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What causes muscle loss as you age, and can anything be done about it? A common complaint from my more competitive patients, who find themselves at the less desirable side of 50, is that they have to train double as hard to perform at their previous levels. They usually dread taking even a few days off training, as they feel that their fitness levels decline much faster than in their younger days. (If you like facts and details please continue to read. If, however, you would like a quick summary and succinct advice, skip to the end of the post) A recent review by Dickinson et al. (2013) looked at the causes of muscle loss in seniors and offers some insight into the processes that may partly be to blame for this decline in performance. What follows is essentially a summary of their article with some of my own thoughts interspersed. It is important to note that all of this research was conducted using older adults (above the age of 50), who are mobile but not following a regular exercise regime. How these findings relate to physically fit older adults, who train on a regular basis, is unknown. I was unable to find any research that specifically compared older adults who trained regularly with young adults who trained regularly. There are also other factors than muscle strength that could influence performance in older adults namely a decreased aerobic capacity. It has long been known that aging is characterised by the gradual loss of skeletal muscle. I use the word ‘aging’ very loosely here since it has been shown that muscle mass may start decreasing as early as the ages of 25 to 30. Interestingly it appears that the contractile properties of muscles remains unchanged and that it is thus the gradual loss of muscle size that is to blame for the decreases in strength and function. In their review, Dickinson and colleagues, focused on the role exercise and nutrition can play in reversing or slowing down the process of muscle loss. Background: Skeletal muscle The body continuously breaks down and rebuilds skeletal muscle. The process of rebuilding muscle is called muscle synthesis. Changes in muscle size occur when one of these two processes (breakdown vs. synthesis) dominates the other. Nutrition and exercise have previously been shown to be strong stimuli for muscle synthesis. One of the main factors thought to contribute to muscle loss in older age is an impaired ability of the muscle tissue to respond to the stimuli that cause muscle protein synthesis. Building new muscle: Effects of nutrition and aging It has been established that the balance between skeletal muscle breakdown and synthesis (building new muscle) is strongly influenced by the levels of amino acids (the building blocks of protein) circulating in the blood. The exact science involved in the process is still unclear but results thus far suggest that there is an intricate relationship between amino acid availability, skeletal muscle synthesis and aging. Ingesting small quantities (7-10g) of essential amino acids (protein) is capable of stimulating skeletal muscle synthesis in young individuals but not in older adults. However, ingesting large quantities (20-40g) of amino acids stimulates muscle protein synthesis to the same degree in both age groups. The authors conclude that the data indicates that the ‘threshold’ at which amino acids stimulates muscle synthesis is increased with age and that it could be overcome by ingesting adequate quantities. A specific type of amino acid has been identified to be the most important for muscle synthesis, namely leucine. Leucine has previously been shown to be a potent stimulator for muscle growth and in studies where they increased the leucine concentrate in the protein consumed by subjects, they found that young (28/30yrs) and old (66/70years) subjects showed the same level of muscle synthesis despite the small dose of protein (7g but more than 2g leucine) ingested. Thus increasing the amount of leucine in a meal may promote muscle synthesis in older adults. NB: As with all processes in the body there is not just one factor involved in the synthesis of skeletal muscle and this is demonstrated by the conflicting results reported in the literature. As an example of this, see our post regarding Vitamin D and Athletic Performance for the influence Vitamin D can have on muscle synthesis. Pennings et al. (2010) stand in contrast with the above findings in that they found no difference in muscle synthesis in response to 20g amino acid ingestion between age groups. This may be due to cultural differences(1). (Could the subjects in the Netherlands' study have a different lifestyle which impacts on their ability to maintain muscle mass in later life?) Verhoeven et al. (2009) does not seem to agree with the above recommendations either. They found no increases in muscle strength or mass in healthy elderly men after taking a 2.5g leucine supplement for 3 months. Possible differences in study design that could have contributed to these results are: The subjects may have already been taking above threshold levels of protein in their normal meals and therefore showed no further increase in muscle synthesis. Also, in contrast with the subjects in the previous studies, the subjects in this Verhoeven’s study consumed mixed meals which may have influenced how their muscles responded to the leucine(see section on insulin). A recent randomised control trial conducted over 3 weeks looked at the effect of 20g protein supplement on muscle mass post total knee replacement surgery. They found that the control group showed attenuated muscle atrophy in all the muscles of the operated as well as un-operated leg. Dickinson and colleagues warn that it is important to remember that exercise has been shown to play an important role in muscle synthesis and that physical activity or base level fitness may be an important reason for differences in results. I fully agree with this statement since the subjects in Dreyer’s study were asked to administer their supplements an hour after physical therapy, while Verhoeven and colleagues did not report on the activity levels of their subjects. See the section on exercise below for an explanation of why the timing of food intake may be important. The role of insulin There is evidence that the physiological response elicited by ingesting a mixed meal (carbohydrates and 40g protein) interferes with the ability of amino acids to elicit a protein synthesis response in older adults. This puzzled researches since a meal containing carbohydrates causes an increase in circulating insulin and insulin is known to stimulate muscle growth. Further investigation suggested that this effect may be due to the inability of insulin to stimulate an increase in muscle blood flow in older adults, since artificially increasing the blood flow in the muscles of older adults caused the difference in muscle synthesis between age groups to disappear. These results are supported by those of Fujita et al. (2007) who found that a bout of aerobic exercise performed before eating a mixed meal could restore the normal muscle protein synthesis reaction to insulin. Building new muscle: Effects of exercise and aging Resistance exercise Protein synthesis in older adults has an impaired response to resistance exercise. It can increase muscle size and strength in older individuals but just not to the same level as in younger individuals. There is evidence that more protein is incorporated into muscle if exercise is performed before the meal. Drummond et al. (2008) also found a similar response to ingesting 20g of essential amino acids after a bout of resistance exercise in young and old. Aerobic exercise There is not a lot of research available that look at the ability of aerobic exercise to stimulate skeletal muscle synthesis in older individuals. Traditionally it has been thought to rather bring about metabolic changes in muscles than increase muscle size. Recently it has been shown that a 12 week cycling programme was effective in increasing muscle mass in young and old individuals. The researchers think that the secret may lie in aerobic exercise’s ability to overcome age related insulin resistance. It is once again important to note that we are talking about untrained individuals, so it may have been a case of these individuals showed improvement because of their low baseline muscle mass. Summary: Why do older adults lose muscle strength Our bodies build new muscle when it receives a message telling it to do so. The two main events that sends this message to the body is when you eat protein and when you exercise a muscle. Researches have found that one of the reasons that older adults' bodies does not build new muscles as readily is because it does not respond in the same way to the food they eat as when they were young. These guidelines can help you optimise your muscle strength in older age Ingesting 20 to 30 grams of quality protein or 2 grams of leucine per meal is recommended to maintain muscle mass in older age. Ingesting more than this will likely not have any beneficial effect and excessive leucine intake may have a very negative effect. A table containing natural sources of leucine can be found on Wikipedia. The timing as well as the content of protein rich meals may be important, but the relevance of this is not yet fully understood for the older athletic population. Protein ingestion combined with resistance exercise could overcome age related impairments in muscle growth. Ingesting a mixed meal (carbohydrates and protein) may impair the ability of amino acids to stimulate muscle growth in older adults due to insulin resistance. Insulin resistance in older adults can be overcome by a bout of moderate aerobic exercise before a meal. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram. References Dickinson, J. M., Volpi, E., & Rasmussen, B. B. (2013). Exercise and Nutrition to Target Protein Synthesis Impairments in Aging Skeletal Muscle. Exercise and Sport Sciences Reviews, 41(4), 216-223. Dreyer, H. C., Strycker, L. A., Senesac, H. A., Hocker, A. D., Smolkowski, K., Shah, S. N., et al. (2013). Essential amino acid supplementation in patients following total knee arthroplasty. Journal of Clinical Investigation, 123(11), 4654-4666. Drummond, M. J., Dreyer, H. C., Pennings, B., Fry, C. S., Dhanani, S., Dillon, E. L., et al. (2008). Skeletal muscle protein anabolic response to resistance exercise and essential amino acids is delayed with aging. Journal of Applied Physiology, 104(5), 1452-1461. Fry, C.S., Drummond, M.J., Glynn, E.L., Dickinson, J.M., Gundermann, D.M., Timmerman, K.L., et al. (2011). Aging impairs contraction-induced human skeletal muscle mTORC1 signaling and protein synthesis. Skeletal Muscle, 1, 11. Fujita, S., Rasmussen, B. B., Cadenas, J. G., Drummond, M. J., Glynn, E. L., Sattler, F. R., et al. (2007). Aerobic exercise overcomes the age-related insulin resistance of muscle protein metabolism by improving endothelial function and Akt/mammalian target of rapamycin signaling. Diabetes, 56(6), 1615-1622. Harber,P.M., Konopka, A.R., Undem, M.K., Hinkley, J.M., Minchev, K., Kaminsky, L.A., et al. (2012). Aerobic exercise training induces skeletal muscle hypertrophy and age-dependent adaptations in myofiber function in young and older men. Journal of Applied Physiology, 113(9) 1495-1504. Katsanos, C. S., Kobayashi, H., Sheffield-Moore, M., Aarsland, A., & Wolfe, R. R. (2006). A high proportion of leucine is required for optimal stimulation of the rate of muscle protein synthesis by essential amino acids in the elderly. American Journal of Physiology, Endocrinology andMetabolism, 291(2), 28. Kumar, V., Selby, A., Rankin, D., Patel, R., Atherton, P., Hildebrandt, W., et al. (2009). Age-related differences in the dose–response relationship of muscle protein synthesis to resistance exercise in young and old men. The Journal of Physiology, 587(1), 211-217. Paddon-Jones, D., & Rasmussen, B. B. (2009). Dietary protein recommendations and the prevention of sarcopenia. Current Opinion in Clinical Nutrition and Metabolic Care, 12(1), 86-90. Pennings, B., Koopman, R., Beelen, M., Senden, J. M., Saris, W. H., & van Loon, L. J. (2010). Exercising before protein intake allows for greater use of dietary protein–derived amino acids for de novo muscle protein synthesis in both young and elderly men. The American Journal of Clinical Nutrition, 93(2):322-31. Peterson, M. D., Sen, A., & Gordon, P. M. (2011). Influence of resistance exercise on lean body mass in aging adults: a meta-analysis. Medical and Science in Sports and Exercise, 43(2), 249-258. Verhoeven, S., Vanschoonbeek, K., Verdijk, L. B., Koopman, R., Wodzig, W. K., Dendale, P., et al. (2009). Long-term leucine supplementation does not increase muscle mass or strength in healthy elderly men. The American Journal of Clinical Nutrition, 89(5), 1468-1475. Volpi, E., Mittendorfer, B., Wolf, S. E., & Wolfe, R. R. (1999). Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction. American Journal of Physiology - Endocrinology and Metabolism, 277(3), E513-E520.

One of the most common myths in exercise science is that muscle cramps during exercise are caused by dehydration and/or electrolyte depletion. Don’t get me wrong, these two factors can cause muscle cramps (think severe vomiting etc. when you have a stomach bug), but research has found that these are mostly not to blame for the cramps we get during or after exercise. Buskard (2014) recently published an article in the Strength and Conditioning Journal in which he reviewed all the available research on this topic. Muscle cramp causes: What we used to think Factors that we traditionally blamed for muscle cramps during exercise include: Accumulation of waste products that interfere with the muscle contraction Electrolyte depletion (loss of salts or electrolytes) Loss of fluid volume (dehydration) Extreme environmental conditions e.g. extreme heat or cold The research has, however, shown that most of the above factors are likely NOT the cause of muscle cramps in healthy individuals. There's an easy way to test to see if you're dehydrated so if you don't quite believe me check out this article. Two large studies that tested athletes after an Ironman triathlon and an ultra-marathon found no difference in hydration status or blood electrolyte levels between athletes who cramped up and those who did not. Heat and cold also do not induce cramps in muscles, but researchers do agree that the extreme weather conditions may lead to greater fatigue, which is currently seen as the main cause for cramping. What we currently think causes muscle cramps during exercise Muscle fatigue is the one factor that nearly all studies in this area has identified as a cause for exercise induced muscle cramps. The exact mechanism involved in this process is however still unclear. The altered neuromuscular control theory is the one that currently has the most scientific evidence in support of it. ‘Neuromuscular control’ can be defined as ‘how the nervous system (brain, spinal cord, nerves) controls the muscle’. This theory is based on the belief that fatigue causes changes in the firing patterns of the nervous system which in turn leads to muscle cramps. A muscle’s tone (how tense or relaxed it is) is controlled via the spinal reflex, where a receptor in the muscle sends a message to the spinal cord which in turn triggers a message to be sent back to the muscle. There are receptors in the muscle itself that can either increase the nerve’s activity (muscle spindles) via the spinal reflex and thus increase the muscle tone/contraction or decrease the nerve’s activity (Golgi tendon organs) and thus decrease the muscle tone/contraction when stimulated. These receptors have the ability to influence each other’s output e.g. increased firing of the Golgi tendon organs will lead to a decrease in the muscle spindle activity and cause the muscle tone to decrease (muscle relaxes). What the researchers are suggesting is that muscle fatigue causes the neural control of these receptors to become unbalanced so that the muscle spindles’ activity increases and causes a strong unregulated contraction. Researches view the fact that stretching a muscle helps to alleviate cramps as support for this hypothesis. When you stretch a muscle, you activate the Golgi tendon organs, which in turn decrease the muscle spindle activity. This hypothesis is further supported by the findings that cramps more frequently occur in shortened muscles and in ones that cross 2 joints since the Golgi tendon organs will be less active under these conditions. The research currently suggest that the following factors appear to predispose a person to exercise induced cramps: Having a history of cramping Individuals who cramp regularly have been shown to have a lower threshold frequency for cramps. This means that, during testing, it took less electricity to annoy the nerve and cause a muscle cramp in people who often cramp vs. ones that don’t. (Who volunteers for these studies?!) This may point to a genetic predisposition to cramping. Competing at a faster race pace than training pace (putting in a greater effort = greater fatigue). It was also suggested, but not yet investigated, that sub-clinical muscle damage due to insufficient tapering can cause cramp during a race. What can you do to prevent muscle cramps while exercising? Race nutrition. A group of researchers found that using a sports drink consisting of a mixture of carbohydrates, electrolytes and water significantly delayed the onset of muscle cramps during exercise. Their participants still experienced muscle cramps while drinking this mixture, but it allowed them to exercise for about 150% longer before cramping up. This study can unfortunately not tell us which of these 3 ingredients worked the magic, but my guess would be that the water and carbohydrates were the most important. It has previously been shown that adequate water and carbohydrate intake during exercise can prolong the onset of fatigue. Your body should have enough electrolytes unless you are following a very restricted diet. Train at race pace. Make sure that you complete some of your training at race pace. This will limit fatigue on race day. Dress appropriately. Overheating can lead to increased fatigue which may increase your chances of cramping. Taper your training in time to allow your muscles to recover. Racing on tired muscles will once again lead to early fatigue. What to do if you cramp up during exercise Stretch. Hold the stretch for a loooong time. As explained above, this will activate the Golgi tendon organs and relax the muscle. Slow down and walk or free wheel if cycling. This will give the muscle time to recover. 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: Buskard, A. N. L. (2014). Cramping in Sports: Beyond Dehydration. Strength & Conditioning Journal, 36(5), 44-52

This article will help you to identify the signs of overtraining and provides some practical advice on how to treat as well as avoid overtraining syndrome. “Stress and adaptation” – My boyfriend’s favourite mantra when he parks himself on the couch (beer in hand) after a Saturday morning training session. Granted, his main aim is to get out of doing the household tasks and beer may not be the best recovery drink, but he makes a very important point. To take full advantage of a training session one has to allow an adequate period of time for the body to recover and rebuild stronger. In fact, you should view rest or recovery days as an extension of your training days, since the positive gains from training are only realised during these periods. It is so easy to get carried away when training for a big event and I see the following scenario so often, especially with novice athletes. They download a training programme or even find themselves a coach. They complete every training session to the minute, they can feel themselves getting stronger and fitter and they feel EPIC... This is when they enter the danger zone. The training high they are experiencing often make them push too hard during easy days and they ignore niggles and other signs that their bodies are struggling with the load. Inevitably this leads to injury or decreased performance and overtraining. Part of the problem is that no one can predict how your body will cope with training demands. The number of years you have been training, your own genetics and your normal lifestyle can all impact on how your body copes with training. That is why a beginner’s programme that works for one person may lead to injury and overtraining for the next. Inexperience may be the most common driver for overtraining that I see in my practice, but this may just be due to the population I work with. It has been reported that 60% of elite female and 64% of elite male athletes experience at least one episode of overtraining syndrome during their careers. The most likely cause in their case may be the constant pressure to perform at their best. The literature makes a distinction between overreaching and overtraining. Both conditions occur due to an accumulation of training and/or non-training stress, which results in a long-term decrement in performance. In the case of overreaching this can last a few days or weeks but if you have ignored the signs you may find yourself with full blown overtraining syndrome, which can take months to recover from. It is generally accepted in the literature that the main cause for overtraining syndrome is excessive training stress (volume, intensity, competition, inadequate recovery, environment e.g. heat), but it has been shown that other sources of stress can also play a significant role e.g. work or school demands, money hassles, pressure from parents or coaches and loss of sleep. This is because, when you exercise, the body produces some of the same hormones that you produce in reaction to normal life stresses. In the short term these hormones help to bring about the positive effects of training e.g. strength and speed gains, but if their levels remain too high over a long period of time they wear the body out. This is also the reason why some of the signs and symptoms experienced by people suffering from psychological burnout also manifests in athletes suffering from overtraining syndrome. Perfectionism is a personally trait that may further predispose an athlete to this condition due to the high standards they set themselves. Signs of overtraining The most obvious sign that you may be overreaching or overtraining is if you consistently underperform in training sessions and races. More subtle signs include constant physical exhaustion, mental exhaustion, mood disturbances and sleep disturbances. There are a myriad of other conditions that can cause the same symptoms and the diagnosis of overtraining syndrome should only be made once all other possible causes have been excluded e.g. anaemia, glandular fever, diabetes, thyroid dysfunctions, viral infections or inadequate energy intake (not eating enough). Several researchers have tried to develop psychological scales to monitor and identify athletes that may be over trained. The most widely researched are the Training-Distress-Scale (see picture below) and Recovery Stress Questionnaire for Athletes. A relative new tool that measures psychomotor speed is showing some potential in the early detection of overreaching and may therefore be able to prevent overtraining. The test measures reaction and attention, since it has been shown that central fatigue is an early manifestation of overreaching. Overtraining syndrome treatment Consult your GP and have some blood tests done to rule out any other diseases or deficiencies. Rest. If you have just temporarily overreached, you may be able to recover through just reducing the training load. If, however, you have ignored the signs for too long you will have to have complete rest in order to recover. Do sport for fun for a while and cross train. Check your nutrition. Make sure you are getting enough nutrients and energy in through your diet. Inadequate energy intake has been shown to affect mood negatively and a recent review of the literature has found that athletes tend to have sub-optimal levels of Vitamin D which can lead to a drop in performance. Sleep. This is the time the body uses to rebuild itself and you should be getting between 7 and 9 hours of sleep a night. Resumption of training should be individualised on the basis of signs and symptoms as there is no definitive indicator of recovery. How to avoid overtraining syndrome Keep accurate records of training and race performances. Be willing to take rest days and decrease training intensity if your performance declines or you experience excessive fatigue. It may help to use the Borg Scale of perceived exertion (picture below) to gauge the intensity of a session. Honour rest days. Avoid monotony of training. Ensure adequate hydration, nutrition and sleep. Identify other stressors in your life e.g. work or relationships and try to gauge its effect on your overall state. I use a very simple Stress Assessment Tool (see above), used for performance profiling, to assess the magnitude of different stressors. It may help to regularly complete some form of psychological evaluation e.g. the Training-Distress-Scale (see below) to identify changes in mood. Also, take note if your partner complains that you are turning into a grumpy old git. I find that partners are very good at detecting mood swing. :) Allow yourself time to recover after illness or injury. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. You can read more about her here. Follow her on LinkedIn or ReasearchGate References: Gustafsson, H., Kenttä, G., & Hassmén, P. (2011). Athlete burnout: an integrated model and future research directions. International Review of Sport and Exercise Psychology, 4(1), 3-24. Meeusen, R., Duclos, M., Foster, C., Fry, A., Gleeson, M., Nieman, D., et al. (2012). Prevention, diagnosis and treatment of the overtraining syndrome: Joint consensus statement of the European College of Sport Science (ECSS) and the American College of Sports Medicine (ACSM). European Journal of Sport Science, 13(1), 1-24.

A Harvard study compared the accuracy of 23 online symtom checkers and found that, on average, they were correct only 34% of the time. We explain why this might be. So, you develop an ache in your neck and take yourself off to the GP or physio. They ask you a few questions and readily provide you with a diagnosis. You feel quite chuffed until you see the notice behind them: “My diagnosis is usually correct in 34% of cases.” Hmmm, starting to lose your confidence in your diagnosis a bit? A recent study from Harvard suggests that this is the “best case scenario” when you use a symptom checker for an online diagnosis. In this article: Online symptom checker accuracy What is a symptom checker? Why are symptom checkers so inaccurate? Accurate online diagnosis is possible Online symptom checker accuracy The researchers from Harvard checked the performance of 23 symptom checkers found on the internet and the results were alarming. They found that the correct diagnosis was listed first in only 34% of cases. It gets even worse - performance varied by urgency of condition. For conditions that required emergency care, the correct diagnosis was only listed first in 24% of cases! Some of the symptom checkers did not offer a diagnosis, but provided triage advice only. Triage advice is when someone tells you if you should visit a GP or Emergency Department or whether you can manage your condition/injury yourself at home. The symptom checkers performed slightly better in this department with the correct triage advice being given in 57% of cases (still not going to let me sleep easy). There was of course a big variation in accuracy across the 23 symptom checkers. The most accurate at providing the correct online diagnosis was DocResponse. They had a 50% success rate while MEDoctor only managed it in 5% of the cases. HMS Family Health Guide gave the correct triage advice in 78% of cases (that’s looking better) while ITriage only manage it in 33% (I think they should reconsider their name!). The following Symptom Checkers were included in the study: AskMD (USA), BetterMedicine (USA), DocResponse (USA), Doctor Diagnose (USA), Drugs.com (USA), EarlyDoc (Netherlands), Esagil (USA), Family Doctor (USA), FreeMD (USA), Harvard Medical School Family Health Guide (USA), Healthline (USA), Healthwise (USA), Healthy Children (USA), Isabel (UK), iTriage (USA), Mayo Clinic (USA), MEDoctor (USA), NHS Symptom Checkers (UK), Steps2Care (USA), Symcat (USA), Symptify (USA), Symptomate (Poland), WebMD (USA). What is a symptom checker? Symptom checkers are designed to provide you with an online diagnosis of your injury or ailment and/or advise you about whether or not you have to visit your GP or Emergency Department. Symptoms are subjective signs of your injury or disease that you experience, e.g. pain, numbness or nausea, to name a few. These online diagnosis tools usually ask you to input the part of the body that you are experiencing trouble with and then ask you a few questions about this. They feed your answers into an algorithm and there you have it…your diagnosis! I tried a few symptom checkers this morning and was told my pain in my left thigh could be anything from a blood clot to fibromyalgia. The real cause wasn’t even listed: Irritation of my lower back brought on by my terrible posture while working on my laptop (#dontjudgeme). Why are symptom checkers so inaccurate? The short answer is that the “symptoms” of an injury or condition is only one piece of the puzzle. The symptom checker tools simply do not ask enough questions to provide an accurate online diagnosis. Pain in my thigh for instance can be caused by a muscle tear, a bruise, varicose veins or a parasite from the Amazon river, to name but a few. To narrow a diagnosis down, clinicians will listen to your symptoms and then ask more questions in reaction to these. E.g. have you visited any foreign country in the last 3 months? No? Then we can take exotic parasite off the list. How these symptoms behave, adds another important clue. Understanding the mechanism of injury, under what circumstances you experience your symptoms, how severe they are, what alleviates them etc. all helps to fine tune your diagnosis, since different injuries/conditions behave differently under the same circumstances. The medical signs associated with your condition also tells the clinician a lot. A knee that swells up severely immediately after injury usually indicates that your injury will require a scan. On the other hand, a joint that gradually swells up over time has usually sustained a mild strain only. Accurate online diagnosis is possible At Sports Injury Physio we first conduct a detailed interview over video call. We then get you to perform the same movements that we would use if we examined you in a regular clinic. This allows us to form a diagnosis and provide you with a treatment plan tailored to your specific needs. We will also communicate with your GP (with your consent) if we feel that you should have some further investigation done. 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.

THE ANKLE SPRAIN SELF-TREATMENT SERIES: How to diagnose your ankle sprain (this article) How to know if you've broken your ankle How to treat your ankle sprain Ankle sprains are very common and most people reading this blog would have twisted their ankles at some stage in their lives. The patients we see in our online clinic describe a wide range of causes - some as innocuous as stepping off a curb - while others are sustained through high-impact collisions on the sports pitch. Recovery times can vary from 4 weeks for a mild ankle sprain to more than 12 weeks if you have done a proper job of it. Being able to walk in a near normal way within 48 hours is usually a sign that you will make a good recovery. The recovery time of an ankle sprain is heavily dependent on what structures you've injured and the quality of your rehab programme. In this article: What happens when I sprain my ankle? How do I know if I have torn a ligament of the ankle? How do I know if I have torn a muscle in my ankle? Should I go to A&E for a sprained ankle? What happens when I sprain my ankle? The ankle joint consist of three bones (tibia, fibula, talus) which are held together by a strong capsule and ligaments. The joint surfaces are covered with articular cartilage. The tendons of the muscles that control the different movements of the foot also cross the ankle joint on all sides. Which structures are injured when you roll your ankle, depend on what direction you twist the foot into. In most cases you will stretch the ligaments and muscles on one side of the ankle while you compress the joint surfaces on the opposite side. You can even cause the bone to bruise or fracture if the movement is forceful enough. The joints and ligaments of the rest of the foot can also be injured during an ankle sprain. Ankle Sprain: How do I know if I have torn a ligament of the ankle? You can be pretty sure that you've at least partially torn an ankle ligament if there's some local swelling and bruising in the area of the ligament and it is painful to press on it (see picture below). There are 3 grades of ligament tears: Grade 1: You have only torn a few of the fibres of the ligament. It is painful to stretch the ligament but there's no noticeable laxity (i.e. the ligament still stops the joint from moving too far). There is usually only a mild area of swelling. Grade 2: You have torn a significant number of fibres, but not all of them.  There is usually a lot of swelling. It is painful to stretch the ligament and the joint is moving slightly further than what it should. Grade 3: You have fully torn the ligament. There is usually significant swelling in the area. It may not be painful to stretch the ligament (since there is nothing left to stretch) and the joint moves a lot further than what it should when you compare it to the uninjured side. Grade 3 tears will require an extended period of protection (in a brace or boot) and may even require surgery, while you can usually walk with a pretty normal gait after sustaining a Grade 1 ankle ligament tear. Ankle Sprains: How do I know if I have torn a muscle in my ankle? You have likely torn a muscle or tendon if it is painful to press on it and if it hurts to actively contract that muscle against resistance. For instance, use your hand to try and turn your foot inwards while you actively resist the movement with your foot. The net effect should be that the foot stays in the same position. If it hurts when you do this or if you are unable to keep your foot in the same position, you may have torn your peroneal muscles. The movement you use during testing will depend on which muscle you want to test. Should I go to A&E for a sprained ankle? You should go to A&E if you suspect that you may have broken a bone in your foot or ankle.  I know, you're not a doctor, but you can use the Ottawa Rules to help you decide. You can find a detailed explanation of how to use the Ottawa Rules to diagnose an ankle fracture in this blog post. Steph also explains it very well in the video below. You should also go to A&E if your ankle swells up very quickly, within 30 minutes of injuring it, or you are unable to walk on it for four steps (walking with a limp counts). Swelling that occur this quickly is usually indicative of an injury to the cartilage or bone inside the ankle joint and it is good to have it investigated further.  These types of ankle sprains are typically the ones that take 12 or more weeks to recover from. If, however, you can walk on the foot and it gradually swells over a few hours, I would rather consult a physiotherapist. Knowing exactly what structures you've injured and how to strengthen them will speed up your recovery. This is something that our team of sports physios can easily help you with via an online consultation. Research has shown that a physical examination carried out 4 or 5 days after an ankle injury produces more accurate results than if it is done on the day of injury. You can read more about how to treat ankle sprains in this blog post or if you find that you're stuck in a cycle of recurring ankle sprains, then this article may be of use. 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: Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A. M., van Beek, P. A., Hullegie, W. A. M., Bloemers, G. M. F. M., et al. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854-860. Tayeb, R. (2013). DIAGNOSTIC VALUE OF OTTAWA ANKLE RULES: SIMPLE GUIDELINES WITH HIGH SENSITIVITY. British Journal of Sports Medicine, 47(10), e3.

Incline walking might be a good substitute for running for people who are at risk of injury from the latter. A growing body of evidence is showing that vigorous physical activity holds much greater health benefits than moderate level activity. The problem with this is that the people who are most in need of these types of improvements (e.g. the older population) are often not able to do vigorous physical activity due to other health issues e.g. lower back pain or arthritic knees … or are they? What pops into your head when you hear the words vigorous physical activity? Army training, spinning, running, or boot camp? Activities that we traditionally class as vigorous, e.g. running, put a lot of strain on the lower limbs and may therefore not be ideal if you have other injuries. But what about walking? Do you think that walking can be classed as vigorous physical activity? A study conducted by researchers from the University of Norfolk has shown that our definition of what constitutes vigorous activity may be a bit warped.  It may indeed be possible to do vigorous activity without placing high loads on the joints in the lower limbs. Research into walking, incline walking, and running The researchers did a study where they compared three activities: Horizontal walking on a treadmill Incline walking (11%) on a treadmill Horizontal running on a treadmill They worked out the intensity of each activity by calculating how much oxygen participants used during the activities. Then they set the speed for it so that the incline walking’s intensity was equal to that of the horizontal running. Both of these activities were 3 times more intense than the horizontal walking. By doing this, the incline walking qualified as vigorous activity. They then measured all the forces that went through the lower limbs of the participants and their results were very interesting. Incline walking vs running - Results They found that the peak force as well as the rate of loading were significantly higher during running than during both walking conditions (this as expected). Interestingly, they found that the rate of loading during uphill walking was also lower than during horizontal walking. Looking at the total force during each activity, the researchers found that the participants experienced a 79% increase when running compared to walking uphill. What this means Uphill walking may thus be a safe (low orthopaedic load) alternative to get your dose of vigorous exercise from. I say low orthopaedic load because while walking puts less strain on your legs, it still puts a high strain on your cardiovascular (heart and lungs) system. You should consult your doctor or physiotherapist if you plan to take up vigorous exercise for the first time. The high intensity exercise may increase your risk for heart attacks or strokes. The researchers point out that for people who are not used to vigorous physical activity, the risk of having a heart attack etc. goes up 105-fold. In contrast, people who are used to vigorous activity only experience a 2.4-fold increased risk. Basically, what the research is showing is that vigorous activity is safe as long as you train responsibly. Gradually increase your fitness to the point where the body is able to cope with it. It is important to consult a professional if you feel uncertain. If you suffer with a specific condition e.g. high blood pressure, make sure that the person you consult is qualified to deal with different health conditions. 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.

Starting to run again when you have been ill or after an injury is in many ways more "dangerous" than when you start running for the first time. Novice runners are usually quite careful and tend to follow strict training regimes. The more seasoned runner often risk reinjury through impatience and pushing their mileage too quickly. I know all the theory and I advise my patients daily about the importance of slowly building up running strength and endurance. When it comes to my own training, I turn into a typical athlete and often get carried away with the running bit and neglect the strength aspect. As runners we like to run. Period. I interact with lots of runners of varying abilities and ages per week and most of them (including me) do not really like doing much else. The reasons for this range from not having time (it’s so easy to just put your shoes on and run) to just really disliking strength training, cycling or swimming…the list goes on. This time round, I have decided to chronicle my return to running programme. This will hopefully help me keep myself on track with my strength training, stop me from increasing my mileage by super-human chunks and serve as a guide for other runners to make a safe return to running. Mistakes we make when we start running again One of the biggest reasons why people get injured when they start running is that they don't give their joints, ligaments, bones and muscles enough time to adapt to the new load they are placing on them. Your body is always looking out for you to make sure that you have the best chance of survival. One of the methods it employs is to not waste energy on things that it thinks you don't need. It will for instance only give you enough muscle to complete your daily tasks, since any more would not be used. In the same way as it will only thicken your joint cartilage and bones and tendons to the extent that they can cope with the loads you put through them. How does the body know how much muscle you need? You tell your body to adapt through carefully loading or straining it. If you work a muscle a bit more than what it is used to, it causes micro-damage which signals to the brain that it is time to rebuild that muscle a bit stronger so that it can cope with the new load. The same goes for joints, ligaments and tendons. With each step you give the ground reacts to the force you put on it by sending an equal force through your foot and up your leg. This force is then absorbed by the muscles, ligaments and joints in your body and acts as the stimulant to create stronger muscles, ligaments, joints and bones. To prevent injury, you have to give the body enough rest and nutrition after your training session so that it can recover from the micro-injuries and rebuild the body stronger and also not increase your training load too quickly. You're heading for an injury if you train too frequently and do not allow your body to recover after a session. As you get fitter, your body can tolerate much higher training loads and require much shorter rest periods to recover. This is the reason why some people can train 7 days a week while others only 3. It is really important that you choose your training regime according to your own level of fitness. If you lack the basic muscle strength and control in your legs needed for running, you also risk straining other structures e.g. joints and ligaments. A strength training programme is therefore a must if you want to remain injury free. In summary: To stay injury free strengthen your muscles, increase your mileage slowly and allow enough rest days. My return to running plan 1. Join the gym and start a strength training programme I'm more than capable of doing strength training at home, but the simple fact is that I have tried this in the past and always found something else to do instead. I have therefor joined the gym across the street from our clinic and am not allowed to catch the train home if I have not done my workout. I am happy to report that this has happened and I am now "pumping iron" every Monday and Thursday. I am going to keep the load low (15RM) and reps high for the first 6 weeks to give my muscles time to adapt to the new load and also suss out how my body copes with the way I have scheduled training. Do I need more rest days and fewer run days at the beginning? Only time will tell. RM stands for repetition max and just means that I will be using a weight that just allows me to complete 15 repetitions before the muscle is exhausted. After 6 weeks I will likely shift towards using a 10RM load. I will also start combining exercises e.g. the chest press and plank will be replaced by push-ups etc. You may be wondering why I have included upper body exercises in the programme since you run with your legs. I will spare you the long winded detailed answer at this point and just say that the whole body contributes to your running style and form. If you want to be a strong runner, you need a strong core and upper body. My ultimate goals for the strength training (end of 2016): Single leg press 1.5 times my bodyweight (which roughly translates to 105kg…gulp!) Be able to do 1 pull-up with my full bodyweight (this has been a secret ambition for the last 36 years!) Mondays and Thursdays (I have simplified my original programme so that it fits into an hour): Leg press (single leg) Assisted pull-up Single leg bridge (foot on high bench) Overhead press Various abdominal exercise set Seated Row Single leg calf raises Bench press 2. Do a slow run/walk programme until I am able to run 5km without walking I don't care how many years of running you have under your belt - if you are coming back from injury or illness you will be well advised to do a few run/walk session to test your body's ability to cope with the load. This has worked well for me, especially since I was still battling with the tail end of my last cold. I never looked at my watch, but instead forced myself to walk as soon as I started feeling out of breath. It took me about 3 weeks to achieve this goal. It may take you longer to reach this goal depending on your general fitness/condition. I had a fair baseline level of fitness since my bike is my main mode of transport in and about town and I had still completed the odd run 6 weeks earlier. If you are a total beginner, you may want to consider the NHS’s couch to 5km programme. It is a well thought out programme and my patients do very well on it. 3. Do little bits often and apply the 10% rule In the past I mostly ran on weekends only. This time round I want to get my body used to running more regularly and get my mileage up without tiring my legs out too much. I have opted to run 4 times a week, with a harder session followed by an easy or slow run. With the 10% rule I just mean that I will try not to increase my weekly mileage by more than 10%. Research has shown that novice (and thus deconditioned) runners are more likely to sustain an injury if they increase their mileage by a large margin every week. Granted, this may be a bit on the conservative side, but my gym programme will also count towards the total load my legs have to cope with each week. 4. Run a fast 5km (that's around 24min for me) by July (done!) and then a fast 10km (50min) by September Why this goal? Being able to do a fast 5km with good form, will mean that my legs are strong enough to cope with the training needed to complete a fast 10km and so forth. And I am definitely not allowed to enter any race if I have not yet run the distance in training. I am renowned for entering long events, not managing to complete full training and then doing the race in any case…still chasing my original planned pace. This rule is very specific to me and my own personality. One of my patients mentioned that he had used Bupa’s marathon training programme in the past. It turns out that they have some good training programmes for 5km and 10km as well. I have adapted their intermediate 5km plan which consists of a nice mix of strength and endurance sessions. You can follow my progress on Strava. 5. Have an easy week every third week This will give my body time to recover as well as adapt to the new training load and hopefully stave off injury from overuse. 5km PB DONE!!! 3 July: 24:34 or 4:54/km Update end June 2016: 15RM Single leg press: 84kg 15 RM Assisted pull-up: 49.5kg (translates to being able to lift 24kg) Best 5km time: 25:13 or 5:03/km Update end May 2016: 15RM Single leg press: 84kg 15 RM Assisted pull-up: 49.5kg (translates to being able to lift 24kg) Best 5km time: 26:40 or 5:20/km Update end April 2016: 15RM Single leg press: 81kg 15 RM Assisted pull-up: 54kg (translates to being able to lift 20kg) Best 5km time: 28:16 or 5:40/km 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. You can read more about her here. Follow her on LinkedIn or ResearchGate

Are high heels bad for you? I thought that we could take the barefoot vs shoes debate a step further this week and look at what high heels do to your body. :) My mother is a firm believer that high heels are to blame for all sorts of foot trouble (and she is usually right about most things), but is there any research evidence to back this up? It turns out that mom may actually be right. Since anything that influences the feet usually also causes a reaction higher up in the body, I’ve searched the available literature to answer the following: Are high heels bad for your feet? Are high heels bad for your knees? Are high heels bad for your back? All is not lost, a heel can sometimes be useful. Are high heels bad for your feet? The first and most obvious change that happens in the body when you wear high heels is that your weight is shifted from your heel onto your forefoot and research has shown that the higher the heel, the more pressure it puts on the ball of your foot (metatarsal bones). It is this increase in pressure on the forefoot that can cause the balls of your feet to ache after a night out. Stomp et. al made 3 healthy women walk 7km in flat shoes and then in high heels on two consecutive days and MRI scanned their feet after each session. The scans showed swelling not only under the balls of their feet, but also over the top of the metatarsal bones after walking in high heels. So, if you are struggling with pain in your forefoot or metatarsal bones, also known as metatarsalgia, you may want to ditch the high heels. Incidentally, I find that making a switch from wearing normal hard soled (flat) shoes to wearing trainers a very effective treatment for forefoot pain or metatarsalgia. Especially for my patients who have a long walk during their commute to work. Barnish et al. did a review of the literature to see if they could find any evidence that high heels causes lasting problems for your feet. Interestingly they did not find any evidence that wearing high heels causes osteoarthritis in the foot, but it does seem to cause your big toe to push out over time. Halux valgus deformity is the academic name for when the big toe decides to wander over to the second toe. This is more commonly known as a bunion.  Bunions can be extremely painful and problematic and also cause the other toes to lift up and deform. Are high heels bad for your knees? It is obvious that high heels change the position of your feet, but what a lot of people don’t realise is that it causes the whole body to alter its posture. Kerrigan et al. were interested to see how the forces around the knee change when you put high heels on your feet. What they found correlates well with what I see in practice. They found that high heels increased the force across the patellofemoral joint (kneecap) and also produced a greater compressive force on the medial compartment of the knee (average 23% greater forces) compared to walking barefoot. The patients that I see in practice who suffer with patellofemoral pain (pain over the front of the knee) often report walking in high heels as a major aggravating factor. This study does, however, not prove that high heels causes knee osteoarthritis. The only study that I could find that specifically investigated this issue did not find a relationship between wearing high heels and developing knee osteoarthritis, but the researchers stated that this may have been due to people with knee pain being forced to give up high heels at a young age due to pain. Are high heels bad for your back? Physios and other healthcare professionals often state that high heels can cause back pain, but I have not been able to find any research to back this up. I think the reason for this is that back pain can have many different causes, but also that the flexibility of the entire lower limb will determine what happens at the back when you wear high heels. There is also a massive lack of research in this area and we may get the answer to this in a few years from now. For now, we will have to make do with what I (and others) observe in my clinic. You generally end up with an increased curve in your lower back when you put high heels on your feet. This increased curve or lordosis will be bigger in someone who generally has a big lumbar lordosis, an anterior tilted pelvis or very tight quadriceps muscles. If you back pain is predominantly caused by facet joint irritations, you may find this position very painful since it will cause extra pressure on the facet joints. However, if your back pain is predominantly caused by a structure towards the front of the spine, you may find that wearing high heels provide relief since it will offload that part of the spine. Do any of this cause long term damage? The verdict is still out on that one. All is not lost - a heel can sometimes be useful. No, I haven't lost my mind. Granted, I am not talking about stilettos. Wearing a medium heel can be very useful in the early treatment of calf strains and Achilles tendinosis. The heel will offload the calf muscle and Achilles tendon by putting them in a slightly shortened position. This can give the damaged tissue a chance to calm down and will protect it during the acute stages of healing. 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 Kerrigan, D. C., Todd, M. K., & Riley, P. O. (1998). Knee osteoarthritis and high-heeled shoes. The Lancet, 351(9113), 1399-1401. McWilliams, D. F., Muthuri, S., Muir, K. R., Maciewicz, R. A., Zhang, W., & Doherty, M. (2014). Self-reported adult footwear and the risks of lower limb osteoarthritis: the GOAL case control study. [journal article]. BMC Musculoskeletal Disorders, 15(1), 1-7. Rossi, W. A. (2001). Footwear: The primary cause of foot disorders. Part, 2, 129-138. Russell, B. S. The effect of high-heeled shoes on lumbar lordosis: a narrative review and discussion of the disconnect between Internet content and peer-reviewed literature. Journal of Chiropractic Medicine, 9(4), 166-173. Speksnijder, C. M., vd Munckhof, R. J. H., Moonen, S. A. F. C. M., & Walenkamp, G. H. I. M. (2005). The higher the heel the higher the forefoot-pressure in ten healthy women. The Foot, 15(1), 17-21. Stomp, W., Krabben, A., van der Helm-van Mil, A., & Reijnierse, M. Effects of wearing high heels on the forefoot: an MRI evaluation: Scand J Rheumatol. 2014;43(1):80-1. doi: 10.3109/03009742.2013.847117. Epub 2013 Dec 3.

It’s important that high ankle sprains (also called syndesmosis sprains) be identified correctly, because their treatment differs somewhat from other types of ankle sprain. If this is not handled correctly, it can lead to chronic ankle instability. This article covers the symptoms and diagnosis of high ankle sprains, as well as their grading and treatment, and what the recovery times might be. 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: Anatomy of the syndesmosis joint Why it’s important to identify a syndesmosis sprain correctly High ankle sprain symptoms and diagnosis Grading of high ankle sprains High ankle sprain treatment High ankle sprain recovery times How we can help We've also made a video about this: This article is about high ankle sprains, which should not be confused with the more common ankle sprains that injure the medial (inner) and/or lateral (outer) ankle ligaments and require different treatment. Anatomy of the syndesmosis joint The ankle joint comprises your two shin bones – the tibia and the fibula – and the talus bone in your foot, upon which the shin bones rest, as well as the various ligaments that hold the shin bones together and join them to the talus. Then there’s the interosseous membrane, which runs between the tibia and fibula all the way up to just below the knee, and which also helps to keep these two bones together. The syndesmosis joint is between the lower ends of the tibia and fibula. A syndesmosis or high ankle sprain is when you tear the ligaments and interosseous membrane that hold the lower parts of these two bones together. Why it’s important to identify a syndesmosis sprain correctly Almost all of your body weight goes through your tibia and fibula when you stand, walk, run, and jump; so it can have serious consequences if you have instability between these two bones and/or between them and the talus bone. If a high ankle sprain isn’t rehabbed properly or, in the case of a Grade 4 sprain, if it’s not fixed successfully with surgery, it can lead to chronic instability and pain in the lower leg and ankle. This type of ankle sprain also takes longer to recover (see the section on high ankle sprain recovery times below) than the more common sprains lower down the ankle, and this is especially something to be aware of in rehab management. High ankle sprain symptoms and diagnosis Mechanism of injury The first clue that an injury might be a high ankle sprain is if it happened in the following way: the foot was forced upwards, towards the shin bone (dorsiflexion) and then the lower leg twisted inwards. This doesn’t always cause a high ankle sprain, but a severe case of this movement is how it usually happens. A typical example in football/soccer is when someone plants their non-kicking foot firmly on the grass just before kicking the ball, and then they get tackled. Physical tests The next step in the diagnosis process would be to replicate the movement described above. So, the physiotherapist would take the foot, move it into dorsiflexion (bend it upwards), and then twist it outwards. If this causes the patient pain, it’s very likely that it is a high ankle sprain. The next test is to squeeze the tibia and the fibula together at mid-calf level; this will cause them to want to separate lower down, placing strain on the ligaments that connect them. If this hurts, it’s another strong indication that the patient has a high ankle sprain, and also that the injury might take longer than usual to recover. The last hands-on test is to press along the line between the tibia the fibula where the interosseous membrane runs and also over the front of the ankle where the anterior inferior tibiofibular ligament sits; if the patient reports pain, it’s another sign of this injury. Because everything in the ankle is usually painful and sensitive directly after an injury happened, it is be better to wait about five days before doing these tests; they are more accurate and yield more information at that stage. Scans What about scans? X-rays don’t show up damage to soft tissue such as ligaments, and in most cases they won’t show the tell-tale gap between the tibia and the fibula. However, they can be useful to see whether any bones have been broken in the incident that caused the high ankle sprain. MRI and CT scans are better for diagnosing high ankle sprains and for grading them (see below). However, if you don’t have access to these scans, the hands-on tests are usually sufficient for a correct diagnosis. Grading of high ankle sprains The grading system I’m discussing here is the one they use when interpreting MRI scans, and it goes from Grade 1 to Grade 4. Grade 1: The ligament that ties the tibia and the fibula together over the front of the ankle – the anterior inferior tibiofibular ligament – is the only one that’s injured. Grade 2: Like Grade 1, and the interosseous membrane – the bit that runs between the tibia and fibula – is also injured. Grade 3: Like Grade 2, and the ligament that ties the tibia and fibula together round the back of the ankle – the posterior inferior tibiofibular ligament – is also injured. This little ligament is responsible for 42% of the strength of the whole syndesmosis joint, so if the injury to it is significant, things are getting quite serious. Grade 4: Like Grade 3, and you’ve also injured the deltoid ligament – so, the one that runs on the inside of the ankle – and the joint is very likely now quite unstable. A football/soccer player who gets a Grade 1 high ankle sprain is usually able to get up and continue playing, and then the pain sets in after the match. If the player has to come off the pitch, it is usually a Grade 2 sprain or worse. High ankle sprain treatment Conservative treatment vs. surgery for high ankle sprains Grade 1 to 3 high ankle sprains can usually be treated conservatively, i.e. you rehab the injury with the right combination of rest and strengthening exercises. With Grade 4 sprains, you would usually have to get a surgeon involved to first stabilise the joint, after which you would rehab it. Severe Grade 3 sprains might also need surgery, but it's always best to try conservative treatment first, and if you find that that doesn't work, then consider surgery. Avoid dorsiflexion! The treatment regime for high ankle sprains is similar to that of other types of ankle sprain, with one major exception: avoid dorsiflexion. Bending the foot upwards naturally makes the bottom ends of the tibia and fibula want to move away from each other. So, if the ligaments that are supposed to hold them together are injured, this movement is going to stretch them and injure them even further, and they won’t heal. With most other ankle sprains, it’s the ligaments on the outside and/or the inside of the ankle that are injured, so dorsiflexion doesn’t affect them that much. This doesn't mean that you should avoid dorsiflexion for ever – just during early rehab. How long to avoid it for will depend on the grade of your sprain. For instance, in a study on the treatment of high ankle sprains in professional footballers, they avoided dorsiflexion for only a few days for a Grade 1 sprain, whereas they avoided it for four weeks for Grade 3 and 4 and then re-introduced it very gradually, being guided by what the ligaments would tolerate. First three to five days Be as kind to your ankle as possible and apply the classic PRICE regime for injuries: Protect, Rest, Ice, Compression, Elevation – anything you can do to help the swelling and the pain to calm down. Avoid using anti-inflammatory drugs or rub-ons. Inflammation plays an important part in the body’s natural healing process. In this case, it helps with getting rid of the damaged ligament fibres and replacing them with new ones. Partial weight-bearing Like dorsiflexion, putting weight on your foot naturally wants to make the bottom ends of the tibia and fibula move away from each other, and this puts strain on the ligaments that are supposed to keep them together. So, you need to start with partial weight-bearing, using crutches, and then gradually progress to putting more and more weight on your foot. How much weight and when should be determined by how much your injured ligaments can take without too much pain. If you don’t have the luxury of an MRI scan to see the exact amount of damage to the ligament(s), wait a week or two after the injury before you begin with this process. Use crutches to take all weight off the injured ankle initially, and then gradually add some bodyweight as you go along. If you have access to a swimming pool, it’s a very good way to do walking, heel raises, and balance exercises while only putting some weight on the injured ankle. Not many of us have access to an anti-gravity treadmill, but that would also be useful. Strengthening the muscles that support the ankle The classic calf strength exercise is to go up and down on your toes. However, if you’re still in the partial weight-bearing phase, obviously you can’t be doing this yet, especially not on the injured leg only. So initially, it would be better to use exercise bands or do gentle isometric presses with your foot in plantar flexion (pointing down). The same goes for your invertor muscles – the muscles that turn your foot in an out – because they also help to stabilise your ankle. Again, an exercise band is the way to go here. High ankle sprain taping A regular ankle brace doesn’t help for high ankle sprains, because it only stabilises the ankle against sideways movement. What you want is to support the ligaments by keeping the bones of the joint together. So, you’ll notice on the picture how they are taping strips around the ankle to keep the lower ends of the tibia and the fibula together (top two photos). And then they add some heel-lock taping to that to support the deltoid ligament on the inside of the ankle (bottom two photos). Balance and proprioception Proprioception is the ability to know where a limb or other body part is without having to look at it. Our brains depend on signals being sent by receptors from various parts of our body for balance and proprioception. When we get injured, these signals get muddled to a certain extent, which diminishes our balance and proprioception. It is important to restore this, because poor balance and proprioception put us at risk of re-injuring ourselves once we start with our normal activities and sport again. Fortunately, this is very easy to retrain through various balancing activities. However, like with the calf muscle exercises, it’s obviously not a good idea to try and balance on your injured leg before the injury has recovered somewhat. In the meantime, the swimming pool is a good place for balancing exercises. Once you’re out of the pool with your balancing exercises, make sure that you can properly balance on flat surfaces before you start thinking of balancing exercise aids like wobble boards. Running and plyometrics Once your ankle has recovered enough for you to run again, start with running in a straight line to save the recovering ligaments from having to deal with twisting forces. If your sport requires you to change direction quickly, like football/soccer, you’ll have to add in drills for these at a later stage, but at that point your ankle has to be really strong and pain-free. If your sports also involves jumping, like basketball, you’ll have to add in plyometric exercises, with the same caveat as above. This article has some examples of plyometric exercises, with video demos. High ankle sprain recovery timelines Recovery times for high ankle sprains among us mere mortals are not very well-researched. This is what they found in the study on the professional footballers: Players with a Grade 1 sprain lost about a week of full-on training. Move on to Grade 3, and players lost out on about ten weeks of active play. Bear in mind that if you’re not in an elite football team, you probably won’t have access to the level of daily input and monitoring that these players have, so you might well take somewhat longer to recover from your high ankle sprain. Because high ankle sprains can so easily cause ongoing ankle pain and instability, it is better not to rush and rather be super conservative with how quickly you progress your rehab. 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 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References Sikka, R. S., Fetzer, G. B., Sugarman, E., Wright, R. W., Fritts, H., Boyd, J. L., & Fischer, D. A. (2012). “Correlating MRI findings with disability in syndesmotic sprains of NFL players” Foot & Ankle International, 33(5), 371-378. Calder, J. D., et al. (2016). "Stable versus unstable Grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports" Arthroscopy: The Journal of Arthroscopic & Related Surgery 32(4): 634-642. Sman, A. D., et al. (2015). "Diagnostic accuracy of clinical tests for ankle syndesmosis injury" Br J Sports Med 49(5): 323-329. Morgan, C., Konopinski, M., & Dunn, A. (2015). "Conservative Management of Syndesmosis Injuries in Elite Football" Aspetar Sports Medicine Journal: 602-613.

There’s nothing like getting injured to throw a spanner in the works when you’re earning a living abroad as a Digital Nomad. It doesn’t even have to be as serious as falling off an elephant. (Serves you right!) Just that persistent niggle in your neck from sitting hunched over your laptop for far too long can thoroughly spoil your adventure. But hey, you’re used to doing lots of stuff remotely, aren’t you? Making money, wrangling your personal admin and keeping in touch with friends and family. So why not have your injury treated remotely? Yes, remote physiotherapy is a *thing*! In this post: How remote physiotherapy works Why remote physiotherapy is so useful for Digital Nomads Please don’t do this How remote physiotherapy works People often ask us how we treat our remote patients without being able to touch them. The answer is simple: a massage may make your injury feel better for a while, but it won’t heal it. Our years of combined clinical experience and the latest research say it’s the right combination of rest and exercise – based on an accurate diagnosis and taking your lifestyle into account – to help along your body’s natural healing processes that does the trick. Here’s the drill when you have your first remote consultation with one of our physios: We hook up via Skype, Zoom, WhatsApp or whatever video platform suits you; We discuss how you got injured, your lifestyle and your daily routine, to give the physio a good understanding of the injury and its surrounding circumstances; Your physio will ask you to do some movements while they watch, and you give them feedback on what you feel and experience – these tests are similar to the ones used in a face-to-face clinic and will help your physio to figure out exactly what you have injured as well as what your muscle strength, flexibility and control are like; Then your physio guides you through a palpation examination and get you to examine different parts of your body by hand to distinguish between different ligaments, muscles and bones; All this helps the physio to arrive at a diagnosis, which they will discuss with you; Your physio compiles a personalised treatment plan based on your diagnosis, lifestyle, and abilities and explains it to you; If this includes exercises, they will get you to do them on video so that they're happy that you’re doing them correctly; You wave goodbye and log off; Your physio emails you a written report summarising the examination findings and treatment plan as well as pictures and/or videos of the exercises; Your physio is available on email after the consultation if you have any questions or concerns. Voilà! (You can read more about the nuts and bolts of it all here.) Why remote physiotherapy is so useful to Digital Nomads With having to live and work in many various settings, things aren’t always as ergonomic for Digital Nomads as we’d like them to be. Yes, you escaped the 9 to 5, but actually you’re more at risk of work-related aches and pains than someone who’s had their own office desk and chair set up *just so*. Not to mention long stints on public transport and having to lug all your possessions and kit around with you every time you move base. You’ve learnt the basics of the local language and maybe you can even hold your own in an argument after a tuk-tuk accident. But do you really feel up to communicating your needs properly and getting injury advice in a lingo you’re not familiar with? With remote physiotherapy, you can summon a medical professional who speaks your language. Physio treatment often involves more than one consultation. You’ve been living and working in Medellín and your next face-to-face appointment with your physio is in two weeks’ time...but by then you’re due in Buenos Aires! Back *home* (wherever that is) you might have been content to tough it out on the couch while your sprained ankle takes care of itself. But it sucks to be stuck in an Airbnb while everyone else goes off to gorge themselves on street food at the night market. Better to get yourself sorted so that you can make the most of your lifestyle. Please don’t do this You may be tempted to hack your injury by googling it for a DIY cure. Please don’t. A Harvard study of 23 online symptom checkers examined how accurate their diagnoses and triage recommendations were. The findings don’t exactly inspire confidence. “The online services listed the correct diagnosis first in about one-third of instances and listed the correct diagnosis in The top 20 possible diagnoses in more than half of cases. Concerningly, symptom checkers provided varying triage recommendations, with appropriate advice ranging from 33% to 78% of evaluations.” It takes years of clinical experience to figure out exactly what’s going on with an injury and what to do about it. All our physios have Masters degrees, each of us has more than 10 years' experience, and we've been fixing people remotely since 2014. So, if you’re struggling with an injury or aches and pains that won’t go away, please feel free to get in touch. We won’t really judge you if you fell off an elephant. 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

Remote worker Tom* booked into our online physiotherapy clinic from the Canary Islands after he had injured an elbow doing Brazilian jiu-jitsu. The injury kept him from fighting and hampered his strength training in the gym, and he didn’t want to wait until his return to the UK to get it fixed. We diagnosed his injury and gave him a bespoke rehabilitation programme via WhatsApp video and e-mail. Tom is one of a small but growing number of people who have come to realise the value of online physiotherapy. “But how can you fix my injury without touching me?” you may ask. Most injuries can be self-treated as long as you have an accurate diagnosis and a sensible treatment plan, which we can do on a video call. A massage may make you feel better for a while, but it won’t fix your injury. Our team of physiotherapists' combined years of clinical experience and the latest research suggest that it’s the right mix of rest and exercise, prescribed by a physio, that will heal you in the long run. Our typical international patient is someone who doesn’t have access to a physio where they live. We also get English-speaking expats who can’t find an English-speaking physio. And online physiotherapy is especially useful for people who can’t take time off work or find it difficult to travel with an injury to go and see a physio. They consult one of our team on a video call right there in the comfort of their own home to get a diagnosis and a bespoke treatment plan. Obviously this is handy for people in far-flung locations, but also in the UK, where we are based. All our physios have Masters degrees in a sports and exercise injury related field and each has more than 10 years' experience. We started offering our services online in 2014 and have seen the concept of online physiotherapy gradually gain acceptance. Business travellers, digital nomads and other regular users of video calls don’t find it strange anymore to access physiotherapy in this way. Soon it will be as normal for everyone as ordering groceries, take-out food or a cab online. Do you 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. 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.

Increased neural tension in the sciatic nerve can cause pain along the back and outside of your legs and feet, but it may also predispose you to getting injuries like calf strains, hamstring strains, and Achilles tendinopathy. In this article, we explain what neural tension is, what causes it, how to test for increased neural tension in your sciatic nerve, and what exercises or treatments may help. 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 neural tension or increased neural tension? Where is the sciatic nerve? Causes of neural tension Symptoms indicating increased neural tension in the sciatic nerve Test for sciatic nerve tension Neural tension treatment - Common mistakes Exercises for increased sciatic neural tension How we can help Please note that this article is not about sciatica, which is a different condition. We've also made a video about this: What is neural tension or increased neural tension? Our nervous system consists of our brain, spinal cord, and the nerves that run into all parts of the body, all the way to the tips of our toes and fingers. When we move, our spinal cord and nerves are meant to slide and glide. Neural tension (or increased neural tension) is when a nerve is prevented from sliding (we’ll discuss what causes this lower down) and is stretched instead. Nerves don’t like being stretched; when this happens, they can cause pain or funny sensations or simply not perform their job very well. Where is the sciatic nerve? Our spinal cord is housed within the spinal canal, which is formed by our vertebrae that are stacked on top of each other, forming the backbone. There’s a disc made of strong cartilage between the vertebrae and also small openings to the sides (where the vertebrae rest on each other) where the spinal nerves branch out from the spinal cord. These spinal nerves then combine and fuse to become the nerves that run into the various parts of our body. The sciatic nerve is formed by the spinal nerves that exit right at the lower part of the back as well as from the sacrum (L4 to S3 spinal nerves). It’s quite thick, as nerves go – about as thick as your thumb. It runs through the buttock area, either underneath or through the piriformis muscle, and very close to the hamstrings along the back of the thigh. It splits at the back of the knee to form the tibial and common fibular (also called peroneal) nerves. These nerves then further split into several branches that serve the back, sides, and front of the lower leg and foot. Causes of neural tension Our spinal cord and nerves slide through openings in our bones, past our joints, in between our muscles, and often over or close to our tendons. Various injuries or circumstances can cause them to get a bit stuck at any of these points: The most common cause is simply having tight muscles and fasciae, which then don’t allow the nerves to slide freely. This can happen due to spending long periods of time in the same position or repeating the same movement. It can also happen if you train very hard without doing any mobility work. An injury to the nerve itself will cause it to swell and generally not tolerate much tension. Disc bulges or injuries in the back can press directly on the nerve, or swelling around the injury can increase the pressure on the nerve. If our bones change shape, e.g. the openings in the vertebrae narrow, or perhaps you get a little bone spur (osteophyte), e.g. on your knee joint, that irritates the nerve. The swelling and muscle tension caused by acute injuries like muscle tears or sprains can cause a temporary increase in pressure on the nerve. This is normal and usually resolves by itself if you follow the correct treatment regime for the injury. Scar tissue or adhesions that form in reaction to other injuries, e.g. between the hamstrings and the sciatic nerve when you have high hamstring tendinopathy, can attach to a nerve and prevent it from sliding freely. This often happens in chronic injuries where someone is trying to ignore the injury and train through it, or they just rest it and don’t do any exercises to train and remodel the scar tissue. Doing the correct strength training exercises not only strengthens the area but also prevents adhesions and helps the scar tissue to form in a functional way. Symptoms indicating increased neural tension in the sciatic nerve None. You can have increased neural tension without it causing any symptoms. It only becomes a problem when you try and move your body into positions that actually require the nerve to slide. Feeling of tightness or discomfort, e.g. calf or hamstring tightness that doesn’t want to resolve. Referred pain (sharp, dull, or burning). Nerves often cause pain quite far away from the actual problem. Strange sensations like tingling, pins and needles, or reduced sensitivity. Suffering repetitive calf or hamstring injuries without any clear cause. These symptoms can be felt anywhere along the line of where the sciatic nerve and its branches run. The symptoms are often mistaken for other injuries, e.g. the fibular nerve can cause pain in the area where it wraps around the head of the fibula, which is often misdiagnosed as IT band syndrome or lower hamstring tendonitis. Test for sciatic nerve tension To test if the sciatic nerve is free to slide, we want to tension it all the way from the spinal cord to the toes. The simplest test is the slump test. There are many variations that a therapist can use to further pinpoint the problem, but I find that the standard test is good enough in most cases. There is no perfect test score or gold standard that has been identified in research. The test can highlight large decreases in range of movement and differences between your left and right side, but the results should always be interpreted in combination with your other signs and symptoms. This is how I do the slump test This method is not appropriate for back injuries. Do not force any movements through pain – it will just make things worse. Step 1: Sit on a sturdy chair (like a dining room chair) with your back straight and your thighs fully supported. Step 2: Place your hands behind your back. Step 3: Now slump forward slowly by placing your chin on your chest, then bending your upper back, and then your lower back. What I’m looking for: At this point, I would be looking if my patient can get a nice rounding of the spine. If you notice that you struggle to keep your neck flexed when you bend the rest of your spine, or that your upper back remains straight rather than curved, it might indicate that you would benefit from mobility exercises for your back. Step 4: Maintain this slumped position and slowly straighten one leg as far as possible while pointing your toes like a ballet dancer (plantar flexion). Observe how stiff your leg is (how far straight or not your knee can go) and whether you feel any pulling or pain in your leg, buttock, or back. If you are able to fully straighten your leg without much pulling or pain, go to Step 6. If you aren’t able to get your leg straight and/or feel significant pulling or discomfort in your leg, buttock, or back, go to Step 5. Step 5: Maintain the position with your leg as straight as possible and slowly raise your head to look at the ceiling. Try not to move your back too much. Does this allow your leg to go straighter or decrease the amount of pulling you feel? If yes, it’s a sign that you have some increased neural tension in that leg. Stop the test for this leg. Repeat it with the other leg for comparison. If looking up doesn’t change anything, it’s a sign that the tightness, pulling, or discomfort is likely NOT caused by neural tension but rather by tight muscles. Move on to Step 6. Step 6: Lower your leg to the floor. Make sure your chin is still on your chest and your spine still rounded. Now flex your foot and ankle up into dorsiflexion (so your toes move toward your shin). Maintain that position and straighten your leg out again. Once again, observe what you feel in your leg, buttock, and back and how straight your leg can go. Test whether looking up changes anything for you (like in Step 5). If looking up changes things, it’s a sign that you have some increased neural tension in that leg. If it doesn’t change anything, it’s a sign that the tightness, pulling, or discomfort is likely NOT caused by neural tension but rather by tight muscles. Step 7: Do the test from Step 1 with the other leg for comparison. Neural tension treatment - Common mistakes Trying to stretch or slide the nerve when it is still stuck It is really important to identify the most likely cause of your increased neural tension before jumping straight into doing exercises. For example, if your neural tension is secondary to an acute disc injury or muscle tear that is causing increased swelling and pressure in that area, you should first target your treatment at those injuries. In most cases, doing the correct exercises for your back or muscle injury will also help to resolve the neural tension, and no further intervention will be needed. You don’t need any special scans for this; an experienced sports physiotherapist will be able to identify the cause by listening to how your injury started, what your current signs and symptoms are, and getting you to do a variety of movement tests. These test can even be done via video call, and we use them regularly in our assessments. Overstretching You don’t need to be super flexible, and you can really aggravate your nerves by overstretching and pushing too hard. It is absolutely normal and expected to have some level of increased neural tension; this often varies depending on the time of day or the activities you’ve just done (e.g. sitting still vs. moving around). It is also normal for your right and left sides to not be exactly the same. When we do the slump test, we look for significant differences and whether it recreates symptoms that feel similar or are located in the area of your injury. Slight differences can often be ignored. Exercises for increased sciatic neural tension Whom these exercises might benefit: These are usually appropriate for people who are in the mid to later stages of rehab for acute injuries or have neural tension due to a more chronic cause. But this still doesn’t mean that these exercises are necessarily right for you, so discuss it with your physio before trying any of them. This exercise routine is NOT appropriate for anyone: With a recent or acute injury. Who has something pressing directly on the nerve, e.g. disc bulge, spinal stenosis, narrowing of the openings where the spinal nerves exit, etc. Neural tension exercise routine I usually introduce the exercises in stages, e.g. in the first few weeks we may work on getting good mobility in the spine and around the pelvis and see how that improves things. Then we slowly work towards movements that specifically tension the nerve. How quickly we progress and what we do will always depend on what I found when I assessed my patient. I advise doing these exercises in the following sequence, because it allows you to first loosen off the parts that could potentially hold on to the nerve before you then ask it to slide. This way, it is more likely to move without restriction. Standing calf stretch Roll-down Arm opener Piriformis stretch Figure 4 stretch Supine knee extension Straight-leg plantar flexion / dorsiflexion Seated slump slider I may ask some patients to do this daily, and others will only have to do it two or three times per week. Standing calf stretch Stride stand with the leg to be stretched at the back. Your toes must point straight forward. Keep the heel of your back foot on the floor and that leg straight at all times. Slowly bend the knee of your front leg until you feel a stretch in the calf of your back leg. Hold the position for 30 seconds. Switch legs and repeat on the other side. Do twice with each leg. Roll-down Breathe normally throughout the movement. Stand with your feet hip distance apart and your knees slightly bent. Your knees must remain bent throughout the movement to reduce the tension on your sciatic nerve. Tuck your chin into a double-chin and then drop it all the way onto your chest. Curl your spine down, starting from the top, until you’re hanging from your hips. Allow your arms to hang loosely as you bend forward. While in this position, wiggle your buttocks a few times from side-to-side and feel your neck and spine relax. Take a nice deep breath and let it all out – feel how this further relaxes everything. Reverse the movement by pulling in your stomach muscles and gently curling back up, starting from your lower back and ending with your neck until you’re upright. Do 3 repetitions. Arm opener Lie on your side with your hips and knees bent to 90 degrees and your arms straight out in front of you, palms facing each other. Lift your top arm up to the ceiling and follow it with your head as you drop it behind you. This should cause your upper body to rotate, but your hips should not roll back. Only move to your natural restriction. Don’t try and cheat to go further by letting your arm drop towards your feet – your hand should be in line with your shoulders or higher up as you move. You will likely feel the main stretch over the front of your chest or in the middle of your upper back. Take a deep breath and drop your arm further down behind you as you breathe out. Now rotate back to the starting position. Do 3 times, then switch sides. Piriformis stretch Lie on your back with your legs bent and cross your right leg over your left leg. Place your right hand on your right knee and your left hand on your right shin. Pull with both hands so that your right knee moves diagonally towards your left shoulder. You should feel a stretch in your right buttock. Make sure that your knee moves across your body (not straight up) and check that you also pull with the hand that is on the shin – this twists the hip and increases the stretch. Hold the position for up to 30 seconds. Do twice with each leg. Figure 4 stretch Lie on your back with your legs bent. Place a pillow under your head if you struggle to keep your neck and upper back flat on the floor. Place the outside of your right ankle on your left thigh, just above the knee. Hook both hands behind your left thigh and pull it towards your chest. You should feel the stretch in your right buttock, thigh, or lower back, depending on which part is the tightest. Hold the position for up to 30 seconds. Do twice with each leg. Supine knee extension Lie on your back with your legs straight. Bend your left leg up so that your thigh is perpendicular to the floor and your knee is pointing at the ceiling. Hold your thigh with your hands, but be careful not to pull it too far towards you. Keep your foot POINTED away from you (plantar flexed, like a ballet dancer) throughout the exercise. Slowly straighten your leg until you feel a gentle stretch – it doesn’t matter if it can’t go fully straight. Pause for a moment and then bend your leg again (your thigh should remain perpendicular to the floor). Do this 12 times, then switch legs. Do 1 or 2 sets per leg. Straight-leg plantar flexion / dorsiflexion Lie on your back with your legs straight. Bend your left leg up so that your thigh is perpendicular to the floor, then straighten your leg to where you can and hold it there. Slowly bend your ankle back into dorsiflexion (toes move towards your shin) until you feel a gentle stretch in your calf. Hold that position for 2 seconds. Point your toes away from you, so that your ankle moves into plantar flexion. Hold that position for 2 seconds. Do this 12 times, then switch legs. Do 1 or 2 sets per leg. Seated slump sliders The aim here is to slide your sciatic nerve, NOT to stretch it. So, you alternate between tensioning it at the top (neck and back), which causes the sciatic nerve to slide up, and then transferring the tension to the legs while releasing it at the top, causing it to slide down. Sit on a sturdy chair with your back straight, your thighs fully supported, and your feet resting on the floor. Place your hands behind our back, your chin on your chest, and flex your spine (slump position like in the test above). This tensions the nervous system at the top. Slowly straighten one leg out in front of you (tensioning the sciatic nerve in the leg) and at the same time lift your head up to look at the ceiling (releasing tension at the top). This causes the sciatic nerve to slide down. Lower your leg (releasing the tension in the leg) while at the same time placing your chin back on your chest (so tensioning at the top, causing the nerve to slide up). Repeat 6 times per leg. 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 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Majlesi, J., Togay, H., Ünalan, H., & Toprak, S. (2008). The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. JCR: Journal of Clinical Rheumatology, 14(2), 87-91. Coppieters MW & Butler D. (2008). Do "sliders" slide and "tensioners" tension? An Analysis of Neurodynamic Techniques and Considerations Regarding Their Application. Manual Therapy 2008 13(3): 213-221. Web. 26 October 2013.