Reflections from the RTP 2016 conference

So at the weekend I attended the Isokinetic, Football Medicine Strategies, Return To Play conference in London, which is arguably the biggest football medicine conference in the country if not the world, and it also arguably has the biggest conference title in the world, however fortunately for us it was shortened to RTP2016. Now after attending a conference like this I like to reflect on the highs and the lows and of course the key learning points, and I thought I would share them with you here. So without any further ado, here is my review of RTP2016.
First things first, this is a big conference, in fact its huge, with over 2,000 delegates in a massive conference centre split over 5 floors, with multiple streams of content, and 3 trade exhibitions. Personally I found it to be just like the world of professional football, big, bold, brash and in your face, with lots of slick promotion and marketing and lots of big names and ego’s floating around. But just like professional football, it had some real gems, interesting twists and and a few unexpected surprises.

Day 1

So the conference kicked off with the welcome presentations by Dr’s Davidson, Brukner and Della Villa, we were told that 83 countries where represented and that this is the biggest attendance so far for this conference. Dr Brukner then reminded us of the difficulties many sports medicine teams have faced recently in the crazy world of English professional football, where managers and players egos have interfered with medical decision making, and how constant pressures from the media make professional sports medicine challenging.
A talk by Dr Bahr followed and he reminded us all of the fundamental discrepancies between the key factors of sports and medicine, and how they are most of the time, at complete odds with each other. He reminded us that waiting for things to heal perfectly and the pressures of returning a player to competition are simply impossible to occur together, so a compromise has to be made. This in my opinion is the true skill of any sports medicine professional, balancing the demands of sport and medicine with their two opposite goals, and it’s a skill that should never be under estimated.

Next was a rather controversial talk from Dr Batty who informed us about ‘gestalt cognition’ and how common sense must be used in sports medicine. He even used a duck call to emphasis his point about how if something looks like a duck, walks like a duck and… sounds like a duck, it is a duck. He ended his talk by explaining how we should respect science, but not be slaves to it!
Although I can understand what is trying to be said here I have some big issues with how this was promoted and explained, especially at conference like this in the fad driven, money is no object, highly susceptible and unfortunately influential world that is professional football sports medicine. In my opinion this kind of thinking although can help promote new ideas and thinking, can also open the door to woo, quackery and pseudo science. All too often nonsense interventions and treatments are done with the get out clause of ‘science just hasn’t caught up with us yet’, you only had to look at some of the exhibitors peddling some weird and wonderful crap to get an idea of how much this already happens.
Next was Prof Synder-Mackler who did a talk on ACL injury and made one of the biggest key points of the whole conference. If return to play after ACL surgery can be delayed beyond nine months then the risk of recurrence falls by 60% each month thereafter. This is simply a huge statistic and is something I think we need to be informing players more about, in this world of high pressure to return as soon as possible is it that sometimes the rush to get back can be detrimental in the long run.

After coffee there was a shoulder injury session which a shoulder nerd like me just had to attend. Although nothing ground breaking was presented there were some interesting points, first that shoulder injuries do happen in football with an incidence of between 2 – 3.3%, and that return to ‘same level’ sport took between 3-8 months but only for about 65-75%.
Next I went to listen to a short talk by Prof Jill Cook who did her usual great job of promoting the effects of loading in tendinopathy and the processes of mechanotherapy, but unfortunately like most of the talks it only just scratched the surface of the subject before time was up, 15 minutes isn’t really long enough to do a topic like tendinopathy justice.
After lunch there was a good session on ACL injury with Markus Walden discussing his research on reconstruction surgery and showing some really impressive results for return to play, with 97% going back to the same level of play within 12 months. However a recent 15 year review of here does show that really this figure is a lot lower, with only around 65% returning to same level of play within 3 years

The next talk was by Andy Rolls a physio at Arsenal FC, and a friend of mine. Now I am biased but I found this to be one of the highlights of the whole conference. Andy gave a very open, honest, and frank account of a case study here that he was closely involved in whilst the head of medical services at West Ham FC of a first team player who elected not to have surgery after he ruptured his ACL.
Andy put the meat on the bones of this case study and gave us the finer details of what actually happened during the rehab, as well as his own personal thoughts and feelings. I found it really powerful to hear Andy bravely and humbly tell us how he was nervous about the players decision not to have surgery and the concerns he had of it going wrong, and the fears of the potential come back on him from the manager, board and fans if it went wrong. I find this honesty and openness in a talk rare and refreshing and wish more would do this, so congrats Andy.
Lastly there were some other talks on ACL preventive neuro muscular training that I found quite frustrating. Firstly because of the ridiculous use of the term ‘neuro muscular training‘ which is just a nonsensical description as all exercise is neuro muscular. What they were actually trying to describe is movement retraining or motor control exercises, as they went onto describe interventions and exercises that attempt to reduce knee valgus, and this is the second reason I found these talks really frustrating.
Now there is no doubt that research demonstrates a link with excessive knee valgus and ACL injury, however, the reality is that knee valgus is impossible to avoid in many sports and tasks, and no matter how many drills or retraining you do in a sterile environment like a gym or a lab this just isn’t going to change. So I question the use of exercises loke these and the premise of avoiding knee valgus. I question if we are in fact by constantly asking players/athletes to avoid knee valgus in training and rehab making them LESS tolerant and robust to cope with it when it does occur. Should we be asking and training players/athletes to adapt to valgus by exposing them to it?
Also as Erik Meira (my go to lower limb sciencey guy) informs me knee valgus usually occurs due to a lack of ability to develop knee flexion under load, and so we should be spending our time on improving this, but as he says, who the hell just wants to do the simple easy stuff right!!!

Day 2

So the morning session of the second day was fully packed, and first up was the legend that is Carl Askling talking about his lengthening hamstring rehab protocol here which has been shown to be highly effective and efficient in returning to play after hamstring injury, simple, precise, and elegant.
Next was a disappointing presentation on quad injury in footballers and how Thomas tests help diagnose functional deficits, and transverse abdominal strengthening with PBUs is needed in its rehab, they both don’t. This was followed by another disappointing case study on a groin injury and subsequent surgery in a professional football player, and how a possible infection may have been a cause for persistent pain after surgery. What I found interesting here was that although the antibiotics eventually helped and the player returned to play, no-one considered the multitude of post surgical injections he had as a potential cause of the infection.
Next up however, was another highlight of the conference for me from Seth O’Neil on calf injuries. Seth gave a great talk on the role of the Soleus muscle in calf function and injury. Key points for me was how the Soleus is the largest muscle in the calf and is the primary force generator. Also how it has a key role in knee flexion and tibial rotation and possibly could have a role in ACL issues. Also its capacity and strength doesn’t seem to recover or return well even with rehab and how it needs heavy loading to get it back to full function, music to my ears.

After the break was a good talk by Lorenzo Masci who discussed the role of imaging in tendinopathy. Lorenzo showed us the uncertainty between imaging, pain and function, and came up with one of the quotes of conference. “Forget the structure, treat the function”. However, he went on to show how other technology such as UTC or shear wave elastography may give us better ability to assess the structure and give us insight into its role in pain and function..
Next up was another legend Prof Karim Khan the editor in chief of the British Journal of Sports Medicine who changed his planned talk on anterior knee pain at the last minute, and choose to highlight the issues with Platelet Rich Plasma (PRP) injections that where being heavily promoted at the conference as being the best thing since penicillin.

Karim disclosed that as editor in chief of BJSM he has no conflicts of interest receiving no finical support or incentives from PRP companies which he went on to quite clearly state many others can not say. Karim then went on to explain how financial incentives are given to journals and individuals by PRP companies and how publication bias is very strong with PRP research, with negative trials being quashed and not reported. As with Andy Rolls talk the day before I found Karims honesty, integrity and most importantly his bravery to speak up about this topic refreshing and admirable and it needs to be done more, a lot more!
Finally the last gem from RTP2016 was a talk by Dr Tim Gabbett on his recent work here on the acute/chronic ratio of load/training and its role in prevention of non contact injuries. Tim used a brilliant analogy of tolerance to load by asking us to switch training with beer. He explained if you over the years gradually drink a lot of beer you need more beer to get the same effects, basically your tolerance goes up. But if you stop drinking for a while and start again, you get drunk quickly as your tolerance goes down. And just because you can drink a lot of beer, don’t think you are tolerant to vodka, which he explained can be though of like high intensity v’s low intensity training.

Tim’s work shows that if you monitor the last 4 weeks of training of an athlete and ensure that the subsequent weeks training load is kept within 0.8-1.3 of this then the risk of injury is low. However start to spike the load/training in one week above 1.3 or rest too much and it dips below 0.8 then you are increasing the risk of injury. This is a great concept and so easy to use and implement. Tim was clear though that this ratio of 4 weeks and 1 week is only for certain sports and this ratio needs to be looked at in other sports. Tim finished his talk and my conference with a great finishing line “training hard is not dangerous, spikes in training load are” For more from Tim on this listen to me and him talking on the NAF physio podcast here
So that wrapped up my RTP2016 conference and in summary as I said at the beginning, I found it to be big, bold, and brash, and I’m afraid to say apart from a few gems mentioned above, it was lacking in any real science or substance. Instead there was much more focus on promotion, publicity, and prima donna’s, but is this really that surprising in the crazy world that is professional football and is it really that surprising that this then rubs off onto the sports medicine profession around it.
Unfortunately, probably not!
Oh and the lunch supplied was terrible, a limp soggy sandwich. Top tip: If you want to keep delegates happy, feed them better!!!
As always thanks for reading
Adam