Plantar Fasciitis is one of the more common ailments we see in clinic and Susie Burness is here to outline some of the reasons for it followed by best treatment plans.  

What is Plantar Fasciitis?

Plantar fasciiopathy, as it is technically known, is characterised by pain focused under the heel, classically at the inner part, or as it is anatomically known the medial tubercle of the calcaneus. This is the insertion or attachment point of the plantar fascia. The Plantar fascia ligament is a fibrous tissue along the bottom foot that connects your calcaneus (heel bone) to your metatarsals (toes).

It is responsible for supporting our arch and helps to propel us in walking.

Classic symptoms include:

• Start up pain – pain on starting to walk following prolonged periods immobility (i.e. sitting)
• Morning pain – worst pain experienced first thing in the morning when taking first few steps.

It can occur both in the sedentary person and the athlete and is generally thought to be caused by ‘overload’. Overload to the plantar fascia can occur due to a sudden increase in frequency, intensity or time of training per week, or a change in terrain.

The prevalence in the general population is estimated between 3.6-7%. It is most common between the ages of 40-60.

What risk factors are there?

• reduced medial arches or flat feet
• increased BMI – if you are carrying more weight than is optimal for your frame.
• reduced control around the hip and core, which can lead to increased loading at the foot
• increased pronation (rolling in with your foot when walking)
• poor footwear
• A spike in loading through the foot i.e. suddenly doing a lot more than normal for you

 

How do we best treat it?

 It is a notoriously difficult thing to treat and there has been a significant lack of research over the last few years. Developments more recently mean that we are progressively treating it with loading based exercises as we would treat an overuse tendon problem such as with an achilles tendinopathy. Flexibility and load modification are also key components to the management.

Physiotherapists would also look to insure we treat any biomechanical factors that maybe contributing from the knee, hip or lower back.  These may include reduced gluteal and calf strength and reduced control of muscles such as the tibialis posterior that controls the arch of the foot.

Gel heel inserts or medial arch supports can also be a helpful tool to help offload and support the foot to help things settle.  Our biomechanist, Michael Thompson, would assess walking and running styles to see if there would be suitable orthotic adjuncts that may help the foot as well.

Rehabilitation

Strengthening your calf which is made up your gastrocnemius and soleus, is key to the treatment of plantar fasciiopathy whilst ensuring you regularly update your trainers and keep on top of stretching and foam rolling your calf muscles. If doing large amounts of walking or running you also need to ensure you keep up strength and conditioning work to maintain strong core, gluts and lower leg muscles.

Click here for a link to our YouTube Channel for form rolling ideas.

 

If you feel as though you are being affected by plantar fasciiopathy, it is important to get a correct diagnosis and then treatment plan.  Please contact Bristol Physio to get an appointment with one of our expert physiotherapists or Michael Thompson.

 

 

 

 

 

Spring Marathon Training – Tips for Training and Injury Prevention

By Susie Burness

 

It’s the New Year when many often increase their training on a drive to kick start their fitness, and may have signed up to an event to help with the process. Both London and Brighton Marathon are looming closer with Brighton 7 weeks away and London 9 weeks away.

 

“How do we do train for these, reaping the maximal benefits whilst minimising the risk of injury?”

The following article seeks to look at a few top tips to train well.

 

Training Error

Training error accounts for 60-70% of running injuries (with some articles reporting a figure of up to 80%).

Our musculoskeletal system made up of muscles, bones and tendons can tolerate a certain amount of load without any issue. However, when we suddenly demand more of it than it is ready for, that’s when pain or injury can occur.

 

Training Load is made up of the volume (amount), frequency and intensity of our training.

I have often seen people in Clinic who, on having signed up for running events have jumped from one run once every few weeks to 3-5 runs a week. Even though those runs themselves individually may not be perceived as difficult or challenging, the overall load on the body has significantly increased.

Gradual increase is important whilst allowing the body time to adapt to the new demands we are placing on it and therefore minimising the risk of injury.

 

Training error can commonly include things like:

 

• A rapid increase in mileage or overall volume (the amount of training you do per week)

 

• Not enough rest time

 

• Bunching of training (i.e. all sessions completed over the weekend due to a busy working week)

 

• An inappropriate mix of high versus low intensity sessions (too much high intensity).

High intensity sessions would include things like sprint sessions or intervals.

 

• A big change in the terrain or gradient that you normally train on

 

 

A few things may be useful to keep in mind as you increase your training heading towards your goal.

• 10% rule

Only increase your mileage by 10% each time (particularly when thinking about your ‘long’ run)

• Step up, step back

On increasing the mileage of your runs, keep at this distance for several weeks before increasing it again

• 80:20 ratio of low vs high intensity

Low intensity, steadier state work should make up the bigger proportion of your running training versus sprint or interval based work for pace.

• One goal each run

Try not to focus on too many things at once, i.e. don’t run long runs too quickly

• Plan training to allow rest after longer or harder sessions

I.e. plan your rest day after your speed session

Gradually increase the number of runs per week, allowing your body time to acclimatise.

Take into account other exercise you may also be doing in the week, your body will need to recover from this too. Plan your training and plan your rest days.

 

How else can we decrease risk of injury?

Maintenance

Many of the below may be things we reach for or think about once we already have a problem. However, as the saying goes, “prevention is better than cure.” Fitting several short foam rolling sessions in a week or periodically treating yourself to a sports massage will improve your performance as well as avoiding the niggles that build up.

Foam rolling

Foam rolling is a great tool to aid recovery. A low cost roller is simple and effective and can be used to release muscle groups all over the body.

More information on this can be found in the foam rolling article on the Bristol Physio Blog. Videos of rolling methods for different muscle groups are also available on our YouTube page.

Sports massage

Though foam rolling is a good tool, sometimes we require the expertise of a Sports Masseuse. They can affectively assess and treat more specifically tight muscles groups in a way that we can’t with a foam roller.

My colleague and Sport Masseuse Anna recently published an article that can be found on the Bristol Physio Blog.

Strength & Conditioning

Running places a lot of load on your body. To put this into some perspective statistically, a 80kg runner who averages 500 foot contacts per mile will tolerate 100,000 kg of load per mile. (This takes into account the effect of ground reaction force) That’s a lot of load!

Therefore, being strong and having good muscular endurance is important. Especially if we’re asking our legs to tolerate the demands of 3-5 hours of running during a marathon.

Good gluteal, core and lower limb strength can contribute to improved biomechanics and load tolerance when running.

Strong core and gluteal muscles help to stabilise your pelvis and minimise valgus forces at the knee (when your knee drops in), which is a common contributor to ITB syndrome and patellofemoral pain.

The calf complex (made up of your gastrocnemius and soleus) plays an important part in both propulsion and shock absorption. A strong calf can both improve your speed and minimise the forces translated up your leg.

Mo Farah can squat 1.5 times his body weight. He uses regular strength and conditioning sessions to not only minimise the risk of injury, but to improve his running performance.

Incorporating some simple exercises like squats and lunges can be excellent for maintaining this.

A good pair of trainers

Running shoes are designed to last for a certain mileage and how long they last will depend on your weekly running volume. Digging that pair from the depths of the cupboard that have been around since the early 2000’s may not be ideal for pounding the streets multiple times a week in the run up to a marathon.

The general rule is to find a pair of trainers that you feel comfortable in though some people may benefit from more support in their trainers than others.

The best way to find a shoe that works for you is to go to a running shop where they can assess this.

Our friends at Moti can advise you on what kind of shoe would work for you. They do running assessments in house and have a great range of running trainers to suit all needs.

 

I hope this gives you some useful tips for marathon season. However, if you’re having pain or discomfort that isn’t settling despite adhering to the above, we’d advise you pop in to see one of our Physio’ s for an expert assessment. Happy running.

 

 

Sports Massage for the Active Person

Our resident Sports Massage Therapist, Anna Wright, answers your questions and more!

 

Why do we require massage and what benefits will you get from a Sports Massage?

Professional athletes have regular sports massage as they strive to improve their performance. This is for a number of reasons:

• To reduce risk of injury by breaking down adhesions
• To maintain flexibility
• To flush out waste products of heavy exercise
• To decrease localised swelling if an injury has occurred

Massage will help in reducing scar tissue and speed up recovery time.
The physical & brutal collisions in sport mean injuries are inevitable. If we think specifically about rugby; all the tackling, rucking and scrumming, hitting the ground and smashing into one another lead players to become injured. Injury can also happen in other activities that involve running and jumping and lifting and carrying, and overuse injuries are all common in all physical activities.

Muscular and soft tissue injuries are most common.

When an injury occurs, players want to regain their strength and flexibility as soon as possible.

The repairing of damaged muscle tissue results in scarring. Scar tissue is fibrous and bulky tissue, which is so tough that it can be as hard as bone. If this area around the injured site continues has reduced flexibility it may affect the player’s function as that area will demonstrate limited range. The muscles and tissues will not be able to glide next to each other as smoothly as they should, as the scar tissue will cause them to fuse together.

What does this mean for our active person?

The result of scarring may mean a loss of Power, Strength, Flexibility and a risk of further injury in the same area.

Without treatment, the tissue in the injured site may never be as strong. Untreated scar tissue can be a common cause of re-injury, often weeks after it is thought that total recovery was achieved.

Deep tissue massage techniques will break down these tough fibrous tissues, and if achieved in a timely manner after the injury, it can stop these cells binding and causing adhesions. Certain techniques are used to break down fibrous tissue into smaller particles and remove the unwanted waste products through the lymphatic system. This system is a vital mechanism of clearing the body of toxins and waste products.

Can massage increase general circulation?

Massage helps pump blood and lymph around the body. If the fluid is pumped in an upward direction towards the heart, the force of this movement creates a suction space behind it that is immediately filled with fresh oxygenated, nutrient rich blood. This oxygenated blood is full of the ingredients that we need for growth and recovery.

Massage can reduce delayed onset muscle soreness (DOMS) and prevent injury.

After a tough match or training session when the muscles have been worked hard, a pain message is sent to your brain telling you that your muscles are sore and painful. This is due to the byproduct heavy exercise called lactic acid. Massage soon after exercising can help to remove this acid and other waste products.

A massage therapist can help to identify where more attention is needed in an individual’s training program.

Massage therapists are trained to recognise tightness in certain muscles, therefore advise can be given on stretching those areas. They can also identify micro-trauma from over-training (training above the bodies capacity to cope with load) and in this case, recovery strategies can be discussed. Overall these skills will help to avoid future injuries.

Often when we are experiencing pain due to ‘tight muscles’ it is due to weakness and over working of those muscles. Function will be affected in a bid to avoid further pain but this may result in further injury to another part of the body. Massage will help stimulate muscles and then exercises can be given to build strength where needed to allow the body to work better as one unit.

Massage can instantly make someone feel relaxed and improve sleep.

The feeling of relaxation reduces stress and anxiety. By releasing tension in the soft tissues then balance can be reinstated to the body, this can improve many conditions such as high blood pressure, migraines, stress, and anxiety, and it can also improve sleep. More sleep means better recovery as when we sleep growth hormones are released allowing the body to fix itself.

 

Should you feel any of the advice above will be relevant to you, please contact Bristol Physio and we will arrange an appointment with Anna so you can help your overall recovery.

School sport update from September to December 2016

Bristol Physio is extremely proud to be associated with a number of local schools where we’re managing their sports injuries at the weekend, primarily on the rugby field. This requires all our staff to be trained in Sports Trauma Management as well as their other physiotherapy qualifications. Our role involves the treatment of minor niggles, strains and sprains using physiotherapy techniques and to provide medical support for more serious injuries.

All our staff are fully trained on concussion management. In under 19s, concussion management is very precise and is taken very seriously. At Bristol Physio we have designed our own Concussion Protocol based on the latest findings from the Sports Concussion Consensus (2012) and the RFU Guidelines. This is the most up-to-date researched based findings on how to deal with concussion in sport and is the basis that all governing bodies around the world are using for their concussion management. Should you wish to see a copy of this protocol please email andy@bristolphysio.com.

We are pleased to announce that all our schools have achieved great results this term.

Bristol Grammar School.

The 1^st XV Rugby Team managed a great season this year with significant wins over many local rivals. The highlight of the season probably remains their tour of New Zealand in the summer, however extremely close results against Colston’s and Clifton College should highlight the improvement in their performance this term. They unfortunately lost to Blundell’s in the Natwest Trophy having beaten Sherbourne in the previous rounds.

Queen Elizabeth’s Hospital

For the first season ever, Bristol Physio were helping QEH teams at Failand. The rugby was hotly contested and whilst the 1^st XV may have had a developing side, there were some great results throughout the school.   The U15s were flying the flag for the school with impressive over KES Bath and Beechen Cliff School.

Prior Park College

In the second season at Prior, we were very impressed with an emerging 1^st XV that clearly had made great strides forward. The team consists of a number of Lower 6^th players, who showed great potential coming into the 7s series; wins over Kings College, Taunton and Kings School Bruton were some of the highlights of the term.

Looking forward, all three schools will now enter into the 7’s season. All age groups will be participating in tournaments throughout the South West culminating with the Rosslyn Park 7s at the end of March.

Bristol Physio will continue to provide our services throughout next term to all hockey, football, netball and rugby teams at all three locations.

Please remember that all students, parents and staff from the schools are eligible for discounted treatment and services at Bristol Physio. Just click here to contact us.

Introduction to Foam Rolling

By Susie Burness

What is foam rolling?

Foam rolling is a method of self myofascial release using a cylindrical foam roller. It is an inexpensive and convenient adjunct to help with the maintenance of mobility and healthy muscle tissue. Foam rollers themselves can vary in size and texture but all do a similar job, though you can be more specific with some of the more textured rollers. They can be found in most gyms but are a useful and compact piece of equipment to have in your home.

What are the benefits?

A foam roller uses similar principles to that of massage through physical manipulation of the tissue to help release knots and reduce muscular tension. However, instead of a therapist applying the pressure, you use your own body weight to affect the area of the muscle you are rolling. You can alter your position on the roller to target specific areas of the muscle whilst rolling back and forth.

By doing this there is an increase in blood flow and lymph to the muscles which increases the supply of oxygen and nutrients. This increased blood flow brings with it many benefits:

• Increased muscle flexibility
• Improved joint mobility
• Decreased recovery time
• Decreased risk of injuries
• Improved Posture

Foam rolling cannot completely replace the skill and accuracy of a massage therapist but can help to reduce the amount of time (and money!) you may need to spend seeing one.

Decreasing Recovery Time

For those frequent gym attendees you may be acquainted with that delayed stiff and achy feeling in your muscles that builds up a day or two post workout. It tends to occur after a particularly hard session or, more commonly after integrating a new exercise into your regime. This is known as DOMS (Delayed Onset of Muscle Soreness). It not only limits our ability to exercise but can interfere with daily tasks. (I’ve definitely struggled up and down the stairs after a hard session).

The soreness felt is secondary to micro-tears in the muscle fibers followed by an inflammatory response and chemical reaction. It can cause discomfort and stiffness for up to a week unless treated with massage therapy or a foam roller. The increased blood flow provided through rolling, can help remove waste products from the tissues, helping your muscles to move more easily again and therefore can decrease your recovery time.

When our muscles become more pliable we in turn increase our flexibility which can help with decreasing our risk of injury.

Improving Posture

Many of us spend long hours in the day sitting in front of screens, (or we may be on our feet for work, but get home to wind down by slumping for several hours on the sofa). It’s very easy to lose your postural awareness and before you know it you’ve slouched over your screen for hours at a time.

Over time these repeated positions can cause respective lengthening and shortening of certain muscle groups resulting in a deviation of our posture from our optimal mechanical position.

For example, in slouching at our desks with our chins poking forwards and our shoulders and upper back rounded, the pecs muscles in our chests tighten and the rhomboids and trapezius in our upper back lengthen. Long periods of sitting also tend to tighten our hip flexors and hamstrings.

Using a foam roller to lengthen the shortened muscle groups can help to oppose these daily dysfunctional positions and therefore improve our posture.

How does it work?

The exact process behind foam rolling is still up for debate, but it is evidenced by its affects.

By releasing “knots” or “trigger points”

Knots or trigger points are hyper-irritable points in the muscle or fascia surrounding it. You can palpate them as nodules in tight bands of muscle. Trigger points are characterised by a referral pattern where by pain can be felt (but not always) at a point further away. For example, some headaches can be caused by tight muscles in the neck due to referral from these muscles.

Trigger points are differentiated from muscle spasm as they only occur in a small part of the muscle, whereas muscle spasm will involve tightness in the whole muscle.

They can occur as a result of injury, excessive or unusual exercise or following persistent overload of the muscle i.e. those used to maintain posture due to poor sitting or working habits. Repetitive tasks at work or home can also be a cause.

These trigger points can be released using the foam roller to pressure them. In smaller areas such as the neck, more benefit may be gained by using a massage ball. 

By manipulating the fascia

Fascia is a continuous network of connective tissue that envelopes and separates our muscles, bones and organs in one long connected structure. In order for fascia to function correctly it needs to be able to glide smoothly over the tissues that it surrounds. Through excessive postural or mechanical stress the fascia can get stuck and adhere to itself or other tissues.

When foam rolling, we also affect the fascia and can release these adhesions, allowing it to glide freely again.

When and how to use it?

How and for how long?

If using for general maintenance each muscle (or muscle group – i.e. the quadriceps) should be rolled for up to 2 minutes. So the total time for rolling will depend on muscles you are focusing on for the session.

For example, for runners, the calf, quadriceps and hamstrings are key muscle groups to roll. Office workers may find they benefit from rolling their spinal muscles and hip flexors as these muscles are frequently affected by hours of sitting.

Gently rolling back and forth to increase circulation prior to focusing in on more specifically tight sections will warm the muscle up first. As a general rule for long muscles – i.e. quadriceps, hamstrings or calf it’s good to start at one end and roll upwards towards your body.

It’s important to ensure you focus more on the tight and tender spots in the muscles you are rolling. Roll more slowly and hold at these points until the pain dissipates for maximal benefit. This will help your treatment to be more specific. Ensure you breathe normally and try to relax the muscle you are working on as much as you can.

Listen to how your body feels – you will gain nothing from pressing too firmly and can even cause more pain and tightness if you’re too firm or if you spend too long on a painful point. If you have a specific injury, don’t roll it directly, instead try to influence the muscles around that may be tight. You can offload particularly tight or tender areas by putting more weight through your supporting arms or legs. You may also find placing a towel over the roll will make it more comfortable in the first instance.

When?

Rolling can be beneficial both pre and post training. Prior, it increases the circulation to the muscles, helping the body to warm up and prepare for physical activity and post it can help to remove the waste products of exercise aiding recovery.

In the same way as you may have a post event massage – it should be done gently as its primary focus is not muscle release but its main aim is relaxation and recovery.

Fitting a quick 10 minutes after work whilst you wind down in front of the TV may also be useful to release tension from the day and aid your sleep.

In terms of rolling for the specific release of muscles, time this on days you are not training heavily, it may be worth fitting 5-10 minutes several times a week to release tightness and help optimise your recovery.

If you feel as though even with a large amount of foam rolling you are unable to change your tightness or soreness then it would be best to contact us and see one of our experienced therapists to get a definitive diagnosis on the problem.  Occasionally you may not find any change with the rolling therefore the need for a proper diagnosis for the cause of the pain should be explored.  

Happy Rolling!

 

We are delighted to welcome Susie Burness to our practice following a move from London back to her native Bristol.

Susie graduated with a BSc(Hons) from Manchester Metropolitan University in 2010 and began work in London where she gained valuable experience in the NHS. This included rotations in stroke and neurosurgery, community rehabilitation, cardiorespiratory, and orthopaedics before specialising in musculoskeletal physiotherapy. Susie gained most of her experience at The Royal London which is one of London’s major trauma centres.

Here she worked across a variety of specialities including sports injuries, rheumatology, chronic pain, post-operative orthopaedics and complex poly-trauma’s, this also included hydrotherapy.

Once specialised, she also worked at Guys’ and St Thomas’s where she had the opportunity to assist in teaching undergraduate physiotherapists. Susie has also gained a post-graduate qualification in acupuncture and has completed further courses including lower limb tendinopathy, the sporting shoulder and running repairs.

A keen exercise promoter, Susie has experience rowing at national level, as well as participation in triathlon and half marathons and she brings knowledge of these sports to treatment of her patients. She has a passion in facilitating patients to return to function whether it be day-to-day tasks or sporting participation.

She uses a combination of treatments to facilitate this, including manual therapies, exercise, education and self-management. She has more recently been working in Private Practice in London, but has just relocated to Bristol to be closer to fresh air and family. When not at work, Susie enjoys baking, running, cycling and yoga, and planning her next travel adventure.

 

SHIN SPLINTS

Shin splints, or Medial Tibial Stress Syndrome (MTSS) to use the more medical term, is a common injury amongst runners.

Like so many of the running injuries we see in clinic every day, shin splints is classed as an ‘overuse injury’. It does appear in other sports, but is certainly much more prevalent in runners.

TYPICAL SYMPTOMS

In typical cases of shin splints, pain is usually felt two-thirds of the way down the shin bone (Tibia), just off the inside edge of the bone.

In the early stages of the condition, pain is usually felt at the beginning of a run and then normally subsides during the training session itself. Commonly, symptoms also tend to reduce a few minutes after a given run session has finished.

As the injury gets worse the pain can be felt when walking and at rest.

It is often painful when direct pressure is applied to the inside border of the tibia. Occasionally some swelling can be present.

THEORIES

So what exactly is going-on to cause the pain of shin splints?

THE SOFT TISSUES OF THE TIBIA

One group of suspects in this case, are the soft tissues of the tibia. The muscles of the calf and the smaller muscles of the ankle have their attachments along the tibia. Specifically, the tibialis posterior, flexor digitorum longus and soleus muscles, have been implicated as possible sources of injury.

The theory being, that tightness, weakness, or excessive movement at the ankle of foot causes traction or tugging at the site of their origin on the tibia, leading to an irritation of the lining of the bone (periosteum).

There is another soft tissue that does attach to the lower medial border of the tibia, in the location of the symptoms. That structure is the deep crural fascia (fascia is a thin sheath of fibrous tissue enclosing muscles and organs).

This structure has deep insertions to the medial tibial border, finishing at the medial malleolus (inside ankle bone). It’s highly likely that the above mentioned muscles will be continuous with this fascia. Therefore, the deep crural fascia could tug on the periosteum, in the location of symptoms, and create the traction mechanism of injury detailed above.

DECREASED CALF STRENGTH

Some studies have suggested that smaller calf size, and decreased calf strength, could be connected with shin splints. The theory being, that it is the bone tissue of the tibia itself that is the source of pain.

Bigger, stronger calf muscles encourage the tibia to become stronger, and therefore, able to take greater loading. Additionally, stronger calf muscles would be able to absorb impact forces directly, again taking the load off the tibia.

TIBIAL BOWING / BENDING

This alternative explanation, again implicates the tibia itself. With this hypothesis suggesting that the problem arises via micro-trauma to the bone, due to repeated bending or bowing of the tibia.

It is well known in engineering, that when you load a long, narrow structure (like the tibia) axially, e.g. place a force through the centre of the object, lengthwise, it will result in bending moments at the structure’s lowest cross-sectional area (the narrowest part). The narrowest part of the tibia is the distal third where symptoms of shin splints are commonly felt.

It is generally suggested by biomechanists, that the tibia bends in the sagittal plane (forwards and backwards plane of movement) when running, placing most force at the distal anterior section of the tibia. But this of course depends on form; dictating where and how you strike the ground as you run.

Think of this a bit like a pole vaulter’s pole…

As they approach the jump, they plant the pole ahead of themselves (similar to an over-stride when running). Subsequently, we you see this big, anterior bowing of the pole. Great for pole vaulting but not so good for shins!

If we factor in three potentially important elements, we see that this anterior bowing force, in many runners, will be shifted medially, to where the symptoms of shin splints are reported.

1. As the foot loads, pronation occurs, (we all do it to varying degrees) which will shift the ground reaction force more towards the medial shin, and cause more of a side-bending force in the tibia.
2. Pronation is usually coupled with medial rotation of the tibia, which also places more stress medially.
3. When we run, we tend to land more towards the midline than directly in line with our hip. This is because it’s easier to get our centre of mass over our base of support. The consequences of this, are that our tibias will absorb the ground reaction force at an angle, and therefore a side-bending force, will again, be applied to the medial tibia, at the part of the tibia with the least cross sectional area e.g. where most people with shin splints have their symptoms.

Additionally, the muscular contractions of our plantar flexors, namely soleus, can also cause a tibial bending moment. If you imagine the attachment site of soleus, at the top of the tibia, and its insertion at the calcaeneus (pictured left).

As we go through mid-stance, and the soleus begins to contract to slow the acceleration of the tibia, the origin and insertion sites will be pulled towards each other, again causing an anterior bending in the sagittal plane.

It is important to note at this point, that bone stress is not a problem, if it’s applied at a gradual rate. Bone is an organic and dynamic structure. Like all living structures in the human body, it responds to stress by remodelling itself, to ensure it can cope with the demands being placed on it.

The problem comes, when the accumulated stress of training exceeds the body’s ability to remodel the area. This gives us an insight into why this condition is more prevalent in novice runners, or less fit runners, because their bones have not adapted over time to the stress of repetitive, high impact exercise.

It also gives us another layer of evidence to illustrate that when it comes to injury prevention it is important to obey the law of adaptation, and accumulate the stress slowly, giving your body’s tissues the chance to adapt and get stronger.

PREVENTION

Prevention is always the best medicine when it comes to running injuries. Shin splints are similar to most running injuries, in that the most effective way to prevent them is to respect the laws of adaptation. This means, firstly, listening to your body.

If you are feeling pain when running, it’s because your brain has decided, that a particular area of your body needs protecting. Usually, but not always, this is because too much stress, or load, is being accumulated in the painful area, and you are not leaving enough time in between stresses to allow the tissues to adapt.

So the key to injury prevention is gradual, patient loading.

Another key factor is ensuring that you have strong pelvis stabilisers (Core muscles and glutes), good flexibility and up to date trainers.

RUNNING RE-EDUCATION

The goal of running re-education is to assess an individuals running style, and see if, through subtle changes to their biomechanics, you can shift the load from the painful area, whilst not jeopardising their performance or creating an environment for another injury elsewhere in the body.

So in the case of shin splints, we are trying to reduce the anterior and medial tibial load.

Here’s some of the running cues that I like to try with this condition. It’s important to note that there is huge variability in what works for different patients.

Word of warning with these: If the cue is going to work for you, you should feel marked relief, and ideally no pain at all, within 30s – 1min of adopting the cue.

If you’re not getting any relief by then, try not to run through it.

If none of the below cues are working for you, then it may be time to book in with one of the Bristol Physio team for some advice.

1.           INCREASE CADENCE

One of my most used running re-education cues across the board. The best way to do this is with the aid of a digital metronome (there are many phone Apps available).

The theory behind increasing your cadence is to decrease an over stride, get you landing closer to your centre of mass and with a straight tibia, as opposed to your tibia flicking out ahead of the knee.

As mentioned earlier this article, think of it a bit like a pole vaulters pole. As they approach the jump, they plant the pole ahead of themselves so you see this big, anterior bowing of the pole, great for pole vaulting but not so good for tibas!

If you can imagine the pole vaulter placing the pole down vertically, and not ahead of themselves, you will see a poor pole vault, but also less anterior bowing of the pole, that’s what we are looking for – less anterior bowing = less force through the painful area.

2.           INCREASE STEP WIDTH

Trying to move the load from the medial shin, to achieve less side bending/tibial bowing. I try to bring about this change using a variety of cues. Generally, asking people to have some daylight between their legs or imagine running on either side of a yellow parking line, gets the right changes.

3.            STIFFEN THE ANKLE

The idea here is to decrease the amount of dorsiflexion (toes travelling towards your shin) the ankle goes through. Lessening dorsiflexion means less tibial bowing from the action of soleus, as it tries to decelerate the tibia as it moves into end of range dorsiflexion.

Stiffening the ankle also helps to pretension the muscles, so they can work reactively and elastically. Good for speed but also takes the load of the bone itself.

4.   CHANGE THE DIRECTION OF THE GROUND REACTION FORCE

Again, we are trying to decrease the anterior tibia bowing. If we go back to our rubbish pole vaulter, as we discussed, if he places the pole out in front of him with forward and downwards force it will create anterior bowing.

However, if he plants the pole down with a backward and downwards force, it will not bow anteriorly, but posteriorly. Bad for a pole vaulter, but good in our tibial context! i.e the force will go more through the back of the tibia.

Any change in the direction of the ground reaction force, to a more backwards and downwards force, will decrease the load in the anterior tibia and may be enough for us to keep running without pain. To cue this, think of pushing your leg back and down in a backwards tick type direction, using your glutes to perform the movement. Often I’ll say paw back on the ground like a raging bull! And think of kicking your leg back and out behind. [See Mo Farah running above: look at his kick back and the degree of hip extension. This will automatically make him land on his mid-fore foot].

CALF STRENGTHENING

As mentioned earlier, weak calves have been implemented in shin splints. So seems like a good idea to strengthen these muscles as a way to create a stronger, thicker tibia, but also being able to take more load themselves. But remember to maintain your flexibility when strengthening by stretching post work out.

ORTHOTICS / TAPING

Often a medial arch support works well to offload the medial tibia. Taping (and sometimes orthotics) can be great tools to offload an injured or sensitised area which physio’s will use to assist you in your rehabilitation.

CHANGING THE SURFACE YOU RUN ON

Bit of a weird one this, intuitively you would think that running on softer ground, such as an athletics track, sand or grass, would be easier on the legs, but the literature suggests that when we run on softer ground our leg actually stiffens more to compensate for the softness, and the reverse is true when running on hard ground i.e. less stiff legs.

This has led many to suggest that it may be better for runners with shin splints to run on harder ground. I remember when I had my shin splints, I found it better running on softer ground, but might be worth bearing in mind if you find the pain is worse on softer ground.

Cross Training

Cross-training can be effective at this point, to maintain strength and fitness. Remember you only need to offload the painful area, not your whole body. I will often suggest aqua-jogging which will allow you to work on technique and keep your running specific movement patterns with very little stress on injury.

To see the May 2016 Newsletter with a Special Edition focusing on Postural Pain; why it occurs and how to manage it and many other things click on the link below:

May 2016 Newsletter

Office Based Exercises

Neck or Back Pain when sitting at a computer?

We all sit in front of our computers for too long!

We have as many at 30.6 million hours lost due to some joint, bone or muscle problem therefore it affects all of us in some way.

We have put together a small list of stretches and strengthening exercises to try and help neck and back pain.  Click on Office Exercises and a PDF version of the exercises can be printed off and the whole office can gain benefits from these.  Also Jason Heddington has put together further advice on poor sitting posture whilst at work.

N.B. these exercises should not cause pain and if they do then consult one of the physiotherapists at Bristol Physio.  

If chairs and desks are an issue at work, have a read of this advice, in conjunction with Gazelle Office Furniture, regarding the best furniture for your office.

Office Exercises

 

Is Poor Posture Causing Your Back Pain?

By Jason Heddington

 

Do you have an office job? Do you sit at your desk for up to 8 hours a day?

Do you suffer from back and neck pain?

Our backs were not designed to spend long periods of time sitting at desks – a common feature of many work environments. 

Taking time off work with a bad back is common, but for many businesses such employee absence is a real problem. A government report this year into sickness absence in the labour market highlighted that more days were lost to back, neck and muscle pain than any other cause.

Musculoskeletal (MSK) disorders accounted for 30.6m working days off in 2013 and, according to the Department for Work and Pensions, were the cause of a third of long-term sickness absences between October 2010 and September 2013.

What problems can I get from sitting in a poor posture all day?

Spending six to eight hours a day in front of a computer can lead to shoulder, arm, hand and neck problems, as well as issues with balance and coordination.

If you slump in your chair you can develop tight muscles around your neck and upper chest, weak muscles in your back, tight muscles around your hips and knees. Also sitting for long periods will decondition your muscles, tendons and ligaments making you prone to injury.  A physiotherapist can do much to help these issues – but this must be in conjunction with ensuring the workstation is set up correctly and that regular breaks away from computer are taken. Otherwise, the issues may keep recurring.

What can I do to help prevent these problems occurring?

The good news is that postural issues can be corrected, and even, in most instances reversed.

1. When in a working environment that requires a lot of desk and computer work, make sure your workstation equipment is ergonomically sound. Check that your desk, keyboard and computer screen is at the correct height and position.
2. Ensure you have a comfortable chair that puts you in an ergonomically friendly positions making sure your knees, hips and elbows are at the correct angle. Your physiotherapist will be able to assess this and advice you on correct positioning.
3. Finally, make sure you take regular breaks to stand up, walk around and stretch at least every 30 minutes, keeping yourself well hydrated with water.

What can help further…

We at Bristol Physio have teamed up with the guys at Gazelle Office Furniture Ltd. Based in Bristol, this national company offer office solutions to poor workstation positioning. Fully ergonomic chairs, manual and machine operated standing or sitting desks are among their wide range of furniture ideas. At Bristol Physio we have two KX2 Task chairs and if we had the space we would opt for the standing desks. Do pop into their store in Lawrence Hill, Bristol or come into our Clifton branch to see the furniture in the flesh.

We also offer Work Station Assessments. One of our trained physiotherapists would visit you in your office environment, ask a number of questions not only about your work station but also lifestyle and take an assessment of the work space.We can advise on aids for your environment and give solutions to help you get the best position for you at the desk, as everyone is unique therefore a ‘one size fits all’ approach is neither appropriate or able to achieve in an office environment.

 

 

 

 

To see the April 2016 Newsletter with articles on Surfing Warm Ups, a new partnership with Gazelle Office Furniture, updates on our supported clubs and teams and many other things click on the link below:

April 2016 Newsletter

To see the March 2016 Newsletter with articles on Shoulder Injury & Pain by Tony Gill and an article on success for British Basketball and many other subjects click on the link below:

March 2016 Newsletter

To see the February 2016 Newsletter with articles on Winter Cycling Training, Prehab before surgery and our OFFERS, OFFERS, OFFERS and many other things click on the link below:

February 2016 Newsletter

With Spring in sight, It’s time to get back in the water!  People from all over the country will be contemplating returning to ‘The Green Room’, however, how do you know that you are in good shape?  Lucy Johnson our expert surfer will tell you how…

Surfers across the UK will be crawling out of winter hibernation or fresh off planes from exotic locations. The waters here are still Baltic so this article will be about focussing on a decent warm up you can do at the beach before jumping in and also signs of hypothermia.

Should you be concerned about a dodgy shoulder, either book in to see any of the expert physiotherapists, or click here to see an article by Tony Gill on Shoulder Injuries.

A Dynamic warm up is great for improving functional range of motion, mobility and coordination pre surf which is essential. It gets the blood flowing to the skeletal muscles and gets the body ready for producing greater amounts of force for paddling, pop-ups and manoeuvres.

The video below shows Dynamic stretches you can do on the beach to get you ready for your session:

Surf Warm Up video

And a side note…

Hypothermia; the signs to be aware of.

90% of heat loss occurs through the skin and 10% through the lungs. In Theory, Hypothermia begins when your body temperature goes below 35°C.

There are four levels of hypothermia: mild, moderate, severe and profound.

Signs of moderate Hypothermia suggest that you need to urgently get out of the water, get warm and tell someone you’re struggling:

– Tiredness/drowsiness. This can be subtle at first and gets more and more severe. Don’t just put it down to the surf and outdoor exercise.

– Delayed thoughts/ dazed consciousness.

– Slurred speech.

– Extreme dizziness

– Pale face and purple extremities.

– Bad surfing! You start to lose your fine motor control e.g. in the hands and feet.

– Pauses between shivering. A good test is if you can stop yourself shivering you only have mild hypothermia. Pauses between shivers means things are getting more serious.

– Irrational behaviour. If someone is acting unusual be suspicious!

Severe hypothermia can cause paradoxical undressing, in which a person removes their clothing as they feel very hot but this will lose more body heat. Heart rate, respiratory rate and blood pressure all decrease, and there’s a risk of the heart stopping, it is possible to lose consciousness. With Profound Hypothermia vital organs will begin to shut down as the body tries to protect essential function i.e blood supply to the heart and brain.

So don’t forget that extra neoprene and if in doubt get out.

If the surf is flat or you want to work on things at the gym that will help your body prepare for the rough and tumble, see the following videos.

Functional exercises for surfing video

Happy Surfing!!!

Lucy J

Shoulder pain is one of the most common musckuloskeletal problems in the human body after Back pain. Millions  of pounds are lost in the UK each year to sickness and time off work due to shoulder pain. Our Bristol Physiotherapy Clinic is lucky enough to have its own dedicated shoulder specialist who is able to assess diagnose and treat your problem. Tony Gill is not only a shoulder specialist but also a qualified diagnostic ultrasonographer and injection therapist. This means as well as this specialist service our Bristol Physio Clinic has onsite diagnostic ultrasound, guided ultrasound injections and excellent links to all the top shoulder specialist surgeons in Bristol to fast-track your care if appropriate.

Common problems include;

Shoulder Impingement and Sub-Acromial pain

Frozen Shoulder or Adhesive Capsulitis

Rotator Cuff tear

Shoulder Instability/ Dislocation

Acromio-Clavicular shoulder pain and dysfunction

 

Click HERE for more information on each Injury.

If your shoulder is giving you pain or dysfunction then use the  Contact Form or call us on 0117 923 7506 to book a session.

Common Shoulder Injuries by Tony Gill

 Shoulder Pain, Shoulder Problems and Shoulder Dysfunction

Shoulder Impingement

The most common of shoulder problems, this is a symptom not a diagnosis as lots of separate conditions cause impingement.

Overuse, trauma, rotator cuff weakness or rotator cuff tear all cause Impingement.

Symptoms: Pain raising the arm above horizontal or above the head. A weak shoulder with power movements like throwing  can be painful to lie on but usually has a good hand behind the back movement.

Treatment: Manual therapy to treat tight painful muscles and joints. Specific exercise to retrain the Rotator Cuff to optimise the shoulder control. Exercise and posture work to maximise the trunk and Scapula control which are the base the shoulder works from.

 

Frozen Shoulder

Also known as Adhesive Capsulitis this is a condition that usually occurs in our late 40’s to 60’s and has genetic links. Early diagnosis is crucial as treatment is far more effective in the first 6 weeks and we strongly recommend an early Steroid injection as this condition can last anywhere between 6 months and 3 years. In the initial stages inappropriate therapy can actually prolong the condition and lead to more pain and dysfunction and why it is important to be seen by a specialist who can recognise this condition and arrange the most effective treatment.
This condition usually has 3 stages. The initial painful stiffening freezing phase.  The less painful but stuck frozen phase and finally the improving thawing phase.

Symptoms: Shoulder begins to stiffen and has reduced movements behind the back and out to the side, painful to lie on and severe pain with reaching out movements or jerk movements.

Treatment:  Early Treatment usually involves discussion regarding a capsular Steroid injection which we are able to perform in clinic with discussion with your G.P.
We then treat the associated cervical and myofascial symptoms with a care not to flare the shoulder and worsen or prolong the problem.

 

Rotator Cuff Tear

Under the age of 30 these are rare and usually involve a high impact trauma. As we age and
get closer to 50-60 years even small forces can cause a tear in an already worn tendon.

Symptoms: They give similar symptoms as shoulder impingement. When the symptoms are more severe we are unable to move the arm away from the body with any power, but might be able to move it with the other arm. This indicates the stability muscles may be torn.

Treatment: Treatment depends on accurate diagnosis highlighting why suspected tears should be seen by a specialist. If a large tear is suspected this should be referred for investigation and a shoulder surgeons opinion. We have excellent links to surgeons in the area and can have you seen rapidly when required.
Smaller tears can be optimised with therapy and even larger tears that are non operable can be treated effectively with specialist physiotherapy.

 

Shoulder Instability

Shoulder Instability is a big group of problems including Dislocation, Labral tear, Hyper-mobility laxity, Muscle patterning,  Subluxations. 

Symptoms: This is too big a group to discuss in a simple page but if you have dislocated your shoulder and continue to have problems, feel the shoulder keeps popping out or almost popping out or is weak after a trauma then it should have a specialist assessment from a shoulder therapist or surgeon.

Treatment: This depends on the diagnosis but with stable Labral tears, laxity without trauma or hyper-mobility, very specialist exercise and therapy is required. This can get very complex and usually the area we shoulder specialist therapists spend a great deal of time rehabilitating. For the dislocation group it is very important we make sure there is no structural damage and we usually organise specific scans or investigations and/or shoulder surgeon advise to ensure you have the best treatment.

 

Postural Shoulder Pain

This is becoming far more prevalent with the use of laptops, mobile phones, Ipads and general reduced extension or upright activities in our lives.

Symptoms: Pain in the epaulette area and scapula and upper back region. Can be worse with static sitting postures and also give us pain in the neck area.

Treatment: Its unrealistic to think any therapist can fully cure this without addressing the postural issues. Treating this effectively requires your full effort to work on posture changes, exercise to stabilise and give more power to your upper trunk plus awareness of the bad habits that are adding to the problem. A good therapist will spend time identifying these as well as giving specific exercise and lifestyle changes. We also use manual techniques to change the joint stiffness, muscle tightness and pain.

 

A/C joint (Acromio/Clavicular Joint) pain

I see many of these and when we are young it is usually from trauma even from a fall on an outstretched hand as well as impact to the shoulder. These are often missed as a source of continual shoulder pain post road traffic accident (RTA) form the seatbelt.
As we age usually 40 years onwards this joint can become slightly degenerative and give pain.

Symptoms: Pain on top of the shoulder you can usually put one finger on. Painful with across body movements and end of range high arc movements.

Treatment: As a shoulder specialist who is able to treat with steroid injection as well as physiotherapy, my treatment of choice tends to be a steroid in the vast majority of these as it seems to be the most effective treatment I can offer. I also settle them with manual therapy and acupuncture. If the pain is not settling I do not think it is fair to continue to treat you if it is not improving the problem.

Cross training for cyclists by Simon Shepherd

Remind you of anything:

“New Year, New Goals, New Kit and clothing you want to try out on the bike…But oh look its winter out there, damn. Oh well I’ll go tomorrow!!”

Wrong answer.

Lets be honest no-one really likes getting on the bike for a 3-4 hour training ride when all around you the rain is coming in horizontally and the trees are blowing over at 90 degrees. Kind of takes the fun and beauty out of cycling.

Now lets face facts, its not all about the bike after all, there are other activities we as cyclists can and should engage in to benefit us as the cycling season approaches. Strength and conditioning work is as equally important as getting the miles under your belt. As cyclists we work in a linear motion often for hours on end, day after day, week after week. lots of repetitive movements in one plane. Trouble is, we are made of bones, joints, ligaments, tendons, muscles; and not forgetting our nervous system, all of which helps us through 3 dimensions in our everyday function and activity. It is therefore important that we make ourselves fit for purpose in a 3 dimensional way.

Core strength

Ah yes the old ‘core strength’.  A group of muscles including Rectus Abdominus, Transverse Abdominus, Mulitifidus, Internal and External obliques, Erector Spinals, Gluts to name a few.

So what I hear you say??

Well it’s these muscles that need to be strong and fit for purpose to help avoid predisposition to injury and support ourselves whilst we hold our linear static postures for 3-4 hour plus rides. Its these muscles that when strong, fit and efficient help our pedaling become more efficient, help our handling and control of the bike improve and make the sport we all love become much more enjoyable!

Ideas to help train the core:

Firstly keep it simple! The harder and more complicated you make your training regime the more likely the chance of bad form, bad training and potential risk of injury. Aim for 2 sets of 12 to 15 reps initially, 3 times a week, aiming to progress onto 3 sets, then sets with load (weights).  Its also important to stop exercising when your form has gone, or indeed if you feel pain. It is all about quality not quantity after all.

Some simple exercises to consider in your core sessions:
Plank

Side plank

Lunges

Squats

Press ups

For further ideas feel free to have a look at our YouTube Channel. There you will find a plethora of wonderful exercises. My personal favorite being The Founder.

[youtube]https://www.youtube.com/watch?v=rY5qxNxhIqU[/youtube]

Good luck, and remember consistency pays off.

See you on the road

Simon

Andy Howse

Having surgery in the future?

Thought about strengthening up beforehand?

At Bristol Physio we believe there is huge scope to increase general fitness prior to any surgery that will then increase your ability to increase stamina and speed up recovery after you get out of hospital.

For anyone that saw our Tweet on January 25^th, we highlighted an excellent blog describing the evidence behind doing ‘Prehab’ before surgery. It has been found that patients about to have bowel operations are more likely to have a speeder recovery if they are able to perform some prehab prior to surgery.

In the musculoskeletal world (joints and muscles), we would always encourage patients to perform a course of prehab prior to any elective surgery. Operations to replace knees and hips, surgery for shoulder injuries and back surgery would all benefit from specialist strengthening prior to ‘going under the knife’.

The principles of prehabilitation are to strengthen and improve the current ability of the patient within the confines of the limbs or body part that requires the surgery in order to gain general fitness or muscle mass. MacMillan Cancer Support also highlight a trend in some hospitals that perform versions of prehab

known as Enhanced Recovery Programmes, just to speed up getting back to normal life after surgery.

Benefits can include quicker tissue healing rates, fast return to normal walking or daily activities, reduced blood pressure and improved health overall. If you happen to need crutches after the operation, some upper body strengthening will greatly improve your speed in getting around and reduce the ache on the limbs supporting the body.

Feel free to discuss with any of our therapists at Bristol Physio if you are keen for more information or a prehabilitation programme to help you prior to your surgery.  If coming into see us if tricky, have a look on our Exercise page to see our YouTube Channel for exercise ideas.

 

To see the January 2016 Newsletter with articles on Goal Setting, Important Sporting Dates for your Diary, Helping Your Goals and many other things click on the link below:

January 2016 Newsletter

To see the December 2015 Newsletter with articles on getting fit for Skiing and Snowboarding, Jamie Pierce, Christmas Gift Ideas and many other things click on the link below:

December 2015 Newsletter

To see the November 2015 Newsletter with articles on associations with sports clubs, massage therapy, Ski and Board Fit and many other things click on the link below:

November 2015 Newsletter

To see the September 2015 Newsletter with articles on working with schools, our Services, Core Stability with Riding and many other things click on the link below:

September 2015 Newsletter

 

To see the August 2015 Newsletter with articles on Mergers, Basketball and many other things click on the link below:

August 15 Newsletter

 

GB Women’s Basketball

The bench vs Russia

Teamwork, never say die attitude, pushing the limits are all phrases that could be said to be used too often. With the GB Women’s Basketball squad, they are extremely apt. After 4 back-to-back games at the EuroBasket 2015 in Hungary, the players continued to push themselves to the limits. We had managed to surpass expectations to reach Hungary and now the end of the competition was in sight. We played our best basketball in the last game against Croatia and only lost by 6 in the final quarter. An admirable achievement for all involved.

The squad did not achieve their own high targets. External factors disrupted the lead into the tournament with illness and injury but this seemed to galvanise the squad. Pre-tournament trips to France and Spain were great learning opportunities and it is worth noting that we beat the eventual European Champions Serbia while in France. A number of younger players were given their first caps throughout the campaign and I even was initiated into GB Basketball.

GB Women’s Basketball staff

With my assistant, Nick McCarthy

From a physiotherapy perspective I worked hard and I hope had a positive impact on the players and the campaign. We finished EuroBasket with no soft tissue injuries and the monitoring systems that were implemented were robust and hopefully prevented further disruption from injuries. Overall the staff and players felt the campaign was one of the best structured camps in years and a lot of that is down to the Sports Science and Medical team helping to design a robust programme.

I thoroughly enjoyed the experience and I would like to thank all the players, staff and management for a great rewarding experience. GB Basketball will continue to thrive if we have positive experiences and continue to give younger players the exposure to the top level of the sport. Watch out for the BBL and WBL this season!

A Testing Week

The first 10 days have been completed and the Great Britain Basketball squad are looking in good shape on our way to France.

For those of you that don’t know, I took on the role of physiotherapist for the GB Basketball Women’s squad a few months ago. Last year the ladies did very well and qualified for the prestigious EuroBasket 2015 tournament in Hungary and that’s where I come in, to help them stay fit and healthy throughout the campaign leading up to and through the tournament.

I am one of various members of staff that support the group of 16 athletes. I work very closely with the Strength and Conditioning (S&C) coach and our roles are to get the players into the best shape we can over a limited time frame. Michael, the S&C coach has worked at a very high level for a number of years with the Australian Swimming squad at the London 2012 Olympics, an inspiring person to work with.

The life of a Physio in camp is one of long hours, large amounts of caffeine and being constantly ‘available’, the first couple of days being busiest! In the first full day of camp this year, Michael and I devised a number of tests for the players (known as Screening). The results of Screening give you a basic introduction to the current physical strengths of each player, and an indication of areas that require improvement.

In our Screening session, we had a number of facets. Flexibility Screening: gives us an idea of the range of movement of each player’s major joints and allows me to compare one side of the body to the other. This provides a baseline to re-achieve after any injury that may occur. Functional Tests: Were incorporated within a movement screen and were followed with physical markers such as speed over 20m, an agility test and a jump score. These scores are collated and then the next couple of days were spent creating a profile of each player so we know where improvements need to be made.

 

This year we had another tool at our disposal. Spin bikes were used to create a physiological profile of each player. Specialised spin bikes were set up for each individual,

calculating various factors including wattage output. Using the bikes we have been able to add to the profile of each player. The data is used to tailor each individual’s cardio workout, thus increased cardiovascular fitness without increasing the loading through the legs. Each athlete has a personalised goal to reach each time they get on a bike, making for more individual specific fitness.

Well, after a week of training we are all heading off to France to compete against the Olympic silver medallists – France, moving onto games against Serbia and Slovakia. Having had a focussed and intense week, we are all ready and raring to go. The weather is looking good so I am looking forward to our rehab sessions in the outdoor pool….maybe the next investment for Bristol Physio? 🙂

Working as a Physiotherapist for 13 years and a being a martial artist for 25 years I’ve seen a few injuries along the way caused by poor striking technique. This is common in any martial art that has upper limb striking as part of its repertoire.

The most common injuries are cuts and abrasions but if we are really looking at upper limb injuries that stop people boxing and training they are usually of the:

 

Hand

Wrist

Elbow

Shoulder

 

The hand has its own unique “boxers fracture” and is susceptible due to the high force transmitted from the lower limb and trunk into the fist. The Metacarpal(bone between the wrist and fingers) on the outside of the hand is exceptionally vulnerable to a fracture as it is a small and only has a support on one side. This is the reason boxers wear wraps under their gloves. This support allows some element of protection to the hand.

Striking poorly and overusing the smaller knuckles of the hand can increase the risk of stress or a fracture to this area. This risk can be significantly reduced with good technique.

 

The wrist injuries usually come down to poor technique again I’m afraid. A good coach or trainer ensures you are striking with a strong and stable wrist. A bend at the wrist on impact can lead to trauma and injury to the ligaments and tendons of the wrist or in worst case even a fracture. Pain on the outer wrist can be trauma to the small pad that sits in-between the forearm and wrist called the TFCC for short

 

The elbow suffers if you miss the target causing hyperextension. This can be down to technique or a poorly placed pad from a sparring partner. Over locking or hyperextension can lead to posterior impingement of the elbow which in serious cases can require an operation. It pays to have a good trainer teaching you the basics and building your power from control. Overzealous training of boxing to build cardio can lead to these types of problems where technique comes second to the cardio element.

 

The other interesting injury I’ve come across more recently is tennis elbow and golfers elbow on the person holding the sparring mitts for prolonged periods as the elbow tendons have to work extremely hard in an inner range and take the impact of a punch and the flexors work to absorb and slow down the impact in outer range. This can affect you if working in pairs and long sessions without changing over. Trainers and coaches are especially vulnerable.

 

Shoulders also suffer from over extension of the elbow and missing a target repetitively. The shoulder is the most mobile and therefore unstable of all the bodies’ joints. The rotator cuff group of muscles have to work amazingly hard to control the shoulder joint with the power in a punch. Fatigue certainly plays it’s part in shoulder injuries. For instance, when you are tired and barely able to keep your hands up, the cuff still needs to control your punches and blocks.

 

Over fatigue leads to more punches that miss the target. This double jeopardy effect will place the cuff under significant stress and can lead to overuse and impingement type injuries.

 

Ido Portal, one of my movement idol’s has a great saying; “every time you specialise you compromise”. This is true of fighters who just focus on the Pec and Deltoid power. As a shoulder specialist physiotherapist I can assure you, it’s all in the Cuff, Scapula and Back. You need just as much control behind as you do in front to decelerate and control the shoulder and scapula.

 

Shoulder dislocation despite being widely reported as a common injury in boxers, is incredibly rare. The normal striking position of the arm is a stable position and I would suggest that those who are unfortunate enough to dislocate have had their arm placed in an abduction external rotation position (hands up position) or are hypermobile and prone to dislocation or have had previous dislocations and are susceptible

 

My advice is if you want to box, kick-box, or use boxing as a form of training then get a good coach who understands fighting. They will build you up slowly focusing on technique and power from the lower limb and trunk, teaching good arm placement and correct punching technique. This will not only keep your injuries down to a minimum but also teach you an effective strike. You never know when you might need it !!

 

Tony Gill

Sports massage is a form of deep tissue massage that is mostly focussed on alleviating the stress and tension which builds up in the body’s soft tissues. It works by breaking down muscular adhesions brought about by physical activity.

Muscle adhesions, also known as ‘knots’, occur where there is a greater demand or stress on particular parts of the muscle. During exercise, minor injuries and lesions (tears) occur, due to overexertion and/or overuse. The body then heals, producing stronger and additional muscle fibres. It is during this healing process that the fibres can ‘glue’ together forming a tight bundle. I often describe this as being similar to when cooking spaghetti and the strands clump together! This leads to an in-efficient muscle as the individual fibres are unable to fully contract or stretch. Furthermore, blood flow to the area becomes restricted, reducing oxygen and nutrient delivery and removal of waste products.

The aim of post-event massage is RECOVERY and geared towards reducing the muscle spasms and metabolic build-up that occur with rigorous exercise. The massage usually takes place 0-24 hours after the event. However, a light recovery sports massage lasting 10-20mins immediately after a race is very helpful in removing metabolic waste. The pressures applied are modified to provide a soothing effleurage – the pace is slow, rhythmical and gentle. Avoid any deep tissue massage as it could actually be more damaging than beneficial as the muscle will be in a highly stressed state.

The Good Stuff

• Flush away waste products that build up during exercise i.e. lactic acid through the promotion of blood and lymphatic flow.
• Fresh oxygen and nutrients are also brought into the muscle which are vital for repair and replenishing.
• Reduce the risk of delayed onset muscle soreness (DOMS) therefore allowing for a quicker return to training.
• Relaxation. Massage is a wonderful way to relax after an event and gives you time to mentally recover as well as helping to return the muscles to a relaxed state. In addition, massage is an excellent way to improve mood, reduce anxiety, lower blood pressure and increase the feel good chemicals i.e. dopamine, oxytocin and endorphins.
• Help an athlete with their cool down routine, this is especially good after an event when an athlete is often too tired to cool down properly.
• Post event massage can also be that first assessment for potential injuries and more serious medical conditions (heat exhaustion, hypothermia) which may be identified early and treated promptly.

To optimise full recovery recommended things to do post massage:

• Foam Rolling (check out our channel on YouTube to see how it’s done)
• Self-massage with a hard ball (hockey, cricket or specialised trigger point balls)
• Stretching
• Light exercise – active recovery
• Heat – especially now it’s approaching winter. Keep your muscles warm by adding layers and/or wearing compression clothing

 

Written by Tony Gill.

As a shoulder specialist physiotherapist in Bristol I see quite a few surfers shoulders.

Often labelled as a swimmers shoulder, there are specific differences between these conditions:

 

1: Swimmers performing crawl rotate around the central axis or spine, imagine a hog on a spit. Surfers cannot rotate around this central axis in the same way due to the buoyancy of the board. This requires more force to be produced at the shoulder, as the trunk musculature cannot generate the same force through the rotational movement as a swimmer can.

2: The stroke in surfing requires more power in mid-range of the stroke as you are riding far higher on the surface of the water and unable to generate any power at the end of a swimmers stroke as your arm is already clear of the water. This means you have to generate more power in the middle of the range which increases the stress of the shoulder as the hand is further away from the trunk. It’s basic physics of the long lever.

3: Surfers manage to generate force through good thoracic and lumbar extension range and dynamic stability. If they lack this, the shoulders are far more likely to have to overwork as a compensation for the stiffness or weakness. Anecdotally, I find this seems to be especially so for the weekend surfer who spends many hours on a day to basis hunched like a prawn in-front of a laptop or desktop. ( you know who you are!!)
There is an old saying “you are what you eat” – the same holds true for what you do.
I suspect sitting flexed for hours a day teaches habitual postures, tightness’s and weaknesses that are difficult to break once or twice a week on a board. Usually this effects 30-60 year olds and in my practice seems to effect the office worker more often than a manual worker. I acknowledge this may be a bias of my client group rather than a true link between impingement and posture.

4: The swim stroke on a board has to be further away from the body due to the width of the board which increases the lever effect on the shoulder. This in turn increases the stresses placed on the stabilisers of the shoulder ball into its socket. (Rotator cuff)

5. Surfers ask for short sprint power repetitively to get through the breaking waves and then another sprint to catch the wave. It is rare a swimmer operates on sprint/rest/sprint/rest approach to a given distance. Their swim tends to be paced.

6: Surfers push up on an unstable surface, swimmers don’t. This can increase the stress on the top joint of the shoulder where the collar bone joins the scapula called the A/C joint. For some of is this joint already starts to have arthritic changes in our 30’s and while this is usually not a problem, if irritated already can flare with continual push up postures that surfing requires.

Both swimmers and surfers suffer from impingement symptoms. In layman’s terms the ball needs to stay centralised into the socket but is only able to do this by activating 4 dynamic muscles called the rotator cuff. If they fatigue the powerful Latisimmus Dorsi Upper Trapps and Deltoid act together to internally rotate and elevate the ball in the socket which increases the joint pressure and over time can cause pain and dysfunction.

So what can you do?…… If you live in the South West you should be visiting us at Bristol Physio!

The simple rules I apply to all rehab are:
What movements cause the pain?
What areas seem to be weak?
What areas seem to be tight or stiff?
Can we address the dysfunction and optimise function?

i.e. what task is being required of the body?
How is this different from the norm?
How do we optimise the desired function?

If therapists miss the unique differences and requirements a surfers shoulder is under, we fail to address the primary problems driving your pain.

If your suffering from a painful shoulder with surfing, my advice would be to see a good therapist who understands the stresses places on surfers shoulders and how to address this. If we the therapist are not teaching you how to change this and address the problem within 3-5 sessions then your either being lazy with your rehab, we haven’t identified all the dysfunctions to correct or it might not be able to respond to rehab and requires more help in the form of a steroid injection or surgical input.

Your welcome to come see us in Bristol but be prepared to be actively involved in your own rehab as its your body and therefore will require you to make the changes to optimise your recovery.

If your interested in rehabilitating your own shoulder we have a few links to sensible exercises below for common problems associated with surfers shoulder issues. But this is not a recipe and I would always advise seeing a good shoulder Physio.

Thoratic Flexibility and Strength

Rotator Cuff External Rotation Elevation with Band

Press Up Plus

Dynamic Side Plank

 

Modern lifestyle has got us sitting for hours at a time in a poor position, whether it’s at a desk for work or web browsing at home or slumped on a couch watching TV and using a laptop. This leads to muscle imbalances causing postural problems, even in the active triathlete.

In triathletes, there is the additional training factor that both swimming and cycling tend to develop hunched shoulders. If you do not have the muscle flexibilities and strength balances to naturally hold proper, efficient posture all the time, you will struggle to reach your potential, no matter how hard you train!

In summary, forward head, round-shouldered posture decreases triathlon performance because:

1. A forward head requires more energy to hold up during cycling and running, which can prematurely fatigue the neck, shoulders, and upper back.
2. Changes to spinal curvature top to bottom occur, making the body less biomechanically efficient. Pelvic angle and limb range of motion also affects running stride.
3. Hunched shoulders and tight chest muscles impede upward movement of the ribcage, increasing the energy necessary for breathing.
4. Decreased shoulder range of motion due to tight chest and shoulder muscles decreases swim stroke length and strength.
5. Forward head posture positions the head further down into the water, forcing one to roll excessively and work harder to breathe.

Most importantly, taking care of your postural imbalances will prevent injuries of all kinds. For example; the swimming and cycling aero position increases load on the neck, which when combined with forward head posture, increases the probability of ruptured discs and pinched nerves.

At Bristol Physiotherapy we aim to address these imbalances brought about by poor posture and educate you on how to avoid injury and enhance performance.

By Emma Davies

In 2012 Australian Triathlete Pete Jacobs achieved his 10 year dream of winning the Ironman World Championships in Hawaii. Here’s a video of his tips on how to improve your run technique.

https://www.youtube.com/watch?v=JucHwHW3LQ8

Running Posture

Running tall with a proud posture and your chest up will help you to maintain alignment. As soon as you slump forwards in your posture, you’ll start dropping your hips back – sticking your butt out! As Pete says “if you drop your hips back, you slow down a lot”.

Holding your posture tall encourages you to hold your hips over the landing foot, leading to a lighter, quicker contact on the ground.

Foot Contact

Pete recommends a very flat midfoot strike, with the heel and ball of the foot striking the ground in unison, with more weight being put through the ball of the foot.

This is a great option for so many distance runners, far less aggressive that the forefoot strike many attempt to achieve. Of course, appropriate foot strike pattern will vary from runner to runner, and even within an individual from pace to pace. Experiment on your runs!

Cadence & Arm Carry

So frequently overlooked is the inherent link between the rhythm of the upper body and that of the legs.

Once you’ve perfected the relatively simple action of the arm swinging back and forth, independent of the torso, the rhythm of this movement will directly influence leg speed. Keeping a relatively short, fairly choppy arm carriage at marathon pace will keep your legs turning over quickly and efficiently.

Relaxation

Pete recommends to focus on remaining relaxed, and removing feelings of tension through muscles that “don’t need to be working”. As long as your core is strong and switched on, everything else will “find it’s place more easily”.

 

The knee is a complicated joint and there a variety of injuries that can occur, but the two most common injuries are patellofemoral pain syndrome (PFPS) and Illio tibial band syndrome (ITBS). Both of these conditions have a nasty habit of starting off slightly niggly and then developing into a full-blown chronic injury if not assessed and rehabilitated appropriately.

These injuries generally occur when there is a sudden increase in running volume and frequency or changes have been made to the type of training, i.e adding hills or sprints (interval training). These changes exacerbate pre-existing flaws in running technique, biomechanics or muscle balance leading to such injuries.

Should you find yourself fighting with a niggly knee or you have just developed a knee injury, then RICE (Rest, Ice, Compress and Elevate) should be applied. I advise my athletes to use Physicool (physicool.co.uk), a cooling bandage that can be easily applied to any peripheral joint – much easier than trying to secure a bag of peas to your knee not to mention a lot more comfortable!

Check your Trainers! Are they over 2 years old? Have they done more than 400 miles? If you answered ‘yes’ to either of those questions then you need to update them. I also advise that you go to a reputable running shop with a gait analysis service. It may be a bit more expensive than what you can find online, but you will be fitted with the correct trainers for you and should there be an issue you can take them back. We recommend our clients to go to Moti.

Next, would be to address your biomechanics. Anatomically speaking, the knee is positioned in an unfortunate position. It is located between two very mobile joints: the hip and the ankle. We often find that control at the hip and/or foot and ankle is compromised, disrupting the alignment and loading of the knee as we run. Hence, exercises designed to strengthen your hip (Glutes) and core stability are nearly always prescribed in knee injury rehabilitation AND prevention.

Your hip and leg flexibility also plays an important role in biomechanics. Ensure you are stretching all the major muscle groups after exercise and you should spend at least once a week doing extensive stretching such as yoga or a session on the foam roller. Although, during rehabilitation I frequently advise a daily stretching program.

This advice is based on the most common knee issues. It is strongly advised that you seek an assessment from a Chartered Physiotherapist should you be experiencing any niggle or injury.

A common running injury is a calf strain or a tear. The calf muscles, Gastrocnemius and soleus, are loaded repetitively and heavily during running. With every stride we take when running, the calf gets loaded, firstly to absorb the shock of our body weight landing, then to help propel us forward into the next stride. When running, we take roughly 1500 strides per mile. Which makes it easy to see that if there is a weakness in the calf complex, or a fault elsewhere in the kinetic chain or running technique leading to increased load on the calf, injury is almost inevitable.

The calf is classified as a global mobilizer muscle, meaning that its main anatomical function is to absorb and then create large motions and forces. It is accompanied above and below by stabiliser muscles which are responsible for keeping the joints stable – so that it can carry out its main function. However, if stability is compromised, particularly at the foot and ankle complex, leading to excessive pronation, the calf will begin to try and take on a stabilising role also – leading to loading it is not positioned well to cope with. An example of which would be an overpronating foot or weak glutes causing excessive inward rotation of the knee.

Often a poor warm-up is cited as a reason why athletes sustain calf injuries. Most of us appreciate the necessity for a thorough warm-up. I often use ‘blue tack’ as an example when describing how muscles and tendons respond to a warm up. When you try and stretch cold blue tack it is tough and usually breaks, whereas when is has been warmed up it stretches nicely. It is also important to note that as we age, these elastic properties of tendons and muscles diminish – thus accounting for the increased occurrence of calf strains in the more senior of our athletic population.

A final contributor to soft tissue injuries in runners, especially long-distance runners is dehydration. Dehydration negatively impacts muscle function by reducing blood flow to muscles and decreasing muscle elasticity or flexibility and endurance.

Grades of strain or tear:

Muscular strains are classified according to their severity in terms of how many fibres have been disrupted or ruptured:

Grade 1	Grade 2	Grade 3
This is the least severe of calf injuries. A small number of muscle fibres have been damaged within the muscle. Signs and symptoms of this type of less serious strain may not be noticed until cessation of the activity. Tightness, cramping feelings and slight soreness are common when the muscle is stretched.	This is sometimes referred to as a partial calf tear. A greater number of muscle fibres have been torn, but the muscle remains largely intact. More immediate localised calf pain is present during activity, especially walking and running. Often the area is sore to touch.	Total rupture. All the muscle fibres have been torn, losing continuity throughout the muscle. This is a serious injury and highly disabling. The athlete will be unable to walk pain free. Often bruising will appear below the tear site and there may well be a palpable bulge where the calf muscle has recoiled upon itself.

Treatment and Rehabilitation:

Initially, the Rest, Ice, Compression, Elevation (R.I.C.E) principal should be followed. Therapeutic Ultrasound, Acupuncture, Sports massage and Taping are all methods used to facilitate soft tissue healing. Sports massage, however should not be performed until the acute phase has passed (3 days +). Approximate timescales for rest are; 3 weeks for a grade 1 strain and 4-6 weeks for a grade 2 strain. Grade 3 tears will most likely require surgery followed by a 12 week rehabilitation programme.

As with any injury, progressive and comprehensive exercise based rehabilitation is key to avoiding recurrence or secondary injuries. Secondary injuries often occur through compensatory mechanisms which may have become habit during the injured period. The rehabilitation period is also an ideal opportunity to target those areas that get ignored in weekly training routines. Core stability and gluteal muscles are a great place to focus on when activity is restricted. Research has found that the stronger these muscles can become, the more likely a successful outcome is to be reached in terms of injury recovery, injury prevention and most importantly performance.

Rehabilitation Exercises:

Specific single-leg exercises are important to build the strength in the injured limb and to regain balance which will have been lost on the injured side during the injury period. Here are some suggested exercises. However, I recommend you see a Physiotherapist for a tailored program and appropriate guidance.

Single Leg Standing

Stand on one leg keeping your bottom squeezed and core engaged. Ensure that your pelvis is level, your knee is facing forward and your trunk is upright. Try not to lock your knee. If you can successfully hold this position on each leg for 15-20 seconds you are ready to progress to a single leg squat.

This exercise targets your core and glute muscles.

Single Leg Squat

The same principles are applied in this exercise as in the single leg stand. The picture shows the athlete squatting to a chair. The chair provides a nice prompt to ensure that you are squatting correctly (sticking your backside out and not just bending at the knee).

I suggest that you start by only squatting down as far as you can control your knee (keep you knee cap over your 2nd toe) and keep your pelvis level. This may only be a tiny dip to start with, but it will improve.

Supported Heel Raise

This exercise should be pain-free and should therefore not be considered until you are symptom free walking up a flight of stairs. Begin with 50:50 of your body weight in both feet and raise up on to your toes, if you feel the need you may hold onto a rail/kitchen unit for support. Complete 3 sets of 10. If this is easy then you may progress on to 60:40, increasing the load in the injured side. The increases my continue 70:30, 80:20 up to a single leg heel raise.