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Understanding the “side strain” in cricket fast bowlers: Your guide to rehabilitation

Understanding the “side strain” in cricket fast bowlers: Your guide to rehabilitation

by | May 26, 2023 | Gym and Strength, Return to Sport

Cricket is a game that demands immense physical prowess, especially from fast bowlers who generate incredible power during the delivery stride. However, it is this intensity that can often lead to injuries, with side strains being a common condition among cricketers. In this blog, we will discuss the causes, prevention, and rehabilitation strategies for cricket fast bowler side strains, shedding light on the often vital role of physiotherapy in ensuring a successful recovery and return to play.

What is a side strain?

Side strains, also known as intercostal muscle strains, typically occur due to the rapid rotation and forceful actions involved in fast bowling. The repetitive and high-intensity nature of this movement can lead to fatigue and ultimately a single incident leads to a tear of the intercostal and or oblique (more frequently internal oblique) muscles. It is these muscles that are responsible for aiding in generating stabilisation of the rib cage and force generation during the powerful trunk rotations during bowling actions. A side strain is characterised by the onset of pain and localised tenderness over the lateral trunk near or over the rib cage, usually on the opposite side to the bowling arm. It is often felt after a single delivery when the front arm “pulls” down during the delivery action. Side strains require rehabilitation and often significant time spent away from sport. In fact, side strains are the second longest injury that keeps a player out of cricket other than a lumbar stress fracture.

Risks

The early part of the competitive playing season has been associated with relatively higher incidence of side strain injury, particularly in younger bowlers. Those that are returning from a different injury that has limited their bowling loads are also at risk. Fast bowlers, as opposed to spin bowlers are at a much higher risk given the higher forces associated with fast bowling. Finally, those who have sustained a side strain are also more likely to re-injure that same season.

Diagnosis

Diagnosis of side strain is based on the athlete’s clinical history and physical presentation. An MRI may also be utilised to confirm the diagnosis. Clinical features include acute pain over the outside thoracic wall over one or more of the lowest four ribs. There is also pain on activation of the oblique muscles in activities such as resisted side bending or rotation. Deep inhalation can sometimes be an aggravating factor.

Management

The goal is to allow the injured intercostal muscles to heal fully, regain strength, and gradually reintroduce sports-specific movements before returning to full competitive play. On average, it may take upwards of 4-5 weeks to return to sport. More severe side strains can take longer to heal, typically requiring 6 to 8 weeks or even more. However, early management and loading of the side can improve prognosis and return to play timeframes. It is important to graduate from low level exercise through to more challenging sport specific exercise (shown below). It is also important to cross train wherever you can so that you maintain as much lower body conditioning as possible.

In summary, fast bowling is tough work so your body has to be strong and resilient. Good structured strength training helps! If you do suffer a side strain, patience, adherence to rehabilitation protocols, and close monitoring are essential for a successful recovery from a side strain.

If you would like to learn further about side strains / would like to prevent injuries or have a suspected side strain – book in to chat to one of our Praxis Physios today!!

Until Next time,

Praxis what you Preach

#preventprepareperform

Nealon, A. R., Kountouris, A., & Cook, J. L. (2017). Side strain in sport: a narrative review of pathomechanics, diagnosis, imaging and management for the clinician. Journal of Science and Medicine in Sport, 20(3), 261-266.

Chicago

Split Squat vs Squat vs Deadlift: How to tailor your lower body training

Split Squat vs Squat vs Deadlift: How to tailor your lower body training

by | May 26, 2023 | Gym and Strength, Return to Sport, Running Injuries

The age old question: What’s the best gym activity for my sport? Well – the answer should always be “it depends”. Even the same athlete playing the same sport will have different requirements at different parts of a season. Generally speaking, there are some common exercises in utilised by strength coaches when programming for athletes. The split squat, squat, and deadlift are all compound exercises that target various muscle groups and are commonly included in strength training programs. In today’s Praxis What You Preach article, we are going to breakdown the kinematic (joint angles) and inverse dynamic (joint forces from assumed joint angles) differences between these exercises. We’ll also briefly discuss what sports may benefit, but as just mentioned, the answer is “it depends”.

The Split Squat

The split squat is a unilateral lower body exercise that primarily targets the quadriceps, hamstrings, glutes, and hip stabilisers. It is a personal favourite of mine as I believe it replicates many athletic positions and helps identify any asymmetries there may be. In this exercise, you start in a staggered stance with one foot forward and the other foot positioned behind. The front leg performs most of the work, while the back leg provides support.

The Movement

  • The front knee flexes and extends, moving vertically.
  • The rear leg remains relatively stationary, providing balance and stability.
  • The hip joint of the front leg moves through flexion and extension.

What’s working?

  • The front leg experiences greater joint forces and moments due to supporting most of the load.
  • The knee extensors (quadriceps) and hip extensors (glutes) generate the majority of the force to extend the knee and hip joints.
  • The rear leg primarily acts as a stabilizer rather than generating significant force.

Sports?

The split squat is a versatile exercise that can benefit individuals participating in a wide range of sports. Running, jumping and change of direction field sports such as AFL and soccer seem to benefit well due to the asymmetrical load on the pelvis. The increased loading of the hip stabilising muscles make this a useful exercise for tennis players, volleyballers and track and field (eg triple jumpers) athletes as well.

The Squat

An absolute staple of the gym! The squat is a bilateral lower body exercise that primarily targets the quadriceps, hamstrings, glutes, and lower back muscles. For the sake of this argument, talking about a Barbell back squat. It involves descending into a squatting position while maintaining a relatively upright trunk and then returning to a standing position.

The Movement

  • The hips and knees flex simultaneously, moving in a coordinated manner.
  • The knees move forward, tracking over the toes
  • The torso tilts forward slightly, maintaining a neutral spine but a bit of flex here is fine (and biomechanical studies show you can’t not flex the spine)

What’s Working?

  • The quadriceps, hamstrings, and glutes generate force to extend the hips and knees during the ascent phase.
  • The erector spinae and other lower back muscles provide stabilization and contribute to maintaining an upright posture.
  • The knee extensors (quadriceps) experience higher forces and moments during the descent and ascent phases.

Sports?

Squats help with vertical force generation so jumping sports like basketball and volleyball are sports that would benefit. The Barbell back squat is also central in powerlifting, olympic lifting and Crossfit. Given you can load significant weights to the bar, back squats are also useful for football codes whe are required to absorb impacts during tackles.

The Deadlift

The deadlift is a bilateral exercise that primarily targets the posterior chain, including the glutes, hamstrings, erector spinae, and upper back muscles. It involves lifting a loaded barbell or other weight from the floor while maintaining proper form.

The Movement

  • The hips hinge backward, allowing the torso to lean forward while maintaining a neutral spine.
  • The knees flex to a lesser extent compared to the squat.
  • The barbell moves vertically in a straight line close to the body.

What’s Working?

  • The glutes, hamstrings, and erector spinae generate force to extend the hips and maintain a neutral spine.
  • The quadriceps contribute to knee extension.
  • The upper back muscles help stabilize the spine and prevent excessive forward flexion.
  • The lower back muscles experience significant forces and moments due to their role in maintaining spinal alignment.

Sports?

Powerlifting, Olympic lifting and Crossfit are the obvious ones that spring to mind. But tackling sports such as rugby can benefit. Given the predominance of back musculature, rowers will benefit here. Wrestlers and MMA athletes will also benefit due to the whole body nature of a deadlift.

Overall, while all three exercises involve lower body movements, they differ in terms of joint angles, muscle activation patterns, and force distribution. Understanding these differences can help tailor training programs to specific goals and individual needs. We also modify these exercises further to tailor our rehabilitation needs, In that vein, it’s important to be conscious of technique when performing these exercises to maximise their effectiveness and reduce the risk of injury.

So if you are growing stale in your lower body workouts, try and mix it up with some of the above. There are also plenty of variations of the above to alter the movement and forces even more! If you are after some help to modify your gym program, chat to us today – we are here to help!

Until next time,

Praxis What You Preach

Split Squat vs Squat vs Deadlift: How to tailor your lower body training

Unilateral vs Bilateral Training: Part 1 – Your Comparative Guide

by | May 19, 2023 | Gym and Strength, Hip, Knee, Lower Back, Return to Sport

We often get asked what are the benefits of one form of exercise versus another. Sometimes this is as simple as discussing the difference between cardio and weights. Today’s article focuses on the difference between a two types of gym based loading programs Bilateral vs Unilateral training. In Part 2, we delve more into some of what the evidence says regarding these modalities.

In general, strength training plays a pivotal role in athletic development, enhancing performance, preventing injuries, and promoting overall fitness. This is especially true for the injured population. As such, our Praxis physiotherapists will discuss with you how your rehabilitation plan will incorporate strength training.

When it comes to strength training though, two primary approaches are often employed: unilateral and bilateral training. Unilateral training focuses on exercises that isolate a single limb or side of the body, whereas bilateral training involves movements that engage both limbs simultaneously. This blog aims to contrast the benefits and drawbacks of unilateral and bilateral strength training methods, examining their impact on athletic performance and overall physical development.

Unilateral Strength Training

Unilateral strength training involves exercises that emphasize working one limb or side of the body independently. One of the significant advantages of unilateral training is its ability to identify and correct muscle imbalances. By targeting each limb separately, athletes can pinpoint weaknesses, imbalances, or asymmetries, and address them with specific exercises. Unilateral training also enhances proprioception and balance by requiring greater neuromuscular control. It activates stabilizer muscles and enhances coordination, which can lead to improved athletic performance and injury prevention.

Moreover, unilateral training allows for greater range of motion and flexibility development, as each limb can move freely without the restrictions imposed by bilateral movements. This can be particularly beneficial for athletes who need to improve mobility and functional strength in specific joints or muscle groups. Additionally, unilateral exercises offer sport-specific advantages by simulating movements that athletes encounter during competition, such as single-leg jumps in basketball, change of direction football or one-arm strokes in swimming.

However, unilateral training does have limitations. It generally requires more time and effort to complete a full-body workout due to the need to perform exercises separately for each limb. Additionally, unilateral exercises tend to involve lower weight loads, which may limit their potential for developing maximum strength.

Bilateral Strength Training

Bilateral strength training, on the other hand, focuses on exercises that engage both limbs simultaneously. One of the primary benefits of bilateral training is the ability to lift heavier weights. This can lead to significant gains in maximal strength and power, making it particularly advantageous for athletes involved in sports that require explosive movements, such as weightlifting or sprinting.

Mid Potion Achilles Tendinopathy Location

Bilateral exercises also promote increased overall muscle mass and hypertrophy due to the higher loading potential. By engaging multiple muscle groups simultaneously, bilateral training can provide a time-efficient method for achieving muscle growth and development. Additionally, the bilateral movements help improve intermuscular coordination, allowing athletes to transfer strength gains more effectively across various activities.

However, bilateral training may not address asymmetries or imbalances as effectively as unilateral training. In some cases, stronger limbs may compensate for weaker ones, perpetuating muscle imbalances and potentially increasing the risk of injury. Moreover, bilateral exercises may not fully translate to specific sport-related movements that often require unilateral actions.

In summary, both unilateral and bilateral strength training methods offer unique benefits and drawbacks for athletes. Unilateral training aids in identifying and correcting muscle imbalances, enhancing proprioception, and improving sport-specific movements. It is a valuable tool for injury prevention and rehabilitation. On the other hand, bilateral training allows athletes to lift heavier weights, develop overall muscle mass, and enhance intermuscular coordination. It is particularly effective for activities that demand explosive power. Ultimately, the choice between unilateral and bilateral training should be determined by an athlete’s specific needs, goals, and the demands of their respective sport. Further, an accurate assessment of any asymmetries that may be present helps to decide where to start. A well-rounded strength training program can incorporate elements of both methods to optimize performance and minimise the risk of injuries.

To read more about the specifics of athletic performance, read our Part 2 Blog.

To help with the genesis of a training program or to chat about your training your goals, book in with one of our knowledgeable Praxis physiotherapists. We are here to help!

Until next time,

Praxis What You Preach

Treatment Strategies

Physiotherapy plays a pivotal role in the management of Achilles tendinopathy. Treatment strategies focus on reducing pain, promoting healing, and improving function. These will include calf strengthening exercises, stretching routines and activity modification as frontline options. Moreover, physiotherapists can guide patients in proper footwear selection, gait retraining, and implementing preventive measures to minimize the risk of reinjury.

Rehabilitation and Prevention

Rehabilitation programs are essential for individuals recovering from Achilles tendinopathy. Gradual progression of exercise intensity, functional training, and sport-specific drills enable patients to regain strength, flexibility, and proprioception while minimizing the risk of relapse. Educating patients on proper warm-up and cool-down routines, appropriate footwear selection, and regular monitoring of training loads can significantly contribute to preventing Achilles tendinopathy in the future. One of the common errors patients make is making rehabilitation too easy, or returning to sport too quickly. Again, physiotherapy play a pivotal role in ensuring you undertake a graduated return to loading as the application of mechanical stress to the Achilles tendon promotes tendon healing and remodeling.

Conclusion

Achilles tendinopathy requires a comprehensive approach for effective management. As physiotherapists, our knowledge and expertise are invaluable in helping you overcome this condition and return to their active lifestyles. To discuss your Achilles issues with us to get you back to what you love doing, book online with Praxis today.

Until next time, Praxis What Your Preach.

Team Praxis

Stress Fractures in Young Cricket Fast bowlers: A persistent challenge

Stress Fractures in Young Cricket Fast bowlers: A persistent challenge

by | May 16, 2023 | Lower Back, Return to Sport

Lumbar stress fractures are a common and persistent injury among cricket fast bowlers, particularly adolescents. The repetitive and high-intensity nature of the bowling action places tremendous stress on the lower back, leading to the development of stress fractures in the lumbar vertebrae. With several years of cricket physio experience, I’ll explore the causes, symptoms, treatment, and prevention strategies associated with these usually season ending injuries.

Causes and Symptoms:

The primary cause of lumbar stress fractures in fast bowlers is the high volumes of repeated hyperextension and rotation of the lower back during the bowling action. This repetitive motion places excessive strain on the bony structures of the spine (pars interarticularis), eventually leading to small cracks or fractures. Adolescent fast bowlers are of particular risk as this strut of bone has yet to fully develop (as with most of their surrounding musculature) and thus is more susceptible to overload. Symptoms of lumbar stress fractures may include lower back pain, stiffness, tenderness, and discomfort, particularly during bowling.

Treatment and Rehabilitation:

The management of lumbar stress fractures requires a comprehensive approach. Initially, rest and avoiding activities that exacerbate the pain are essential to allow the bone to heal. A period of complete rest from bowling, coupled with appropriate pain management is usually recommended. A structured rehabilitation program focusing on core stability, flexibility, and strengthening exercises on the lumbar spine, pelvis and lower limbs is crucial for a safe return to bowling. Once a players has reestablished the requisite physical attributes, a graduated bowling plan is established.

Prevention Strategies:

Prevention is key in mitigating the risk of lumbar stress fractures. Fast bowlers should maintain a balanced training regime that includes multi-joint strength training, flexibility exercises, and proper warm-up and cool-down routines. Regular monitoring of workload and ensuring adequate recovery time between bowling spells can also minimize the likelihood of injury. Of particular note, is avoiding back to back days of fast bowling in adolescent cricketers.

In summary, lumbar stress fractures pose a significant challenge to cricket fast bowlers, especially those in their teen years or as they transition to junior cricket to senior cricket. A diagnosis typically requires extensive time away from bowling and requires a targeted rehabilitation plan and a cautious return to the sport. By understanding the causes, recognizing the symptoms, and implementing effective prevention and strengthening strategies, bowlers can continue to bowl fast and trouble the batsmen down the other end!

If you wanting to minimise your risk of a stress fracture, or think you may have one, feel free to consult with one of our expert physiotherapists, well versed in the cricket literature.

Until next time,

Praxis What You Preach

About the author. Stephen is an experience Cricket Physiotherapist having spent 15 years working in elite and semi-elite cricket. He was fortunate enough to have Dr Marc Portus as his mentor early on in his career. Dr Portus is an authority on stress fractures in fast bowlers having completed his PhD in the area and helped shape modern day workload parameters. Stephen’s particular area of interest is in the high performance pathways (U16-U20’s) cricket where stress fractures are often first experienced. To read more about Stephen or book, click here

Understanding Sever’s Disease: A Common Foot Condition in Active Growing Children

Understanding Sever’s Disease: A Common Foot Condition in Active Growing Children

by | May 16, 2023 | Ankle and Foot, Return to Sport, Running Injuries

Sever’s disease, also known as calcaneal apophysitis, is a prevalent foot condition that primarily affects growing children. While not a true “disease,” it is an overuse injury that causes pain and discomfort in the heel.

Sever’s disease occurs when the growth plate in the heel, known as the calcaneal apophysis, becomes inflamed and painful due to repetitive stress and tension. This condition typically affects children between the ages of 8 and 15 who are actively involved in sports or activities that involve running or jumping. During a growth spurt, the heel bone can grow faster than the surrounding tendons and muscles, leading to strain and irritation during loading.

Symptoms and Diagnosis

The primary symptom of Sever’s disease is heel pain, usually felt at the back or bottom of the heel. The pain is typically aggravated during physical activities such as running and jumping and may improve with rest. The pain is often described as aching or throbbing and is usually located at the back of the heel or bottom of the foot. A physical examination by a Praxis Physio, combined with a review of the presenting history and symptoms, is usually sufficient to diagnose the condition. In some cases, an X-ray or MRI may be recommended to rule out other possible causes of heel pain.

Treatment and Management

The treatment for Sever’s disease focuses on relieving pain and reducing inflammation. Initially, the R.I.C.E. (rest, ice, compression, elevation) method is often recommended to manage symptoms. As many parents know, rest is easier said than done so avoiding or modifying activities that aggravate the pain is crucial. Your physio will be able to aid in planning the week’s loading to ensure symptoms are kept at bay. In some cases, heel pads or shoe inserts can provide additional cushioning and support. Exercises that stretch and strengthen the calf muscles and Achilles tendon to improve load tolerance are also provided by your physiotherapist as shown in the video above. Pain relief medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), may be prescribed in severe cases.

Prevention and Prognosis

Preventing Sever’s disease involves maintaining a balance between activity and rest. Encouraging children to warm up properly before physical activities can help reduce the risk. Additionally, the rehabilitation between bouts of physical activity will also allow for the easing of symptoms. The prognosis for Sever’s disease is excellent, with most cases resolving as the growth plate closes. Once the bones and muscles have finished growing, the symptoms typically disappear.

In summary, Sever’s disease is a common condition that affects growing children, primarily those engaged in sports or activities involving repetitive stress on the heel such as running. Recognising the symptoms, seeking early diagnosis, and implementing appropriate treatment and preventive measures are key to managing this temporary condition and ensuring a smooth recovery for children experiencing Sever’s disease. To ensure your child is back playing sports quickly, book in with the friendly and professional physios at Praxis today!

References

James, A. M., Williams, C. M., & Haines, T. P. (2016). Effectiveness of footwear and foot orthoses for calcaneal apophysitis: a 12-month factorial randomised trial. British journal of sports medicine, 50(20), 1268–1275. https://doi.org/10.1136/bjsports-2015-094986

Scharfbillig, R. W., Jones, S., & Scutter, S. D. (2008). Sever’s Disease: What Does the Literature Really Tell Us? Journal of the American Podiatric Medical Association, 98(3), 212–223. doi:10.7547/0980212

Weert, H. C., van Dijk, C. N., & Struijs, P. A. (2016). Treatment of Calcaneal Apophysitis: Wait and See Versus Orthotic Device Versus Physical Therapy: A Pragmatic Therapeutic Randomized Clinical Trial. Journal of pediatric orthopedics, 36(2), 152–157. https://doi.org/10.1097/BPO.0000000000000417

Tibialis Anterior – The missing link to pain free legs and performance?

Tibialis Anterior – The missing link to pain free legs and performance?

by | May 16, 2023 | Ankle and Foot, Return to Sport, Running Injuries

Shin splints? Painful knee with jumping? Recurrent ankle sprains? These are the types of injuries we fix day in and day out at Praxis Physio. There are number of recommended paths for rehabilitation in theses injuries backed by the research and our clinical experience, but has the evidence been missing something? There is some social media traction in the fitness and exercise world recently around tibialis anterior (TA) loading as a ‘cure all’ for every lower limb injury. Being the physio nerds that we are, we looked in to it for you!

The tibialis anterior is located on the front (anterior) portion of the shin (tibia) – hence the name. Its role is to lift the foot (dorsiflex) the ankle as well as provide some stability for the outside of the ankle . This action is key for movements in walking and running especially in negotiating steps and hills as the foot needs to clear a certain height before landing. It is also very important in landing from a height and changing directions rapidly, as it acts as shock absorber for the knee and ankle joints (reference).

Like any muscle or joint in the body, the TA is not without its problems. Physios are regularly confronted with patients who complain of pain and stiffness around the muscles of the shin. Such conditions may include shin splints, compartment syndrome, patellofemoral pain syndrome (aka runner’s knee) and general ankle joint pain and stiffness post ankle sprain.

As mentioned, there has been a lot of discussion lately in the strength and conditioning community about whether training this muscle can prevent or treat musculoskeletal conditions, such as the ones mentioned above. Anecdotally, training of the TA has been described several benefits. Specific athletes have explained that they have seen improvements in vertical jump height, running speed, running stamina and squat depth. From a prevention and treatment point of view, it has been said that training the TA has helped improve symptoms associated with knee pain, ankle pain and shin splints. Also let us not forget, that from an aesthetics point of view, a strong and bulky looking TA does make our legs look more attractive, as bodybuilders would argue.

Unfortunately, the scientific community has not provided strong evidence that training the TA can aid in affecting the above musculoskeletal pathologies, or attain the performance benefits. So what do we know from previous scientific literature? Well, Munoz et al (2015) describes the tibialis anterior as key during an efficient gait cycle as well as being critical for balance control. Furthermore, an increase in strength of the TA helps greatly reduce the risk of falling. Maharaj et al (2019) confirms that during walking and running , TA’s tendinous tissue absorbs energy during contact and controls foot position during swing.

The proposed mechanisms to aid in athletic performance include:

  1. Increased ankle stability: Strong tibialis anterior muscles provide better stability to the ankle joint during jumping movements. This stability allows for improved force transmission from the lower leg to the foot, enabling athletes to generate greater power and maintain proper alignment during takeoff and landing.
  2. Enhanced dorsiflexion range of motion: Adequate dorsiflexion range of motion is essential for optimal jumping performance. Strengthening the tibialis anterior helps to improve flexibility and mobility in the ankle joint, allowing athletes to achieve a greater degree of dorsiflexion during the pre-jump phase. This increased range of motion enables a longer and more powerful push-off, resulting in higher jumps.
  3. Improved jump height and explosive power: The tibialis anterior plays a significant role in generating propulsive force during the takeoff phase of a jump. By strengthening this muscle, athletes can produce a more forceful and efficient push-off, leading to increased jump height and explosive power. The ability to generate greater force through dorsiflexion contributes to a more powerful and effective jump.
  4. Injury prevention: Weak tibialis anterior muscles can contribute to imbalances in the lower leg, potentially leading to various conditions such as shin splints or ankle sprains. Strengthening this muscle group helps to maintain proper muscle balance around the ankle joint, reducing the risk of injuries that could hinder jumping performance.

So if we are to believe TA holds the key to athletic performance and injury mitigation, how do we unlock it?

To strengthen the tibialis anterior, physiotherapists often prescribe specific exercises that target this muscle, such as toe raises, resisted dorsiflexion exercises, or using resistance bands to provide resistance during dorsiflexion movements. These exercises should be performed in a controlled manner and progressively increased in intensity to promote muscle strength and endurance. Below you see variations on how you can load the TA and progress and regress it respectively. Remember that we need to treat the TA like any other muscle we are wanting to train – progressively overloading it!

As Physiotherapists, we greatly value and adhere to evidence-based practice, however one could argue that this particular muscle has not received the scientific study treatment it rightly deserves. So if you are having some lower leg issues, or haven’t quite got that bounce you are wanting, come and chat to one of our friendly and knowledgeable staff. We can do a full assessment and put the spring back in your step!

Until next time, Praxis what you preach!

Prevent. Prepare. Perform

References:

Maharaj JN, Cresswell AG, Lichtwark GA. Tibialis anterior tendinous tissue plays a key role in energy absorption during human walking. J Exp Biol. 2019 Jun 4;222(Pt 11):jeb191247. doi: 10.1242/jeb.191247. PMID: 31064856.

Ruiz Muñoz, M., González-Sánchez, M. & Cuesta-Vargas, A.I. Tibialis anterior analysis from functional and architectural perspective during isometric foot dorsiflexion: a cross-sectional study of repeated measures. J Foot Ankle Res 8, 74 (2015). https://doi.org/10.1186/s13047-015-0132-3