Strength or resistance training involves much more than simply going to the gym a couple times a week. To gain the most from strength training it’s crucial to understand the science behind exercise choice, dosage and planning. This is the foundation of designing a strength training program.


In fact, strength training is more about the design of the program than the exercises themselves. Recent evidence highlighting the significance of concepts such as load management and periodization emphasize this point. These concepts include progressively building your training volume and intensity, providing appropriate variety in the program and accounting for the physical profile and injury history of the patient.


The idea of strength training can make some people who’ve been previously or currently injured apprehensive. However, the risk of aggravating an injury must be balanced with the risk of staying in a deconditioned state and maintaining a higher re-injury risk. Which brings me to one of the most common questions I get asked by patients, ‘what can I do to prevent this happening again?’ Thankfully these days my answer is both simple and based on sound scientific evidence – improve your strength.


It would be wonderful if improving strength were an easy process. Though physical and mental effort is required to complete the actual strength program, it’s structure need not be complicated. With the guidance from an appropriately qualified Physiotherapist, a simple yet highly effective strength training program can be designed to progress your injury rehabilitation and reduce your injury risk.


In summary there are three main reasons you should strength train following an injury:


1. Resistance Training is a valid treatment option for musculoskeletal rehabilitation.

A recent systematic review using data from 1545 rehabilitation patients demonstrated that strength training improved outcomes in chronic low back pain, knee osteoarthritis, chronic tendinopathy and post hip replacement patients (Kristensen and Franklin-Miller, 2012. Other studies have shown that a structured resistance training program can reduce pain and improve function in neck pain (Gross, 2015), groin pain (Jensen, 2012), shoulder pain (Andersen, 2014) and also osteoporosis (Gomez-Cabello, 2012).


2. Strength training reduces sports injury risk
A recent systematic review using data from over 26000 patients showed that ‘strength training reduced sports injuries to less than a third’ and suggested that strength training may also halve overuse injuries (Lauersen et al, 2014).


3. Strength Training is easy to start
As most patients following injury are starting from a low base of fitness, strength training doesn’t need to involve large weights, squat racks, benches or sweaty mats in a gym with blaring music. In most cases to achieve an appropriate training stimulus simple bodyweight training is ideal.



  • is effective in treating a range of common musculoskeletal conditions
  • is effective in reducing sports injury risk
  • is easy to perform.


By John Contreras

APA Sports Physiotherapist, S&C Coach, Pilates Instructor


Find out more about John’s Strength & Conditioning Essentials for Physiotherapists Course


PYS078 Running Flyer FAWith marathon and triathlon season fast approaching we often see an increase in injuries around the foot and ankle, in particular Achilles tendon pain. Last weekend Physiosports hosted a weekend conference for physios and sports doctors run by the world’s best tendon experts. Here are their 5 super important tips for anyone who thinks they have Achilles Tendinitis (although we call it Tendinopathy).


1. Ensure a correct diagnosis.

There are lots of tendons and other structures around the back of the ankle that can get sore with running. Given that management of tendon injuries is very different from injuries to joints and other structures, being sure it is your tendon that is the problem is vital before undertaking any treatment plan.


2. The findings of your scans are inconsequential to your recovery.

Often those with tendon complaints will have an MRI or ultrasound reporting partial tears or degeneration. The latest evidence suggests that these same findings often exist in pain-free tendons and is an expected tissue response. Furthermore, it has been found that these altered tissues can be rehabilitated back to normal function through exercise.


3. A specific loading program is vital.

Your Achilles tendon acts like a giant spring; this is why only performing calf raises for your exercise will not be enough to get you back to running and jumping sports. A carefully graduated exercise program, starting with low load activities (calf raises) and eventually progressing to dynamic jumping/hopping exercises are needed to prepare the tissue for the demands of your sport.

4. Complete rest and passive treatments (injections, needling etc) will not fix the issue.

As for point 3, tendons act like springs. Any treatment that stops you loading the tendon is ultimately making the tendon less capable of being a spring and this, in turn, makes it harder to rehabilitate the tendon back to normal strength. While sometimes injections and medications can reduce the pain, they do not ever help to restore the tendon’s strength or function and should be used very carefully.


5. Do not stretch the tendon.

Achilles tendon problems exist where the tendon wraps around the heel bone. The injury is a result of a combination of tensile (stretching) and compressive forces on the tendon that are too large for it to cope with; as a result the tendon makes itself stiffer through changing its cellular structure. Even though the tendon feels tight walking around (especially in the morning or when you start running) – remember this is a response in the tissue to protect itself. When you try and stretch the tendon to loosen it up you are actually placing a compressive and stretching force on the tendon and actually making it worse.




Professor Jill Cook – JC

Craig Purdam (FACP) – CP

Ebonie Rio
- ER

Sean Docking – SD



Friday  6:30-9:30pm


Time Topic
7:30 Revisiting the continuum of tendinopathy…again? – CP/JC
7:50 Characteristics and evidence around pain in tendons – ER
8:30 How do tendons adapt to load? SD
8:50 Management of tendinopathy in season – ER/CP
9:10 What to do if it’s not working? – JC/CP


Saturday  9:00am – 5:00pm


Time Topic
9:00 Tendinopathy – basic science and clinical presentations– SD/CP
9:45 The pain of tendinopathy – bottom-up, top-down where are we at?– ER
11:00 Tendon imaging – SD
11:45 Understanding load – CP
12:30 LUNCH
1:30 Assessment of tendinopathy and differential diagnosis – JC/ ER
2:15 Phases of rehabilitation – JC/ER/CP
3:30 Adjunct therapies and adolescent tendons – JC/SD
4:15 Q/A



Sunday  9:00am – 4:00pm


Rotating 4 workshops:

1. JC – Achilles/Glut tendons

2. ER – Patella

3. CP – Hamstring

4. SD – Imaging – when, how, what does it tell us?

Time Topic
9:00 Workshop 1
9:45 Workshop 2
11:00 Case studies
11:45 Clinical presentations and other tendons
12:30 LUNCH
1:30 Workshop 3
2:15 Workshop 4
3:30 Q&A / concluding remarks



As sports injury managers, we are often asked this question, and especially regarding children and adolescents, with the expectation that ‘kids shouldn’t get injured’.

In a general sense ‘too much’ sports or activity is related to the individual CAPACITY (red line below).  Each body has a capacity to endure a certain LOAD, with many variables playing a role.  If the individual is active above this capacity, then the body is more at risk of injury. Importantly the body can increase its capacity.

This is called the training effect.



By working just in the right range, we get a training effect that increases the capacity of the body, tissues, bones and joints, to handle sport and activity as per diagram 2 below.


The calculation is not as simple as shown, as day-day and month-month other factors can affect capacity including fatigue, lack of sleep, diet, poor immune function, stress and hormone changes.  During the growth phase of children many of these ‘other factors’ come into play, as well as the mechanics of the body and the unique nature of the way muscles attach to bone during puberty.

How much sport is too much is difficult to quantify.  In adults and children pain and soreness can be a good guide, as well as fatigue and wellness.

For a TRAINING LOAD INJURY (ie not a specific acute injury but soreness or pain due to overload) one can pain monitor – soreness which is a maximum of 1-2/10 is tolerable and maybe normal during and for 24 hours after activity, but any higher ratings OR pain that limits training/playing is too much.  Activity needs to be modified or decreased.  Extreme fatigue or being unwell related to activity is another indicator that activity should be modified or reduced.


In children growth and development phases are from 8-16years with girls slightly earlier, and the capacity of the individual will vary greatly with spurts of growth and hormonal change.



  • Capacity of the body is key.
  • Rest and over-activity is bad = need to do just enough to maintain and improve capability and fitness.
  • PAIN MONITOR – over-load injury >2/10 pain or not resolving or affecting performance needs activity modification or advice.
  • FATIGUE and BEING UNWELL will decrease capacity – pull back if this is occurring.
  • Control what you can control – can’t control growth but can control CAPACITY (ie conditioning training) and ACITIVITY – if your child is continually sore and breaking down take advice regarding these 2 options.


For more information about athlete load management go to physiosports.com.au/blogs or email paul@physiosports.com.au


As parents, coaches and injury managers we look for the magic number regarding the amount of sport our kids should undertake. What is clear is that children and adolescents need to exercise. The question is do we know how much exercise and what type of training and play will optimise their athletic development rather than compromise it resulting in injury.

The recent study ‘The Youth Physical Development Model: A New Approach to Long-Term Athletic Development’ by Lloyd and Oliver (2016) gives a nice description of many different types of activity in strength and conditioning training and relates the type of training to the BIOLOGICAL or MATURATION age of the child.

In SUMMARY, before the ‘growth spurt’ that occurs in adolescence (the early teenage years), one should focus on basic strength, movement skills, speed and agility. It is important in this phase to jump, land and do strength activities to optimise bone development.

Once the ‘growth spurt’ begins one can take advantage of growth hormones and optimise muscle bulk with hypertrophy work (i.e. weights), power and sports specific skills BUT only if the athlete is competent.

YPD for females

The YPD model for females. Font size refers to importance; light pink boxes refer to preadolescent periods of adaptation, dark pink boxes refer to adolescent periods of adaptation. FMS = fundamental movement skills; MC = metabolic conditioning; PHV = peak height velocity; SSS = sport-specific skills; YPD = youth physical development.


While specific sporting load guidelines are limited across all sports, governing bodies of Cricket and Baseball have published articles which outline age appropriate fast bowling and pitching loads respectively to help minimise risk of injury in children. Furthermore, consensus statements exist to help guide how much time kids should be engaged in organised sport and training per week. These recommendations are outlined below.



Recently Cricket Australia published a number of guidelines surrounding fast bowling loads for adolescents. These have been designed to minimize the risk of injury.


Under 11 2 over limit each spell & 4 over limit per match
Under 13 4 over limit each spell & 8 over limit per match Target* of 100-120 balls per week
Under 15 4-6 weeks bowling preparation before the season 5 over limit each spell & 12 over limit per match Target 100-120 balls per week
Under 17 6-8 weeks bowling preparation before the season 6 over maximum each spell & 16 over limit per match Target 120-150 balls per week
Under 19 8-10 weeks bowling preparation before the season 7 over limit each spell & 20 over limit per match Target 150-180 balls per week

*weekly targets are a combination of training and match bowling



Elbow and shoulder injuries are common in adolescent baseball pitchers.  These injuries are often the result of overuse, poor conditioning or suboptimal pitching technique.

Recommendations to avoid these injuries were outlined by the American Sports Medicine Institute in 2013:

  1. Monitor levels of fatigue, often associated with deteriorating technique as well as with decreased accuracy or pitching speed. If these signs are beginning to surface, allow a break from pitching/throwing.
  2. Furthermore, if a child reports pain in the elbow or shoulder, cease throwing activities and seek an expert’s opinion.
  3. Allow a period of 2-3 months with no competitive overhead throwing per year.
  4. Prevent pitching duties on multiple teams with seasons that overlap.
  5. A child should not have both pitching and catching duties. This places too great a load on the upper limb with the throwing requirements.
  6. Ensure spikes in pitch counts are offset with increased rest in the days following.
  7. Pitching more than 100 competitive innings in a calendar year in considered an injury risk.
  8. Emphasise the importance of correct technique prior to a velocity focus.


A consensus statement from the American Orthopaedic Society for Sports Medicine recommends several measures to prevent burnout and injury in children including ‘avoiding over-scheduling and excessive time commitments’. (LaPrade, et al. 2016)

As a rule of thumb kids should limit the number of hours they participate in organised sports each week to the number of years they’ve been alive — or less. ‘So a 10-year-old should not play or practice more than 10 hours a week,’ (McGuine, et al. 2017)


  • Strict activity guidelines are scarce.
  • ‘Hours for age’ has no evidence but can be a guide.
  • No need to specialise early – a broad range of sports may be beneficial.
  • Be aware of stages of maturation – wait until late puberty and spurt before commencing ‘super heavy’ strength and plyometrics work.
  • Monitor pain, fatigue and wellness, and rest, sleep and eat well.
  • Avoid excessive spikes in load.




McGuine, T. A., Post, E. G., Hetzel, S. J., Brooks, M. A., Trigsted, S., & Bell, D. R. (2017). A Prospective Study on the Effect of Sport Specialization on Lower Extremity Injury Rates in High School Athletes. The American Journal of Sports Medicine, 0363546517710213.

LaPrade, R. F., Agel, J., Baker, J., Brenner, J. S., Cordasco, F. A., Côté, J., … & Hewett, T. E. (2016). AOSSM early sport specialization consensus statement. Orthopaedic journal of sports medicine, 4(4), 2325967116644241



With the remarkable amount of resources being invested into the sporting world, the popularity of youth talent identification programs has increased sevenfold. In Australia, these elite youth programs are popular in the AFL, tennis and basketball settings. These programs have the long-term aim of developing elite athletes from an early age, thus guiding them along a specific sporting journey. Because of this, many parents are unsure whether their child should focus on a specific sport, or continue to diversify.

Cote (et al. 2009) has previously outlined key concepts of athletic development, concluding:
1) Playing different sports in the younger age groups does not effect one’s potential for elite sport participation after puberty.

2) Variety in sporting involvement at a younger age is linked to a longer sporting career and a decreased likelihood of drop out.

3) Exposure to a range of sports positively influences youth development in the areas of relationship formation, behavioural tendencies and an understanding of healthy habits.

4) Injuries may be more likely if a high-school student specialises in one particular sport (McGuine, et al. 2017), or this increase in injury rate could be related to an increased volume and intensity (Di Fiori, et al. 2014).
With the evidence considered, your child will benefit from participating across a range of sports at an early age, which prevents injury and improves participation and well-being, without impacting their chances of reaching an elite level once they mature.




Côté, J., Lidor, R., & Hackfort, D. (2009). ISSP position stand: To sample or to specialize? Seven postulates about youth sport activities that lead to continued participation and elite performance. International Journal of Sport and Exercise Psychology, 7(1), 7-17.

DiFiori, J. P., Benjamin, H. J., Brenner, J. S., Gregory, A., Jayanthi, N., Landry, G. L., & Luke, A. (2014). Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med, 48(4), 287-288.

McGuine, T. A., Post, E. G., Hetzel, S. J., Brooks, M. A., Trigsted, S., & Bell, D. R. (2017). A Prospective Study on the Effect of Sport Specialization on Lower Extremity Injury Rates in High School Athletes. The American Journal of Sports Medicine, 0363546517710213.

Do you play basketball?

Ankle Injury

Ankle injuries are common in basketball players. A sprained ankle may seem like nothing at first, but it can cause significant problems. In Basketball, players over half the time missed due to injury is because of ankle injuries.

What is it?

Your ankle joint is made up of bones; tibia, fibula and talus, and ligaments; lateral and medial, Inversion injuries or ‘rolling your ankle’,

(where you fall onto the outside (lateral) of our foot) are far more common than eversion injuries, where you fall on inside (medial) of your foot. Inversion injuries may result in the lateral ligaments of your ankle becoming damaged or torn.

What can we do?

Ankle injuries often swell and bruise. Therefore the immediate treatment of RICE (Rest, Ice, Compression and Elevation). It is also important to apply the principles of no HARM (which is no Heat, Alcohol, Running or Massage) in the first 24-48 hours.

Depending on severity of the injury there may be a period of time on crutches. But hopefully not! The aim is then encourage the joints to move properly and to strengthen the muscles around the joint as soon as the pain allows.


It is important to prevent ankle injuries because recreation basketball players with a history of ankle injury are 5 times more likely to hurt their ankle again. To help prevent ankle injury you can wear correct shoes, ensure stretch and warm up appropriately before training or playing, tape or a brace.

Stiff ankles are poor landing technique also increase your risk for ankle injury. This can be picked up by your physiotherapist in a screening review.

Ankle braces and taping

Not everyone need to wear ankle braces or tape there ankles. There is an indication that ankle taping or bracing can decrease the risk of re-injuring in those of you that have a history of ankle injuries. We can help teach you the best techniques to safely tape your ankle or provide you the ankle braces required.


Ankle injuries are painful and frustrating because they cause you to miss games, not only for McKinnon but at school too. Prevention is just as important as treatment and the team at Physiosports Brighton are available for screenings and treatment to help manage your ankle injuries.

Why calories don’t count

LOCO CICO – Calories in, calories out is crazy!

By Shari Aubry

Over the last forty years, the health message for weight management has been pretty simple – burn more calories than you consume, also known as ‘calories in calories out’ (CICO). It sounds simple and at face value it makes sense, but how often has it worked for you?

Sure, you may have reduced calories and successfully nailed race weight, or lost that extra 5kg – but has the weight stayed off; or crept back on? For most of us, it’s the latter; because at the end of the day calorie restriction isn’t that sustainable – nor enjoyable.

So, you can keep up the battle to count calories – or, you can rethink calories and why the CICO model may be flawed.

The Math Myth

One aspect of CICO that doesn’t add up is the oft quoted equation that for every 3,500 calories consumed (and not burned off) you score a pound of body weight (0.45kg). The CICO theory treats it a little like a bank account – once your balance hits 3,500, transaction complete and you’re 0.45kg heavier.

But let’s play around with this. Using CICO math:

  • a daily increase of 100 calories – that’s a medium sized apple,
  • will result in 36,500 extra calories a year, and
  • a weight gain of 5kg…from an apple a day. 

The Women’s Health Initiative followed 48,000 women for a seven-year period; the intervention group (19,541) reduced calorie consumption by 350 calories a day.

  • Using CICO math that should result in a weight loss of 115kg each (350*365*7/3,500[/2.2]).
  • Okay, 115kg is clearly unrealistic, but at the end of the day they reduced calories so they must have lost weight, right?
  • They did. A mean of 0.1kg each – for seven years of diligent calorie counting.

At which point you might argue, ‘well, there’s a lot factors that contribute to weight loss’. And that’s the point – human physiology is complex and multi-faceted; and CICO doesn’t account for this.

5,000 calories a day

So, if reducing calories doesn’t always result in weight loss, does increasing calories result in weight gain? Yes, and no.

Sam Feltham documented a self-experiment (Smash the Fat blog) where he ate 5,800 calories a day, for 21 days using a low-fat, high carbohydrate approach. He didn’t change exercise. The result?

  • he gained 7.1kg,
  • added 9.25cm to his waist, and
  • increased body fat 4.2%

I can hear you thinking; ‘…of course he did, he ate WAY too many calories’. But before you go back to calorie counting…

After performing a metabolic reset, he repeated the experiment; the same number of calories, the same duration and no change to exercise. This time:

  • he gained 1.3kg, but
  • reduced body fat, suggesting weight gain was lean tissue, and
  • lost 3cm from his waist.

All whilst eating 5,800 calories a day. So, what was different? The quality of calories.

The second experiment was a low carbohydrate, high fat (LCHF) diet. The nutrient quality of these calories, and the hormonal response elicited, positively affected weight and body composition; as opposed to the CICO assumption that it’s just about the quantity of calories.

The idea that ‘a calorie is a calorie’ is outdated, because we know what you eat activates different physiological responses and pathways including insulin, ghrelin and leptin. The problem with CICO is human physiology is not singular, but complex and multi-faceted and that’s what CICO doesn’t account for.

When it comes to calories, it may be that quality matters much more than quantity. To be clear, we don’t advise you regularly over consume – it will bite at some point – but nutrition science is becoming more definitive that the hormonal response to food vastly overwhelms the simple number of calories consumed.

Once you get your head around that concept, the next step is to educate yourself on what foods elicit a positive hormonal response, versus those that activate a less desirable outcome.

So, the message

In short, calories do count, but you shouldn’t count calories. Eat real food, eat to satiety and understand the nutrient quality of your calories, and you’re well on your way to a much easier and sustainable model of weight management – not to mention health, longevity and generally feeling great.

Adolescent Athletic Development

Growing Shouldn’t Hurt

By Angus McDowell

The physical stress put on a young body during periods of rapid growth and also high levels of sport can be immense. It is not uncommon for children to be participating in up to 4 different sports at the same time and having multiple training sessions per day, often back-to-back. This stress is then amplified by adolescent rapid growth and hormonal changes that often coincide with a high sporting load. The result of this cumulative stress can result in vulnerability for young bodies. It is paramount that at this time they remain protected from overload and non-contact traumatic injury but also from growth associated issues such as Osgood-Schlatters, Severs Disease, and Patello-femoral Joint overload.

The area of “athletic development” has undergone dramatic expansion over the last few years with a much greater focus being put on guiding and nurturing adolescent athletes. The “Long Term Athletic Development” model suggests a time line for both timing and focus of athletic development and acts as a guide to when, during a child’s growth, that they develop different sporting characteristics (e.g Speed, Agility, Power, Sports Specific Skills and muscle development). This timeline can then be used to structure periods during which protection is the focus and periods where development is the focus, and even timeframes where adolescents should focus on specific sports and activities.

The development process that an adolescent goes through has the potential to dictate a large quantity of their physical characteristics and sports specific characteristics for the future, as an adult. From a sporting perspective, this can have a dramatic effect not only on their athletic careers but also on their injury prevention and long-term health. It is important to consider the future when deciding on sport participation and training to maintain the highest level of physical protection and promote proper development in adolescent athletes.

If you would like us to develop a personalised development timeline for your sporting son or daughter to protect them and allow them to flourish, please contact Reception 9596 9110 to book an appointment with Angus McDowell or John Contreras or book online at www.physiosports.com.au.

Blood Flow Restriction Training

By Georgia Koutrouvelis

Patellofemoral (knee cap) pain is a very common injury which we see in both males and females, and  adolescents and adults.

The effectiveness of increasing quadriceps strength to reduce patellofemoral (knee cap) pain has been well established in the literature.  In order to achieve true strength changes, the use of high intensity training at a load greater than 70% of one-repetition maximum is required.  This high resistance not only loads up the quadriceps, but also the patellofemoral joint.

The people who would mostly benefit from quadriceps strengthening are those with kneecap pain, but unfortunately, they can experience a flare up of their discomfort during high load strengthening exercises.  We also know that quadriceps activity is reduced in the presence of knee cap pain, so the notion of exercising into pain thresholds is not recommended.

So, this raises the following questions:


How do we increase quadriceps strength, in the presence of patellofemoral pain?

A recently researched option is Blood Flow Restriction Training (BFRT).


What is Blood Flow Restriction Training? 

Research on BFRT was first published in Japan as Kaatsu training in 2000.  The aim is to increase both muscle strength and size through by exercising under reduced blood flow conditions to and from the muscles.  A sphygmomanometer (blood pressure cuff) is used to apply the pressure restriction at a desired measurement.


Does it work?

Yes.  In 2012, a meta-analysis of all the literature illustrated the effectiveness of using BFRT as a method of increasing both muscle strength and size.  These changes were achieved by using only 30% of one- repetition maximum (as compared to the 70% required with traditional strength training).


Is it safe?

A review of the literature in 2011 showed that BFRT appears to be as safe as traditional strength training methods.  Although this is quite a safe intervention, any potential participants will still undergo a medical screening questionnaire to assess their relative risk.


How does it work?

The physiological mechanisms behind BFRT training aren’t very well understood, however we do know that there is a build-up of metabolic waste product within the muscle, an increase of growth hormone factor greater than traditional strength training, and reduced oxygen to the muscle.


Will it change my patellofemoral pain?

A published studied in 2016 compared an eight-week traditional strength training program with and eight week BFRT program, to assess whether there was a significant change in pain, function, quadriceps strength and size in patients experiencing patellofemoral joint pain.  I assisted in this study by being a facilitator of the intervention.  The intervention compared eight-week training program, 3 times a week, of knee extension and leg press exercises. One group performed the program under traditional strength training, methods (70% one-repetition maximum) and the other under BFRT conditions (with partial occlusion via a blood pressure cuff, at a resistance of 30% one-repetition maximum).  The patients who demonstrated significant changes in daily levels of pain were those with knee cap pain on resisted knee extension and runners.


Who should I consider BFRT?

  • If you have patellofemoral pain and traditional quadriceps strength training is too painful
  • If you would like to increase quadriceps strength but high levels of load on the knee is not appropriate in the short term or longer term. For example, post-operative patients, those with patellofemoral osteoarthritis

For more information or to book an appointment with Georgia Koutrouvelis, please contact Reception 9596 9110.