Search Results

Just admit it. As runners, we are forever looking for ways to make us go just that little bit faster. In my case this will easily be achieved if I can just drag my lazy body out into the cold on a few more days of the week. But what if you are already training at your max? How can you tweak your training to get more out of your body? One way may be by improving your running economy. Pellegrino et al. recently found that a 6 week plyometric training programme improved the running economy of a group of experienced runners. In this article: What is running economy? What are plyometric exercises? How do plyometric exercises improve your running economy? 6 Week plyometric training programme for runners What is running economy? Your running economy is calculated by looking at how much oxygen and energy you use when you run. Someone with a good running economy uses less oxygen and energy while running at a certain speed than the person next to them and this usually equates to a better performance/result. One would assume that you should be able to improve your running economy by simply improving your fitness, but research has actually shown that this is not always the case. Specific training regimes that have been shown to help are interval training, resistance training, altitude training and plyometrics. This said, if you are a novice runner, you are far more likely to improve your performance by just improving your fitness rather than trying to focus on running economy. What are plyometric exercises? Plyometric exercises are essentially jumping exercises – jumping over cones or lines or onto boxes etc. They are mainly used in sport to develop power (strong contractions that can be performed quickly) and their magic is due to the combination of quick stretch and contract cycles in the muscle. How do plyometric exercises improve your running economy? Plyometric exercises lead to specific changes within the muscles fibres which lead to an increase in stiffness in the muscles during exercise. Increased stiffness in the muscles and tendons means that you “lose” less energy or get a better return of energy while running and you therefore use less energy and oxygen to run. Plyometric exercises to improve your running - 6 Week programme Pellegrino and his colleagues used a 6 week programme to train their runners. They started slowly with 2 sessions of plyometric exercises per week for the first 3 weeks and then increased it to 3 sets. They allowed between 1.5 and 3 minutes of rest between sets. I include their training schedule and their explanation of how the exercises should be performed below. Please note that all the credit for the training programme and description of the exercises should go to Pellegrino and colleagues. I have selected a variety of videos from youtube to show examples of the exercises that they used. Some of the videos show very agile people performing the exercises while others include novices. You should always make sure that you do the exercises slowly with the proper technique and control before you try and do them at speed. Exercise roster (taken from Pellegrino's dissertation) Description of exercises Warmup consisted of jogging, leg swings, skipping, light bounding, bouncing and submaximal jumps as well as stretching for 20:00 each session. All jumps were encouraged to be as high and as fast as possible. Maximizing flight time while minimizing contact time. SQUAT JUMP:  2 legged maximal vertical jumps done in succession as quickly as possible. SPLIT SCISSOR JUMP:  2 legged staggered stance maximal vertical jumps done in succession, switching the forward and rearward foot with each jump. Done as quickly as possible. 2-LEGGED FORWARD JUMP FOR DISTANCE:  2-legged jumps in succession (like a frog hopping or a kangaroo) across the gymnasium. Done for maximal distance rapid-fire. ALTERNATE LEG BOUND:  Jumping for maximal distance from leg-to-leg as far and as fast as possible. Similar to running strides, only more explosive in nature. SINGLE LEG FORWARD HOP:  Performed with each leg: successive maximal jumps for distance on one leg. Emphasis again on rapid jumping with maximal force application. STEPPING-DROP JUMP:  Participants walked across a mat and stepped as if the mat continued. Upon "falling" off the end, they brought both feet underneath them and rebounded from contact with the floor into a maximal vertical jump (slight forward movement). LATERAL LINE JUMPS: Jumping from side to side over a line on the gymnasium floor. They were encouraged to jump as if over an object (which for safety was not actually there). 180 - TURN LINE JUMPS: As per Lateral line jumps except that a 180-degree turn was completed with each jump. The direction of the turn reversed with each single contact (forward/backward/forward...). SPLIT SCISSOR JUMP WITH STEP: This was done as per the Split scissor jump, only the forward foot was elevated -on a step (12-16" based on height and ability) during both the take off and the landing. Jumps were still completed in succession as quickly as possible, and were still done with maximal jump height. HIGH-BOX DOUBLE JUMP: Participants jumped onto a secure box and then immediately jumped again (maximally) slightly backwards and for height. A mat was placed on the floor to soften the final landing, as total jump height for the 2 jumps was as high as 60 -70 inches). They were instructed to jump onto the box landing with bent legs, and to attempt to complete the second jump as soon after landing as possible with a maximal effort. The boxes were of varying heights based on vertical jump ability... sufficient to encourage significant knee flexion upon landing. A few seconds in between each pair of jumps was permitted, but not required. Several of these jumps were designed intentionally to activate the quadriceps muscle and specifically the VL in order to maximize gains in that muscle. While this is not typical of plyometrics, it is a fair variation, and still includes the plantar flexion at the ankle that is associated with traditional plyometric training. Let me know if you have any questions. Need more help with an injury? You can consult me online using Skype video calls. Best wishes Maryke Sports Physiotherapist References Pellegrino, J., Ruby, B. C., & Dumke, C. L. (2016). Effect of Plyometrics on the Energy Cost of Running and MHC and Titin Isoforms. Med Sci Sports Exerc, 48(1), 49-56.

The dark cloud of the obesity crisis that currently hangs over our heads has meant that the focus has very much shifted to getting our children to be more active during school hours. This has also led to an increasing number of kids reporting injuries. In Denmark, 25% of all injuries in children and adolescents treated at hospitals each year are related to sport. In this article: What we know about knee injuries in children What the researchers did What type of knee injuries were the most common? Risk factors for traumatic knee injuries in children Risk factors for overuse knee injuries in children Surprises in the results What this means in practice What we know about knee injuries in children Most of the research in the past has focused on statistics from hospital settings. The problem with this is that the data only represents traumatic injuries that are bad enough for parents to take children to hospital and from working in school level sport in the UK, I can assure you that a parent will do nearly anything to avoid the busy A&E on a Saturday! A further issue is that these studies give no information about growth-related overuse injuries which have been shown to be a lot more prevalent than traumatic knee injuries in kids. (1) I also find this in our clinic with Osgood-Schlatter’s being a very common diagnosis in growing children. This has led a group of Norwegian researchers to conduct a study to find out what the true incidence of knee injuries was for kids between the ages of 8 and 15 years and also if they could identify any risk factors that may predispose a child to a knee injury. What the researchers did They enrolled 1326 children between the ages of 8 and 15 in the study and monitored them weekly, from 2011 until 2014, for musculoskeletal pain, sports participation and sports type. They also specifically looked if any of the following factors increased the children’s’ risk of sustaining knee injuries: Gender Age Height Body mass index General joint hypermobility Having had a previous knee injury Amount of organised sports participation They monitored these factors repeatedly over time to ensure that they picked up any changes that may have occurred over the 3 years. What type of knee injuries were the most common? A total of 952 knee injuries was reported during this period. Of this, 15% was traumatic knee injuries and 85% was overuse knee injuries. The traumatic knee injuries consisted mainly of sprains and contusions (bruising), while traction apophysitis, e.g. Osgood-Schlatter’s and Sinding-Larsen-Johansson’s, made up most of the overuse knee injuries. The researchers observed a peak in overuse knee injuries in the children between 11 and 12 years of age. This makes sense since children often experience growth spurts during these ages which predisposes them to traction apophysitis due to increased tension in the soft tissue. Simply put, their bones grow quickly and their muscles and tendons lag behind. In practice this means that they become a lot less flexible and their ability to coordinate/control their movements decreases for a short period until the brain can figure out how to ‘drive’ this new body. This may put extra strain on the bit of cartilage that connects their tendon to the bone resulting in inflammation, pain and swelling in the area. Risk factors for traumatic knee injuries in children The only risk factor identified for sustaining a traumatic knee injury was taking part in tumbling gymnastics. None of the other factors appeared to increase the children’s risk of sustaining a traumatic knee injury. When they looked at specific risk factors per sports type and sports participation they identified that the following increased a child’s risk of a traumatic knee injury: Participating in soccer and handball four times per week Participating in tumbling gymnastics twice a week Participating in handball only once a week (This seems counterintuitive but it may likely be that these kids lacked the necessary skills to safely play the sport due to a lack of training, which then predisposed them to injury.) Risk factors for overuse knee injuries in children Girls appeared to be at greater risk of developing overuse knee injuries than boys. Having had a previous knee injury also put a child at a greater risk of developing an overuse injury. The researchers also found that children participating in specific sports, e.g. soccer, handball, basket, rhythmic and tumbling gymnastics, more than twice a week had significantly higher odds of sustaining an overuse knee injury compared to children not participating in sports. Participating in handball and soccer also increased a child’s odds compared to other sports. Sports participation above two times per week in specific sports such as soccer, handball, dance, rhythmic and tumbling gymnastics increased the odds for both types of knee injury. Surprises in the results It surprised the researchers that having generally hypermobile joints did not predispose the children to knee injuries in this study, since a previous meta-analysis had found it to be a significant risk factor in other populations. They concluded that this finding may be due to the specific population of kids that they studied. What this means in practice This study on its own is not enough to make recommendations about the volume of sport that is good or bad for a child, but it give us a much better idea of the real extent to which children get injured from sport. Importantly, it also did not give us any information regarding the severity of the knee injuries or the time children had to refrain from sports, if any, so the situation may look a lot more gloomy than what it really is. It did, however, highlight that overuse injuries is a bigger problem than traumatic injuries and that these tend to occur mostly in children when they experience growth spurts. I plan to write another blog next year where I'll share our clinic's treatment approach to children suffering with overuse knee injuries, e.g. Osgood Schlatter's. My advice for now is that if you suspect your child has an overuse knee injury to: Make him/her take a break from any sports that aggravate it - usually jumping and running sports. Stretch the quads three times a day - this should be done pain free. They can use a foam roller to massage their quads. Work on balance. They usually lose their ability to balance when they go through a growth spurt. 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 Jespersen, E., Rexen, C. T., Franz, C., Møller, N. C., Froberg, K., & Wedderkopp, N. (2015). Musculoskeletal extremity injuries in a cohort of schoolchildren aged 6–12: A 2.5-year prospective study. Scandinavian Journal of Medicine & Science in Sports, 25(2), 251-258. Junge, T., Runge, L., Juul-Kristensen, B., & Wedderkopp, N. (2015). Risk Factors for Knee Injuries in Children 8-15 Years: The CHAMPS-Study DK. Med Sci Sports Exerc, 10, 10. Pacey, V., Nicholson, L. L., Adams, R. D., Munn, J., & Munns, C. F. (2010). Generalized joint hypermobility and risk of lower limb joint injury during sport: a systematic review with meta-analysis. Am J Sports Med, 38(7), 1487-1497.

We know that different types of exercise e.g. Pilates and Yoga have been shown to be effective in the treatment of lower back pain. But what if you hate these types of exercise? Well, the good news is that new research has just been published to show that resistance training with free weights can also be effective in helping people who suffer with lower back pain – especially chronic lower back pain. In this post: Weight training for lower back pain - New Research How ‘protecting’ your back can cause lower back pain So what about this bend with your knees business? How to use free weights to strengthen your lower back Weight training for lower back pain - New Research The researchers enrolled 30 participants, who had lower back pain for more than 3 months, in a 16 week training programme. All the participants underwent MRI investigations to look at the size and shape of the muscles in their lower backs. The MRI scans also identified a total of 33 herniated discs without nerve compression, 11 herniated discs with nerve compression, 1 disc injury without herniation and 20 cases of facet joint degeneration. The aim of the study was to see if they could decrease pain, improve muscle bulk and strength in the lower back as well as improve the participants' movement patterns in the squat exercise. The researchers reported an impressive 72% and 76% reduction in pain and disability by the end of the 16 week period. They also found a significant decrease in fat infiltration as well as an increase in muscles bulk in the lower back muscles. It is important to note that in addition to exercise, the researchers also worked with the participants to address any beliefs that they may have held regarding their injury that may have hampered their recovery. We know for instance that one of the reasons that a person can continue to suffer back pain may be due to them overprotecting their backs. How ‘protecting’ your back can cause lower back pain We know that people start to move differently when they have suffered back pain. This may be because they are frightened of injuring their backs again or in an attempt to ‘protect’ their backs. They often end up splinting their spines during movements or avoiding certain movements, e.g. forward bending, altogether or overusing their superficial back muscles to keep their backs in extension. While this may sound like a clever or logical thing to do, it can actually lead to more back pain for 2 reasons: You end up with a stiff back. Our bodies and joints have to move to stay healthy and strong and pain free. The deep muscles, the multifidi, that lie right next to your spine and are meant to stabilise it during movements, become weak. We know this because studies have shown that if you looked at an MRI scan of someone with longstanding lower back pain, you often find that these deep stability muscles along the spine have a lot of fat in them and have shrunk in size. No, this does not mean that you are overweight. This is as a result of not using your back muscles enough. Because you are splinting with the big superficial muscles of the back, these smaller ones that are meant to be active throughout the day are not really working much. The end result is that they become deconditioned. People who suffer with lower back pain are usually also less active on the whole, which can contribute to these muscles becoming weaker. So what about this bend with your knees business? Yes, of course you should look at your posture when you pick things up – especially heavy things. I am by no means advocating that you just ignore your back pain and bend and move as you like after an injury. You will always have a period of a few days or even weeks, depending on the severity of your injury, during which time there will be certain movements and activities you should avoid. My point is just that they should not necessarily be avoided for the rest of your life! Any treatment plan for lower back pain should involve a slow and gradual training programme during which movement and strength training are slowly reintroduced. How to use free weights to strengthen your lower back The participants in this study all had back pain for longer than 3 months. They did not include anyone who had active nerve root compression or inflammatory disease. It is important to note that emphasis was placed on teaching the participants the correct technique to perform these exercises. I would advise that you ask a physiotherapist or experienced trainer to teach you how to do these exercises before you attempt this programme. I also think that the participants must have had a relatively OK basic level of fitness, since the single leg glute lift is not easy to perform with good form. The 16 week programme was divided into a 4 week familiarisation phase, followed by a 12 week strength phase. Familiarisation phase: Lasted for 4 weeks and included: 1. An assessment of the beliefs participants held regarding back pain. I am often surprised at how many people think that once you have suffered back pain, you are stuck with it for life. This is just one example of a belief that may hamper recovery. They often just need a period of ‘good behaviour’ combined with carefully graded exercise to get them pain free. Another example is when people think that their back pain should continually improve and that it is a bad sign if they have a slight increase in pain on certain days. The truth is that recovery never follows a linear path. Your road to recovery is much more likely to look like a mess of spaghetti as Adam Meakins have shown in the diagram below. It is normal to have good days and bad days as long as the bad days become fewer, less intense and are quicker to recovery from. 2. The participants were all taught lumbo-pelvic control. In short, this means that they were taught how to stabilise their lower backs and pelvises during movement. 3. Each participants' posture was analysed and they were taught how to correct their posture and keep their lumbar spines in a neutral position and not to overuse their back muscles when standing or sitting. 4. Strength exercises Exercise intensity: 3 exercise sessions a week, load approximately 10RM, 3 sets of 8 repetitions They used two different sets of exercises and alternated between them. They would for example do Set A twice and Set B once in week one and then switch to do Set A once and Set B twice the following week. Warm-up before sets: Self-myofascial release of glutes by rolling on a hard ball Glute raises Multi-direction lunges Standing hamstring stretch Overhead squat Assisted squats Set A included: Single leg glute bridges Goblet squats Planks Standing row exercises Set B included: Deadlifts Step-ups Lat pull-downs Side bridges Press ups Strength phase This phase stretched from weeks 5 to 16. The exercises remained the same but the load changed to approximately 6-7RM, 2 sets of 5 repetitions done in 3 sessions per week. 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 may also be interested in: Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 1: Pilates Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 2: Yoga Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 3: Other Exercise 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: Welch, N., Moran, K., Antony, J., Richter, C., Marshall, B., Coyle, J., et al. (2015). The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back. BMJ Open Sport & Exercise Medicine, 1(1).

The anterior cruciate ligament is a very important ligament in the knee and is usually injured when a player forcefully rotates his leg with his foot planted in the ground - often combined with a blow to the knee from the knee or foot of another player. A full tear requires surgery and the recovery time can take anything from 9 to 12 months. Anterior cruciate ligament (ACL) injuries can have very poor recovery rates despite surgical repair. A recent review of the literature found that only 55% of players return to competitive sports after an ACL rupture and only 61% to their pre-injury level of sport. In this post: Improve your chances for recovery from an anterior cruciate ligament injury Potential problems with the research Treatment for a torn ACL Pre-op exercise programme for a torn ACL Post-op exercise programme for a torn ACL Improve your chances for recovery from an anterior cruciate ligament injury What if you could do something before and after surgery to improve the results of your ACL reconstruction? This is the question a group of Norwegian researchers (2) recently tried to answer. They compared the knee function in two different patient groups before and 2 years after ACL reconstructive surgery. Group 1 included patients who underwent treatment and rehabilitation at a sports injury clinic. They underwent an intense 5 week exercise programme BEFORE surgery with the aim to regain at least 90% of their hamstring and quadriceps strength and hop performance. They also received an individually tailored exercise programme after surgery. Group 2 included patients in the Norwegian national registry who received ‘usual care’. The rehabilitation group (Group 1) not only reported better knee function immediately after surgery but also at a 2 year follow-up! Potential problems with the research The researchers unfortunately did not elaborate on the details of the ‘usual care’, so it is impossible to tell if the specific rehab programme was indeed superior. It may very well have been a lack of adherence to any exercise programme that led to a worse outcome in Group 2. One can also assume that the patients attending the sports clinic may have been less likely to smoke which could have contributed to their superior results. A previous study using the same cohort of 22 000 patients as used in Group 2, found that smoking led to significantly poorer outcomes after surgery. The results from this study are, however, backed up by other studies that have found that strengthening the muscles around the knee, especially the quadriceps, can lead to superior knee function after ACL surgery. The authors do point out that the superior results may also have been due to other advantages of being treated at a specialised sports injury clinic e.g. quality education, attention to psychological issues during the rehabilitation process and taking part in supervised goal orientated programmes. One could also argue that patients attending sports clinics may be more motivated to do their exercises. But there is no arguing about the fact that their exercise programme produced good results, so it is worth taking a look at what they did. Pre-op treatment for a torn ACL The pre-op treatment programme in this study was divided into 2 phases. Phase 1 pre-op Phase 1 commenced immediately after the person tore their ACL. The aims during this period were: 1. To regain full range of motion in the knee 2. To decrease swelling in the knee As soon as the swelling inside the joint was resolved and the knee regained full range of motion, Phase 2 was implemented. It took the study participants roughly 60 days after they injured their anterior cruciate ligaments to move from Phase 1 to Phase 2. Treatment during this phase: Use ice often during the day. Apply it for 10 minutes around the knee joint. Remove it for 10 minutes and then reapply it again. I find a packet of peas works best – it’s easy to shape around the knee and gets very cold. You can read more about how to use ice to treat injuries here. Do gentle movements with your knee often during the day. Try to bend it up as far as you can and then to straighten it out fully. Do not push into pain, but rather just move it to where you can feel the discomfort kicking in. Repeat this up to 20 times in one go and do it every two hours. This should not make your knee hurt or swell more. Activate your quadriceps muscles: Tense your quadriceps muscle for 10 seconds and relax. Repeat 10 times every hour. Progress this to lifting your straight leg into the air about 20cm above the bed and holding the position for 10sec. Do not spend too much time on your feet and use a crutch or stick if you go for long walks. Reducing the weight through the joint during the initial few weeks will help to reduce the swelling. Phase 2 pre-op The main aims during Phase 2 were to regain muscle strength and control. They interestingly included both open and closed chain exercises. An example of an open chain exercise is the knee extension machine. The ‘open chain’ refers to the fact that the foot is free and moves during the exercise. An example of a closed chain exercise is the squat. During this exercise the foot is planted and stays still throughout the movement – the chain is thus closed. Back in the day when I was a student we were taught to avoid open chain knee extension e.g. with the knee extension machines, since this was thought to put too much strain on the torn ACL. Research has now shown that this is actually not the case and that these exercises are safe and beneficial for ACL injuries. This is a good example of why physios should keep up to date with the latest research! They also included plyometric training in the form of hops and jumps, but I would suggest that you only do this if a physiotherapist has examined you and told you it is safe to do so. The only adverse effects reported during the study was as a result of the plyometric exercises. It caused a worsening of pain and swelling in 4 of the participants. Pre-op exercises for torn ACL The exercise regime used during Phase 2 of the study consisted of: A 15 minute warm-up on the cross trainer or stationary bike Lasted for a maximum of 75 minutes Exercises were aimed at strengthening the quadriceps and hamstring muscles and included the leg press, leg curl and knee extension machines as well as variations of the squat and glute bridge. A minimum of 2 and a maximum of 4 exercise sessions per week 3 to 4 sets of an exercise 6 to 8 repetitions The exercise intensity was progressed using the +2 principle. A person was instructed to do as many reps as they could during the final (3rd or 4th sets) set of an exercise. If they could do 2 extra reps during the last set, the load was increased during the next training session. They did include plyometric exercises that aimed to develop soft landings and controlling the knee-over-toe position, but please be careful with these. Balance exercises were progressed from standing on a stable object e.g. one leg balance on the floor to using roller boards or doing single squats on balance pads. The exercises were tailored to the specific needs of each patient and slowly progressed. I would advise that you start with light weight exercises and make sure that you control them properly like they did during the post-op period below. You should not feel pain during or after exercising and your knee should not swell after exercise. Post-op exercises for torn ACL The post-op treatment regime was divided into 3 phases. They used the same exercises and progression as with the pre-op programme, but added a third phase during which they did specific drills to prepare the athletes for their sport. Phase 1 post-op Your surgeon will give you specific guidelines to follow during this period but your aims are very much the same as during Phase 1 of the pre-op phase: Regain full range of motion Decrease swelling Prevent muscle atrophy You can find detailed exercises for post-op rehabilitation of an ACL here. Phase 2 post-op This phase lasts between 2 to 6 months post surgery. Your aims during this phase should be: to regain full control of weight-bearing terminal knee extension regain at least 80% muscle strength and hopping ability The strength training was initiated with two sets of 30 repetitions (low load) and gradually progressed to four sets of 4–6 repetitions (high load). Plyometric exercises were introduced once the strength training progressed to high load (typically 4 months postoperatively). The intensity of the exercises were increased according to the guidelines above. Phase 3 post-op The third phase lasted roughly from 6 to 12 months post-op. The aims during this phase included: was to regain at least 90% muscle strength and hopping ability to enable the transition to sport This phase consisted of heavy resistance strength training and increasingly demanding plyometric exercises, as well as sport-specific drills. 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: Perry, M., Morrissey, M., Morrissey, D., Knight, P., McAuliffe, T., & King, J. (2005). Knee extensors kinetic chain training in anterior cruciate ligament deficiency. Knee Surgery, Sports Traumatology, Arthroscopy, 13(8), 638-648. Grindem, H., Granan, L. P., Risberg, M. A., Engebretsen, L., Snyder-Mackler, L., & Eitzen, I. (2015). How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. British Journal of Sports Medicine, 49(6), 385-389. Granan, L. P., Forssblad, M., Lind, M., & Engebretsen, L. (2009). The Scandinavian ACL registries 2004–2007: baseline epidemiology: Acta Orthop. 2009 Oct 1;80(5):563-7. Epub 2009 Oct 1 doi:10.3109/17453670903350107. Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2010). A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Journal of Orthopaedic & Sports Physical Therapy, 40(11), 705-721. Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British Journal of Sports Medicine, 48(21), 1543-1552.

Sciatica has become a bit of a buzz word among my patients when they speak about lower back pain. They use it for anything from localised pain in their lower backs to pain down their legs. But what is sciatica and why is it called that? What is sciatica? Simply put: Sciatica is pain that you feel in your leg due to irritation of the sciatic nerve or any of the nerve roots in the spine that form part of the sciatic nerve. The sciatic nerve is a thick nerve that runs down the back of your leg. Sciatica is defined as: pain in a person’s leg that is well defined (The person can normally tell you that it runs down the back of their leg and often into their foot or toes.) usually follows the dermatomal distribution of the sciatic nerve (see picture 4) is often accompanied by changes in sensation e.g. pins and needles or numbness Sciatica can come in a variety of intensities. It can sometimes cause constant, severe pain with patients struggling to get comfortable in any position. Sitting and standing can be very aggravating and cause immediate pain. They often struggle to sleep due to pain. In milder forms of the condition people only suffer with intermittent pain down their leg e.g. if they sit or stand for a certain period of time or drive their car. To fully understand this condition one has to have a basic knowledge of the anatomy of the lower back. The anatomy of the lower back Our spines consist of several vertebrae (bones) that are stacked on top of each other. There are 7 in the neck, 12 in the mid back (where the ribs attach), 5 in the lower back (lumbar spine) and it terminates with the sacrum and the coccyx at the bottom. The vertebrae in the lower back sit on top of each other, resting on two facet joints (one on each side) and a disc between them. The discs consists of a thick fibrous cartilage layer on the outside and a softer inside. Each vertebra has a hole in it and together these holes form the spinal canal. Your spinal cord runs in the spinal canal. The spinal cord gives off little branches known as spinal nerve roots at each vertebra and these nerve roots exit the spinal canal through openings near the facet joints. Each nerve root provides sensation to specific areas of the skin (known as dermatomes) and also control specific muscles in the body. That's why you can make a pretty accurate "guess" as to which nerve you have injured depending on where you feel your pain/numbness or which muscles are weak. This is the reason why the physio or doctor tests the sensation and muscle strength in different parts of your body. If, for instance, you are unable to lift your toes up and walk on your heels, it tells us that you have likely injured your L5 nerve root. Once the nerve roots exit the spine, they combine to form the different nerves that travel down your limbs. The sciatic nerve is formed by the L4 to S3 nerve roots. What can cause sciatica? It was traditionally believed that sciatica is mainly caused by prolapsed discs in the lumbar spine pressing on the nerve roots. People like talking about "slipped discs", but the disc can’t actually slip. What happens is that their fibrous outer layer tears and the soft inner filling then pushes out (prolapses). It then causes swelling and inflammation in the nerve if this ‘leaked’ inner layer presses (pinches) on the nerve root. Osteoarthritis in the facet joints can cause little bony spurs which can also directly press on the nerve root or just narrow the canal so that it is easier to irritate the nerve root. We now know that direct pressure on the nerve is, however, not needed for you to develop sciatica. Inflammation in structures close to the nerve root e.g. in the disc can also cause swelling and inflammation in the nerve root, even if it is not pressing on it. Will I need surgery to relieve sciatica? Not very likely. Most cases of sciatica can be treated successfully via conservative treatment. Surgery will/should only be considered if you still have severe pain after a year of conservative treatment, unless you have severe loss of muscle function and strength. Why wait so long? Because surgery is no guarantee for success and most cases of sciatica do resolve within 12 months. Disc protrusions can be reabsorbed by the body over time. Do not believe any therapist that tells you that they can push discs back into place – the body does not work that way. Also, do not allow anyone to manipulate your back if you have a disc injury – it will very likely aggravate it further. What does conservative treatment for sciatica consist of? I tend to split my patients with sciatica into 2 groups: 1) those with severe, constant pain or funny sensations (pins & needles etc.) and 2) those with more dull and intermittent symptoms. 1. Treatment in cases with severe, constant symptoms Pain medication – consult your GP so that they can prescribe adequate pain relief. This is a very painful condition and you will feel worse if you cannot sleep due to pain. Anti-inflammatory drugs may also help to decrease swelling and pressure around the nerve. Activity modification – Stop doing the activity that is aggravating your back. Physiotherapy: It will be money well spent to consult an experienced physiotherapist for advice. They will be able to tell you the likely cause for your sciatica and be able to advise you on daily activities that can help or hinder your recovery. I do not find hands-on techniques of any use during the acute stage of sciatica. Acupuncture or dry needling can however provide some pain relief. Hands-on techniques and exercises become more effective once the symptoms have started to calm down a bit. Consult a back specialist doctor e.g. orthopaedic consultant if your pain has not decreased over a period of 6 weeks. They will request further investigation and likely offer you one of 2 types of injections: a) an epidural if a disc is causing your problem or b) a facet joint injection if the facet joints are deemed to be the problem, consisting of a corticosteroid and a local anaesthetic. 2. Mild, intermittent symptoms Your first port of call should be your physiotherapist. I find that these type of patients respond extremely well to treatment consisting of soft tissue release, dry needling, gentle exercises and advice regarding their activites of daily living. Your physio will also refer you on for further investigation if they feel it is needed. Should I avoid surgery at all cost? No, surgery can be effective when it is absolutely needed. Research has shown that it can be very effective in relieving leg pain and improving quality of life. There is also research that shows that elite athletes can successfully return to sport after micro-discectomy surgery, but this will depend on the type of sport they do. 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: Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., et al. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology, 44(11), 1399-1406. Atlas, S. J., Keller, R. B., Wu, Y. A., Deyo, R. A., & Singer, D. E. (2005). Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine, 30(8), 927-935. Bicket, M.C., Horowitz, J. M., Benzon, H. T., & Cohen, S. P. (2015). Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. The Spine Journal, 15  (2), 348-362. Bush, K., Cowan, N., Katz, D. E., & Gishen, P. (1992). The Natural History of Sciatica Associated with Disc Pathology: A Prospective Study with Clinical and Independent Radiologic Follow-Up. Spine, 17(10), 1205-1212. Dodwad, S.-N. M., Dodwad, S.-J. M., & Savage, J. W. (2015). Lumbar Discectomy Review. Operative Techniques in Orthopaedics, Published Online: June 09, 2015: http://www.optechorthopaedics.com/article/S1048-6666%2815%2900033-6/abstract. Manchikanti, L., Nampiaparampil, D. E., Manchikanti, K. N., Falco, F. J., Singh, V., Benyamin, R. M., et al. (2015). Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surg Neurol Int, 6(Suppl 4), 2152-7806.

You may think that the answer to this question is rather obvious….drink lots of water. Well, it is and it isn’t. It is important to get the balance right when you rehydrate after exercise. If you drink a lot of fluid quickly, your body naturally increases the rate at which it produces urine (you just pee most of it out again). You also run the risk of causing yourself harm if you only replace water and not salts and minerals. This can lead to cramps or hyponatremia (a condition that may be fatal). In this article: The importance of Salt (sports drinks are not enough) How you rehydrate after exercise should be dictated by 2 factors The time interval before your next exercise session Other nutrients that are important after exercise The importance of salt (sports drinks are not enough) You should always make sure that you replace the salts that you have lost during exercise at the same time as the fluids. If you drink too much fluid without replacing the salts, you may be at risk of hyponatreamia - a condition that causes swelling on the brain and that can be fatal. The good news is that you can easily get the salt you need from regular food e.g. pretzels, soup bouillon (2.2 g/L sodium) or tomato juice (2.2 g/L sodium). Sports drinks usually only have a sodium concentration of around 0.46 g/L which is not enough (see next section). While sodium-chloride is the most important to replace, other minerals such as potassium and magnesium may also play important roles in dehydration at a cellular level. Natural sources of potassium and magnesium are asparagus, bananas, leafy greens such as spinach, Swiss chard, kale, white and sweet potatoes with skin on, citrus fruits, tomatoes, kiwi, papaya, squash, almonds, cashews, peanuts and walnuts. How you rehydrate after exercise should be dictated by 2 factors: 1. How much fluid you have lost You can get an idea of how much fluid you have lost during exercise by measuring your body weight before and after the race or activity. Learn more about how you can use your weight loss, thirst and urine colour to determine if you are dehydrated. 2. The time interval before your next exercise session If you have 24 hours until your next session Research has shown that athletes naturally take in enough food (that include salts and electrolytes) and fluids during a 24 hour period to fully replace all the fluids lost during exercise. You do not have to follow any special guidelines. Just eat a balanced diet and drink fluid according to thirst. If you have to exercise within 6 hours of your previous session In this case, you will have to ingest a combination of water and sodium in excess of your existing body weight deficit (more than the weight that you've lost). This will ensure that you replace all your fluids and allow for the amount you'll lose to the toilet. The ACSM recommends that you aim to replace 125% to 150% of your decrease in body mass combined with the equivalent of about 1 g/L to 2 g/L of sodium. They further recommend that you divide the fluid into 500ml portions and take it about 30 minutes apart. Drinking large quantities of fluid all at once stimulates urine production. This means that you'll lose most of the fluid you drink in the loo. Example: If you found that you had lost 2kg of body weight during exercise, you would aim to drink a mixture of water and salt which equates to about 2.5L to 3L of water with around 5,7 g to 6,9 g of sodium (salt) in it. Yes, this will likely taste worse than seawater so rather choose foods like tomato juice (2 g/L sodium) than salt tablets. You can have sports drinks, but you'll have to add some salt since they normally do not contain enough. Please make sure that you first ask your doctor's advice if you're supposed to follow a low salt diet. Other nutrients that are important after exercise Research has also shown that it is important to restock on protein and carbohydrates after exercise to ensure a full recovery. I have previously written about exactly how much protein you should eat and when, for best recovery. The ACSM guidelines further state that caffeine and low alcohol content drinks (beer) are OK to drink in moderation if you are aiming to rehydrate over 24 hours. It may be best to avoid them if you want to rehydrate quickly, since they have a mild diuretic action. Strong alcohol (spirits) is not advised, because it acts as a strong diuretic (makes you lose a lot of fluid). In this video, we interview former athlete Jesse Funk about how individuals have different sweat rates and the best way to go about replacing lost electrolytes: 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: Sawka M, Burke L, Eichner E, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Medicine and Science in Sports and Exercise 2007;39(2):377.

Most people, when asked how much fluid they should drink in a day, will say 6 to 8 glasses. This is also the message being shouted out in most health magazines and blogs. But why then, do so few of us die when we don’t? Well, the answer to this is quite simple… there is absolutely no scientific evidence to back this up. How much water you need heavily depends on the climate you're in, what you eat (you can get up to 1 litre of fluid through a regular diet) and what activities you're doing. Caffeinated drinks e.g. tea and coffee have traditionally been bad mouthed since it is commonly believed to act as diuretics and to cause your body to lose fluid. Research has, however, shown that this may only be the case for people who are not used to drinking these substances. The American College of Sports Medicine has the following to say on caffeine: “Caffeine ingestion has a modest diuretic effect in some individuals but does not affect water replacement in habitual caffeine users, so caffeinated beverages (e.g. coffee, tea and soft drinks) can be ingested during the day by athletes who are not caffeine naïve (who regularly drinks caffeine).” In this article: So how do you know if you are drinking enough water? Daily test After sport I have read that I should drink before I get thirsty... So how do you know if you are drinking enough water? Research has shown that there are 3 ways in which a person can tell if they are dehydrated. They usually become thirsty, their urine becomes concentrated (darker colour) and they lose more than 1% of their body weight over a short period e.g. hours or a day. It is important to understand that there are 2 types of dehydration a healthy person can experience: 1. Acute or sudden dehydration which occurs over a period of hours or days. Examples of this is when you work or do exercise in the heat. This is normal and research have found that people are very good at rectifying this by drinking according to their thirst. You may also be interested to know that muscle cramps during sports are not actually caused by dehydration. 2. Chronic dehydration where a person’s fluid intake is just a bit too low over a long period of time so that it causes mild chronic dehydration. In this case, you won't notice a drop in body weight or increased thirst as your body would be used to this dehydrated state. Urine colour is your best measure for this. Chronic low-level dehydration can cause kidney stones and may also contribute to chronic kidney disease. 3-Step test to see whether you are dehydrated – daily test You have to perform this test first thing in the morning. Any one symptom on its own does not indicate dehydration. You have to display at least 2 of the 3 symptoms before you consider yourself dehydrated. You may for instance have lost a lot of weight due to eating less and doing a lot of exercise the previous day, but be well hydrated. Similarly you may be thirsty, but not have lost so much fluid that you are deemed to be dehydrated. You are very likely to be dehydrated if you display all 3 symptoms. Step 1: Urine Look at the colour of your urine after your first visit to the loo in the morning. Use the standardized urine colour chart to assess your urine’s colour. You are very likely dehydrated if you score a 4 or higher. Remember, if you have been drinking too little fluid daily for a very long time, dark urine may be the only sign that you're dehydrated. Step 2: Weight Weigh yourself after your first visit to the loo. If you have lost more than 1% of your body weight compared to the previous morning, you may be dehydrated. Step 3: Thirst Are you thirsty when you wake up? Research has shown that a combination of thirst and loss of body weight is a strong indication of dehydration. 3-Step test to see whether you are dehydrated – after sport You can use the same 3 step test described above to see if you are dehydrated after a run, long walk or even a rugby match. The only difference is that you perform it immediately after completing your sports activity and you have to make sure that you were well hydrated when you weighed yourself before the activity. It is not necessary or possible to replace all your fluids that you lose during exercise while you are training. Research conducted on athletes in laboratories has shown that a 2% loss of body weight due to dehydration can cause a decrease in performance, but this stands in stark contrast with results from field studies where the top performing athletes have been measured to have lost between 6 and 8% of their body weight. "Time and again, studies, even those by researchers expecting different outcomes, have shown that the runners who are the most dehydrated, as measured by percentage of body weight loss, run the fastest. As two examples, notice the results in figure 2.4, from the 2000 and 2001 South African Ironman Triathlons and the 2004 New Zealand Ironman Triathlon. The five fastest finishers in the South African Ironman all finished in less than 9 Hours and all lost 6% to 8% of their body weights during the race (arrowed in figure 2.4a). Three years later, this relationship was confirmed in finishers in the 2004 New Zealand Ironman Triathlon (figure 2.4b)." - taken from Waterlogged: The Serious Problem of Overhydration in Endurance Sports Dehydration has, however, also been shown to affect concentration. The effects of dehydration on your sports performance may thus depend on the type of sport that you participate in. Endurance athletes may for instance benefit more from losing some body weight while racing despite the dampening effect on their concentration. One can argue that a tennis or hockey player's performance will suffer a lot more if their concentration lapses. The American College of Sports Medicine advises that you should try and keep fluid losses below 2% of your body weight, but they warn that you should not drink too much during exercise either since this can cause dangerous electrolyte imbalances in the body (see below). While it may not be necessary to replace all your fluids while exercising, you should aim to do so afterwards. You can read about the best methods to replace fluid losses quickly and safely by following this link. I have read that I should drink before I get thirsty This is simply not true and may even be dangerous advice. Research has shown that healthy humans are more than capable of maintaining healthy hydration levels during normal daily activities as well as during exercise by simply drinking when they are thirsty. This is surely also common sense? The “drink at least 8 glasses of water” and “drink before you are thirsty” advice have only been around in the last century and the human species have very successfully managed to survive in and populate some of the harshest environments on earth. There's also evidence that the “drink before you are thirsty" advice may have been pushed by companies to increase sales. Drinking too much water without replacing the salts that you lose during sweating can lead to a condition called hyponatremia.  Hyponatremia causes swelling on the brain and it can be fatal if not treated swiftly. This is really only a problem for people who do not eat a normal diet or who drink excessive amounts of water for prolonged periods e.g. while running a marathon. In the video below, Prof Tim Noakes explains about the dangers of drinking too much water. The only time that a healthy person cannot trust their thirst sensation is if they have been chronically dehydrated over a very long period of time. Research have shown that your thirst detection can be less sensitive in these cases. You can also see this interview with former ultra-athlete Jesse Funk, which touches on the subject of drinking too much water during endurance sports: 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: Cheuvront SN, Kenefick RW. Am I Drinking Enough? Yes, No, and Maybe. Journal of the American College of Nutrition 2016;35(2):185-92. Cohen D. The truth about sports drinks. BMJ 2012;345. Cotter JD, Thornton SN, Lee JK, et al. Are we being drowned in hydration advice? Thirsty for more? Extreme physiology & medicine 2014;3(1):18. Sawka M, Burke L, Eichner E, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Medicine and science in sports and exercise 2007;39(2):377. Valtin H. “Drink at least eight glasses of water a day.” Really? Is there scientific evidence for “8 × 8”? American Journal of Physiology - Regulatory, Integrative and Comparative Physiology 2002;283(5):R993-R1004.

I don’t know about you, but I’m steadily becoming more and more paranoid about growing older (maybe it’s the fact that I’m turning 40 next year!). I’m often amazed at the differences I observe in my older clients that I see in private practice. Some of them still dance 3 times a week and fly kites in their free time while others struggle to bend down to tie their shoe laces. This made me wonder: Is how I age predetermined by my genetics or do I have a say in this affair? For this article I specifically investigated what happens to our muscular systems and why we seem to lose muscle strength and power as we age. I won’t lie, it was rather depressing to read about all the things that may be in my future. The good news is that I’ve come to the conclusion that, while we all will grow old, there are plenty of things that we can do to maintain our strength and performance. In this article: What happens to our muscles and tendons as we age? Is it possible to avoid these changes? What triggers our bodies to build muscle? The role of chronic inflammation Vit D is also important In summary What happens to our muscles and tendons as we age? The things that I list in this section all relate to the average person. The exciting news is that this does not have to be you! But first, here’s a list of changes that happen with age: On average we can lose around 0.37% (for women) and 0.47 % (for men) of our lean muscle mass per year. For people over the age of 75 this rate increases to 0.64-0.70% per year for women and 0.80-0.98% for men. Our muscle fibres reduce in number and in size. We seem to be specifically prone to losing Type 2 (fast twitch) muscle fibres. These are the main fibres that that we use when we perform quick strong movements. Their loss may explain why so many older people struggle to get up off the floor or climb stairs. Studies in rats have shown that older muscle also forms fibrosis or scar tissue between muscle fibres which may explain why we tend to get stiffer as we age. You tend to find more fat cells between the muscles fibres of older people. There’s a reduction in the number of mitochondria within our muscles cells. Think of mitochondria as the batteries of the cells. They produce the energy for the contractions. Our tendons lose some of their stiffness so that they become less effective at propelling us forward when we run or walk. The number of nerve endings that supply a specific muscle reduces and the nerves no longer optimally activate the muscles. Is it possible to avoid these changes? Wroblewski et al (2011) investigated muscle mass and body composition in masters athletes. They found that chronic intense exercise (more than 4 sessions a week) preserved lean muscle mass into old age despite the body’s total body fat increasing. The increase in total body fat did not lead to fatty infiltration into the muscles themselves. The researchers concluded that the declines in muscle mass previously thought to be a natural part of aging, was more likely due to lifestyle choices e.g. a sedentary lifestyle and poor nutrition. McKendry et al. (2018) supported these findings in their recent review and meta-analysis. They concluded that the current evidence suggests that chronic exercise training preserves physical function, muscular strength and body fat levels in old age similar to that of young, healthy individuals. Piasecki et al (2016) found that, despite the fact that master athletes experience a drop in the number of nerve endings that supply their muscles (similar to sedentary old people), they still managed to preserve their muscle mass and performance. In a nutshell: It is possible to avoid some of the changes that has previously been contributed to “natural again”. Others may be unavoidable, but we may be able to reduce their impact through regular exercise and eating the right stuff. What triggers our bodies to build muscle? There are 2 main things that act as triggers for our bodies to build new muscle. The first is exercise and the second is when we eat protein. When we eat protein (e.g. meat, eggs, beans etc.) our bodies break it down into its simplest form namely amino acids. Our muscles then use these amino acids to build new muscle cells. It’s easy to see why it’s important to make sure that we eat enough protein during the day. When we’re young, the presence of these amino acids in our blood is enough to kick-start the muscle building process. Interestingly, this does not seem to be the case for older adults. Researchers think that this is mainly due to our cells becoming more insulin resistant with age. If our cells don’t absorb insulin properly, it can’t build new muscle despite there being enough amino acids floating around. This is where exercise can make a big difference. Not only does it stimulate your muscles to grow stronger, but it can also decrease your insulin resistance.  Researchers have found that, if older adults perform a bout of exercise shortly before eating a meal, their muscles responds just like young muscles. Fujita et al. (2007) even found that the positive effect of the exercise bout carried over to the next day! Not enough research has yet been done to provide us with specific guidelines, but I would suggest that you aim to do at least 5 sessions of moderately hard aerobic exercise a week. This can include swimming, cycling, walking, running or any other exercise that makes you breathe harder. You’ll see even greater benefits if you can also include a couple of strength and flexibility training sessions per week. In a nutshell: If we eat enough protein and exercise regularly, we can preserve our muscle strength and performance much better than people who follow sedentary lifestyles. You can read more about how to use exercise and protein together for maximum gains. The role of chronic inflammation Ageing is often accompanied by inflammatory disorders, slight elevations in circulating pro-inflammatory mediators and decreases in anti-inflammatory cytokines which result in chronic low-grade inflammation which has been shown to enhance muscle loss in older people. Strategies that decrease chronic low grade inflammation e.g. antioxidant supplements and taking omega 3 fatty acids have been shown to increase muscle volume and strength in the elderly. Other things that has been shown to contribute to low grade inflammation include smoking, alcohol, high sugar diets, processed food and stress. These are all things that are within your power to change! Vit D is also important Vit D is important to maintain strong bones, prevent muscle wasting and maintain our immune systems. If you don’t get in contact with the sun on a daily basis and/or always wear very strong sunblock, you may be at risk of being Vit D deficient. Food like eggs do contain Vit D, but it’s very difficult to get enough through your diet. Speak to your GP if you think that you may be lacking in Vit D. I don’t like swallowing tablets, but luckily you can get a mouth spray (in the UK) that I use in the winter. In summary: We can reduce the negative effect aging has on our muscles and tendons if we: Exercise regularly; eat enough protein; take steps to avoid things that cause chronic low level inflammation; and make sure that our Vit D levels are topped up regularly. 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 Dalle S, Rossmeislova L, Koppo K. The Role of Inflammation in Age-Related Sarcopenia. Frontiers in physiology 2017;8:1045. Dickinson JM, Volpi E, Rasmussen BB. Exercise and nutrition to target protein synthesis impairments in aging skeletal muscle. Exercise and sport sciences reviews 2013;41(4):216. Drummond, M. J., Dreyer, H. C., Pennings, B., Fry, C. S., Dhanani, S., Dillon, E. L., et al. (2008). Skeletal muscle protein anabolic response to resistance exercise and essential amino acids is delayed with aging. Journal of Applied Physiology, 104(5), 1452-1461. Fujita S, Rasmussen BB, Cadenas JG, et al. Aerobic exercise overcomes the age-related insulin resistance of muscle protein metabolism by improving endothelial function and Akt/mammalian target of rapamycin signaling. Diabetes 2007;56(6):1615-22. Mckendry J, Breen L, Shad BJ, et al. Muscle Morphology and Performance in Master Athletes: A Systematic Review and Meta-analyses. Ageing research reviews 2018 Mitchell W, Atherton P, Williams J, et al. Sarcopenia, Dynapenia, and the Impact of Advancing Age on Human Skeletal Muscle Size and Strength; a Quantitative Review. Frontiers in Physiology 2012;3(260) doi: 10.3389/fphys.2012.00260 Piasecki M, Ireland A, Coulson J, et al. Motor unit number estimates and neuromuscular transmission in the tibialis anterior of master athletes: evidence that athletic older people are not spared from age‐related motor unit remodeling. Physiological reports 2016;4(19) Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. Journal of cachexia, sarcopenia and muscle 2018;9(1):3-19. Volpi, E., Mittendorfer, B., Wolf, S. E., & Wolfe, R. R. (1999). Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction. American Journal of Physiology – Endocrinology and Metabolism, 277(3), E513-E520. Wroblewski AP, Amati F, Smiley MA, et al. Chronic exercise preserves lean muscle mass in masters athletes. The Physician and Sportsmedicine 2011;39(3):172-78. Zhai Y, Xiao Q. The Common Mechanisms of Sarcopenia and NAFLD. Biomed Res Int 2017;2017

Most runners that I speak to know that they should be doing strength training to help prevent injuries, but very few of them actually follow a regular strength training programme. Reasons for avoiding it include not having time, not knowing what to do or my own personal one: “I just find it boring!” The problem is that as a physio who regularly treats running injuries I know that having a good base strength is essential for me to reduce my chances of injury. That’s why I’ve decided to create a strength training programme that can be done in 30 minutes and provide me with the basic strength I need to keep running strong. Please note: These exercises and recommendations may not be right for you. Please consult your healthcare professional before trying any of these exercises. Remember, you can also consult our team of sports physios via video call for a bespoke training programme or diagnoses of any injuries. In this article: The criteria I used when I compiled this strength programme How to work out how many repetitions to start with How often should you strength train? How to progress the exercises safely My Strength Programme For Busy Runners Single Leg Sit-Stand-Sit Toe Taps Single Leg Chair Bridge Single Leg Heel Raise The criteria I used when I compiled this strength programme It must strengthen all the major muscle groups in the lower body including the Glute Max, Glute Med, Hamstrings, Quadriceps and Calves. It must include exercises for Core Strength. It should develop my Position Sense. I want to be able to do the exercises anywhere. I don’t want to use any fancy equipment. A person who is new to strength training should be able to perform the exercises safely. It should take 30min or less to complete. It should be easy to progress the exercises as I grow stronger. How to work out how many repetitions to start with Step 1: Test your endurance for each exercise: How many repetitions can you do before you get tired and have to stop or you lose good form. It does not count if you are able to continue, but you have to cheat by using momentum to get you up there or your leg does not move in a straight line etc. For example: When testing my endurance with the Single Heel Raise, I find that I can do 12 reps before my calf shakes and I have to stop. My endurance for this exercise is 12. Step 2: Work out the number of reps that you’ll start with. Subtract 4 from your endurance score. The answer is the number of repetitions that you'll start with. For example: My endurance score for the Single Heel Raise was 12. So my starting number of repetitions will be 8. How often should you strength train? The answer to this question is slightly different depending on what your running habits are. I’m not training for any races Frequency: Aim to strength train twice a week with at least 48 hours between sessions. Be careful to allow enough recovery time between strength training and hard running sessions. Repetitions per exercise: Work out your starting repetitions with the method above. Rest between exercises: Rest for at least 1 to 2 minutes between sets. You can save time by allowing one muscle group to rest while training another. For example, you can go straight from doing the Single Leg Sit-Stand-Sit to doing the Toe Taps, because they don’t work the same muscles. Sets: Do 3 sets of each exercise. Aim: I’ve listed below what you should aim to achieve with each exercise before you can progress. I’m training for a race Frequency: Aim to strength train once a week only. Make sure that you allow enough recovery time between strength training and hard running sessions, otherwise you can cause yourself injuries due to over-training. Repetitions per exercise: Work out your starting repetitions with the method above. Rest between exercises: Rest for at least 1 to 2 minutes between sets. As mentioned above, you can save time by creating a circuit. This allows one muscle group to recover while you work another. Sets: Do 3 sets of each exercise. Aim: If you are training for a race, you should really just aim to maintain the strength that you currently have. Don’t push the strength training too hard – leave that for during the off season. How to progress the exercises safely You should always aim to slowly progress the difficulty of the exercises over time. To ensure that you do this safely you should cut the number of repetitions you do per set every time that you make an exercise harder. Perform a new endurance test at the harder level and use the formula mentioned above to work out how many repetitions you should start with. For instance, pretend that I’ve built up to doing 3 sets of 15 repetitions of the heel raise exercise. I now want to make it harder by holding a 2kg weight. I test my endurance with the 2kg weight and find that I can do 13 repetitions before my calf gets tired. I use the formula (13 – 4) and work out that I can start doing 3 sets of 9 repetitions with the extra weight. My aim is now to build the repetitions up to 3 sets of 15 with the added weight before progressing it further. My Strength Programme For Busy Runners Single Leg Sit-Stand-Sit The benefits: This is an amazing all in one exercise that helps to develop your balance and Position Sense and strengthens your Glute Max, Glute Med, Hamstrings and Quadriceps. Starting position: Choose a chair that you can manage to get up from using only one leg. Your aim should be to use a chair that places your knee in 90 degrees flexion, but if this is too hard use a higher surface. I usually place some pillows on the chair to make it easier. Sit on the edge of the chair with your one leg on the floor and the other one in the air. Movement: Slowly stand up from sitting, using only one leg. Make sure that your pelvis stays level and your knee moves in line with the middle of your foot. Then slowly sit down again. You can initially hold on to the back of another chair to help you stabilize and control the movement. Check that: Your pelvis and knee stays aligned. If you find that you “plonk” down instead of slowly lowering yourself down, you may have to use a higher chair or raise that one by placing a few pillows on it. Aim: Your ultimate aim is to build up to being able to do 3 sets of 15 repetitions from a normal chair (90 degrees knee flexion). Rest at least 2 minutes between sets. You will likely have to start by doing it from a higher surface and you may initially have to hold on to something for balance. Build up to 3 sets of 15 slow repetitions on each leg at this higher height. If you’ve been holding on to a chair for balance, you should also aim to be able to do it without holding on before you progress. Once you can achieve this, lower the height of the chair and slowly start building up your strength at this new height. Progression: You can progress this exercise by holding a dumbbell in your hand or wearing a backpack with extra weight on your back. Please read the section higher up in the article on safe progression before you add extra weight. When am I strong: When you can do more than 22 slow repetitions (in one go) from 90 degrees knee flexion (about the height of a low dining room chair) Toe Taps The benefits: This exercise is great for developing core strength and lumbo-pelvic control. It teaches you how to keep your pelvis and lower back stable while moving your legs. Starting position: Lie on your back with your knees bent. Some people find it useful to place their hands under their lower backs so that they can feel if it moves. Use your lower stomach muscle to press your lower back flat onto the floor by tilting your pelvis backwards. Your chest and neck should be totally relaxed. Movement: Make sure that YOUR BACK STAYS FLAT ON THE FLOOR throughout the exercise. Lift one leg up to 90 degrees hip flexion, keeping the knee bent. Then lift the other leg up to join the first. Slowly tap with your one heel on the floor and then bring it back up. Then tap with the other. Check that: Your pelvis does not twist and lower back DOES NOT LIFT off the floor as you lift and lower your legs. I find it best if you concentrate on making sure that you feel the pressure of your back pushing into your hands or the floor, rather than thinking about lifting the legs. Aim: Build up to 3 sets of 20 lifts (alternating legs) with 2 minutes' rest between sets. Once you can achieve this, progress the exercise. Progression: Start tapping further away from your bottom, but make sure that you are still able to keep your back flat on the floor. Please read the section on safe progression before you start this. When am I strong: When you can manage the 3 x 20 repetitions at the most difficult level. Single Leg Chair Bridge The benefits: It strengthens your Core, Lower Back, Glutes and Hamstrings. Starting position: Lie on your back with your one heel on a chair and your other leg bent up into your stomach. Make sure that your bottom is close to the chair – you are looking for a 90 degree angle in your knee. Also ensure that the chair is wedged against a wall so that it can’t slip away from you. Movement: Activate your pelvic floor and deep abdominals by squeezing as if you don’t want to wee. Keep them activated and lift your bottom into the air so that your body forms a straight line. Make sure that your pelvis is level! Once at the top, you should squeeze your 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. Slowly lower back to the floor. Check that: Your pelvis should remain level throughout the exercise. You should not feel any strain in your lower back. If your hamstrings cramp, move your bottom closer to the chair. Aim: Build up to 3 sets of 15 slow repetitions on each leg. Rest 2 minutes between sets. Once you can achieve this, progress the exercise. Progression: Move your bottom further away from the chair so that your knee is nearly straight when you’re at the top. This will make the hamstrings work harder. IMPORTANT: Your knee should still be slightly bent e.g. 15 degrees when you’re at the top. Please read the section on safe progression before you do this. When am I strong: When you can manage more than 25 repetitions (in one go) with your knee in the straighter position (15 degrees knee flexion). Single Leg Heel Raise Over Step The benefits: It strengthens the Calf muscles and Achilles tendon. Starting position: Stand on one leg on a step. Hold on to something for stability – this is not a balance exercise. Movement: Slowly lift up on your toes and then lower yourself down so that your heel drops below the level of the step. Do not hang there - immediately lift back up on your toes. Check that: Don’t hang at the bottom – if you want to stretch the calf muscle, do so afterwards. If you do it during the exercise, you’ll stop the muscle working optimally. This exercise should be performed very SLOWLY (especially the lowering down part). Aim: Build up to doing 3 sets of 15 repetitions on each leg. Rest 2 minutes between sets. Progression: You can progress this exercise by holding a dumbbell in your hand or wearing a backpack with extra weight on your back. Please read the section on safe progression before you add extra weight. When am I strong: When you can manage 3 sets of 15 repetitions with a weight that is equal to about 20% of your bodyweight. E.g. I weight 75kg. 20% of my bodyweight is 15kg. So my aim would be to slowly build up to doing 3 sets of 15 repetitions with 15kg in a backpack on my back. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate.

Chances are that if you run or play any sports that requires a bit of running, you would have experienced discomfort in your calves at some point. This article is a summary of the final session of the Injury Prevention series. Other topics that I’ve covered in this series include Position Sense, Core Stability, Glute Med, Glute Max, Quads, and Hamstrings. In this article: Why does stretching my calves not always help? Overuse injuries Training errors Strength imbalances Calf strains and tears Your sciatic nerve may play a role Flexibility exercises for tight calves Receive exercises as PDF In summary: How to deal with calf pain Why does stretching my calves not always help? I often get people in my clinic complaining of tight and sore calves despite doing regular stretching and foam rolling. The reason for this is that the tightness or discomfort that they experience is only a symptom and it won’t go away if they don’t address the cause. You can divide the causes for calf pain or tightness into 3 broad categories: Overuse injuries Calf strains or tears Nervy reasons I can pretty much write a chapter on each of these, but I’m going to try and keep it succinct! Overuse injuries Overuse is by far the most common cause I see in practice for calf injuries. What does it mean to overuse your calves? It means that you’ve asked it to work too hard, too often and it’s not had enough time to rest and recover. Training errors obviously fall into this category, but you can also overuse parts of your calf muscles if other muscles e.g. your glutes aren’t strong enough. So it may be useful to break this section into Training Errors and Strength Imbalances. Training Errors I’ve written in the past about the importance of allowing the body enough time to recover after exercise. When you train, you sustain micro-injuries to your muscles and tendons etc. It then needs a period of rest to recover and rebuild itself. If you give it enough time to recover, the muscles and tendons become stronger over time. If, however, you train again and again and again BEFORE you have fully recovered, that muscle or tendon will break down faster than what it can recover and you end up with an injury. This can also happen if you do a bout of exercise that’s a lot harder (longer or more intense) than what you’re used to. In this case you end up with an injury because the muscles or tendons are just not strong enough for what you're doing. Changing your running style to running more on the front of your foot or wearing flatter shoes than normal will also make your calf muscles work a lot harder than normal and can cause calf and Achilles tendon pain. The most common training errors that can lead to overuse injuries of the calves are: Increasing your weekly mileage too quickly Increasing the intensity of your training too quickly e.g. by adding in hilly runs or ramping up speed work or both! Introducing other activities or sports that also uses the calf muscles e.g. dance or basketball Switching to flatter running shoes. Changing your running style to run more on the front of your feet. Strength imbalances Weak or switched off glutes can cause quite a few issues for the calves. Firstly, the glute max has to help propel you forward when you run. If it’s switched off or weak, your calves may have to work harder which can lead to strains. Secondly the glute max and glute med are very important hip stabilisers. They should stop your legs from rolling in excessively when you run. If they aren’t doing their job properly, it will cause your foot to over-pronate (roll in) which over time can cause a variety of injuries around the lower leg including soleus strains, tib post tendinopathy and medial tibial stress syndrome (shin splints). All of these injuries can make your calves feel tight and sore. I should really mention shoes again. Wearing really flexible running shoes that provide little to no stability can cause similar problems for some people as they can also make your foot over-pronate. I’ve written in the past about how you can test your hip stability. You can also find exercises to strengthen your Glute Max and Glute Med in the previous articles of the Injury Prevention series. Calf strains or tears Not all calf tears have to be sharp and bruise or swell. Tears in the Soleus muscle often just feel like persistent tightness. It’s really important to carefully strengthen your calf muscles if you have sustained a strain or tear. You will find yourself suffering repetitive calf strains if you just rest it and don’t strengthen it before you go back to running or sport. Your sciatic nerve may play a role Your sciatic nerve runs from your back, through your buttocks and down the back of your legs. When it’s irritated it can cause a wide variety of symptoms in the calf ranging from strange sensations (e.g. tingling), sharp pain, numbness, weakness, cramping or just a feeling of perpetually tight calves. If you’re experiencing very sharp pain that does not want to subside, funny sensations, numbness or weakness, you’ve likely got an injury to your lower back. I would suggest that you consult a physiotherapist as they can test it properly and provide you with a treatment and exercise plan to help this heal. You don’t always have to have a back injury to have an irritated sciatic nerve. If your problem is just very tight and sore calves without any funny symptoms, your sciatic nerve may just be a bit stuck. Your nervous system is continuous from your brain to the tips of your toes. When you walk and move the nerves slide happily in their sheaths. Tight muscles or other structures can sometimes hold on to or press on the nerves and prevent them from sliding, causing increased neural tension and symptoms lower down in the limbs. A very common culprit, that can affect the sciatic nerve, is the piriformis muscle in the buttocks. In some people the sciatic nerve runs through or under the piriformis and gets squashed when this muscle becomes very tight. Tight buttocks often go hand in hand with a tight lower back and I find it most effective if you improve the flexibility in both areas. Flexibility exercises for tight calves For the reasons listed above, it should be obvious that you should be stretching more than just your calves. I always get my clients to work on the flexibility around their lower backs and glutes (to free the sciatic nerve up) before they stretch their hamstrings and calves. Glute 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 stretch your piriformis and allow your sciatic nerve to slide 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 glute stretch for 30 seconds and repeat on the opposite side. Repeat 3 times. Hamstring stretch Purpose: This is a gentler hamstring stretch. Starting position: Lie on your back. Bend your one knee up and grab hold around your thigh. Movement: Gently straighten your leg until you feel a comfortable stretch at the back of the leg. Aim: Hold the stretch for 10 seconds. Then bend your knee again. Repeat 12 times with each leg. Calf Stretch Purpose: To improve the flexibility of the calf muscles. Starting position: Stride stand with the foot to be stretched at the back. Your toes must point straight forward. Movement: Keep your heel on the floor and bend the knee of the front leg until you feel a stretch in the calf of the back leg. Aim: Maintain the calf stretch for 30 seconds before switching legs. Repeat 3 times with each leg. Receive the exercises as PDF In summary: How to deal with calf pain Identify the cause and address that. A health professional who specialises in sport can help you with this if you’re struggling to identify the reasons for your symptoms. This is also something that we can easily help you with via an online physio consultation. While you recover, cut your training down to a volume that you can do without causing or increasing your symptoms e.g. shorter runs or running on flatter surfaces or grass etc. If your calves are very painful, you may have to ease off running and cross train by swimming or cycling. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn, ResearchGate. References: Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Current Reviews in Musculoskeletal Medicine 2009;2(2):74-77. doi: 10.1007/s12178-009-9045-8 Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? British Journal of Sports Medicine 2004;38(4):502-04. doi: 10.1136/bjsm.2003.011346

The quadriceps is the large muscle group at the front of your thigh. Weakness and/or inflexibility of the quads can lead to a variety of injuries. This article is a summary of the penultimate episode of the Injury Prevention Series. Other topics that I covered in this series included position sense, core stability, glute max, glute med, hamstrings, and calves. In this article: Where are your quads? Problems due to a tight Rectus Femoris Hip flexor and quad stretch Problems due to a tight Vastus Lateralis How to foam roll your quads Injuries due to weak quads Strength exercises for the quads Leg press Double leg squat Single leg sit-stand-sit Download exercises as PDF Where are your quads? Your quadriceps or quads refers to the large group of muscles at the front of your thigh. It is made up of 4 parts: The Rectus Femoris (Rec Fem) runs in the middle of your thigh; The Vastus Lateralis (VL) runs towards the outside of your thigh; The Vastus Medialis (VM) runs more towards the inside of your thigh and the Vastus Intermedius runs between the VL and VM but underneath the Rec Fem These four muscles come together at the knee and forms the patellar tendon which attaches to the tibial tuberosity. Your kneecap sits inside the patellar tendon. As a group, they work together to extend your knee or to control your knee during bending e.g. when you climb up stairs they help propel you upwards and when you climb down, they control the lowering of your body. The Rec Fem is the only one that also crosses the front of the hip joint which means that it also helps with hip flexion. Problems due to a tight Rectus Femoris The Rec Fem forms part of the hip flexors. Research has shown that tight hip flexors can cause your glutes to switch off. As mentioned before, weak or switched off glutes can contribute to a wide variety of lower limb injuries at the hip, knee and ankle. It is therefore important that you include stretches for the Rec Fem in your regular training programme. Hip flexor and quad stretch The main hip flexor muscles are the iliopsoas and rectus femoris. You should stretch both of these. Purpose: It should be clear from the discussion above that this is extremely important. You will activate your glute max much better if your hip flexors aren’t tight. Starting position: Half kneel with your one knee on a pillow and your other leg out in front of you. Hold on to something for balance if needed. Movement: A. Push your hip forward, but at the same time tilt your pelvis backwards. This is important – if you allow your pelvis to tilt forward, the stretch will not be as effective. This will mainly stretch the iliopsoas muscle, but if you’re very tight you may have to spend time on this part first and then add in part B. 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. Problems due to a tight Vastus Lateralis (VL) Remember that I mentioned that your kneecap sits in the middle of your patellar tendon? All four of the quadriceps muscles attaches to this tendon. If your VL on the outside is tight, it will pull your kneecap slightly out of alignment. Your kneecap is meant to move friction free in its groove, but if the VL is very tight it can cause the kneecap to strain. The current clinical opinion is that this is one of the causes of patello-femoral pain or runner’s knee. In addition to stretching, you can also use a foam roller to improve the flexibility of your VL. How to foam roll your quads In this video I demonstrate how to foam roll your quads. Injuries due to weak quads Having strong quads are extremely important if you want to avoid knee pain. Your muscles are meant to absorb significant amounts of the force when you walk. If they aren’t strong, it will increase the strain on your joints. So one of the best ways to protect your knees is to ensure that your quads are very strong. Not only does it prevent knee strain, but there is also evidence that people with arthritis have less pain and better quality of life if they strengthen their quads. Research in elderly people have also found that people with stronger thigh muscles are less likely to fall. Weakness in a specific part of the Vastus Medialis, the VMO, has also been found to be one of the causes of patello-femoral pain and is often found in combination with very tight lateral quads (as mentioned above). Strength exercises for the quads These exercises may not be right for you and I would suggest that you consult a physiotherapist or other healthcare professional to help you find an exercise that works for you – especially if you suffer with knee pain. The three exercise below are my favourites, but there are loads of other options available. The leg press My favourite exercise to improve quad strength is the leg press machine. I love it because: It’s stable and has a very low injury risk for beginners. You can really ramp up the weights over time and get good strength gains. You can easily do it with one leg at a time and make sure that both legs are equally strong. I’ve described how to use the leg press (even if you have knee pain) before, so will not go into detail again. Double leg squat Purpose: It strengthens your glutes, quads and hamstrings and teaches you good movement patterns for your legs. 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 sit-stand-sit with. Single leg sit-stand-sit Purpose: It’s a great exercise to strengthen your glute med, glute max, quads and position sense. Starting position: Choose a chair that you can manage to get up from using only one leg. Your aim should be to use a chair that places your knee in 90 degrees flexion, but if this is too hard use a higher surface. I usually place some pillows on the chair to make it easier. Sit on the edge of a chair with your one leg on the floor and the other one in the air. Your hands can either be in your sides or out in front of you. Movement: Slowly stand up from sitting, using only one leg. Make sure that your pelvis stays level and your knee moves in line with the middle of your foot. Then slowly sit down again. Check that: Your pelvis and knee stays aligned. If you find that you “plonk” down instead of slowly lowering yourself down, you may have to use a higher chair to start with. Aim: Test how many your can do with good form from 90 degrees knee flexion. Your aim should be to get to 22 with no wobbling and keeping your pelvis and knee aligned. I can only manage 8 with rather poor form so I should work on the exercise single leg squat with support before doing these. Retest this every 4 weeks to check on your progress. Start strengthening it by doing sets of 8 reps until fatigue. Rest at least 1 to 2 minutes between sets. Download these exercises as a PDF Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. References: Granacher, Urs, et al. "The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review." Sports Medicine 43.7 (2013): 627-641. 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. Moreland, Julie D., et al. "Muscle weakness and falls in older adults: a systematic review and meta‐analysis." Journal of the American Geriatrics Society 52.7 (2004): 1121-1129. Papadopoulos K, Stasinopoulos D, Ganchev D. A Systematic Review of Reviews in Patellofemoral Pain Syndrome. Exploring the Risk Factors, Diagnostic Tests, Outcome Measurements and Exercise Treatment. The Open Sports Medicine Journal 2015(9):7-17. Witvrouw E, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013. British Journal of Sports Medicine 2014;48(6):411-14. doi: 10.1136/bjsports-2014-093450

In this article I summarise the main points from the second episode of the Injury Prevention series which is all about core stability and how it influences lower limb injuries. The other topics that I’ll cover include position sense, glute med, glute max, hamstrings, quadriceps and calf. In this article: What’s your core and why is it important? The deep core muscles The superficial core muscles What is the perfect back/pelvis position? How to train the core effectively Nail the basic core exercises Download the core stability exercises What’s your core and why is it important? Most people know that your stomach muscles are part of your core, but it’s actually a lot more than that. Your core muscles include all the muscles around your pelvis, trunk, back and shoulder girdle. These muscles all have to work together to provide a stable base so that your arms and legs can move in a coordinated way. Imagine your arm or leg is a catapult and you want to use the catapult to shoot at a target. If the catapult is standing on a solid concrete base (your core), you can aim it accurately and it will move in a predictable way so that you hit the target every time. If, however, the catapult is standing on a block of jelly (poor core stability), it’s impossible to accurately aim the catapult and it will move in a slightly different way every time that you fire it. From the above example it is clear that a lack of core stability will affect how your legs move when you exercise. It’s therefore no surprise that the research has shown that poor core stability can predispose athletes to a range of lower limb injuries including ACL tears, other knee ligament injuries, patello-femoral pain or runner’s knee, medial tibial stress syndrome (shin splints) etc. For this article, I’m going to focus on the core muscles around the pelvis, trunk and lower back as I’m only interested in lower limb injuries for now. The muscles in these areas can roughly be divided into 2 layers namely the deep and superficial layers. Despite all the research that has gone into this area we’re not yet exactly sure how the core muscles work and I’m going to provide a very simplified explanation below. The deep core muscles Think of this layer as providing the main stability to your spine and pelvis. They don’t create any movement when they contract, but instead increases your intra-abdominal pressure which helps to stabilise your spine. They have to fire milliseconds before the other muscles and include the pelvic floor muscles, transverse abdominus (deep stomach muscles) and multifidi (deep back muscles). That’s why you have to work on isolating these muscles, before you move on to more taxing core exercises. The superficial core muscles These are the large muscles e.g. your erector spinae, obliques and rectus abdominus muscles. They play an important role in core stability as they have to ensure that your core moves in a controlled way. Core stability is not just about having abs of steel in static position e.g. the plank. We are constantly moving and we have to strengthen and train our core muscles to effectively control our trunk and pelvis throughout the full range of movement. For examples, when you walk your trunk and pelvis rotates as your legs move and arms swing. This is normal and needed to move effectively. An example of poor core stability would be if someone allows their pelvis to tilt forward excessively or their trunks to side bend when they walk. What is the perfect back/pelvis position? There is no such thing as perfect alignment. We all have unique bodies and no 2 peoples' bones and muscles are exactly the same. This said, there are some broad parameters that are seen as “ideal”: Your lumbar spine should have a gentle curve. Your pelvis should not be tilted severely forward. If this is the case you will likely also have an excessive curve in your lumbar spine. Your pelvis should not be tilted all the way back. If this is the case your will likely also have a flat lumbar spine with nearly no curve. When you stand on one leg, your pelvis should remain level (one side should not drop) and it should not tilt forward or backwards. When standing on one leg your trunk should remain upright and not lean to one side. How to train the core effectively Step 1: You have to start by teaching yourself how to move your spine and pelvis segmentally and find your neutral spine position. As discussed above, your neutral position is where your lumbar spine has only a gentle curve. The Cat/Camel exercise (see below) is great for teaching you segmental movement. Step 2: The deep layer of your core muscles should always fire before the big superficial muscles kick in and the next step is to learn how to isolate these. When you contract your pelvic floor muscles, they usually automatically activate the multifidus muscles in the back and the transverse abdominus muscles in your stomach. I’ll explain how to do this in detail below. Step 3: Once you can effectively find your neutral spine and activate your deep core muscles, it’s time to start adding in movement. The Toe Taps level 1 exercise is a great exercise to teach you how to maintain a stable back and pelvis while moving your legs. This is very important, because you want your back and pelvis to remain in good positions regardless of what your legs may be doing. Step 4: From this point on, you can slowly make the exercises harder and more difficult and also incorporate complex movements as long as you always ensure that you activate/contract your deep core muscles first. The Toe Taps level 2 and 3 are good progressions. Nail the basic core exercises Cat/Camel Aim: To teach you how to move your spine and pelvis one segment at a time. Start on all fours with your back straight, hands under the shoulders and knees under the hips. Imagine you have a tail attached to your bottom. Using your stomach muscles, tuck your tail between your legs and continue the movement with the rest of your spine so that your whole spine is curled up to the ceiling. Now reverse the movement by sticking your bottom up to the ceiling and curling your spine down to the floor so that you make a hollow in your lower back. You should initiate the movement from the pelvis and lower back and follow it with the rest of the spine. Do 10 times Activating the deep core muscles Aim: Your deep core muscles should contract before the rest of the core. This exercise will teach you how to isolate them. Research has shown that when you contract the anterior pelvic floor muscles (those are the ones that stops you from urinating and wetting yourself), you also automatically contract the transverse abdominus muscle. Similarly, when you contract the posterior pelvic floor muscles (those are the ones that stops you from farting in public), you automatically activate the multifidus muscles in your back. So we can use the pelvic floor muscles to activate the rest of the deep core muscles. Lie on your back with your knees bent and your lower back in a neutral position. Contract your anterior pelvic floor muscles by imagining that you’ve got a massive wee and you don’t want to wet yourself. For men, it’s also that sensation that you get when you walk into very cold water and everything down there tries to pull up and away from the cold. At the same time contract your posterior pelvic floor muscles by imagining you have wind and you don’t want to fart in public. It’s not squeezing your bum cheeks or glutes. You should just tense the muscles around your anus without tensing your glutes. The key to getting this right is to contract these muscles gently and slowly at first. If you do a quick hard contraction, the other stomach muscles usually kicks in. Make sure that your neck and chest is relaxed and that you’re not tensing the rest of your body. Hold the contraction for 10 sec while breathing normally. Repeat at least 10 times and practise this throughout the day in all positions e.g. sitting and standing as well. It can be hard to isolate these muscles at first but practise makes perfect. Toe Taps level 1 Aim: To teach you how to maintain a stable back and pelvis while your legs move freely. Starting position: Lie on your back with your knees bent. Some people find it useful to place their hands under their lower backs so that they can feel if it moves. Use your lower stomach muscle to press your lower back flat onto the floor or onto your hands. Your chest and neck should be totally relaxed. Movement: Engage your core by recruiting your pelvic floor and lower stomach muscles. Lift one leg up to 90 degrees hip flexion, keeping the knee bent. Keep your back and pelvis completely still at all times. Then slowly place the foot back on the floor and repeat with the other side. Check that: Your pelvis does not twist and lower back DO NOT LIFT off the floor as you lift and lower your foot. I find it best if you concentrate on making sure that you feel the pressure of your back pushing into your hands, rather than thinking about lifting the leg. Aim: 2 sets of 10 lifts each side Once you find this exercise easy, move on to level 2. Toe Taps level 2 Aim: To teach you how to maintain a stable back and pelvis while your legs move freely. It’s just harder than the exercise above. Starting position: Lie on your back with your knees bent. Some people find it useful to place their hands under their lower backs so that they can feel if it moves. Use your lower stomach muscle to press your lower back flat onto the floor or your hands. Your chest and neck should be totally relaxed. Movement: Engage your core by recruiting your pelvic floor and lower stomach muscles. Lift one leg up to 90 degrees hip flexion, keeping the knee bent. Keep your back and pelvis completely still at all times. Then lift the other leg up to join the first. Now slowly place your first leg back on the floor followed by the other one. Repeat, but start with the other leg first. Check that: Your pelvis does not twist and lower back DO NOT LIFT off the floor as you lift and lower your foot. I find it best if you concentrate on making sure that you feel the pressure of your back pushing into your hands, rather than thinking about lifting the legs. Aim: 2 sets of 10 lifts Once you find this easy move on to level 3. Level 3: Single leg stretch Aim: To strengthen the core muscles and teach you how to maintain a neutral spine and pelvis while moving your legs. 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. Only straighten the leg as far as you can control your back e.g. if you feel your spine lifting off the floor when your knee is half extended, only extend it half way. As you get stronger, you can then straighten your leg out further. 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. Do 10 reps, Rest 1 minute, Do 3 sets Build up to 20reps x3 sets In this video PT Timmo demonstrates some more core exercises that you can do in the gym. Download the core stability exercises as a PDF Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate References: De Blaiser C, Roosen P, Willems T, et al. Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy in Sport 2018;30:48-56. doi: 10.1016/j.ptsp.2017.08.076 Roussel NA, Nijs J, Mottram S, et al. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers. A prospective study. Manual therapy 2009;14(6):630-35. Verrelst R, De Clercq D, Vanrenterghem J, et al. The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study. Br J Sports Med 2013:bjsports-2012-092126. Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in Neuromuscular Control of the Trunk Predict Knee Injury Risk: Prospective Biomechanical-Epidemiologic Study. The American journal of sports medicine 2007;35(7):1123-30.