1. What’s Hot in Sport and Exercise Medicine Dr Jon Houghton MBBS MRCP MFSEM BSc DipSEM PgCert MSK US Consultant Rheumatologist and Sports Physician Honorary Senior Lecturer University of Wales Institute Cardiff Sports Orthopaedics UK

2. Contents A Brief Introduction How to advise patients about Exercise The role of Musculoskeletal Ultrasound Summary

3. 1999 MRCP 2000 Rheumatology NTN 2000 Training in MSK Ultrasound 2003/04 Diploma in Sports Medicine UCL 2006 CCT in Rheumatology/GIM 2006 Consultant DMRC Headley Ct 2010 Joined Sports Orthopaedics UK

4. Exercise Prescription Benefits of Exercise Reduction of mortality from All forms of Cardiovascular Disease Diabetes Cancer Improved Mental Health Improved Bone Health

5. Components of Exercise Prescription Type of exercise or activity Duration and frequency Specific workloads Intensity Guidelines Precautions Goals

6. Type of Exercise/activity What does the pt enjoy? Access Funding Commuting/Daily routine Housework Vary Aerobic with resistance/isotonic

7. Duration and Frequency Generally aim for 20-60 minutes 5/week V low capacity aim for multiple short sessions daily Moderate capacity 1-2 sessions daily with slightly increased duration

8. Specific Workloads Walking Pace Watts Calories/hour

9. Intensity %Max Heart Rate (220-Age) 40-60 Fat Burn 60-85 Aerobic 85+ High/anaerobic Heart rate reserve (max stress test- resting) METS - 1 MET is resting O2 consumption

10. Intensity Rate of Perceived Exertion (RPE) Borg Scale 6 No effort 11 Light 12-13 Moderate 14-15 Hard 16-17 Very Hard 18-19 Extremely hard

11. Precautions/Special groups Obese/Overweight - Reduce impact exercise Respiratory - Regular short duration Diabetes - Decreased Insulin requirements Osteoporosis - combine impact with resistance Pregnancy - maintain pre exercise level and watch for joint laxity and overheating Cardiovascular - Often require stress test prior and work to very specific intensities.

12. Case studies 48 Year old male office worker with mild hypertension 14 year old boy with obesity 68 year old female with osteopenia

13. Top Tips Involve the Patient! Include enjoyable activities Set Goals - SMART Warn about pain and stiffness Start slow and progress Review progress

14. Musculoskeletal Ultrasound Rapidly Growing Field High Frequency probes - excellent resolution Portable and cheaper Extension of the clinical examination Diagnostic Guided Injections

18. Tissues visible Muscle Tendon Ligament Bones Bursae Nerves Synovitis Calcification

19. Muscle

20. Tendon

22. Bones

23. Nerves

24. Synovitis

25. Tenosynovitis

26. Guided Injections

27. Guided Therapy for Tendinopathy Supraspinatus Extensor Origin Elbow Patella Achilles Plantar fascia

28. Neovascularisation Hallmark of tendinopathy Power Doppler USS Abundant sensory nerves No Inflammation Substance P and CGRP

29. High Volume stripping

30. Ultrasound Summary Extension of the clinical examination Real time assessment Comparable to MRI in many instances Exceeds MRI in tendinopathy Guide therapeutic intervention

31. Questions? Sports Orthopaedics UK - Delia Sittert - Caterham clinic@sportsortho.co.uk 08445 617131 clinic@sportsortho.co.uk jon.houghton@sportsortho.co.uk