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So, you’ve read the advice, watched the YouTube videos and been doing all the exercises, but your tennis elbow STILL isn’t getting better. Before you sink into total despair, let me explain a few common reasons why this might be the case and what you can do about it. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Quick recap on what tennis elbow is So why isn’t my elbow pain getting better? And finally... How we can help I've also explained all of this in more detail in this video: Quick recap on what tennis elbow is Tennis elbow is that nagging ache on the outside of your elbow that tends to be more bothersome when trying to grip, lift or carry things. Most of the time, it has absolutely nothing to do with playing tennis , which makes the name ‘tennis elbow’ seem slightly daft. Tennis elbow’ is also known as ‘Lateral elbow tendinopathy’ and this is the term we’ll stick with for now, as this is the up-to-date term for it in the most recent scientific literature – it basically means ‘a problem with the tendons on the outside of the elbow’ . For some reason, medical people love to turn simple descriptions half into Latin, but ‘lateral elbow tendinopathy’ does fit the bill better than ‘tennis elbow’. What do tendons do? Tendons are there to attach muscles to bone. Many of the muscles in the back of the hand, wrist and forearm all attach via a common tendon to the outside of the elbow on the ‘lateral epicondyle’ – the source of pain in lateral elbow tendinopathy. When you grip, lift or carry things, these muscles are put to work and load the tendon attachment. Why do tendons get irritated? Like most of the tendon problems that start without any obvious trauma or accident, lateral elbow tendinopathy is usually caused by a mismatch between the load being placed on the tendon versus the load it can consistently cope with. In real terms, the sudden increase in load might have been from chopping a stack of logs, completing a DIY job, starting a new regime at the gym, or completing a particularly nasty CrossFit WOD. Sometimes it can be from resuming normal activities but following a period of relative deconditioning – like if you had been out of action for a period of time, and sometimes it can be a more gradual build-up such as a change in job or workstation set up over a period of several months. Here's a more comprehensive article on the causes of tennis elbow . How do tendons recover? The earlier you deal with an irritated tendon the quicker it can recover. Generally speaking, the management of lateral elbow tendinopathy tends to follow the same stages as any other tendon problem: OFFLOAD  – temporarily modify activities so the tendon doesn’t get irritated and has a chance to settle down; REHAB  – address underlying individual biomechanical issues, work out what loads are tolerated without causing an increase in pain and start working on them (this is the bit a physio can be of most help after a thorough assessment); STRENGTHEN  – gradually add resistance to the exercises, strategically progressing the type and amount of loading, working towards your individual goal; RECONDITION / GRADUAL RETURN TO LOAD  – gradual return to the activity that may have caused the overload in the first place, but in much better condition so it doesn’t happen again! So why isn’t my elbow pain getting better? OK, so let’s say you know all that already. And it’s STILL HURTING. Here are the most common reasons, in my experience, why lateral elbow tendinopathy can fail to progress: 1. Inadequate offload Most of the YouTube videos and existing advice for lateral elbow tendinopathy tends to include ‘eccentric’ exercises for the wrist, slowly lowering the hand using a weight or a hammer – if you do these while the tendon is still irritated, this just overloads the tendon even more. It’s not the fault of the video makers or the leaflet writers, because some of the research on elbow pain suggests these are the exercises to do. BUT, that’s because elbows seem to be rather an unfashionable thing to research, so there really isn’t much good quality research out there. If there was, they would soon see the hammer exercises at the early stages are a bad idea and that giving it time to settle down first is more effective. 2. Over treating Friction massage, heat balms, freeze rubs, anything that perpetually pokes at a painful tendon is likely to keep it irritated. If you were already angry, wouldn't it make you more irritated if someone kept poking at you? Leave it alone for a bit to let it settle down. 3. Forgetting other factors It’s easy to think ‘elbow, elbow, elbow’ and concentrate only on the bit that hurts. But to get the elbow better, attention also needs to be paid to shoulder stability, core stability, ergonomics at work / in the gym, general fitness, diet, sleep, anxiety / stress, nerve irritation / sensitisation, or other medical conditions. All of these can contribute to elbow pain and might need addressing in order to get things better. 4. It might just need more time Unfortunately, a great deal of patience is often required for lateral elbow tendinopathy to get better. And we’re talking 3 to 6 months, if not more, most of the time. Why does it take so long? Most likely because it is REALLY HARD to offload an elbow tendon that you use every day for simple things, like pouring a kettle, opening doors and having a drink. Tendons are also mainly made up of collagen, and producing and strengthening collagen fibres takes much longer than producing muscle fibres for instance. So, if your symptoms are slooowly getting better and you find you can do more before it hurts (even though the pain is not gone yet), then it might just need more time. And finally… When things aren’t getting better, it is important to get a qualified healthcare professional to assess you, whether it is your GP, a physiotherapist or a sports medicine physician. Just in case it isn’t what you thought it was. It is always worth trying simple treatment and rehab first, before seeking further interventions such as injections, shockwave therapy and surgery. Most of the time the basics, when done correctly, can not only solve the issue but address some of the underlying causes that went with it. Injections with corticosteroid have more recently been shown to provide short-term benefit, but symptoms tend to be worse in the intermediate term and the long term effects are not yet known. Research has also shown that Platelet Rich Plasma (PRP) injections have been ineffective in the treatment of persistent lateral elbow tendinopathy. Another recent clinical trial compared the outcomes for surgery for chronic lateral elbow tendinopathy with ‘sham surgery’ and found that both groups improved and were no different to each other at follow up – suggesting it wasn’t what was done in surgery that helped, it was what they did afterwards during rehabilitation that mattered. Food for thought. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call  for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can follow Steph on LinkedIn . References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Kroslak M, Murrell GAC (2018) Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2018; 46 :1106–13 Millar NL, Murrell GAC, Kirwan P (2020) Time to put down the scalpel? The role of surgery in tendinopathy British Journal of Sports Medicine ; 54: 441-442 Olaussen M, Holmedal O, Lindbaek M , et al (2013) Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review BMJ Open Scott A, Squier K, Alfredson H , et al (2020) ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology British Journal of Sports Medicine ; 54: 260-262 Scott A, Docking S, Vicenzino B , et al (2013) Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012 British Journal of Sports Medicine ; 47: 536-544 de Vos R, Windt J, Weir A (2014) Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review British Journal of Sports Medicine ; 48: 952-956

Many people who have sprained their ankle playing sport may wonder whether it is necessary to go to A&E to have the injury diagnosed and treated, or whether it will be sufficient to rest it up at home. The short answer is: If you think you need to go to A&E, you probably should. A slightly longer answer is: It depends to a large extent on whether your ankle is broken or you have ruptured a tendon. This article will help you to figure out whether you should go to the emergency room or not. YOU MAY ALSO FIND THESE ARTICLES USEFUL: - How to treat a sprain – an update on the latest research - How to avoid recurring ankle sprains - Exercise treatment for broken ankles - Ankle braces for sprains – Do you need one, what type works best, and when to wear it When you should NOT go to A&E with an ankle injury Just to clarify, this article is about an injury that may have only just happened, with a sudden onset of pain because your foot was either forced sideways or upwards or downwards through trauma, like twisting it or being tackled. We're not talking about pain that's come on over a period of time, even though it can be really sore, because that is more likely to be an overuse injury. It still needs to be checked by a health professional as soon as possible so that you can get on the right track to recovery, but it's less likely to be broken and to require a trip to the emergency room. So, in this article, we're talking about something that's just happened through a traumatic mechanism of injury. How to test your sprained ankle for a fracture like they do at A&E At most accident-and-emergency departments they will apply what are called the Ottawa Ankle Rules. These are a set of rules to determine whether or not you need an X-ray of your sprained ankle. You can watch this video if you want to see Steph demonstrate this. Below are two pictures – one showing the inside of the ankle and foot and one showing the outside. These highlight the various places they will examine to determine whether they are painful or tender to the touch, which will indicate whether you need X-rays. They will be looking to see whether you've got tenderness at the tip of your lateral malleolus, which is the bottom of your fibula bone (Area 1 in the pictures), along the back edge of it for six centimetres. So, if you feel along the bone there and it's sore, then you will probably need to have your ankle X-rayed. The same goes for the bottom of the tibia (Area 2). You would probably need to go to hospital for your sprained ankle if you've got pain along the six centimetres at the bottom of the tibia, at the back edge of it, when you touch it. If you've had a trauma injury but actually have pain in your midfoot instead of your ankle, they will be looking to see whether you've got pain on your navicular (Area 3) or the base of your fifth metatarsal (Area 4). If either of these are painful to the touch, you may well need to go to A&E for X-rays of your foot and ankle. Lastly, you should check whether you can walk four weight-bearing steps. If you can walk four steps while carrying weight on the sprained ankle or foot, it is probably not necessary to go to A&E for your injury. If you do have tenderness in those bony areas or you have real difficulty weight-bearing and you do decide you need to go for an X-ray, it doesn't necessarily mean that your foot or ankle is broken. It is one of those things that some severe sprains can behave just like a fracture, and that's why you need an X-ray to decide whether or not it is broken, because actually the symptoms can be the same. Without an X-ray, it is very difficult to tell. Another reason to go to A&E even if you can stand on your foot If you think you've ruptured your Achilles tendon, you heard a pop, or it felt like someone kicked you in the back of your leg, or like you've been shot in the back of your Achilles, you also need to go to A&E. You probably won't have an X-ray, but the injury definitely needs to be seen the same day as you will need immediate treatment if you have torn your tendon. What to do for your sprained ankle if you do not have to go to A&E If you don't have any pain in those bony areas and you're able to weight-bear completely fine, then the good news is that there is less than a one percent chance that you've broken a bone in your ankle. So, you may well be able to save yourself a trip to A&E and having to sit there for hours, only to be sent home eventually with a bit of advice to rest the injured ankle. However, we would still advise you to see a health professional in the next couple of days, just so that they can give you some good advice on early management of the injury and to look at things properly. This will enable you to do the right things and to avoid the risk of getting persistent problems after it's healed or recurrent problems where it happens again and again, because this can happen in up to 70 percent of people after a lateral ankle sprain. So, you might want to look at the second article in this series of three, which tells you what you should be doing those first few days after an acute ankle sprain. The third article is focused on how to avoid the risk of spraining your ankle over and over again. Need more help? Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can read more about her here , and she's also on LinkedIn . References Kerkhoffs, G. M., van den Bekerom, M. et al. (2012). "Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline." British Journal of Sports Medicine 46 (12): 854-860. Tayeb, R. (2013). "DIAGNOSTIC VALUE OF OTTAWA ANKLE RULES: SIMPLE GUIDELINES WITH HIGH SENSITIVITY." British Journal of Sports Medicine 47 (10): e3. Wang, X., Chang, S. et al. (2013). "Clinical Value of the Ottawa Ankle Rules for Diagnosis of Fractures in Acute " PLoS One http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063228.

Hip bursitis or trochanteric bursitis is a tricky condition. It’s sometimes called “the great mimicker” because its symptoms are easily mistaken for other conditions like back pain or gluteal muscle injuries. But I’ve also found that quite a few patients I’ve seen have been misdiagnosed as having trochanteric bursitis when in fact the pain was caused by something else. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In the video below, I give a very detailed explanation of what causes the bursae over your lateral hip to become inflamed and sore and how you can help it to recover. In this article I’ve highlighted some interesting facts that even clinicians sometimes don’t take into consideration. 1. You have about 9 different bursae in the area of your lateral hip (the outside of the hip) and any of them can be the cause of your pain. A bursa is a sac filled with fluid and you find them in most areas where your muscles and tendons cross over or attach into bones. They are meant to help reduce friction between the bones and overlying soft tissue. There are several layers of muscle that attach into the top of your thigh bone from several directions, so it makes sense that you’ll have more than 1 bursa there. Bursae have lots of nerve endings and when they become irritated or inflamed can cause a lot of pain. A popular treatment for bursitis is a corticosteroid injection. If your injection did not work, it may be that the clinician missed the spot. I always try to refer my patients to someone that I know will do an ultrasound guided injection. This means that the person doing the injection uses ultrasound to look at where she/he places the needle and can aim it much more accurately . 2. It’s difficult to diagnose You would think that diagnosing trochanteric bursitis should be easy. Surely it’s a case of just pressing on the outside of the hip where the bursae are and seeing if it hurts? Erm no - the research has shown that there are several other injuries that also cause pain with pressure over that area. Even the two most sensitive tests (pain when standing on one leg for 30 sec; pain with resisted hip external rotation) can also produce pain when you have gluteus medius tendinopathy. Some of the injuries that can feel very similar to hip bursitis include referred pain from the lower back, gluteal tendinopathy and gluteal tendon tears. An experienced clinician will be able to distinguish between these conditions by taking a thorough history and listening to how you describe your symptoms, what makes it worse or better and by getting you to perform some specific tests. 3. Trochanteric bursitis likes company Not only can lateral hip bursitis be misdiagnosed but it can also be present in addition to another condition. In one study researchers found that 91.6% of the patients that they examined had other associated conditions. One of the most common “combinations” that I see in clinic is patients with ongoing lower back pain who also present with bursitis. Another example is glute med tendinopathy. If you want all the symptoms to improve you shouldn’t just treat one and leave the other. I go into this in a lot more detail in the video. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Rothschild B. Elusive trochanteric bursitis relief. Clinical Rheumatology 2019:1-1. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia 2009;108(5):1662-70.

If you’ve injured your anterior cruciate ligament (ACL), someone may have told you that you’ll likely need surgery to fix it. Or someone else may have told you that you don’t need surgery to fix it. Or you might not want surgery. In fact, being told different things by different people is one of the things that leads many to search for answers on Dr. Google. Luckily for us mere mortals, a group of sixty-six ACL injury experts from eighteen countries have formed a working group named ‘Panther’ in order to provide a world-wide consensus on the current optimum management of ACL injuries, based on the most recent research evidence and their expert opinion. The latest consensus from the ‘Panther’ group was published in July 2020 in the British Journal of Sports Medicine and provides some good advice on when surgery for an ACL injury is or isn’t a good idea. I have attempted to summarise some of this in normal language for normal people below. My colleague Maryke Louw has also made a video about this: Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.   Quick recap: What does the ACL do? The ACL is one of the ligaments that attaches your femur (thigh bone) to your tibia (shin bone) at your knee. Its job is to keep the knee stable , limiting how much the tibia glides forward on the femur as you move your knee. It also helps to control rotation. Injuring it can sometimes cause the knee to give way, particularly when pivoting on it or turning quickly. The ACL is usually injured by a non-contact twist of the knee. The most common description we physios hear is “my foot was stuck on the ground, I twisted, my knee went inwards and I felt (or heard) a sudden ‘pop’, I couldn’t continue. The knee swelled up massive within hours and now it doesn’t feel right.” Only an MRI scan can definitively diagnose or disprove an ACL tear. I have seen many cases where patients have been told in A&E that they ‘definitely haven’t torn their ACL’, only to find out later on an MRI that they actually had torn it. Likewise, occasionally a knee injury can sometimes have all the hallmarks of an ACL tear, but then turns out to be something else, like a tibial plateau injury. That said, if you fall into the category of somebody who would do well without surgery, then an MRI scan might not change how you manage the injury. In this case, it wouldn’t matter whether the ACL was officially torn or not, because your life would be fine anyway, just like all the people who injured their ACLs unwittingly in the past, were never diagnosed, and are now none-the-wiser. Anyway, back to the topic. Should you have surgery or not? Here’s a summary. Can an ACL injury heal on its own? Yes, a recent study showed that ACL tears can heal without surgery. The researchers also found that, two years after the injury, the patients whose ACL showed signs of natural healing on MRI reported less pain and better function than those who underwent surgery. However, not everyone's ACL will heal on its own, and some people do require surgery. Researchers are not yet sure why some people's ACL injuries heal spontaneously and others don't. When surgery is NOT required Based on the current consensus, non-surgical management can be successful if: The ACL is injured in the absence of any other concurrent injury (e.g. meniscus, cartilage, other ligaments); There is no ongoing feeling of instability or giving way after completing a progressive, targeted and individualised rehabilitation programme* (more on this later); The individual’s anatomical differences (e.g. the shape of an individual’s actual bones and joints, compared to someone else’s) are such that the knee is still quite stable despite the ACL injury; The individual only wishes to return to ‘straight line’ activities , such as running, cycling, and swimming. Benefits of not having ACL surgery There are obvious risks associated with having surgery – e.g. risk of infection or graft failure, which are avoided if you can manage your ACL injury without surgery. The rehabilitation period without surgery is quicker (usually about 3 months to return to sport) vs. after surgery (usually 6-12 months). This is because running is not recommended before 12 weeks post-op, as it often takes this long for the graft to be strong enough to tolerate running loads. There is also the donor site to consider – if it is a hamstring graft, you will be sacrificing a hamstring tendon for it to be used for the ACL graft during surgery. When surgery is recommended An advantage of surgery is that there tends to be less ongoing laxity, so the knee is structurally more stable. However, this is obviously dependent on the skill of the surgeon. The benefits of having surgery need to outweigh the risks for it to be an option. Surgical management is recommended if: You've also torn your meniscus , LCL or MCL ; The individual’s anatomical differences (e.g. the shape of an individual’s actual bones and joints, compared to someone else’s) are such that the knee is less stable with an ACL injury; A targeted, progressive, individualised rehab programme* has been completed but the knee continues to give way ; The individual regularly plays sports involving jumping, cutting and pivoting e.g. football, rugby, basketball – as there is a higher risk of secondary injury on return to sports if managed without surgery; There is ongoing instability / giving way on straight line activities despite rehab *. *Targeted progressive rehabilitation 100% of the experts agreed that both post-operatively, if surgically managed, or post-injury, if non-surgically managed, people need a progressive, targeted, and individualised rehabilitation programme to return to pre-injury activities. There is also evidence that performing rehab exercises while waiting for your ACL surgery can improve your outcomes. Rehab should be split into phases: Acute – Eliminating swelling, restoring range of movement, activating key muscle groups, addressing other contributing individual biomechanical issues. Mid – Neuromuscular control, proprioception/balance, and stabilisation exercises. Late – Restore full strength, function, sport/activity specific movement patterns. This is where a specialist physio guiding you through the rehab, tailoring it to your individual needs, and adapting the programme where necessary, can make a big difference compared with looking up ‘knee exercises’ on YouTube. Sometimes the best interests of a team differ from the best interests of the individual, e.g. if the player’s best outcome would be from surgery, but the team want the player to try non-surgical first as the rehab is quicker, to get them back on the pitch more quickly. So, watch out. So, there we have it. Both surgical and non-surgical management have their merits, but it depends on the individual’s circumstances as to which is the best approach for them . It’s important that this decision is guided by both the individual and by a healthcare professional. Whether managed surgically or non-surgically, the rehab is really important, and needs to be done well to have a good outcome. Does it increase my risk of osteoarthritis if I don't have ACL surgery? In the past, it was thought that ACL surgery reduced the risk of developing osteoarthritis in the knee, but they have since found that this is not necessarily the case. Development of osteorarthritis is multifactorial, and there are many contributing factors other than whether or not someone has had surgery for their ACL tear. Does it increase my risk of injuring my meniscus if I don't have ACL surgery? Sometimes. If you want to get back to a sport that involves a lot of pivoting and changing of direction, it might increase your risk of injuring your meniscus if you don't have ACL surgery. However, if you're not interested in doing those sports and your knee feels stable after completing your rehab, the research shows that your risk of a meniscus tear is low. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call  for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can read more about her here , and she's also on LinkedIn . References Diermeier TA, Rothrauff BB, Engebretsen L et al (2020) Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group British Journal of Sports Medicine doi: 10.1136/bjsports-2020-102200 Richard B Frobell (RB), Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS (2013) Treatment for acute anterior cruciate ligament tear: Five-year outcome of randomised trial BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f232 Saueressig, T., Braun, T., Steglich, N., Diemer, F., Zebisch, J., Herbst, M., ... & Belavy, D. L. (2022). Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis. British journal of sports medicine , 56 (21), 1241-1251. Filbay, S. R., Roemer, F. W., Lohmander, L. S., Turkiewicz, A., Roos, E. M., Frobell, R., & Englund, M. (2023). Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. British journal of sports medicine , 57 (2), 91-99.

There is a basic treatment recipe that you can use to treat nearly any muscle strain or tear. Muscle tears can be graded from 0 to 5, but for this article I’m going to simplify things and talk about Grade 1, 2, and 3 muscle tears. In this article: Grading muscle tears Recipe for treating muscle tears / strains The golden rules when doing strength training for an injured muscle Here's the video I did about this: Grading muscle tears Grade 1: You likely have a grade 1 muscle tear if you have some pain in the muscle when you use it, but you can nearly do everything as normal. You usually don’t feel any pain when you rest it. Grade 2: With a grade 2 tear you’ve torn a significant number of muscle fibres and there is usually quite a bit of swelling and bruising as well. You may have pain even when you’re lying down or sitting still and it is usually quite painful when you try and use the muscle. Grade 3: A grade 3 tear is a more serious one where you’ve torn more than 85% of the muscle fibres. There is usually a lot of swelling and bruising (but not always). If the muscle is fully torn through, you may not have much pain but you’ll find that you can’t use the muscles – there’s just no power or strength in it. You may get an ache even while resting it. Please make sure that you consult a physio or other healthcare professional if you have a significant tear in your muscle. Recipe for treating muscle tears / strains Day 1: Apply the RICE regime. Rest the injured body part and apply ice and gentle compression while elevating it. This will help stop the internal bleeding and limit the swelling. Day 2 to 5: Continue using ice as needed, but you should now start to gently move your injured muscle. DON’T stretch it! The injured muscle has to grow back together and you’ll make your injury worse if you stretch it at this point. DO start to gently move it, but don’t push into pain. Gentle movements will help it recover more quickly. Check out the video above for a detailed explanation on how to do this. After day 5: You now have to slowly start strengthening the muscle back up. What you do for strength training and how heavy you start can vary dramatically depending on how badly you’ve torn your muscle. For instance, for severe quad strains I may first get a patient to just tense their quadriceps muscle with their leg straight (isometric contraction) and hover the straight leg 5cm off the bed while if it was only a mild quad strain, I may get them doing squats. The golden rules when doing strength training for an injured muscle are: Forget what you could do before your injury – you have to test what the muscle is capable of doing now and start there. Don’t push into pain. Especially during the first few weeks, you want the exercises to be totally pain free and also to not feel any increase in pain after doing your exercises. Do not go back to doing your sport if you’ve not done specific exercises to strengthen your injured muscle to the level that is needed for your sport. The strength training has to be a progressive programme that starts light but then increases in intensity so that it resembles what will be expected of your muscle when you play your normal sport. Grade 1 muscle tears take about 4 weeks to regain full strength while Grade 2 tears can take between 6 to 12 weeks. Let me know if you have any questions . Need more help with your injury? You're welcome to consult me online via video call for an assessment of your injury and a bespoke treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References Bisciotti, G. N., et al. (2018). "Italian consensus conference on guidelines for conservative treatment on lower limb muscle injuries in athlete." BMJ Open Sport & Exercise Medicine 4(1): e000323. Pollock, N., et al. (2014). "British athletics muscle injury classification: a new grading system." British Journal of Sports Medicine 48(18): 1347-1351.

There are few things as frustrating as thinking that you’ve gotten rid of an injury just for it to flare back up after a few sessions of running or exercise. In this blog post I’ll explain how you can make sure that you make a smooth return to sport without reinjuring yourself. In this article: What happens when you get injured What strains that part of your body? Use your running / sport as final strength training Here's the video I did about this. What happens when you get injured I’ve written in detail about how injuries heal so I’ll keep this brief. The main thing that you need to understand is that your injured body part’s strength reduces significantly when you injure it. As a result its capacity to cope with the forces from running or other activities drops. This is why it doesn’t work to just rest an injury until it feels better and then try and jump back in to what you think is an easy run. You have to actually first strengthen that part of your body back up to the point where it can handle the forces from running. An easy run may still “feel” easy because it hardly makes you breathe hard, but the forces that go through your body may be too much if you’ve not done enough strength training. How much is enough? You can’t just pull a figure out of the air. You have to test it to find out. For example, if you’ve strained your calf muscle, I would want you to be able to do all of the following BEFORE I give you the green light to start running: be pain free with walking, easily do 3x15 heel raises, and hop 10 times pain free. Every injury has a different set of things that you’ve got to be able to complete before you go back to your sport, because every structure in the body works in a different way when you run or play sports. What strains that part of your body? It’s really useful to understand exactly how that part of your body normally works – when does it normally take a lot of strain? Understanding this can actually allow you to get back to running or other sports more quickly as long as you make certain adjustments. A medial meniscus strain in the knee is a good example of this. Some of my patients have found that they can continue running as long as they avoid uneven ground and stick to flat surfaces. This is because the meniscus mainly takes strain when you twist your knee so, depending on where the tear is, you don’t strain it if you stick to doing activities or running in straight lines. Use your running / sport as final strength training OK, so let’s assume that you’ve done all your strength training and passed the tests that shows that you’re ready to get back to running. The forces generated in your muscles, ligaments, tendons and joints when you run are very high. For the Achilles tendon it can be equal to up to 6 times your body weight! That’s why you should view your first few weeks of running as an extension of your strength training programme. I usually get my runners back doing a run/walk programme for the first 2 or 3 weeks, depending on the injury. Yes, it may be frustrating because you just want to get out there and run, but what’s the use of doing 6 weeks of rehab to go and mess it up and then having to start from scratch? Every run or training session that you do will help your injury grow stronger as long as you make sure that you don’t increase the volume and intensity too quickly. If it was a significant injury that took 6 weeks or longer to settle down, I would advise that you take about 12 weeks to build back up to your normal training programme. This period of time could be shorter but may also have to be longer – it all depends on your injury and your goals. Let me know if you have any questions . Need more help with an injury? You can consult me online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References: Cook J, Docking S. “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine 2015;49(23):1484-85. doi: 10.1136/bjsports-2015-094849

A SLAP lesion is a type of shoulder injury that involves the labrum inside the shoulder joint. SLAP stands for Superior Labrum Anterior Posterior. It is most commonly found in athletes who do "overhead" sports, e.g. pitching, tennis, or volleyball. It usually happens when they are throwing a ball or hitting an overhead shot, but you can also sustain it by falling on an outstretched arm or when tackling an opponent in rugby. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. SLAP lesions vary in severity. The long head of biceps’ tendon attaches to the top of the labrum in the shoulder and can sometimes also come away from the bone (Type 2 lesion). Minor labral tears can be managed without surgery through a carefully graded rehab exercise programme. In this article I’ll discuss how the research suggests you do this. In this article: Relative Rest Medication Rehab exercise programme for SLAP lesions Look further than just the shoulder I've also made a video about this: Relative Rest Relative rest forms an important part of any rehab programme. Relative rest means that you reduce your activity and sport to a level that doesn’t aggravate your injury. In other words, you don’t have to stop all activity – only the movements that cause pain. Medication You may think that it’s strange that I include a section on medication when the article is about rehab exercises. SLAP lesions, even minor ones, can often be very painful and you can’t really do any meaningful exercise while you’re in pain. NSAIDS can be useful for pain management and to help reduce swelling and inflammation – especially in the early stages. In some cases the pain may not respond to pain medication, in which case a corticosteroid injection may be appropriate. Steroids can, however, interfere with the healing process so it should only be used if really needed. Hands-on treatment consisting of soft tissue release and dry needling can be a very effective alternative to using pain medication or injections. It can provide very good pain relief and does not come with so many side effects. Rehab exercise programme for SLAP lesions The length of the rehab programme should really be tailored according to your injury, but 16 weeks is a good starting point. You may take longer if your injury is more severe or shorter if you only have a tiny tear in your labrum. The current theory with regards to why this injury happens is that, due to the high volume of repetitive overhead movements these athletes do, they: develop a tight posterior joint capsule that pushes the head of the humerus forward and up, causing increased strain on the labrum. The tight capsule usually causes the shoulder to have less internal rotation than on the other side, so it is useful to test the total rotation range of motion in the one shoulder vs. the other shoulder. often also develop a muscle strength imbalance between the internal rotators (stronger) and the external rotators (too weak) of the shoulder. That’s why a rehab programme for SLAP lesions usually have to include stretches to improve internal rotation range of motion and pay special attention to strengthening the muscles that control external rotation. Early Rehab: Weeks 1 – 4 If you have a Type 2 SLAP lesion, which means that the the biceps tendon is also pulling away from the glenoid, you have to make sure that you choose exercises that DON’T load the biceps during the first 4 weeks. This will allow the tendon time to reattach and settle down. Your first aim should be to restore full range of motion in the shoulder into all directions. Free active movements, where you move the arm into all directions but stop just short of pain can be useful for this. The Sleeper stretch is one that is commonly prescribed to help stretch the posterior capsule and increase internal rotation, but it can actually cause a lot of pain during the early stages of this injury. Doing a gentler stretch where you just pull your arm across your body may be a better option to start with. The focus during this early stage should be on activating and strengthening the stability muscles of the scapula and shoulder, which include the lower trapezius, middle trapezius, serratus anterior and rotator cuff. Choose exercises that are done in relatively low load and stable positions. Use low resistance and high reps, but do the movements slowly while focusing on control. Examples of exercises that may be useful during the early stages of rehab include: Forward flexion in side lying Prone extension Seated row Serratus punch Knee push-up plus Supported internal rotation in 20 degrees of abduction Supported internal rotation in 90 degrees of abduction Internal rotation diagonal with pully Supported external rotation in 20 degrees of abduction Supported external rotation in 90 degrees of abduction Forearm supination with arm supported External rotation Mid Rehab: Weeks 5 – 12 Start loading the biceps through using exercises like: Forward flexion in external rotation and forearm supination – starting with short levers (elbow bent) and progressing to long levers (arm straight) Full can Elbow flexion in forearm supination Uppercut Progress your strength training to using heavier loads in more unstable positions. Include fast and/or ballistic exercises e.g. throwing a ball against the wall. You should strengthen the shoulder into all directions and think about what you need to be able to do in your sport. Late Rehab: Weeks 13 - 16 During this period your exercises should be very sport specific and resemble movements and forces that you would experience when you play your sport. This will obviously vary depending on the sport. Look further than just the shoulder Your neck and back posture has a direct influence on your shoulder position and function. When you hit or throw a ball, a large part of the force should be generated lower down in the kinetic chain, through your hips and core. You’ll place extra strain on your shoulder if those areas aren’t playing their part properly. This is why the person who creates your rehab programme should also consider your posture, strength and movement patterns in the rest of their body. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References: Brukner, P, et. al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Abrams, G. D. and M. R. Safran (2010). "Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes." British Journal of Sports Medicine 44(5): 311-318. Cools, A. M., et al. (2014). "Rehabilitation exercises for athletes with biceps disorders and SLAP lesions: a continuum of exercises with increasing loads on the biceps." The American Journal of Sports Medicine 42(6): 1315-1322. Helgeson, K. and P. Stoneman (2014). "Shoulder injuries in rugby players: Mechanisms, examination, and rehabilitation." Physical Therapy in Sport 15(4): 218-227. Manske, R. and D. Prohaska (2010). "Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete." Physical Therapy in Sport 11(4): 110-121. Moore-Reed, S. D., et al. (2017). "Conservative Treatment for Patients with Suspected SLAP Tears: A Case Series." urkiye Klinikleri Journal of Health Sciences 2(2): 121. Wright, A. A., et al. (2018). "Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis." Br J Sports Med 52(4): 231-237.

Tarsal Tunnel Syndrome is one of many conditions that can cause pain or funny sensations on the inner part of your ankle as well as under your foot. In this article, I'll explain what it feels like, how you can test for it, and what treatments may be useful. In this article: What it is What can cause it? What it feels like How do you test for it? Treatment for Tarsal Tunnel Syndrome Here's the video I did about this: What it is Your Tarsal Tunnel is located on the inside of your ankle. The tunnel is formed between the bones on the inner part of the ankle and a thick fibrous band (the flexor retinaculum) that runs from the medial malleolus to your heel bone. The Tarsal Tunnel contains the posterior tibial tendon, the flexor digitorum longus tendon, the posterior tibial artery and veins, the posterior tibial nerve and the flexor hallucis tendon. The posterior tibial nerve runs behind and below the medial malleolus and divides into two smaller nerves, the medial and lateral plantar nerves. Tarsal Tunnel Syndrome develops when the pressure inside the tunnel increases, compressing the posterior tibial nerve or any of its smaller branches. What can cause it? Tarsal Tunnel Syndrome can be caused by anything that decreases the space and therefore increases the pressure inside the tarsal tunnel. Some of the most common causes include: Changes in the foot anatomy e.g. when the foot arch flattens. Excessive pronation of the foot Thickening of retinaculum or the tendons that run inside the tunnel e.g. thickening of the tibialis posterior tendon when you have Tib Post Tendinopathy Cysts or growths inside the tunnel What it feels like We all have slight differences in where the tibial nerve runs and also at what level it splits into the medial and lateral plantar nerves. As a result you may find that where you feel your pain or symptoms is in a different area than other people with this condition. You can experience pain, throbbing, numbness, tingling or funny sensations on the inside of the ankle or underneath your foot, but it can also shoot up into your calf. The pain from Tarsal Tunnel Syndrome can easily be misdiagnosed as plantar fasciitis , because it can cause a similar pain under the heel. Nerve root irritation involving the L4, L5 or S1 nerve roots can also refer pain into that area. You can even have a “double crush” injury where the nerve can be stuck higher up the leg or in the lower back, causing it to pull extra tight around the ankle when you walk. This is why it is useful to consult a clinician who can listen to all your symptoms and test everything from your lower back down to your ankle. How do you test for it? Important! None of these tests are 100% accurate. This means that the test may sometimes produce pain even when you don’t have Tarsal Tunnel Syndrome and other times all the test may be pain free despite your nerve being compressed. The tests have to be combined with a full examination of the rest of your leg and lower back. Tinel’s test: You tap over the nerve in the area that you think it may be compressed. If it produces funny sensations or pins and needles, the test is positive and you may have Tarsal Tunnel Syndrome. Combined Dorsiflexion & Eversion test: You bend the foot up into dorsiflexion and at the same time turn it out into eversion. This position puts extra strain on the posterior tibial nerve. Combined Plantar flexion & Inversion: You point the toes down and at the same time turn the foot in into inversion. This position compresses the tarsal tunnel. Treatment for Tarsal Tunnel Syndrome Treatment for Tarsal Tunnel Syndrome has to be specifically designed for you. It has to address the reason why YOUR nerve is being compressed. Is it your foot’s position or thickened tendons or maybe an activity that you’re doing on a regular basis that is causing your problem? Conservative treatment consisting of soft tissue massage, dry needling and stretches can work well for some. Just be careful – calf stretches can sometimes make the pain feel worse. Orthotics or supportive insoles can also be useful to help reduce over-pronation. Strengthening the muscles that support the foot and leg may help for others. In cases that does not respond to conservative treatment, corticosteroid injections and immobilising the foot for a period in a boot may work. Surgery, where they release the nerve, is also an option and can give good results. However, that too doesn’t work for everyone. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References: McSweeney, S. C. and M. Cichero (2015). "Tarsal tunnel syndrome—a narrative literature review." The Foot 25(4): 244-250. Tu, P. (2018). "Heel pain: diagnosis and management." American family physician 97. Raikin, S. M. and J. M. Minnich (2003). "Failed tarsal tunnel syndrome surgery." Foot and ankle clinics 8(1): 159-174. Yang, Y., et al. (2017). "Fine dissection of the tarsal tunnel in 60 cases." Scientific reports 7: 46351.

Our spines naturally curve in at the lower part (lumbar spine) and out in the top part (thoracic spine). For some people the curve in their lower backs may be increased and this can sometimes lead to lower back pain. In this video I explain what causes hyperlordosis in the lower back and I demonstrate some exercises that you can do to improve it. You can also download the exercises as a PDF on this page , but I would advise that you watch the video first to see how I demonstrate them. Let me know if you have any questions . Need more help with an injury? You’re welcome to consult me online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram .

THE BODY HACK SERIES: Body Hack 1: How to look after your joints Body Hack 2: Recipe for strong bones (this article) Body Hack 3: How to keep your muscles happy Body Hack 4: How to avoid tendon pain You’re making a mistake if you think that “brittle bones” or poor bone health is something only older people have to worry about. Athletes of all ages can suffer stress fractures and I’ve seen several patients through the years who have been diagnosed with poor bone density before the age of fifty. The advice in this article is vitally important for children as well as adults. Research has shown that kids who have optimal bone health grow into adults with strong bones. So, how do you ensure that you have strong bones? There are four main ingredients to this recipe: Vitamin D Minerals: Calcium, Magnesium and Phosphorus Eat enough food Impact activity I also discussed this topic in my Facebook group. Vitamin D I do like to go on about Vitamin D, but it’s because it plays such an important role in so many aspects of our health. It’s been shown to not only affect bone health but also muscle function, heart function, your immune system and chronic inflammation, to name but a few. Vitamin D is produced in our skin when the UV rays of the sun shines on it. You need Vitamin D in order to absorb Calcium and Phosphorus (the main building blocks for bone) from your gut. Alarmingly, the research in recent years have shown that a large proportion of us seem to be running low when it comes to this important vitamin. Researchers think that due to a combination of factors including spending more time indoors and using sunblock when we’re outside. Also, in countries that are located far away from the equator (like the UK), the UV rays are not strong enough during the winter months to produce enough Vitamin D. Top tip: Make sure that you take a Vitamin D supplement if you’re not able to get at least 15 minutes of strong sunshine a day. You can read more about how much Vitamin D you should take in this blog post . Minerals: Calcium, Magnesium and Phosphorus Most of you may know that Calcium is needed to build strong bones, but Magnesium and Phosphorus are also important. You can check the nutrient content of different food sources on the USDA website . It seems that dairy products contain significantly more of these 3 minerals than any other type of food, but lots of fruit and veg (kale, carrots, potatoes, spinach, fortified orange juice etc.) also contain it to a lesser extent. Top tip: Look at your diet. Are you getting enough Calcium, Magnesium and Phosphorus? Eat enough food This may sound like a strange comment, but let me explain. Research has shown that people who constantly under-eat or starve themselves develop poor bone health over time. I’m not talking about cutting out rubbish food so that you can weigh your ideal healthy weight. I’m talking about eating less calories than what your body needs to survive and doing this over a long period of time. You may fall into this category if you have an eating disorder e.g. anorexia nervosa or bulimia. Athletes in certain sports e.g. cycling, endurance running or horse racing may also chronically under-eat because they can potentially perform better if they weigh less. What the research is showing is that this type of behaviour predisposes athletes to developing stress fractures . In the ordinary population it can lead to osteoporosis which means that you may be at higher risk of breaking your bones. Top tip: If you suspect that you may not be getting enough energy from your diet, find a dietitian or sports nutritionist to help you achieve your goals. Impact activity Weight bearing activities that jolt your bones e.g. walking, running, tennis etc. stimulate your bones to grow stronger. Research has shown that people of all ages who take part in impact activities tend to have stronger bones than their sedentary contemporaries or people who do non-weight bearing exercise e.g. swimming. Injury may be preventing you from doing ordinary impact sport, but you can also gain some benefit from other activities e.g. weight training. As mentioned, swimming may not be the best for building bones but research has shown that swimmers still have better bones than sedentary people. You can read more about the bone building benefit of different activities in this article about osteoporosis. Top tip: Speak with your physiotherapist if you have an injury and is struggling to find exercise that works for you. A clued-up physio should be able to devise an exercise plan that does not affect your injury. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate . References: Close GL, Russell J, Cobley JN, et al. Assessment of vitamin D concentration in non-supplemented professional athletes and healthy adults during the winter months in the UK: implications for skeletal muscle function. Journal of sports sciences 2013;31(4):344-53. Gómez-Bruton, Alejandro, et al. “Is bone tissue really affected by swimming? A systematic review.” PLoS One 8.8 (2013): e70119. Maughan RJ, Burke LM, Dvorak J, et al. IOC consensus statement: dietary supplements and the high-performance athlete. International journal of sport nutrition and exercise metabolism 2018;28(2):104-25. Owens DJ, Allison R, Close GL. Vitamin D and the athlete: current perspectives and new challenges. Sports Med 2018:1-14. Tenforde AS, Nattiv A, Ackerman K, et al. Optimising bone health in the young male athlete. British Journal of Sports Medicine 2017;51(3):148-49. doi: 10.1136/bjsports-2016-097000 Zanker CL, Swaine IL. Responses of bone turnover markers to repeated endurance running in humans under conditions of energy balance or energy restriction. Eur J Appl Physiol 2000;83(4):434-40.

THE BODYHACK SERIES: Body Hack 1: How to look after your joints Body Hack 2: Recipe for strong bones Body Hack 3: How to keep your muscles happy Body Hack 4:  How to avoid tendon pain In this article I specifically discuss overstrain injuries of tendons, including how they’re caused and what you can do to recover. This type of tendon injury is commonly referred to as tendinitis, tendinosis or tendonitis. All three these terms refer to the same thing. Check out our online service for treating Achilles tendonitis . In this article: Examples of common tendon injuries What happens when a tendon gets injured? Causes of tendon pain How do you know it’s a tendon that you’ve injured? What to do about tendon pain I've also discussed it in detail in this video: Examples of tendon injuries A tendon is the thick sinewy bit that attaches your muscles to your bones. In theory you’re able to develop tendinosis in any tendon in the body, but there are certain ones that are more prone to injury than others. Check out the picture below the list to see where this is. These include: Tennis elbow – This is caused by an injury to the common extensor tendon of the wrist Golfer’s elbow – This is caused by an injury to the common flexor tendon of the wrist where it attaches to the inside of the elbow. Biceps tendon where it runs over the front of the shoulder Rotator cuff tendons in the shoulder joint Iliopsoas (hip flexor) tendon where it runs over the front of the hip Hamstring tendon where it attaches to the sit-bone Glute med tendinopathy can be felt deep inside the buttock – usually more towards the side. Adductor tendons where they attach on to your pelvic bone in your groin Patellar tendon where it attaches into the lower end of your kneecap Achilles tendon – This can get tendinosis either where it attaches into the heel bone or in the middle of the tendon. Tibialis posterior tendon that wraps around the inside of the ankle What happens when a tendon gets injured? Tendons mainly consists (70%) of tightly packed collagen bundles that are aligned in parallel. Collagen is pretty tuff stuff to start with but this parallel alignment ads to the tendon’s strength. Think of a piece of sewing thread. When single, it’s quite easy to break but if you take 5 pieces of thread together (in parallel) it becomes significantly stronger and more difficult to snap. When you injure a tendon, it affects the collagen in the following ways: The collagen fibres become thinner. They become wavier and lose their parallel alignment in certain areas. The overall density of the collagen fibres in certain parts of the tendon decreases. Tendons also contain cells (e.g. tenocytes). Some of these cells change shape when a tendon is injured. When you look at an injured tendon using an ultrasound scanner, you often see little blood vessels that are present in the injured part. Healthy tendons don’t tend to have blood vessels growing inside them. The end result of all of these changes is that you end up with a painful tendon that isn’t quite as strong as it used to be. The tendon may also appear to have a thickened bump in it – this is most prominent when you have Achilles tendinosis. Causes of tendon pain The number one cause of tendinosis or tendon pain is when you overwork the tendon. This can be done suddenly or slowly over time. Let me explain. Sudden overload This is when you do an activity that is much harder than what the tendon has been trained to cope with. Examples include increasing your training volume too quickly e.g. you’re only used to running 5 and 10km and then suddenly do a 20km run. Or you do a more intense training session e.g. you lift a much heavier weight than what you normally lift; or you’re used to running mainly on the flat and suddenly jump into a hard hill session; or you’re used to running only slowly and suddenly do a hard speed session. When your tendon pain is caused by sudden overload, you usually develop quite intense pain within hours of your last training session or wake up with a painful tendon the next morning. Gradual overload When we train or exercise our bodies undergo micro-damage in our muscles, bones, ligaments and also our tendons. This micro-damage acts as the stimulant to tell the brain to make your body stronger. If you give yourself enough recovery time after exercise , the body repairs this exercise induced damage and you end up with stronger tendons etc. BUT if you don’t allow it to recover fully and train too often, this micro-damage accumulates and can cause a wide variety of injuries. This is how you can developed a tennis elbow by working long hours on a computer and repeating the same wrist movements for hours on end. The poor wrist muscles and tendons also need a break! Poor technique can cause tendons to overstrain over time. Thinking of tennis elbow again. A tennis player may develop it if they don’t use their hips enough and try to create all the force for their backhand shots with their arms. Muscle weakness in other parts of the body can cause trouble. Glute med weakness may cause your leg to turn in more when running which in turn can cause your foot to turn in or pronate excessively. This whipping action can often contribute to Achilles and Tibialis Posterior tendinopathy. Tendon pain caused by gradual or cumulative overload usually develops over a period of weeks. Other causes of tendinosis include: Conditions like diabetes and very high cholesterol Inflammatory conditions e.g. psoriasis can cause tendon pain The menopause (yip, another symptoms to add to the list ladies…sigh) Certain antibiotics (Fluoroquinolones) can cause tendon damage How do you know it’s a tendon that you’ve injured? The pain is usually pretty much localised to the specific tendon and does not tend to refer into other body parts – see the picture. It often feels worse after you’ve stretched it. This is not always the case but is especially true for glute med tendinopathy, tennis elbow, hamstring, tib post and insertional Achilles tendinopathy. If gradual overload is causing your tendon pain, you may find that it follows a pattern where you can feel the pain at the beginning of an exercise session, it then improves as you continue to train, but then comes back worse later in the day. If you caused your tendon injury through a sudden overload, you will likely find that you cannot exercise it due to the pain. You may find that the tendon feels very stiff after you’ve sat still for a period of time or first thing in the morning. Depending on your injury, this stiffness may disappear quickly with movement or stay there for most of the day. When it may not be tendinopathy If the pain came on as a sudden sharp pain while exercising – this usually means that you’ve torn something and it’s best to go and see a physio. If you’re getting any pins and needles or funny sensations in your arm or leg. Chances are that you’ve injured a nerve and I would again consult a physio for a proper diagnosis. If the pain refers up or down your arm or leg e.g. you have buttock and heel pain or you have shoulder and elbow pain. I would once again want to make sure that your pain is not coming from a nerve rather than your tendon. If the injury throbs or feels hot, please go and see your doctor. These are signs of infection and will likely need medical attention. What to do about tendon pain Figure out the cause. You have to know the cause if you want your tendon injury to recover and not come back in the future. Relative rest. You don’t necessarily have to stop all exercise. You can often just adjust your training volume, intensity or even the terrain you train on. The important thing is to establish a baseline of training that you can perform that does not make your pain worse. It’s OK to feel some discomfort while exercising but it should not increase it by more than about 3/10 in the 24 hours afterwards. I tend to spend a large portion of my consultation time on making sure that I fully understand my patient’s training schedule and history as this part of the treatment is key to making a successful recovery. Follow a carefully graded strengthening programme to help the tendon recover. Those damaged collagen fibres has to be replaced by healthy well organized ones. The only way to do this is by exercising them, but the level of exercise has to be pitched at the right intensity for your specific tendon. There is no one-size-fits all. Fix the other things that may have contributed e.g. poor technique, muscle weakness in other parts of the body, shoes or equipment etc. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate . References: Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports medicine and arthroscopy review 2018;26(1):16-30.

THE BODYHACK SERIES: Body Hack 1: How to look after your joints Body Hack 2: Recipe for strong bones Body Hack 3:  How to keep your muscles happy (this article) Body Hack 4: How to avoid tendon pain Muscle injuries make up a significant portion of the injuries I treat in my physio clinic every week. Fun fact: You don’t have to do exercise to injure muscles! Sitting still for long periods can cause just as much trouble! In this article I’ll discuss the best ways to avoid muscle tears, overuse muscle injuries and muscle pain caused by tension or inactivity. In this article: Muscle tears may not be preventable…or are they? The key to avoiding overuse muscle injuries How to avoid or treat tension muscle pains I've also discussed this topic in this video. Muscle tears may not be preventable…or are they? There are plenty of reasons why someone may tear a muscle and I totally agree that it may sometimes not be your fault. For instance, a while back I did a good job of tearing my hip flexor when I crashed my mountain bike (yeah I know I could have gone slower, but I’m going to say that I couldn’t avoid it!). However, most of the muscle tears that I see in practice happened when the athlete either did not warm up properly or when they were tired. The importance of warming up A good warm-up routine not only raises your core temperature but also wakes up your nervous system. Your nervous system (brain, spinal cord and nerves) is in charge of every single thing in your body – including your muscles and how they contract. Your muscles may be strong, but they can only work properly if the nervous system is fully awake and giving it clear and well timed signals. Have you ever misjudged the height of a step? It’s amazing how that miscalculation on the brain’s side can jolt you or even cause you to fall. We don’t give it much thought but just think of all the calculations of exact muscle contraction speed, force and length the brain has to make with every step you give when you’re running in a straight line. Now imagine how this intensifies when you’re playing a game of football! If you don’t wake your nervous system up properly before you do sport, you are at a greater risk of spraining or straining your muscles and joints. Top tip: Warm-up properly before you exercise! How being tired can cause muscle tears Did you know that your nervous system can get tired? I never did. We often speak about our bodies feeling tired or our muscles feeling tired, but people don’t realise that their nervous system can also get exhausted and tired. Remember how your nervous system controls the quality of your movements and muscle contractions? When your nervous system gets tired your muscles fibres may contract slightly out of sync with each other and that can cause muscles tears. That’s why athletes are often at a higher risk of tearing a muscle when they train on tired legs or towards the end of a hard training session or match. It’s not only exercise that can tire your nervous system out. Mental fatigue has also been shown to increase your risk of sustaining injuries . Top tip: Schedule your more complex training moves towards the start of a session so that your nervous system is still fresh and in full control. If you’re feeling mentally drained, choose an easy workout that does not involve complex movements and focus on relaxing and enjoying the session. The key to avoiding overuse muscle injuries Up your training intensity/volume gradually Your muscle fibres are only strong enough to cope with a certain load. What do I mean with load? Depending on what sport you do, load can mean weight (e.g. lifting 50kg) or miles you can run (20 miles per week) or number of exercise classes you can do etc. If you do an activity that’s a lot harder or more intense than what your muscles can cope with, you’ll likely end up straining them. If, however, over time you add little bits of extra load slowly and carefully your muscles become stronger. This feels like common sense but it’s amazing how easy it is to overstep the mark when you’re on a training high. Top tip: Keep a training diary so that you can look back and see if you’ve increased your training too quickly. For runners, the current advice is to stick to the 10% rule and not increase your training volume or intensity by more than 10% per week. Recovery, recovery, recovery….. When we exercise our bodies sustain micro-trauma and they fatigue. This micro-trauma is actually important as it acts as the stimulus to tell the brain that we need our muscles to be stronger. During the hours immediately after training the body has to repair this micro-trauma. If you give your muscles enough recovery time before your next training session, they will be stronger than before. If, however, you train again too soon (before they’ve fully recovered) they may be weaker than before. If you do this too often, you may end up giving them an overuse injury. How much recovery time you need will depend on your level of fitness as well as the intensity of the exercise session you’ve done. As a rough guide the research suggests that you should allow at least 24 hours after a moderate training session and 48 hours after an intense exercise session. Top tip: Your recovery is just as important as your training. You can read more about how to schedule your running training to avoid injury in this article. The article’s written for runners, but the general principles can be applied to any sport. How to avoid or treat tension muscle pains Hands up if you’ve ever ended up with a stiff neck or back from spending hours in front of the computer. Or do you perhaps find your neck muscles tighten up when you’re in a stressful situation? One’s natural instinct is often to want to stretch the muscles that are tight or click your joints. This can provide some temporary relief but a much more effective and lasting solution is to exercise them. By doing exercise that moves your whole body (especially the stiff bits) and that increases your heart rate you: increase the blood flow through the tight muscles which makes them more flexible and provides them with the oxygen and nutrients they need; your body produces endorphins (happy hormones!) that calms the nervous system down, improves your mood and decreases your stress levels. Other modalities e.g. massage and dry needling are also very good at providing pain relief, but this usually doesn’t last very long. I find that active exercise provides more lasting relief from tension related muscle stiffness and pain for my patients. It’s also something that they can do without my help! It is, however, important to choose your exercise wisely. If you have a sensitive, painful neck, doing quick uncontrolled movements with arm weights may not be the best option. Choosing more controlled activities that are set at the right level for you may be more appropriate. So speak with your physiotherapist before you dive in. Top tip: Counter the effect of tension muscles aches and pains with active exercise. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate