BJSM Podcast

Stop swimming upstream - a new model for swimmer’s shoulder

Struggling with swimmers and their shoulders? It’s something we clinicians struggle with, and have been for a long time. Today we’re gonna take this head on, how we can move the model from external impingement to anterior superior internal impingement (ASII).
We are joined on this BJSM podcast with Andrew Delbridge and Craig Boetcher from Australia. Craig completed his PhD through Sydney University examining shoulder EMG back in 2010. He’s been the physiotherapist for the Australian swim team for the last 8 years, and offers a unique perspective to this issue, having been an elite swimmer himself.
Craig is currently supervising Kylie Holt who is completing her PhD on Shoulder pain and pathology in elite swimmers. Kylie is a senior sport physio at the Australian institute of sport, and has been looking after the swimming programme since 2009.
Our second guest is Andrew Delbridge, who has been working with Craig at Regent St Physiotherapy for the last 17 years. Andrew has been working in elite sport with throwing athletes, and has found a fresh way of looking at the swimmer’s shoulder.
1:25 What is swimmer’s shoulder? External impingement model from the 70s outdated
2:00 Difference between primary and secondary impingement
3:40 We’ve got swimmer’s shoulder wrong. Andrew explains some of the reasons.
5:10 Spoiler alert - you guessed it, its internal impingement.
ASII- Anterior superior internal impingement
6:00 Clinical background that initially drove the reason for the new ASII approach
8:20 What can baseball teach us about swimming? The loads don’t make sense!
Buhrkart influenced throwing shoulder which led to applying that in swimmers
9:25 3 questions to understand the swimmer’s shoulder:
1) What is the unique position for swimmers in their stroke,
2) what is the anatomical relations in that position,
3) can we reconcile pathology we see?
10:00 Unique position for the demands of swimming - elevation and internal rotation while in large amount of elevation
10:30 Literature also looks at this position (classic Hawkins & Kennedy) investigating the anatomy in this position.
11:30 Position vs load - which causes the pain? It’s mix of tensile and compressive load
12:00 ASSI explained
Swimmers are super overhead workers
13:15 The data are building, but it’s still early. 60 swimmers included in large MRI study
15:00 Does this only apply to elite swimmers? No.
16:25 Key differences in ASII model:
Internal not external, tendinopathy (anterior or posterior).
Mix loading (compressive load in ASII) which might apply to the whole cuff,
Broad term of swimmer’s shoulder to vague, sub-classification needed to differentiate treatment
18:15 3 practical tips for the clinician:
1) Shift in thinking, apply your tendinopathy theory
2) Use dynamometry to assess cuff health
3) Monitor training load.
Full text now available here: https://goo.gl/rQ4EMF

Do you see golfers in your clinic? Golf as a public health panacea? Dr Roger Hawkes explains all

Joining us for this BJSM podcast is the vastly experienced, Dr Roger Hawkes. We chat to him about a wide range of issues, from his role as CMO to the European Golf Tour - where he has built an incredible service, and provided incredible quality of care to the world’s best golfers – to common golfing injuries, and how to assess them.
We also touch on the innovative work being done that is looking into the health benefits of golf, and the challenges of working in such a dynamic, and multi-disciplinary environment. So if you want to get better at assessing & managing the golfers that walk through your clinic door, or want to know more about the benefits of golf (so you can further justify next weekend’s round), look no further!
Extra Resources
Andrew Murray Golf & Health podcast: https://soundcloud.com/bmjpodcasts/andrew-murray-1
ETPI twitter account: https://twitter.com/ETPI_Physiounit
Golf & Health Infographic: http://bjsm.bmj.com/content/51/1/20
The relationships between golf and health: a scoping review: http://bjsm.bmj.com/content/51/1/12
Pictorial review of wrist injuries in the elite golfer: http://bjsm.bmj.com/content/50/17/1053
Hip morphology in elite golfers: asymmetry between lead and trail hips: http://bjsm.bmj.com/content/50/17/1081
The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour: http://bjsm.bmj.com/content/47/17/1075

Why we get fat. Insulin is a fat-storing hormone: Dr Sarah Hallberg, renowned obesity doctor

Are you confused about healthy nutrition, the role of insulin, this concept of ‘insulin resistance’? Can one largely ignore a macronutrient (i.e. carbohydrates) and not drop dead within a few days?
Karim Khan, the Editor in Chief of the BJSM vouches for this podcast personally and describes Dr Hallberg as one of the people that has most influenced his understanding of a key medical concept.
In addition to Dr Hallberg’s popular (nearing 2 million views!) TEDx talk https://youtu.be/da1vvigy5tQ
Here are her further credentials. https://www.virtahealth.com/about/hallberg
When Dr Hallberg refers to blood glucose being ‘100’ she is referring to the US convention – using mg/dL which is 5.6 mmol/L in many countries (Europe, UK, Australia, Canada etc.)
Highlights include:
Dr Hallberg has great training for exercise prescription from her undergraduate and Master’s degrees in Kinesiology. She’s a medical doctor who runs a clinic for obese patients – that’s a better place to speak from than a lot of theorists in the field.
Dr. Sarah Hallberg is the Medical Director at Virta Health, a specialty medical clinic that reverses type 2 diabetes safely and sustainably, without the risks, costs, or side effects of medications or surgery.
As a physician and exercise physiologist with a passion for helping people be healthy through diet and exercise, she is responsible for providing medical supervision to Virta’s expert team of physicians and oversees the clinical strategy for Virta Clinic participants.
Dr. Hallberg is also the executive director of The Nutrition Coalition, a nonprofit organization that aims to educate the public and policymakers about the need to strengthen national nutrition policy so that it is founded upon a comprehensive body of science.
Link to Dr Hallberg’s paper:
Recent trial she refers to: http://diabetes.jmir.org/2017/1/e5/ A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes
Link to other podcasts on BJSM relating to this topic:
Professor Timothy Noakes: “High-fat for health” (11k listens) https://soundcloud.com/bmjpodcasts/high-fat-for-health
Professor Stephen Phinney “Science behind lo-carb for performance” (9K listens) https://soundcloud.com/bmjpodcasts/prof-stephen-phinney-on-the-science-behind-low-carb-diets-for-athletes-a-rational-approach
Professor Jason Fung: “Diet and obesity and diabetes” (6K listens) https://soundcloud.com/bmjpodcasts/dr-jason-fung-on-the-impact-of-diet-on-obesity-and-type-2-diabetes-mellitus
Link to Dr Hallberg’s nearly 2 million view TEDx talk: “Reversing Type 2 diabetes starts with ignoring the guidelines” https://youtu.be/da1vvigy5tQ

Kathryn Schneider talks concussion: primary, secondary and tertiary prevention

Whilst at the 2017 IOC Prevention of Injury & Illness Conference, BJSM’s Liam West spoke to a key figure within the concussion research world, Associate Professor Kathryn Schneider. Kathryn is a Clinical Specialist in Musculoskeletal Physiotherapy working at the Sport Injury Prevention Research Centre located at the University of Calgary, Canada.
She was the lead author in the landmark RCT look at cervicovestibular rehabilitation in sport-related concussion in 2014 (link below). Her most recent research is discussed in this podcast and formed part of the discussion in the 2016 Berlin Concussion in Sport Meeting.
Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial (2014)
http://bjsm.bmj.com/content/48/17/1294.long
Rest and treatment/rehabilitation following sport-related concussion: a systematic review (2017)
http://bjsm.bmj.com/content/early/2017/03/24/bjsports-2016-097475
What strategies can be used to effectively reduce the risk of concussion in sport? (2017)
http://bjsm.bmj.com/content/early/2017/03/01/bjsports-2016-097452
Remember to check out the literature on the new Sports Concussion Assessment Tool (SCAT5) here: http://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097699
The new tool can be found here: http://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097506SCAT5

Sham surgery for meniscal knee pain – Boom! Boom! Boom! Prof Teppo Järvinen rocks the boat

Ahead of the Finnish Sports Physiotherapy Congress (June 9 and 10, 2017), BJSM editor in chief Karim Khan, chats with the senior author of a study that proved that partial removal of a degenerative torn meniscus does not alleviate mechanical symptoms when compared with sham surgery. That was Teppo Järvinen (http://bit.ly/2rlfW5I), professor of orthopaedics and traumatology at the University of Helsinki and a speaker at the Finnish Congress in June.
Before that study (link below), orthopaedists were confident of the benefits of arthroscopic surgery on patients suffering from mechanical symptoms. However, “scientific proof of the benefits had been based entirely on uncontrolled follow-up studies,” said Dr Raine Sihvonen, specialist in orthopaedics at the Hatanpää Hospital in Tampere and first author of the study.
Here is the link to the study in the New England Journal of Medicine:
http://www.nejm.org/doi/full/10.1056/NEJMoa1305189#t=article
In the podcast we cover:
- A bird’s eye view of Bruce Moseley’s seminal sham surgery study – arthroscopy was no more helpful for knee arthroscopy in older people than sham surgery http://www.nejm.org/doi/full/10.1056/NEJMoa013259#t=article
- The fact that MRI is not a good predictor of who will benefit from knee arthroscopy. Here’s Dr Martin Englund’s NEJM paper. http://www.nejm.org/doi/full/10.1056/NEJMoa0800777#t=article
- Ewa Roos’ and Nina Kise’s study showing that exercise provides as good results as arthroscopic meniscectomy. Remember – the patients who fail rehab also fail surgery. Look for other solutions – not arthroscopy – to cure that patient. http://www.bmj.com/content/354/bmj.i3740
Links:
Here’s a YouTube video summarizing the FIDELITY study in 4 minutes. https://www.youtube.com/watch?v=RaDWkJHmEB0
Here the link to the Finnish Sports Physiotherapy Congress – June 9 & 10, 2017.
http://fspa-congress.com/

Doping mit Prof Dr Patrick Diel

Doping ist immer ein heisses Thema, besonders in Jahren der Olympischen und Paralympischen Spiele.
Dr Markus Laupheimer (London/Zürich) stellt die Fragen in deutscher Sprache an Prof. Dr. Patrick Diel. Patrick ist Professor an der Deutschen Sporthochschule Köln am Institut für Kreislaufforschung und Sportmedizin, Abteilung Molekulare und Zelluläre Sportmedizin. Er hat ein spezielles Interesse an präventiver Dopingforschung und beantwortet uns einige interessante Fragen:
- Was ist Doping?
- Wo liegen die Nutzen und Risiken von Nahrungsergänzungsmitteln?
- Was ist Gen-Doping?
- Was ist eine Medizinisch Therapeutische Ausnahmegenehmigung (TUE)?
- Wie können wir unsere Athleten vor Doping schützen?
Weitere Informationen zum Thema Doping findet Ihr unter:
https://www.nada.de/de/nationale-anti-doping-agentur-deutschland/
http://www.doping-prevention.com/
https://www.dshs-koeln.de/visitenkarte/einrichtung/zepraedo/
Für weiter englischsprachige und deutschsprachige Inhalte folgen Sie uns gerne auf Twitter @BJSM_BMJ

Time to reset: What causes coronary artery disease? Dr Aseem Malhotra.

Britain's leading anti-sugar campaigner and one of the most prolific doctors in the world influencing obesity thinking and highlighting the harms of too much medicine.
In addition to being a Consultant Cardiologist, Dr Malhotra is a member of the board of trustees of UK health think tank, The King’s Fund and a member of the Academy of Medical Royal Colleges Choosing Wisely Steering Group
Here’s the link to his website: http://doctoraseem.com/biography/
Topics covered include:
No association of saturated fats and heart disease in primary or secondary prevention studies.
Focus on sugar -
• CVD mortality has come via reduction in smoking & trans fats with better acute AMI management.
• Statins have a number needed to treat of 1 in 83 for mortality in secondary prevention in men
• Stents save lives during heart attacks but not for 'stable' coronary disease
• PREDIMED and Lyon heart study
• Cholesterol is not the mechanism of action of how diet studies work
• Practical explanation-of frying vegetable oils and dangerous omega 6 (high omega 6 to omega 3 is bad)
• Butter and coconut oils have saturated fatty acids and are stable in cooking.
• Criticism from the Centre for evidence based medicine (Oxford).
Here is the editorial (Free) in BJSM:
http://bjsm.bmj.com/content/early/2017/03/31/bjsports-2016-097285

Exertional Rhabdomyolysis: What you don’t diagnose may kill a patient. Prof Francis O’Connor

What is rhabdomyolysis?
Can it sneak under a clincian’s radar?
What the key clinical features?
When to be alert for rhabdomyolysis
Problems when coaches are too aggressive with a new load
Two cases – clinical scenarios
When sickle cell trait complicates matters
Which athlete with sickle cell trait is at increased risk?
Can clinicians identify the athlete with sickle cell trait who is at risk of death?
To screen or not to screen. Ethics and science.
Who is ready to return to play?
Who is at risk of recurrence? It applies to athletes and war fighters.
Role of genetics – the genetic markers that clinicians can test for in a tertiary care centre
Links to a previous podcast by Fran O’Connor – Exertional leg pain http://ow.ly/j9IU30bs1oe
Links to papers:
Sickle Cell paper in Medicine and Science in Sports and Exercise: https://www.ncbi.nlm.nih.gov/pubmed/?term=harmon+and+Med+Sci+Sports+Exerc
Pathophysiology of exertional death associated with sickle cell trait: can we make a parallel with vaso-occlusion mechanisms in sickle cell disease?
Connes P, Harmon KG, Bergeron MF.
http://bjsm.bmj.com/content/47/4/190.long
Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator.
Harmon KG, Drezner JA, Klossner D, Asif IM.
http://bjsm.bmj.com/content/46/5/325.long
To screen or not to screen for sickle cell trait in American football?
Harmon KG, Drezner JA, Casa DJ.
http://bjsm.bmj.com/content/46/3/158.long
Return to Physical Activity After Exertional Rhabdomyolysis
O'Connor FG; Brennan FH, et al.
http://journals.lww.com/acsm-csmr/Fulltext/2008/11000/Return_to_Physical_Activity_After_Exertional.8.aspx

Mayo Clinic and AMSSM sports medicine specialist, Dr Jon Finnoff, on managing leg pain in sport.

Dr Jonathan Finnoff, DO, is the Medical Director for Mayo Clinic Square, Sports Medicine Center, Minneapolis, Minnesota. He is a specialist in Physical Medicine and Rehabilitation and Sports Medicine. He benefits from his experience as a former professional athlete in his work as the Team Physician for professional basketball teams -- the Minnesota Timberwolves and Lynx.
Dr Finnoff addresses the case of a 24 year old basketball player who has calf pain that stops her from playing but responds relatively quickly when she stops running.
Timeline
• The differential diagnoses include chronic exertional compartment syndrome, vascular problems such as popliteal artery entrapment, as well as neurological causes
• Physical examination is critical and there are some key tests to distinguish those different pathologies
• The role of investigations including imaging
• How does one make the compartment pressure diagnosis?
• Treatment for chronic exertional compartment syndrome including gait retraining
• More aggressive treatment including use of the meniscotome, botox injection and surgery
• Outcomes of treatment including botox and surgery
Link to previous podcasts:
This podcast is complemented by one with Professor Francis O’Connor: https://soundcloud.com/bmjpodcasts/professor-francis-oconnor-from-the-amssm-challenging-leg-paincalf-pain-and-military-injuries?in=bmjpodcasts/sets/bjsm-1
Andy Franklin-Miller’s BJSM podcast on exertional compartment syndrome and gait retraining: https://soundcloud.com/bmjpodcasts/running-injuries-with-andy
Andy Cornelius on how to assess a runner and what to do when you see abnormalities:
https://soundcloud.com/bmjpodcasts/keeping-runnners-running-the-secrets-of-running-assessment-advice-and-exercise-progressions

Professor Francis O’Connor, from the AMSSM: Challenging leg pain/calf pain and military injuries

BJSM’s good friend Fran O’Connor is Director of Emergency Medicine and Sports Medicine at Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland. He is a former President of the American Medical Society for Sports Medicine (AMSSM, @theAMSSM). He also held leadership positions in the American College of Sports Medicine and the American Medical Athletic Association. He is a prolific researcher with more than 60 scientific journal publications, 25 book chapters and numerous national and international presentations.
In the podcast he addresses the following questions:
• What are the main challenges seen by clinicians who work in military settings?
• What is the differential diagnosis to consider in the patient with calf pain, leg pain?
• How does one make the compartment pressure diagnosis?
• What are the challenges of measuring compartment syndrome?
• What is the conservative management for compartment syndrome? (Prof O’Connor touches on gait retraining first and foremost, Pose running technique, botox injection)
• Is there a role for surgery, and if so, which surgery? What are the outcomes?
• What is the role of orthoses?
Link to previous podcasts:
This podcast is complemented by one with Dr Jonathan Finnoff: https://soundcloud.com/bmjpodcasts/mayo-clinic-and-amssm-sports-medicine-specialist-dr-jon-finnoff-on-managing-leg-pain-in-sport?in=bmjpodcasts/sets/bjsm-1
Andy Franklin-Miller’s BJSM podcast on exertional compartment syndrome and gait retraining:
https://soundcloud.com/bmjpodcasts/running-injuries-with-andy
Andy Cornelius on how to assess a runner and what to do when you see abnormalities:
https://soundcloud.com/bmjpodcasts/keeping-runnners-running-the-secrets-of-running-assessment-advice-and-exercise-progressions