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THE BODY HACK SERIES: Body Hack 1: How to look after your joints (this article) Body Hack 2: Recipe for strong bones Body Hack 3: How to keep your muscles happy Body Hack 4: How to avoid tendon pain My 40s are looming and, while I don’t normally take much notice of age, I’m finding myself becoming just a little bit paranoid about my health. My mom has arthritis and I can’t help wondering whether my joints are destined to give me trouble in the future. I would really like to be able to stay active and enjoy life right into old age. This has prompted me to create the Body Hack Series, in which this article is the first of four. In this article: What are joints actually? Why movement is important for joints How strong muscles can protect joints What exercise is best for joints? Is it worth using joint supplements? I also discussed this topic in this video: What are joints actually? Most of your joints in your body are synovial joints. Take for example your main knee joint (the knee actually has 3 joints, but for demonstrative purposes let’s pretend there’s just one). It is formed where the thigh bone (femur) meets the shin bone (tibia). The bony surfaces are covered in very smooth cartilage. They are held together by a thick fibrous capsule that fully surrounds the joint. The joint is filled with synovial fluid. Synovial fluid has a similar consistency to egg white and helps to reduce friction inside the joint. It is also the main transport system to get nutrients and oxygen to the different parts of the joint. Your joints and the cartilage that covers the bones don’t have any blood vessels inside them. They rely fully on the synovial fluid to get enough nutrients and oxygen. Which brings me to my next point. Why movement is important for joints As mentioned above, joints don’t have arteries and veins inside them and have to get all their nutrients and oxygen from the synovial fluid. They rely on the changes in pressure created when you move them to force fresh nutrients and oxygen into the joint and cartilage. In short, you need to move joints regularly to keep them healthy and well fed. This is one of the reasons why you can feel so stiff after sitting for a few hours. I have written in the past about how sitting for long periods can affect your hip joints in particularly. Top tip: Make sure that you take regular breaks from sitting during the day. Don’t just stand up for a second and stretch – go for a quick 2 minute walk or run up the stairs to move your joints and feed them properly. How strong muscles can protect joints Your joints are not supposed to take all the force when you move. Take your hips for instance. Around 60% of the force that goes through your legs when you walk is meant to be absorbed by the muscles that surround your hips. If your muscles aren’t strong enough, your joints will have to take more force and may become overused and injured. The knees are another good example. Every treatment programme for knee pain usually starts with some sort of strengthening or activation exercise for the thigh muscles. What exercise is best for joints? From the discussion above it should be obvious that you need two types of exercise. Exercise that moves the joints and improve their nutrition. Examples include swimming, cycling, running, walking and cross trainer. If your joints are sore or you have a condition like arthritis, you may benefit more from non-weightbearing exercise where you get a lot of movement but do not have a lot of force going through the joint e.g. cycling or swimming. Strength training to build strong muscles that support and protect your joints. Examples include weight training, gym machines and bodyweight training. You don’t have to go to a gym to achieve this. Other activities like wall climbing can provide very effective strength training for the whole body. Is it worth using joint supplements? When I started researching this questions, I was overwhelmed by the number of herbs, pills and other substances people claim can protect joints. Most of them don’t seem to have any solid research to back them up, so I have chosen some of the most prominent ones to discuss here. Chondroitin and Glucosamine Supplements containing chondroitin and glucosamine are touted as being able to protect joints and rebuild cartilage. Looking at the research, I’m not convinced that these supplements are worth taking. Research studies conducted by independent research groups have consistently found very little benefit from using chondroitin and glucosamine.  On the other hand, research studies funded by the large pharmaceutical companies have shown that they are effective. Hmmmm, anyone else smells a rat? Ginger The evidence shows that ginger can hold modest benefits for people who suffer with arthritis. What this means is that it may decrease your pain slightly. Turmeric Turmeric contains curcumin which has been shown to have positive effects on joint cartilage. Just how much you need has not yet been established. Tumeric on its own is also not useful as the curcumin has to be activated by combining it with black pepper. It is therefore advised that you rather use it in food than take it as a supplement. A balanced diet Green and colleagues have written a very interesting article in which they looked at what foods and nutrients can potentially help to protect your joints or to treat arthritis. Guess what, nearly every Vitamin you can think of contributes something towards joint health. Then you also get other bioactive components like flavonoids, flavonols, plant sterols etc. that all play an important role. So I would suggest that, before you rush off to buy tonnes of one supplement or nutrient, rather consider the quality of your general diet. Incorporate lots of fruit and veg and use spices like turmeric and ginger when you cook. Sugar, alcohol and processed foods Diets high in sugar, alcohol and processed foods have been shown to contribute to chronic inflammation in the body which in turn isn’t good for your joints. All the more reason to take an honest look at your diet. 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 Bartels E, Folmer V, Bliddal H, et al. Efficacy and safety of ginger in osteoarthritis patients: a meta-analysis of randomized placebo-controlled trials. Osteoarthritis and Cartilage 2015;23(1):13-21. Black C, Clar C, Henderson R, et al. The clinical effectiveness of glucosamine and chondroitin supplements in slowing or arresting progression of osteoarthritis of the knee: a systematic review and economic evaluation. 2009 Green JA, Hirst-Jones KL, Davidson RK, et al. The potential for dietary factors to prevent or treat osteoarthritis. Proceedings of the Nutrition Society 2014;73(2):278-88. Kucharz EJ, Kovalenko V, Szántó S, et al. A review of glucosamine for knee osteoarthritis: why patented crystalline glucosamine sulfate should be differentiated from other glucosamines to maximize clinical outcomes. Current Medical Research and Opinion 2016;32(6):997-1004. Saengnipanthkul S, Waikakul S, Rojanasthien S, et al. Differentiation of patented crystalline glucosamine sulfate from other glucosamine preparations will optimize osteoarthritis treatment. International Journal of Rheumatic Diseases 2017 Vasiliadis HS, Tsikopoulos K. Glucosamine and chondroitin for the treatment of osteoarthritis. World Journal of Orthopedics 2017;8(1):1.

Yes, doing a warm-up before walking actually does have some benefits. This article explains when you need a pre-walking warm-up and demonstrates four easy walking warm-ups that cover all the relevant muscles and joints. 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: Why bother warming up for walking? Warm up before walking with these exercises How many repetitions to do Don't start out too fast How we can help I demonstrate the four pre-walking warm-ups in this video: Why bother warming up for walking?   If you’re just going for leisurely stroll, don’t bother .   However, these warm-ups are beneficial if you’re going to be walking at a brisk pace or if you’re going to do some power walking . They get your joints moving freely. They warm up the muscles you use for walking. They get your tendons and ligaments ready for some action. You’ll have quicker reactions if something unforeseen happens, because your nerves will be firing better.   You want to include movements in your pre-walk warm-up that use the same muscles and joints that you're going to use when you're walking . These are your: Hips Knees Ankles Glutes Hip flexors Front thigh muscles (quads) Hamstrings Calf muscles Warm up before walking with these exercises   1. Roll-downs 📽️ Watch video demo   👉 This warms up your hamstrings, glutes, hip joints, and, as a bonus, your back.   Instructions Stand with your feet hip distance apart and your knees slightly bent. Put your chin on your chest and tighten up your tummy muscles. Roll your upper body down until you hang from your hips. Take a deep breath in and relax further into the stretch as you breathe out. Then, return to upright, reversing the movement by straightening your lower back, then your middle and upper back, and finally your neck. Repeat 3 to 5 times.   💡 Top tip I’m quite flexible. If you can’t go down as far as I do in the video, just go to where you can without discomfort.   2. Squats 📽️ Watch video demo   👉 This will warm up your glutes, quads, ankles, knees, and hips.   Instructions Stand with your feet hip distance apart. Squat down slowly – don’t let gravity do the work for you and plonk down. Stick your bum far out to the back, as if you intend to sit on a chair. Ensure that your knees stay in line with your feet – they shouldn’t swivel in or out. Come back up. Repeat 10 times.   💡 Top tips Hold on to something if you feel that you’re going to lose your balance, or you can even do it from a chair, standing up and sitting down slowly. You don’t have to squat very deep when warming up before a walk, because you don’t move through a large range of motion when you walk. This warm-up exercise strengthens your legs as well, so it’s two birds with one stone. 3. Calf stretches 📽️ Watch video demo   👉 In addition to warming up your calf muscles, this loosens up your hip and ankle joints and warms up your hip flexors and quads.   Instructions Place one foot forward. Place the other one back, so that you can still put it flat on the floor but feel a stretch in the calf muscle. Gently rock forwards and backwards. Switch legs and repeat. Do a total of 10 on each side.   💡 Top tips Hold on to something for balance if necessary. Again, don’t stretch your calf muscle as far as you can – just to where you feel a gentle stretch. The same goes for the front knee; just bend it as far as is comfortable.   4. Heel raises 📽️ Watch video demo   👉 These warm up your calves and ankle joints.   Instructions Stand with your feet hip distance apart. Slowly go up on your toes. Hold for a second, and slowly lower yourself back down; again, don’t plonk down. Do 10 repetitions, rest a bit (maybe do some squats), and then do 10 more.   💡 Top tips Hold on to something for balance if necessary. In the video, I do these in bare feet so you can properly see what I’m doing, but rather do these in your walking shoes. You can easily injure the front of your foot with this warm-up if you do it barefoot, especially on a hard surface. How many repetitions to do   This will depend on how fit and strong you are. I wouldn’t do more than two sets of 10 of any of these warm-ups, because you just don't need that many for walking.   If you're not that fit and you're new to these exercises , I would start off with two sets of 5 , just to get used to them first.   ⚠️ Don't start out too fast   So, you've now done these walking warm-ups. Please don’t go into speed-walking mode immediately; you may still pull a muscle. I would do about 2 to 5 minutes of just slow walking , getting everything progressively warmer, and then switch to faster walking. 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 Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate .

This article explains why a steroid injection for an injury should only be used in very specific circumstances. It also discusses the steroid injection side effects, such as the risk of rupturing your tendon, you should consider when deciding whether to have one. 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: How does a steroid injection work? Sometimes used with local anaesthetic Short-term vs. long-term use Risk of tendon rupture Other negative steroid injection side effects A steroid injection is not a magic fix How we can help We’ve also made a video about this: How does a steroid injection work? A steroid injection consists of corticosteroid, which contains cortisone, which is a synthetically produced substance that mimics the effect of the cortisol that our bodies produce naturally in response to stress. It dampens down our immune response as well as our bodies’ inflammatory reaction to injuries. So, the cortisone is usually injected when an injury has resulted in inflammation that causes pain and maybe also some other issues. However, many musculoskeletal injuries are not very inflammatory, so the positive effects of cortisone on these conditions won’t be significant. Sometimes used with local anaesthetic Some steroid injections contain a local anaesthetic, which obviously also provides pain relief, but much quicker than the cortisone. So, if you get almost immediate pain relief after such an injection, it is a good indication that the injection was done in the right spot – where your pain is actually coming from. For example, if you get a steroid injection containing a local anaesthetic in the knee joint and the pain goes away almost instantly, then it is the joint that is causing your issue and not any of the structures around it. Short-term vs. long-term use For most injuries to heal, you need an inflammatory response; it’s part of your body’s process of getting rid of damaged or dead cells and replacing them with new ones. So, you don't want to dampen your inflammatory response if you can help it. However, sometimes the inflammation from an injury causes a patient so much pain that they can’t do their rehab exercises. This is where the sensible use of a steroid injection would provide them with sufficient short-term pain relief to get going with their exercises; and it’s those exercises that will get their injury better in the long run. The least sensible way to use steroid injections is to try and manage an injury in the long term. It will become clear from the side effects discussed below why long-term use is a no-no, and also why you should think twice about even its short-term use in certain instances. Risk of tendon rupture Most tendinopathies do not have a lot of inflammation, so for this reason alone a steroid injection won’t be of much use. But also, one of the side effects of cortisone is a risk of tendon rupture. It is a small risk, and it doesn’t affect everyone, but it’s there. So, it’s better to address things like the loads that the injured tendon is being subjected to and getting it stronger through exercise than to inject it with something that could potentially cause it to rupture. Other negative steroid injection side effects Corticosteroids are immunosuppressive, so you would not want to have it before you’re having a vaccine, for example, or when you are ill or have some sort of infection. You might not want to have the cortisone injection done if you’re on other medication that it's likely to interact with. For example, if you’re taking diabetic medicines, cortisone will cause your blood sugar levels to fluctuate for a while after. An injection obviously breaks the skin, so there's a small risk of infection. It's common to have a bit of redness and soreness after the injection, but if there’s a worsening redness and/or worsening pain after 24 hours, then obviously that is a sign that there's an infection that needs immediate medical treatment. Another possible side effect is fat atrophy. The skin has a layer of fat just beneath it, and sometimes a steroid injection can cause some of that fat to disappear, which will leave you with a little bit of a dent in the skin. It can also cause skin depigmentation, leaving you with a spot that is lighter than the rest of your skin. A steroid injection is not a magic fix I hope it is clear from the above that it’s not just a case of turning up at your GP and going, “Hey, I’ll have myself a steroid injection! Happy days!” You do need to think about why you would want to have the steroid injection. Is it to provide you short-term pain relief in order to do your rehab exercises, or are you expecting some miracle cure? Like I said, it can be really helpful for short-term pain relief to get you going with your rehab. And what you need to do then, is to get the right rehab plan so that you can benefit fully from the effects of the injection, using the injection as an adjunct to help you get better and not as a magic fix. If you've got, for example, a tendon issue, then you need to address the loading, the exercises, the strength of the tendon, and the activities that you're doing; you need to address all those things whether you have a steroid injection or not. 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. 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: Coombes, B. K., et al. (2010). "Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials." The Lancet 376(9754): 1751-1767. Del Valle Soto, M., et al. (2016). "Consensus on the use of infiltration in sport. Document of Consensus of the Spanish Society of Sports Medicine." Orchard, J. W. (2020). "Corticosteroid injections: glass half-full, half-empty or full then empty?" British Journal of Sports Medicine 54: 564-565.

Dynamic stretches can help prevent injuries and improve performance, but they also have a few disadvantages. In this article I discuss the benefits of dynamics stretches, how to avoid common pitfalls, and share example exercises of dynamic stretches for your legs. 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: The benefits of dynamic (or active) stretching Dynamic stretching exercise examples for legs Drawbacks of dynamic stretches What it doesn’t do How we can help We've also made a video about this: The benefits of dynamic (or active) stretching Dynamic stretches use repetitive movements that take your muscle and joints through their full range of movement. It involves actively contracting your muscles throughout the movement as opposed to passive stretching, where you just relax into the position. Research has shown that you can improve your sports performance and help prevent injuries when you include dynamic stretches in your warm-up routine. This is because dynamic stretching activates your nervous system and muscles, improves your joint movement and muscle flexibility, as well as your balance and control. When it comes to flexibility, dynamic stretches are not quite as effective as static stretches . However, static stretches have been shown to sometimes switch muscles off (if held for longer than 45 sec), which is not ideal if you're about to compete! This is where dynamic stretches can come to the rescue. Performing a set of dynamic stretches after static stretches can wake your muscles back up, thereby ensuring that there isn't any negative effect on your performance ( reference , reference , & reference ). If having good flexibility is important for your sport (e.g. gymnastics) and you have to do static stretches in your warm-ups, I would suggest that you hold the static stretches for less than 45 seconds and follow it up with a good set of dynamic stretches and a sports specific warm-up. Dynamic stretching exercise examples for legs 1. Free squats Benefits: Mobilises hip, knee, and ankle joints Activates quads and glutes 2. Lunge dips Benefits: Mobilises hips and knees Stretches hip flexors and glutes Activates quads and glutes 3. Bridges Benefits: Activates back muscles, glutes, and hamstrings Stretches hip flexors 4. Good mornings or Romanian deadlifts Benefits: Stretches hamstrings Activates hamstrings and glutes 5. Heel lifts + drops over step Benefits: Stretches your calf muscles Mobilises your ankle joints Activates your calf muscles 6. Leg swings forward and back Benefits: Stretches hamstrings and hip flexors Mobilises your sciatic nerve and hip joint Activates your hip flexors and glutes 7. Leg swings side-to-side Benefits: Stretches your inner thigh muscles (adductors) and outer glutes Mobilises your hip joint Activates your inner thigh muscles and outer glutes Drawbacks of dynamic stretches Dynamic stretches can tire your muscles out and decrease your performance if you do too many repetitions. There are currently no clear guidelines on what actually constitutes “too many”. It may very well depend on your level of fitness. As a guideline, I would suggest that if you feel out of breath or tired after your warm-up, you have likely done too much. What it doesn’t do There is currently no evidence to suggest that dynamic stretches can decrease muscle soreness (DOMS) after exercise. 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. 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 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: Behm, David G., et al. “Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review.” Applied Physiology, Nutrition, and Metabolism 41.1 (2015): 1-11. Chatzopoulos, Dimitris, et al. “Acute effects of static and dynamic stretching on balance, agility, reaction time and movement time.” Journal of Sports Science & Medicine 13.2 (2014): 403. Herbert, Robert D., Marcos de Noronha, and Steven J. Kamper. “Stretching to prevent or reduce muscle soreness after exercise.” The Cochrane Library (2011). Kay, Anthony D., and Anthony J. Blazevich. “Effect of acute static stretch on maximal muscle performance: a systematic review.” Medicine & Science in Sports & Exercise 44.1 (2012): 154-164. Loughran, Martin, et al. “The effects of a combined static-dynamic stretching protocol on athletic performance in elite Gaelic footballers: A randomised controlled crossover trial.” Physical Therapy in Sport 25 (2017): 47-54. Murphy, Justin R., et al. “Aerobic activity before and following short-duration static stretching improves range of motion and performance vs. a traditional warm-up.” Applied Physiology, Nutrition, and Metabolism 35.5 (2010): 679-690. Opplert J, Babault N. Acute Effects of Dynamic Stretching on Muscle Flexibility and Performance: An Analysis of the Current Literature. Sports Med 2017:1-27. Samson, Michael, et al. “Effects of dynamic and static stretching within general and activity specific warm-up protocols.” Journal of Sports Science & Medicine 11.2 (2012): 279. Simic, L., N. Sarabon, and Goran Markovic. “Does pre‐exercise static stretching inhibit maximal muscular performance? A meta‐analytical review.” Scandinavian Journal of Medicine & Science in Sports 23.2 (2013): 131-148. Yamaguchi, Taichi, and Kojiro Ishii. “An optimal protocol for dynamic stretching to improve explosive performance.” The Journal of Physical Fitness and Sports Medicine 3.1 (2014): 121-129. Bizzini M, Dvorak JFIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review British Journal of Sports Medicine 2015; 49: 577-579.

You’re missing a trick if you don’t do a good warm-up before you run or do sport. Not only does it enhance your performance but it also prevents injuries. In this article, I’ll discuss what types of exercise you should include in your warm-up, according to the latest research. You can read more about how warming up prevents injuries here . 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: The components of an effective warm-up routine Deciding on the right warm-up for you Warm-up Phase 1: Raise core temperature and increase cardiovascular activity Warm-up Phase 2: Activate and mobilise Warm-up Phase 3: Max potential How we can help We've also made a video about this: The components of an effective warm-up routine The FIFA 11+ was the first warm-up programme that was found to effectively reduce injuries for young and adult players. A similar programme was tested with rugby players and was found to not only prevent muscle and joint injuries but also concussions. These programmes have the following components in common: The exercises are sport specific. This means that they’re not a one-size-fits-all. They use movements and exercises that actually mimic what happens in that sport. It is athlete specific. The programmes start at an easy level for less experienced or less fit athletes and become progressively harder and more advanced as the athletes improve. The warm-ups are done regularly. The researchers found the best results when the programmes were completed two to three times a week or before every training session and match. They consist of three phases. Phase 1: Aims to raise your core temperature and increase cardiovascular activity. Phase 2: Aims to activate and mobilise your muscles, nerves, and joints. Phase 3: Aims to prepare you for performing at your maximum level. I’ll discuss this in more detail below. Deciding on the right warm-up for you When you design your warm-up programme, I suggest that you follow these steps to ensure that it’s right for you: Step 1: Decide what range of motion you need for your sport, which muscles need to be activated, and what type of movements you should include. I’ll explain this in more detail below. Step 2: How fit are you? Choose exercises that challenge you a bit, but that aren’t too hard. Step 3: Do a warm-up before every exercise session. What your warm-up includes may vary depending on the activity that you’re about to do. For example, a high-intensity track session will require a different warm-up from an easy run. Step 4. Decide if you need to include exercises that provide max effort prep. Only doing an easy run? You could probably leave this phase out. Now that you know what you need from your warm-up routine, let’s take a look at what type of exercises you should do in each phase. I have used runners and rugby players as examples to demonstrate how the warm-ups should be sport specific. Warm-up Phase 1: Exercises that raise core temperature and increase cardiovascular activity The aims of this phase are to increase the body’s core temperature, heart rate, respiratory rate, blood flow, and joint fluid viscosity. This is achieved through easy, low-level exercise, e.g. easy jogging or cycling. Making it sport specific: Runner: Doing an easy jog may be enough. Rugby player: Playing small-sided games or doing slow running drills may be more appropriate. Warm-up Phase 2: Exercises that activate and mobilise The aims during this phase are: To mobilise your joints and lengthen your muscles to allow for the full range of motion that you need for your sport or activity. To wake your nervous system up. This is done through any exercise that contracts your muscles and challenge your balance. To activate your muscles. Which muscles are important for your specific sport? Choose exercises that contract those muscles. The best exercises to achieve all of these goals are dynamic or active stretches. Dynamic stretches are movements that take your joints and muscles through their full range while also requiring you to contract your muscles. They often resemble the movements you would do as part of your strength training regime, e.g. squats and lunges. I've written a detailed article about the benefits of dynamic stretching, which includes exercise examples for the legs . Unsurprisingly, researchers have also found that a warm-up routine that included these types of exercise had the added benefit of making the athletes stronger over time. Making it sport specific: Runners: It is mainly your core and leg muscles that you use when going for a jog. But if you’re doing sprinting, your arms and upper body will work much harder, and you may benefit from including upper body exercises, using bands. Rugby players: They would include similar movements for their legs, but they should also include exercises for their necks, arms, and upper bodies. Examples include push-ups, side planks, and buddy-resisted neck pushes. Warm-up Phase 3: Max potential The aim during this phase is to take your body to the point where everything is primed to fire at maximum capacity. These are usually quick speed or agility drills and include plyometrics . Again, this should be sport specific: Running: If you’re just going out for an easy jog, doing some active stretches and activation movements as described above may be enough. If, however, you’re about to do the 100m sprint, you would have to include sprints, plyometrics, and other drills that fire your muscles at full power. Check out this quick warm-up that you can use before an easy run . Rugby players: In addition to plyometrics, they would do things like shuttle sprints or quick direction changes, falling to the floor and getting up, etc. 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. 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 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 References: Attwood MJ, Roberts SP, Trewartha G, et al. Efficacy of a movement control injury prevention programme in adult men’s community rugby union: a cluster randomised controlled trial. British Journal of Sports Medicine 2018;52(6):368-74. doi: 10.1136/bjsports-2017-098005Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. British Journal of Sports Medicine 2015;49(9):577-79. doi: 10.1136/bjsports-2015-094765 Fulcher ML, Carlson I, Mitchell C, et al. Development and implementation of the ACC SportSmart Warm-up programme: a nationwide sports injury prevention initiative in New Zealand. British Journal of Sports Medicine 2018 doi: 10.1136/bjsports-2017-098860 Hislop MD, Stokes KA, Williams S, et al. Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. British Journal of Sports Medicine 2017;51(15):1140-46. doi: 10.1136/bjsports-2016-097434 Jeffreys I. Warm up revisited–the ‘ramp’method of optimising performance preparation. UKSCA Journal 2006;6:15-19.

I can probably count on one hand the number of patients I see in clinic every week who actually do a proper warm-up before they exercise. I suspect the main reasons for this low number are (1) that they’ve been able to get away with not warming up and avoided injury until now and (2) that they don’t actually understand why a warm-up is important. In this article, I first look at what the research says regarding the link between warm-ups and injury prevention and then at how exactly warm-ups prevent injuries. 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 I’ll discuss: Does warming up prevent injuries? Getting the range you need Prepping your muscles Activating your nervous system How we can help We've also made a video about this: Does warming up prevent injuries? There is strong evidence that a thorough warm-up routine can prevent injuries in all parts of the body. For example, the FIFA11+ warm-up programme that was developed for football/soccer has been shown to decrease the number of injuries a team racks up in a season by up to 30% while it can decrease severe injuries by 50%! Research done in rugby (school level as well as adults) has shown that you can even reduce the number of concussions players get if they warm up properly. You’ll notice that I use the words “thorough” and “properly” in the paragraphs above. Not all warm-up routines are equal. Running slowly for the first 5 minutes of a run or doing a quick jog around the pitch before you play football does not count as a warm-up! It has to include specific types of exercise to be effective, and I discuss these in detail in the second article of this series . A second benefit of warming up is that it improves your performance. Researchers have found it can improve a wide variety of performance markers, including sprint times, jump height, agility skills, and balance, to name but a few. This is because a well-designed warm-up programme prepares your joints, muscles, and nerves for exercise, and I’ll discuss in more detail below exactly how it does this. Getting the range you need A good warm-up routine will always start with gentle aerobic exercise that improves the viscosity of your joint fluid, which helps them to move better.  It further includes dynamic stretches that take your muscles and joints through the full range of motion that you need for your sport. The range of motion that you need in your joints and limbs to effectively do your sport will very much depend on what sport you do. Think for instance of a gymnast vs. a sprinter. The gymnast will require a large range of motion in their hips and may even have to do the splits during their routine. The sprinter only requires the range of motion that will allow them to swing their legs freely through the full running cycle, and excessive flexibility may even negatively impact their performance. The warm-up routines and goals for these two athletes will be very different. But they will both have to ensure that they achieve the full range of motion that they need for their individual sports before they start training or competing. Prepping your muscles A good warm-up will increase your core temperature, muscle temperature, and the blood flow to your muscles, which reward you with stronger and more powerful muscle contractions.  It’s easy to see how this will result in better performance. There is strong evidence that doing a comprehensive warm-up routine two to three times a week not only leads to better performance on the day but also increases your muscle strength over time.  How it does this will make more sense when you read the article about the components of the perfect warm-up routine . Activating your nervous system Think of your nervous system (brain and nerves) as the captain of a ship (your body). The ship may be nice and strong, but if the captain is drunk or passed out it will not move in its intended way and may even crash (get injured). An important aim of a warm-up routine is to wake your nervous system up and make sure that it is fully alert and ready for exercise. Your nerves have to make sure that your muscles fire at the right time and intensity and that your limbs move in the correct sequence. A good example of how switched off muscles (due to the nerves not firing properly) can cause injury is when your glutes (muscles in your bottom) do not activate properly, allowing the knee to turn in while you run. This can cause any number of injuries in the hip, knee, or ankle. One of the top causes for switched-off glutes is when you sit for long periods. I've previously written about how you can wake up and strengthen your glute max and glute med . Your nervous system is also constantly feeding back information to the brain about where your limbs are in time and space. Have you ever wondered how you can manage to run down a flight of stairs without really looking at your feet and not trip? This is thanks to proprioception. Proprioception or position sense refers to your brains ability to know exactly where every part of your body is without having to look at it. A good example of what can happen when the brain gets it wrong is when you misjudge the height of a step (as either lower or higher) and stumble or fall. Poor position sense predisposes you to a variety of injuries. The good news is that there is strong evidence that doing a structured warm-up routine can wake your ship’s captain up and lead to improved static and dynamic balance, agility skills, core and hip muscle activation, as well as core and leg stability . Now that you fully understand the benefits of warming up, next take a look at what a thorough warm-up routine should include . How we can help Need more help with an 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 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: Attwood MJ, Roberts SP, Trewartha G, et al. Efficacy of a movement control injury prevention programme in adult men’s community rugby union: a cluster randomised controlled trial. British Journal of Sports Medicine 2018;52(6):368-74. doi: 10.1136/bjsports-2017-098005Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. British Journal of Sports Medicine 2015;49(9):577-79. doi: 10.1136/bjsports-2015-094765 Fulcher ML, Carlson I, Mitchell C, et al. Development and implementation of the ACC SportSmart Warm-up programme: a nationwide sports injury prevention initiative in New Zealand. British Journal of Sports Medicine 2018 doi: 10.1136/bjsports-2017-098860 Hislop MD, Stokes KA, Williams S, et al. Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial. British Journal of Sports Medicine 2017;51(15):1140-46. doi: 10.1136/bjsports-2016-097434 Jeffreys I. Warm up revisited–the ‘ramp’ method of optimising performance preparation. UKSCA Journal 2006;6:15-19.

Bone bruising in the knee can be caused by a sudden trauma, such as twisting or a severe impact to the knee, or it can develop over time due to repetitive low impacts – for example in endurance running. Sports physio Maryke Louw explains what the best treatment is in both cases and gives some pointers on whether you can continue running with a bone bruise in your knee. 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: What is a bone bruise? What causes bone bruises in the knee? Bone bruise symptoms and diagnosis Effect on recovery How to treat bone bruises in the knee Healing time for knee bone bruises Can I run with a bone bruise in my knee? How we can help We've also made a video about this: First, I should point out that this article is about bone bruises in the knee associated with activity, sport, or trauma; it's not about bone bruises associated with osteoarthritis or osteoporosis . Those types of bone bruise have different causes, and the advice in this article does not apply to them. What is a bone bruise? Bone bruising’s medical names are oedema, bone marrow oedema, and contusion of the bone. It’s the same as a bruise you would get under your skin, except that it is in a part of a bone. So, there was an impact or several impacts on the bone, and now blood and other fluids have accumulated there. There may also be pain and swelling, same as with a bruise under the skin. What causes bone bruises in the knee? Trauma The most common cause of bone bruising in the knee is obviously trauma. So, it's anything where you've had a sudden twist in or impact on the knee joint. The knee and ankle are the joints that typically suffer bone bruises this way. In the knee, bone bruises typically go hand-in-hand with injuries to the anterior cruciate (ACL) ligament , which usually involve a sharp twist of the knee. Injuries to the medial collateral ligament (MCL)  and to the meniscus often also cause bone bruises. Repetitive low impact However, you can also get a bone bruise to the knee without a once-off impact. This happens mostly due to activities that involve high-volume, low-intensity impact on the knee joints, such as running or dancing. Marathon runners with bone bruising in their knees have been studied comprehensively. First, it should be noted that not everyone who trains for and runs marathons will get bone bruising in their knees. And interestingly, they found that, in some cases, bone bruising can actually get better during marathon training. The people in the white lab coats speculate that this type of bone bruising develops in some cases because some people's running style cause a repetitive impact in a certain part of the knee. The terrain or shoes might also play a role, e.g. if you constantly run on a severe camber or in worn-out shoes. Bone bruise symptoms and diagnosis The only symptom is pain in the knee. But how do you know that this is pain caused by a bone bruise and not something else? The only sure-fire way to diagnose a bone bruise is by doing a scan, typically an MRI scan. However, many people never know that they have or had bone bruising in the knee, because often there is no pain . In some research studies where they took scans of athletes’ knees before and after a season, many of them had developed bone bruises during the season but didn’t complain of pain or other symptoms. Effect on recovery When you have suffered a knee bone bruise due to trauma, such as injuring your ACL, the bone bruise may or may not affect how long it will take you to recover from the main injury. In some ACL injury cases, pain from bone bruising can delay the patient’s being able to fully straighten their knee, which will influence how quickly the rehab of their ACL can progress. The research suggests that bone bruising doesn’t seem to affect long-term ACL recovery or return to sport. So, when you look at the rehabbed ACL a few years down the line, it’s the same as a rehabbed ACL where there was no bone bruise. However, if the cartilage that covers the bone around the bone bruise is also injured, it might affect your long-term recovery. The scientists are not sure yet whether there is a specific volume or area of bone bruising that might have a bigger effect on recovery than others. How to treat bone bruises in the knee It’s quite simple (but admittedly not always easy): Keep active and move your knee as much as you want to but without aggravating your pain. This is the basic approach for most joint injuries in any case, so it would slot in well with any rehab you might have to do for a main trauma knee injury such as an ACL or MCL tear at the same time. 1. Respect the pain It is normal and expected to have some pain while you move and exercise with an injury. The aim is to stay as active as possible without making the injury worse, and pain can be a useful tool for monitoring this. You wouldn't constantly be prodding a bruise on your arm and expect it to heal. So, firstly, don’t force any movements that cause the pain in your knee to increase significantly. Don't push into pain – respect it. If it hurts to extend your knee fully, work in the pain-free range and just move it gently. And then, as the bone bruising heals, you can increase how far you move your knee. The same goes for standing, walking, and running. Limit your weightbearing activities to what you can do with nothing more than mild discomfort. So, if it hurts to walk for 30 minutes, shorten your walks for the time being. Or if having to stand for lengthy periods at work is an issue, see if you can perch on a stool instead. So, the realistic aim is to not increase the pain significantly rather than to be pain-free. 2. Keep moving your knee The pursuit of not increasing your pain doesn’t mean that you should do nothing with your knee. Movement increases your circulation and is greatly beneficial for healing. That's why it's important to do your rehab (in the case of a concurrent knee injury) and to do other activities as much as you can, as long as you respect the pain levels. Healing time for knee bone bruises Bone bruises are slow healers, and they usually take a few months to resolve. Healing times vary too much from person to person to provide more specific timelines; it depends on factors such as the severity and how it was caused. Can I run with a bone bruise in my knee? The research provides no clear answers here, and expert opinion is divided. Some clinicians advise that you avoid impact sports until the bruise has recovered, while others recommend tailoring your activities to the symptoms. Like I mentioned above, there are researched cases of marathon runners whose knee bone bruising actually got better during marathon training. Others picked up bone bruises in the knee during training; some of those had healed six months later (while still training) and others hadn’t. In some cases, it might be that it’s not whether you run, but how and where you run. As mentioned earlier, bone bruising in the knee might be caused by your running style or the terrain you run on, so this might also influence how fast your bone bruising heals if you continue running with it. Your type of running shoes might also be a factor. From what I've read, I recommend that you use your common sense and let your symptoms guide you. If running does increase your knee pain (and there’s no other injury to blame for it), I would stay away from it for a while (or ease up so there’s no increased pain) and rather choose lower-impact activities such as cycling or swimming. 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 Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Gage, A., et al. (2019) "Factors Associated With a Delay in Achieving Full Knee Extension Before Anterior Cruciate Ligament Reconstruction" Orthop J Sports Med 7(3): 2325967119829547. Galloway, C., et al. (2023) "Relationship Between Bone Bruise Volume and Patient Outcomes After ACL Reconstruction" Orthop J Sports Med 11(2): 23259671221146205. Horga, L. M., et al. (2020) "Is the immediate effect of marathon running on novice runners’ knee joints sustained within 6 months after the run? A follow-up 3.0 T MRI study" Skeletal Radiology 49: 1221-1229. Kompel, A., et al. (2021) "MRI-Detected Knee Ligament Sprains and Associated Internal Derangement in Athletes Competing at the Rio de Janeiro 2016 Summer Olympics" Open Access J Sports Med 12: 23-32. Mandalia, V., et al. (2020) "Bone marrow oedema in the knees of asymptomatic high-level athletes: prevalence and associated factors" Indian Journal of Orthopaedics 54: 324-331. Mester, B., et al. (2023) "The influence of distribution, severity and volume of posttraumatic bone bruise on functional outcome after ACL reconstruction for isolated ACL injuries" Arch Orthop Trauma Surg 143(10): 6261-6272. Villari, E., et al. (2024) "Bone marrow edema of the knee: a narrative review" Archives of Orthopaedic and Trauma Surgery: 144(5): 1-12.

Why would some bodybuilders take a muscle building supplement that might shrink their testicles and cause ruptures to their Achilles tendons when there are safer alternatives out there? We take a look at research into the safety of selective androgen receptor modulators (SARMs), a controversial group of anabolic agents that has recently gained popularity among people who want to build muscle mass and grow stronger. 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: What makes SARMs so special among anabolic agents? SARMs: The good, the bad, and the ugly The legal situation with SARMS Our recommendation How we can help We've also made a video about it: What makes SARMs so special among anabolic agents? The world “selective” in its name refers to the fact that SARMs target only your muscles and bones, whereas most other anabolic agents affect other areas of the body as well, and not always in a good way. SARMs activate the androgen receptors in your muscles and bones. This increases the testosterone uptake there, which in turn increases muscle size and bone density. This class of drugs was developed in the late 1990s in an attempt to replace anabolic androgenic steroids, which have various medical uses but also a wide variety of negative side effects. SARMs are sold – mostly online – under names such as enobosarm (aka ostarine), ligandrol, vosilasarm (aka RAD-140), and S-23. Well, this all sounds pretty positive so far! So, what’s the problem? SARMs: The good, the bad, and the ugly The good The vast majority of SARMs users are young men who want to grow bigger muscles. However, they are also popular as a muscle building supplement for women because, unlike some other anabolic agents, they do not cause a deeper voice and male-pattern hair growth. Some competitive athletes use SARMs in the hope that it will make them stronger. A 2022 survey among people on the social media platform Reddit who use SARMs found that more than 90% of the male respondents were satisfied with their SARMs usage and reported increased muscle mass. The bad and the ugly However, that same survey found that more than 50% of SARMs users reported significant side effects, including mood swings, shrinking testicles, and acne. In 2023, a team of scientists in the USA published the results of their systematic review of the research into the safety of SARMs for recreational users. They looked at 15 case studies as well as 18 clinical trials involving more than 2,000 people. Among the more serious negative side effects of SARMs that these studies found were: liver damage ruptured Achilles tendons rhabdomyolysis (when high concentrations of toxins released from your muscles enter your blood stream, which can damage your kidneys) a reduction in HDL cholesterol (i.e. “good” cholesterol), which can increase the risk of heart disease. Some of the less serious side effects of SARMs were found to be: smaller testicles mood swings acne headaches dry mouth upper respiratory infections constipation indigestion nausea. The legal situation with SARMs Recreational and medical use SARMs are illegal in the USA and many other countries. This is not because the government doesn’t want you to be ripped – it’s because of the serious health risks! The USA’s Food and Drug Administration (FDA) said in 2023 that SARMs cannot be legally marketed in that country as a dietary supplement or as a drug. So, it’s not even legal for your doctor to prescribe you a SARM. The FDA warns that SARMs “are often sold with no warnings on the labels, potentially leading consumers to believe the products are safe”. A 2023 study of how SARMs are being marketed on the social media platform TikTok found that: Sellers of SARMs try to circumvent the law by claiming it is being sold as “research chemicals” and that it is “not for human consumption”, while featuring pictures of ripped people and hashtags that refer to bodybuilding. (Nudge-nudge, wink-wink!) In the USA alone, content on TikTok with hashtags referring to SARMs had 40 million views over the course of three years, with 33 million of those views coming from 18- to 24-year-olds. Sports performance SARMs are banned in sport for two reasons: It might enhance performance (although this has not been proven scientifically). And obviously, due to the dangerous negative side effects. The World Anti-Doping Agency has banned the use of SARMs since 2008 for all levels of sport – from professional to recreational. The US Anti-Doping Agency reported in 2020 that more than 50 USA athletes have been sanctioned for the use of SARMs since 2010, and that there have been more than 230 positive tests worldwide since 2012. Our recommendation It’s obvious from the above: Don’t use it. There are safer supplements, such as creatine, which have proven benefits and don’t pose serious health risks. If you are already using it, we suggest that you stop, and seek medical help if necessary. How we can help Need more help with an 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 Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References Vignali, Jonathan D., Kevin C. Pak, Holly R. Beverley, Jesse P. DeLuca, John W. Downs, Adrian T. Kress, Brett W. Sadowski, and Daniel J. Selig (2023) "Systematic Review of Safety of Selective Androgen Receptor Modulators in Healthy Adults: Implications for Recreational Users" Journal of Xenobiotics 13(2): 218-236. Efimenko, I.V., Valancy, D., Dubin, J.M. et al. (2022) “Adverse effects and potential benefits among selective androgen receptor modulators users: a cross-sectional survey” Int J Impot Res 34: 757-761. U.S. Food & Drug Administration (2023) “FDA Warns of Use of Selective Androgen Receptor Modulators (SARMs) Among Teens, Young Adults” World Anti-Doping Agency (2023) “The Prohibited List” U.S. Anti-Doping Agency (2020) “Selective Androgen Receptor Modulators (SARMs) – What Athletes Need to Know” Center for Countering Digital Hate (2023) “TikTok’s Toxic Trade”

Is CBD (cannabidiol) for runners and other athletes a fad supplement, or does it indeed live up to the promise that it will help you to perform better and recover faster? We take a look at the latest research and also at the doping situation. 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: What is CBD? How does CBD work in the body? CBD effects on the brain So, is CBD good for runners? If you do take CBD – how much? CBD and doping How we can help We've also made a video about this: What is CBD? Cannabidiol (CBD) is extracted from the cannabis plant. It should not be confused with the much more famous tetrahydrocannabinol (THC or delta-9-THC), which is the stuff that makes you high and which can be present in CBD extractions. CBD is legal in some countries, illegal in others, and in some countries it must contain less than a certain amount of THC to be legal. In some countries where it is legal, it can only be obtained with a medical prescription. Some athletes use it due to its apparent physiological and psychological effects. It can be taken in several ways, such as drinks, capsules, mouth sprays, and vaping. How does CBD work in the body? A 2023 review of research on how CBD could improve performance and recovery in sports found the following effects that could potentially enhance performance and/or help recovery: Anti-inflammatory: Inflammation is a part of the natural repair-and-recovery process that kicks in as a response to the micro-damage caused by exercise. However, too much inflammation can cause damage to muscles, bones, and organs, and CBD could be useful to regulate inflammation after exercise. Pain relief: CBD interferes with the information about pain sent to the brain, and it is already being used (in non-sports settings) for the management of acute and chronic pain. Also, it “appears to have a possible effect on reducing swelling and avoiding soreness after hard activity”. Muscle repair and growth: CBD has the potential to increase the release of arachidonic acid in the body, which helps with the repair and growth of muscles. Sleep quality: It is well-established that sleep plays an important role in post-workout recovery and injury prevention. CBD can help people to fall asleep quicker and to sleep with fewer interruptions. 💡What does this mean for runners? It’s tempting to read the list of potential positive effects and immediately assume that CBD must be beneficial for recovery. However, suppressing inflammation after a training session may eventually turn out to be a bad idea for runners. We know from the research on ice baths that routinely taking an ice bath after strength workouts actually decreases performance gains. This is thought to be due to reducing the natural inflammatory response needed to complete the muscle repair process. So we have to ask ourselves … Is it a good idea to use CBD after every training session, or should it only be used in specific situations (like with ice baths)? This is why more sport-specific research is needed. Indeed, the researchers that did the review study found that: the CBD studies that have been carried out so far are insufficient to adjudicate whether and to what extent CBD enhances and/or impairs performance, and there is a lack of experimentation in humans, especially in its effects on athletes and physically active people. Also, the suspected benefits of CBD for runners must be weighed up against possible side effects, and at this point, due to a lack of sport-specific research, we don’t know what those might be. CBD effects on the brain What sets CBD apart from most other (legal) supplements that are claimed to enhance sports performance and/or recovery is its suspected psychological effects. Reduced stress and anxiety before or during competition might help athletes to perform better. (Although some would argue that a certain level of stress helps performance.) Post-competition stress (due to tiredness and/or due to a disappointing performance) can impair sleep and therefore recovery. The researchers who reviewed the science found the following ways in which CBD might help to relieve stress and anxiety: It has been found to restore the impaired transmission of serotonin to the brain. Serotonin is a “chemical messenger” that induce feelings of well-being. CBD inhibits the productions of stress hormones such as cortisol. The research that looked into CBD and sleep quality also found that it helps people to have fewer nightmares. However, the researchers note that there is “no evidence of reduced anxiety or mood regulation in sports”. 💡What does this mean for runners? Each to their own, but my feeling is that it is more sustainable to try and remove the cause of the stress or to learn coping mechanisms than to try and combat the stress biochemically once it has taken hold. However, I also appreciate that this is often easier said than done. CBD may be a useful tool if you need help getting your stress down and to sleep better, but it is not the only tool in the shed. So, is CBD good for runners? The short answer is, we don’t know (yet). Much more research is needed, and I hope to return to this article in a few years’ time to rewrite it with much more definitive answers for athletes. It may be easier to recommend when not to take it: If it is illegal where you are. If you’re an athlete subject to doping regulations – see below. As for CBD helping with post-exercise recovery, there are many other ways to help us recover that have been studied much better, and I would rather use those. If you do take CBD – how much? The research review does not go into much detail about CBD dosage, but it does mention the following in passing: For anxiety, 300 mg of CBD seems to be more effective than 150 mg or 600 mg. (However, the next sentence is where it says there is no evidence that this works in sport situations.) 10 mg of CBD for each kilogram of body weight might help to control inflammation. CBD and doping CBD is the only cannabinoid (cannabis-derived substance) that is not prohibited in-competition by the World Anti-Doping Agency (WADA). The reporting threshold for THC in an athlete’s urine is 150 nanograms per millilitre. However, THC and other cannabinoids (there are about 110 of them!) are often found in CBD, because it is difficult to extract pure CBD from cannabis. UKAD, the UK’s anti-doping agency, points out that a study in the USA found THC at levels higher than the threshold permitted by WADA in some CBD products. And because there is no threshold for other types of cannabinoid, even the slightest trace of those in CBD will land you in trouble. The fact that you inadvertently ingested the offending substance via CBD, which is an allowed substance, won’t wash with WADA. How we can help Need help with an 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 Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References Rojas-Valverde Daniel, Fallas-Campos Andrea. "Cannabidiol in sports: insights on how CBD could improve performance and recovery" Frontiers in Pharmacology 14, 2023. World Anti-Doping Agency. "The Prohibited List - Cannabinoids" 2023. UK Anti-Doping. "Supplement Warning - Cannabidiol (CBD)"

The gluteus maximus muscle is the largest muscle in your bum. It not only propels you forward, but also plays an important role in hip and pelvic stability. Weakness in the glute max can lead to lower back injuries, hip, knee, hamstring, adductor and even calf strains! This article is a summary of the fourth session in the Injury Prevention series. The other topics include position sense, core stability, glute med, hamstrings, quadriceps and calves. In this article: What the glute max does Why your hip flexors are important Glute max exercises Download the exercises as a PDF What the glute max does The glute max is you main hip extensor muscle (taking your leg back).  It is also used to accelerate the body upward and forward from a position of hip flexion e.g. when sprinting, squatting, or climbing a hill. The glute max is not the only muscle that propels you forward. The hamstrings, hip adductors and calf muscles all play a part. If the glute max is weak or switched off, the other muscles have to work harder which can lead to muscle strains or tendinopathies (e.g. Achilles tendon pain). Because 75% of the glute max attaches into the iliotibial band, it also plays an important role in pelvic and hip stability by preventing your pelvis to drop and your hip to turn in excessively when you walk and run. Thus playing a part in preventing back, hip, knee and ankle injuries. I've explained how you can test your own hip/pelvic stability here. Interesting fact: The clam exercise is usually prescribed as an early stage rehab exercise for the glute med muscle. However, studies have shown that you activate the glute max to the same extent as the glute med when you do the clam at 60 degrees hip flexion. Why your hip flexors are important There is some research to suggest that tight and overactive hip flexor muscles can inhibit your glute max. Mills et al.  tested glute max muscle activation during a double leg squat in 2 groups of students. The one group had tight hip flexor muscles and the other group were deemed to have normal hip range of motion. They found that the group with the tight hip flexors had 60% less glute max activation. Interestingly their hip extension strength was the same as the other group, but they demonstrated 2.6 times more hamstring activation relative to the glute max. This is the first study to investigate this, but it does seem to suggest that tight hip flexors deactivates your glutes and can predispose you to strains in other muscles e.g. that hamstring. Glute max exercises You’ll be happy to know that all of the exercises that we talked about in the Glute Med article also activate the Glute Max. The most beneficial ones that I listed there are the supported single leg squat and the single leg sit to stand. That said, I do prefer to start with double leg bridges so that you can make sure that you get a feel for how to activate your glutes properly. NB: These exercises may not be right for you and you should check with your healthcare provider before trying them. Remember, you can our team of sports physios via video call for a diagnosis of any injuries or a bespoke treatment plan. Hip flexor stretches Remember, tight hip flexors can switch the glutes off. The main hip flexor muscles are the iliopsoas and rectus femoris. You should stretch both of these. Purpose: It should be clear from the discussion above that this is extremely important. You will activate your glute max much better if your hip flexors aren’t tight. Starting position: Half kneel with your one knee on a pillow and your other leg out in front of you. Hold on to something for balance if needed. Movement: A. Push your hip forward, but at the same time tilt your pelvis backwards. This is important – if you allow your pelvis to tilt forward, the stretch will not be as effective. This will mainly stretch the iliopsoas muscle, but if you’re very tight you may have to spend time on this part first and then add in part B. B. Once you can easily achieve part A, maintain that position and grab hold of your foot. You may have to loop a belt or towel around your foot if you are very stiff. Check that: Your pelvis remains tilted backwards throughout the stretch. Remember, strong sustained stretches switches muscles off, so these should be followed by dynamic movements if you're doing them shortly before doing sport. Aim: Hold the stretch for 30sec and repeat 3 times on each side. Glute max strengthening level 1 Double leg bridge – feet up I prefer to do the bridge with my feet on a chair. It allows the glutes to work through a much larger range and my patients don’t seem to strain their backs as easily as when they do it with their feet on the floor. Starting position: Lie on your back with your heels on a chair. Make sure that your bottom is close to the chair – you are looking for a 90 degree angle in your knees. The straighter your knees, the more it becomes a hamstring exercise and that’s not our goal for now. Movement: Activate your pelvic floor and deep abdominals by squeezing as if you don’t want to wee or fart. Keep them activated and lift your bottom into the air so that your body forms a straight line. Once at the top, you should squeeze your buttocks and make sure that you don’t feel any strain in your lower back. If you do feel strain in your lower back, make sure that you are squeezing your stomach and glutes and not trying to just arch your back. Check that: You don’t feel any strain in your lower back. If your hamstrings cramp, move your bottom closer to the chair. Aim: Hold the position for 10sec. Rest 10 sec. Repeat 10 times. Build up to 4 reps of 30sec holds. Glute max strengthening level 2 Single leg bridge – feet up Starting position: Lie on your back with your one heel on a chair and your other leg bent up into your stomach. Make sure that your bottom is close to the chair – you are looking for a 90 degree angle in your knee. Movement: Activate your pelvic floor and deep abdominals by squeezing as if you don’t want to wee or fart. Keep them activated and lift your bottom into the air so that your body forms a straight line. Make sure that your pelvis is level! Once at the top, you should squeeze your buttock and make sure that you don’t feel any strain in your lower back. If you do feel strain in your lower back, make sure that you are squeezing your stomach and glutes and not trying to just arch your back. Check that: Your pelvis should remain level throughout the exercise. You should not feel any strain in your lower back. If your hamstrings cramp, move your bottom closer to the chair. Aim: Build up to 3 sets of 10 slowly reps on each leg. Glute max strengthening level 3 The research shows that the Glute Max is most active during activities like single leg squats, single leg step-ups and single leg deadlifts. So the single leg sit-stand-sit exercise that I described in the Glute Med article will work very well for strengthening your Glute Max. Two birds with one stone! Single leg sit-stand-sit Purpose: It’s a great exercise to strengthen your glute med, glute max, quads and position sense. Starting position: Choose a chair that you can manage to get up from using only one leg. Your aim should be to use a chair that places your knee in 90 degrees flexion, but if this is too hard use a higher surface. I usually place some pillows on the chair to make it easier. Sit on the edge of a chair with your one leg on the floor and the other one in the air. Your hands can either be in your sides or out in front of you. Movement: Slowly stand up from sitting, using only one leg. Make sure that your pelvis stays level and your knee moves in line with the middle of your foot. Then slowly sit down again. Check that: Your pelvis and knee stays aligned. If you find that you “plonk” down instead of slowly lowering yourself down, you may have to use a higher chair to start with. Aim: Test how many your can do with good form from 90 degrees knee flexion. Your aim should be to get to 22 with no wobbling and keeping your pelvis and knee aligned. I can only manage 8 with rather poor form so I should work on the exercise single leg squat with support before doing these. Retest this every 4 weeks to check on your progress. Start strengthening it by doing sets of 8 reps until fatigue. Rest at least 1 to 2 minutes between sets. Download the exercises as a PDF 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. References: Mills M, Frank B, Goto S, et al. Effect of restricted hip flexor muscle length on hip extensor muscle activity and lower extremity biomechanics in college‐aged female soccer players. International journal of sports physical therapy 2015;10(7):946. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiotherapy theory and practice 2012;28(4):257-68.

To choose the right exercises for your specific case of gluteal tendinopathy, you first have to understand what causes it, what happens to the tendons, and what type of exercises are best suited to correct it. So we'll kick this article off with a quick overview of the causes and injury process before we discuss what exercises to do. Remember, if you need more help with an injury, you're welcome to consult our team of sports physios online via video call. 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 this article (click or tap to skip straight to a specific section): What causes gluteal tendinopathy and how does it affect the tendons? Gluteal tendinopathy exercises to avoid What are the best exercises gluteal tendinopathy? How we can help via video call What our patients say Research references What causes gluteal tendinopathy and how does it affect the tendons? What it is Gluteal tendinopathy is one of the most common causes of pain that you feel in your buttock or over the outside (lateral) hip. It's an overuse injury that mostly affects the glute med tendon but can also involve the glute minimus and glute max tendons. It's quite common to have gluteal tendinopathy and hip bursitis at the same time, which is why researchers have started to refer to it as greater trochanteric pain syndrome. Now, that is quite a mouthful, so in this article we'll just call it gluteal tendinopathy or lateral hip pain. What causes gluteal tendinopathy? Gluteal tendinopathy is an overuse injury which develops when you overload your gluteal tendons. In other words, the volume or intensity of the activity you did was too much for the tendons (they weren't strong enough). Whenever we exercise or do physical activity such as gardening or walking, our bodies sustain micro-damage. This is normal. The body then repairs this micro-damage to a better level than before the exercise or activity and that is how we grow stronger. However, if you don't give your body enough time to repair this damage between training sessions or activities, or the activity is a lot more than what your body is used to, the micro-damage can accumulate and cause an overuse injury like gluteal tendinopathy. Other factors, like the menopause, can predispose you to developing gluteal tendinopathy because it influences how well or quickly your body can repair itself after exercise. The person in charge of your rehab plan should take this into consideration. Alison explains how the menopause affects your gluteal tendons in the video below. She also shares some useful tips on how to adapt your training and rehab to minimise this effect. What happens in the gluteal tendons and how can you fix it? Once injured, the tendons lose some of their strength. This causes a vicious cycle because it now takes even less activity or exercise to overload them. So, people often find that as time goes on, they can do less and less activity before the pain kicks in. How do you fix this? Through a combination of relative rest and a carefully graded strength training programme. Relative rest means that you limit all your activities to a level that doesn't cause your pain to increase. This allows the injury to settle down. The strength training programme will help to restore your gluteal tendons' strength to their previous level and beyond, so that they are strong enough to cope with all the activities that you want to do. We'll explore what this strength training should look like in the next sections. > Back to top Gluteal tendinopathy exercises to avoid Stretches - any and all gluteal stretches, iliotibial band stretches, and tensor fascia latae stretches should be avoided (see the video below for examples). These stretches used to be (and unfortunately still often are) commonly prescribed as part of the treatment of gluteal tendinopathy because practitioners used to think that the cause of this injury was overly tight gluteal muscles. However, in recent years the research has shown that this is not the case and that stretching the gluteal muscles and their injured tendons usually just further irritate them. Alison explains this in the video below. The tightness that you feel in your buttock or hip muscles when you have a gluteal tendinopathy is caused by the injured tendons that also irritate the muscles, causing them to tighten up. It is not a tightness that can be stretched out. The tightness will reduce as your injured tendons heal. Stretching the glutes can often feel good while you're doing it, but then cause increased pain later in the day or the next day. So, if you're struggling with a case of gluteal tendinopathy that doesn't want to get better and you've been doing glute stretches, stop doing them for a week or two and see whether there's any improvement. > Back to top What are the best exercises for gluteal tendinopathy? Strength training exercises are the best exercises to do, but the success of your rehab plan also depends on choosing the correct type/intensity of strength exercise for your specific case. I'll explain this in more detail in this video and below it. Isometric exercises These exercises are usually most appropriate during the early stage, when the tendons are still very sensitive and easy to irritate. When you do an isometric contraction, you tense the gluteal muscles but without actually moving the leg. The most common exercise used is an isometric side leg lift. Here, it is also important to avoid any positions that cause a stretch in the tendons. To achieve this, we like to use a pile of cushions or pillows to keep the leg in a more neutral position. Maryke demonstrates it in the video above. Isometric exercises should start with short holds and low loads (e.g. 10-second holds with just the weight of your leg) and be progressed to longer holds and heavier loads (e.g. 30 seconds with a weight or heavy shoe on your foot). What we prescribe very much depends on what we find when we assess our patients. Gluteal tendinopathy often only causes pain several hours after you do an exercise, so it's best to ease into strength training and carefully test the tendons' tolerance. Not everyone will find lying on their side comfortable, but fortunately you can do isometrics while standing, sitting, and even lying on your back. If your exercises are making your pain worse, tell your physio so that they can adapt them. How often to do isometrics: You may be able to do them daily, but this will depend on your tendons' tolerance. Some of our patients require several recovery days in between and will typically do them every other day or just three times a week. Isotonic exercises (concentric/eccentric exercises) Once you've built a good base with your isometric exercises, you should migrate to doing isotonic exercises. If we think of the side leg lift exercise again, an example of doing that as an isotonic exercise is when you lift your leg up and down to the side. We tend to start with these exercises in positions that still avoid stretching the tendons (so keep using that pile of pillows), as it is often still easy to irritate them. Once you've built a good base level of strength in this protected range, then you can usually safely transition into positions that cause a bit of a stretch on the tendon by removing some of the pillows. Other examples of isotonic exercises that work the glutes include squats, bridges, and the leg press. What exercises are most appropriate for you and how you should progress them will depend on your current level of strength and also what goals you have. Runners, for instance, will have to build a much higher level of strength and endurance than someone who just wants to walk their dog for 30 minutes. That's why we don't have a one-size-fits-all programme that we dish out to our patients. We test their strength (easily done via a video call) and do a thorough review of all their current activities and how these affect their symptoms, discuss their goals, and then design and adapt their programme with these factors in mind. How often to do isotonic exercises: These exercises usually require a bit more recovery time than isometric exercises and should NOT be done daily. You usually need at least one recovery day between sessions if you're doing light to moderate strength training (max three sessions a week). If you're doing heavy strength training or doing other exercise that also load the glutes (e.g. running), it's best to leave at least two recovery days between sessions and only do two strength training sessions per week. > Back to top How we can help via video call 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. What our patients say References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. (5th ed.) Vol 1: Injuries. (2017) McGraw-Hill Education. Grimaldi, A. and A. Fearon (2015). "Gluteal tendinopathy: integrating pathomechanics and clinical features in its management." Journal of Orthopaedic & Sports Physical Therapy 45(11): 910-922. Grimaldi, A., et al. (2015). "Gluteal tendinopathy: a review of mechanisms, assessment and management." Sports Medicine 45(8): 1107-1119. Mellor, R., et al. (2018). "Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial." British Journal of Sports Medicine 52(22): 1464-1472.

The #UKRunChat feed has at least one person a day complaining about sore or tight calves while running and at SIP we often get asked for advice regarding this. The problem is that there are several reasons why your calves may be sore or tight during or after sport and every one of them requires a slightly different treatment approach. Needless to say, I cannot cover this on Twitter and its 140 characters, so I thought I’d try and answer your questions in this blog post. Some of the most common reasons why people get painful or tight calves from exercise are: Training errors/changes Change of shoes You’re a tight arse (or back) You’ve upset a nerve Muscle tears Medial tibial stress (shin splints) Training errors that may cause tight or painful calves Any change in your training routine that will cause a sudden increase in load on the calf muscles may cause them to tighten up or hurt. The two best examples are speed work and hilly runs – both of these training sessions force you to run more on your toes, which will increase the load on the calf muscles. For the same reason, changing your running style to running more on your mid foot or forefoot can cause trouble if you introduce it too quickly. Interestingly, a study of 1500 recreational runners have found that running less than 40km per week and being a member of an athletics club appears to protect you against calf injuries! One could argue that being a member of a club may give you access to better training advice, but the researchers did not investigate this further. I would advise “relative rest” if you suspect that training errors may have caused your calf issues. Relative rest means that you don’t have to cease all exercise, but just choose sessions that will allow the injured or aggravated body part to recover e.g. cycle, swim or do a shorter easy run on grass. Introduce speed work, hills or changes in running style gradually to prevent calf pain and injury. Shoes that may cause calf pain Most runners these days know about “minimalist” shoes that claim to make you run more naturally. However, I find that a lot of the runners I see in practice have never heard of or considered the heel-to-toe-drop (offset) when buying a new trainer. The heel-to-toe-drop basically tells you how much higher your heel is than your toes when you’re wearing the shoe. Standard running shoes usually have a drop of around 12 degrees, but you can get 8, 6, 4 and 0 degrees as well. Minimalist shoes typically have a 0 degree heel-toe-drop (your foot is essentially flat). A flatter shoe will force most people to change their running style to run more on their toes. As mentioned in the section above, this will increase the load on the calf muscles. Your calves may become overworked and sore if you transition too quickly from a regular trainer to a flatter one. If you want to make a transition to flatter shoes, I would suggest that you: Transition slowly by initially doing only shorter runs in your new shoes or do some walk/run sessions. Strengthen your calf muscles. Walk in flat shoes most of the day. You’re a tight arse (or back) No, it’s not the money you keep in your pockets that weigh you down and stress your calves. :-) Your tight calves or calf pain may be caused by something called “increased neural tension”.  Don’t worry, it’s not nearly as serious as it sounds. What is increased neural tension? Your nervous system is continuous from your brain to the tips of your toes (and fingers). When you walk and move the nerves slide happily in their sheaths. Tight muscles or other structures can sometimes hold on to or press on the nerves and prevent them from sliding, causing increased neural tension and symptoms lower down in the limbs. A very common culprit is the piriformis muscle in the buttocks. In some people the sciatic nerve runs through or under the piriformis and gets squashed when this muscle becomes very tight. Tight buttocks often go hand in hand with a tight lower back and I find it most effective if you improve the flexibility in both areas. Why do people get tight in these areas? It may just be lifestyle. I often find that my runners who spend most of their day sitting or driving end up with very stiff lower backs and buttock. They often have associated increased neural tension when I test them. There is also some evidence that sports people tend to suffer a bit more wear and tear in the lower lumbar spine (especially in contact sport) over time and that older athletes tend to suffer more injuries to the muscles that are supplied by the nerves that originate from this area (sciatic nerve). Both of these cases can easily be improved/fixed by following a regular flexibility programme. In cases that do not respond to conservative treatment, a cortisone injection into the lumbosacral canal can produce good results. You can download an example of a flexibility programme if you follow the button below. Please be careful with the hamstring stretches since it can make your symptoms worse if you stretch them too aggressively while the nerve is still stuck. I would suggest to stretch the glutes and back first and then gently stretch the hamstrings. You’ve upset a nerve This is a bit more serious than the cases described above. If you experience tingling, numbness, very sharp pain or a lot of pain at night, chances are that you have injured a nerve in your back. Now, before you say “But I don’t have back pain!” – you often don’t feel back pain when you experience pain in your leg. This is because the pain/sensation in the leg is often too strong and blocks the pain signals from the back. As the nerve pain or funny sensations in the leg calms down, people usually start experiencing more pain in their backs. I would suggest that you consult a physiotherapist if you are experiencing any of these symptoms. Some muscle tears can feel like tight calves It’s usually easy to tell when you tear a muscle – you feel a sharp sudden pulling or pain and you can often see some swelling or bruising. But some muscle tears may not be this obvious. The soleus muscle, which can be found mostly in the lower 2 thirds of the calf, often just feels like it’s just very stiff when you first tear it. This stiffness then increases as you continue to exercise on it (this may take several sessions) until you are usually forced to stop due to pain. If you suspect that you have torn a muscle, you should use a combination of rest and strengthening exercises until it is strong enough to run again. You may be able to cycle or swim to maintain your fitness. A physio will be able to provide you with a rehab programme that is right for your injury and takes your sporting goals into consideration. This is also something that we can easily help you with via an online video consultation. Medial tibial stress (shin splints) Medial tibial stress syndrome (shin splints) may initially feel just like very stiff or tight calves. People usually experience some discomfort along the inside of the shin bone – where the muscle attaches to the bone. In the beginning people usually only experiences pain in this area when exercising, but as the condition worsens they also feel pain with walking and in severe cases at rest. You should not neglect this condition as it can easily develop into stress fractures if left unchecked. It is also a notoriously stubborn injury and may take several months to resolve (depending on how bad you allowed it to get). You should definitely consult a physiotherapist if you have pain along the inside of the shin bone (where the muscle attaches to the bone). 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. References: Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Current Reviews in Musculoskeletal Medicine 2009;2(2):74-77. doi: 10.1007/s12178-009-9045-8 Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? British Journal of Sports Medicine 2004;38(4):502-04. doi: 10.1136/bjsm.2003.011346 Van Gent, R. N., et al. "Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review." British journal of sports medicine 41.8 (2007): 469-480.