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

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.

Exploring patients’ narratives of health professional communication skills

UntitledDo you have any stories to tell about your communication with a healthcare professional? One of our physiotherapist’s, Charlotte Denniston, is doing her PhD at Monash University investigating the development of communication skills in undergraduate health professionals.  She wants to hear from the general public as consumers of healthcare about their experiences of health professional communication skills.

Maybe it was when you saw a health professional and they counselled you through the recovery of your illness/injury? Or maybe when you witnessed a health professional communicate poorly with your family member? By telling your story YOU could WIN a $100 or $200 Coles Myer Voucher.

Your stories will be vital in shaping the way we teach communication skills in health professional training programs. If you are interested in telling your story please follow this link:

If you have any queries about this research please contact Charlotte Denniston by phone on 99050781 or at

Please note: This survey may take 30 minutes to complete. You must be over 18 years of age and able to provide responses in English to enter.

The Benefits of Massage

By Dom Walker

As a cyclist and sports massage therapist who has been treating cyclists and runners for a number of years, I am often asked whether a regular massage can be a beneficial component to a training program.

The simple answer is absolutely! A regular massage will help improve your movement, increase circulation and promote recovery and in turn improve performance however, the key word here is REGULAR.

Massage shouldn’t be seen as a luxury or indulgence and only used when every muscle and tendon in your body has seized up but, as an integral part of your training with a therapist who understands sports massage and your body.

Here’s the reason why…..

One of the great benefits of massage is that it relaxes tense muscles, improves joint range of motion and reduces the potential for injury.

Cycling and running requires sustained, repetitive muscle contractions, the greater these contractions, the more force is generated and in turn the more muscle fibres are recruited and therefore shortened. Whilst all this translates into increased power, speed and distance, it also means adhesions and minor scar tissue forms between the muscle and the surrounding fascia. Left untreated, it is these adhesions and unwanted muscle tightness which can restrict movement and joint range of motion which over time can lead to abnormal movement patterns that can cause overuse injuries.

Recovery is another benefit of massage. Regular massage can help reduce pain and the intensity of muscle soreness following a big run, ride or swim. Pain can alter how we move and even inhibit healing so, a well timed massage can help us get out of that stress dominated response of our nervous system and into a more relaxed state.

Massage can also improve the circulatory system delivering increased oxygen and nutrients to muscles. Better circulation means better recovery however, one thing to keep in mind and contrary to popular belief, massage won’t clear out the lactate or lactic acid build up in your muscles. Lactate is cleared from your system fairly quickly once stopped and is not the reason for muscle soreness which is actually caused by cell damage in your muscles.

Cycling and running go hand in hand with massage but it is important to remember that the benefits are cumulative. A one off massage here and there will provide some relief for a short time but won’t give you the same benefits when used as part of your training plan – quicker recovery, injury prevention and the benefit we all want, improved performance.

Dom Walker is a Remedial Massage Therapist and leads the massage team at Physiosports Brighton. See his full bio here

Mastering Load 3 : Training Load and Injury – A Cycling Coach Perspective

In the first blog of this series it was mentioned that when it comes to fit there has been more of a focus on performance than injury prevention. This is also true for the load modeling that occurs in the sport of cycling; training load is managed more to optimize performance than prevent non-traumatic injury. In this blog we will investigate the potential that properly managed training load has the serendipitous effect of also helping to prevent non-traumatic and overuse injuries in cyclists.

Performance load modeling was first developed by Banister et al in 1975. Their model was based on heart rate (HR) during training bouts. Later, training load models that used power as a metric to determine training stress were developed and used Banister’s model as a base. This method of modeling training load for cyclists via power data vs. HR became viable mainly due to two factors:

1) HR correlates with the power output for an individual at a given training status and

2) the advent of portable power meters that cyclists could utilize to track power output during training and racing scenarios- outside of a lab setting.

Power based training load models have attributes that could be argued advantageous in modeling for injury prevention. 1) While not scientifically validated in most cases, these training load models are commercially available for cyclists and coaches to use and can be easily accessed via the internet. Couple this with the automated data upload that many cycling computers offer and data management becomes very easy. 2) Modeling training load with power better represents overall mechanical load vs. using HR which more a measure of internal stress.

Of the commercial training load models, Performance Management Chart (PMC) developed by Dr. Andrew Coggan and marketed via Peaksware is one of the most popular.

Figure 1. shows the training load modeling for an athlete over the time span of one year.

Figure 1- Training load modeling for a cyclist for one year. Each red dot represents a workout and its corresponding training stress. The blue line represents fitness, the purple line represents fatigue, and the yellow represents freshness.

The Coggan method of modeling training load relies on some basic sport science ideas that have rebranded. The first idea is the idea of “threshold”. With the Coggan method “threshold” is defined as the maximum power output an athlete can maintain for 60 minutes. It is officially named Functional Threshold Power (FTP). Another concept unique to the Coggan model is the idea of normalized power. Normalized power (NP) was developed mainly because the average power (and kjs of work) for a ride or race doesn’t necessarily correlate to its physiological stress. This is especially true with rides/races that have high amounts of intermittent bursts of power. NP and FTP, along with workout duration are used to calculate an athlete’s training stress score (TSS) for a particular workout/day. TSS is the underlying data point that is compiled and utilized in the Coggan model and used to calculate Fitness, Freshness, and Fatigue for an athlete.

Fitness, know as Chronic Training Load (CTL), is calculated by an exponentially weighted rolling average of the last 42 days’ TSS. It shows up as a blue line in PMC. An athlete’s fatigue is known as Acute Training Load (ATL) and is again calculated with an exponentially weighted rolling average, but instead it defaults to the last 7 days. ATL is a purple line in PMC.  Freshness is calculated by subtracting ATL from CTL. This is called Training Stress Balance (TSB) and is illustrated with a yellow line in PMC.

Training load modeling has allowed for coaches and athletes to break away from classical and block periodization and still see gains. When these schemes are often employed an athlete can go a whole or multiple microcycles of training (e.g. a week or more) without returning to a “fresh” state. One could argue this might lead to a higher chance of overtraining syndrome and illness. On the other hand, cyclists utilizing a functional non-linear periodization scheme (as seen above in Figure 1) coupled with training load modeling, can potentially be in a “fresh” state once or twice a microcycle and still see gains. This helps to ensure that stress from training load is not too high too soon or for too long.  This is especially important for cyclists who are building back fitness after coming back from time off of the bike (e.g. after traumatic injury, health issues, seasonal breaks).

In Figure 1 notice that there is a quick and drastic decline in CTL in the middle of the graph. Also note that there are a group of TSS data points clustered around zero on the x-axis. In reality this athlete had a bad crash in a race that forced them off of the bike. You can see their CTL dropped to the levels they had in January. Interestingly, their interval power numbers matched the numbers they were putting out during that time. You see the athlete’s return to fitness over the course of the next month or so. One thing to also point out about this particular incident is that the athlete’s FTP was not retested/reentered into PMC after the crash/loss of fitness. This would have decreased the accuracy of the model. But, as many practitioners know, best practice for an athlete does not always include testing them. In many cases it is better for the overall scenario if testing can be avoided.

In rugby, cricket (Gabbett 2016) and athletics (Raysmith 2016), an increase in injury risk has been shown with spikes of increased load, troughs of unloading (Drew 2015), or unloading due to an initial injury, and inadequate chronic load (pre-season training). It has been suggested that the chronic load (long-term): acute load (short-term) relationship is extremely important in training load injury management.

In conclusion, at this time the idea that training load modeling can help prevent cycling injury is merely a hypothesis based on evidence from other sports, anecdote and reasoning (and some may say it is actually more conjecture). We do not believe this is problematic for the obvious reason that anecdote drives research questions and therefore our understanding of sport.

Cycling coaches are in the unique position to have the data required to monitor training load at their fingertips, so in recording data there is no cost or burden to the cyclist above and beyond something they would normally do to increase performance. If injury prevention is an unexpected side effect of training load modeling for performance then we might already have the answer to mastering load in cyclists.


Jason Boynton, M.S.
Postgraduate Student– Exercise and Health Science
School of Exercise and Health Sciences
Edith Cowan University

How do we analyse loading in cycling: Part 2

The cycling kinetic chain

In part 1 of this series, we introduced the concept of “Mastering Load” in cycling, essential knowledge for treatment and injury management, with its inherent requirements being a knowledge of:

  • tissue reaction to load,
  • tissue pathology,
  • the mechanics of cycling,
  • cycling kinetic chain deficits,
  • how to analyse and reason the findings of local, entire kinetic chain and whole body assessment
  • interpretation of training loads and wellness measures

Whilst we have touched upon the lack of ‘conversation’ regarding the cycling kinetic chain and its relationship with injury, there have been informed commentaries in the past eschewing a kinetic chain approach:

Gregor, in his classic review paper of 1996, commented “knowledge of….load sharing among all segments responsible for the co-ordination of energy delivery to the crank is important..”

In that same review he quoted Van Ingen Schenau, 1989,

“…uniarticular muscles are power producers and bi-articular power distributors….”.

FACT: The kinetic chain approach to analysing pedalling is a viable construct

As a background I think we must explore the “Perfect” vs “Imperfect” technique of pedalling, and how this imperfect technique can be a source of pain or injury. And what the measures are which guide us in assessing that a pedal stroke is imperfect – kinematics, muscle activation, co-ordination, strength, length-tension relationships, force, power, posture?


In the area of normal muscle activation in the pedal stroke, the historical perspective was simplistic, with the more realistic pattern represented in figure 1


(TDC = top of pedal stroke; BDC = bottom of pedal stroke)












And whilst the gluteals and quadriceps are seen as the main muscles for power production, co-ordination of the pedal stroke utilizing the hamstrings and calves seems an important feature of “perfect” pedaling (Blake 2012).

Note the extensive range of hamstring activation, as well as the calf, especially in the power phase, in an agonist/antagonist relationship to control the pedal stroke.  Also the activation of tibialis anterior, and vastus lateralis and medialis, at the end of the recovery to prepare to push over the top of the pedal stroke.

The most efficient pedaling needs to maintain power at the top and bottom of the pedal stroke (Dead Centres – Leirdal 2011). Given that the peak of power is at 3 o’çlock on the clock-face, maintaining power at the Top Dead Centre (TDC) and Bottom Dead Centre (BDC) becomes a challenge of co-ordination/activation.


Blake (2012) looked at muscle co-ordination patterns in cycling, finding that peak efficiency occurred at 55% VO2 max, with efficiency being the relationship between power output and metabolic cost. At optimal efficiency there was an even spread of activation levels between the muscle groups, but as the workload increases, there was a greater emphasis upon the power muscles (GMx, VL, VM), and less efficiency (least at 90% VO2 Max), with a higher level of variation in the timing of the co-ordination muscles (Hamstrings, RF, Gastrocnemius).

EMG Intensity Maxiums













Blake showed that the GMx and VL/VM are the power muscles acting vertically, but with the VL/VM activating earlier in the pedal stroke at higher workloads, and GMx increasing the most relatively, as workload increases. An increase in the work done by the power muscles relative to the co-ordination muscles is a common theme with increased workload and fatigue states (Dingwell 2008, Bini 2010).

Periods of high workload (hills/powering) and fatigue have a relationship with the clinical presentation of pain in the cycling community. Rarely does pain present in “easy” riding.

The GMx has the greatest potential for increased power as it functions at low MVC at maximum efficiency. One can imagine it, and the VL/VM being the gears, and the co-ordination muscles the clutch, allowing for synchronous change in gears and timing of activation. So the “gears/power muscles” increase their activation level significantly with increased workload, whilst the co-ordination muscles don’t increase their activation for power, but they function for smooth transmission of the power, especially in the TDC/BDC positions.

The idea that the hamstrings and calf muscles work synergistically with the power muscles to co-ordinate the fast and powerful moments of hip, knee and ankle extension resonates well from a movement analysis perspective, with early activation of quadriceps and tibialis anterior at TDC to gain a good angle for the horizontal vector component, also a notion that makes sense. Add the strong and smooth transmission of force to the pedal through ball of foot contact and good foot and ankle range and position, and the proposed model of power and co-ordination presented by Blake is highly usable for the physiotherapist in optimising efficiency and injury prevention in cycling.

The co-ordination correlate on the bike is high cadence pedaling (100RPM+), with riders who struggle with their co-ordinative muscle activation finding it difficult to maintain a smooth pedal stroke and “bouncing” around on the seat. Practice of high cadence pedaling is common in well-trained cyclists – therefore the practice of optimising co-ordinative patterns exists.

So the higher the workload, the more dominant the power muscles become, with a less efficient and more vertical pedal stroke. If the power muscles are deficient other muscles must fill the gap as workload and fatigue increase. Riders with poorer co-ordination will use the power muscles more at lower loads, with earlier fatigue, less efficiency and greater potential for adverse kinematics.

FACT: There is a “more perfect” way to pedal which may influence injury risk.


As a clinician analyzing the cycling kinetic chain for a relationship between pain/injury and a posture, movement or strength parameter, one soon realizes that the evidence is minimal and not strong.

We look to use the evidence base, to extrapolate from “on-land” activity theory, to use performance based knowledge, and clinically reason the findings of a thorough assessment in best practice management.


  • Lower back pain if there is Increased Lumbar Spine Flexion (Van Hoof 2012, Salai 1999, Burnett 2004, Schulz 2010)
  • Knee pain is associated with increases in knee abduction and ankle dorsiflexion (Bailey 2003), as well as hamstring muscle inco-ordination (Dieter 2014)
  • Cycling volume (Andersen 1997, Akuthota 2005) is associated with neuropathies of the hands, feet and saddle area
  • Handlebars lower than saddle (Partin 2014) is associated with saddle neuropathy

Extrapolation to Land based presentations:

  • Gluteal Deficit is associated with patella-femoral pain syndrome (PFPS) (Souza and Powers 2009) and patterns of “anterior hip overload” (Lewis and Sahrmann 2008)
  • The ankle joint is required for load dissipation – a first order worker (Zhang 2000)
  • Quadriceps weakness is a risk factor for PFPS (Langhorst 2012)
  • Dynamic Knee Valgus is associated with PFPS and ITBFS (Powers 2009, Fairclough 2009)

Performance based parameters:

  • Knee Angle at Bottom Dead Centre (BDC) STATIC 25-35 degrees (Peveller 2007); DYNAMIC 33-43 degrees (Fonda 2014)
  • Force Transfer foot-pedal is mainly ‘ball of foot’ (Gregor 1996)
  • Fatigue/High VO2 leads to increased use of POWER muscles (Blake 2012), increased DF (Bini 2010) and Knee Splay (Dingwell 2012), increased lumbar and pelvic lateral flexion (Sauer 2007, Chapman 2008)
  • The gluteals and quadriceps are important for power; hamstrings and calf for co-ordination (Blake 2012)

FACT: Plumb Line measures and fore-aft seat measures are not represented in the evidence.


It would seem that key features of the CYCLING KINETIC CHAIN are lumbar spine position, degree of lateral pelvic tilt, gluteal and quadriceps muscle ability, degree of knee valgus (splay), the ability to be smooth and co-ordinated in the pedal stroke, knee angle at BDC, ankle DF angle and ankle joint ability and the point of force application foot to pedal.


Pain and injury in the athletic population is complex in its aetiology. Clinical reasoning is essential to optimising management, and in cycling understanding the knowledge base regarding the interaction between the body and the bike is an important cornerstone to expert practice. The kinetic chain approach to analysis of cycling injury is a valid pathway and will bring cycling injury management to a level similar to other high performance sports.


Paul Visentini is a Specialist Sports Physiotherapist, with his awarded sub-specialty in the area of lower limb tendinopathy.

Paul is a keen recreational cyclist and is highly involved in teaching and management in the area of Cycling Injury, ‘PhysioBikeSetUp’ and ‘Mastering Load’. He has been involved in Cycling Injury Management at both elite and recreational level, and is undertaking his Doctorate in Physiotherapy, investigating “Clinical Measures of the Closed Kinetic Chain in Cycling”.

Paul will be presenting at the Mastering Load Symposium 3 & 4 June 2017 in Melbourne visit for more information. Email for a registration form.

Stay tuned for:
PART 3: Training Load and Injury : A coaches perspective

CYCLING Mastering Load – How do we analyse loading in cycling: Part 1


compressedCYCLING Mastering Load is not a hot topic of discussion in journal articles or blog spots, not-withstanding the significant levels of
non-traumatic injury or pain suffered by cyclists both recreational and elite (DeBernardo 2012, Clarsen 2010, Dannenberg 1986).

Mastering Load implies a detailed understanding of the features and characteristics which can influence non-traumatic injury.  More recently there has been strong emphasis upon training load and its influence upon injury, from thought leaders such as Tim Gabbett, Yann LeMeur and Michael Drew, but mainly related to rugby, cricket and Australian football.

Historically, injury management practitioners have analysed mechanical components of movement such as kinematics, vertical ground reaction forces and muscle activation to predict and/or explain tissue overload.  Jumping and landing theory gives evidence of the ability to change mechanical loading characteristics during activity, and current concepts in the management of patellofemoral pain syndrome (PFPS) and anterior cruciate ligament (ACL) rupture also have mechanical deficiency and subsequent rehabilitation as key tenets (Hewett 2006).

FACT: We can change mechanical loading AND it is important in injury management.

What about cycling?

The Mastering Load conversation is not quite as evolved in cycling, and is complicated by the nature of cycling, which of course involves a bike.  The emphasis regarding the mechanics of cycling has always been focused upon bike geometry and rider set-up to the bike.  There is little or no discussion of the mechanical ability of the body, as there is in PFPS or ACL injury.

Power production, VO2 max, joint moments, seat height, knee angle, fore-aft seat position are all parameters measured in cycling research, but a recent systematic review of cycling non-traumatic injury  related research (Visentini 2015, in press) found no evidence that these parameters are related to injury.  The emphasis in research has been upon performance.

FACT: Most bike set-up theory is not based upon injury data but performance data.

There is some evidence that excess lumbar flexion is related to lumbar pain (Van Hoof 2012), and that volume in cycling relates to altered nerve conduction (Akuthota 2005, Anderson 1997).  There is softer evidence that excessive dorsiflexion in the pedal stroke as well as knee valgus in the frontal plane could be related to knee pain.

FACT: Body related parameters have a relationship with cycling injury/pain.

What if?

Taking on board the theory of mechanotransduction being a cellular reaction to mechanical load (Khan and Scott 2009), what if a cyclist suffers a fall and subsequent back pain, which can affect gluteal muscle activation.  At times of peak power the cyclist has been shown to maintain power levels regardless of the activation pattern.  In this case the gluteals may be deficient and the other power group, the quadriceps, need to work 15% harder.  What effect on the articular cartilage matrix of the retropatellar surface with this increase in patella-femoral compression force (PFCF) due to an increase in the quadriceps moment arm (McLean and Blanche 1994).  Isn’t this like a training load error – increasing local loading by 15% as compared to the same session the previous week?

FACT: All non-traumatic pain or injury in cycling is essentially an error in loading which causes a cellular and matrix response.

The clinical reasoning process in cycling injury management requires a knowledge of the cycling body, bike set-up, pedaling mechanics and activation, training load measurement and analysis, and tissue response characteristics.  In essence a “mastery of loading” is required to best manage the cyclist in-clinic.


Paul Visentini is a Specialist Sports Physiotherapist, with his awarded sub-specialty in the area of lower limb tendinopathy.

Paul is a keen recreational cyclist and is highly involved in teaching and management in the area of Cycling Injury, ‘PhysioBikeSetUp’ and ‘Mastering Load’. He has been involved in Cycling Injury Management at both elite and recreational level, and is undertaking his Doctorate in Physiotherapy, investigating “Clinical Measures of the Closed Kinetic Chain in Cycling”.

Paul will be presenting at the Mastering Load Symposium 3 &4 June 2017 in Melbourne visit for more information. Email for a registration form.

Stay tuned for
Part 2: Breaking down the cycling kinetic chain
Part 3: Measuring Cycling Training Load

Ice Ice Maybe?

A lot has changed in sports medicine over the last few decades. With an obvious shift towards evidence based practice, treatment modalities that were once the foundations of our injury management are being investigated and replaced when research cannot support their use. This is evident again with the role of icing, or its scientific name cryotherapy, in injury management.

Dr Gabe Mirkin coined the acronym RICE (rest, ice, compression, elevation) in 1978 advocating the use of ice to reduce swelling and inflammation in the acute stage of injury management. The rationale for the use of ice was that cooling the injured area results in reduced blood flow and limits inflammation and swelling leading to improved tissue healing.

But inflammation is a vital component of healing cascade, the increased blood flow to the area supplying the injured tissue with oxygen, inflammatory cells and hormones to clean up the area and trigger a proliferative phase that leads to tissue regeneration.  On today’s evidence, inhibiting the body’s inflammatory response may actually lead to incomplete healing. This has been scientifically proven with regard to the use of non-steroidal anti-inflammatories in acute injury management, maybe its time we consider the effects of cryotherapy in the same way.

The flip side of this argument is that an uncontrolled inflammatory response may lead to excessive swelling and pain. POLICE (protection, optimal loading, ice, compression, elevation) is the new acronym for acute injury management protection with optimal loading being considered the most important elements of the program. Optimal loading encompasses the principle of mechanotherapy where tissue loading results in a cellular response leading to positive structural change. Excessive pain and swelling may diminish the individual’s ability to load the injured area effectively. In this case ice may play a role as an analgesic or to limit excess swelling allowing for controlled early loading.

How long does ice need to be applied for to have a positive analgesic effect without having a negative impact on the tissue healing process? Unfortunately there is no clear answer for this. The impact that ice will have on cooling injured tissues will be dependent on the depth of the injured structure, surrounding adipose tissue and muscle bulk.

There is a lack of evidence either way, which is largely the point. We have used ice in injury management as dogma but maybe its time to start using our clinical experience and knowledge of physiology and tissue healing to determine when cryotherapy is appropriate and in what dosages. Even Dr Mirkin, the man behind RICE, has changed his mind and thinks that excessive icing after injury has a negative effect on tissue healing.

Ice is not the enemy of tissue healing. Inflammation and pain are a normal and a required physiological response to injury. The evidence is not calling for ice to be banned from our acute injury management. The advice we give our patients should encompass the facts that a controlled inflammatory response is vital for good tissue healing and that ice can be used to reduce pain and excessive swelling to allow for early protected loading.

A delicate balance exists between protection to prevent further insult to damaged tissues and our interventions to speed up recovery. Every patient should be assessed and considered on their merits and our intervention, even acute injury management, should be tailored to their specific injury.

As the title of this blog says – Ice Ice Maybe?


  1. Bizzini M. Ice and modern sports physiotherapy: still cool? Br J Sports Med 2012;46:219
  2. Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE?
Br J Sports Med 2012;46:220–1.
  3. Bleakley CM, Glasgow P, Webb MJ. Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting?
Br J Sports Med 2012;46:296–8.
  4. Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52.
  5. Mirkin G –
Steve Whytcross (FACP)
Steve Whytcross (FACP)

Steve Whytcross is Specialist Sports Physiotherapist (awarded 2015) with a special interest in lower limb overuse injuries and load management strategies. Over the last 16 years, Steve has worked extensively in both Australia and the UK and has previously worked in elite soccer, tennis and Australian Rules Football. With an ongoing dedication to professional education, Steve has co-developed and delivered the “Mastering Load” series (2008-present) and Science of Cycling course (2013-present). Steve has presented for the APA on the use of new technology in physiotherapy, and has a special interest in bike set-up and the integration of technology in assessment, rehabilitation and feedback.