Optimal recovery from training and competition is most definitely a subject that we are seeing more frequently discussed and addressed in elite sport and the sports medicine world. Away from sporting competition, we can also inform and educate individuals on how to ensure their recovery is as good as it can be to enable them to be on the top of their game in their day to day life whether that be at home or at work. With useful data collecting tools such as; the Whoop, Oura ring and Apple watch, it is becoming much easier for people to keep an eye on their vital metrics and determine when rest is needed or when is a good time to place their body under higher strain through training, competition or a stressful life event.

Here at Opus, we often have the ‘optimal recovery’ discussion with our patients. It tends to be part of a greater conversation of how we assist in managing that individual’s training load and or managing their current state of physical and mental health. By doing this we can reduce the risk of injury and illness and aid in the patient performing to the best of their ability in whatever task it may be that matters to them.

So what is optimal recovery? The fact is, it is not just any one thing, but instead a combination of a number of components that contribute to restoring a person’s physical, and mental well-being after a period of physical or mental exertion. By ‘optimising’ as many of these components as possible, we can in turn reduce the potential risk of both illness and injury.

Two specific musculoskeletal injuries linked to fatigue which have been researched in depth are hamstring and ACL injuries. One study by Mclean and Samorezov (2009) (2), reported that the inhibitory action of the fatigued muscles in landing activities,  increases the possibility of ineffective perception, decision, and movement execution strategies therefore increasing risk of injury to the ACL. Small et. Al (2009)(3) focused their investigation on the risk of hamstring injury at the ends of each half of a football match. Their findings suggest that due to decreased flexibility of the hamstring muscle group during fatigued sprinting, with a reduced maximum combined hip flexion and knee extension angle observed during the late swing phase of the sprinting cycle, the strain on the hamstring muscle group is increased in this fatigued state and the risk of hamstring injury is amplified.

Jones et. Al (2016)(1) looked more into the impact of training load on the risk of illness due to fatigue. They found that during periods of training load intensification, or where there was a greater accumulation of training load, the risk of acquiring illness increases.

So what are these key components of optimal recovery and how can they impact an individual? Some of those we discuss regularly with our patents at Opus are:

• Getting sufficient rest and good quality sleep are fundamental for recovery. Sleep is when the body repairs tissues, consolidates memories, and regulates the hormones which are crucial for recovery and overall health.
• Being hot on your nutrition. A good diet focused around the right food types, supports the body’s recovery processes and replenishes energy stores, repairs tissues, and supports immune function.
• Maintaining proper hydration levels. Water is crucial for transporting nutrients, regulating body temperature, and facilitating various biochemical processes in the body.
• Opting for ‘Active Recovery’ when necessary. A pool session, stretch and mobility routine or flush on the watt bike, can enhance circulation, reduce muscle stiffness, and promote recovery by aiding in the removal of metabolic waste products from muscles.
• Managing stress. Using techniques such as meditation or deep breathing exercises, can help reduce stress levels and promote recovery. Alternatively if that’s not for you, surrounding yourself with friends and family and taking part in activities that you find fun and relaxing can be of great help.

So in short, what we do away from the more strenuous or testing activities in our day to day life, is vital in ensuring our performance is at its best. Optimal recovery leads to reduced risk of injury and illness and in turn, optimal performance.

Reference List

• Jones, C.M., Griffiths, P.C. and Mellalieu, S.D. (2016). Training Load and Fatigue Marker Associations with Injury and Illness: A Systematic Review of Longitudinal Studies. Sports Medicine, 47(5), pp.943–974. doi:https://doi.org/10.1007/s40279-016-0619-5.
• MCLEAN, S.G. and SAMOREZOV, J.E. (2009). Fatigue-Induced ACL Injury Risk Stems from a Degradation in Central Control. Medicine & Science in Sports & Exercise, 41(8), pp.1661–1672. doi:https://doi.org/10.1249/mss.0b013e31819ca07b.
• Small, K., McNaughton, L.R., Greig, M., Lohkamp, M. and Lovell, R. (2009). Soccer Fatigue, Sprinting and Hamstring Injury Risk. International Journal of Sports Medicine, 30(08), pp.573–578. doi:https://doi.org/10.1055/s-0029-1202822.

It’s that time of year again where the managers at the top premier league clubs resent the hectic fixture list that’s thrown at them. Less time to prepare and to recover and as a result, a risk of a reduction in the quality of performance. However, is there also an added risk to the player’s well being? With a forced significant change in their pre and post match routines, are they at higher risk of injury?

If we take a look at one of those clubs affected in this manner, West Ham (European Champions and Premier League heavyweights), their fixture list over the next month consists of 10 games. A mix of league, Carabao cup, FA Cup and Europa League games make for an incredibly intense festive period. As a club that doesn’t have the same luxury, as say Man City, when it comes to squad size, and therefore the ability to rotate playing staff, there is a good chance you will see a very similar starting 11 in most of these games. The intensity of each of these games, the colder weather, the travel up and down the country and into Europe are all factors that can impact how a player feels and therefore performs on the pitch.

Julian, Page and Harper, 1, (2020) conducted a systematic review on the effects of fixture congestion on performance during male professional football matches and found that performance variables such as low and moderate intensity distances covered during the 90 mins reduces. They also suggest a possible reduction in tactical performance, with decreased synchronisation between the players.

Page et. al, 2, (2022) have then gone on to take a look at a direct correlation between fixture congestion and injury in professional male soccer. They state that overall injury risk is increased during matches completed within fixture-congested periods. This is further supported by findings from a substantial European competition review which shows an increase in hamstring and quadricep muscular injuries during periods of fixture congestion. 3. (Bengtsson et. al 2014)

This leads to a very valid point of discussion, that these findings could help provide a source of scientific evidence for governing bodies to elicit change  to support player welfare and develop a more sustainable match calendar that promotes a player’s career longevity.

In the meantime however, it will continue to be a period of time where coaching and medical staff will have to regularly review and adapt their training, pre and post match plans in order to keep injury risk at a minimum and performance levels as high as possible. Players may be required to take on a role of being more active in their own recovery away from the training ground. Nutrition plans being altered to suit the increased regularity of match days. The use of alternative therapies such as heat, ice and compression when at home and ensuring plenty of sleep and rest when the opportunity arises.

Reference List

• Julian, R., Page, R.M. and Harper, L.D. (2020). The Effect of Fixture Congestion on Performance During Professional Male Soccer Match-Play: A Systematic Critical Review with Meta-Analysis. Sports Medicine, 51. doi:https://doi.org/10.1007/s40279-020-01359-9.

• Page, R.M., Field, A., Langley, B., Harper, L.D. and Julian, R. (2022). The Effects of Fixture Congestion on Injury in Professional Male Soccer: A Systematic Review. Sports Medicine. doi:https://doi.org/10.1007/s40279-022-01799-5.

• Bengtsson, H., Ekstrand, J., Waldén, M. and Hägglund, M. (2014). MUSCLE INJURY RATES IN PROFESSIONAL FOOTBALL INCREASE WITH FIXTURE CONGESTION: AN 11-YEAR FOLLOW-UP OF THE UEFA CHAMPIONS LEAGUE INJURY STUDY. British Journal of Sports Medicine, 48(7), pp.566.2-567. doi:https://doi.org/10.1136/bjsports-2014-093494.19.

What a game. What a Rugby World cup. What a final performance from both the Springboks and Kiwis. But, as always when there is any form of controversy in a big match, we will ask the question. If New Zealand captain Sam Cane didn’t have his yellow card upgraded to a red card so early on in the contest would it have been the same outcome? The rugby fan in me would love to have seen 15 vs 15 for a full 80 mins of course. However, to witness the sense taken by the officials in making an example of what is a direct shoulder to head shot, on the biggest stage there is, was a great decision. We need to protect contact sport athletes around head and spinal injuries and I personally hope this particular event will help to amplify this.

Some fantastic research was done into the frequency and type of head injuries experienced at the 2019 rugby world cup. Across 45 matches, 68 head injuries occurred with just over half of these players being removed from the field of play (Cooke et al 2023). 1. It’s going to be fascinating to see if with the recent changes in approach to the treatment and discipline of head injury related incidents in this year’s tournament correlates to a significant statistical shift compared to 2019.

Thankfully there has been much change In recent years in both the medical management of head injuries in rugby union and also the disciplinary approach to offending players.

A huge contributing factor to the progression of management and increase in discipline towards head injuries has been driven by the recent cases of ex players receiving a diagnosis of dementia with probable chronic traumatic encephalopathy. A recent paper on ‘Football’s Influence on Lifelong health and Dementia risk (FIELD)’ found that ex-professional international rugby players had twice the risk of developing dementia in later life than compared to the general population (Russell et. al 2019)2.

From the medical side, there’s been much clearer guidelines set out on the in play decision making on concussion and also on the return to play protocol. The emphasis on both the ‘recognise and remove’ principle and ‘Graduated return to Activity and Sport (GRAS) programme’ are highlighted in the HEADCASE extended guidelines posted by the RFU. 3.

Hopefully, the sensible refereeing decision made in last weekend’s final will have had a suitable impact on all those involved in the coaching and playing of rugby union. Understanding the importance of trying to abide by the safe tackling laws of the game, should correlate to us seeing less cases of longer term head injury consequences in competitors of the sport.

• Cooke, R., Strang, M., Lowe, R. and Jain, N. (2022). The epidemiology of head injuries at the 2019 Rugby Union World Cup. The Physician and Sportsmedicine, pp.1–7. doi:https://doi.org/10.1080/00913847.2022.2083458.
• Russell, E.R., Stewart, K., Mackay, D.F., MacLean, J., Pell, J.P. and Stewart, W. (2019). Football’s InfluencE on Lifelong Health and Dementia Risk (FIELD): protocol for a retrospective cohort study of former professional footballers. BMJ Open, 9(5), p.e028654. doi:https://doi.org/10.1136/bmjopen-2018-028654.
• September 2023 Headcase EXTENDED Guidelines. (n.d.). Available at: https://keepyourbootson.co.uk/wp-content/uploads/2023/09/HEADCASE_Extended-Guidelines_Aug_2023.pdf [Accessed 1 Nov. 2023].

Osteoporosis is a common condition characterised by a reduction in bone density and quality, leading to an increased  risk of fractures. As per the Royal Orthopaedic Society, risk factors for developing Osteoporosis include; smoking, too much alcohol and low body weight. We also know the females, particularly post menopausal females, are at higher risk of being diagnosed.

Recent research has suggested that resistance training can be highly beneficial for individuals with osteoporosis (Zhang et. al 2022). (3)

Resistance training involves placing stress on bones, which stimulates bone remodelling and increases bone density. This can help counteract the bone loss associated with osteoporosis, making bones stronger and more resistant to fractures. Resistance training targets not only bones but also muscles. Strengthening muscles can improve balance, stability, and coordination, which are important for reducing the risk of falls and fractures, particularly in older adults with osteoporosis. Regular resistance training has numerous other health benefits, including improved cardiovascular health, better insulin sensitivity, and enhanced mood and well-being. These benefits contribute to overall better health and may indirectly help in managing osteoporosis.

The LIFTMOR trial 2017 (2) shows that targeting large multi joint strength exercises is an effective way of enhancing – or at least limiting a reduction in bone density. Through the use of 4 fundamental exercises; deadlifts, overhead presses, back squats and a chin up landing drill, positive results were shown.

The frequency of resistance training for individuals with osteoporosis can vary depending on factors such as your current fitness level, overall health, and goals. However, general recommendations suggest aiming for resistance training exercises at least 2-3 times per week with a day of rest between sessions to allow for muscle recovery. This frequency was also tested and shown to be efficacious and superior to previous programs for enhancing bone at clinically relevant sites, as well as stature and functional performance of relevance to falls in postmenopausal women with low to very low bone mass. (Watson et al 2017) (2)

Another important component in the management and prevention of Osteoporosis is nutrition (Garach et. al 2020). (1). The correct nutritional changes to your diet can support bone health, especially when combined with resistance training. Some key components to consider include:

• Calcium: Adequate calcium intake is essential for maintaining bone health. Good dietary sources of calcium include dairy products (such as milk, yogurt, and cheese), leafy green vegetables (such as kale and broccoli), tofu, almonds, and fortified foods (such as fortified plant-based milk alternatives and breakfast cereals). Aim for the recommended daily intake of calcium, which varies depending on age and sex.
• Vitamin D: Vitamin D helps the body absorb calcium and plays a crucial role in bone health. Sources of vitamin D include sunlight exposure, fatty fish (such as salmon and mackerel), fortified foods (such as fortified dairy products and cereals), and supplements. Consider getting your vitamin D levels tested and talk to your healthcare provider about supplementation if necessary.
• Protein: Protein is important for maintaining muscle mass and supporting bone health. Include sources of lean protein in your diet, such as poultry, fish, beans, lentils, tofu, eggs, and dairy products. 
• Magnesium: Magnesium is involved in bone formation and metabolism. Good dietary sources of magnesium include nuts, seeds, whole grains, leafy green vegetables, and dairy products. 
• Vitamin K: Vitamin K plays a role in bone metabolism and may help reduce the risk of fractures. Include foods rich in vitamin K, such as leafy green vegetables (such as kale, spinach, and Swiss chard), broccoli, Brussels sprouts, and fermented foods in your diet. Limit Sodium and Caffeine: High sodium intake can increase calcium excretion in the urine, potentially weakening bones. Limit your intake of high-sodium processed foods and try to minimize added salt in your diet. Excessive caffeine intake may also negatively impact calcium absorption, so moderate your consumption of caffeinated beverages. 
• Maintain a Healthy Weight: Being underweight can increase the risk of osteoporosis and fractures. Aim for a balanced diet that supports a healthy weight and includes a variety of nutrient-rich foods.
  

We are proud to be able to assist all of our patients at Opus who require assistance in the prevention or management of osteoporosis through a full MDT approach including our Sports Medicine physician – Dr Porter, physiotherapy team and nutritionist. Through our expertise we are able to implement the important points made above into the patient’s package of care.

Reference List

• Muñoz-Garach, A., García-Fontana, B. and Muñoz-Torres, M. (2020). Nutrients and Dietary Patterns Related to Osteoporosis. Nutrients, [online] 12(7), p.1986. doi:https://doi.org/10.3390/nu12071986.
• Sl, W., Bk, W., Lj, W., At, H., Sa, H. and Br, B. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. [online] Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. Available at: https://pubmed.ncbi.nlm.nih.gov/28975661/.
• Zhang, L., Zheng, Y.-L., Wang, R., Wang, X.-Q. and Zhang, H. (2022). Exercise for osteoporosis: A literature review of pathology and mechanism. Frontiers in Immunology, 13. doi:https://doi.org/10.3389/fimmu.2022.1005665.