So as the dust settles but before the memories fade I thought I would put down some thoughts and reflections from another excellent Danish Sports Medicine Conference more simply called ‘Sport Kongres’ which is, in my opinion, one of the best annual sports medicine conferences in the world, although the Norwegians do come very close as well.
This is my 4th time at Sports Kongres although I’ve had a gap of 4 years since the last time I attended back in 2016 so I was interested to see how it has changed and progressed.
One thing that hasn’t changed thankfully is this conference is extremely well organised and packs a HUGE amount of content in 2 and a half days, with 4 simultaneous streams of talks and workshops making is hard to decide what to go and watch but also giving a huge choice of options based on your interests and experience.
Due to my flights, I, unfortunately, missed the opening key note lectures on ACL rehab and groin pain, but I did hear that Per Holmich was promoting the role of psoas palpation and was looking for me to demonstrate this on which would have been tempting as I don’t get many offers from men (or women these days) wanting to touch my groin, so I may have taken him up on his offer.
The first session I did make was after lunch and was on the management of traumatic ACJ injuries. The first speaker who was an orthopaedic surgeon highlighted how the traditional Rockwood classification system of ACJ injury is poorly correlated with pain and disability and doesn’t guide us how best to manage ACJ injuries, which was music to my ears.
Often the claim made with ACJ injuries is grades 1-2 are always rehab-able, grade 3s are 50/50, and all grades 4-6 need surgical stabilisation. However, I think this is nonsense and have personally seen ACJ grades 4-5 do very well without the need for surgery, even returning to high-level sporting activity. But I have also seen many grade 2’s do very poorly and continue to have high amounts of pain and not be able to return to basic activities.
The reasons for this I think are many, things such as age, occupation, level of sport, fear, anxiety, threat, and a host of other psychosocial factors, which unfortunately were not mentioned or considered by the speakers. Instead, they only focused on the biomechanical features, which although are surely a factor they are still only a part of the bigger picture.
Anyway, there was a suggestion that I really liked in that we should move away from using the traditional Rockwood ACJ injury classifications and instead use a much more simple system instead. That is ACJ injuries are either stable or not stable. This I think is a great idea as personally I think those ACJ injuries that tend do the best without the need for surgery are not just those with small amounts of displacement but how much this displacement moves on tasks and activities.
For example, I see some ACJ injuries that have huge displacements on x-rays which don’t move around much when they move their arm, whereas I see some other ACJ injuries that have no or minimal displacement on x-rays yet move around a lot on some activities and exercises. Its this dynamic ACJ movement not the static displacement on scans that I think predicts if an ACJ injury is going to settle or not without any surgical intervention.
It was also suggested that horizontal movement is far more painful and provocative than vertical displacement. The theory is if the lateral end of the clavicle is rubbing across the top of the acromion this tends to cause more problems than if its vertically displaced with a gap between the bones. It may even be that the larger vertical gap the less pain and disability they may have
Going Wrong Getting Strong!
The next speaker was a physio and was talking about an exercise rehab protocol she designed for ACJ injuries which I found very disappointing. First was because of the focus and attention on the use of silly little exercises at the beginning, which I know have a role in many sports injuries at the start when we are trying to get a person to take it easy, let things heal, and keep them occupied, but why don’t we just all be a little more open and honest about this and say thats what these exercises do, occupy and distract the person for a while before we start the real rehab, instead of talking about alignment and optimal fucking motor control bull shit!
Anyway, the far more disappointing thing for me and one that I saw on a few other talks was how they prescribed their ‘strengthening’ exercises with only the sets and reps described without any mention of the load, or intensity, or % of 1RM, RPE or even RIR.
This sloppy lazy habit that many physios have with exercise prescription drives me up the wall, and its even worse if you’re presenting your rehab protocol at a Sports Conference. If you are going to call an exercise ‘strengthening’ it needs to fit the definition what the research tells us causes muscle adaption and strength to be gained.
Now before my buddy Greg Lehman or any other of you false dichotomy building knob heads kick-off, I am WELL AWARE that you don’t need to get stronger to get out of pain, and that many different sets and rep ranges can cause muscle tissue adaptions and get people stronger.
So yes you could use 3×10, or 5×30, or 23×452, and get the same strength gains… BUT only if the intensity of those set and reps is sufficient to signal the metabolic pathways for muscle tissue adaption, and this usually requires the reps to work close to fatigue or at least an RPE of 7-8 or RIR of 2-3 as far as I am aware.
Prescribing 3×10 or 5×30 and calling them ‘strengthening’ exercises without describing what intensity or effort you want these sets and reps to be done at is pointless, lazy and ineffective. I could do 3×10 at 20% of my 1RM and get no strength adaptions, or I could them at 70-80% of my 1RM, or use an RPE of 8, or even an RIR of 2 and get stronger.
The next session I attended was on Achilles Tendinopathy and started off with a very interesting talk highlighting how nearly a 1/4 of all those with Achilles tendinopathy still have pain and disability up to 10 years later, and how symptoms at 1 year match those at 10 years with patients stagnating. Now again the reasons behind this are many and multifactorial but again I do think poor loading is a key issue hear!
Next up was a paper on isometrics for Achilles tendinopathy and unfortunately, I wasn’t allowed to take any photos or share the results with you due to it currently being in review for publication soon, but lets just say that this is going to rock the isometric advocates boat a lot and hopefully make many realise that isometrics are not a panacea for pain and dont work that well for some.
The last session of the day was on over diagnosis in medicine and sports medicine. The first speaker tried to define what over diagnosis is, which is finding something that never needs treatment but gets treatment. The example used was prostate cancer which has had a huge increase in detection rates yet the mortality rate of those who die because of prostate cancer hasn’t changed at all. It was also pointed out that this often gets misrepresented as there being a high survival rate for prostate cancer when it actually hasn’t changed at all, its actually got a low mortality rate, and always has.
This was an interesting session although a little heavy on the statistics for my simple brain so I left early to hit the awesome hotel gym with its fully kitted up S&C facilities and do some deadlifts before everyone else clogged it up.
In the evening there was poster presentations and a get together which I thoroughly enjoyed thanks to the copious and constant free red wine, and after some eye opening conversations about PhD projects, conflicts of interest, student finances and me trying to do some drunken handstands in the lobby and failing dismally, I called it a night, or rather early morning.
Morning Afternoon After
The next morning was a bit hazy, mainly as I was in bed nursing a mofo of a hangover, but I dragged myself out for the afternoon sessions and went into the talks on traumatic shoulder instability in athletes. The first speaker was an Italian surgeon who went through the bony factors that can lead some shoulder to have ongoing instability after trauma.
The one I found most interesting was his finding on the Hill Sachs lesions and how the location of these was far more important that the size or depth. Hills Sachs lesion can be classified as either ‘on track’ or ‘off track’ if they cross the line of the humeral heads articulating surface on the glenoid and these tend to create further episodes of instability, and the more medial the Hill Sachs Lesion is the greater the chance of it being off track.
Next was a talk on surgical management of SLAP lesions and the results from a placebo-controlled surgical trial that showed no difference in pain or disability if a SLAP was repaired, debrided, pretended to be operated on (eg placebo). This was interesting study but the population were mostly around 40 years old and not regular over head athletes so we cant extrapolate this study to another population, however, it still highlights the placebo effect of surgery and all that we do in healthcare.
Finally was a talk on SLAP rehabilitation and how EMG data could possibly help us select exercises that have higher or lower forces acting on the biceps complex. For me this was way too over-complicated, complex, and unnecessary. I do understand that EMG can give us some idea of what muscles are working and how much when doing exercises, but what they don’t tell us is how much pain or effort an individual feels when doing them.
For me the far easier, simpler and I would argue evidenced-based way to select rehab exercises is not from EMG studies done on healthy people in laboratories, but based on your patients issues, goals and more importantly how the exercise feels for them in terms of its pain and effort.
The final session was presentations from 6 studies selected for their value and promise on advancing sports medicine all aiming for the first prize. In the running was my mate from Dublin Paul Kirwan who did his recent PhD on GTN + exercise for Achilles tendinopathy, which he found had no extra benefit, and eventually came 2nd in the competition.
The winner was Mikkel Bek Clausen with his RCT looking at the addition of extra strengthening exercises on sub acromial pain and function which has the best study acronym ever, the SExSI trail (Shoulder Exercise Shoulder Impingement). Anyway, long story short, ‘extra’ strengthening exercises (and these were strengthening exercises as Mikkel did a good job of measuring the load, TUT, and effort) had no extra effect on pain levels than standard shoulder exercises alone, highlighting once again that strengthen is not necessary to reduce pain, but exercise most definitely is!
There was also a very interesting study from the UK presented on blood flow restriction training for post-op ACL’s compared to traditional strengthening which found similar gains in strength but better results in function, this is believed to be due to less knee swelling and pain due to the lighter loads being used on BFR training.
After the presentations, it was time for the famous Sports Kongres gala party. Now I dont want to distract attention away too much from the academic content and quality but all I will say is that the gala dinner was yet again a highlight of the conference even with a stinking hangover still from the night before to start with.
The atmosphere, fun, and games had were just second to none. Tell me where else in the world would you get physios, doctors, surgeons, PhDs, professors and students all dancing, bouncing, limboing, crowd diving, neck wrestling, and doing no hands get downs and back up competitions at 3 am… nowhere except at Sports Kongres
So once again thanks to the Danish Sports Medicine Association for organising an excellent conference. Thanks to everyone who came and said hello and all your kind comments about my blogs and ‘antics’ on social media being a positive influence for you to be more critical or just give you the confidence to stay in the profession.
Finally thanks to all the #TeamWhisky members including (but not limited to) Tom ‘the goomster’ Goom, Greg ‘snake hips’ Baggely, Rich ‘scouser’ Norris, Seth ‘Achilles’ O’Neil, Paul ‘soon to be Dr’ Kirwan, JC ‘fist up’ Anderson, JF ‘left right left’ Esculier Sarah ‘the lovely’ Haag, all the crazy Swedes from Gothenburg SportsRehab, and last but by no means least Lous ‘the craschy sexschy dutch lady’ for making the evenings a blast!
I’m looking forward to next years kongres already, hope to see you there.