this right means less fatigue, better performance next time, and potentially less soreness.

Why the Buzz About Chocolate Milk?

Chocolate milk naturally contains a mix of things your body needs after exercise:

• Carbohydrates (Carbs): For refueling energy stores.
• Protein: For muscle repair and building. Milk protein (whey and casein) is high quality.
• Fluids: To help rehydrate.
• Electrolytes: Like potassium and sodium, lost in sweat.

This mix is quite similar to many specially designed sports recovery drinks, but chocolate milk is often cheaper and easier to find.

What Does the Research Show for Chocolate Milk?

Scientists have compared chocolate milk (usually low-fat versions) to water, placebo drinks, and other sports drinks. Here’s a simple breakdown:

1. Performance Boost?

• Endurance (How long you can last): Compared to just water or a plain drink, chocolate milk seems to help people go a bit longer in their next exercise session. When compared to other sports drinks, the results are mixed.
• Strength: For those doing resistance training (like lifting weights), studies suggest chocolate milk helps build strength and muscle size more effectively than drinking just a carbohydrate sports drink. The protein seems to make the difference here.

1. Muscle Repair and Soreness?

• Muscle Building/Repair: This is where chocolate milk seems to shine compared to carb-only drinks. Its protein content helps kickstart the muscle repair process (called muscle protein synthesis) after exercise.
• Soreness and Damage Markers: Can it stop you from feeling sore? The evidence here is inconsistent. Some studies show slightly less soreness or lower levels of muscle stress markers compared to water, but it's often not significantly better than other recovery drinks providing similar nutrition.

1. Refueling Energy Stores?

• Chocolate milk definitely helps restock your muscle fuel (glycogen) because it contains carbohydrates. However, research suggests it's not necessarily better at this than other drinks that provide the same amount of carbohydrates or total calories.

What About Dark Chocolate?

Dark chocolate is different from chocolate milk. Its potential benefits come from compounds called cocoa flavanols, which act as antioxidants. Some studies suggest these flavanols might help reduce exercise-induced oxidative stress. A couple of studies in elite athletes even found that daily dark chocolate intake reduced markers of muscle damage or muscle soreness.

However, the overall picture for dark chocolate and recovery is much less clear than for chocolate milk.

Many scientific reviews state the evidence is inconsistent or mixed regarding its effects on muscle function, soreness, inflammation, and performance. Some studies found no benefit from cocoa flavanols for recovery.

So, while dark chocolate might offer some antioxidant effects, its role specifically in muscle recovery needs more research.

The Bottom Line for Physios and Active People

• Chocolate milk is a viable, convenient, and often affordable recovery drink, better than having nothing.
• It seems particularly useful after strength training due to its protein content.
• It helps refuel energy, but getting enough total carbs is key.
• Don't rely solely on it to eliminate muscle soreness.
• Dark chocolate/cocoa flavanols might help reduce oxidative stress, but evidence for improving muscle recovery, soreness, or performance is inconsistent.
• Always tailor advice to the individual!

So, this Easter, while enjoying those treats, remember that a glass of chocolate milk after your workout is a solid, science-backed option for recovery.

The jury is still out on whether munching dark chocolate provides the same muscle recovery benefits, though it may offer other antioxidant advantages.

References

1. Amiri M, Ghiasvand R, Kaviani M, Forbes SC, Salehi-Abargouei A. Chocolate milk for recovery from exercise: a systematic review and meta-analysis of controlled clinical trials. Eur J Clin Nutr. 2019 Jun;73(6):835-849. doi: 10.1038/s41430-018-0187-x. Epub 2018 Jun 19. PMID: 29921963. 
2. Wang L, Meng Q, Su CH. From Food Supplements to Functional Foods: Emerging Perspectives on Post-Exercise Recovery Nutrition. Nutrients. 2024 Nov 27;16(23):4081. doi: 10.3390/nu16234081. PMID: 39683475; PMCID: PMC11643565.
3. Pritchett K, Pritchett R. Chocolate milk: a post-exercise recovery beverage for endurance sports. Med Sport Sci. 2012;59:127-134. doi: 10.1159/000341954. Epub 2012 Oct 15. PMID: 23075563.
4. Vliet SV, Beals JW, Martinez IG, Skinner SK, Burd NA. Achieving Optimal Post-Exercise Muscle Protein Remodeling in Physically Active Adults through Whole Food Consumption. Nutrients. 2018 Feb 16;10(2):224. doi: 10.3390/nu10020224. PMID: 29462924; PMCID: PMC5852800.
5. Margolis LM, Allen JT, Hatch-McChesney A, Pasiakos SM. Coingestion of Carbohydrate and Protein on Muscle Glycogen Synthesis after Exercise: A Meta-analysis. Med Sci Sports Exerc. 2021 Feb 1;53(2):384-393. doi: 10.1249/MSS.0000000000002476. PMID: 32826640; PMCID: PMC7803445.
6. Yapici H, Gülü M, Yagin FH, Ugurlu D, Comertpay E, Eroglu O, Kocoğlu M, Aldhahi MI, Karayigit R, Badri Al-Mhanna S. The effect of 8-weeks of combined resistance training and chocolate milk consumption on maximal strength, muscle thickness, peak power and lean mass, untrained, university-aged males. Front Physiol. 2023 Mar 15;14:1148494. doi: 10.3389/fphys.2023.1148494. PMID: 37007992; PMCID: PMC10064218.
7. Molaeikhaletabadi M, Bagheri R, Hemmatinafar M, Nemati J, Wong A, Nordvall M, Namazifard M, Suzuki K. Short-Term Effects of Low-Fat Chocolate Milk on Delayed Onset Muscle Soreness and Performance in Players on a Women's University Badminton Team. Int J Environ Res Public Health. 2022 Mar 19;19(6):3677. doi: 10.3390/ijerph19063677. PMID: 35329361; PMCID: PMC8954613.
8. Karp JR, Johnston JD, Tecklenburg S, Mickleborough TD, Fly AD, Stager JM. Chocolate milk as a post-exercise recovery aid. Int J Sport Nutr Exerc Metab. 2006 Feb;16(1):78-91. doi: 10.1123/ijsnem.16.1.78. PMID: 16676705.
9. Benedetti, L., Nigro, F., Malaguti, M., Di Michele, R., & Angeloni, C. (2025). Acute Effects of Dark Chocolate on Physical Performance in Young Elite Soccer Players: A Pilot Study. Applied Sciences, 15(2), 965. https://doi.org/10.3390/app15020965
10. Massaro M, Scoditti E, Carluccio MA, Kaltsatou A, Cicchella A. Effect of Cocoa Products and Its Polyphenolic Constituents on Exercise Performance and Exercise-Induced Muscle Damage and Inflammation: A Review of Clinical Trials. Nutrients. 2019 Jun 28;11(7):1471. doi: 10.3390/nu11071471. PMID: 31261645; PMCID: PMC6683266.
11. Corr LD, Field A, Pufal D, Clifford T, Harper LD, Naughton RJ. The effects of cocoa flavanols on indices of muscle recovery and exercise performance: a narrative review. BMC Sports Sci Med Rehabil. 2021 Aug 14;13(1):90. doi: 10.1186/s13102-021-00319-8. PMID: 34391456; PMCID: PMC8364049.
12. Decroix L, Soares DD, Meeusen R, Heyman E, Tonoli C. Cocoa Flavanol Supplementation and Exercise: A Systematic Review. Sports Med. 2018 Apr;48(4):867-892. doi: 10.1007/s40279-017-0849-1. PMID: 29299877.
    

Right, let's talk Pelvic Girdle Pain (PGP) coming from the SIJ region.

We all see it. It can be bloody debilitating for patients, and let's be honest, sometimes frustrating for us clinicians too.

Over the years, Motor Control Exercises (MCE) – you know, the targeted stuff for Transversus Abdominis, Pelvic Floor, Multifidus, Glutes – have become pretty popular in rehab circles for this stuff.

But you know me, I like to ask: what does the evidence actually say? Is MCE the secret sauce, or just another ingredient?

A solid systematic review and meta-analysis by Mapinduzi et al (2022) (looking at studies up to the end of 2019) crunched the numbers from 12 RCTs, mostly decent quality, trying to answer this.

So, let's break down what they found, and importantly, what it means for us on the clinic floor.

The Evidence Breakdown:

They basically compared MCE against, or added it to, other common physio approaches (manual therapy, belts, general exercise, education, modalities etc.).

1. MCE Flying Solo (Short-Term): When MCE was the only intervention compared against other therapies? The pooled data showed no significant advantage for MCE in reducing pain (VAS scores) in the short term (up to 12 weeks). There was maybe a slight positive effect on disability scores (like the ODI), but it certainly wasn't knocking it out of the park for pain relief on its own compared to other approaches.
2. MCE as a Team Player (Short-Term): Now, this is where it gets more interesting. When MCE was combined with other MSKTs (think MCE plus standard physio, maybe some manual work, etc.), this combined approach significantly outperformed the other MSKTs alone for reducing both pain and disability short-term. High-quality evidence backed this finding.
3. The Long Haul: What about down the track (>12 weeks)? Honestly, the evidence gets a bit thinner and murkier here. Fewer studies, more mixed results. Some signs of potential long-term benefit with MCE involved, but not as clear-cut as the short-term combined effect. Moderate evidence level, so proceed with caution.

Okay, Here’s the BIG Caveat:

Before we all rush off and change everything, we really need to consider who was in these studies. The overwhelming majority – like, nearly everyone (around 96% where reported) – were women in the peripartum period.

This is HUGE. We're talking about a specific population group undergoing significant physiological and hormonal changes. Can we confidently take these findings and apply them directly to our male patients with SIJ pain? Or women presenting years post-partum, or with no pregnancy history? Probably not without some serious critical thinking. The generalisability is limited here, folks.

So, What's the Clinical Takeaway for Us Busy Physios?

• Don't Rely Solely on Isolated MCE: If your main strategy for SIJ pain relief is just isolated deep muscle activation drills, this evidence suggests you might be leaving potential gains on the table, especially concerning pain.
• Combine and Conquer: The real juice seems to be in integrating MCE-style exercises into a broader, active rehab plan. Think of it as part of your strength and conditioning approach, alongside appropriate manual therapy (if indicated), load management, education, and addressing psychosocial factors. It’s about the whole package.
• Load & Adaptation Still Rule: Remember, MCE exercises still involve applying load and promoting adaptation. Maybe the benefit isn't just about 'switching on' muscles in isolation, but about appropriately loading the system within a comprehensive, graded exercise program? Food for thought.
• Know Your Population: If you work with peripartum women experiencing PGP/SIJ pain, this combined approach looks pretty promising for short-term relief. For everyone else? Assess thoroughly, use your clinical reasoning, manage load intelligently, and don't just assume these results apply universally.

The Bottom Line:

Based on this review, MCE probably isn't the standalone magic bullet for SIJ-related pain we might have once hoped. But, it looks like a valuable component when thoughtfully integrated into a comprehensive, multimodal treatment plan – especially for improving function and when combined with other therapies for pain relief, particularly in that peripartum group short-term.

As always, keep reading, keep thinking critically, tailor your approach to the individual in front of you, and focus on robust, active rehabilitation.

Want to read the full text paper? Click on the link here for a deep dive!

We all know ACL reconstructions are becoming increasingly common in our younger athletic populations.

While we have established pathways for adults, the evidence guiding specific aspects of paediatric post-op rehab, like the use of cryotherapy, has been a bit thin on the ground.

Opinions vary, and protocols differ between centres, leaving many of us wondering about best practice.

That's why a recent study by Wong et al. (2024) caught my eye.

It’s the first prospective Randomised Controlled Trial (RCT) specifically looking at whether cryotherapy helps kids (<18 years old) recover after ACLR. We love Level 1 evidence, so let's dive in.

What They Did

Researchers in Singapore took 42 paediatric patients undergoing primary ACLR (using hamstring autografts) and randomised them into two groups:

1. Cryotherapy Group (Ice): Received a standardised icing protocol using a specific ice pack (BodyICE) immediately post-op, then three times daily for 20 minutes over 6 weeks. Compliance was tracked via diaries.
2. Non-Cryotherapy Group (No Ice): Instructed not to use ice.

Both groups followed the same standard post-op rehab protocol. The team measured pain (using VAS at rest and on movement) and knee range of motion (flexion and extension) at postoperative day 1 (POD1), and weeks 1, 4, and 6. Importantly, the surgical and anaesthetic teams were blinded to group allocation.

What They Found

• Pain: The cryotherapy group reported lower overall mean pain scores throughout the 6 weeks, both at rest (though not statistically significant) and significantly lower pain on movement (P = 0.032) compared to the no-ice group. Early on (POD1 and Week 1), pain scores were generally lower with ice, becoming negligible at rest for both groups by week 4.
• Range of Motion (ROM): This was interesting. On POD1, the cryotherapy group actually had less knee flexion than the control group (P = 0.013) – perhaps some initial apprehension with the device? However, their recovery trajectory was better. From Week 4 onwards, the ice group showed better flexion, and the improvement in flexion from POD1 baseline was statistically significant at Week 6 (P = 0.010) and for the overall mean improvement (P = 0.005).
• Extension: Both groups did well with extension. The cryotherapy group showed a statistically significant better overall mean extension (less lack of full extension, P = 0.032), but the authors noted this difference was likely clinically negligible.

Clinical Takeaways for Us Physios

This study provides valuable Level 1 evidence supporting the use of cryotherapy in the paediatric ACLR population.

The key benefits appear to be:

1. Reduced Pain on Movement: Clinically relevant for facilitating early rehab exercises.
2. Improved Rate of Flexion Recovery: Significant improvements noted by week 6 compared to baseline.

The authors acknowledged limitations, such as the relatively small sample size (though it met their power calculation), the potential confounding effect of compression from the specific ice device used, not tracking analgesic use, and the physios assessing ROM not being blinded (though surgeons were).

Despite these, the findings suggest that a simple, standardised icing protocol is a worthwhile, low-risk adjunct to our standard rehab. It seems to provide tangible short-term benefits for pain control and helps patients regain knee flexion more effectively in those crucial early weeks.

Given the lack of consensus previously, this RCT provides solid backing for recommending cryotherapy as part of our post-operative management plan for young athletes undergoing ACLR.

Want to read the full text paper? Click on the link here for a deep dive!

Insertional Achilles tendinopathy presents a significant challenge for physiotherapists managing sport-active individuals. A recent randomised clinical trial published in the British Journal of Sports Medicine led by Pringels et al (2024) has provided compelling evidence supporting the efficacy of low tendon compression rehabilitation (LTCR) compared to high tendon compression rehabilitation (HTCR).

The study involved 42 sport-active individuals with chronic insertional Achilles tendinopathy, randomly assigned to either the LTCR or HTCR group. Both groups underwent a 24-week progressive tendon-loading programme. However, the key distinction was the approach to managing compressive forces at the Achilles tendon insertion.

The LTCR protocol incorporated modifications to minimise compression, including limiting ankle dorsiflexion, eliminating calf stretching exercises, and utilising heel lifts. Conversely, the HTCR group performed exercises in end-range ankle dorsiflexion, maximising compression.

The primary outcome measure was the Victorian Institute of Sports Assessment-Achilles (VISA-A) score, a validated tool for assessing pain and function. The study revealed that the LTCR group demonstrated significantly greater improvements in VISA-A scores compared to the HTCR group (p < 0.05) at both 12 and 24 weeks.

Specifically, at 12 weeks, the LTCR group’s VISA-A score improvement was 24.4, while the HTCR group’s was 12.2, resulting in a mean between-group difference of 12.9 points (p < 0.001). At 24 weeks, the LTCR group’s improvement was 29.0, and the HTCR group’s was 19.3, with a mean between-group difference of 10.4 points (p < 0.001). Crucially, the differences between the groups at both time points exceeded the minimal clinically important difference (MCID) of 10 points.

The VISA-A score is a widely used and validated tool that quantifies pain and function in Achilles tendinopathy. A higher score signifies better pain management and improved function. The fact that the study showed improvements exceeding the MCID means that patients undergoing LTCR experienced a clinically meaningful improvement that they themselves would recognise as worthwhile.

Furthermore, patient satisfaction was significantly higher in the LTCR group. While not statistically significant, a trend towards a higher rate of return to desired sports was observed. Objective measurements revealed a significant reduction in Achilles tendon thickness in the LTCR group (p < 0.05).

Key findings include:

• VISA-A Score Improvement: Significant improvement in the LTCR group compared to HTCR at both 12 and 24 weeks (p < 0.05), with improvements exceeding the MCID of 10 points.
• Tendon Thickness: Significant reduction in tendon thickness in the LTCR group (p < 0.05).
• Patient Satisfaction: Higher satisfaction reported by the LTCR group.

These findings strongly suggest that minimising compressive forces on the Achilles tendon insertion during rehabilitation is crucial for optimal outcomes. Limiting end-range dorsiflexion, avoiding calf stretching, and utilising heel lifts are critical components of an effective rehabilitation strategy.

Clinically, this study underscores the importance of critically evaluating current rehabilitation protocols. A shift towards compression-reducing strategies could lead to improved outcomes for patients with insertional Achilles tendinopathy. While further research with larger sample sizes is warranted, this study provides compelling evidence supporting the efficacy of LTCR.

Want to read the full text paper? Click on the link here for a deep dive!

Today, let's dive into the increasingly popular topic of post-activation potentiation (PAP).

If you're looking to help your athletes squeeze out those crucial performance improvements, PAP might be exactly what you're after.

PAP is all about priming muscles by using a heavy resistance exercise before an explosive or powerful movement. You might already know this as "complex training," where a heavy lift precedes a similar, explosive movement. The idea here is simple: briefly overload the muscles to enhance their performance in subsequent explosive actions.

What's going on behind the scenes? Well, two main things. Firstly, there's phosphorylation of myosin regulatory light chains, which basically makes muscle contractions more efficient. Secondly, there's an increase in motor neuron excitability, leading to better muscle fibre recruitment. Also, it's essential to ensure your resistance activity closely resembles your target performance movement for maximum benefit.

Here are four key factors you’ll need to consider when implementing PAP in practice:

1. Intensity: Higher intensities help recruit fast-twitch (type II) muscle fibres essential for optimal potentiation.
2. Volume: Less is more—typically, lower volume with higher intensity helps manage fatigue and maximises potentiation.
3. Rest Intervals: Allow enough rest to reduce fatigue, with duration dependent on the intensity and volume used.
4. Movement Similarity: Your resistance exercise should closely mimic the explosive movement you're trying to enhance.

Current research highlights the importance of finding the right balance between intensity and volume (known as volume load). Generally, lifting at around 85%-90% of your athlete's one-repetition maximum (1RM) provides superior results, though lighter loads (around 65% 1RM) can also be effective if you use sufficient volume.

For instance, Mina et al. (2019) showed better jump heights and peak power outputs using variable resistance squats compared to traditional free-weight squats.

Similarly, Dello Iacono et al. (2019) found significant improvements by structuring exercises into cluster sets—helping athletes manage fatigue better and maximise PAP.

Timing matters too. Kilduff et al. (2008) demonstrated peak performance roughly 8 minutes after conditioning at 87% 1RM. Shorter rest periods typically don't allow enough recovery, limiting potentiation benefits.

Here are some practical tips you can start using straight away:

• Optimal Load & Volume: Aim for 1-3 sets at 85%-90% 1RM, leaving around 2-3 reps in the tank to manage fatigue.
• Rest Intervals: Plan for around 7-8 minutes rest after conditioning, although letting athletes select their own rest intervals based on individual feel can work well too.
• Know Your Athlete: Athletes with a higher percentage of type II fibres typically benefit most from heavier loads and longer rest intervals.
• Plyometric PAP: Try plyometric exercises (e.g., plyometric push-ups before bench pressing) for potent upper-body gains, using shorter to medium rest intervals.

Bottom line?

PAP can significantly enhance athletic performance when tailored to individual needs and the specific demands of their sport.

Give it a go in your practice—you might be surprised at the gains you see!

Want to read the full text paper? Click on the link here for a deep dive!

As health professionals, we're all too familiar with the challenges of rehabbing young athletes after ACL injuries.

We focus on quad strength, getting that limb symmetry index (LSI) up, and making sure they're ready to return to sport.

But what about other knee injuries?

Do they fly under the radar when it comes to long-term strength deficits?

A recent study in the Journal of Orthopaedic & Sports Physical Therapy by Losciale et al (2025) really got me thinking.

They followed a bunch of young athletes (11-19 years old) for two years after various knee injuries – ACL tears, meniscus tears, ligament sprains, the lot.

What they found was pretty eye-opening.

Turns out, these young athletes, regardless of the specific injury, had significant strength losses early on – we're talking 30% for knee extension and 28% for knee flexion!

Now, while they did improve in the first year, those gains plateaued after that.

And get this: they still had a 10-11% strength deficit two years after the injury!

This got me thinking: are we doing enough for these young athletes?

Are we focusing too much on the ACL and not enough on the bigger picture?

Here's what I took away from this study:

• Don't forget the hamstrings! We need to give those flexors just as much attention as the quads.
• Rehab is a marathon, not a sprint. Getting to 90% LSI isn't the finish line. We need to keep working with these athletes to address those lingering deficits.
• One size doesn't fit all. Every injury and every athlete is different. We need to tailor our rehab programs accordingly.
• Education is key. Let's empower our patients with the knowledge and tools they need to maintain their strength long after they leave our clinic.

This study is a good reminder that knee injuries, no matter the type, can have lasting effects on muscle strength.

As health professionals, we have a responsibility to provide comprehensive and long-term care to help these young athletes return to sport safely and prevent future problems.

What are your thoughts? How do you approach rehab for non-ACL knee injuries in young athletes? Let's keep the conversation going!

Want to read the full text paper? Click on the link here for a deep dive!

Knee arthroscopy, particularly meniscal surgery, remains one of the most frequently performed orthopedic procedures.

However, recent research challenges the necessity of early surgical intervention, particularly in young adults with traumatic meniscal tears.

A recent multicenter randomized controlled trial (RCT) by Skou et al (2022) investigated whether early arthroscopic meniscal surgery was superior to a supervised exercise therapy and education program with the option for delayed surgery if needed.

The study's findings provide valuable insights for physiotherapists managing patients with meniscal injuries.

Study Overview

This RCT included 121 young adults (18 to 40 years) diagnosed with a meniscal tear confirmed by MRI and deemed eligible for surgery.

Importantly, patients with MRI confirmed buckethandle tears of the meniscus were excluded from this trial.

Participants were randomly assigned to either early arthroscopic surgery or a structured 12-week supervised exercise therapy program, with follow-ups at 3, 6, and 12 months.

The supervised exercise therapy consisted of twice-weekly 60–90-minute sessions, focusing on neuromuscular control, strengthening, and patient education.

Participants in the surgical group underwent either arthroscopic partial meniscectomy or meniscal repair, followed by post-operative rehabilitation as necessary.

The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS4), assessing pain, function, and quality of life.

Key Findings:

• At 12 months, both groups showed significant and clinically relevant improvements in KOOS4 scores, but there was no statistically significant difference between the surgical and exercise groups.
• 26% of patients initially assigned to exercise therapy opted for surgery within the 12-month period, while 74% avoided surgery altogether.
• The surgical group demonstrated slightly greater improvements in KOOS4 and other secondary measures, but the differences did not reach clinical significance.
• Serious and non-serious adverse events were comparable between groups.

Implications for Physiotherapists

The findings suggest that for young, active adults with a meniscal tear (excluding buckethandle tears), a strategy of structured exercise therapy and education is a viable alternative to early surgery.

Given that nearly three out of four patients in the exercise group avoided surgery while still experiencing meaningful improvements, physiotherapists play a crucial role in guiding patients through conservative management.

Clinical Considerations for Physios

• Patient Selection: While exercise therapy is effective, patient selection remains important. Those with locked knees or concomitant ligament injuries may still require early surgical intervention.
• Shared Decision-Making: Educating patients about the risks and benefits of both treatment options empowers them to make informed choices that align with their lifestyle and preferences.
• Rehabilitation Strategies: A well-structured, progressive neuromuscular and strength-based rehabilitation program is essential for optimising outcomes in non-surgical patients.
• Monitoring and Reassessment: Regular follow-ups help identify patients who may require surgical intervention due to persistent symptoms or functional limitations.

Conclusion

This study reinforces the growing evidence that structured exercise therapy and patient education can be an effective first-line treatment for young adults with meniscal tears.

Physiotherapists should take an active role in conservative management, ensuring patients receive high-quality rehabilitation while considering surgical referral when necessary.

By integrating these findings into practice, physiotherapists can contribute to improved patient outcomes and potentially reduce unnecessary surgical interventions in this population.

Want to read the full text paper? Click on the link here for a deep dive!

Knee osteoarthritis (OA) is a common cause of pain and disability, and while exercise is a cornerstone of management, uptake remains low, contributing to overuse of joint replacement surgery.

A recent study by Lawford et al (2025) investigated whether the use of X-rays in diagnosing and explaining knee OA influences patient beliefs about its management.

This online randomized controlled trial (RCT) involved 617 Australian participants aged 45 and over, who had never consulted a clinician for knee pain. Participants were presented with a hypothetical scenario of knee pain and were randomised into three groups:

1. Clinical Explanation (No X-rays): Participants watched a video of a general practitioner (GP) providing a clinical diagnosis based on age and symptoms, followed by an explanation of OA and its management.
2. Radiographic Explanation (No Images): Participants were told an X-ray was needed and then received a summary of the X-ray report (joint space narrowing, osteophytes) without seeing the images, followed by the same OA explanation.
3. Radiographic Explanation (With Images): Similar to the second group, but participants were shown the X-ray images during the explanation.

The study aimed to determine if a radiographic diagnosis, with or without showing images, influenced beliefs about OA management compared to a clinical diagnosis.

Key Findings:

• Participants who received a radiographic explanation with images believed joint replacement surgery was more necessary than those who received a clinical explanation.
• Showing the X-ray images did not significantly alter beliefs compared to just explaining the report findings.
• Participants who received the radiographic explanation with images also believed exercise to be more damaging, had more concern about their knee worsening, and had a higher fear of movement.
• The radiographic explanation also lead to participants believing that Orthopaedic surgeons, rheumatologists, and Physiotherapists would be more helpful than the clinical explanation group.
• The radiographic explanation group were also more satisfied with the consultation, the information given, and were more confident in the accuracy of the diagnosis.
• There were no significant differences between the groups regarding the perceived helpfulness of exercise and physical activity.

Implications for Physiotherapists:

• These findings highlight the potential negative impact of using X-rays to diagnose and explain knee OA. Showing patients X-ray images can reinforce misconceptions about joint damage and increase perceived necessity for surgery. This can lead to decreased engagement in exercise, which is a key component of OA management.

While patients may feel reassured by X-ray results, physiotherapists should be aware of the potential for these images to negatively influence patient beliefs. It is crucial to emphasise that structural changes seen on X-rays do not always correlate with pain or predict prognosis.

Recommendations:

• Prioritise clinical diagnosis based on symptoms and age, as recommended by guidelines.
• If X-rays are necessary, provide clear explanations that address misconceptions and emphasise the importance of exercise.
• Focus on patient education that promotes a positive outlook on OA management.
• Continue to advocate for best practice care, and educate patients on the value of physiotherapy in managing OA.
• Recognise that patients may expect imaging, and find ways to meet this expectation, without causing detrimental beliefs.

This study underscores the importance of careful communication and patient education in managing knee OA. By understanding the impact of diagnostic methods on patient beliefs, physiotherapists can play a crucial role in promoting effective self-management and reducing the overuse of surgery.

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Soccer's global popularity makes injury prevention a critical concern, impacting both players and healthcare systems.

The FIFA 11+ program has emerged as a valuable tool, demonstrating significant reductions in injury rates when implemented before training.

However, emerging research suggests that maximising its potential may involve expanding its application to include post-training sessions.

The FIFA 11+ program, a comprehensive warm-up routine, focuses on strengthening core and leg muscles, improving coordination, balance, agility, and neuromuscular control.

Previous studies have established its effectiveness when used pre-training, leading to significant injury reductions. This new research explores the potential benefits of adding a post-training component, hypothesizing that training in a fatigued state could further enhance neuromuscular control and resilience, ultimately reducing injury risk.

This study by Al Attar et al (2017) involved amateur male soccer players aged 14-35.

Teams were divided into two groups: an experimental group performing the FIFA 11+ program both before and after training, and a control group performing the program only pre-training. The post-training routine, similar to the pre-training but with reduced intensity and duration, focused on jogging, strength, plyometrics, and balance exercises.

The results were compelling.

The experimental group, implementing both pre- and post-training FIFA 11+, experienced a remarkable 72% reduction in overall injuries compared to the control group.

This translates to preventing one injury for every five players participating in the combined program.

The program also significantly reduced the incidence of initial injuries.

While no significant difference was observed in recurrent injury rates or injury severity, the overall reduction in injury incidence is a significant finding.

Interestingly, the intervention seemed to have a greater impact on older players (16-17 and >18 years) compared to younger players (14-15 years), possibly due to the influence of maturation.

This study offers novel insights into optimising injury prevention strategies in soccer.

While the traditional pre-training FIFA 11+ program has proven effective, adding a post-training component further reduces injury risk.

This combined approach likely enhances neuromuscular control, balance, and core stability, particularly under fatigued conditions, mimicking the demands of match play.

The study highlights the importance of compliance with the program, emphasising that consistent implementation is crucial for maximising its benefits.

While the study has some limitations, such as more frequent monitoring of the experimental group's compliance, the findings are robust and have practical implications for physiotherapists working with soccer players.

Encouraging the adoption of the pre- and post-training FIFA 11+ program could significantly reduce injury burden, improve player well-being, and potentially enhance team performance.

Future research could explore the specific mechanisms by which the combined program exerts its protective effects and investigate its applicability across different age groups and skill levels.

These findings underscore the importance of considering post-exercise routines in injury prevention strategies and provide a valuable tool for physiotherapists seeking to optimise player health and performance in soccer.

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Exercise-induced hypoalgesia (EIH), the phenomenon where exercise temporarily reduces pain sensitivity, has shown promise in managing chronic pain.

However, its application to chronic low back pain (CLBP) has been inconsistent. While some studies have demonstrated pain reduction after exercise, others have found no effect, or even increased pain sensitivity.

This variability highlights the complex interplay between pain, exercise, and individual factors.

This research review will discuss a recent study by Tomschi et al (2025) investigating the acute effects of core stabilisation exercises on EIH in CLBP patients and its implications for physiotherapy practice.

The Challenge of EIH in CLBP

The inconsistent EIH responses observed in CLBP patients are likely due to several factors. These include central sensitisation, where the nervous system becomes overly sensitive to pain signals, and alterations in descending pain inhibitory pathways, which normally help to suppress pain.

Psychosocial factors, such as fear of movement (kinesiophobia) and pain catastrophising (exaggerated negative thoughts about pain), also play a significant role.

Furthermore, the type of exercise performed seems to be a crucial factor.

Core Stability: A Potential Solution?

Core stabilisation exercises, designed to strengthen and improve the coordination of trunk muscles, are a common recommendation for CLBP management.

While their long-term benefits are well-documented, their immediate impact on pain perception through EIH has been less explored.

A recent study aimed to address this gap by investigating the acute effects of a short, bodyweight-only core stabilisation routine on EIH in CLBP patients.

The Study and its Findings

The study involved 32 participants with non-specific CLBP. Participants performed a 10-minute core stabilisation routine consisting of forearm planks, static swimmers, side planks, and bridges.

Pain sensitivity was measured using pressure pain thresholds (PPT) at both local (lumbar) and remote (hand and forehead) sites before and after the exercise.

The results were encouraging. The core stabilisation exercises significantly increased PPT in the lumbar region, indicating local EIH.

Importantly, no significant changes in pain sensitivity were observed at remote sites, suggesting that the EIH effects were localised to the exercised area.

Interestingly, the study found a strong association between EIH effects and lower pain catastrophising scores, but not with other psychological or physical activity measures. No adverse effects were reported.

Implications for Physiotherapy Practice

These findings offer valuable insights for physiotherapists managing CLBP.

• Integrate Core Stabilisation Exercises: A short session of core stabilisation exercises can be a safe and effective way to provide immediate pain relief to CLBP patients through local EIH mechanisms. The exercises used in the study (planks, static swimmers, and bridges) are easily implemented and require no specialised equipment. Consider incorporating these into your treatment plans. For example, a warm-up could include a set of planks (30 seconds hold, 10 seconds rest, repeated 3 times), followed by static swimmers (30 seconds each side, repeated 3 times) and bridges (30 seconds hold, 10 seconds rest, repeated 3 times).
• Address Pain Catastrophising: The study highlights the importance of considering psychological factors. Pain catastrophising can influence EIH outcomes. Therefore, it is crucial to address fear and negative pain beliefs through education and reassurance alongside exercise therapy. Cognitive Behavioral Therapy (CBT) techniques may be beneficial in addressing these beliefs.
• Individualised Exercise Prescription: While core exercises can be beneficial, individual responses may vary. Carefully monitor each patient's pain response and adjust the intensity and duration of the exercises accordingly. Start with a low intensity and gradually increase as tolerated. Consider using outcome measures such as the NPRS before and after treatment to quantify change.
• Mechanism of Local EIH: While the exact mechanisms are still being investigated, increased blood flow, neuromuscular activation, and the local release of pain-inhibiting substances are likely contributors to the pain relief observed. Educating patients about these potential mechanisms can further empower them in their recovery.

Conclusion

This study supports the use of core stabilisation exercises as a promising strategy for managing CLBP through local pain modulation.

By understanding the potential of EIH and considering individual patient factors, physiotherapists can effectively incorporate core exercises into rehabilitation programs to enhance pain management and improve functional outcomes for individuals with CLBP.

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Chronic low back pain (CLBP) is a complex, multifaceted condition affecting a significant portion of the population and leading to substantial disability and economic burden.

Despite its prevalence, clinicians often struggle to provide a definitive diagnosis for up to 90% of CLBP cases, classifying them as nonspecific CLBP.

One contributing factor to CLBP may be the deconditioning of the posterior chain muscles, which play a crucial role in spinal stability and function.

The Role of Exercise Therapy in CLBP

Exercise therapy is widely recognised as an effective non-pharmacological intervention for CLBP.

Systematic reviews indicate that exercise can significantly reduce pain and disability.

However, uncertainty remains regarding which specific types of exercise are most beneficial.

Current clinical guidelines recommend graded and individualised resistance or aerobic exercises at low to moderate intensity, performed at least twice per week for six weeks.

Despite these recommendations, the lack of specificity in exercise prescription remains a challenge for clinicians.

Comparing Posterior Chain Resistance Training (PCRT) and General Exercise (GE)

A recent systematic review by Tataryn et al (2021) and meta-analysis sought to determine whether PCRT is more effective than GE in treating CLBP.

This study examined key outcome measures, including pain, disability, muscular strength, and adverse events, in sedentary and recreationally active populations with CLBP.

The study found that both PCRT and GE significantly reduced pain, but PCRT resulted in greater pain relief, particularly when implemented for 12 to 16 weeks.

Similarly, PCRT demonstrated superior improvements in disability and muscular strength compared to GE.

The progressive overload characteristic of PCRT may play a vital role in these enhanced outcomes, as gradual increases in load stimulate muscle adaptation and resilience.

Implications for Clinical Practice

The findings suggest that PCRT should be prioritised over GE when designing rehabilitation programs for CLBP patients.

Key takeaways for physiotherapists include:

• Emphasising Posterior Chain Strength: Exercises targeting the thoracic, lumbar, and hip musculature should be integral to rehabilitation programs.
• Incorporating Progressive Overload: To maximize strength gains and functional improvements, resistance should be gradually increased over time.
• Ensuring Adequate Duration: Programs lasting at least 12 weeks yield greater benefits compared to shorter interventions.

Addressing Safety Concerns

Contrary to common misconceptions, the study found no significant difference in adverse event rates between PCRT and GE.

While strength training is often perceived as high-risk for lower back injury, evidence suggests that properly structured resistance training is safe and may even offer protective benefits against injury.

Future Research Directions

Although this study highlights the benefits of PCRT, several questions remain unanswered. Future research should focus on standardising exercise protocols, examining the relationship between strength gains and reductions in pain/disability, and comparing PCRT with other interventions such as walking programs or mixed resistance training.

Conclusion

For physiotherapists treating CLBP, these findings underscore the importance of tailored, progressive resistance training.

By prioritising posterior chain strengthening and ensuring program adherence over an adequate duration, clinicians can significantly improve patient outcomes and enhance quality of life for individuals with CLBP.

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Anterior cruciate ligament (ACL) injuries are a significant concern in sports, with an estimated 250,000 cases annually in the USA, costing over $2 billion.

These injuries often occur in young athletes through non-contact mechanisms, such as landing on one leg or executing cutting movements, and can lead to long-term issues like posttraumatic knee osteoarthritis.

Sports like soccer exhibit high ACL injury rates due to actions such as landing from jumps and sharp directional changes.

To address this, organizations like FIFA have promoted injury prevention programs, including the FIFA 11+ and its variations, which incorporate neuromuscular, proprioceptive, balance, and plyometric training.

Plyometric exercises, involving explosive movements like jumping, have gained popularity for their potential in reducing ACL injury rates.

Recent systematic reviews and meta-analyses have further explored this link, revealing significant benefits of incorporating plyometrics into prevention programs.

Key Findings

A meta-analysis by Al Attar et al (2022) of nine randomized controlled trials involving over 13,500 athletes demonstrated a 60% reduction in ACL injuries among participants who followed prevention programs with plyometric exercises.

Subgroup analyses showed notable differences:

• Non-contact ACL injuries: Reduced by 66%.
• Contact ACL injuries: Reduced by 41%, though results were less precise.
• Sex differences: Males experienced a 79% reduction, while females saw a 50% decrease.

The studies highlighted the critical role of plyometric exercises in mitigating factors contributing to ACL injuries, such as landing force, knee valgus moments, and insufficient knee flexion.

Implications for Practice

Physiotherapists, coaches, and players should prioritise the integration of plyometric exercises into injury prevention routines.

Programs like the FIFA 11+ and Perform+ provide structured guidelines, but further customisation may optimise results.

Although the effects were more pronounced in males, the benefits for females remain substantial, warranting implementation across all athlete groups.

Recommendations for Future Research

While this review provides robust evidence, more research is needed to fine-tune plyometric training parameters and assess their efficacy in diverse sports populations.

Investigating the impact on athletes with previous ACL injuries and exploring the mechanisms behind the observed benefits can further enhance clinical practice.

Conclusion

The evidence strongly supports the inclusion of plyometric exercises in ACL injury prevention programs.

With a potential to reduce injury rates by 60%, these findings should encourage physiotherapists to advocate for and implement plyometric training as part of comprehensive injury prevention strategies.

By adopting evidence-based practices, we can protect athletes from debilitating ACL injuries and promote long-term athletic health.

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Hamstring injuries are a significant concern in soccer, accounting for 12% of all muscle injuries and causing substantial downtime for players.

A meta-analysis highlights the role of core muscle strengthening exercises (CMSEs) in reducing these injuries, with findings suggesting a potential 50% reduction in risk when CMSEs are incorporated into injury prevention programs (IPPs).  

Risk Factors and Prevention Strategies  

Hamstring injuries often stem from a combination of factors, including prior injuries, poor flexibility, weak core stability, and muscle imbalances. Age, lumbar posture issues, and high competition levels also contribute to the risk. Addressing these modifiable risk factors is key, as nonmodifiable ones like age or prior injuries require strategic management.  

CMSEs have emerged as a cornerstone of injury prevention and rehabilitation. These exercises target the lumbopelvic-hip complex, involving muscles such as the gluteus maximus, hamstrings, and transverse abdominis. By enhancing stability and neuromuscular control, CMSEs not only reduce injury risk but also am to optimise athletic performance.  

Key Exercises and Implementation  

Effective CMSEs include planks, side bridges, single-leg stances, lunges, and Swiss ball exercises like prone hip extensions and roll-outs. These exercises improve muscle activation, dynamic stabilization, and load transfer, essential for injury prevention. Programs such as FIFA 11+ and Perform+, which incorporate CMSEs, have shown notable success in reducing injury rates.  

Nordic hamstring exercises are particularly effective when combined with CMSEs. Studies report an 86% reduction in injury rates among players with previous hamstring strains when these exercises are included. High compliance is critical, as adherence to preventive protocols directly correlates with reduced injury incidence.  

Evidence from Meta-Analysis  

This systematic review included five studies analysing 4,728 soccer players over 379,102 exposure hours. Results revealed a significant 47% decrease in hamstring injury rates among teams using CMSEs as part of their IPPs compared to standard protocols. However, further research is needed to explore the effectiveness of CMSEs in female players and other sports with high rates of hamstring injuries, such as rugby and Australian football.  

Clinical Recommendations  

Physiotherapists should advocate for the integration of CMSEs into both preventive and rehabilitative strategies for soccer players at least 2x per week.

And simply using the FIFA 11+ or Peform+ programs (as highlighted above), they are simple and evidenced based way to keep your athletes on the park.

By targeting the lumbopelvic-hip complex and promoting compliance with structured programs, these exercises can significantly reduce injury risk, improve recovery, and prepare athletes for the demands of competitive play.  

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Blood flow restriction training (BFR-t) has garnered attention as a potential tool for enhancing rehabilitation following anterior cruciate ligament (ACL) injuries and reconstruction.

This summary delves into recent evidence from a systematic review by Colombo et al (2024) that examined the effects of BFR-t on muscle strength, muscle size, and perceived knee function.

Unclear Impact on Muscle Strength and Size

The review analysed five studies investigating the impact of BFR-t on knee extensor and flexor muscles. Results showed mixed outcomes:

• Muscle Strength: Some studies suggested BFR-t might enhance strength gains compared to traditional rehabilitation, while others found no significant difference.
• Muscle Size: Findings were equally varied, with some studies reporting increased cross-sectional area (CSA) in BFR-t groups and others finding no advantage over standard protocols.

These discrepancies may stem from variations in study design, intervention timing, and exercise protocols.

Importantly, BFR-t did not consistently prevent post-operative muscle loss more effectively than non-BFR approaches.

Potential Benefits for Knee Function

Despite the unclear effects on strength and size, BFR-t showed promise in improving knee-specific patient-reported outcome measures (PROMs) and physical function.

One study highlighted reduced knee pain and enhanced function in BFR-t participants, potentially linked to its use of lower loads and associated hypo analgesic effects.

Methodological Variability

The heterogeneity of study methods complicates drawing definitive conclusions. Factors such as pre- versus post-surgery application, intervention duration, and compliance rates varied significantly across studies.

For instance, interventions lasting less than six weeks might be insufficient to yield meaningful strength or size improvements.

Recommendations for Practice and Future Research

While BFR-t offers potential as a prehab or rehabilitation tool, its role remains uncertain. To refine its application, future research should:

• Standardise protocols for intervention timing, exercise selection, and outcome measurement.
• Address gaps in high-risk populations, such as late teens, often overlooked in studies.
• Utilise larger, sham-controlled trials to reduce bias and clarify efficacy.

Conclusion

The promise of BFR-t in ACL rehabilitation lies in its potential to enhance knee function and reduce pain with minimal loading. However, its effects on muscle strength and size remain inconclusive. For physiotherapists, incorporating BFR-t into ACL rehabilitation should be approached with caution until further research establishes standardised guidelines and robust evidence.

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Hamstring injuries, particularly acute muscle strain injuries, remain among the most common non-contact injuries in athletes.

Their incidence has steadily risen, with European soccer teams reporting a 10–20% annual increase from 2001 to 2022.

These injuries primarily occur during high-speed activities, especially in the late swing phase of sprinting, where the hamstrings are both highly activated and significantly stretched.

Key Findings on Hamstring Activation

A recent study by Moiroux-Sahraoui et al (2024) compared hamstring activation levels during sprinting, Nordic Hamstring Exercises (NHE), and high-speed concentric exercises on an isokinetic dynamometer.

The results highlighted the following:

1. Sprinting: Demonstrated the highest hamstring activation levels, emphasising its critical role in both injury prevention and rehabilitation.
2. Nordic Hamstring Exercises (NHE): Produced greater activation than isokinetic exercises, with significant engagement of both the biceps femoris (BF) and semitendinosus (ST). NHE also showed transferable benefits to high-speed movements, despite being a slow, controlled exercise.
3. Isokinetic Exercises: Although beneficial, they elicited lower activation levels compared to sprinting and NHE.

Implications for Practice

The findings reaffirm the importance of sprinting in rehabilitation programs due to its ability to maximize hamstring recruitment.

However, it should be incorporated carefully to avoid overloading recovering athletes.

NHE serves as an effective complement, offering substantial muscle activation and potential performance adaptations.

The study underscores the need for physiotherapists to carefully select and combine exercises to target hamstring strength and flexibility.

A mixed approach—integrating sprinting, NHE, and other strengthening exercises like deadlifts—can optimise outcomes for both prevention and rehabilitation.

Challenges and Considerations

Despite the efficacy of these exercises, hamstring injuries continue to rise, raising questions about their implementation in real-world settings.

Limitations in existing studies, such as small sample sizes and lack of gender diversity, point to the need for broader research. Additionally, factors like fatigue and electrode placement variability in EMG analysis highlight the complexities of measuring muscle activation accurately.

Conclusion

Sprinting remains indispensable for injury prevention and recovery, offering unparalleled hamstring activation. When combined with targeted exercises like NHE, it provides a robust framework for addressing the persistent challenge of hamstring injuries. As physiotherapists, leveraging these insights can help refine training and rehabilitation strategies, ultimately improving athlete outcomes.

Encouraging ongoing dialogue and research will be crucial to bridging the gap between theoretical knowledge and practical application, ensuring that these evidence-based methods are used effectively in sports and clinical settings.

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Rehabilitation after an ACL reconstruction (ACLR) demands more than just restoring physical strength and mobility. Emerging evidence highlights the critical role of neurocognitive training in optimising recovery, enhancing performance, and minimising the risk of reinjury.

As physiotherapists, understanding and incorporating these strategies into ACL rehabilitation protocols is essential for preparing athletes to meet the complex demands of their sport.

The summary below is from the recent framework by Thomas et al (2024)

Neurocognitive Deficits in ACL Rehabilitation

Research underscores that neurocognitive deficits, such as slower reaction times and impaired decision-making, persist even in advanced stages of ACL rehabilitation. These deficits can negatively impact return-to-sport (RTS) outcomes. Studies by Swanik et al. and Silvers-Granelli et al. show that incorporating neuromuscular and neurocognitive training not only improves athletic performance but also significantly reduces injury rates in competitive athletes.

Mid-Stage Rehabilitation Phase (Weeks 9–16)

The mid phase of ACLR focuses on restoring full knee flexion, building strength, and introducing low-level plyometric exercises. Neurocognitive training during this phase is critical. Techniques such as visual feedback (e.g., laser-guided drills) and perturbation exercises enhance neuromuscular control, while blood flow restriction training helps build strength without overloading healing tissues. Athletes also begin a gradual running progression based on objective criteria, ensuring readiness through comprehensive assessments.

Functional Sport Training Phase (Months 5–9)

In this phase, the focus shifts to sport-specific drills and cognitive-motor challenges. Multitasking exercises, such as performing agility drills while responding to visual or verbal cues, prepare athletes for the unpredictable nature of their sport. Strength training remains pivotal, with targets set at 85–90% limb symmetry index. Incorporating tasks that require reactive decision-making and visual processing builds athletes' ability to perform under stress.

Return to Sport & Performance (Months 9+)

The final phase emphasises advanced drills integrating cognitive and motor demands. Exercises such as reactive single-limb hops or multitasking ladder drills simulate real-game scenarios, helping athletes refine skills while maintaining focus under pressure. Transitioning to open environments, such as team practices, ensures that neurocognitive challenges continue, fostering a seamless return to competition.

The Importance of Objective and Reactive Testing

Traditional RTS tests often focus on symmetry and pre-planned tasks, failing to account for bilateral deficits or cognitive demands. Emerging tests that incorporate reactive elements, such as the Visual-Cognitive Reactive Triple Hop, demonstrate how cognitive loads can affect functional performance. These approaches better replicate the demands of sport, allowing clinicians to make more informed decisions about an athlete’s readiness.

Long-Term Implications and Preventative Programs

Incorporating neuromuscular training into preventative programs like FIFA 11+ can reduce ACL injuries by up to 67% in female athletes. Compliance improves when programs emphasize both injury prevention and performance enhancement, making education key for physiotherapists.

Conclusion

ACL rehabilitation is evolving beyond musculoskeletal recovery to include neurocognitive training that addresses central nervous system changes. By integrating these strategies throughout all phases of rehab, physiotherapists can better prepare athletes not only to return to sport but to excel beyond their pre-injury performance. This holistic approach ensures safer, more confident RTS decisions and a reduced risk of reinjury.

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