Ep 195: Building a career in high-performance sports medicine, with Dr Enda King

[00:00:05] Insights, the podcast that aims to help you translate quality research to quality practice.

[00:00:12] I'm Clara Dern, the editor-in-chief of the Journal of Orthopenic and Sports Physical Therapy.

[00:00:17] It's great to have you listening today.

[00:00:22] Ever wondered what a day in the life of a busy sports medicine clinic and research unit looks

[00:00:26] like?

[00:00:27] My guest today has spent a few years honing his craft in some of the leading sports

[00:00:32] medicine and sports by mechanics clinics in the world.

[00:00:35] He joins me to share how he approaches working in successful sports medicine and performance

[00:00:39] teams.

[00:00:41] Dr Enda King combines his roles as a sports physiotherapist, strengthening conditioning

[00:00:45] coach, researcher and educator through his work with individual athletes and elite teams

[00:00:50] across the spectrum of sports and disciplines.

[00:00:54] Currently he's the head of elite performance and development at the Asper tyre sports

[00:00:58] and hospital indoor harcatar, and travelling to work with athletes and professional clubs around

[00:01:03] the world.

[00:01:05] Dr Enda King, welcome to JOSPT Insights.

[00:01:08] Clara, thank you very much for the invitation, we'd be delighted to be involved.

[00:01:11] It's a pleasure to have you on the podcast today, Enda.

[00:01:14] You are really well known for your work in ACL rehabilitation and in hip and groin pain as

[00:01:19] a practitioner and as a researcher.

[00:01:21] Your approach to rehabilitation draws on your understanding of biomechanics so let's tease

[00:01:26] that out a little bit if we can.

[00:01:28] Let's say a female rugby sevens play a steps into the clinic and she describes to you

[00:01:33] longstanding hip pain it's been getting worse over the last six months especially.

[00:01:38] And now it's at a point where she's having to modify her running load in training, especially

[00:01:43] any direction change type activities.

[00:01:46] Where do you start in a scenario like that?

[00:01:49] The initial goal is to have clarity on where the pain is coming from and why she's

[00:01:53] and to split those things quite the cut and the same to two.

[00:01:57] Obviously there's multiple sources of symptoms in and around let's say it was anterior hip pain as

[00:02:02] an example but the danger is obviously there's a lot of false positives in terms of

[00:02:05] your view scan 50 players you'll find for T.A. Labraltareus for example so I think number one

[00:02:11] is getting a definitive idea on where her pain is coming from that'll be a future your clinic

[00:02:16] of tests, it may be true radiology or not, maybe diagnostic, flash therapeutic injection to

[00:02:21] inform or not whether it's a hip related pain. So that's number one. The second part then is

[00:02:26] irrespective of then, your look at this side is this for rehab or is it for something else?

[00:02:30] Okay so we go with the rehab side of things but even if it is the hip joint is the source of pain

[00:02:36] it may be a functional or bi-mechanical overload that's happened for whatever reason that may be

[00:02:42] and with some appropriate deloding and rehabilitation even in the presence of a laboral tear or whatever

[00:02:48] may go on to live happily ever after and have no issues. In terms of the rehabilitation side of

[00:02:53] things you can start at either end, you can start at the end stage activity so she's saying

[00:02:58] the change direction is our let's say is our most provoking activity or you can start more locally

[00:03:04] in your assessment of workout and what I mean by that is that when you're looking at change

[00:03:08] direction there will be certain patterns that influence hip loading. So far example is plenty of

[00:03:17] hated in your hip or externally your tears that will preferentially know the head neck junction

[00:03:21] and in the presence of a calm lesion that may leave you with less room for error that the

[00:03:25] neutral if you're in a more anti-utely tilted position it influences the range of motion before

[00:03:30] you start to dynamically impinge. So you can look at those big ticket items and say right the

[00:03:35] strategies here right versus left or one actually compared to another where that hip joint will

[00:03:40] be preferentially noted. The second part then is why is she doing that? Okay how much of that

[00:03:46] strategy is because of motor control definite at the hip those of us that have a hip history

[00:03:51] of hip issues or hip surgery we would generally have inhibition of the deep muscles around the hip

[00:03:56] anteriorly in your soul is laterally glooming posterior to deep rotators that a bit like the

[00:04:02] rotator comfort the shoulder the ability for the large superficial muscles that do what they need to

[00:04:06] do is underpin by the motor control of those small muscles. So assessing that small muscle control

[00:04:12] assessing the larger strength around the glute max the obitress the doctors the quadriceps the

[00:04:18] hamstrings and then looking at power output and reactive strength maybe through your jumps or

[00:04:23] your drop jumps you start to build a picture that okay her change direction strategy is this

[00:04:28] we can see certain things in terms of trunk rotation for rotation tilt that lever more susceptible

[00:04:33] on that side but why is she doing that? Will we conceive from our assessment or posterior hip

[00:04:39] deficits or laddering hip as deficits or reactive strength is down and it's always very difficult

[00:04:44] to say well is that there because she saw her from a rehab point of view our job as the restore function

[00:04:49] so I in many ways I don't really care what was there before and what after because I have no idea

[00:04:54] in reality what I do know is if you retain that pattern there is a good chance she continued to

[00:05:00] dynamically impinge the hip joint and that's where you would see often and actually like that might

[00:05:04] the scan of a neighborhood tear go for hip surgery per se but a persistent symptoms after

[00:05:10] is not that the joint pain wasn't coming from the joint or that the surgery wasn't indicated

[00:05:14] but I haven't gone back and addressed the reasons why either from the term of the small

[00:05:18] muscle control or the larger compound movements that was repetitively irritating that hip joint so

[00:05:24] I think your first thing is where is the pain coming from and once you decide that if it's a stress

[00:05:30] to the neck of femur that's very different than if it's an illio so or so overload so your

[00:05:35] thing is is it for rehab only or is it for rehab on something else and then if it's the rehab component

[00:05:41] what are the drivers about why she's presenting with those symptoms almost independent of where

[00:05:46] that pain is coming from. That's brilliant and I love the way you've laid out your clinical reasoning

[00:05:51] process and in in big picture of course every individual athlete is going to have nuances and

[00:05:55] different things that you pick up as you alluded to. This idea of having the framework of how

[00:06:00] you're applying the biomechanics and thinking through what's that influencing which bit do I

[00:06:05] care about which bit do I not is going to help guide the decisions that you make? So you're doing

[00:06:11] a lot of this in your day-to-day work as the head of elite performance and development at Aspartar

[00:06:17] and that's our hospital in Doha in Ketar for people who are listening who are maybe unfamiliar

[00:06:23] with Aspartar. Pain is a picture what it's what's it like when you walk in on your first day or when

[00:06:28] you're walking into work every day? Aspartar sits on the larger aspires own campus which

[00:06:33] it's an incredibly impressive place to be perfectly honest with you and you see the Aspartar

[00:06:37] facility beside Khalifa Stadium beside the aspires own and the Fouple Performance Center

[00:06:42] and the torture that sort of campus itself is you're a little less struck different the first

[00:06:47] day you walk in if you have an ear here before. Aspartar itself when you walk in the front door I

[00:06:52] think it's very busy both in terms of the most disciplinary team whether that's our sports medicine

[00:06:57] colleagues or the pitty colleagues radiology and then you come to the rehab department and

[00:07:03] to give you an example in any given week we would have 200 Asian reconstructions that were

[00:07:08] actively rehabilitating and that's just the knee group side of things so it's a very very

[00:07:12] very busy department and we've just very fortunate on a loving new refurbishment of our high

[00:07:17] performance gym and so what you see there is a facility both in terms of the by-mic

[00:07:22] slab that we have but also the rehabilitation facility both indoor and outdoor that

[00:07:29] every facet of what you should need should be able to be invited for the athletes and that's not

[00:07:33] that you need all of that to rehab every at least but picking with the athletic population

[00:07:38] specifically the ability to take them from the bed into the gym onto the track and onto the field

[00:07:45] and and dress and progress through that you need to have the facilities and also you know

[00:07:50] the staff are fantastic expertise to tap into that so I think you see a busy department there's

[00:07:56] over 70 staff in the rehabilitation department alone there's over 40 nationalities in Aspirata

[00:08:01] so you know culturally very diverse very very enjoyable and what we've been pleased to work

[00:08:07] how do you approach your role as a leader in that head of elite performance and development at Aspirata

[00:08:13] what does a typical day for you specifically look like indoor and and how do you collaborate across

[00:08:18] all of those different services you alluded to a couple of them there how does that work

[00:08:22] support or might be a better word than then leader our mission is support and support every

[00:08:27] at least return to performance or to achieve their best ability not even return to performance

[00:08:30] and our vision is to be a set global center and sports medicine and I think part of that is just

[00:08:36] keeping that from the center because everyone busy big case load 70 in just in the rehab department

[00:08:41] and so really our day to day work is as a group how do we do things how do we do hamstring how

[00:08:49] do we do growing how do we do whatever it's because when you have 60 or 70 clinicians and you

[00:08:54] have one hamstring injury in front of you how do you ensure that 80% of what we do is the same stuff

[00:08:59] okay we will also the 20% that's the evolution of our thought processes,

[00:09:02] clinical expertise people at different experience are research evolving what we're doing

[00:09:06] but do we have a process that we all do to continuity care

[00:09:11] but that we can reflect back on to say right that worked well but next year

[00:09:14] here's what the evolution of our practice needs to be so that's number one and then number

[00:09:18] two obviously is the development of education pathways and training pathways for the new

[00:09:25] equipment that we have for the biomechanics lab for the various rehabilitation intervention that

[00:09:31] there's that continuity of care across the board of what we're doing and obviously part of my goal

[00:09:36] is to attract the best talents of the world to comment and contribute to that clinically

[00:09:40] and also to attract the best international athletes and to provide them with a care that

[00:09:44] like one of our big things is that your biggest advertising should be your athletes the walk away

[00:09:49] it's the personal referrals regardless of what business you're in is the best indication of

[00:09:54] the quality of care that you're doing so my role kind of spreads across that it's a little

[00:09:59] little bit of delivery it's a lot of learning off my colleagues and then trying to put all

[00:10:03] what we have together into a defined pathway and saying right this is what we're doing now

[00:10:07] that should evolve year on year and much of what we're doing we've a I've thought you

[00:10:12] also conference at the end of the year in November part of that is to is to force us

[00:10:17] to to share what we do and to to put that in a structured fashion both in our practical workshops

[00:10:22] and education or conference part of it is to ask good research questions at the time that conference

[00:10:27] comes around again we've new information to bring it and part of us to bring the best in the

[00:10:30] world of doha and learn off them and share ideas and see where the room for collaboration forward

[00:10:35] it's really as it was trying to keep the mission in vision front and center for everyone

[00:10:40] which is very difficult when you're busy fashion commitments family commitments everything else

[00:10:44] and to make sure that at the end of the year we are a bit further on bit further evolved

[00:10:49] than we are at the beginning of the year. Now you talked about consistency in high value care

[00:10:56] and the education component to that as Petra has had a long history of disseminating

[00:11:01] any information you mentioned the conference if one went back through the high impact

[00:11:07] sports meds and papers over the last say decade at least I reckon in the top 10 there's

[00:11:13] quite a few that are coming from Aspeta whether it's on the rehabilitation side on the injury

[00:11:16] prevention side so it's a credit to the research and the performance and medical and

[00:11:22] rehabilitation teams there how do you find the time how do those team meetings look when you're

[00:11:28] to control these people to get everyone on board to work towards those you know whether it's

[00:11:33] delivering high value care whether it's figuring out which research projects and how to fit

[00:11:37] that all in what does that look like? I don't have the right answer I have what we're currently

[00:11:42] doing and how that evolves over time it's it's in just new look at any of the papers about learning

[00:11:48] and retention the best way to do is to teach and so writing research papers makes you

[00:11:55] focus it makes you narrow down what you want to do it makes you ask the question and evolve it

[00:12:00] delivering workshops or delivering comments or even teaching among ourselves makes us to say

[00:12:05] what do we really think here and where is the disagreement between us and disagreement is good but

[00:12:10] what you're looking for is variety you're not looking for inconsistency and there's a very,

[00:12:14] very subtle difference between the two is that we should be consistently addressing all the factors

[00:12:19] that say for a growing or a hamstring but there's a variety of ways of doing that and so by making

[00:12:26] ourselves publish our protocols by making ourselves publish the paper by making ourselves host these

[00:12:33] workshops and conferences etc it makes us as a group come together because we're all busy everyone's

[00:12:38] practicing it's very easy, easy for one month to roll into one month to roll into one month

[00:12:43] but actually having these defined outcomes whereby we can't put this into public on to everyone

[00:12:48] had their feedback and input and we condense it has the defined outcome that you're looking for

[00:12:54] and it should look different in two years time because we should have research further which

[00:12:59] would have evolved technology is all with evolving in terms of what we're able to do that is

[00:13:03] the driver of our process is that through making ourselves formalize these landmarks of which are

[00:13:11] research papers education workshops conferences there's an end point it all has to come together

[00:13:16] and therefore the learning is really in the process rather than the outcome.

[00:13:20] I think there's something to be said for committing to publicly putting on paper or presenting

[00:13:25] what it is that you're doing in practice and it takes courage to do that it's also as you say

[00:13:30] very much part of giving back to the community and helping us all do better together as

[00:13:34] a sports medicine and performance community which bits of your training in sports medicine,

[00:13:40] sports physiotherapy and performance do you feel have best prepared you for your current role

[00:13:45] and of course you've worked in other eye performance settings. I'm thinking particularly

[00:13:49] in your previous role in Dublin at S.S.A.C. Century however you approached developing and building

[00:13:56] your career in sports medicine. I thought a bit this a lot and I think about it regularly

[00:14:01] it ends up being a lot of luck because so much of your development is the people that you

[00:14:06] rub up against a new comma cross along the way that's partly professionals and partly the

[00:14:12] injuries that you come across that were a little bit different that forced you to evolve

[00:14:16] your tar process along the way. If we look at my growing background I played a lot of

[00:14:20] geolic forp on an as younger, I had lots of growing issues and interest and a bias that was

[00:14:26] developed through that process. I was very fortunate where I worked in the sports surgery clinic

[00:14:31] there was Dr. Raina Falve, Dr. Andy Frank-Temellar and you had a couple of people who are very

[00:14:35] committed and energetic and focused on growing the time and pulling at each other's bias

[00:14:40] along with other colleagues that were there at the same time, Sam Bader as well. I did my

[00:14:45] masters in Kirkman University in Pertin Australia and fantastic time, fantastic program,

[00:14:52] one of the next we had with Peter O'Sullivan talking about non-specific low back pain and

[00:14:57] if you take those principles and apply them in a growing setting it's all the same stuff

[00:15:01] and there's a naturally a more chronic pain and psychosocial element perhaps sometimes to

[00:15:07] low back but the principle of there's pain there but it's non-specific and can we really

[00:15:12] sure we're coming from like that's it. That was hugely farmed so you end up evolving along

[00:15:17] this process and then being lucky enough to work in the sports surgery clinic where there

[00:15:21] was a support structure for research okay and we don't have to work however, but the biomechanics

[00:15:26] lab was built the opportunities were presented and you work in a country where there's

[00:15:31] huge number of change directions for sports, very high training loads, very good for business

[00:15:34] so you end up with lots of up to work on and similarly when you come to the to the biomechanics

[00:15:40] side of things, fortunately clinic used to do I think it was 1,500 or almost 2018 as per year

[00:15:47] so you don't have to go look at for subjects for a PhD and biomechanics in the NCN reconstruction

[00:15:52] I had loads of fantastic colleagues like Chris Richter, Shavon Strike, Catania's where

[00:15:59] your clinician looking into a biomechanics world you've a biomechanist looking into

[00:16:03] clinicians world and the friction is beautiful because you just keep calling out each other's

[00:16:07] nonsense and I mean that in the most affectionate way possible and to I mean with one of

[00:16:13] the main reasons I came to ask but I was because Rod Vike was here, really cut the fact he was here

[00:16:17] the lab was here and so when the majority of your case told us going through a biomechanics lab

[00:16:22] it's very humbling because your work is constantly underscruiting and so your biases get exposed

[00:16:28] and an ongoing basis you know I did x, y and z but then if it hasn't changed the lab well

[00:16:33] can play in the testing or in reality my program didn't do what I said how to do and that's

[00:16:37] probably where the SNC kind of side of things comes in that okay my masters and part was minutes

[00:16:42] but the reality is we're developing strength we're developing coordination we're looking

[00:16:46] around in conditioning and we're not doing the sports specific right?

[00:16:50] I personally am not doing the sports of conditioning but I need to be able to bleed into

[00:16:53] my colleagues working understand what they're doing and how that yearning angst closely together

[00:16:58] I would say the one thing that was consistent I just always wanted to be good at my job

[00:17:02] we hear a lot about the interdisciplinary team or the sports medicine team it sounds like you've

[00:17:07] worked in some and continue to work in some incredibly well functioning well put together

[00:17:13] teams what's the key to that success in your eyes? It's like a good marriage it's constant work

[00:17:19] and it's constant communication I think it's a case of no one where my roles and responsibilities

[00:17:24] begin where they end acknowledging where that is in other people and making sure I'm doing my

[00:17:31] component correct and regardless of what team you're in for the most part everyone wants to do the best

[00:17:37] and so the best environments I worked in or and I'm working in is where we're constantly

[00:17:43] discussing around individual cases because we can talk about this research paper said this

[00:17:49] and this research about and I believe this and I believe that but when you've any equals one in front

[00:17:52] of you it shappens the focus of the discussion very very very very very quickly it's all well and good

[00:17:58] that's not what we have in front of us in this given point time or we don't next

[00:18:02] why in Z and that has and worked therefore this is where we need to go so I think regular communication

[00:18:10] the best team they ever worked in either from a sporting point of view or from a clinical

[00:18:13] point of view where it's where you were the one that didn't want to let the team down so your focus

[00:18:17] was far more on how can I make sure I'm doing my bit well versus what you're looking at someone

[00:18:21] else's work and I think when you're in an environment like that it encourages other people to do that

[00:18:27] that's when everyone opens up and their learnings and the respect goes to it to another level

[00:18:33] and you get the best outcomes for all and I think the temptation there is to say that's where

[00:18:37] the magic happens and that's really to diminish the work and what people are bringing to that table

[00:18:43] there's no magic there this is really serious highly qualified very serious people bringing

[00:18:47] their best game it's like the sporting team analogy is a great analogy there everyone's coming

[00:18:52] to that team trying to give their best to that team and as you say not wanting to let the

[00:18:57] team down I love that framing around what's the key there. I want to come back to this idea of

[00:19:02] blending the research and the clinical worlds lots of people I think see research

[00:19:08] and clinical practice as either or careers you can't have both you've successfully combined both

[00:19:14] how do you make that work end up? Thank you for the compliment on the successful combination

[00:19:19] I'm not so sure but that cared to be honest but how I felt into research I have no idea

[00:19:23] I was not a fan of the research modules it didn't interest me per se and yes here you are

[00:19:30] those two sides of it people do research for different reasons people go down a research career

[00:19:35] pathway or people go down a clinical pathway and that's not the right around okay my research

[00:19:42] was I know interest necessarily informally working in the university environment

[00:19:46] that doesn't mean I won't change my mind but that was not the motivation to do

[00:19:49] I felt that doing research would make me better because it would make me ask the question

[00:19:55] it would make me formalize my process it would make me do the letter of view to fully understand

[00:20:00] what was there and apply that accordingly and so that was why I did it and it was why I

[00:20:06] did research across multiple areas so that I didn't in my own clinical practice or my own mind

[00:20:11] get you wrong because you apply principles to a hamstring and then you change it for a calf or

[00:20:15] you apply them for a show you it's all the same stuff so being being varied with it would increase

[00:20:20] your learning and the second thing then was that I know lots of really good researchers

[00:20:25] who are immaculate what they do but no necessarily have the rehabs because if they were had to

[00:20:30] apply that to someone the end up the skill said that's fine and conversely someone that is in a

[00:20:36] sport environment working very well but wouldn't necessarily know fundamental research

[00:20:40] and so I felt having a foot in each would make me stay a current would make me change my biases

[00:20:48] but also it's all well and good being published if you can't apply it or if your research is not

[00:20:55] applicable to any quotes one then is it really truly useful information? I'm doing research

[00:21:01] more to be a better clinician as opposed to being a better researcher because you're a clinician

[00:21:06] and you can ask better questions could the public seem front to you doing research either

[00:21:10] reinforces your bias and proves what you thought or especially with biomechanics it's

[00:21:15] or I never thought of that and as you say again comes back to this collaborating across the

[00:21:21] team because no one's expecting you to be the world leader in clinical practice and the world

[00:21:26] leader in research and the world leader in leadership and all of the facets of your job because

[00:21:30] that's simply impossible for all of us to do. What would you advise people who are listening today

[00:21:36] who might be thinking about contributing to research whether that's as a formal

[00:21:40] research degree like a PhD or perhaps getting involved in research in other ways?

[00:21:46] Right, right so everyone entering into research is do it in an area that you have an interest

[00:21:51] and then an area that you have access so I think if you see a lot of Achilles or you see a lot

[00:21:58] hamstring or you see a lot of whatever or you have an interest in that area that's a good area

[00:22:02] to focus but it's also good area to focus because if you're going to do something observational

[00:22:06] or interventional or whatever else you need to have enough subjects to answer or participants

[00:22:11] to answer the question properly. So there's a lot of beautiful methods that are completely underpowered

[00:22:17] and are questions that are not realistic to be in reproductions and globally one and you can

[00:22:22] play that to almost anything is that I mean in reproduction for ACL will always be impossible

[00:22:27] because the lepremium of ruptures or re-ruptures with full data collection to be able to

[00:22:32] prospectively think and that's fine that that's just an acknowledgement of what that problem is.

[00:22:38] So I think it should be an area you're interested it should be an area you have access to

[00:22:43] and then ask a question that you can answer properly or get support in identifying one

[00:22:49] at a question that you have to properly. And I think that's the perfect place to end our chat for today.

[00:22:55] Thank you so much for sharing your expertise, a bit of career planning advice it's always

[00:23:01] helpful for the listeners and for sharing and reassuring us that we can effectively blend

[00:23:07] the clinic and the research environment so thanks so much for joining me on Joe's PT Insights.

[00:23:12] My pleasure thanks for joining. Thanks for listening to this episode of Joe's PT Insights.

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