It’s hard to believe that it has been a year since I had the privilege to attend and speak at the Danish Sports Kongres in Copenhagen which I wrote about here. As I’ve mentioned before this conference is one of, if not the best that I have ever attended over the years, both in content and company, and this years was even better, but maybe that was because I wasn’t speaking :0)
The kongres was held this year in the quaint town of Kolding, a little different from the bustling vibrant city of Copenhagen but very nice all the same. The theme was on my favourite topic the shoulder. However there were multiple streams of talks and workshops for all tastes and interests, such as running injuries, back pain, hamstrings, and even sports nutrition.
So here are my reflections from the Sports Kongres 2016.
Keynote Talks
After the welcomes and introductions the kongres started with Prof Andy Carr from Oxford talking on the epidemiology, pathology and treatment of rotator cuff tears. Prof Carr started by telling us very clearly that musculoskeletal issues are a real global burden, and things are only likely to get worse. He showed us that five MSK issues are in the top 15 lived with diseases from a recent paper in the Lancet here.
Prof Carr then went on to show us the factors involved in tendon disease and what he thought are the key areas. The topic of inflammation and tendinopathy was a hot one throughout the kongres and it was discussed multiple times. What I took from all these talks and views on inflammation and tendinopathy, is that yes inflammation is present in all tendinopathy, but to what extent and what role it plays is still unknown and seems to vary depending on many factors
Next up was Dr Chris Littlewood who discussed his PhD work and the SELF study here. He discussed how with the appropriate education patients can self manage their own rotator cuff tendinopathy rehab just as effectively when compared to usual physiotherapy, what ever the hell usual means nowadays?
Chris made a couple of excellent points in his talk, the first was that self management isn’t about neglecting or discharging the patient after their first visit, rather it is about the patient deciding when they need to come back, not the physio. The second was that asking a patient to do an exercise into pain didn’t have any significant negative effects, and one simple exercise that if it hurt to much, was reduced a bit, or if it helped, was increased a bit works well.
However judging by one of the longest drawn out questions I have ever heard at a conference, I think this made a few in the audience very, very uncomfortable. The idea that they only have to offer effective advice and reassurance and give one simple resistance exercise, and not measure or modify the scapula, not rub, poke, tape, stab any muscles, seemed to scare the shit out of them.
Thickened Traps
After lunch we had three talks on the painful shoulder in sports and working life. First up was Prof Lars Andersen, who clearly practices what he preaches when it comes to strengthening exercises, as I didn’t know professors could have such big biceps and be so ‘hench’.
Anyway Lars talked about how chronic painful upper trapezius muscles have increased thickness, not decreased as would be assumed due to atrophy. However this thickness doesn’t mean they are strong, just the opposite, they are very weak, but this maybe due to pain inhibition or fear avoidance. The thickening may be from increased numbers of enlarged muscle fibres called megafibres that are twice as thick as normal ones, possibly in response to a lack of oxygen. He also highlighted how other factors such as cold drafts and noise can affect painful neck and shoulder muscles in manual workers.
After Lars there was a rather disappointing talk on painful shoulders in swimmers, not to dwell on this to much other than to say when the first slide described adverse scapula dyskinesia as anything thats asymmetrical or sticking out, you know it is a slippery slope from there.
However, quickly bringing the standard back up was Dr Rod Whiteley from Aspetar. It was a pleasure to finally meet Rod and to be able to talk a little with him. Rod has a wealth of experience but more importantly a shit load of common sense and a very relaxed approach. Anyone who can be told that the hotel they were booked to stay in have given away your room and you need to go to another hotel, at midnight, in the rain, after a day’s long journey, the night before you present, and laugh about it, is alright in my eyes. I would have gone full diva!
Rod gave us an informative and engaging talk on the throwers shoulder, highlighting the role of humeral torsion as being protective, how SLAPs are often developed in throwers, and also how anterior laxity in a throwers shoulder is most likely a myth.
Wobbly Scapulas
After coffee and cakes it was three more presentations on the role of the scapula and the kinetic chain in shoulder pain. Again the first two talks were slightly disappointing with lots of opinion and conjecture, but some lovely videos of how the body and shoulder are intermittently linked in many sports. However their interpretation of how much importance and when they are to be considered aberrant seemed to be based on nothing more than plausible speculation. Some data or research presented here would have been nice.
However, the final talk of the day was from Dr David Christiansen who again brought the standard straight back up. He gave a fantastic talk on his yet unpublished systematic review on the effectiveness of scapula based rehab for shoulder pains. Long story short… there isn’t any. And yet again judging by the long winded question speech from the same delegate who did it before, this seems to also scare the shit out of some. Many it seems are desperate to cling to the belief that trying to correct and fix the scapula is the answer to everything.
So that wrapped up day 1 and we soon went into wine and conversations for the rest of the evening.
Day 2
Day 2 started bright and early at 8am with a symposium on rotator cuff tendinopathy. Two great talks here from Dr Karen McCreesh from the University of Limerick talking about her recent paper in JOSPT here and Kay Stevenson from Keele University on the SUPPORT trial here.
Karen gave us an excellent review of where we are in our best management options for rotator cuff tendinopathy. She brilliantly highlighted how education is so important by asking us to consider if it is any surprise that patients don’t want to do rehab exercises when they have been told they have torn tendons. Karen also showed us how we can separate our loading strategies dependant on if the cuff tendinopathy is highly irritable and reactive, or less so.
Next Kay Stevenson talked very clearly and eloquently about the SUPPORT trial that showed no difference between guided or unguided sub acromial injections, but how supervised physiotherapy is better than an education leaflet.
Frightening Patients
After some coffee it was the free paper session. These sessions are a chance for new researchers to present their research, and a couple of papers stood out for me. First was Martin Askers work on adolescent handball players shoulders and his data collection process that may help give us some prospective injury prevention ideas for the future.
And then a really interesting paper from a young Belgium clinician/researcher called Kevin Kuppens. Kevin did a cracking little study on musicians with chronic neck and shoulder pain and demonstrated a significant increase in their pressure pain thresholds when exposed to exercise, but also when exposed to an acute stress response.
This acute stress was given to the subjects by showing them ‘fearful’ images, such as pictures of big fat ugly looking hairy spiders, or even big arsed hyper-dermic needles, and it was really interesting to see that the pain reduction effects were just as effective by doing this as giving them exercise.
So may be we need to start scaring our patients showing them spiders or needles… Oh hang on a minute, some of you dry needlers already do that? So may be thats how it all works?
After lunch there was a talk by the legend that is Criag Purdam on the history and future of tendinopathy. Craig expertly in 90 minutes took us through the intricacies and debates surrounding tendinopathy. It was a great talk and Craig discussed the role of inflammation, over load, genetics and central sensitisation in tendinopathy.
After Craigs talk I went to Dr Kieran O’Sullivan’s back pain in sports workshop. If you haven’t heard Kieran talk before I highly recommend you do. Kieran did a great job in getting the delegates to think about the wide and diverse factors that contribute to pain. He showed us how a cold sore can be a great metaphor for painful things being triggered by other health issues like stress and lack of sleep. He also gave us a warning that telling a stressed and agitated patient to relax and calm down is probably the worst thing you could do, and asked us to consider if we would do this with our wives or husbands when they are agitated.
Sexy X-Rays
That wrapped up day 2 beautifully and left us all ready for the infamous Danish Kongres gala dinner. As usual the Danish out did themselves, good food, good wine, great company, and some interesting entertainment. There was also some rather provocative X rays for us to admire whilst eating our dinners and there was even a song about getting old and suffering with erectile dysfunction… something about being ‘quiet in your pants’?
It was also time to make new friends and smooth over some old issues, I even had to hug a grown man for a photo… yeah yeah… me and Brad Neal kissed and made up… He forgot his tie and waistcoat (what a peasant)
Anyway, after a late night it was up early again with slightly heavy heads for the final session. This again was on the scapula… To be honest I was getting pretty SCiK of the scapula by now… There is a really geeky joke in there, sorry!
However the best was saved for last. Karen McCreesh presented again but this time on her own PhD work, and showed us some of the issues it can produce. She told us about her journey on designing a validity trial on measuring the acromio-humeral distance with ultrasound and some of the issues it created, and how a Rotator Cuff tendon that is tendinopathic does significantly thicken after loading for up to 6 hours after and can take 24 hours to return to baseline.
But last up was Dr Filip Struyf from the University of Antwerp in Belgium. Filip started off by mirroring some of my own thoughts on these so called scapula stability exercises, that maybe they are just really good rotator cuff exercises, he then took us through all the confusing and conflicting research on if scapula dyskinesia is a risk for injury.
Filip showed us that for every paper that shows it is, there is another that shows it is not. However he cleverly demonstrated that maybe, just maybe, scapula dyskinesia could be a risk factor in some elite athletes, who use their shoulders more, under more loads, more frequently… maybe?
He also very nicely used a football team analogy to demonstrate that we can not keeping looking at the scapula in isolation, just as we can’t keep blaming an individual player for a poor team result in a football team. When it comes to shoulder problems we need to look at whole shoulder not just the scapula.
That for me was a perfect end to a great conference. As usual there were many talks and presentations I really wanted to see but couldn’t, such as Dr Rich Willy on running and gait re education and Dr Tony Shield on hamstring strengthening, it was just impossible to fit everything in.
It was also impossible to see and speak to everyone in the breaks, but to all of those who I did, a big thank you for saying hello, a huge thank you for all your kind comments, and a massive thank you for so many of you reading this blog, it really is humbling and flattering.
However, will you all go and read some real research now as well please… :0)
But seriously thanks for reading and I will finish off by urging you all to consider attending the very informative, very entertaining, and very fun Danish Sports Kongres conference next year, I most certainly will be.
Tak
Adam
