Dr Sinead Holden is an Assistant Professor in Sport and Exercise Science in UCD School of Public Health, Physiotherapy and Sports Science. Her research interests are in optimizing musculoskeletal health and development during adolescent growth, with a view to understanding and preventing overuse and loading – related injuries and their consequences on health and performance in youth. Her track record includes over 60 peer reviewed publications and >10 invited presentations.
In this episode she discusses:
- The differences between Osgood-Schlatters and Patellofemoral pain.
- A simple rule of thumb for helping reduce the likelihood of Osgood-Schlatters.
- Why being physically prepared for the chosen sport is critical.
- What type of sports Osgood-Schlatters presents in.
- The risk factors for developing Osgood-Schlatters and why Severs may be an early warning sign.
- Why removing kids from sport is a bad idea and how treatment should focus on continued participation in sport.
- The Long term consequences of Osgood-Schlatters on physical performance and participation.
- The excellent rehab guide that Aalborg University group put together on Osgood-Schlatters.
You can listen to the episode in full here!
You can keep up to date with Sinead’s work via her ResearchGate profile here: https://www.researchgate.net/profile/Sinead-Holden and via Twitter here: @Sinead_Holden .
To learn more about the LTAD Network check out www.ltadnetwork.com or follow on Instagram: @ltadnetwork or Facebook: https://www.facebook.com/ltadnetwork .
You can keep up to date with Athletic Evolution via our www.athleticevolution.co.uk , Instagram: @athleticevouk and Twitter: @athleticevouk .
Rob Anderson
Sinead, welcome to the podcast. It’s amazing to have you on this morning.
Sinead Holden
Thank you very much. And thank you for the invite. I’m always happy to talk about kids and research and knees. It’s great.
Rob Anderson
I know, speaking with a lot of academics and people who are doing research and lecturing, it’s always difficult to find a slot to fit in. So I’m really glad that we were able to do that in there. And connect.
Sinead Holden
Yeah, absolutely.
Rob Anderson
So before we diveinto your research in the areas of interest, take us back to a young Sinead. What were the sports that grabbed your imagination? What did you dip in and out of as you were growing up?
Sinead Holden
Yeah, and I played field hockey, mostly, I still play field hockey. Now, despite I’m getting a little bit older, I play at a relatively competitive level. And so that’s been my main thing I would say I’m, I’m not the most. I’m a hard worker. I’m one of the one of those who works really hard on the pitch, I’m eager to get involved. I tried my hand at gymnastics, basketball, como II, which we have in Ireland, a Gaelic sport, and none of them really stuck, because I wasn’t particularly good at any of them. But yeah, I’ve always been involved in sport. And, you know, as a result, suffered my own dose in the pit of knee pain as an adolescent, and as well, which is a very typical story.
Rob Anderson
Hmm. So what what was it that took you down the research path? What did that kind of look like, as you get to the end of the school era and start heading into university? What would the university academic kind of path begin to look like?
Sinead Holden
Yeah, so I did, my undergrad was in Sport and Exercise Science. And I was really, really interested in research and the idea that we could, you know, I think sports science in itself is still a really growing area. In terms of the research historically, there’s, you know, bad research, I mean, sports science and sports medicine are definitely improving in terms of what’s available and what’s going on out there. So I just thought it was a really, really exciting place to be. And so I basically just applied for a scholarship for my PhD I was interested in in growth and maturation at that time. And looking at how adolescents develop neuromuscular control was vaguely the area in which I was investigating. And just followed on from from that I ended up going to Denmark and doing my postdoc there where I was heavily involved in research on adolescent knee pain, and all sorts of kind of issues that arise with being involved in a lot of sports participation, when you’re young. And I guess my real interest is how can we strike that balance of getting all the positive benefits of physical activity and sport like from recreational to elite, but without, you know, having all the negative impacts that come with injury, and especially those chronic injuries that kids don’t really know how to deal with, they don’t know who they should tell about it, they might end up telling someone a little bit late, and then, in a lot of cases, stop them from actually participating in their sport, despite we we like to think they’re all self limiting. Unfortunately, they’re not.
Rob Anderson
So how did Denmark pop
Rob Anderson
up on the scene? How was that? Was that a particular hub of research in that area? Or was it something else that came up?
Sinead Holden
Yeah. So in the final year of my PhD, I went to the Danish sports medicine Conference, which is a relatively big conference in sports medicine world, or at least it’s relatively well known. And I was just taken by the the level of science that was presented there. And because it was based in Denmark, of course, it had international speakers, but a lot of local speakers as well. And at that I actually connected with with Michael Ratliff, who’s one of my colleagues and co authors. And, you know, arising from that we developed a really nice collaboration, and I ended up moving over because we had all the same common interests in Youth and Sports, and he had done a lot in the world of patellofemoral pain at that time. So that was kind of how that arose.
Rob Anderson
So what was your in terms of your postdoctoral research? Whatwere some of the projects and research investigations you were undertaking there?
Sinead Holden
Yeah. So I think the way it started was that I was looking at some of the longer term impacts of knee pain during adolescence. So the impacts on you know, function into adulthood or its participation, again, with that real strong focus of keeping kids healthy and active. And so I think we were probably myth busting some of the common misperceptions with adolescent pain as a starting point, so that was kind of where I started, but I was working in a very multidisciplinary team, so, you know, working with sports scientists, but also with pain scientists, engineers, sports medicine physicians, physiotherapist, so there was a lot of different stuff that I got involved in, but I would say you know, the Uh, the main focus was in these common musculoskeletal complaints that we see in adolescents and how we can, you know, understand them better? What are the risk factors for developing them with a view to like both primary and secondary prevention of them basically, you know, taking a more proactive approach to keeping kids in their sports and not letting them, you know, struggle for a long time and drop out.
Rob Anderson
Now you’re back in Ireland at UCD, what is your role look like day to day is primarily lecturing primarily researchers 50/50? Or what does that look like?
Sinead Holden
Yeah, it’s hard to put a number on it. So I ordinated number of modules in exercise science. And so I do do teaching, exercise physiology and things like that. And then, of course, I’m very keen to keep up my my research profile. So I do have a number of research projects ongoing. It’s it, I would say very, so at the moment, we’re in the middle of the semester. So it’s a heavy teaching and assessment load, you know, we’re having all of our mid semester exams and that type of stuff. But come summer, I’ll be definitely spending a little bit more time on all the research projects that are kind of sitting waiting for my attention.
Rob Anderson
Good. Well, let’s dive into some of that research and some of the kind of topic areas. So the first big one for me, and for the people who perhaps are initiated in this the first time they’re hearing, maybe a bit more in depth, can you give us a bit of an understanding of what he’s asking Schlatters? And how does it differ from patella
Rob Anderson
femoral pain?
Sinead Holden
Yeah, so I guess the easiest place to start there is is with the commonality. So they’re both really common, and they happen, you know, they tend to increase during adolescence. So they’re common week, complaints that we see during adolescence, both anterior knee pain, I would say, that’s kind of where the similarities and that one of the big differences is that the both loading related, but one of the big differences is that we see a much higher proportion of females with solid femoral veins relative to males, whereas in males good slaughter, it’s historically been thought to be a male condition, however, thought appears to just be linked to the higher sports participation in in males. So if you can infer that there’s actually no real difference in risk between males and females, that taller femoral pain is like, some people have used the term low back back pain of the knee. So there’s no real structural pathology that we’re aware of. So pain is typically, you know, response to either trash or actual tissue damage. And I think in sports, we often term things overuse injuries, but there’s not necessarily any tissue damage there. And I’m sure femoral pain is one of those cases, which also makes it you know, it tricky thing. And then I think that the big difference with as good Slagter is that it does appear to be a specific pathology. So again, it’s related to a high level of sports participation, knee joint loading, it’s common in activities with a lot of stretch, shortening cycle activities. So it’s an Apophis itis. And so when you are growing and maturing, you have these areas of of cartilage where the tendon inserts onto the long bone. And then Osgood slaughter, that is where the patellar tendon inserts onto the tibial tuberosity. So, other common things are severs disease, which many of your listeners might be familiar with, as well, which is the same thing, but which happens in the heel. And what we can see is that there is changes both that depended on the side of attachment to the hypothesis, which is, you know, soft cartilage as we’re growing. And then during that period, it’s actually ossifying and turning into heart bone. And we can see, you know, different characteristics on imaging at that site. So
Rob Anderson
we’ve kind of dive into a little bit, but so the risk factors we’re talking about as a high training load, do we see particularly is that particularly running base sports or is it jumping landing bay sports, you mentioned the stretch shortening cycle, do we see as much Osgood Schlatters. In, for example, CT based sports versus running based field sports? Was it pretty much the same?
Sinead Holden
Yeah. So like football is is the big one that it’s really commonly seen in and I think probably where the majority of research come from, but that’s probably just because we have more research coming out of football academies and things like that. In terms of court and field based sports. It’s actually quite common in basketball. And in Denmark, there’s a lot of humble plays. So a lot of the kids we see come from humble gymnastics, there’s cases and things like martial arts sports. But yeah, a lot of that that jumping and landing volleyball and things like that as well. Are some of the common sports where we see it. I played field hockey, where we’re not jumping landing. We are obviously still, you know, running and doing lot of other activities that load the quadriceps to the patellar tendon. And we do see kids with it there as well. So it just might not be quite as common in some of the other sports at the other thing, just, which I think is quite interesting when you’re talking about risk factors is a couple of studies have actually shown that having a history of severs disease is actually quite a potent risk factor for us good slaughter. Now, that could be for a number of different reasons, one of the prime ones being that probably they share the common risk factor of butterfly sports loading itself. But it is quite interesting because the way that we mature is that our bones also fly to sleep approximately. So savaris typically starts at that slightly younger age group than Osgood slaughter. So it could almost be perceived as like a warning sign. Because as we move up the kinetic chain, we actually see a little bit more severity and time loss with the epiphyseal injuries higher up the kinetic chain, so the knee and then as we get into the hip as well, they occur even later in adolescence. So I just think that’s, that’s, that’s quite interesting.
Rob Anderson
Yeah, that is I hadn’t come across that before. I mean, obviously, aware of the similarities itself as being in a prophesied, etc. And obviously, in that period of growth and maturation, etc. But I didn’t realise the connection there. But I guess it makes sense. As you say, if high sports loading is a common risk factor, and you haven’t modified that behaviour, it’s probably going to pop up again.
Sinead Holden
Yeah, exactly. I think that that could be the main driver, and we could hypothesise about all sorts of like, you know, genetic considerations. But I do think that that’s the probably the prime confounding factor that would flag at me. And that, you know, some people who work within sports as well have observed this, that that the same kids, it might relate to some of the practitioners who are listening, they’ll say, oh, yeah, you know, I’ve seen that in my practice, as well. But, you know, they had the history of servers, and then they come back with us good, and so on.
Rob Anderson
So I guess this, this is a bit more of a grey question, because it’s, I guess, a bit more subjective. But when we talk about high sports loading, what are some of the things that we consider to be highest? So the average person might look at training schedule and say, Oh, that’s not high? That’s quite a low level sport. Like, what if we were to try and put some characteristics around? What is high mean, as as a kind of warning sign or an indicator? What are some of the things that we would be looking out for?
Sinead Holden
Yeah, I think I think that’s a really good question. And I mean, I think it’s actually very, very difficult. Because, first of all, we don’t have a huge amount of prospective data on it. And it’s obviously gonna vary hugely between sports and sporting populations. So then you have to also consider things like training history and athletic preparedness. So are you prepared for the volume of sport that you’re actually going to be doing? You know, we do know that even things like cardiovascular fitness can decrease your risk of injury. No, that’s, that’s obviously not just overuse injuries, but it is an important component to be aware of. So how we’re actually preparing kids for what they’re going to be exposed to. But, you know, they, they’ve done a lot of work in the in the US in, in basketball, and baseball as well, in terms of monitoring, training loads. And in baseball, you know, they monitor the page counts that kids do. But one of the things that that came across, that I came across before, from that research was, you shouldn’t be doing more hours per week than your age in years. So if you’re 12 years old, you probably shouldn’t be doing more than 12 hours a sport. And that kind of stuck with me because it’s something really easy to say to parents and kids themselves. But that being said, I think it is really, really hard to put a number on it because it does probably depend on how ready you are for what you’re going to be exposed to but also what you’re doing and like not to get too much into the multi sport versus single sport debate. But certainly doing really repetitive activities and a very high volume certainly seems to increase the risk of all sorts of injuries, whether that’s, you know, kicking and Osgood Slatter, or jump landing and Osgood slaughter, or those pitching on your shoulder and elbow pain in in other types of sports. So having that variability and movement and also kind of an S&C bass could potentially be productive from from a high volume of sports.
Rob Anderson
And I guess that is you kind of alluded to kind of leads to the early specialisation kind of context doesn’t if you have someone who’s very early specialised, they’re going to be repeating the same movement patterns, they’re not getting a different stimulus from a sport that’s entirely different in the movement base. So the likelihood is there’s gonna be a high volume and particularly if you’re a decent level, when you’re playing an academy, you’re probably gonna be doing multiple sessions in a week and you can kind of see Yeah,
Sinead Holden
yeah, exactly. And you’re stressing the same tissues in the same manner and maybe not giving them a break. And then you know, there’s Yeah, so there are sports which actually encourage participation in other sports outside of your primary sport now And it probably depends what level you’re playing at and who you’re talking to, or they’re not that’s recommended. But it’s definitely an interesting one. Because, you know, often parents might think that encouraging their kid to play multiple sports is actually increasing the training loads, which it is we still need to be aware of what they’re doing outside of their primary sport, but it’s yeah, it’s an interesting balance anyway. So
Rob Anderson
there’s obviously a number of risk factors that we’ve talked about one being growth and maturation, which isn’t particularly modifiable, but your your scheduling, you know, the activities you’re involved in are a bit more modifiable. So is it? Can we reduce the risk of Osgood Schlatters? I mean, prevent preventing injuries is always a bit of a grey area, because we can’t always necessarily get the risk down to zero. But how can we influence some of these modifiable risk factors that we know this is potentially something that we won’t be aware of down the line?
Sinead Holden
Yeah, so I would say that, yes, we actually can. And I say that in the face of a lack of evidence to prove that we can. But I think we also have to take a little bit of common sense and what we’ve learned about overuse injuries in general. So first of all, we do know that overuse injuries are preventable. And things like strength training, in terms of preventing injury in general seem to be one of the best things and have a lot of systematic reviews on that. And then, you know, quite interestingly, something like the FIFA 11 Plus, again, going back to soccer that’s been rolled out internationally. And there’s quite a large amount of data on that. And one of the randomised trials on account number was it 2018 That was published in the BDSM. They were obviously it was huge, but they were obviously looking at the effect on all injuries, but they actually split it down into categories. And they looked at overuse injuries. It was I think it was in youth football, and they actually looked at what they termed growth related injuries. And they actually found that the FIFA 11 Plus in randomised design had a tendency to reduce the incidence of growth related injuries. Now, what are growth related injuries? Well, most of them are things like Osgood, Schlatter, and SAVVIS. So I do think that there is definitely opportunity for more work in that space. But already, we kind of have a little bit of common knowledge and evidence of what type of things we could potentially apply to reduce that. So again, coming back to preparedness for for competition, and the loads, you’re going to be exposed to the FIFA 11 Plus, like it, you know, it’s designed as a warm up probe programme, we can argue over whether or not that’s the best design and all the problems with adherence and when we should actually get kids to do it. But the principles of when they do this, and I’m what comprises love are probably things that we can learn some some lessons about.
Rob Anderson
And I think it’s really important as well, I know from reading some of the reviews around, you know, injury burdens and Academy football, like growth related injuries, or graduated issues can be some of the most burdensome because they can linger on, you know, so I remember seeing like some statistics around 16 17% of all time loss injuries and growth related gang conditions, being in excess of 28 days, that’s a month, essentially, of training time loss. And if you’re a pretty good Academy footballer, that happens to be a crucial point in time, that can be quite quite an influence in, in your progression or whether you’re attend, you know, playing in big fixtures or big tournaments, etc.
Sinead Holden
Yeah, absolutely. And I mean, I think, you know, the challenges are different for the Academy, kids versus the kids outside of the academy. But in that context, that that is a huge impact, and even the academy sell themselves, you know, that’s something that they definitely want to decrease the burden. The other thing is not all of these injuries in the academies lead to time loss, some of sometimes the kids are hesitant to report them because they don’t want to be pulled out of games and so on. So I think the burden is actually underestimated because what we see is not only that initial burden of time loss, which of course, in the context of an academy is huge on that, that players development selection. And also, you know, the, the benefit of them to the club. But if they’re not, maybe fully out of sport, they might be having reductions in performance, or they might be having limited capacity to engage in other activities, which can enhance their athletic development. And that’s something that we see in a huge amount of data is that because some of the data from academies like 28 days is a lot lower compared to some of the durations we see outside I think that’s probably because of the huge amount of support and resources they have there. And obviously there’s a lot of pressure to get them back into sport, which is probably a good thing. I don’t think completely pulling them out. Sport is a bad thing. But I think what what all studies you know, regardless of whether they’ve been done academy or not, because there’s a new one from Russian football academies have shown is that in, you know, the medium to long term, so a couple of years after having us good slaughter, even if you’ve fully recovered, there’s actually still consequences both in terms of sports related disability, but also in terms of huge impairments in lower limb strength, which is going to impact performance, which again, is hugely important in your academy setting. So I think also recognising that those that, obviously stopping sports itself can affect those things. But even those that are continuing to participate in, in sport, and maybe having an impairment in performance, during a period where we kind of have this, you know, window of opportunity, like adolescent growth and maturation, you know, there’s all the hormones and great adaptations that we can get to training during that period that we’re actually missing out on in those kids. So the knock on effect is actually beyond that initial initial immediate period of the pain itself. Anyway. Yeah, that’s
Rob Anderson
a really important point you raise actually. And anecdotally, I had this discussion with one of the athletes that I worked with privately who in a professional football academy set, you know, raised an issue. From my perspective, what I thought was a hamstring overload issue, and said, the head coach said, don’t go and see the physio because the physio just pull you out. So the sort of, you know, the subliminal messages that you’re saying to athletes of, okay, if you’re injured, that means you’re not taking part in the session at all, I don’t want to be doing that. So I’m just not going to raise the red flag to say I’m struggling. And the knock on effect of that is, as you said, Okay. Your body is a very smart system, it’s going to find a way to get the job done, but it may be suboptimal. So suddenly, we get these issues with gate with jumping a ladder incorrectly, because I still need to jump and land. But I want to offload that structure, because it’s a little bit tender. So maybe I’m biassing, the other healthy knee a little bit more, and two or three years down the line, we end up with suboptimal trip mechanics, suboptimal jumping landing, which is going to affect your performance,
Sinead Holden
it’s going to affect your performance as well. And I’m like what you’re saying there is exactly right, it, you’re grown to be overloading the other leg. So we’re seeing huge deficits in terms of of strength and performance, but that again, in itself then can predispose to subsequent injury, whether it’s the same injury or a different type of injury. So so it’s kind of creating that cycle within itself.
Rob Anderson
Because it’s that whole cycle of the best predictor of future injuries, previous injury.
Sinead Holden
Yeah, yeah, for a lot of different reasons.
Rob Anderson
So we’ve got a few modifiable factors we can look at to reduce the likelihood or potentially prevent altogether Osgood Schlatters. If I’m fortunate enough to then end up in a situation where we’ve developed Osgood Schlatters. What are some of the kind of key things that we need to be aware of, both from I guess, parents supporting our athletes, the athletes themselves? What’s, what’s some information that maybe before was kind of given them with has been updated? What are some of the key kind of things Principles of Management? Do you think?
Sinead Holden
Yeah, I, you know, again, I think this is this is a tricky area, because we’re only actually displaced, it’s probably something most people you know, again, especially in Academy football is have heard often, a lot of people might think they know everything about it. But there’s actually a real limitation in terms of our evidence and the randomised trials that we have for conservative management. So historically, I think it was based mainly on, you know, a philosophy that it will go away, it’s growth related. So inevitably, when you stopped growing, it will go away, it will be fine. But maybe during that period of growth, we need to stop kids playing sport. And so there’s kind of two two main things historically that have been recommended. And that’s, you know, something along the pain management side, whether that be ice painkillers, injections, all of these have kind of been been tried and been published on in different case studies and been tried in practice. And then, you know, limiting that loading, which is thought to be causing the pain, and that’s, that’s historically been the management. But I think what we’ve seen from the, you know, in the past five years, even there’s a number of different case series, and what we’ve seen is, okay, well, they’re gonna have longer term effects in terms of, you know, their muscular strength and power. And one of the studies actually showed an increased body fat percentage in kids who had asked Slagter, probably due to the fact that what a number of studies have shown is that a certain proportion actually end up stop playing sport because they’re not supported back into this sport. So they try and go back, they get paid again, and they’re in this cycle where they don’t actually know how to manage it, and it’s not productive for them. So I think, you know, the, the movement has been towards a much more active management approach and appreciation that you know, regardless of whether it’s an academy or just a young kid who’s trying to play sport with their friends, sport is actually He’s really, really good for health. And it’s probably not good for their, you know, emotional mental well being to be pulled out of that, as well as their own physical development. So I think the balance now is trying to say, well, how can we support kids to learn how to manage that load to not cause too much significant pain to not aggravate to not make it worse, so they have to spend, you know, quite significant time out of sport, getting it to settle down. So I think that’s the approach as well as then caregiving, some of the deficits that that we see that are associated with so in terms of the muscular strength and power and actually providing a more active rehabilitation, which is, you know, again, it’s what’s done for most muscular skeletal injury. So, you know, it makes perfect sense that we would do it for ancoats ladder. And I think, you know, some of the approaches that have been taken, probably are not dissimilar to what’s done in like patellar tendinopathy. And if you think like, you know, this is something that’s loading through the tendon, okay, the problem is that the bones not fully mature, and it’s the distal tendon, it’s not the same, but how do we actually, you know, balance that loading and, and things like that, there’s probably the more current thinking and the way, some of the research appears to be moving also, including the case series that have come out of academies, just in the last couple of years.
Rob Anderson
It was it was David Johnson, now at West Ham, but then at Bournemouth, who first kind of put your work on the radar for me in terms of some of the other, I guess, more applied stuff of the rehab programme that’s come out about Aalborg, etc, which, you know, has been a fantastic resource for me, with so many parents being able to direct them to that, there’s a few key concepts in there that I wanted to kind of dive into. So the first is, is utilising a pain scale. So one of the things that previously has kind of been been said is, I’ve experienced with kids being informed, as you know, if you’re in pain, you just have to stop. And actually, potentially, there’s a bit more wiggle room in that isn’t there?
Sinead Holden
Yeah, absolutely. And I think, as I said that, the point is, we actually want to, you know, promote all the health benefits of staying in sports also for because that’s what they want to do, especially, you know, those that are playing to relatively high level they want to be playing sport, being told you have to stop is worth two. So yeah, I guess the idea is, well, what’s that balance? So, you know, we want to probably avoid doing too much, that’s going to make it significantly worse, because actually, the pain intensity associated with us go slider can be quite high. And, you know, we can see the area can get hot and swollen. And, you know, we probably want to avoid going down that end of the spectrum. But is there some amount of activity that we can teach our lessons that they can do, and also to enable them to actively rehabilitate in the context of pain without causing a huge flare in their pain? And I guess the the idea is also about giving them some sort of tools and ownership because, as I said, like, you know, studies have shown it’s like 20 to 30%, kids without cause bladder and on squats louder and not getting back into sport. So giving them a tool where they know, okay, well, if I go back, even if they have had a breakout, and I have a small amount of pain, I know that that’s not necessarily meaning I have to completely stop again. And I just need to modulate my own activity. And I understand how to do that. And it’s giving them that way in which they can continue participating in sport.
Rob Anderson
Yes, fantastic. Because I think that that is one of the kind of problematic things is it tends to be a bit black and white. Oh, this has given me some issues, right, come and sit out. And it’s actually well, actually, it’s certainly a two out of 10 it’s manageable. Yeah, I feel it a little bit. But it’s not, I’m not No, I’m not in agony. And actually, there’s a bit more nuanced than just sitting on the couch for three to six months, hoping it’s gonna improve itself. Yeah,
Sinead Holden
and I think you’ve hit on something really important there, it’s only a two out of 10. So so a lot of these might not start so bad. And if we can actually catch them early, keep kids playing sports and maybe, you know, do a little bit of rehabilitation. That probably for a lot of kids might be enough and they might not end up being the kids with these, you know, long term consequences dropping out of sports. I think the problem comes when, you know, it goes on reported for quite a long time until the pain actually gets so severe that they might actually need to, you know, quite substantially reduced their sport and and then all of those other challenges come in. So even if, and this is something that I’m working with some Blanchard and in Man City Academy is trying to normalise it so that the kids feel that they can report it early on, and that they won’t be pulled out of sport to actually enable that to be done. Have that early identification and intervention that hopefully prevent any kind of longer term consequences.
Rob Anderson
One other concept that I think, you know, the group that put together that that that quick knee pain guide did really well was around that activity ladder, because I think that’s a concept that a lot of parents and athletes to understand, like, again, coming back to this kind of black or white thinking, thinking, I’ve arrested now I’m ready to go, I’m gonna jump back into training and then play the weekend. And actually trying to explain the principles of well a return to play is this kind of gradual, progressive step towards the end goal of playing matches? So can you kind of give us a bit of an understanding of the activity ladder? How?
Rob Anderson
How has it kind of represented that scale up in intensity of activity?
Sinead Holden
Yeah, I mean, I guess the one thing that I will say is that we have updated this actually twice since since the original publication. So the next one, Rudy Hansen, lead the update, and we actually got him from both kids with us good slider, as well as kind of sports medicine practitioners. And I would say that we definitely made mistakes with the first version, we do hope that that one will be available soon. And again, it will be freely available in English when it is it’s under review with them at the moment. But in terms of the activities that we used, you know, maybe that that could have been optimised a little bit, we’ve gone towards looking a little bit more at sports specific activities, because I guess the initial idea was that, you know, what kids do outside of sport can contribute to knee loading as well. So, you know, going up and down the stairs, and all sorts of different activities. And in that original study, we we recommended a four week break from sports. And then we had the activity ladder, which was supposed to guide them into return sport. And I guess, in, you know, our subsequent iterations of the intervention that we’re now testing a new intervention in a three arm randomised trial. So we’ve actually said, we’re not taking them out from sport at all. And we’ve changed that progressive activities to be more sports specific, I would say. So, yeah, but I mean, it’s, as you said, yourself, it’s something that makes a lot of sense in terms of we it’s not all or nothing in terms of sports participation, so it’s having a progressive return to sport if they have stopped but a progressive increase in loading, even if it’s only a decrease that they’ve had. And one of the things that we’ve actually looked at it and again, it’s it’s in preparation at the moment and a group of kids with us, but slaughter is the kind of the temporal association between loading and pain. And we were kind of interested in asking ourselves, what is it that actually leads to these pain flares? And what we found was that it was like, actually the intensity of activity, and not like the duration or the volume, which is quite interesting, because up to that point, I think we’ve mostly been advising kids to reduce the volume, whereas now we’re looking a little bit more about the type of activities they do. So okay, well, maybe at the moment, you need to sit out of the sprint session. But you can still participate in x, y, and Zed and being able to actually give more tailored and specific advice on what they can and can’t do, based on what we are now beginning to understand is, is going to aggravate their pain more.
Rob Anderson
And that was one of the characteristics that stood out to me. You know, coming back to what you said about some of the risk factors in terms of a high, high degree of use of the stretch shortening cycle like like, you know, going from like walking or cycling is very minimal to none up to that, that top end stuff of sprinting, jumping, changing direction in your matches, there’s a lot more element of intensity loading and stretch shortening cycle action happening there, isn’t it?
Sinead Holden
Yeah, and I think that’s just what I’m saying. We probably learned a lot from that first iteration, although it was it was a good starting point. But yeah, as you say, there’s that that’s a big jump. And how we actually get from here to here is probably what we have begun to think about in a little bit more detail. But yeah, I mean, I think it you know, it is a matter of exposing them to these in a low volume dose initially seeing how they cope. And then, you know, trying to develop the resilience within us by progressing as we would you know, any other sort of kind of S&C type activities?
Rob Anderson
Yeah, I think it’s important that because the classic kind of mindset and ethic can fall into when they’re injured is, oh, I can’t do X, Y and Zed. And actually one of the things I try and think is okay, let’s reframe that. What can we do? Okay, well, you know, and so, yeah, we can’t do sprints or high intensity stuff, but we can do you know, your lower level Passing Drills here. You know, the lower intensity stuff. So I think that reframe is really important because we tend to have that negativity bias of our, I can’t do this, this and this, but we’re completely ignoring the 10 Other things you can do.
Sinead Holden
Yeah, exactly. And I think that’s it. That’s the tricky balance as well, because it also requires buy in from multiple people, the kid, but also potentially the coaches. So one of the things that we’ve done is put on the, on our new version of the leaflet on the back information for your coaches, so they can actually, you know, outside of the elite Academy setting for for other types of kids can actually go to their coaches and be like, Look, this is what I’ve been told, and this is why, you know, I can’t participate in this sprinting, or I can’t do kicking drills right now. But I can practice, you know, whatever it might be some of the more technical drills passing, and then kind of building up to the more intense activities. And, you know, I think also just keeping them part of the team is so important for them that we have to engage coaches and parents with that as well, because that’s what makes working with adolescent athletes, so different to adults is that all of these different considerations that we have to have that we wouldn’t for adults,
Rob Anderson
I think that that kind of cross communication from stakeholders is a really interesting point, because that is like it in an ideal world, in the sort of academy or professional setting, that’s, you’d be more likely to get that between the physio, the athlete, the coach, that clarity of information, but as you pointed out, the Oscar slices, you know, isn’t defined by the performance level you’re at. So if you’re paying for your recreational Car Club, and you turn up and tell the coach, I’ve got two slices, and start saying I can do this, but I can’t do that. It might just appear that you’re being very selective on what you want to do. Or lazy or Yeah, exactly, yeah. Which is not, you know, not the case. But actually, I think having that inclusion is, that’s brilliant, because I could see that being hugely useful. And in some ways, I think a lot of, as you’ve kind of mentioned already, with athletes putting their hand up. And that sort of age, you know, you probably don’t have the confidence to walk up to your coach and say, physio says, I’ve got Osgood Schlatters, and I can’t do X, Y, and Zed, you probably just more likely to just get on with things until it kind of really flares up to the point that you can’t, so being able to have something to say, Oh, I’ve been given this, or, you know, like, it kind of takes a bit of the responsibility off the athlete themselves to be able to explain everything, or the parent who maybe yeah, you know, didn’t get all the information.
Sinead Holden
Yeah. And it also it kind of validates them, because something else is that the kids don’t want to feel weak, right? So they want to feel strong and powerful, and, you know, equal to their peers. And sometimes pain can be, you know, perceived as a weakness within sport. So it also gives them a validation of, well, I’m not just saying I have this, it’s actually, you know, health care practitioner, whoever it is, has, has given me this and written this down. So it also gives them that kind of, yeah, I don’t know. Yeah, as you said, confidence as well, to do that, and hopefully not be perceived negatively.
Rob Anderson
And I guess it’s also like, again, these things kind of compound, it makes it far more likely that the athlete is going to do that. Because if they know, this doesn’t mean I’m completely excluded from training, and I can’t do anything I can do, you know, the Passing Drills, or this, I’m just not going to be the guy in the middle of the RONDO during the dog legs, because that’s really going to aggravate what I’ve got, but giving them the confidence to know that I’m still gonna have some involvement, because they’re far more likely to put their hand up, like the scenario said before, where the coach said, don’t talk to the physio, they’re just gonna pull you out there, hopefully eradicate that situation.
Sinead Holden
Yeah, hopefully. I mean, I do think like, we’ve we’ve piloted this, this new kind of version, and you do have trouble with the kids, you know, depending on what period of the season is coming up, do. You know, and these aren’t necessarily kids who were at the elite Elite level, but they like to think of themselves as competitive, and they’re really, really invested in their sport. And, you know, they’ll say, Yeah, I know, I should have done it. But you know, what, I just didn’t do it. Whereas others will come back and say, Yeah, you know, because we did interviews with them, you need to do it, and you need to stick to it. And then it works. And it’s, there’s always going to be some of those challenging cases, and where we need to think a little bit more cleverly about how we can make it easier for them. But um, yeah,
Rob Anderson
the joys of working with kids. So I guess to be fair, human human beings will will maybe don’t adhere to the promises, we set ourselves in our head. What’s been the sort of success rate of a programme like this in terms of, you know, we mentioned some statistics before around athletes potentially not even returning to sport in the longer term. What’s been some of the outcomes that you started to seeing having more of a sort of structured process in place?
Sinead Holden
Yeah, I mean, I guess I did. The initial study we did definitely showed a lot of positive outcomes. I guess the problem here is we don’t have a super good reference point. because we didn’t do it in a randomised trial, so we only had the one group. So that’s actually why we’re actually now going and we’re doing this three arm randomised trial. So we have one group that’s being recommended complete rest, one group that’s effectively being recommended, what you mentioned on the the pain scale and how to just self modify their activity on pay paying. And actually not not any sort of kind of structured progressive rehabilitation, just pain monitoring. And that’s a very kind of low resource, hands off approach to see if you can get kids to kind of manage it on their own. And then the third group regarding content, the full Whammy, so they’re getting this structured, progressive return to sport that tries to help them first modify some of the activities that we think are mostly associated with what’s good slaughter, and then slowly build them up again, and get them back in sport. So I think that’s going to be quite important in terms of knowing how much better it is compared to something else. And compared to that rest arm because that is what traditionally was recommended, and in fact, is still recommended. But you know, in the in the cohort study we did, there was a large portion, who did, you know, come out. And what we did do was we offset what Previous studies have shown in terms of the strength deficits and the power deficits. So we were able to get kids back up to that through doing the structured rehabilitation, we still did have a small proportion who dropped out of sport. And again, that comes back to I think what we’ve learned from that, because in that they were initially pulled out from sport for the first four weeks. So in the new study, we’re not actually pulling them out from sport at all unless, you know, they’re extremely severe cases. And we kind of have a paradigm for them to follow through. So. So yeah, I’m not sure if I’ve answered your question or not. But like, I mean, I guess I guess what I’m saying is that there’s definitely positives. But I still think we’re on a journey of learning and trying to optimise this because historically, there wasn’t a huge amount of research done in this space.
Rob Anderson
That’s fantastic.
Rob Anderson
Is that? Is there anything else from an outsider’s perspective that you wanted to highlight or anything you
Rob Anderson
think that we need to be aware of as practitioners working in that space?
Sinead Holden
Um, no, I mean, I think we’ve had all the the main things, all the challenges, both working in, you know, academies and working with recreational athletes, the stakeholder involvement, I guess, you know, the big thing for me is that the idea that even if they’ve recovered, they might not necessarily recover fully in terms of the impact that it’s had on them. So actually being aware of that and making sure that we address any sort of deficits for predisposition to future injury. But, you know, we’ve already talked about that in quite a bit of detail.
Rob Anderson
Are you I mean, obviously, we’ve zoned in on those good slices, but that, as we mentioned, this is one of sort of three categories, if you like, in terms of in terms of growth related injuries or issues. Are you aware of other groups that are putting together similar sort of guides for the other ones in terms of servers and HIPAA? hypothesises? Or is this fairly unique and what we’re doing around Osgood?
Sinead Holden
Yeah, so, to be honest, there was actually more research done in the area of Saverne than there was announced but Slagter, the only AWS the Slagter randomised trials we had kind of before were for injections. Whereas in cybers, there’s actually been a couple of different randomised trials. And they’ve looked at things like physiotherapy programmes and heel cups. So there’s a little bit more research there, as I said, what we tend to see is that the impact, at least from the the academy research that we have, in terms of time loss seems to be a little bit lower. So it might be, you know, just as common or even more common, but the impact doesn’t seem to be quite severe. And that might also be because of the location that it’s in or I’m not sure. And so they might not be as severely impacted. So there are research groups, certainly that have worked within that area. And then in terms of like, the pelvis, it seems to be less common, but again, the impact is actually quite a bit more severe. And I’m not sure of any groups which have done more than just a couple of case series and stuff on that but something that, you know, I think is potentially under recognised because it can. The research that has been done has shown that because your pelvis isn’t fully mature, perhaps even until you’re 21 years old, and so some of the hip and groyne pain Even in later adolescence or even early 20s, potentially could be unrecognised, as due to policy development. So I definitely think there’s more work to be done in that area as well.
Rob Anderson
Fantastic. So you’re pretty prolific in terms of the research projects you’re involved in. And obviously Research Gate profiles, lots of those studies and PDFs that people can access. What where’s the best place for people to kind of follow up? Because it ResearchGate? Are you pretty active on Twitter, etc? Where can people track you down?
Sinead Holden
Yeah, I’m, I’m on ResearchGate. You can you can, it’s probably relatively up to date, and I’m on Twitter as well, my handles ActionAid underscore Holden. And I don’t tweet a huge amount I first tweet a bit when I go to conferences. And when there is new research coming out,
Rob Anderson
and you obviously mentioned the updated guide that’s coming out, I mean, I’d highly recommend people, you know, keep tabs on that, because I found the first guide, very helpful in terms of being able to communicate some of those ideas to parents. What is, I mean, it sounds stupid, but is it gonna be the same name this next guide? What should people be looking out for when that guy comes out to check it down?
Sinead Holden
Like, I can’t remember what we call this. It’s under review at the moment. It’s not called Print knee pain. I think it’s like a guide to handle as good slaughter or some something like that. And so basically, it’s a report of it so that the original one form the basis of it, but we effectively updated it after interviewing kids and their parents and sports medicine practitioners to make it a little bit more relevant. And then we’ve kind of since so that’s under review, and then we’ve since kind of updated them, but that’s that’s the version we’re using in our randomised trial. So it will be we’ve only included you know, 10 or so patients. There’ll be a little bit more time before that one comes out. Yeah, so
Rob Anderson
well include the link to the current one in the show notes so people can look that up. But certainly when it comes out, I’ll be splashing that all over the place, because I think people definitely need to see it.
Sinead Holden
Yeah, really. Hanson is the lead author on that one. So definitely keep an eye out for it.
Rob Anderson
Fantastic. Well, thanks so much for your time, your expertise today. I know that’s gonna be massively helpful for a lot of coaches and parents listening because it’s something that that is still hugely prevalent in the kids that I work with. So I know that that’s going to be happening elsewhere as well. And I think people Yeah, lack of information is kind of hurting the the abilities of some of these kids to get back into sport. So thanks so much for sharing your time and your expertise with us.
Sinead Holden
No problem. Thanks for having me.