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What happens when your calf muscle pops? We answer this question, as well as why sometimes a pop in the calf muscle has no bruising, why a torn calf muscle can show bruising only a week later, and how to treat a calf muscle that’s popped. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article may be 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: What happens when your calf muscle pops? I felt a pop in my calf muscle but have no bruising Why is my torn calf muscle only bruising a week later? How to treat a popped calf muscle How we can help We also made a video about this: What happens when your calf muscle pops? The pop you feel in your calf muscle when you walk, run, or jump, usually means that you’ve torn a part of the muscle. It’s the sudden tearing of the muscle fibres that can make it feel like a pop, but some people even report hearing a “pop” when this happens. Make sure that it’s your calf muscle and not your Achilles tendon that’s popped. Calf muscle tears can easily be treated with a carefully graded strength training plan. Achilles tendon tears are much more serious and require specialist (usually needs placing in a boot) and quick (best results if done in 24 hours) treatment to ensure a good recovery. I felt a pop in my calf muscle but have no bruising Surely when you’ve torn a calf muscle you would expect to see some bruising? Not always. You will only see a bruise if: You’ve also torn a significant blood vessel, and the blood is able to move to the skin. Muscles are surrounded by thick, sinewy fascia sheaths, which can prevent the blood from moving to the skin, in which case it will be absorbed in due course and you’ll never notice a bruise. Why is my torn calf muscle only bruising a week later? It can take quite some time for the dead blood to move to the skin. If the portion of muscle that you’ve torn was really deep inside the calf or the fascia sheath is in the way, it can take a week or longer for the blood to move to the skin. The bruise may also be much lighter than what it would be in other circumstances, as a lot of the dead blood would already have been absorbed into the body. How to treat a popped calf muscle Exactly like you would treat all muscle strains. First, you have to reduce your activities to a level that doesn’t aggravate your injury. This usually means that you have to stop running or reduce your walking speed or distance. Then you have to slowly rebuild the strength of the injured muscle fibres through a graded strength training programme. Rebuilding the strength is really important, and a lack of proper rehab is in our experience the most common reason why people end up with recurring calf strains. We’ve discussed what an ideal rehab/exercise programme for a torn calf muscle should look like in a previous article. 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 Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. 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

A member of our Facebook community recently asked me what my treatment approach for Osgood-Schlatter disease is. Since it includes a few ifs and buts, I thought it would be best to share it in a blog post. The eagle eyed among you may notice that I have thrown the word “disease” out of most of this article. The reason for this is that I feel that “disease” has lots of negative connotations and is a far too serious word for this condition. In this article: What is Osgood-Schlatter? Why do kids develop it? How do you know that you have Osgood-Schlatter? My treatment approach for Osgood-Schlatter You can watch my discussion about Osgood Sclatter in this video. What is Osgood-Schlatter? Osgood-Schlatter is an overuse injury that develops where the tendon from the knee cap (patellar tendon) inserts onto the top of the shin bone (tibial tuberosity). In adults you find that a muscle terminates in a tendon which then attaches into the bone. Children, however, still has to grow and you find that their tendons attach to soft cartilage plates on the bone. These cartilage plates are vulnerable to excessive pulling (traction) forces and the pain a child feels when suffering with Osgood-Schlatter is due to damage and inflammation in the cartilage. It usually develops in children who: Are going or have just gone through a growth spurt Who does sport involving running and jumping Why do kids develop it? There are a few theories, but currently not much research to back them up. We know from research that children normally develop Osgood-Schlatter during the years when they grow quickly (experience a growth spurt). One theory is that their bones grow quickly but their muscles and tendons lag behind. In practice this means that they become a lot less flexible and their ability to coordinate/control their movements decreases for a short period until the brain has figured out how to ‘drive’ this new body. This may cause extra tugging and strain on the bit of cartilage that connects their tendon to the bone resulting in inflammation, pain and swelling in the area. Their odds of developing this condition goes up if they also do a lot of sport during this time. The patellar tendon normally pulls on the tibial tuberosity when you run, jump or kick a ball. This pull will be much stronger if the child has lost some of his flexibility in his quadriceps muscle due to going through a growth spurt. This theory does seem to link in with what I see in clinic. The kids that I treat for Osgood-Schlatter are often extremely sporty - doing sport up to 6 or 7 days of the week. They are usually also very inflexible. How do you know that you have Osgood-Schlatter? You are likely suffering from Osgood-Schlatter if: You are a child between the ages of 8 and 16 years (adults cannot get this condition, but they can still experience knee pain from the damage that was caused as a child) It is sore to press on the raised bit at the top of the shin bone (tibial tuberosity) Your knee hurts during or after sport You do not remember injuring your knee – the pain just started during or after sport There are, however, other conditions that can give very similar symptoms and it may be best to see a physiotherapist to get a diagnosis. If the kid is also experiencing pain that interferes with their sleep at night, they have to have further investigation done. The pain from Osgood-Schlatter does not keep children awake at night. Osgood-Schlatter Treatment The 2 corner stones of my treatment approach is rest and flexibility. The reasons why I think this work are: Rest or relative rest decreases the inflammation and gives the cartilage in the area time to heal. Stretching the muscles decreases the pulling (traction) forces that may have contributed to the child developing Osgood-Schlatter in the first place. Rest vs. Relative rest People used to talk about Osgood-Schlatter as a self-limiting disease, because it will normally resolve by itself over the course of 2 years. This makes it sound as if you can just happily ignore it and nothing bad can happen. Ignoring it and playing through the pain can cause you to end up with a severely painful knee that may stop you from doing all sports for a very long time. It can also predispose kids to more serious injuries e.g. where the attachment of the tendon can pull off the bone. I don’t like to tell my patients to completely rest from sport unless absolutely needed. I usually ask them to refrain from all running or jumping sports for about 2 weeks if they are experiencing pain as soon as they start sport as well as during the day. I still allow them to do any activities that do not cause pain. I then use those 2 weeks to improve their flexibility. It is important to find out exactly how many hours of what kind of sport the child is doing. Some kids do crazy amounts of sport per week. If a child is unable or unwilling to stop their sport, see if you can get them to just do the important sessions or maybe just play half a match. I tend to allow them relative rest if they only develop symptoms after playing sports and the pain settles within an hour after they stop doing sport. Also, remember that a kid can still practice parts of the sport that does not involve running or jumping e.g. standing still while shooting hoops or just serving balls in tennis. You can read more here about the treatment approach physiotherapists use when treating sports injuries. I don’t allow the kids straight back into full sport after the 2 weeks. A graded return, where you slowly increase the volume of running and jumping usually works best. Summary: They have to refrain from all aggravating activities for at least 2 weeks, sometimes longer, depending on symptoms. Slow graded return to sport if symptoms allow Stretches for Osgood-Schlatter The main muscle I target with stretching is the Rectus Femorus muscle which forms part of the quadriceps. The Rec Fem runs from the pelvis over the front of the hip joint and terminates in the patellar tendon. An easy test to see how tight a child’s muscles are, is to perform the Thomas test. Get them to lie on a table so that their thighs can dangle unsupported. Let them hug one thigh to their chest while they allow the other one to hang freely. A normal test: In clinic I usually want their thigh to be able to fall to parallel and I should easily be able to bend their knee back to about 130 degrees knee flexion at the same time. NB: YOU CAN MAKE THE PAIN WORSE IF YOU STRETCH IN THE WRONG WAY Remember that I said that Osgood-Schlatter develops due to excessive pulling forces where the patellar tendon attaches in the growth plate? So, it makes sense that you do not want to cause more strain on that area when you stretch the quadriceps. I find that the traditional way of stretching the quads, where you catch your foot behind you in standing, often either flare them up or does not produce an effective stretch. This is because it tends to put a lot of strain on the structures around the knee. I prefer to use a combined hip flexor and knee extensor stretch. You can use the fact that the Rectus Femoris muscle crosses both the hip and the knee joint to stretch the muscle without putting strain on the patellar tendon. You can target the top bit of the muscle more by getting them to extend the hip first and then adding in knee flexion. Check out the video below for a step by step explanation. I get them to perform this stretch 3 times a day (yes, mom, you will likely have to get up 15 minutes earlier). They have to hold it for at least 30 seconds and repeat it 3 times (90 seconds in total) in one go. My compliant patients who stick to this religiously usually gets full range within about 2 weeks. 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: Junge, T., Runge, L., Juul-Kristensen, B., & Wedderkopp, N. (2015). Risk Factors for Knee Injuries in Children 8-15 Years: The CHAMPS-Study DK. Med Sci Sports Exerc, 10, 10.

When to change running shoes is a question we often get asked by our patients. It’s really not a good idea to continue running in worn-out shoes. In this article, I explain what can go wrong if you continue running in shoes that are past their prime and how to know when it’s time to change your running shoes. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: Reasons not to run in worn-out shoes How to know when to change your running shoes Injured? We can help We've also made a video about this: Reasons not to run in worn-out shoes Worn-out running shoes have lost the cushioning effect of the foam in their soles. Especially if you're a quite heavy person and you run a lot on hard surfaces without proper cushioning, you can cause yourself injuries like plantar fasciitis, a variety of knee injuries, and even as high up as your lower back. (This obviously doesn’t apply if you’re used to running injury-free in minimalist shoes.) Also, if you're somebody who has a specific movement pattern, like for instance, you overpronate, it means that you're likely going to compress the inner part of the shoe more – whereas if you supinate, you're going to compress the outer part of the shoe more – and the shoe is going to take on that shape. And then as you run, it's going to increase that movement pattern even more, which can lead to more injuries. And then, of course, as your running shoes wear out, especially the top bits, they can also start problems like chafing, blisters, and injuries to your toenails. How to know when to change your running shoes 1. Mileage The first thing that you can look at is, how many kilometres/miles have you done in them? I'm not talking about just running; walking also counts if you also walk around in the shoes you run in. The general guideline is that you need to start thinking about replacing your running shoes at around 700 kilometres or 430 miles. Of course, this may be more or less for you, depending on a few factors such as: Your weight. Heavier people wear their shoes out quicker. The type of running shoe. Some of them are a lot softer, and you'll compress the underside or the sole quicker. If you have a specific running style, e.g. you overpronate, you're going to wear one part out quicker than the others. The terrain you run on most often. For example, if you do a lot of high-impact stuff like fast downhill running, you may wear your shoes out quicker because there will be higher force compression. How do you keep track of the distance your shoes have covered? My Garmin app allows me to log when I buy new running shoes. So, when I start to feel some niggles, I just look at my app and go, “How many miles have I done?” If you walk a lot in your running shoes, be sure to log your walks also on Garmin or whatever fitness tracker you use. Last summer, I couldn't understand how my shoes were starting to feel uncomfortable after only three months, because I hadn't done that much running. But then, when I looked at my total steps for those three months – my walking and my running, and we were touring in Europe, so we did lots of walking and sightseeing – I realised I did way more than 700 kilometres. So keep an eye on that. 2. Things start to feel uncomfortable Now, let's face it, very few of us are going to keep constant track of our mileage to decide when to change running shoes. One of the first signs that your shoes might not be right for you anymore is when things start to feel uncomfortable. If your training has stayed pretty much constant and you've not done anything excessive, but you're starting to get aches in your knees or your back, or your feet just feel really uncomfortable after a run, chances are that your running shoes are worn. Also, if you're getting blisters on your feet or you get warm patches underneath your feet just in specific places, those can be signs that you need to be changing your running shoes. 3. Inspect your shoes Inspect the tread on the soles, like a traffic cop inspects a car’s tyres when they’re intent on finding a reason to fine you. It may not be bald all over; e.g. if you're pronating, it might be bald only on the inside. Take a look at the shape of the shoes. If they look wonky and skew, they’re likely to be worn out. If the uppers look like the dog's breakfast and they’ve got holes in them and they’re just really worn, it's likely also a sign that the rest of your shoes are not going to be doing their job anymore. Injured? 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.

This post was inspired by one of my patients that I saw in clinic last week. She’s a keen runner who is recovering from a foot injury. She’d been recovering well but then did a run that was a bit too long and too hilly and her foot hurt again. Her words as she walked into my room were: “But I used my foam roller immediately after the run! I don’t understand why it hurts.” When you have an injury of any kind it means that you’ve damaged some cells in that structure. These can be bone cells, muscle cells, cartilage cells etc. depending on what structure you’ve injured. Three things have to happen for your injury to heal: The damaged cells have to be cleared from the area. This takes about 3 to 5 days. The body has to form new cells to replace the damaged cells. This starts at about day 4 post injury and can take until day 21 (that's 3 weeks) post injury. The new cells have to mature and strengthen so that they can be as strong as or stronger than the cells that were damaged. This happens alongside step 2 but can take more than 12 weeks (that's 3 months) depending on the injury. While foam rolling, massage and stretching are great tools to improve flexibility and decrease discomfort from tight muscles, they do not actually make your cells heal any quicker. The body has to go through its natural healing process. If you do too much exercise too quickly, those new cells aren’t strong enough to cope with the load and will be injured again. The key to successful recovery lies in knowing when and how to start introducing activity/exercise back into your training regime. You can read more advice on the healing process and how to structure your training to allow your body to heal in my previous blog post. 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.

It's natural for your hamstrings to feel a bit tight and stiff after training, and using a foam roller or doing hamstring stretches can really help to ease the discomfort. But you need to be mindful of the fact that rolling or stretching them out may not be enough. If your hamstrings continue to feel tight, sore, or uncomfortable during or after training, they may be telling you that they need a rest or that your lower back isn’t happy. If that’s the case, foam rolling your hamstrings won’t really make any difference. In this article: Video: How to foam roll your hamstrings When to foam roll your hamstrings When NOT to use a foam roller on your hamstrings When foam rolling your hamstrings won’t work Video: How to foam roll your hamstrings When to foam roll your hamstrings Before training: Research suggests that foam rolling before training can improve your flexibility. Researchers are a bit divided on whether or not it actually improves performance, but it has not been shown to have any negative effects on performance. You can read more about the benefits of foam rolling here. After training: It may be useful to foam roll your hamstrings after training as it has been shown to improve flexibility and there is some evidence to suggest that it can reduce the amount of soreness that you feel after exercise. When not to use a foam roller on your hamstrings Do not use a foam roller if you suspect that you may have pulled or torn your hamstring. You’ve likely torn your hamstring if you developed a sudden pain or pull while you were exercising or if you have swelling or bruising. Using a foam roller within the first 5 days can worsen the injury. It will also not help you heal any quicker. Be careful when you roll over the bony points where the hamstrings attach at your sit-bone (ischial tuberosity) or at the knee. Compressing the hamstring tendons onto those bony points can make injuries worse or cause compression injuries if you are too aggressive.. Note: Commission may be earned on the links above When foam rolling your hamstrings won’t work If your hamstrings have been over-worked and you are not giving them enough time to recover between bouts of exercise, they will remain tight and sore and foam rolling will have no lasting effect. In this case they need relative rest. Do activities that are low impact and low intensity. If your hamstring tightness is caused by neural tension. Stiffness in your glutes and lower back or injury to the lower back can sometimes stop your sciatic nerve from sliding freely. Your brain then causes the hamstrings to tighten up in order to protect the sciatic nerve. If this is the case your hamstrings will remain tight until the cause of the neural tension has been addressed. A physiotherapist can help you with this and this is something that one of our team can diagnose and treat via an online physio consultation via video call. If your hamstring discomfort is due to referred pain from your lower back or sciatica, then foam rolling the hamstrings may bring transient relief. But as with the increased neural tension mentioned above, you will have to sort out the injury higher up if you want to permanently improve it. Foam rolling can often also cause sciatic pain to increase if the sciatic nerve is very sensitive. 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: Capote Lavandero G, Rendón Morales PA, Analuiza A, et al. Effects of myofascial self-release. Systematic review. Revista Cubana de Investigaciones Biomédicas 2017;36(2):271-83. Macgregor LJ, Fairweather MM, Bennett RM, et al. The Effect of Foam Rolling for Three Consecutive Days on Muscular Efficiency and Range of Motion. Sports medicine-open 2018;4(1):26. Morales‐Artacho A, Lacourpaille L, Guilhem G. Effects of warm‐up on hamstring muscles stiffness: Cycling vs foam rolling. Scandinavian Journal of Medicine & Science in Sports 2017;27(12):1959-69. Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: a consensus statement. Br J Sports Med 2012:bjsports-2012-091448. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Current Sports Medicine Reports 2015;14(3):200-08. Zazac A. Literature Review: Effects of Myofascial Release on Range of Motion and Athletic Performance. 2015

Foam rolling can be great to loosen off your calves when they’re tight from training. But there are times when foam rolling can actually make your calf pain worse. Other times, you may find that it doesn't really have a lasting effect. In this article, I'll explain why this may be and I've also included a video where I demonstrate my favourite calf rolling technique. 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: When to foam roll your calves When NOT to use a foam roller on your calves When foam rolling your calves won’t work How to foam roll your calves I also discuss all of the dos and don'ts of foam rolling in this video and demonstrate my favourite method. When to foam roll your calves Before training There is some evidence to suggest that you can “wake muscles up” through foam rolling and that it may improve performance, but the research is not quite clear on it yet. It may also help to improve your flexibility. The most important thing is that none of the studies have reported any negative effects from foam rolling under these circumstances, so it is perfectly safe to do as part of your warm-up. I’ve previously discussed the benefits of foam rolling here. After training It may be useful to foam roll your calves after training, as it has been shown to improve flexibility, and there is some evidence to suggest that it can reduce the amount of soreness that you feel after exercise. When NOT to foam roll your calves Calf strains Do not use a foam roller on your calves if you suspect that you may have torn or strained it – especially if you have bruising or swelling. If you felt your calf muscle pop or you felt a sudden sharp pain while running, then you've likely torn it. The muscle fibres need time to recover, and you can worsen your injury if you do strong massage on a recently strained calf. Foam rolling does not make injuries heal faster. Muscle strains require a combination of rest and strengthening exercises to heal. You can read more about the treatment of calf muscles strains in this article. Blood clots If your calf pain started for no apparent reason, and it just suddenly became painful, red, and swollen, you should not foam roll or massage it. Rather consult your doctor immediately or go to the accident and emergency room, because you may actually have a blood clot, and it has to be treated immediately. When foam rolling your calves will not work Overuse If you’ve worked your calves very hard and haven’t given them enough time to recover between training sessions, they may remain tight and sore even after using a foam roller. In this case, you need to give them relative rest through reducing your running intensity and/or volume and rather doing low impact activities, e.g. gentle cycling or swimming. Neural tension Your sciatic nerve originates in your back, passes through your gluteal muscles, and runs down the back of your leg. If your lower back or gluteal muscles are tight, they will prevent your sciatic nerve from sliding freely when you use your legs to run, walk, cycle, etc. I often find this to be the case in patients who complain of chronically tight calves. Including mobility exercises for your lower back and hips in your routine can make a massive difference if your calf tightness is due to neural tension.  A physiotherapist can help you with this, and it is something that our team can diagnose and treat via an online physio consultation via video call. How to foam roll your calves Technique There is currently no gold standard for foam rolling calves, but the methods most frequently used in the research are: Broad or longitudinal strokes along the length of the calf muscle (ankle to knee). They usually spend about two minutes per leg. Point pressure or sustained pressure. This is where they sustain the pressure for between 30 and 60 seconds on a painful spot (until the sensitivity decreases) and then move on to the next. Using a massage ball for this usually works a better than a foam roller. I demonstrate my favourite technique in the video at the start of this article. Type of roller A firm roller is better than a soft one; it should have a bit of give in it but not dent in excessively when you press on it. If you get one with knobbles on it, it may be better for applying point pressure. For massage balls, I prefer the smooth lacrosse ball type made of rubber, as they don't slip around on your exercise mat. A massage stick can also be useful if you don't want to be rolling around on the floor, and it allows you to control the amount of pressure better. Note: Commission may be earned on the links above. Amount of pressure The pressure you apply should be 'comfortably uncomfortable'. One of the reasons why foam rolling helps to relax your calf muscles, is that it desensitizes the nervous system, which in turn reduces the muscle tone. If you are too aggressive and cause too much pain, the opposite happens - the nerve endings become more sensitive and the muscles increase their tone. How we can help Need more help with an injury or perhaps just advice on injury prevention? You’re welcome to consult one of the team at SIP online via video call for an assessment 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: Capote Lavandero G, Rendón Morales PA, Analuiza A, et al. Effects of myofascial self-release. Systematic review. Revista Cubana de Investigaciones Biomédicas 2017;36(2):271-83. Macgregor LJ, Fairweather MM, Bennett RM, et al. The Effect of Foam Rolling for Three Consecutive Days on Muscular Efficiency and Range of Motion. Sports Medicine-Open 2018;4(1):26. Morales‐Artacho A, Lacourpaille L, Guilhem G. Effects of warm‐up on hamstring muscles stiffness: Cycling vs foam rolling. Scandinavian Journal of Medicine & Science in Sports 2017;27(12):1959-69. Mueller-Wohlfahrt H-W, Haensel L, Mithoefer K, et al. Terminology and classification of muscle injuries in sport: a consensus statement. Br J Sports Med 2012:bjsports-2012-091448. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Current Sports Medicine Reports 2015;14(3):200-08. Zazac A. Literature Review: Effects of Myofascial Release on Range of Motion and Athletic Performance. 2015

Poor hip control and pelvic stability has been indicated as a possible cause of several running and sports injuries, including runner's knee, iliotibial band syndrome, and ACL tears. In this article, we explain how to test your hip control. In this article: Quick test for hip control Hip stability: The glute med is only half the story Summary - what exercises to focus on Glute med exercise Glute max exercise Quick test for hip control Stand in front of a mirror and balance on one leg. Now bend your knee to do a single leg squat. Look at the angle between your hip and where your knee moves. Your knee should stay in line with your second toe and your pelvis should stay level. If your knee moves in past your big toe or your pelvis drops, it may mean that you have weak hip stabiliser muscles. Doing hip strengthening exercises may decrease your risk of injury. Hip stability: The glute med is only half the story Most people these days will tell you that you have to strengthen your Gluteus Medius (Glute Med) muscle to improve your hip stability. We fully agree with that, but the Glute Med is not the only muscle in charge of stabilising the hip and pelvis. Fetto et al. argues that the Glute Med alone is not able to prevent the pelvis from dropping during walking. The hip has to absorb the biggest force during the mid-stance phase of gait, so you would expect the glute med to be the most active during this phase. EMG studies (where they test muscle activity) have shown that the glute med is actually most active just before mid-stance which indicates that another structure or muscle must also play a role. They also go into details about how much energy it would cost etc. etc. but you can read their full article here if you are interested. They point out that a person, whose leg is amputated above the knee, always walk with increased hip adduction or a Trendelenburg sign, while a person whose leg is amputated below the knee does not. The difference between the two procedures is that the iliotibial band is cut during the above knee procedure but not the below knee one. The iliotibial band is thus an important passive stabiliser of the hip and pelvis. No one really ever talks about strengthening the Gluteus Maximus muscle (Glute Max) to improve frontal plane hip and pelvic stability (to stop the thigh moving in and the pelvis dropping). Fetto el al., however, points out that 75% of the Glute Max attaches onto the iliotibial band and they therefore argue that the Glute Max has an important role to play in tensioning the iliotibial band and stabilising the pelvis. Summary - what exercises to focus on: You should do hip strengthening exercises that will strengthen the Gluteus Medius as well as the Gluteus Maximus muscles to improve your pelvic and hip stability during running and walking. Gluteus medius exercise The Clam exercise is a good place to start. They should be done very slowly to teach yourself to isolate the muscles and control the movement. Once you can manage 3 sets of 15 slow repetitions of this exercise, you should move on to more challenging exercises in standing. Starting position: Lie on your side with your hips bent to about 60 degrees and your knees at a 90 degree angle. Movement: Tighten your stomach muscles to help stabilise your trunk during the movement. Keep your feet touching but lift your top knee up and back, so that your legs separate and open like a clam. Hold the position for 3 seconds and then SLOWLY take your leg back down. Check that: Your pelvis or hips do not roll back as you lift your leg. Gluteus maximus exercise A good exercise to start with to activate and strengthen the Glute Max is the bridge with your feet on a chair or step. Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair. Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis form a straight line. Squeeze your buttocks and hold the position for 10 seconds. Repeat 10 times. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. 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. Reference: Fetto, J., Leali, A., & Moroz, A. (2002). Evolution of the Koch model of the biomechanics of the hip: clinical perspective. Journal of Orthopaedic Science, 7 (6), 724-730.

Some sports injuries have very obvious causes - you step in a ditch and sprain your ankle or you forget your feet are clipped in and fall off your bike. But what about those aches that suddenly appear halfway through a run? Or the Achilles that stiffens up 2 hours after training? To understand why we suffer these sports injuries with their "mysterious" causes, one has to first understand how the body reacts to exercise. The body has an immediate response to exercise as well as a long-term response. Immediate response to exercise: This is the cells' short term reaction (up to approximately 48 hours) to exercise. Hormones are secreted, energy stores are used up and have to be restored, etc. Long-term response to exercise: This involves structural and functional changes to the tissue. For example, muscle fibres get bigger during long-term strength training and your heart and lungs get fitter during prolonged endurance training. The body’s immediate response to exercise can be explained at the hand of the supercompensation cycle which is divided into three stages: Fatigue (your cells run out of energy, develop micro-damage, etc.) Recovery (the cells start to repair and replenish energy stores) Adaptation (your cells "super" compensate in case you expect them to do more exercise). Fatigue phase (Your cells are tired out) When you exercise, the body uses energy stores at higher rates than at rest. Your body starts to fatigue and your performance starts to decline as the energy stores are depleted. By-products accumulate and the cells suffer micro-damage. The micro-damage can increase to the point where it causes an injury if you ask your muscles, tendons, ligaments or bones to cope with a load that is above their physical ability (you haven't trained it for it). For example if you pick up a weight that is too heavy, run too far or too fast. You are also at more risk of being injured when you become fatigued. Fatigue may cause your muscles to lose their ability to absorb the shock during exercise and can lead to your ligaments or joints taking more strain. Nutrition also plays an important role during this phase. You will fatigue much faster if your energy stores are not at optimal levels to start with. You can further delay fatigue by taking on food and drink while exercising. Recovery phase (Your cells have to recover from training) The name is pretty much self-explanatory. Once you finish your exercise session, the energy stores have to be refilled, by-products removed and micro-damage repaired to prevent more serious damage. You increase your risk of injury if you train while your body is still in the recovery phase. If you do this too often, it may even lead to overtraining syndrome, a condition that can take months to recover from. Different activities of varying intensities require different recovery times. Muscle can take between 24 and 36 hours to normalise after resistance training, while between 10 and 48 hours are required to replenish glycogen stores after aerobic exercise. Certain hormones, e.g. testosterone, can enhance recovery, which is why men generally recover quicker than women. Athletes younger than 18 years and older than 25 years also require longer rest periods to reach the adaptation phase. Trained athletes usually require less time to recover since their bodies have adapted to high training loads and have become more efficient over time. Novice runners, for instance, should really not run more than 3 times a week, while professional triathletes can cope with having just one rest day in 10! Getting your nutrition strategies right during this phase is as important as rest. Recent research suggests that you benefit most from consuming a combination of protein and carbohydrates within 30 minutes of completing exercise. Restricting your energy intake (not eating enough) between training sessions means that the body cannot repair the damaged cells. In extreme cases it may have to break down muscle and bone just to survive. Stress actures are a good example of an injury that can develop due to athletes not eating enough. The environment, travelling and sleep can also influence your recovery from exercise. There is no one size fits all when it comes to recovery and it is worth consulting an experienced coach or sports physiotherapist if you think you may be overtraining. Adaptation phase ( Your cells are ready to train and stronger than before) This phase is the most important phase for training. During this phase the body rebuilds itself and replenishes its energy stores to a higher level than before your previous exercise bout. You will see the best training results if you can time your next exercise bout to fall in this phase. Summary: What causes sports injuries? Sports injuries are caused by: Trauma Doing more exercise than what you have prepared your body for e.g. lifting a weight that is too heavy, running too far or suddenly doing a very hilly run. If you do not give your body enough time to recover between training sessions. The result is that different tissues in the body (bone, muscle, tendons) become weaker rather than stronger. This is usually the case when you suddenly develop an injury during an exercise session that normally does not cause you trouble. 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: MacLaren, D., Spurway, N., & Whyte, G. (2006). The Physiology of Training: Churchill Livingstone.

I find in practice that my patients often think that only yoga and Pilates type exercises can help lower back pain. If the thought of you being told to breathe in deep while contracting this and moving that fills you with dread, you’ll be happy to know that these are not the only forms of exercise that can relieve lower back pain! In this series of three blog posts, I have so far looked at: Part 1: Does Pilates benefit people with lower back pain? Part 2: Does yoga hold any benefits for lower back pain sufferers? My third and final post in this series looks at other forms of exercise that have been shown to help people with lower back pain. So, do you have to do yoga or Pilates if you have lower back pain? You may have guessed the answer to this by now. No, there are plenty of other forms of exercise that you can do that can also help lower back pain. The most effective exercise for lower back pain Hayden et al. looked at all the different exercise strategies employed in studies that investigated exercise for lower back pain. They identified that the most effective strategies: Were individually designed exercise programmes, delivered in a supervised format (for example, home exercises with regular therapist follow-up), done often. Adding other conservative treatment, such as advice to stay active, NSAIDs, or manual therapy, also resulted in improved pain and function outcomes when compared to exercise only. What type of exercises should be included for lower back pain? Researchers have found that stretching exercises appear to be the best type of exercise to decrease pain while strengthening exercises are the most effective at helping people function better. A recent study has even shown that free weight training can be an effective treatment for lower back pain. Other types of exercise that has been found to be useful include aerobic exercise, mobilising and coordination exercises. My ideal exercise programme for lower back pain I usually prescribe a combination of stretching, mobility and strengthening exercises that should be done daily and cardiovascular exercise that should be done at least 3 times a week. My patients usually consult me on a weekly basis for 2 or 3 weeks, during which we adapt their exercise programme to make sure it works for them. I usually also include self-massage techniques that help with their pain. Once their pain starts to settle and they are confident with their exercises, I send them away to continue their exercises and only see them every few weeks to progress their programmes. 1. Stretches These should be very gentle to start with and what I choose will depend heavily on the cause of my patient’s lower back pain. Someone with acute nerve pain down the leg will for instance make their symptoms worse if they try to stretch their hamstring, since this stretch will also stretch the irritated nerve. I have included some examples of my favourite stretches for lower back pain in the next section. 2. Gentle mobility exercises People who have had severe pain or have been in pain for a long time can be very fearful of movement. Prolonged lower back pain can also cause the subconscious brain to be over-protective and cause it to shout “Pain!” for things that is not supposed to be painful. You can switch this over-protective system off by doing gentle movements in positions that the “brain” feels safe in and then slowly move on to more challenging positions. A good example of this is the spine curl exercise (see below) that you do while lying on your back. I use it often for patients with lower back pain who cannot bend forward in standing or who try to avoid flexing their spine when I tell them to touch their toes. 3. Strengthening exercises These can take many forms and can include: bridges, squats, abdominal exercises, back extension exercises etc. The main point to remember is that you should be able to do very simple stable exercises first, before you can progress to more dynamic things e.g. kettle bell swings. You can find an example of a strength training programme for lower back pain here. Your exercise selection will once again be dictated by the cause of your lower back pain. 4. Cardiovascular exercise This is a very important component of any exercise programme for lower back pain and one that I feel is often neglected. It helps to improve the whole body’s health status, but can also act as a potent pain killer due to the "happy hormone" released during cardiovascular exercise. My weapon of choice is usually cycling on a stationary bike. I prefer this exercise due to its low impact and your ability to play with your position on the bike. I find it especially useful for people who spend a lot of time sitting during the day. In my experience, the gluteal muscles (your bum muscles) can often contribute to my patient’s lower back pain and cycling seems to have a positive effect on them, which is likely due to increasing their blood supply. Other useful choices can include walking, using a cross-trainer and swimming. Your choice should be influenced by your personal preference and how your back reacts to it. I usually ask people to avoid breast stroke, because the rotation movement of the legs can sometimes stir things up a bit. Choose something you enjoy! Otherwise you will not stick to it. Try to do it at least 3 times a week. Example exercise programme for someone with acute lower back pain: You should feel either better or the same after you have done these exercises – not worse. These exercises will not suite everyone. 1. Be as active as your back allows you to be. Do any activity that does not cause an increase in your pain. Swim, cycle or walk. You may have to decrease the time you do these activities for e.g. swim for 30 minutes rather than your normal hour. 2. Piriformis and gluteal stretches You should only feel a gentle stretch – not pain. DO NOT PULL TOO HARD. Lie on your back with your knees bent. Place the outside of your right ankle on your left thigh. Place your right hand on your right knee and your left hand on your right lower leg. Now pull your leg up to your chest so that your right knee moves towards your right shoulder. Hold the position for 30 seconds. Repeat with your other leg. Do 3 repetitions on each leg. Then repeat the exercise, but pull your leg diagonally across your chest so that your right knee approaches your left shoulder. Hold the position for 30 seconds. Repeat with the other leg. Do 3 repetitions on each leg. You should feel a stretch in your buttock and/or back of your thigh. You can sometimes feel a stretch in your back if you are really tight. 3. Lumbar rotation stretch You should only feel a gentle stretch – not pain. DO NOT PULL TOO HARD. Lie on your back with your legs straight. Place your left foot on your right thigh just above the knee. Now use your right hand to pull your left knee over to the right so that your lower body rotate to the right. You should feel a stretch in your left buttock or lower back. Your buttock and lower back are allowed to lift off the bed, but your upper back should stay flat. Hold the position for 30 seconds and repeat it 3 times to both sides. 4. Spine curls This exercise is great for regaining some mobility, but it is also a gentle strengthening exercise for the back, gluteal and thigh muscles. Lie on your back with your knees bent. Pull in your lower tummy muscles so that your pelvis tilts backwards and your lower back flattens into the bed. Slowly lift your bottom off the bed and then imagine lifting one vertebrae at a time until your trunk forms a straight line. If you find that it causes you pain to lift your back up, only lift to before you feel the pain (this may sometimes mean that you only do the pelvic tilt and do not even lift up). The more you do it to just short of pain, the better you will get. Eventually you will be able to do the full movement. Once you reach the end position, maintain the position for 10 seconds before slowly rolling down to the bed. Make sure that your bottom is the last thing to touch the bed. So you roll up in a wave and then come down in a wave. Repeat this 10 times. Be careful not to try and lift too high. It can cause you pain if you try and over-extend your back. 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: Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain. Annals of Internal Medicine, 142(9), 776-785. Mostagi, F. Q. R. C., Dias, J. M., Pereira, L. M., Obara, K., Mazuquin, B. F., Silva, M. F., et al. (2014). Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. Journal of Bodywork and Movement Therapies. Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., et al. (2015). Effects of Pilates Exercise Programs in People With Chronic Low Back Pain: A Systematic Review. Medicine, 94(4), e383.

Lower back pain affects 85% of us at least once in our lifetime. Most of us are lucky enough to recover within a few months, but around 10% of people continue to suffer. The most commonly prescribed forms of exercise for lower back pain are yoga and Pilates, but this type of exercise does not necessarily suit everyone's personality or schedule. In this series of three blog posts, I take a closer look at the evidence behind these forms of exercise and hope to answer the following questions: Part 1: Does Pilates benefit people with lower back pain? Part 2: Yoga for lower back pain - does it actually work? Part 3: Is there any other form of exercise that can help your recovery from lower back pain? In Part 1, I looked at the evidence behind the use of Pilates to treat lower back pain. Part 2 will now take a closer look at what yoga is and whether there is any evidence that it may be useful in the treatment of lower back injuries. What is Yoga? Yoga is an ancient form of exercise that consists of a combination of meditation and yoga poses. People tend to think of yoga as mainly consisting of stretching exercises, but the poses develop strength, endurance and flexibility depending on how you perform them. I highly recommend that you read the section on “What is Yoga” on about.com for a deeper understanding of how this ancient exercise form works. Yoga for lower back pain - does it actually work? Yes, two literature reviews of the most current research agree that Yoga can reduce pain and disability associated with lower back pain. I can unfortunately not make any recommendations as to what type of Yoga is best for lower back pain, since the included studies used several different types. The sessions were all led by experienced teachers which may have attributed to the positive results. "But why does Yoga hurt my back?" There may be several reasons why yoga can make your pain worse, but the main two are: 1. Your teacher does not understand your condition and is not giving you appropriate exercises. Not all movements and poses are appropriate for everyone. The yoga classes used in the research studies were all tailored to the specific needs of the patients. 2. You are trying too hard – stop competing with the guy in the corner who can hook his leg behind his ear! I always advise my patients to: Book 1 to 1 sessions with an experienced yoga teacher (preferably one with a physio background) for 6 weeks. Make sure that your teacher provides you with an exercise sheet and do the exercises EVERY DAY. Only join a class once you understand the movements and know your limitations. Make sure that you join a class that suits your skill/activity level. DO NOT PUSH THROUGH PAIN. While it may be normal to have a slight increase in your pain after a class, you should not experience a big flare in pain or other symptoms. “But I really don’t like yoga!” Don’t worry. The research has found that yoga is no more effective than other mind-body exercises like Thai Chi and Pilates. Next week I’ll discuss what exercise regimes other than Pilates and yoga have been shown to be beneficial for decreasing lower back pain. 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: Cramer, H., Lauche, R., Haller, H., & Dobos, G. (2013). A Systematic Review and Meta-analysis of Yoga for Low Back Pain. The Clinical Journal of Pain, 29(5), 450-460. Saragiotto, B. T., Yamato, T. P., & Maher, C. (2015). Yoga for low back pain: PEDro systematic review update. British Journal of Sports Medicine, 49(20), 1351.

I am often asked by my patients what is the best type of exercise to relieve or prevent lower back pain, or rather the questions usually sound something like this: “Should I do Yoga or Pilates for lower back pain?” “I know I should be doing Pilates, but I find it sooo boring and the breathing confuses me. Should I go back to it?” “I tried Yoga and Pilates for a while but I found that it hurt my back.” I’ll try and answer these questions in a series of three blog posts: Part 1: Pilates for lower back pain - does it really help? Part 2: Does Yoga help for lower back pain? Part 3: Do I have to do Yoga or Pilates if I have lower back pain, or can I try something else? Part 1: Pilates for lower back pain - does it really help? What is Pilates? Pilates is an exercise method where you focus on developing your body control, strength and flexibility. Yes, Pilates increases your core strength, but more importantly it also teaches you how to move your body in a coordinated way. If, for instance, you have poor control and strength in your back and trunk and move you back every time you use your arms or legs, you are more likely to injure it. If, however, you are able to control your back’s position while you are using your arms and legs, you are less likely to strain it. By control, I do not mean brace your body as hard as you can so that your back does not move at all. What I mean is that you are actually aware of the position of your joints and control the movement of the back as you move rather than just allowing it to go wherever it wants to go. Having a well-controlled and strong trunk will also improve your accuracy and performance during sport and is one of the main reasons why different sports teams (including our tough rugby boys) have integrated Pilates classes into their training regimes. I attended The Young Athlete Conference held by the ACPSEM over the weekend and the physiotherapist from Southampton football club presented data that showed how they have decreased the incidence of groin injuries in their footballers through Pilates exercises that were aimed at the lower back, pelvis and hip. Pilates is named after its founder, a German by the name Joseph Hubertus Pilates. He developed the exercise regime for himself and incorporated several elements from other exercise forms e.g. Yoga into it. “In 1912 Joe went to England, where he worked as a self-defence instructor for detectives at Scotland Yard. At the outbreak of World War I, Joe was interned as an “enemy alien” with other German nationals. During his internment, Joe refined his ideas and trained other internees in his system of exercise. He rigged springs to hospital beds, enabling bedridden patients to exercise against resistance, an innovation that led to his later equipment designs. An influenza epidemic struck England in 1918, killing thousands of people, but not a single one of Joe’s trainees died. This, he claimed, testified to the effectiveness of his system.” From http://www.pilates.com It was only after his release when he moved back to Germany that the method gained popularity under the dancing community due to its ability to improve body strength and control. It is only in recent years that it has been advocated as a cure for lower back pain. Does Pilates exercise actually help for lower back pain? Yes, a recent review of the literature has found that Pilates based exercises are effective in decreasing pain as well as improving flexibility and function in people with chronic lower back pain. “So, why did Pilates hurt my back?” Pilates exercises can come in various forms and intensities and your experience can be heavily dependent on you instructor’s skill to understand your condition and adapt the exercises for you. It has also been shown that exercise programmes that are specifically designed for a specific person is more effective in decreasing lower back pain and increasing function. Not all exercises and positions are appropriate for all people. I always steer my patients towards classes taught by experienced physiotherapists. They have a much better understanding of the different health issues and are better placed to provide exercise in the beginning stages. They may even conclude that Pilates is not the appropriate form of exercise for you and prescribe something totally different! But I find Pilates sooooo boring! My answer to this is: “You are attending the wrong class.” While it is important to get the basics right at the beginning, you should progress on to more challenging and complex exercises as you get stronger. There is, however, no getting past it – you have to master the simple, low level breathing combined with move-this and move-that exercises first, before you can get to do the more exciting stuff. You will not work up a sweat in the first 2 months. You may very well leave your first class feeling a bit confused and overwhelmed by trying to activate muscle groups you never knew existed! I usually advise my patients to do the following: Attend 1 to 1 classes with an experienced Pilates instructor (preferably with a physio background) for 6 weeks. Make sure that the instructor provide you with an exercise sheet and things to do at home. Doing these exercises once is week is not enough! Do these exercises EVERY DAY. Then join a class. Choose the intensity of the class according to your ability and pain. There is no use in attending a high intensity class just because you like to sweat, if you are unable to control your body under those circumstances. Use the key concepts that you learn during the Pilates classes in everything you do, from work to sport. Still bored of Pilates? Go and try something else, but apply the Pilates principles that you have learned. It has been shown that while Pilates is effective in decreasing chronic lower back pain, it is no more effective than other types of exercise e.g. cycling. (3) Word of caution: The type of exercise has to be appropriate for your injury, so please consult your physiotherapist before embarking on a new exercise plan. Let’s face it, if you do not enjoy the exercise you are doing, you are not going to stick to it. SO CHOOSE SOMETHING YOU ENJOY! Next week we will look at whether Yoga is effective in treating lower back pain. 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: Patti, A., Bianco, A., Paoli, A., Messina, G., Montalto, M. A., Bellafiore, M., et al. (2015). Effects of Pilates Exercise Programs in People With Chronic Low Back Pain: A Systematic Review. Medicine, 94(4), e383. Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain. Annals of Internal Medicine, 142(9), 776-785. Mostagi, F. Q. R. C., Dias, J. M., Pereira, L. M., Obara, K., Mazuquin, B. F., Silva, M. F., et al. (2014). Pilates versus general exercise effectiveness on pain and functionality in non-specific chronic low back pain subjects. Journal of Bodywork and Movement Therapies.

This article discusses the benefits and risks of strength training for children. It also outlines how to compile a safe and effective resistance programme for children and adolescents. The UK's Strength and Conditioning Association recently published a position statement on resistance training for young people that dispels many of the surrounding the negative impact it may have on the immature skeleton. Part 1 of this article discusses the benefits and risks as well as what effects it can have on performance. Part 2 (below) explains the principles of compiling a safe and effective resistance programme for children and adolescents. Strength Training For Children Part 1: Benefits, Risks and Performance You can find a summary of the key facts at the end of part 1. Health benefits The media in the UK has been full of alarming reports regarding rising obesity and decreasing levels of fitness in our children over the past few years.  Lloyd et al. adds to this by pointing out that recent evidence also shows a decrease in muscular strength levels of school-age children. Resistance training has been shown to have a positive effect on musculoskeletal health, body composition and cardiovascular risk factors. Fears that resistance training would harm the growing skeleton of children and adolescents have thus far not been supported by clinical observations. In fact, research has indicated that childhood may be the opportune time to build bone mass by participating in weight-bearing physical activity. Resistance training may further be of specific benefit to overweight children. Endurance exercise is normally prescribed to help with weight loss but the researchers argue that excess body weight may be an obstacle to performing activities such as jogging. It has also been found that overweight children seem to have decreased motor control and an increased injury risk compared to their peers, which may make strength training a safer option initially. Their view is that the inclusion of a structured strength training programme into a weight loss programme, can help children improve their motor skills and muscle strength while gaining confidence in their physical abilities. It will also help increase muscle mass which adds to a healthier body composition. Injury prevention benefits There is a growing body of evidence that appears to show that participation in regular resistance training by young athletes lead to a reduction in acute and overuse injuries over the competitive season as well as a shortened rehabilitation period if injured. Qualified supervision and appropriate training loads are however essential to prevent young athletes from sustaining injuries through resistance training. Researchers investigating acute injuries related to resistance training found that 77.2 % were accidental and that most could have been avoided with appropriate supervision and a focus on technical competency. Multifaceted programs that increase muscle strength, enhance movement mechanics and improve functional abilities may be the most effective strategy for reducing sports related injuries in young athletes. These programs further seem to be more effective if implemented in younger age groups – before the onset of neuromuscular deficits and biomechanical alignment issues. The researchers recommend that children should build a good basic strength, motor control and fitness base before they start taking part in competitive training. Incorporating basic jumping activities into free play can for instance strengthen their muscles and tendons and prepare them for sport in later life. The problem is that all the evidence these days suggest that kids are less active and do not spend enough time playing outside, which may mean that the musculoskeletal system of aspiring young athletes are ill prepared for their sport. The focus with strength training in children and adolescents should thus be to first produce an individual with balanced muscle strength and good muscular control, before they specialise in a specific sport. A well supervised programme may also help children overcome the loss of coordination and muscular control that they typically experience when they go through a sudden growth spurt. Young females In general injury records show that female athletes of all ages may be predisposed to certain injuries (e.g. anterior cruciate ligament rupture (ACL)) compared to their male counterparts. This is thought to be in part due to differences in biomechanics displayed between female and male athletes. Researchers have found that young female athletes who participated in strength training as they matured demonstrated fewer of the injury risk factors e.g. increased knee angles with landing. A recent meta-analysis of all the available literature revealed that an age related association between resistance training and a reduction of ACL injuries may exist in that strength training only reduced ACL injury incidence when it was implemented between the ages of 14-18. Performance enhancement There is evidence that various forms of resistance training are capable of improving young athletes’ performance in: Muscular strength Power production Running velocity Change of direction speed General motor performance (jumping etc.) Psychological benefits The research on this topic is still open for debate. It does seem to suggest that multi-faceted programs inclusive of resistance training may have psychological benefits as long as self-improvement and enjoyment remain central to the training programme. Excessive volumes of physical training could however lead to negative psychological effects and if the recovery time between training sessions are inadequate it can cause overtraining syndrome. Overtraining syndrome leads to changes in the biological (injury), neurochemical (depression) and hormonal systems (sleep disturbances) and a child can take a very long time to recover from this. See my post on overtraining syndrome for details on how to manage and prevent this condition. Summary Part 1 Resistance training is safe and beneficial for children as well as adolescents. Attention to postural alignment and technical competency during all exercises is essential to prevent injury. It can help increase bone mass and muscle mass and help with weight loss in overweight youths. It can effectively reduce the injury risk over a competitive season and aids recovery from injury. It has specific benefits for injury prevention in young females with best results gained when implemented between the ages of 14 to 18 years. Resistance training can enhance performance in various activities (running, jumping, etc.) It may also have a positive psychological effect as long as enjoyment stays central to a programme. Excessive volumes of any sport can lead to overtraining and have negative psychological effects. Part 2: Developing a strength training programme for children How does muscle strength develop in childhood and adolescence? As children reach the onset of puberty they experience rapid growth along with non-linear gains in muscular strength. Strength gains during childhood are thought to be mainly due to the maturation of the central nervous system (how well the brain and nerves control the muscles) for instance improvements in nerve firing frequency and synchronisation. Strength gains during adolescence are mostly driven by structural changes to the muscle tissue due to hormonal changes but also include some neural development. Interestingly the number of muscle fibres that one possess is already determined before birth, so any increases in muscle cross-sectional area is largely due to increases in muscle fibre size. The focus of resistance training in children should thus be based on goals related to enhancement of muscle strength, function and control as opposed to trying to make substantial increases in muscle size which will only happen during puberty. It is important to remember that children mature at varying rates and that young athletes of the same chronological age can vary with up to 5 years in their biological status. A young athlete should thus be trained according to his biological status. The athlete’s training age should however also be taken into consideration. A technically proficient athlete should not be restricted to introductory training just because of their age. Evidence further indicate that the most effective training programmes lasts more than 8 weeks, involve multiple sets and are executed more than once a week. Detraining can occur quickly once training is stopped and it is therefore advised that they partake in some form of strength training all year round. Weightlifting for young athletes The research, according to Lloyd et al., suggests that the performance of weightlifting movements as part of a strength and conditioning programme can be safe, effective and enjoyable, provided qualified supervision and instruction are available and progression is based on the technical performance of each lift. Conditions for safe training: The child should be mature enough to follow directions It should be done under the supervision of a qualified professional who is knowledgeable of youth resistance training protocols Correct technique and posture should be acquired first Exercises using body weight should be mastered first Free weights should then be introduced since they appear to stimulate more muscle activation than machine based exercises Once the youth is technically competent multi-joint, velocity specific activities can be introduced e.g. plyometrics and weightlifting. Once again technique should first be developed using modified equipment and light loads. High training intensities (heavy weights) at the expense of correct technique will likely lead to acute injuries High training volumes at any load in turn may lead to overuse injuries For individuals without prior experience of resistance training: Low volume (1-2 sets) and low to moderate training intensities (≤ 60% 1 RM) for a range of movement patterns should be used. Also note that when children are initially introduced to multi-joint exercises (e.g. squatting) their motor control development benefits more from fewer repetitions (1-3) and real time feedback after each repetition. Constructive feedback is essential to learn good technique Once technically competent the prescription should be progressed for example 2-4 sets of 6-12 reps at low to moderate intensity (≤ 80% 1 RM). As training age and athletic competency progress, periodic phases of low repetitions (<6) at high external loads (>80% 1RM) can be used. Monitor for accumulated fatigue during a training session to minimise the risk of fatigue –induced technical decrements which could lead to injury. Rest intervals: Children recover more quickly from fatigue-induced resistance training and are less likely to suffer muscle damage. One minute rest should be enough between sets but this should be increased (2-3min) as the intensity of training increases or if a high level of skill is required. Training frequency: 2-3 sessions per week on non-consecutive days are advocated to be the most appropriate for children and adolescents. The competitive season should however also be taken into consideration as training volumes may already be high. Depending on the competitive demands of the sport, anywhere between 1 and 3 strength training sessions should be completed every week to enhance or at least maintain previously acquired muscle strength. Repetition velocity: It basically boils down to technical competence and training age. A youth with limited training experience should perform exercises at a moderate speed to ensure control and good technique. A youth with several months of training experience should be exposed to greater movement velocities in order to develop motor unit recruitment patterns and firing frequencies within the neuromuscular system. Or in normal language, to enable him to produce power quickly as is needed in most sports. When high weights are used, the intention to move it as explosively as possible (even if the movement occurs relatively slowly) is enough to maximise the training effect. 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 Lloyd, R. S., Faigenbaum, A. D., Stone, M. H., Oliver, J. L., Jeffreys, I., Moody, J. A., et al. (2014). Position statement on youth resistance training: the 2014 International Consensus. Br J Sports Med, 48(7), 498-505.