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Ankle injuries are one of the most common musculoskeletal sports injuries, and recurring ankle sprains – also referred to as chronic lateral ankle instability or chronic ankle instability – can come back again and again to frustrate runners and other sportspeople. This article explains how you can avoid suffering from recurrent ankle sprains. It is also something that one of our team of online sports physios can help you with via a video consultation. You may also find these articles useful: - Should I go to A&E with a sprained ankle? - How to treat a sprain – an update on the latest research - Ankle braces for sprains – Do you need one, what type works best, and when to wear it In this article: Why are recurrent ankle sprains so persistent? How to fix chronic ankle instability Other options for fixing chronic ankle instability Need more help? Why are recurrent ankle sprains so persistent? When you sprain your ankle it usually causes a tear in one of the ligaments. It can be a partial tear or a full tear. Your ligaments hold your ankle joint together, so if you tear them, then you are actually causing that joint to be temporarily unstable, if not longer. If someone were to tear a ligament in, say, their knee, most people would go, ‘Oh, gosh! You must get that better before you go back to playing!’ And really, the same thing should be said about your ankle. However, because ankle sprains are so common, people don't really take them as seriously as they should, and they often don't rehab them to the right level before they go back to running or playing sport. In these cases, the injury can either happen again or the ankle can still give you problems, because it is not stable enough for a return to the level of activity you were at before the injury. How to fix chronic ankle instability To prevent or fix recurrent ankle sprains, you should check whether one or more of the following issues need attention. Swelling in the ankle The first thing you might want to consider after you've injured your ankle and you've gone through your initial acute soft tissue management is whether there is still some swelling. If so, firstly, swelling can affect the sensory motor control of the muscles around your ankle, and that can affect your balance, which will predispose you to going over on your ankle again. Secondly, if you go back to playing sport or running with a swollen ankle, the swelling tends to cause some pinching at the top front of your ankle, called impingement, and that can cause problems down the line. So, if you’ve still got swelling in your ankle, the best thing is to say, ‘Actually, is it really ready to be going back to all the things I want to be doing, or does it need a little bit longer to just settle down?’ Range of movement After a sprain, sometimes your ankle can be a bit stiff in dorsiflexion, which is when you pull your toes up towards your chest or when you go into a squatting position. As you can imagine, this movement is also required of your ankle when you are running. Dorsiflexion is easily tested by seeing how far from a wall you can place your foot flat on the floor while your knee is touching the wall. (You can check our video below to see how this is done.) You should compare your recently injured ankle to the other one to see if there's much difference. Quite often after a sprain, this will be stiff and might need some work to get it better so that your biomechanics are right. Steph demonstrates these movements and some of the rehab exercises mentioned lower down in this video about recurrent ankle sprains: Strength exercises for chronic ankle sprain rehab Ankle strength is also important, because if the muscles that control your ankle aren't as strong as they used to be, then they can't control your ankle so well. Examples of strength exercises that you may want to be doing include heel raises and TheraBand work (see the video for a demo). Sometimes you might have problems where you're also not as springy as you used to be. Perhaps when you hop on one foot, you're nice and springy, whereas on the other one, where you injured your ankle, it's all flat-footed, which obviously affects your ability to run quickly. So, you need to not only make sure that your ankle strength is good in all directions - to properly prepare your ankle for sport, you also have to include plyometric exercises that can restore the springiness in your ankle. There's also some research that shows that hip and core strength can make a difference for people with chronic ankle instability, mainly because if you don't have very good hip control, then your biomechanics might not be as good as someone who's nice and steady in their core and around their glutes. Static and dynamic balance exercises for recurring ankle sprains Sometimes when you sprain your ankle, you disrupt the sensory receptors in your ligaments and around the soft tissue that tell your brain what your ankle is doing and help you to balance. This is also known as position sense or proprioception. Static balance is nice and easy to test. Stand on one leg with your eyes shut and compare it to how well you can do it on the other leg. Sometimes, people with a recently sprained ankle will find that their balance is not quite as good. This is another reason why people might sprain their ankle again, because they haven't rehabbed their static balance. However, when you're playing sport, you're not just staying still, so you also have to look at what we call dynamic balance. This may involve reaching in different directions with one leg while you're maintaining your balance with the other, or it might be something more dynamic, like hopping and skipping sideways, forwards, and backwards. That's the next level of balance-type exercises that you need to be able to do to try and reduce the risk of spraining your ankle again. How quickly your ankle muscles can react to unstable surfaces or running over uneven ground can also be a good test to see how it can cope with the sort of mechanism that might injure it and how quickly your muscles can stop it from happening. Biomechanics The way that you walk or run can also tell us some things about your ankle. Sometimes people don't push off the way they do on their other leg, and that is an indication that you need more strength around your ankle. Sometimes, it's just something about the way you're running in general that actually predisposes you biomechanically to going over on your ankle. We can observe this during our consultations by getting you to perform test movements or asking you to film yourself while running on a treadmill. This can usually be fixed by improving the hip and core strength that I mentioned earlier. Other options for fixing chronic ankle instability You could consider getting scans and investigate taking the surgical route to fix recurring ankle instability. However, if you haven't done any of the rehab mentioned in this article to the very top level that you need it – and that depends on what physical activity that you are trying to get back to doing – then I suggest you do a rehab program for chronic ankle sprains first. Give it at least three to six months and try and get it as good as you can get it before you think about whether or not you need any scans or orthopaedic opinions. Need more help? If you need help with such a programme, that's the sort of thing we do all the time, so take a look at our website and then, if you want an individual assessment, please do book in, and we'll compile a bespoke ankle sprain treatment plan for you to get your ankle as strong as it can be. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can read more about her here, and she's also on LinkedIn. Research 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. Lephart, S. M., Pincivero, D. M., & Rozzi, S. L. (1998). Proprioception of the ankle and knee. Sports Medicine, 25(3), 149-155. Vuurberg, G., et al. (2018). "Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline." British Journal of Sports Medicine 52(15): 956-956.

In this article I discuss what causes hamstring injuries and give you some practical tips and exercises to prevent them. It’s a summary of the fifth session in the Injury Prevention series. The other topics include position sense, core stability, glute med, glute max, quadriceps, and calves. In this article: What the hamstrings does What causes hamstring injuries? Flexibility exercises should target more than just the hamstrings Hamstring strengthening exercises Download exercises as PDF What the hamstrings do The hamstrings are made up of 4 muscles that run down the back of your thigh. They attach at your sit-bone (ischial tuberosity) on the lower part of your pelvis and then split so that 2 of them attach on the inside of your knee and the other 2 on the outside. Their main function is to bend your knee (knee flexion) and help with hip extension (taking your leg back). What causes hamstring injuries? Weakness: If there’s a big difference between muscle strength in your right and left legs, it can lead to hamstring strains in the weaker leg. That’s one of the reasons why it’s important to do exercises where you train one leg at a time (e.g. single leg Romanian deadlift) as you won’t notice any differences if you only use double leg exercises. Poor lumbo-pelvic control or core stability: Lumbo-pelvic control refers to your ability to keep your pelvis level and stable while you move. Excessive forwards and backwards tilting can contribute to hamstring strains, because the hamstrings attach to the sit-bone on the pelvis.  You can find an example of basic exercises to improve your lumbo-pelvic control in this article about core stability. Fatigue: When you’re tired your nervous system struggles to control your muscles properly and your muscle fibres become weaker which makes it a lot easier to strain them. Referred pain from the lower back and gluteals: Not all injuries that feel or present like a hamstring strain are always what they seem. Referred pain from the lower back or glutes can feel very similar to a hamstring tear. An experienced sports physiotherapist should be able to tell you if your injury may be more than just a simple hamstring strain. Tight hamstrings: This is a controversial subject as there are several studies that show that tight hamstrings does not necessarily predispose you to injury while others have found that it does. In practice I tend to always address both strength and flexibility. As explained above the lower back and gluteals may also influence your hamstrings, therefore I always include mobility work for all of these areas. Tight hip flexors: Research has shown that tight hip flexors can inhibit your glutes. The glutes are your main hip extensor muscles. If they are switched off, your hamstrings will have to work a lot harder which can lead to strains. Lack of position sense: Position Sense is the ability of the brain to know exactly where your limbs are in space and time. If your position sense is affected, it leads to poorer control which in turn can lead to all sorts of injuries including hamstring strains. Flexibility exercises should target more than just the hamstrings Your nervous system (brain, spinal cord, nerves) is continuous from your brain to the tips of your fingers and toes. It is designed to slide freely past bones and through or between muscles. If it gets stuck somewhere along the line (e.g. due to tight muscles holding on to it), it causes the nerve to stretch rather than slide. Nerves don’t like being stretched and this can manifest in a wide variety of symptoms including a feeling of persistent muscle tightness or twinges or even tingling when you place your leg or arm in certain positions. It is important to understand that this is actually extremely common and can usually be fixed with a few simple mobility exercises. If you're one of those people who struggle with extremely tight hamstrings despite stretching them religiously, you may very well have a sciatic nerve that’s not free to slide. If this is the case the brain won’t allow your hamstrings to fully extend as it is trying to protect the nerve from being stretched. In practice, I often find that these people regain normal hamstring length by just working on the mobility of their lower backs and glutes. As mentioned above, tight hip flexors can also cause trouble, so it’s best to include a stretch for them as well. Please note: The exercises in this article may not be appropriate for you. Please consult your healthcare or fitness provider before doing any of them. You can also consult our team of sports physios via video call if you wanted a bespoke treatment plan. Figure four stretch Purpose: To improve the flexibility around your pelvis and lower back and help your sciatic nerve to slide more freely. Starting position: Supine with both knees bent up. Movement: Place the outside of your left ankle just above your right knee. Take hold of your right thigh with both your hands and pull it towards your chest. You should have a pillow under your head if you struggle to keep your neck in a good position. You should feel the stretch in the left buttock/thigh/back depending on which part is the tightest. Aim: Hold the glute stretch for 30 seconds and repeat on the opposite side. Repeat 3 times. Piriformis stretch Purpose: To improve the flexibility around your pelvis and lower back and help your sciatic nerve to slide more freely. Starting Position: Supine with both knees bent up. Movement: Cross your right leg over your left leg. Place your right hand on your right knee and your left hand on your shin. Pull with both hands at the same time so that your knee moves diagonally towards your left shoulder. You should feel a stretch in your right buttock. Check that: You also pull with the hand that is on the shin – this twists the hip and increases the stretch. Make sure your knee moves across your body. Aim: Hold the stretch for 30 seconds and repeat on the opposite side. Repeat 3 times. Hamstring stretch Purpose: To improve hamstring flexibility Starting position: Sit on the floor with one leg extended in front and with the other foot resting on your inner upper thigh. If your hamstrings are very tight, you may find that sitting on a pillow that lifts you up a bit helps. Movement: Slide your hands down your leg. You will likely not be able to reach your foot and that is OK. Just go to the point where you can still KEEP YOUR KNEE STRAIGHT. It should be a gentle stretch. Your body should be aligned nicely with the leg straight forward and the hips and shoulders squared. Check that: You do not force the movement and that you knee stays straight. Aim: Hold the stretch for 30 seconds and repeat on the opposite side. Repeat 3 times Hip flexor stretch The main hip flexor muscles are the iliopsoas and rectus femoris. You should stretch both of these. Purpose: You will activate your glute max much better if your hip flexors aren’t tight. Starting position: Half kneel with your one knee on a pillow and your other leg out in front of you. Hold on to something for balance if needed. Movement: A. Push your hip forward, but at the same time tilt your pelvis backwards. This is important – if you allow your pelvis to tilt forward, the stretch will not be as effective. This will mainly stretch the iliopsoas muscle, but if you’re very tight you may have to spend time on this part first and then add in part B. B. Once you can easily achieve part A, maintain that position and grab hold of your foot. You may have to loop a belt or towel around your foot if you are very stiff. Check that: Your pelvis remains tilted backwards throughout the stretch. Remember, strong sustained stretches switches muscles off, so these should be followed by dynamic movements if you're doing them shortly before doing sport. Aim: Hold the stretch for 30sec and repeat 3 times on each leg. Hamstring strengthening exercises I always prefer exercises that are easy to do at home. My favourite 2 hamstring strengthening exercises are the single leg deadlift and the bridge and it’s various progressions. Single leg deadlift Why I like it: It’s not only a very good exercise that strengthens the hamstrings and glutes, but it also helps to develop your balance and position sense. So you’re getting a very good return for your effort! Starting position: Balance on one leg with your knee slightly bent. Movement: Tighten your stomach muscles and slowly hinge forward from your hips and lift your other leg straight out to the back. Your back should NOT bend. Try to get your body and hind leg in a straight line. Check that: Your supporting knee stays slightly bent. Aim: Hold the position for 10 seconds. Build up to repeating 10 times on each leg. You can progress this exercise by holding a weight in your hands. Double leg bridge – feet up This exercise is similar to the bridge that we used in the previous article to strengthen the glutes, but you can target your hamstrings by moving bottom further away from the chair. Starting position: Lie on your back with your heels on a chair. Make sure that your bottom is far enough away from the chair so that your knees are bent at about 15 degrees when you reach the top. The straighter your knees, the more it becomes a hamstring exercise and that’s our goal for now. If, however, you find that your hamstrings want to cramp, you may have to move your bottom closer to the chair to start with. Movement: Activate your pelvic floor and deep abdominals by squeezing as if you don’t want to wee or fart. Keep them activated and lift your bottom into the air so that your body forms a straight line. Once at the top, you should squeeze your buttocks and make sure that you don’t feel any strain in your lower back. If you do feel strain in your lower back, make sure that you are squeezing your stomach and glutes and not trying to just arch your back. Check that: You don’t feel any strain in your lower back. If your hamstrings cramp, move your bottom closer to the chair. Aim: Hold the position for 10sec. Rest 10 sec. Repeat 10 times. Build up to 4 reps of 30sec holds. Progress to: Single leg bridge Starting position: Lie on your back and place one heel on the top of a chair and keep the other foot in the air. Movement: With the knee resting on the chair slightly bent, lift your bottom off the floor until your body forms a straight line. Tighten up your stomach muscles and your glutes. Your pelvis must stay in a straight line. Do not allow the one side to drop to the floor. Then slowly lower yourself back down. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp – shift your bottom closer to your feet. Aim: Build up to 3 sets of 15 reps on each leg Progress to: Double leg ball curls Starting position: Lie on your back with your heels on a big ball and knees bent to 90 degrees. Movement: Lift your bottom off the floor so that your body forms a straight line. Engage your stomach muscles and squeeze your glutes. Now slowly roll the ball away from your body by straightening your legs out. Then slowly roll the ball back towards your bottom. Check that: Your bottom stays at the same level in the air. Aim: Build up to 3 sets of 15 reps. Download the exercises as PDF Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. References: Ackermann, Paul, et al. "Neuronal pathways in tendon healing and tendinopathy: update." (2016). Brukner P. Hamstring injuries: prevention and treatment—an update. British Journal of Sports Medicine 2015;49(19):1241-44. doi: 10.1136/bjsports-2014-094427 Cameron, Matt, Roger Adams, and Christopher Maher. "Motor control and strength as predictors of hamstring injury in elite players of Australian football." Physical Therapy in Sport 4.4 (2003): 159-166. Mills M, Frank B, Goto S, et al. Effect of restricted hip flexor muscle length on hip extensor muscle activity and lower extremity biomechanics in college‐aged female soccer players. International Journal of Sports Physical Therapy 2015;10(7):946. Shield AJ, Murphy S. Preventing hamstring injuries – Part 1: Is there really an eccentric action of the hamstrings in high speed running and does it matter? Sport Performance & Science Reports 2018(April 25) https://sportperfsci.com/preventing-hamstring-injuries-part-1-is-there-really-an-eccentric-action-of-the-hamstrings-in-high-speed-running-and-does-it-matter/ Van Hooren B, Bosch F. Preventing hamstring injuries - Part 2: There is possibly an isometric action of the hamstrings in high-speed running and it does matter. Sport Performance & Science Reports 2018(April 25) https://sportperfsci.com/preventing-hamstring-injuries-part-2-there-is-possibly-an-isometric-action-of-the-hamstrings-in-high-speed-running-and-it-does-matter/

I am often amazed and flabbergasted at the lack of attention coaches and players of amateur football teams give to warm-up drills. Football is the most popular sport in the world and the incidence rate of outdoor soccer injuries is among the highest of all sports injuries. Women in particular are at a greater risk of serious injury than men - the rate of anterior cruciate ligament injuries is three to five times higher for girls than for boys. This is largely blamed on women generally having weaker muscles around the hips and pelvis which allows their knees to turn in more when running – putting extra strain on the ligaments. The popularity of the game as well as the silly amounts of money involved have meant that loads of research has been done in an attempt to reduce football injuries. A few years ago researchers from F-MARC, the Oslo Sports Trauma Research Centre and the Santa Monica Orthopaedic and Sports Medicine Research Foundation collaborated and developed the FIFA 11+ complete warm-up programme. In this article: The 11+ can reduce injuries in players of all ages What is the FIFA 11+ programme? Download the programme The 11+ can reduce injuries in players of all ages In 2008 a group of researchers tested the effectiveness of this programme on 1892 female players (aged 13-17). They found that the players whose teams implemented it were not only at a significantly lower risk of sustaining injuries, but they were specifically less likely to suffer severe injuries or overuse injuries. Since then it has been proven effective for men and women across all age groups. It has also successfully been adapted to other sports like rugby. What is the FIFA 11+ programme? It is a 20 minute warm-up programme and should be completed at least twice a week before training. FIFA advises that prior to matches, only the running exercises (parts 1 and 3) should be performed. A key point in the programme is that it has to be performed using the proper technique. You should pay attention to correct posture and good body control, including straight leg alignment, knee-over-toe position and soft landings. The programme consists of 3 parts. Part I:  Running exercises at a slow speed combined with active stretching and controlled partner contacts. Part II:  Six sets of exercises. The exercises focus on core and leg strength, balance, plyometrics and agility. Each of these exercises also include three levels of progression with the aim to ensure that a player continually improves. Part III: Running exercises at moderate/high speed combined with planting/cutting movements. This programme is FREE This programme is free to download and has been proven to work so USE IT! 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: Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 2008;337 doi: 10.1136/bmj.a2469 http://f-marc.com/11plus/manual/ Attwood MJ, Roberts SP, Trewartha G, et al. Efficacy of a movement control injury prevention programme in adult men’s community rugby union: a cluster randomised controlled trial. British Journal of Sports Medicine 2018;52(6):368-74. doi: 10.1136/bjsports-2017-098005Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. British Journal of Sports Medicine 2015;49(9):577-79. doi: 10.1136/bjsports-2015-094765

The best triceps tendonitis treatment is to give your tendon a break without totally resting it (relative rest) and then to strengthen it with exercises that don’t make your injury worse. This article explains the principles behind this approach. It also covers the anatomy involved and the causes of triceps tendonitis – understanding these will help you to understand the rehab process better. 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 triceps tendon Causes of triceps tendonitis Triceps tendonitis symptoms What happens when you get triceps tendonitis? Triceps tendonitis treatment How we can help We’ve also made a video about this: Anatomy of the triceps tendon The triceps muscle has three heads that run down the back of your upper arm and fuse together into one tendon, the triceps tendon. You use your triceps mainly to straighten your arm, for example when doing push-ups or throwing a ball. It also supports the shoulder muscles with movements like adduction (bringing your arm closer to your body) and with general shoulder stability. The triceps tendon attaches the lower end of your triceps muscle to several parts of your elbow. It mainly attaches to the top of the ulna (one of the two bones in your forearm) and to the capsule of your elbow joint (a sinewy sac that you find around most joints). Tendons are made up of many collagen fibres arranged parallel to each other, and these fibres are arranged in bundles, also parallel to each other. This configuration makes a tendon quite strong, in the same way that a cable or rope is stronger than the sum of the strength of its individual strands. Causes of triceps tendonitis Most commonly, you get triceps tendonitis when you overwork the tendon; this is known as an overload injury. An overload injury can happen in several ways. It’s usually movements involving weight, for example gym exercises such as skull crushes or triceps dips, and, less often, fast movements such as throwing a ball or javelin repetitively. Triceps tendonitis can be due to acute overload, where you overdid it in a single exercise session, or it can be chronic overload, when you don’t give your tendon enough time to recover and repair between sessions over a period of time. Other causes In some cases triceps tendonitis can develop after: Taking fluoroquinolone antibiotics - Ciprofloxacin is a commonly prescribed one that has detrimental effects on tendons and other tissues. Getting hit on the tendon. Triceps tendonitis symptoms The pain when you have triceps tendonitis is mainly located at the back of your elbow and in the lower portion of your triceps. The triceps muscle may also feel stiff and sore, and you can get some referral into the forearm. You typically first notice the pain several hours after a hard training session or the next morning. Your elbow may feel stiff, and keeping it bent for long periods of time may make it hurt more. Any activity where you have to extend your elbow against resistance will usually increase your pain. Sometimes, you may not feel pain while doing the exercise or activity, but then it hurts more several hours later. Tendons are known for having a delayed pain response to exercise. Triceps tendon tear vs. tendonitis You’ll usually know when you’ve torn your tendon, because you’ll feel a sudden, sharp pain when you injure it. If this happened, go see a doctor as soon as possible. What happens when you get triceps tendonitis? Triceps tendonitis usually only affects one bundle of fibres or a few of them at most. That injured part loses its parallel configuration, which causes it to lose some strength, whereas the rest of the tendon is still fine. Contrary to a widely held belief, there’s very little, if any, inflammation in a tendon that is injured in this way. So the term “triceps tendinopathy” is actually more correct than “triceps tendonitis” (which implies inflammation), but we use the latter here because that is how most people refer to it. The injured tendon is painful because, in its weakened state, it can’t cope with the loads that it used to be able to cope with when you straighten your arm. Another common source of pain is when the tendon is stretched and/or compressed against the bones in your elbow as you bend your arm. Injured tendons don’t like being stretched or compressed – it’s a bit like pressing on a new bruise. Triceps tendonitis treatment Let’s start with one commonly prescribed treatment that you shouldn’t do. Triceps tendonitis stretches When your tendon is injured, it can often make your tricep muscles feel tight and sore, and it is natural to want to stretch them. It can also feel quite satisfying while you’re stretching it. But in my experience, this often just ends up irritating the tendon further because it causes it to compress against the bone and can prevent the pain from settling down. If you have been doing triceps stretches for an injured tendon and it hasn’t been getting any better, see what happens if you leave them out for two weeks: Are you starting to see any improvement? Some alternatives to doing triceps stretches are massaging the muscle and stretching your arm across your body with a straight elbow - this stretches part of the top of the triceps but avoids compressing the tendon over the elbow. Take care not to stretch your triceps tendon too much unintentionally. For example, try to change your sleeping position if you usually sleep with a deeply bent elbow, and check whether you have a habit of resting your chin in your hand while your elbow is resting on a table or desk. Reduce the load on your injured triceps tendon One of the first questions many of my triceps tendonitis patients ask me is, “Can I still work out with triceps tendonitis?” The short answer is yes, but there is a BUT. This is an overload injury, so you can’t continue with business-as-usual; it will just keep on overloading your tendon, and the pain cycle will persist. For your tendon to recover, you have to reduce the load you put through it to a level that it is currently able to tolerate. This is called relative rest; as opposed to complete rest, it does not require you to drop all activities. Identify those activities that really aggravate your injury and either cut them out (for now) or reduce them (for now) to the point where your tendon pain doesn’t get any worse. For some athletes, it may be that they need to avoid all exercise that involves the triceps action, so no push-ups, bench presses, overhead presses, etc. But for others it will just be that they need to reduce the load that they put through their tendon and perhaps increase the recovery time between exercises and also between training sessions. It may be that you have to bring the weight right down and really start with baby weights to find a level that doesn't actually aggravate it, or do your push-ups on your knees and not in the usual full plank position. Also, especially at the beginning, go for exercises that do not cause your elbow to bend past 90 degrees, to avoid compressing the tendon against the elbow bone. So, just working it from 90 degrees to straight rather than from a fully bent position. Tendons are sneaky things, and they sometimes only complain the next day if you’ve worked them too hard. So, the trick is to figure out what is the most you can do with it without increasing your pain during the session or in the 24 hours afterwards. Exercises for triceps tendonitis However, to make your tendon as strong as before, your exercises should increase in weight and difficulty as you recover. Tendons need strength exercises that gradually increase in difficulty to: stimulate the production of new, healthy collagen fibres, align the newly formed collagen fibres into that strong, parallel structure, and then make them as robust as before you got injured. You can play with three things to manage this, two of which you’ll be familiar with if you’ve been doing weight training for some time: You can increase the weight, and you can increase the sets and reps. For injury rehab, it’s better to increase only one of these two factors at a time. And thirdly, you can (and should) increase the range of motion of your arm so that you can eventually straighten it against resistance from a fully bent position. The process of increasing the difficulty of your strength exercises should happen very gradually. Use pain as your guide. An exercise is at the right level: if you don’t feel pain at more than a niggle level (about 3 out of 10) while you're doing it, if there’s no flare-up or increase in pain in the hours afterwards, and if it’s not more painful the next day. If you get a delayed pain response that lasts for more than just an hour or two and it's more uncomfortable the next day, what you did the previous day wasn't right for it, and you need to dial things down a bit. Massage for triceps tendonitis Massage can make your injury feel less stiff and reduce the pain for a few hours, but it will contribute nothing to the healing process because it won’t make your tendon any stronger. Make sure that whoever is doing the massage doesn’t grind your tendon against your elbow bones, because that will just irritate the tendon further and cause more pain. Let them concentrate on the triceps muscle belly rather than the tendon. Shockwave The very little research that has been done on this doesn’t indicate that it’s very useful. However, if you’ve tried rehabbing your tendon with strength exercises as described above for at least 12 weeks and it has not worked, it's something you could consider. PRP injections Again, there's not a lot of research out there about it yet, so I can't really say whether it works or not. But if you've tried rehab properly and it hasn't really worked, it's always worth trying this. Here’s our article about PRP injections for sports injuries. 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: Donaldson, O., et al. (2014). "Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies." Shoulder & Elbow 6(1): 47-56. Jafarnia, K., et al. (2001). "Triceps tendinitis." Operative Techniques in Sports Medicine 9(4): 217-221. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the "tendinitis" myth. BMJ. 2002 Mar 16;324(7338):626-7. Lappen, S., et al. (2020). "Distal triceps tendinopathies." Obere Extremität: 1-5. Taylor, S. A. and J. A. Hannafin (2012). "Evaluation and management of elbow tendinopathy." Sports Health 4(5): 384-393. Shybut, T. B. and E. R. Puckett (2017). "Triceps ruptures after fluoroquinolone antibiotics: a report of 2 cases." Sports Health 9(5): 474-476.

It can be tricky to safely return to running after injury, but you can avoid re-injuring yourself by following this progressive run/walk programme. In this article: Why the walking component is important The rules Walk/Run programme for return from injury Why the walking component is important The muscles and ligaments can take several months to reach their full strength. The periods of walking allow the tissue to recover between the running bouts and will allow you to strengthen your injured body part without reaching its breaking point. This said, my patients can usually progress to running a continuous 20 minutes within 3 weeks of starting the programme. The Rules: Only start this programme if you can hop 10 times, without pain, on your injured leg. Your first session should only be 10 minutes long. During the following sessions, you’ll first increase the total time of the session by 2 minutes until you reach a total of 20 minutes. Once you reach 20 minutes, you increase the duration of the run periods, but the total time should not exceed 20 minutes. If you feel more than a 3/10 discomfort during the run periods, stop and finish the rest of the session by walking only. You are only allowed to increase the time of a session or duration of the running sections if you did not experience any increase in pain during or after the session - including the following day. Only run/walk on alternate days. You can have more rest days between sessions if you feel you need it. If a session was absolutely OK, you can immediately progress it during the following session. If not, you should repeat the session a couple of days later until you can do it pain free. Walk / Run programme for return from injury: Day 1:        1min Run / 1min Walk x 5    = 10min in total Day 2:        Rest Day 3:        1min Run / 1min Walk x 6    = 12min in total Day 4:        Rest Day 5:        1min Run / 1min Walk x 7    = 14min in total Day 6:        Rest Day 7:        1min Run / 1min Walk x 8    = 16min in total Day 8:        Rest Day 9:        1min Run / 1min Walk x 9    = 18min in total Day 10:      Rest Day 11:      1min Run / 1min Walk x 10 = 20min in total Day 12:      Rest Day 13:      2min Run / 1min Walk x 7    = 20min in total Day 14:      Rest Day 15:      3min Run / 1min Walk x5     = 20min in total Day 16:      Rest Day 17:      4min Run / 1min Walk x4     = 20min in total Day 18:      Rest Day 19:      20min Run You can now slowly increase the total running time. Remember to use the 10% rule and not to increase your total weekly volume by more than 10%. Download Programme as PDF Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.

Exercise in pregnancy is a common topic of concern for mums-to-be.  There are vast resources of information online but this can be overwhelming and it may be difficult to discern which advice is best to follow. Some women may feel anxious because the advice they receive from their peers or health care professionals is inconsistent with the information available online and they do not know who or what information to trust. In this article woman’s health physio, Kim van Deventer, answers common pregnancy exercise related questions. In this article: Is exercise safe during pregnancy? Why is it good to exercise during pregnancy? How can I make sure that I am exercising safely? Exercises that are encouraged or should be avoided during pregnancy When is exercise not safe in pregnancy? What if I can’t exercise because of other issues? When and where to get help One of the first questions I usually get from a new mum-to-be is "What exercise should I be doing now that I am pregnant?". Once the reality sinks in that she is now responsible for growing a little life inside of her, more questions seem to stream out with anxious desperation.  "What should I avoid?", "How much should I be doing?" and "How will I know when I am overdoing things?". No matter what a pregnant woman’s previous level of activity is, most usually have same concerns about exercise during pregnancy. So let’s answer a few important questions and put your mind at ease. Is exercise safe during pregnancy? Yes, it is.  During an uncomplicated pregnancy physical exercise is safe and beneficial for the baby and the mother. Regular, moderate intensity exercise is encouraged in healthy pregnant women and it is not associated with increased risk of preterm birth. According to some low quality studies, however, there may be an increased risk for miscarriage when there is intense exercise at the time of implantation and it is advised that if you want to become pregnant you may want to consider limiting the intensity of high-impact exercise in the week after ovulation, and refrain from repetitive heavy lifting in the first trimester. Why is it good to exercise during pregnancy? What a relief it is to know that there are so many benefits to exercising during pregnancy that it is too difficult to discuss all of them in detail in one article. I have summarised a few of the major benefits for mum and baby in the table below. The above table shows that not only is exercise beneficial for mothers, it is also substantially beneficial for foetal health and well-being which may extend into childhood and adulthood. The programming effect Regular exercise during pregnancy seems to elicit what scientists call a "prenatal program­ming effect".  This means that foetuses adapt to an impaired nutrient supply (either under- or over nutrition) by changing their physiology and metabolism in utero. It has been found that low birth weight is more likely associated with changes in the cardiovascular system whereas a higher than normal birth weight, due to a maternal “obesogenic” environment, is more likely associated with disorders of glucose metabolism such as obesity and diabetes mellitus. This "programming effect" highlights the importance of managing maternal body composition and dietary balance during pregnancy. Essentially, what the science says is that if you are fitter and healthier during pregnancy and if you create a healthy environment in utero dur­ing the critical time of foetal organ development, your baby will also be fitter and healthier at birth. Using this time in your life is a good way to make lifestyle changes that stick for you and your child. How can I make sure that I am exercising safely? Up until recently women were advised to avoid strenuous aerobic exercise during pregnancy, but new research has shown that most women can continue with their pre-pregnancy exercise routines with no adverse effect. 1. Understand how your body changes To make sure that you exercise safely during pregnancy it is important to understand the changes that occur in your body during pregnancy and how they affect you and your baby. Everything from your hormones and connective tissue to your joints and organs will experience phenomenal change. A few of these changes include: Your blood volume increases by almost 50% and there is up to 50% increase in your cardiac output (how hard your heart has to work to move all the extra fluid around). You will have 20% more oxygen consumption and an increased sensitivity to CO2 in your bloodstream. Your rib cage expands and your diaphragm is pushed up by 4cm. There is a 30% increase in kidney volume and the length of your kidneys increases by 1 to 1.5 cm. Your joints loosen, your centre of gravity shifts and your stability is reduced which causes your stance width to increase and your step length to decrease during walking. In addition to this your baby’s core temperature is approximately 0.6 ˚C more than yours. It may be a little easier to understand why you swell up, why you feel out of breath, why you need to go to the toilet more often, why you waddle and why you feel like a human furnace most of the time.  Even in the snow. 2. Understand the aims of exercise during pregnancy The aim is to maintain current fitness levels if previously active and to improve fitness levels and develop healthy lifestyle habits if you have not previously been physically active. Avoid aiming to achieve peak athletic levels during pregnancy.  After pregnancy the aim is to regain your previous level of fitness or if you were not previously exercising, to improve on what you have achieved during pregnancy. 3. Training Volume The UK’s Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women engage in 30 minutes of moderate intensity aerobic activity each day or approximately 210 minutes (3.5 hours) per week. Studies have shown that doing more than 270 minutes each week could potentially lead to pre-eclampsia in some women. For previously sedentary pregnant women and recreationally active pregnant women the guidelines for exercising in pregnancy are now almost the same as for non-pregnant women.  Get fit slowly and build it up gradually, or maintain it. 4. Monitoring workout intensity Traditionally, measuring your heart rate during exercise outside of pregnancy is accepted as the most effective way to monitor exertion and gauge exercise intensity levels.  However, during pregnancy your heart rate response varies day to day due to the previously highlighted physiological changes and using a heart rate monitor is not as reliable. You should aim to avoid over-exertion but you do not need to keep your heart rate below any particular number.  Instead you should use measures that gauge the intensity of your physical activity using perceived rate of exertion like that of the "Talk Test" or "Borg Scale". Keep in mind that every pregnant woman will have her own level of perceived exertion.  Exercising with a friend is a good way to monitor your intensity. The talk test is a simple and reliable gauge that will help to ensure that you meet your cardiovascular and metabolic demands during exercise when pregnant. I find the talk test easier and more practical for pregnant ladies to use. If you are able to maintain a conversation while exercising without feeling out of breath or uncomfortable, then you know you are working at the right level. The Borg Scale is a little tricky to remember each level of intensity if you haven’t used it before and some women have reported that it is also not as easy as the talk test to use on a whim. In pregnant elite sportswomen there may be a limit to how intensely they should exercise. There is evidence that exercising at intensities above 90% of your maximum heart rate may compromise foetal wellbeing. It is advised that elite athletes, trying to keep within ‘safe’ ranges of exercise intensity, should measure heart rate directly. 5. Temperature Regulation: Maternal temperatures above 39 degrees Celsius may harm your baby. Make sure that you do not overheat by choosing cooler times of the day to exercise in, staying well hydrated and wearing loose, breathable clothing. If you exercise in a pool make sure that the temperature of the water is less than 33 degrees Celsius. 6. Risk of falls: You are more susceptible to injury when you are pregnant so you may need to alter your routine if you usually participate in sports or activities that might pose a risk of injury. During pregnancy you will experience temporary balance impairments and you should avoid anything that puts you at risk for abdominal and joint injury due to falls. This includes most contact sports, vigorous racquet sports, and exercise involving balance. 7. Progressing exercise: If you are pregnant with no complications and are new to exercise, start slowly and as low impact as possible and then build it up as you are able. Start with 15 minutes, 3-4 times a week and slowly increase it to 30 minutes every day. If you are already recreationally active and have no pregnancy complications then you can continue to do what your body is used to. Adjust things as your talk test allows. If you are healthy and have no pregnancy complications, adding brief higher intensity intervals to your workout will help you burn more energy and enhance your enjoyment of exercise in late pregnancy. Just remember to keep the intensity below 90% of maximum heart rate. 8. Good to know: Avoid lying on your back for prolonged periods of time during exercise (especially after 16 weeks) if you have symptoms such as faintness or light-headedness. Yoga has been shown to be safe and more effective than walking or general antenatal exercises. Remember that some exercise is better than no exercise so find an exercise you enjoy and stick with it. Exercises that are encouraged or should be avoided during pregnancy Many women often ask me for a list of specific exercises that they should be doing or that they should avoid. In the table below I have listed specific exercises that are encouraged during pregnancy and some of those that are best to be avoided during pregnancy. *Please note:  Exercises should only be done if they are within your capabilities and according to your talk test.  Do not start new high impact or higher intensity activities if you are not accustomed to them. Every day during pregnancy your body is dealing with different changes, so from a fitness and energy perspective your abilities and performance may also change from day to day.  Take exercise one day at a time and always listen to your body. Only do what your body can manage for that day. When is exercise not safe in pregnancy? Exercise is not safe if you have: Vaginal bleeding Reduced foetal movement Serious heart, lung, kidney or thyroid disease Poorly controlled Type1 diabetes History of miscarriage, premature labour or "small for dates" babies in this or previous pregnancies High or low blood pressure (discuss with your doctor) Placenta praevia after 26 weeks (discuss with your doctor) Acute infectious disease Seek medical advice before commencing exercise in pregnancy if you have (or are): Asthma Controlled Type 1 Diabetes (discuss with your doctor) History of miscarriage High blood pressure Early placenta praevia Anaemia Extremely overweight or underweight Heavy smoker Pelvic or low back pain Stop exercising immediately and call your doctor/ midwife as soon as possible if you experience the following: vaginal bleeding and/or fluid leaking from your vagina uterine contractions dizziness chest pain or uneven heartbeat headache severe and abnormal abdominal, calf, back or pelvic joint pain difficulty in walking What if I can’t exercise because of other issues? Pregnancy complications If you have any pregnancy complications you may be limited in what you are able to do, but there may also be certain types of exercises which are still suitable for you. Discuss this with your obstetrician and get clarity about what you may and may not do.  Once you have this information your physiotherapist can help determine if there is an exercise that is appropriate for you. Common complaints During pregnancy there are common physical complaints that you may experience.  These can cause barriers to starting exercise or continuing with an existing exercise routine. Low back and pelvic girdle pain (PGP, SPD etc.) is estimated to affect about 50% of women during pregnancy. This condition can be debilitating, but it does not have to be that way for you. There is specific advice for you and a few simple exercises that you can do to help yourself become pain free and stay that way. Pelvic floor dysfunction and urinary incontinence result in many pregnant women avoiding physical activity during pregnancy (and after).  If you learn how to correctly activate and strengthen your pelvic floor muscles, you can help prevent these issues or cure them. Having a healthy and responsive pelvic floor can help make labour easier for you too! When and where to get help If you have any physical problems during pregnancy the secret is to get help early. The sooner you are diagnosed the easier it will be to manage and the quicker you can get back to enjoying your pregnancy. If you are ever unsure of anything and would like to have information about antenatal, postnatal and women’s health and fitness issues then POGP is a great resource. Physiotherapists, especially those who are specialised in antenatal and postnatal rehabilitation, are able to provide you with the information and guidance that can get you (and keep you) safely exercising and help you manage any of your physical complaints during pregnancy. In the meantime Educate yourself, be kind to your body, appreciate it for what it is accomplishing and learn to really listen and respond appropriately. About the Author Kim Van Deventer is a freelance healthcare writer and digital content strategist for healthcare businesses and medical content agencies. She worked as a physiotherapist for more than 14 years, specialising in sports injury rehabilitation, chronic pain management, and women's health. Kim combines her clinical experience and digital marketing skills to create relevant and helpful content that improves patients' lives. 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I am often asked what the best strength training exercises are for runners. My answer is: ones that you’re actually going to do! Keep them simple and don’t make the list too long – otherwise the thought of having to do it can overwhelm an already busy mind. I suggest that you choose exercises that can be done anywhere (no excuse if you cannot get to the gym) and target more than one muscle group (this reduces the number of exercises you need). The strength exercises below are aimed at runners who do not have a lot of experience with strength training. I have chosen them because they are safe and not very complex. These exercises will give you a good base level of strength, which will allow you to add more complex and heavy exercises in a few months. In this article: How to get the most out of your strength training Strength training programme for beginner runners Hamstring Bridge exercise for beginner runners Squat exercise for beginner runners Core exercise for beginner runners Push-Ups for beginner runners Calf strengthening exercise for beginner runners How to get the most out of your strength training You should continually progress the intensity of your training by either increasing the sets of exercises, the number of repetitions or the weight that you are using. You will not progress if you just do the same thing week in and week out. What I mean by: Reps (repetitions): That is how many times you perform the movement before you rest. Sets: If I ask you to perform 3 sets of 10 reps of an exercise it means that you have to do 10 repetitions, then rest, then another 10 repetitions, rest and then another 10 repetitions – it means doing the required number of reps 3 times, but with rest periods in between. Rest: Your muscles use the rest periods between sets of exercise to recharge its energy stores. Rest periods for beginners should last between 1 and 2 minutes. Download programme as PDF Strength training programme for beginner runners Please note: The exercises below should be OK for most healthy people. You should not feel any pain during or after doing the exercises. If you do experience any discomfort, please contact your healthcare provider. Hamstring Bridge exercises for beginner runners I prefer this version of the bridge exercise, since it targets the hamstring muscles a lot more than when your feet are on the floor. It’s a great all-in-one exercise that strengthens the hamstrings, glutes, back and core muscles. Start by doing the double leg exercise and then move on to the single leg one once you feel ready. START WITH: Double-Leg Hamstring Bridge Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair. Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis form a straight line. Squeeze your buttocks and stomach muscles and hold the position. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp – shift your bottom closer to your feet. Dosage: Hold the position for 20seconds, Rest for 20 seconds, Repeat 6 times PROGRESS TO: Single-Leg Hamstring Bridge Starting position: Lie on your back and place one heel on the top of a chair and keep the other foot in the air. Movement: With the knee resting on the chair slightly bent, lift your bottom off the floor until your body forms a straight line. Tighten up your stomach muscles and your glutes. Your pelvis must stay in a straight line. Do not allow the one side to drop to the floor. Then slowly lower yourself back down. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp – shift your bottom closer to your feet. Dosage: Do 3 sets of 10 slow reps with each leg. Rest 1 minute between sets. Squat exercises for beginner runners Start by doing the double-leg free squat, but move on to doing the single-leg one when ready. You should use this exercise to work on your running form as well as strength. Make sure that your knees move in a line with your second toes, but that they do not cross over the front of your feet. START WITH: Free Squat Starting position: Standing with feet pointing forwards and spaced hip distance apart. Movement: Squat down by pushing your bottom out to the back (pretend you want to sit on a chair) and bending your knees. Hold the position for 3 seconds and return to standing upright. Check that: Your feet stays in a good neutral position. Your knees should move in line with your second toe. Your bottom sticks far out to the back. Dosage: Start with whatever your knee allows you to do but you should aim to get up to 3 sets of 12 repetitions over time. Rest 2 minutes between the sets. Once you can easily achieve this progress by replacing it with the single-leg squat with wall support. PROGRESS TO: Single-Leg Squat With Wall Support Starting position: Stand hip distance away from a wall and balance on the outside leg. Bend the other knee up and press that knee and ankle against the wall (do not lean into the wall with your hip). Movement: Squat down by bending the supporting knee and stick your bottom out backwards. Hold the position for 10seconds before you stand up and rest. Check that: Your knee moves in line with your second toe, but that your knee also stays behind the toes. If your knee hurts, you are either going down too low or you are allowing your knee to drift over the toes which will put more pressure on it. You can fix this by sticking your bottom further out to the back. Dosage: Hold the position for 10 seconds, then repeat it with the other leg. Do 10 reps on each leg. Core exercises for beginner runners The aim of the first exercise is to teach you how to control your spine (keep it flat against the floor) while you move your legs. Only move on to the second exercise once you have mastered this. START WITH: Toe-Taps Level 1 Starting position: Lie on your back with your knees bent and your back flat into the floor. Movement: Engage your core by recruiting your pelvic floor and stomach muscles. Lift one leg up to 90 degrees at the hip, keeping the knee bent. Keep your back and pelvis completely still at all times. Then place the foot back on the floor and repeat with the other side Check that: Your pelvis and lower back do not lift off the floor as you lift and lower your foot down to the floor. Once you find this exercise easy, move on to the single-leg stretch exercise Dosage: Build up to doing 3 sets of 14 reps. Rest 1 minute between sets. PROGRESS TO: Single-Leg Stretch Starting position: Lie on your back with your knees bent and your lower back flat on the floor. Movement: Engage your core by recruiting your pelvic floor and stomach muscles. Slowly straighten one leg out while you make sure that YOUR BACK STAYS ABSOLUTELY FLAT ON THE FLOOR. Slowly alternate legs. Check that: Your back stays absolutely flat on the floor throughout the exercise. Do not rush this exercise – it is more difficult to do it slowly. Dosage: Build up to doing 3 sets of 20 reps. Rest 1 minute between sets. Push-Ups for beginner runners Even though you may think that this exercise is all about arm strength, it's actually not. When done correctly, the push-up strengthens your core muscles as well as your arms. You have to make sure that your back does not sag down towards the floor during the exercise. START WITH: Knee Push-Ups Starting position: Lie on your stomach with your hands on the floor beside your shoulders. Tighten your stomach muscles and keep them braced throughout the whole exercise. Movement: Raise your body off the floor by pushing up and extending your elbows while keeping your knees on the floor, your chin tucked in and your body straight like a plank. Lower yourself back down, nearly touching the floor and repeat. Check that: If your back hurts during this exercise, it may be a sign that you need to tighten your stomach muscles - your back should be flat throughout the movement. Dosage: Build up to doing 3 sets of 15 reps. Rest 1 minute between sets. PROGRESS TO: Full Push-Ups Starting position: Lie on your stomach with your hands beside your shoulders. Movement: Tighten up your stomach muscles. Raise your body off the floor by straightening your elbows, keeping your chin tucked in and your body straight as a plank. Bend your elbows and lower yourself back down - stop just short of the floor. Repeat. Check that: If your back hurts during this exercise, it may be a sign that you need to tighten your stomach muscles - your back should remain flat throughout the exercise. Dosage: Build up to doing 3 sets of 15 reps. Rest 1 minute between sets. Calf strengthening exercises for beginner runners I suggest that you do 2 variations of heel raises over a step to strengthen your calves and Achilles tendons. You target different muscles in the calf by doing this exercise with your knee bent vs. the knee straight. START WITH: Bodyweight Heel Raises (some with knee bent and some with knee straight) Starting position: Stand on one leg on a step. Hold on to something for stability, as this is not a balance exercise. Movement: Keeping your knee STRAIGHT (A) slowly lift up and down on one leg for the required repetitions. Repeat this with the other leg. Rest for 1 minute and do one more set with your knee straight. Then repeat the exercise, but this time keep your knee BENT (B) throughout the movement. Dosage: Build up to doing 2 sets of 15 reps with the knee straight AND 2 sets of 15 reps with the knee bent with each leg. Rest 1 minute between sets. PROGRESS TO: Weighted Heel Raises Once you can easily do 2 sets of 15 reps of the above exercise increase the difficulty by doing it with some extra weight. Either hold a dumbbell in your hand or place some weight in a backpack on your back. Reduce the repetitions and slowly build up to 2 sets of 15 reps of each exercise. Repeat this cycle. Every time that you can execute the required repetitions with ease, add some more weight and slowly build the reps up again. 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.

‘‘More marathons are won or lost in the porta-toilets than at the dinner table.’’ This quote from Bill Rodgers, a marathon legend from the 1970’s, sums up the plight of many a distance runner. Depending on the event and conditions, studies have found that between 30% and 90% of endurance athletes experience intestinal problems while competing. Symptoms vary in intensity and can include nausea, vomiting, stomach cramps, diarrhoea and even bloody stools. The research seems to suggest that some people may have a genetic predisposition to developing these problems, but that does not mean that you can't improve your situation. In this article: How exercise can cause an upset stomach Mechanical causes Nutritional causes of stomach problems during exercise Medication can aggravate your gut 10 steps to fewer stomach problems while running How exercise can cause an upset stomach One of the main causes for stomach problems during exercise is a decrease in blood supply to the gastrointestinal system. During high intensity exercise, up to 80% of the gut’s blood supply is shunted away from it to the exercising muscles and organs (e.g. the lungs). This leads to a lack of oxygen and damages the cells that line the gut wall causing nausea, vomiting, abdominal pain and/or diarrhoea. You may feel that there’s not much that can be done about this, but research suggests that the reduction in the intestinal blood flow is less severe in athletes who train regularly. Low intensity exercise does also not seem to affect the gut as much as high intensity exercise. You may thus improve your symptoms by training regularly and by decreasing the intensity to a level where you do not experience symptoms. There are also some nutritional strategies that you can follow. For instance, ingesting nitrate (found in beetroot and green leafy veg) during exercise has been found to increase the gut’s blood flow and improve performance. I’ll explain this in more detail in the advice section below. High intensity exercise can also contribute to reflux and nausea by decreasing the contractions of the oesophagus, making its valve less effective and causing food to remain longer in the stomach. You can read more about how to manage acid reflux during running here. Mechanical causes These are either related to impact or posture. Symptoms of the lower intestines are for instance more prevalent in runners than in cyclists. The repetitive high impact jostling of running is thought to damage the intestinal lining which contributes to symptoms such as diarrhoea. Cyclist, on the other hand, complain more of symptoms like reflux which may be exacerbated by the position that they are in on the bike. The good news is that these mechanical causes can be relieved by training! Researchers have found that regular training makes people’s guts less susceptible to mechanical strain. Nutritional causes of stomach problems during exercise It has been well documented that what we eat or drink during exercise can have a strong influence on gastrointestinal complaints. Studies done on Ironman athletes have found that ingestion of fibre, fat, protein and concentrated carbohydrate solutions all made it more likely for athletes to develop symptoms. All of these foods delay gastric emptying (stay for longer in the stomach) or causes more fluid to move from the body into the gut which can lead to nausea and diarrhoea. The problem is that we need carbohydrates during exercise and high concentrations of carbohydrates have been linked to better performance. Luckily researchers have found that endurance athletes seem to tolerate concentrated carbohydrates much better if they are made up of different types, such as glucose and fructose, rather than just glucose. This is because glucose and fructose are absorbed through different pathways and the processes can run in parallel, thus allowing the carbs to be absorbed more quickly. Dehydration has also been found to contribute to symptoms. The reason for this is most likely because it causes an even bigger decrease in blood flow to the digestive system. Medication can aggravate your digestive system I am often asked by people if it would help if they take pain tablets before sport. My answer is always NO! Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), of which the most well-known example must be ibuprofen, have been shown to lead to a five-fold increased risk of gastrointestinal complications in athletes. These can range from nausea to intestinal bleeds. You also risk kidney failure if you use them in a dehydrated state. 10 Steps to combat stomach problems while running Do not use aspirin or NSAIDs (especially ibuprofen) before/during training or racing. While a high fibre diet is needed to keep your bowel regular, stay away from high fibre foods the night before or on the day of competition. The same goes for spicy or fatty foods. Avoid high fructose food and drinks. Rather use drinks that contain a combination of fructose and other carbohydrates. Ingest carbohydrates with plenty of water or use drinks with lower concentrations of carbohydrates so that it can be absorbed quickly. When using a single carb solution (e.g. glucose only) it is recommended that you ingest 30–60 g/h (6% concentration) to avoid discomfort. For a combined fructose-glucose or fructose–maltodextrin solution, studies have found that athletes could tolerate 90-105g/h (8-10% concentration). Avoid solid forms of carbohydrates as this will be harder to digest and absorb. Carbohydrates enhances performance, but there is evidence that it is not necessary to ingest large amounts during exercise that lasts less than 60 minutes. In this case, rinsing your mouth with a carbohydrate solution is enough to enhance performance. The carbohydrates stimulate receptors in your mouth that activate the reward system in the brain and helps you to perform better. You must, however, make sure that you start your exercise fully carbo-loaded. Avoid dehydration by starting the race well hydrated and drinking according to thirst. You can learn more about how to tell if you are dehydrated here. Practice your nutritional strategies during training. This will “train” your gut to absorb nutrients better as well as tolerate the mechanical strain of food and drink during exercise. It may further highlight food that should be avoided. There is also research emerging that suggests that you can train your body to rely more on fat during endurance events which will decrease your need for carbohydrates, but more research is needed before one can make specific recommendations for this. Taking in nitrate during exercise can decrease the damage in the gastrointestinal system since it helps to increase the blood supply to the gut. Researchers suggest that you use a natural source e.g. beetroot juice, since it also contains vitamin C which is needed in order for the nitrate to work its magic. The only downside is that the natural food sources can also cause stomach discomfort of their own. Lastly, reduce your training intensity to a level that does not cause you stomach trouble while you test out different strategies. Keep it at this level for long enough to allow your digestive system to adapt. It is thought that regular training at a comfortable level increases the digestive system’s ability to cope with the strains caused by exercise. Once your stomach has settled, slowly increase the intensity. 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: de Oliveira EP, Burini RC. Carbohydrate-Dependent, Exercise-Induced Gastrointestinal Distress. Nutrients 2014;6(10):4191-99. doi: 10.3390/nu6104191 de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal Complaints During Exercise: Prevalence, Etiology, and Nutritional Recommendations. Sports Med 2014;44(1):79-85. doi: 10.1007/s40279-014-0153-2 Rowlands DS, Swift M, Ros M, et al. Composite versus single transportable carbohydrate solution enhances race and laboratory cycling performance. Applied Physiology, Nutrition, and Metabolism 2012;37(3):425-36. van Wijck K, Lenaerts K, Grootjans J, et al. Physiology and pathophysiology of splanchnic hypoperfusion and intestinal injury during exercise: strategies for evaluation and prevention. American Journal of Physiology-Gastrointestinal and Liver Physiology 2012;303(2):G155-G68.

A few months ago my training was nearly derailed by a period of severe acid reflux. It took me a while to figure out what it was, since the main symptom was chest pain during my runs. Of course I first became totally paranoid and took myself off to the GP to have my heart checked out. An ECG and several blood tests later it was confirmed that my ticker was strong and healthy, but I still did not have any answers for the pain that was steadily growing stronger during my runs – especially my hard running sessions. It was only after a weekend of red wine and fatty foods, when the more classic symptoms of heartburn and trouble sleeping in any position other than on my left side joined in, that the penny dropped. Since then, I have done lots of research and experimenting and have finally found a recipe for treating acid reflux that works for me. In this article: What is acid reflux? Symptoms associated with reflux What causes acid reflux during running? Dietary factors that can cause reflux Other factors contributing to reflux Treatment for acid reflux in runners What is acid reflux? Acid reflux is when the contents of the stomach (acid + food etc.) moves up from the stomach into the oesophagus. This happens in all healthy people. It is only considered as a disease or problem when exposure of the oesophagus to gastric acids exceeds normal limits, occurs at night and is not related to meals. Symptoms associated with reflux I always thought that reflux had to be associated with heartburn (and old men!), but that’s not the case for everyone and certainly wasn’t for me. Some of the symptoms include: A burning sensation radiating up from the sternum, commonly referred to as heartburn. Regurgitation Laryngitis A dry cough (I’ve had this for a couple of years now and hadn’t realised what it was.) Erosion of your teeth Irritation of the oesophagus, causing it to spasm (which may explain the chest pain that I’d experienced while running) Irregular heartbeat during sport - this is likely due to irritation of a nerve that runs very close to the oesophagus.(8) Increased asthma symptoms, due to the acid irritating the upper airways. What causes acid reflux during running? Most reflux symptoms during exercise occur during hard or very long sessions. The research suggests that you are a lot less likely to suffer reflux during mild or moderate exercise. Decreased blood flow to the gut and stomach: Exercise can cause up to an 80% decrease in blood flow to your digestive system. This is mostly due to the brain shunting the blood to the exercising muscles, but may also be worsened by dehydration. This means that digestion will slow down dramatically and food will linger for longer in the stomach. Intra-abdominal pressure: The lower oesophageal sphincter works as a valve between the oesophagus and the stomach. It lies at the level of the diaphragm. While the pressure in your chest cavity is higher than the pressure in your abdominal cavity, it stops food from coming back up into the oesophagus. Exercise can increase your intra-abdominal pressure which can lead to the valve failing and reflux to occur. Research has also shown that the oesophagus’ contractions becomes weaker and thus less effective in moving food down towards the stomach during exercise. The valve between the oesophagus and the stomach also tends to relax more often and for longer periods during exercise. Dietary factors that can cause reflux Some of the foods or eating habits that may contribute to increased acid reflux include: Eating within 60 minutes before exercise. Eating large meals in general or eating late at night. Eating solid food, protein or fat before exercise. Fatty foods in general: Some studies have indicated high fat foods to cause reflux symptoms while others have found it to have no effect. I find that it only affects me if I eat very fatty food at night (like lamb chops). I seem to be OK if I have it during the day. Eating spicy foods, chocolate, mint or tomatoes. Drinking orange juice, coffee and carbohydrate/sugary drinks. All types of alcohol has been found to increase reflux symptoms, but white wine is apparently worse than red wine or beer.(6) Eating fibre-rich food during physical activity can increase reflux (stomach takes longer to empty) while having a diet generally high in fibre may decrease the symptoms. Exercising after a carbohydrate drink makes reflux episodes last longer than after water ingestion. Dehydration also increases reflux, so make sure that you are well hydrated before you start training. Other factors contributing to reflux Using NSAIDS or anti-inflammatory drugs has been associated with a threefold increase in upper gastro-intestinal complaints in athletes. Being overweight or obese Smoking Sleeping on your right side. Treatment for acid reflux in runners There are three steps that I would suggest you follow to treat your reflux. Step 1: Confirm your diagnosis Make sure it truly is reflux and nothing more serious. Book an appointment with your GP and make a detailed list of all your symptoms before you see them. This will also give you the opportunity to discuss what medications you can take for the condition as you will likely have to use something during the acute stages. Step 2: Acute management If, like me, you took a while to figure out what was going on, you’ll likely have a very sensitive and irritated digestive system by the time you start treatment. The biggest mistake that I made at the beginning was to not stick to a strict diet for a long enough period. I would take some medication for about 3 days while eating and drinking all the right things, feel better, revert back to bad eating habits and then everything would flare up again despite using the medication. After this happened for the third time, I finally realised that I was being stupid. What I was doing was the equivalent of trying to run on an injured leg after just giving it a few days of rest. Most sports injuries takes about 6 weeks before you can get back to your pre-injury training and I decided to apply this method to treat my reflux. I had to give the cells in my oesophagus enough time to heal before I reintroduced potentially aggravating foods. Please check with your GP before you use any medication. So for 6 weeks I committed to a strict regime: I used PPI (proton pump inhibitor) medication for roughly 10 days while restricting my diet to low fat, bland foods. I stayed away from any refined carbs and sugar as well as coffee (this was difficult) and alcohol. Fruit used to be my snack of choice, but I’ve realised that I can only have it if I combine it with other food. It really plays havoc if I have it on an empty stomach. I had a habit of chewing gum during the day. I’m not sure why, but this is something that I still find can flare up my symptoms especially if I do it on an empty stomach. A big swig of Gaviscon about 15 minutes before a run kept symptoms at bay. I did not find the Gaviscon tablets as effective as the fluid. I would have a very small bowl of porridge about 1 hour before a run, as running on an empty stomach seemed to aggravate my reflux as much as running on a full one. One of my main problems was that, because I sometimes work until late at night, I would have a big meal around 22:00. I made a point of taking enough food to work with me so that I could have several small meals throughout the day and restricted the size of my late meal. I had to either sleep on my left side or elevated on a few pillows. The GP gave me a strange look when I said this to him, but I’ve recently found a research paper that actually shows I’m not crazy! The researchers found that the valve between the oesophagus and stomach relaxes for longer if you lie on your right side and thus increases reflux.(6) Research suggest that you should lift the head of the bed between 6 and 8 inches, but I was too lazy to do this and instead opted to live with a stiff neck for 6 weeks from being propped up on pillows. Gaviscon before bedtime also worked well for me. Step 3: Switch to a long term management strategy After 6 weeks of following the regime above, I found that I could introduce a relatively normal diet again. It’s amazing how quickly I now notice what foods or habits are contributing to my reflux. I no longer need any medication unless I overdo things. I intermittently use Gaviscon before a run or sleeping, but stay away from PPI’s as these have been found to cause bone loss if you use them for a long period. The most important factor for me seems to be what I eat or drink at night. As long as I keep my evening meals small and stay away from wine, I have very few problems. I still suffer if I have spicy meals and wine is pretty much out of the question. Full fat dairy and meat isn’t a problem, except for lamb. I can eat chocolate (massive smile) in moderation. Refined carbs like bread and pasta affect me badly, but rice appears to be OK. I found that my stomach is happy with milky coffee, especially if I combine it with a meal. Fruit has to be very ripe and preferably combined with yogurt. My main concern now is that I am due to start marathon training in January, which means that I will have to eat or drink some form of carbohydrates during exercise. Research has, however, found that you can “train” your digestive system to tolerate food and drink during exercise so I’ll make sure to experiment from the start. 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: De Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal Complaints During Exercise: Prevalence, Etiology, and Nutritional Recommendations. Sports Med 2014;44(1):79-85. doi: 10.1007/s40279-014-0153-2 Djärv T, Wikman A, Nordenstedt H, et al. Physical activity, obesity and gastroesophageal reflux disease in the general population. World Journal of Gastroenterology : WJG 2012;18(28):3710-14. doi: 10.3748/wjg.v18.i28.3710 Festi D, Scaioli E, Baldi F, et al. Body weight, lifestyle, dietary habits and gastroesophageal reflux disease. World Journal of Gastroenterology : WJG 2009;15(14):1690-701. doi: 10.3748/wjg.15.1690 Herregods TVK, van Hoeij FB, Oors JM, et al. Effect of Running on Gastroesophageal Reflux and Reflux Mechanisms. Am J Gastroenterol 2016;111(7):940-46. doi: 10.1038/ajg.2016.122 Jozkow P, Wasko-Czopnik D, Medras M, et al. Gastroesophageal Reflux Disease and Physical Activity. Sports Med 2006;36(5):385-91. doi: 10.2165/00007256-200636050-00002 Martinucci I, de Bortoli N, Savarino E, et al. Optimal treatment of laryngopharyngeal reflux disease. Therapeutic Advances in Chronic Disease 2013 doi: 10.1177/2040622313503485 Ozdil K, Kahraman R, Sahin A, et al. Bone density in proton pump inhibitors users: a prospective study. Rheumatology International 2013;33(9):2255-60. doi: 10.1007/s00296-013-2709-0 Swanson DR. Running, esophageal acid reflux, and atrial fibrillation: a chain of events linked by evidence from separate medical literatures. Medical hypotheses 2008;71(2):178-85. doi: 10.1016/j.mehy.2008.02.017

A group of researchers from Sweden has developed a mobile app (Tät) that has been proven to effectively help people who suffer from stress urinary incontinence. They ran a randomised controlled trial with 123 women and the results were impressive. The group of women who used the app had a significant reduction in symptoms and an increase in quality of life after 3 months. They were also able to reduce the number of incontinence aids that they had to use per week. With regards to patient satisfaction, 96.7% of the women experienced the application as “good” or “very good”, and 100% would recommend the treatment programme to a friend. So what does this magical app do? It guides you through an exercise programme. Most cases of stress urinary incontinence in women can be improved if you can strengthen the muscles of the pelvic floor. Don't be put off by the word "exercise". You have to understand, that while we use the word “exercise” to describe these manoeuvres, you’re very unlikely to break into a sweat when doing them. In fact, you can be doing them in the middle of a room full of people and no one will know it! The video below must be the funniest but also most informative explanation of how the pelvic floor works that I have ever come across. It is well worth a watch! The app provides you with detailed descriptions, including pictures, of the exercises you should do and also how you should progress them. Actually, it is just one exercise, but they progress it by making you do it at a different speed and strength. For the first 3 month period, you have to do the pelvic floor exercises 3 times a day. Once you have reached a satisfactory result, you can then reduce your practice time to a maintenance dose of 3 times a week. If you suffer from urinary incontinence this app is a no brainer You can download the Tät app for free from the Play Store. What I like about the app: It allows you to set reminders on your phone to vibrate when it is time for your pelvic floor exercises. It pauses the exercise if someone phones while you are busy with them. It has a very clear explanation of how the pelvic floor functions and how to do the exercise. It has an “intensity” bar that guides you to do the exercise at the correct strength and speed and for the correct number of seconds. It also counts down the rest period between exercises. 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.

I would like to share this guest blog with you today from someone who has had to learn to accept chronic pain as part of his life, but is no longer ruled by it.  He's gone the full cycle, from being a very active person, to not being able to do much at all, to actually being able to do some jogging again and has agreed to share some of the lessons he's learned with us. This year, it’s 25 years since the first of my four lower-back surgeries, a laminectomy (L4/5) in 1991 – then still in my early 20s – followed by fusions in the late 90s (L4/5, failed), early 2000s (L4/5) and in 2010 (L3-5). Due to damage to my spinal cord (causing chronic pins and needles) and arthritis of the face joints (think creaking joints, almost like the hinges of a dilapidated door!), I will never again be totally pain-free. Add to that muscles in the lower back and up into the shoulder blades that easily become agitated (everyday stiffness to severe spasm), and, let’s just say, it’s a bit of a toxic mix… I cannot remember what it feels like to be pain-free anymore. At the worst of times pain fully governed my life, at the best of times it dictated how I planned out my days (sorry mate, no beers tonight – that kind of thing). On the plus side, living with acute, chronic pain for years and years means it is my new normal. You have to accept it, and then move on. The question is … at what level do you want your “normal” to be? Lessons learnt Over the years, I have learnt a few lessons. I want to focus on four: 1. Inactivity is pain’s bedfellow When in pain, the inclination is to rather not exercise. Big mistake. For it becomes a spiral from where it gets harder and harder to escape. 2. When you exercise, know your limits I was a sports nut, which means I’m “pre-programmed” to want to push my body to see what it can achieve. No pain no gain? I’ll start some form of training, get into it, push myself … and inevitably break down in a big way, taking weeks – in some cases months – just to get back to square one. Out of the above, #2 was harder for me to achieve than #1, for I have always been fairly active in one way or another. But even so, I have to work at both. If you suffer from a situation similar to mine, you will understand when I say that over the years I have seen and worked with several professionals to deal with my pain – in three different markets around the world. Which brings me to lesson #3 (it seems obvious, but it took me years to get right): 3. Find someone who fully understands your problem, and work with them. A big problem I found was working with people who – as this is the “accepted” trajectory for “improving” the body – pushed me to do more, do move A, B or Z or whatever. Inevitably my body broke down, which as I said above meant it all counted for none. No two people are the same; you need your programme customised. It’s therefore vital you find the right person to work with. I have. And am happy to say this August, for the first time in 25 years, I’ve been working out for a full 12 months without serious injury. It feels amazing, for example, to be able to go for a short run now and again (don’t want to pound the back too much!). Even as recently as 15 months ago I would never have thought… Of course, I am not pain free. Heck, sometimes I still have a day or three of sheer agony. The damage to my spinal cord is permanent, the instruments (L3-5) in my back are permanent, the limitations it brings a fact of life. 4. Accept and understand you’ll have good days and bad days. It’s always a cycle. Once you accept that, the bad days become more bearable and the good days more enjoyable. Keep that in mind, and do the right things when you are in a “down cycle” to break through as quickly as you can again. All said and done, after 12 months of being able to exercise without major interruption, I feel fitter, stronger and happier (do you remember how grrreat endorphins make you feel?!) than I have been for a long, long time. Three things I focus on: Here are the three top things I focused (focus) on: 1. Flexibility and mobility Combined, I do at least a couple of hours a week focused on improving my mobility, flexibility and posture. Be warned, however, it’s a process and the going can be slow. But if anything, this is the one area not to skimp on. It makes the world of difference and builds the foundation for doing more. 2. Build strength Linked to the above, I work very hard at strengthening my core, and after that I have a bit of “fun” doing other strengthening exercises too. The core is especially important as in my case it helps stabilise the back and, in combination with #1, improves posture, taking some of the strain off the spine. 3. Diet and fitness When you feel healthier and fitter, you’re generally speaking in a much healthier state of mind. Feeling down in the dumps – brought on so easily by pain and its impact on your life – is the enemy of getting better and coping with the down cycles when they inevitably come. Besides, it has obvious physical benefits too. For example, you know the term “fighting weight” for athletes, right? When you suffer from acute, chronic pain you also want to reach your ultimate “fighting weight” to take off the strain and fend off the pain. Work with someone that understands your pain, find out what works for your body and go for it. Remember, some of us cannot beat pain into submission, but I believe, for as long as you can, there are things you can do not to fall slave to your pain. Life’s much happier that way. Good luck! ______________________________ Many thanks to my guest blogger for sharing his tips. 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.

You’ll be surprised at how many people suffer from stiff or painful necks during or after running. But how can this be, I hear you say. I run with my legs, not my neck! There are broadly 3 main reasons why you can get neck pain while running: Poor posture Poor technique or habits while running An injury that you sustained away from running Poor posture and neck pain while running Research has shown that poor posture of the neck, shoulders and upper back can all contribute to people developing pain in their necks. If you are suffering with neck pain during or after running this should be the first thing to check. The most common postural problems identified are forward rounded shoulders, an increased curve of the upper back and a "collapsed" neck that all contribute to a forward head posture. Your head weighs about 5kg and the strain that it puts on your neck muscles and joints increases if it is held off centre. Do it yourself: Ask a friend to take a picture of you from the back as well as from the side, while you stand as you normally do. Try and avoid the impulse to straighten up because you know you are being watched – you need an idea of what is "normal" for you. Good posture in standing, when looking from the side, is defined as when a vertical line can be drawn to run through your ear lobe, roughly the middle of your neck and the middle of your shoulder joint. From the back you want your head to be in the middle, not tilted to one side and your shoulders nearly level (it is normal to have one shoulder a bit higher or lower than the other). How to fix it: You can find some handy neck and posture exercises in this link but also here, that will help improve and prevent poor posture. You should lengthen your neck when standing and not allow it to slump like in the first picture. Neck pain due to poor running technique or habits Habits or technique that can cause neck pain during running are closely related to posture. Check that you are not pulling your shoulders up or letting your neck hang to one side when you get tired. I have a tendency to squash the left side of my neck when I get tired and I can immediately decrease any discomfort by bringing my neck back to the middle. Do it yourself: Ask your helpful friend again to take a picture/video from the side and back, but this time while you are running on a treadmill. If you want to be really thorough, you can get them to do it at the end of a training session to see if your running posture changes with fatigue. While running, you don’t expect a person’s ear to be exactly above their shoulder, because they should ideally be leaning forward to put their centre of gravity slightly in front of them. What you don’t want to see is a collapsed neck with the chin poking out to the front, the head tilting to one side, the shoulders being pulled up or the head turned down to the floor. How to fix it: A technique that I find useful is to think about lengthening your spine as if a balloon is attached to the back of your head and pulling you up. This does not mean that you should now be running as upright as a lamppost! You should continue to lean while lengthening your spine or not collapsing/slumping your neck. You should lengthen your neck while running, but continue to lean forward. An injury that you sustained away from running Another common cause for neck pain while running is when you have actually injured your neck while doing something else. This can be a sudden injury e.g. by lifting something heavy or repetitive strain while working in poor posture in front of the computer. You will normally also have neck pain with other activities than running if this is the case. You can try and see if maintaining a good posture while running helps to alleviate the symptoms, but you may have to refrain from running to give your neck a chance to heal first, depending on how bad it is. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate, Facebook, Twitter or Instagram. Reference: Griegel-Morris, P., Larson, K., Mueller-Klaus, K., & Oatis, C. A. (1992). Incidence of Common Postural Abnormalities in the Cervical, Shoulder, and Thoracic Regions and Their Association with Pain in Two Age Groups of Healthy Subjects. Physical Therapy, 72(6),