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Incline walking might be a good substitute for running for people who are at risk of injury from the latter. A growing body of evidence is showing that vigorous physical activity holds much greater health benefits than moderate level activity. The problem with this is that the people who are most in need of these types of improvements (e.g. the older population) are often not able to do vigorous physical activity due to other health issues e.g. lower back pain or arthritic knees … or are they? What pops into your head when you hear the words vigorous physical activity? Army training, spinning, running, or boot camp? Activities that we traditionally class as vigorous, e.g. running, put a lot of strain on the lower limbs and may therefore not be ideal if you have other injuries. But what about walking? Do you think that walking can be classed as vigorous physical activity? A study conducted by researchers from the University of Norfolk has shown that our definition of what constitutes vigorous activity may be a bit warped.  It may indeed be possible to do vigorous activity without placing high loads on the joints in the lower limbs. Research into walking, incline walking, and running The researchers did a study where they compared three activities: Horizontal walking on a treadmill Incline walking (11%) on a treadmill Horizontal running on a treadmill They worked out the intensity of each activity by calculating how much oxygen participants used during the activities. Then they set the speed for it so that the incline walking’s intensity was equal to that of the horizontal running. Both of these activities were 3 times more intense than the horizontal walking. By doing this, the incline walking qualified as vigorous activity. They then measured all the forces that went through the lower limbs of the participants and their results were very interesting. Incline walking vs running - Results They found that the peak force as well as the rate of loading were significantly higher during running than during both walking conditions (this as expected). Interestingly, they found that the rate of loading during uphill walking was also lower than during horizontal walking. Looking at the total force during each activity, the researchers found that the participants experienced a 79% increase when running compared to walking uphill. What this means Uphill walking may thus be a safe (low orthopaedic load) alternative to get your dose of vigorous exercise from. I say low orthopaedic load because while walking puts less strain on your legs, it still puts a high strain on your cardiovascular (heart and lungs) system. You should consult your doctor or physiotherapist if you plan to take up vigorous exercise for the first time. The high intensity exercise may increase your risk for heart attacks or strokes. The researchers point out that for people who are not used to vigorous physical activity, the risk of having a heart attack etc. goes up 105-fold. In contrast, people who are used to vigorous activity only experience a 2.4-fold increased risk. Basically, what the research is showing is that vigorous activity is safe as long as you train responsibly. Gradually increase your fitness to the point where the body is able to cope with it. It is important to consult a professional if you feel uncertain. If you suffer with a specific condition e.g. high blood pressure, make sure that the person you consult is qualified to deal with different health conditions. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.

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

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

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

There’s nothing like getting injured to throw a spanner in the works when you’re earning a living abroad as a Digital Nomad. It doesn’t even have to be as serious as falling off an elephant. (Serves you right!) Just that persistent niggle in your neck from sitting hunched over your laptop for far too long can thoroughly spoil your adventure. But hey, you’re used to doing lots of stuff remotely, aren’t you? Making money, wrangling your personal admin and keeping in touch with friends and family. So why not have your injury treated remotely? Yes, remote physiotherapy is a *thing*! In this post: How remote physiotherapy works Why remote physiotherapy is so useful for Digital Nomads Please don’t do this How remote physiotherapy works People often ask us how we treat our remote patients without being able to touch them. The answer is simple: a massage may make your injury feel better for a while, but it won’t heal it. Our years of combined clinical experience and the latest research say it’s the right combination of rest and exercise – based on an accurate diagnosis and taking your lifestyle into account – to help along your body’s natural healing processes that does the trick. Here’s the drill when you have your first remote consultation with one of our physios: We hook up via Skype, Zoom, WhatsApp or whatever video platform suits you; We discuss how you got injured, your lifestyle and your daily routine, to give the physio a good understanding of the injury and its surrounding circumstances; Your physio will ask you to do some movements while they watch, and you give them feedback on what you feel and experience – these tests are similar to the ones used in a face-to-face clinic and will help your physio to figure out exactly what you have injured as well as what your muscle strength, flexibility and control are like; Then your physio guides you through a palpation examination and get you to examine different parts of your body by hand to distinguish between different ligaments, muscles and bones; All this helps the physio to arrive at a diagnosis, which they will discuss with you; Your physio compiles a personalised treatment plan based on your diagnosis, lifestyle, and abilities and explains it to you; If this includes exercises, they will get you to do them on video so that they're happy that you’re doing them correctly; You wave goodbye and log off; Your physio emails you a written report summarising the examination findings and treatment plan as well as pictures and/or videos of the exercises; Your physio is available on email after the consultation if you have any questions or concerns. Voilà! (You can read more about the nuts and bolts of it all here.) Why remote physiotherapy is so useful to Digital Nomads With having to live and work in many various settings, things aren’t always as ergonomic for Digital Nomads as we’d like them to be. Yes, you escaped the 9 to 5, but actually you’re more at risk of work-related aches and pains than someone who’s had their own office desk and chair set up *just so*. Not to mention long stints on public transport and having to lug all your possessions and kit around with you every time you move base. You’ve learnt the basics of the local language and maybe you can even hold your own in an argument after a tuk-tuk accident. But do you really feel up to communicating your needs properly and getting injury advice in a lingo you’re not familiar with? With remote physiotherapy, you can summon a medical professional who speaks your language. Physio treatment often involves more than one consultation. You’ve been living and working in Medellín and your next face-to-face appointment with your physio is in two weeks’ time...but by then you’re due in Buenos Aires! Back *home* (wherever that is) you might have been content to tough it out on the couch while your sprained ankle takes care of itself. But it sucks to be stuck in an Airbnb while everyone else goes off to gorge themselves on street food at the night market. Better to get yourself sorted so that you can make the most of your lifestyle. Please don’t do this You may be tempted to hack your injury by googling it for a DIY cure. Please don’t. A Harvard study of 23 online symptom checkers examined how accurate their diagnoses and triage recommendations were. The findings don’t exactly inspire confidence. “The online services listed the correct diagnosis first in about one-third of instances and listed the correct diagnosis in The top 20 possible diagnoses in more than half of cases. Concerningly, symptom checkers provided varying triage recommendations, with appropriate advice ranging from 33% to 78% of evaluations.” It takes years of clinical experience to figure out exactly what’s going on with an injury and what to do about it. All our physios have Masters degrees, each of us has more than 10 years' experience, and we've been fixing people remotely since 2014. So, if you’re struggling with an injury or aches and pains that won’t go away, please feel free to get in touch. We won’t really judge you if you fell off an elephant. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate

Remote worker Tom* booked into our online physiotherapy clinic from the Canary Islands after he had injured an elbow doing Brazilian jiu-jitsu. The injury kept him from fighting and hampered his strength training in the gym, and he didn’t want to wait until his return to the UK to get it fixed. We diagnosed his injury and gave him a bespoke rehabilitation programme via WhatsApp video and e-mail. Tom is one of a small but growing number of people who have come to realise the value of online physiotherapy. “But how can you fix my injury without touching me?” you may ask. Most injuries can be self-treated as long as you have an accurate diagnosis and a sensible treatment plan, which we can do on a video call. A massage may make you feel better for a while, but it won’t fix your injury. Our team of physiotherapists' combined years of clinical experience and the latest research suggest that it’s the right mix of rest and exercise, prescribed by a physio, that will heal you in the long run. Our typical international patient is someone who doesn’t have access to a physio where they live. We also get English-speaking expats who can’t find an English-speaking physio. And online physiotherapy is especially useful for people who can’t take time off work or find it difficult to travel with an injury to go and see a physio. They consult one of our team on a video call right there in the comfort of their own home to get a diagnosis and a bespoke treatment plan. Obviously this is handy for people in far-flung locations, but also in the UK, where we are based. All our physios have Masters degrees in a sports and exercise injury related field and each has more than 10 years' experience. We started offering our services online in 2014 and have seen the concept of online physiotherapy gradually gain acceptance. Business travellers, digital nomads and other regular users of video calls don’t find it strange anymore to access physiotherapy in this way. Soon it will be as normal for everyone as ordering groceries, take-out food or a cab online. Do you need help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.

Ankle injuries are one of the most common musculoskeletal sports injuries, and recurring ankle sprains – also referred to as chronic lateral ankle instability or chronic ankle instability – can come back again and again to frustrate runners and other sportspeople. This article explains how you can avoid suffering from recurrent ankle sprains. It is also something that one of our team of online sports physios can help you with via a video consultation. You may also find these articles useful: - Should I go to A&E with a sprained ankle? - How to treat a sprain – an update on the latest research - Ankle braces for sprains – Do you need one, what type works best, and when to wear it In this article: Why are recurrent ankle sprains so persistent? How to fix chronic ankle instability Other options for fixing chronic ankle instability Need more help? Why are recurrent ankle sprains so persistent? When you sprain your ankle it usually causes a tear in one of the ligaments. It can be a partial tear or a full tear. Your ligaments hold your ankle joint together, so if you tear them, then you are actually causing that joint to be temporarily unstable, if not longer. If someone were to tear a ligament in, say, their knee, most people would go, ‘Oh, gosh! You must get that better before you go back to playing!’ And really, the same thing should be said about your ankle. However, because ankle sprains are so common, people don't really take them as seriously as they should, and they often don't rehab them to the right level before they go back to running or playing sport. In these cases, the injury can either happen again or the ankle can still give you problems, because it is not stable enough for a return to the level of activity you were at before the injury. How to fix chronic ankle instability To prevent or fix recurrent ankle sprains, you should check whether one or more of the following issues need attention. Swelling in the ankle The first thing you might want to consider after you've injured your ankle and you've gone through your initial acute soft tissue management is whether there is still some swelling. If so, firstly, swelling can affect the sensory motor control of the muscles around your ankle, and that can affect your balance, which will predispose you to going over on your ankle again. Secondly, if you go back to playing sport or running with a swollen ankle, the swelling tends to cause some pinching at the top front of your ankle, called impingement, and that can cause problems down the line. So, if you’ve still got swelling in your ankle, the best thing is to say, ‘Actually, is it really ready to be going back to all the things I want to be doing, or does it need a little bit longer to just settle down?’ Range of movement After a sprain, sometimes your ankle can be a bit stiff in dorsiflexion, which is when you pull your toes up towards your chest or when you go into a squatting position. As you can imagine, this movement is also required of your ankle when you are running. Dorsiflexion is easily tested by seeing how far from a wall you can place your foot flat on the floor while your knee is touching the wall. (You can check our video below to see how this is done.) You should compare your recently injured ankle to the other one to see if there's much difference. Quite often after a sprain, this will be stiff and might need some work to get it better so that your biomechanics are right. Steph demonstrates these movements and some of the rehab exercises mentioned lower down in this video about recurrent ankle sprains: Strength exercises for chronic ankle sprain rehab Ankle strength is also important, because if the muscles that control your ankle aren't as strong as they used to be, then they can't control your ankle so well. Examples of strength exercises that you may want to be doing include heel raises and TheraBand work (see the video for a demo). Sometimes you might have problems where you're also not as springy as you used to be. Perhaps when you hop on one foot, you're nice and springy, whereas on the other one, where you injured your ankle, it's all flat-footed, which obviously affects your ability to run quickly. So, you need to not only make sure that your ankle strength is good in all directions - to properly prepare your ankle for sport, you also have to include plyometric exercises that can restore the springiness in your ankle. There's also some research that shows that hip and core strength can make a difference for people with chronic ankle instability, mainly because if you don't have very good hip control, then your biomechanics might not be as good as someone who's nice and steady in their core and around their glutes. Static and dynamic balance exercises for recurring ankle sprains Sometimes when you sprain your ankle, you disrupt the sensory receptors in your ligaments and around the soft tissue that tell your brain what your ankle is doing and help you to balance. This is also known as position sense or proprioception. Static balance is nice and easy to test. Stand on one leg with your eyes shut and compare it to how well you can do it on the other leg. Sometimes, people with a recently sprained ankle will find that their balance is not quite as good. This is another reason why people might sprain their ankle again, because they haven't rehabbed their static balance. However, when you're playing sport, you're not just staying still, so you also have to look at what we call dynamic balance. This may involve reaching in different directions with one leg while you're maintaining your balance with the other, or it might be something more dynamic, like hopping and skipping sideways, forwards, and backwards. That's the next level of balance-type exercises that you need to be able to do to try and reduce the risk of spraining your ankle again. How quickly your ankle muscles can react to unstable surfaces or running over uneven ground can also be a good test to see how it can cope with the sort of mechanism that might injure it and how quickly your muscles can stop it from happening. Biomechanics The way that you walk or run can also tell us some things about your ankle. Sometimes people don't push off the way they do on their other leg, and that is an indication that you need more strength around your ankle. Sometimes, it's just something about the way you're running in general that actually predisposes you biomechanically to going over on your ankle. We can observe this during our consultations by getting you to perform test movements or asking you to film yourself while running on a treadmill. This can usually be fixed by improving the hip and core strength that I mentioned earlier. Other options for fixing chronic ankle instability You could consider getting scans and investigate taking the surgical route to fix recurring ankle instability. However, if you haven't done any of the rehab mentioned in this article to the very top level that you need it – and that depends on what physical activity that you are trying to get back to doing – then I suggest you do a rehab program for chronic ankle sprains first. Give it at least three to six months and try and get it as good as you can get it before you think about whether or not you need any scans or orthopaedic opinions. Need more help? If you need help with such a programme, that's the sort of thing we do all the time, so take a look at our website and then, if you want an individual assessment, please do book in, and we'll compile a bespoke ankle sprain treatment plan for you to get your ankle as strong as it can be. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can read more about her here, and she's also on LinkedIn. Research references: Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A. M., van Beek, P. A., Hullegie, W. A. M., Bloemers, G. M. F. M., et al. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854-860. Lephart, S. M., Pincivero, D. M., & Rozzi, S. L. (1998). Proprioception of the ankle and knee. Sports Medicine, 25(3), 149-155. Vuurberg, G., et al. (2018). "Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline." British Journal of Sports Medicine 52(15): 956-956.

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

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

Exercise in pregnancy is a common topic of concern for mums-to-be.  There are vast resources of information online but this can be overwhelming and it may be difficult to discern which advice is best to follow. Some women may feel anxious because the advice they receive from their peers or health care professionals is inconsistent with the information available online and they do not know who or what information to trust. In this article woman’s health physio, Kim van Deventer, answers common pregnancy exercise related questions. In this article: Is exercise safe during pregnancy? Why is it good to exercise during pregnancy? How can I make sure that I am exercising safely? Exercises that are encouraged or should be avoided during pregnancy When is exercise not safe in pregnancy? What if I can’t exercise because of other issues? When and where to get help One of the first questions I usually get from a new mum-to-be is "What exercise should I be doing now that I am pregnant?". Once the reality sinks in that she is now responsible for growing a little life inside of her, more questions seem to stream out with anxious desperation.  "What should I avoid?", "How much should I be doing?" and "How will I know when I am overdoing things?". No matter what a pregnant woman’s previous level of activity is, most usually have same concerns about exercise during pregnancy. So let’s answer a few important questions and put your mind at ease. Is exercise safe during pregnancy? Yes, it is.  During an uncomplicated pregnancy physical exercise is safe and beneficial for the baby and the mother. Regular, moderate intensity exercise is encouraged in healthy pregnant women and it is not associated with increased risk of preterm birth. According to some low quality studies, however, there may be an increased risk for miscarriage when there is intense exercise at the time of implantation and it is advised that if you want to become pregnant you may want to consider limiting the intensity of high-impact exercise in the week after ovulation, and refrain from repetitive heavy lifting in the first trimester. Why is it good to exercise during pregnancy? What a relief it is to know that there are so many benefits to exercising during pregnancy that it is too difficult to discuss all of them in detail in one article. I have summarised a few of the major benefits for mum and baby in the table below. The above table shows that not only is exercise beneficial for mothers, it is also substantially beneficial for foetal health and well-being which may extend into childhood and adulthood. The programming effect Regular exercise during pregnancy seems to elicit what scientists call a "prenatal program­ming effect".  This means that foetuses adapt to an impaired nutrient supply (either under- or over nutrition) by changing their physiology and metabolism in utero. It has been found that low birth weight is more likely associated with changes in the cardiovascular system whereas a higher than normal birth weight, due to a maternal “obesogenic” environment, is more likely associated with disorders of glucose metabolism such as obesity and diabetes mellitus. This "programming effect" highlights the importance of managing maternal body composition and dietary balance during pregnancy. Essentially, what the science says is that if you are fitter and healthier during pregnancy and if you create a healthy environment in utero dur­ing the critical time of foetal organ development, your baby will also be fitter and healthier at birth. Using this time in your life is a good way to make lifestyle changes that stick for you and your child. How can I make sure that I am exercising safely? Up until recently women were advised to avoid strenuous aerobic exercise during pregnancy, but new research has shown that most women can continue with their pre-pregnancy exercise routines with no adverse effect. 1. Understand how your body changes To make sure that you exercise safely during pregnancy it is important to understand the changes that occur in your body during pregnancy and how they affect you and your baby. Everything from your hormones and connective tissue to your joints and organs will experience phenomenal change. A few of these changes include: Your blood volume increases by almost 50% and there is up to 50% increase in your cardiac output (how hard your heart has to work to move all the extra fluid around). You will have 20% more oxygen consumption and an increased sensitivity to CO2 in your bloodstream. Your rib cage expands and your diaphragm is pushed up by 4cm. There is a 30% increase in kidney volume and the length of your kidneys increases by 1 to 1.5 cm. Your joints loosen, your centre of gravity shifts and your stability is reduced which causes your stance width to increase and your step length to decrease during walking. In addition to this your baby’s core temperature is approximately 0.6 ˚C more than yours. It may be a little easier to understand why you swell up, why you feel out of breath, why you need to go to the toilet more often, why you waddle and why you feel like a human furnace most of the time.  Even in the snow. 2. Understand the aims of exercise during pregnancy The aim is to maintain current fitness levels if previously active and to improve fitness levels and develop healthy lifestyle habits if you have not previously been physically active. Avoid aiming to achieve peak athletic levels during pregnancy.  After pregnancy the aim is to regain your previous level of fitness or if you were not previously exercising, to improve on what you have achieved during pregnancy. 3. Training Volume The UK’s Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women engage in 30 minutes of moderate intensity aerobic activity each day or approximately 210 minutes (3.5 hours) per week. Studies have shown that doing more than 270 minutes each week could potentially lead to pre-eclampsia in some women. For previously sedentary pregnant women and recreationally active pregnant women the guidelines for exercising in pregnancy are now almost the same as for non-pregnant women.  Get fit slowly and build it up gradually, or maintain it. 4. Monitoring workout intensity Traditionally, measuring your heart rate during exercise outside of pregnancy is accepted as the most effective way to monitor exertion and gauge exercise intensity levels.  However, during pregnancy your heart rate response varies day to day due to the previously highlighted physiological changes and using a heart rate monitor is not as reliable. You should aim to avoid over-exertion but you do not need to keep your heart rate below any particular number.  Instead you should use measures that gauge the intensity of your physical activity using perceived rate of exertion like that of the "Talk Test" or "Borg Scale". Keep in mind that every pregnant woman will have her own level of perceived exertion.  Exercising with a friend is a good way to monitor your intensity. The talk test is a simple and reliable gauge that will help to ensure that you meet your cardiovascular and metabolic demands during exercise when pregnant. I find the talk test easier and more practical for pregnant ladies to use. If you are able to maintain a conversation while exercising without feeling out of breath or uncomfortable, then you know you are working at the right level. The Borg Scale is a little tricky to remember each level of intensity if you haven’t used it before and some women have reported that it is also not as easy as the talk test to use on a whim. In pregnant elite sportswomen there may be a limit to how intensely they should exercise. There is evidence that exercising at intensities above 90% of your maximum heart rate may compromise foetal wellbeing. It is advised that elite athletes, trying to keep within ‘safe’ ranges of exercise intensity, should measure heart rate directly. 5. Temperature Regulation: Maternal temperatures above 39 degrees Celsius may harm your baby. Make sure that you do not overheat by choosing cooler times of the day to exercise in, staying well hydrated and wearing loose, breathable clothing. If you exercise in a pool make sure that the temperature of the water is less than 33 degrees Celsius. 6. Risk of falls: You are more susceptible to injury when you are pregnant so you may need to alter your routine if you usually participate in sports or activities that might pose a risk of injury. During pregnancy you will experience temporary balance impairments and you should avoid anything that puts you at risk for abdominal and joint injury due to falls. This includes most contact sports, vigorous racquet sports, and exercise involving balance. 7. Progressing exercise: If you are pregnant with no complications and are new to exercise, start slowly and as low impact as possible and then build it up as you are able. Start with 15 minutes, 3-4 times a week and slowly increase it to 30 minutes every day. If you are already recreationally active and have no pregnancy complications then you can continue to do what your body is used to. Adjust things as your talk test allows. If you are healthy and have no pregnancy complications, adding brief higher intensity intervals to your workout will help you burn more energy and enhance your enjoyment of exercise in late pregnancy. Just remember to keep the intensity below 90% of maximum heart rate. 8. Good to know: Avoid lying on your back for prolonged periods of time during exercise (especially after 16 weeks) if you have symptoms such as faintness or light-headedness. Yoga has been shown to be safe and more effective than walking or general antenatal exercises. Remember that some exercise is better than no exercise so find an exercise you enjoy and stick with it. Exercises that are encouraged or should be avoided during pregnancy Many women often ask me for a list of specific exercises that they should be doing or that they should avoid. In the table below I have listed specific exercises that are encouraged during pregnancy and some of those that are best to be avoided during pregnancy. *Please note:  Exercises should only be done if they are within your capabilities and according to your talk test.  Do not start new high impact or higher intensity activities if you are not accustomed to them. Every day during pregnancy your body is dealing with different changes, so from a fitness and energy perspective your abilities and performance may also change from day to day.  Take exercise one day at a time and always listen to your body. Only do what your body can manage for that day. When is exercise not safe in pregnancy? Exercise is not safe if you have: Vaginal bleeding Reduced foetal movement Serious heart, lung, kidney or thyroid disease Poorly controlled Type1 diabetes History of miscarriage, premature labour or "small for dates" babies in this or previous pregnancies High or low blood pressure (discuss with your doctor) Placenta praevia after 26 weeks (discuss with your doctor) Acute infectious disease Seek medical advice before commencing exercise in pregnancy if you have (or are): Asthma Controlled Type 1 Diabetes (discuss with your doctor) History of miscarriage High blood pressure Early placenta praevia Anaemia Extremely overweight or underweight Heavy smoker Pelvic or low back pain Stop exercising immediately and call your doctor/ midwife as soon as possible if you experience the following: vaginal bleeding and/or fluid leaking from your vagina uterine contractions dizziness chest pain or uneven heartbeat headache severe and abnormal abdominal, calf, back or pelvic joint pain difficulty in walking What if I can’t exercise because of other issues? Pregnancy complications If you have any pregnancy complications you may be limited in what you are able to do, but there may also be certain types of exercises which are still suitable for you. Discuss this with your obstetrician and get clarity about what you may and may not do.  Once you have this information your physiotherapist can help determine if there is an exercise that is appropriate for you. Common complaints During pregnancy there are common physical complaints that you may experience.  These can cause barriers to starting exercise or continuing with an existing exercise routine. Low back and pelvic girdle pain (PGP, SPD etc.) is estimated to affect about 50% of women during pregnancy. This condition can be debilitating, but it does not have to be that way for you. There is specific advice for you and a few simple exercises that you can do to help yourself become pain free and stay that way. Pelvic floor dysfunction and urinary incontinence result in many pregnant women avoiding physical activity during pregnancy (and after).  If you learn how to correctly activate and strengthen your pelvic floor muscles, you can help prevent these issues or cure them. Having a healthy and responsive pelvic floor can help make labour easier for you too! When and where to get help If you have any physical problems during pregnancy the secret is to get help early. The sooner you are diagnosed the easier it will be to manage and the quicker you can get back to enjoying your pregnancy. If you are ever unsure of anything and would like to have information about antenatal, postnatal and women’s health and fitness issues then POGP is a great resource. Physiotherapists, especially those who are specialised in antenatal and postnatal rehabilitation, are able to provide you with the information and guidance that can get you (and keep you) safely exercising and help you manage any of your physical complaints during pregnancy. In the meantime Educate yourself, be kind to your body, appreciate it for what it is accomplishing and learn to really listen and respond appropriately. About the Author Kim Van Deventer is a freelance healthcare writer and digital content strategist for healthcare businesses and medical content agencies. She worked as a physiotherapist for more than 14 years, specialising in sports injury rehabilitation, chronic pain management, and women's health. Kim combines her clinical experience and digital marketing skills to create relevant and helpful content that improves patients' lives. 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Role of Exercise in Reducing Gestational Diabetes Mellitus. Clin Obstet Gynecol. 2016 Sep;59(3):620-8. 7) Davenport MH, Skow RJ, Steinback CD. Maternal Responses to Aerobic Exercise in Pregnancy. Clin Obstet Gynecol. 2016 Sep;59(3):541-51. 8) Christie Ward-Ritacco, Mélanie S. Poudevigne, and Patrick J. O’Connor. Muscle strengthening exercises during pregnancy are associated with increased energy and reduced fatigue. Journal Of Psychosomatic Obstetrics & Gynecology Vol. 37 , Iss. 2,2016 9) Kissler K, Yount SM, Rendeiro M, Zeidenstein L. Primary Prevention of Urinary Incontinence: A Case Study of Prenatal and Intrapartum Interventions. J Midwifery Womens Health. Jul 2016;61(4):507-11. doi: 10.1111/jmwh.12420. Epub 2016 Mar 11. 10) Haakstad LA, Edvardsen E, Bø K.  Effect of regular exercise on blood pressure in normotensive pregnant women. A randomized controlled trial.  Hypertens Pregnancy.  2016 May;35(2):170-80. doi: 10.3109/10641955.2015.1122036. 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Exercise During Early Pregnancy is Associated With Greater Sleep Continuity. Behav Sleep Med. 2016 Oct 14:1-14. [Epub ahead of print] 15) Artal R. Exercise in Pregnancy: Guidelines. Clin Obstet Gynecol. 2016 Sep;59(3):639-44. doi: 10.1097/GRF.0000000000000223. 16) Pivarnik JM, Szymanski LM, Conway MR. The Elite Athlete and Strenuous Exercise in Pregnancy. Clin Obstet Gynecol. 2016 Sep;59(3):613-9. doi: 10.1097/GRF.0000000000000222. 17) Salvesen KÅ, Hem E, Sundgot-Borgen J.  Fetal wellbeing may be compromised during strenuous exercise among pregnant elite athletes. Br J Sports Med. 2012 Mar;46(4):279-83. doi: 10.1136/bjsm.2010.080259. Epub 2011 Mar 10. 18) Błaszczyk JW, Opala-Berdzik A, Plewa M. Adaptive changes in spatiotemporal gait characteristics in women during pregnancy.Gait Posture. 2016 Jan;43:160-4. doi: 10.1016/j.gaitpost.2015.09.016. Epub 2015 Sep 28. 19) Cakmak B, Ribeiro AP, Inanir A. Postural balance and the risk of falling during pregnancy. 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I am often asked what the best strength training exercises are for runners. My answer is: ones that you’re actually going to do! Keep them simple and don’t make the list too long – otherwise the thought of having to do it can overwhelm an already busy mind. I suggest that you choose exercises that can be done anywhere (no excuse if you cannot get to the gym) and target more than one muscle group (this reduces the number of exercises you need). The strength exercises below are aimed at runners who do not have a lot of experience with strength training. I have chosen them because they are safe and not very complex. These exercises will give you a good base level of strength, which will allow you to add more complex and heavy exercises in a few months. In this article: How to get the most out of your strength training Strength training programme for beginner runners Hamstring Bridge exercise for beginner runners Squat exercise for beginner runners Core exercise for beginner runners Push-Ups for beginner runners Calf strengthening exercise for beginner runners How to get the most out of your strength training You should continually progress the intensity of your training by either increasing the sets of exercises, the number of repetitions or the weight that you are using. You will not progress if you just do the same thing week in and week out. What I mean by: Reps (repetitions): That is how many times you perform the movement before you rest. Sets: If I ask you to perform 3 sets of 10 reps of an exercise it means that you have to do 10 repetitions, then rest, then another 10 repetitions, rest and then another 10 repetitions – it means doing the required number of reps 3 times, but with rest periods in between. Rest: Your muscles use the rest periods between sets of exercise to recharge its energy stores. Rest periods for beginners should last between 1 and 2 minutes. Download programme as PDF Strength training programme for beginner runners Please note: The exercises below should be OK for most healthy people. You should not feel any pain during or after doing the exercises. If you do experience any discomfort, please contact your healthcare provider. Hamstring Bridge exercises for beginner runners I prefer this version of the bridge exercise, since it targets the hamstring muscles a lot more than when your feet are on the floor. It’s a great all-in-one exercise that strengthens the hamstrings, glutes, back and core muscles. Start by doing the double leg exercise and then move on to the single leg one once you feel ready. START WITH: Double-Leg Hamstring Bridge Starting position: Lie on your back with your hips and knees bent to 90 degrees and your feet on a chair. Movement: Tighten up your stomach muscles and lift your bottom off the floor until your trunk and pelvis form a straight line. Squeeze your buttocks and stomach muscles and hold the position. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp – shift your bottom closer to your feet. Dosage: Hold the position for 20seconds, Rest for 20 seconds, Repeat 6 times PROGRESS TO: Single-Leg Hamstring Bridge Starting position: Lie on your back and place one heel on the top of a chair and keep the other foot in the air. Movement: With the knee resting on the chair slightly bent, lift your bottom off the floor until your body forms a straight line. Tighten up your stomach muscles and your glutes. Your pelvis must stay in a straight line. Do not allow the one side to drop to the floor. Then slowly lower yourself back down. Check that: You do not put too much pressure on your neck and that you do not over-extend your back by trying to lift your hips too high. It may be an indication that you are forcing the movement too much if your back hurts afterwards. If you find that your hamstrings cramp – shift your bottom closer to your feet. Dosage: Do 3 sets of 10 slow reps with each leg. Rest 1 minute between sets. Squat exercises for beginner runners Start by doing the double-leg free squat, but move on to doing the single-leg one when ready. You should use this exercise to work on your running form as well as strength. Make sure that your knees move in a line with your second toes, but that they do not cross over the front of your feet. START WITH: Free Squat Starting position: Standing with feet pointing forwards and spaced hip distance apart. Movement: Squat down by pushing your bottom out to the back (pretend you want to sit on a chair) and bending your knees. Hold the position for 3 seconds and return to standing upright. Check that: Your feet stays in a good neutral position. Your knees should move in line with your second toe. Your bottom sticks far out to the back. Dosage: Start with whatever your knee allows you to do but you should aim to get up to 3 sets of 12 repetitions over time. Rest 2 minutes between the sets. Once you can easily achieve this progress by replacing it with the single-leg squat with wall support. PROGRESS TO: Single-Leg Squat With Wall Support Starting position: Stand hip distance away from a wall and balance on the outside leg. Bend the other knee up and press that knee and ankle against the wall (do not lean into the wall with your hip). Movement: Squat down by bending the supporting knee and stick your bottom out backwards. Hold the position for 10seconds before you stand up and rest. Check that: Your knee moves in line with your second toe, but that your knee also stays behind the toes. If your knee hurts, you are either going down too low or you are allowing your knee to drift over the toes which will put more pressure on it. You can fix this by sticking your bottom further out to the back. Dosage: Hold the position for 10 seconds, then repeat it with the other leg. Do 10 reps on each leg. Core exercises for beginner runners The aim of the first exercise is to teach you how to control your spine (keep it flat against the floor) while you move your legs. Only move on to the second exercise once you have mastered this. START WITH: Toe-Taps Level 1 Starting position: Lie on your back with your knees bent and your back flat into the floor. Movement: Engage your core by recruiting your pelvic floor and stomach muscles. Lift one leg up to 90 degrees at the hip, keeping the knee bent. Keep your back and pelvis completely still at all times. Then place the foot back on the floor and repeat with the other side Check that: Your pelvis and lower back do not lift off the floor as you lift and lower your foot down to the floor. Once you find this exercise easy, move on to the single-leg stretch exercise Dosage: Build up to doing 3 sets of 14 reps. Rest 1 minute between sets. PROGRESS TO: Single-Leg Stretch Starting position: Lie on your back with your knees bent and your lower back flat on the floor. Movement: Engage your core by recruiting your pelvic floor and stomach muscles. Slowly straighten one leg out while you make sure that YOUR BACK STAYS ABSOLUTELY FLAT ON THE FLOOR. Slowly alternate legs. Check that: Your back stays absolutely flat on the floor throughout the exercise. Do not rush this exercise – it is more difficult to do it slowly. Dosage: Build up to doing 3 sets of 20 reps. Rest 1 minute between sets. Push-Ups for beginner runners Even though you may think that this exercise is all about arm strength, it's actually not. When done correctly, the push-up strengthens your core muscles as well as your arms. You have to make sure that your back does not sag down towards the floor during the exercise. START WITH: Knee Push-Ups Starting position: Lie on your stomach with your hands on the floor beside your shoulders. Tighten your stomach muscles and keep them braced throughout the whole exercise. Movement: Raise your body off the floor by pushing up and extending your elbows while keeping your knees on the floor, your chin tucked in and your body straight like a plank. Lower yourself back down, nearly touching the floor and repeat. Check that: If your back hurts during this exercise, it may be a sign that you need to tighten your stomach muscles - your back should be flat throughout the movement. Dosage: Build up to doing 3 sets of 15 reps. Rest 1 minute between sets. PROGRESS TO: Full Push-Ups Starting position: Lie on your stomach with your hands beside your shoulders. Movement: Tighten up your stomach muscles. Raise your body off the floor by straightening your elbows, keeping your chin tucked in and your body straight as a plank. Bend your elbows and lower yourself back down - stop just short of the floor. Repeat. Check that: If your back hurts during this exercise, it may be a sign that you need to tighten your stomach muscles - your back should remain flat throughout the exercise. Dosage: Build up to doing 3 sets of 15 reps. Rest 1 minute between sets. Calf strengthening exercises for beginner runners I suggest that you do 2 variations of heel raises over a step to strengthen your calves and Achilles tendons. You target different muscles in the calf by doing this exercise with your knee bent vs. the knee straight. START WITH: Bodyweight Heel Raises (some with knee bent and some with knee straight) Starting position: Stand on one leg on a step. Hold on to something for stability, as this is not a balance exercise. Movement: Keeping your knee STRAIGHT (A) slowly lift up and down on one leg for the required repetitions. Repeat this with the other leg. Rest for 1 minute and do one more set with your knee straight. Then repeat the exercise, but this time keep your knee BENT (B) throughout the movement. Dosage: Build up to doing 2 sets of 15 reps with the knee straight AND 2 sets of 15 reps with the knee bent with each leg. Rest 1 minute between sets. PROGRESS TO: Weighted Heel Raises Once you can easily do 2 sets of 15 reps of the above exercise increase the difficulty by doing it with some extra weight. Either hold a dumbbell in your hand or place some weight in a backpack on your back. Reduce the repetitions and slowly build up to 2 sets of 15 reps of each exercise. Repeat this cycle. Every time that you can execute the required repetitions with ease, add some more weight and slowly build the reps up again. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.

‘‘More marathons are won or lost in the porta-toilets than at the dinner table.’’ This quote from Bill Rodgers, a marathon legend from the 1970’s, sums up the plight of many a distance runner. Depending on the event and conditions, studies have found that between 30% and 90% of endurance athletes experience intestinal problems while competing. Symptoms vary in intensity and can include nausea, vomiting, stomach cramps, diarrhoea and even bloody stools. The research seems to suggest that some people may have a genetic predisposition to developing these problems, but that does not mean that you can't improve your situation. In this article: How exercise can cause an upset stomach Mechanical causes Nutritional causes of stomach problems during exercise Medication can aggravate your gut 10 steps to fewer stomach problems while running How exercise can cause an upset stomach One of the main causes for stomach problems during exercise is a decrease in blood supply to the gastrointestinal system. During high intensity exercise, up to 80% of the gut’s blood supply is shunted away from it to the exercising muscles and organs (e.g. the lungs). This leads to a lack of oxygen and damages the cells that line the gut wall causing nausea, vomiting, abdominal pain and/or diarrhoea. You may feel that there’s not much that can be done about this, but research suggests that the reduction in the intestinal blood flow is less severe in athletes who train regularly. Low intensity exercise does also not seem to affect the gut as much as high intensity exercise. You may thus improve your symptoms by training regularly and by decreasing the intensity to a level where you do not experience symptoms. There are also some nutritional strategies that you can follow. For instance, ingesting nitrate (found in beetroot and green leafy veg) during exercise has been found to increase the gut’s blood flow and improve performance. I’ll explain this in more detail in the advice section below. High intensity exercise can also contribute to reflux and nausea by decreasing the contractions of the oesophagus, making its valve less effective and causing food to remain longer in the stomach. You can read more about how to manage acid reflux during running here. Mechanical causes These are either related to impact or posture. Symptoms of the lower intestines are for instance more prevalent in runners than in cyclists. The repetitive high impact jostling of running is thought to damage the intestinal lining which contributes to symptoms such as diarrhoea. Cyclist, on the other hand, complain more of symptoms like reflux which may be exacerbated by the position that they are in on the bike. The good news is that these mechanical causes can be relieved by training! Researchers have found that regular training makes people’s guts less susceptible to mechanical strain. Nutritional causes of stomach problems during exercise It has been well documented that what we eat or drink during exercise can have a strong influence on gastrointestinal complaints. Studies done on Ironman athletes have found that ingestion of fibre, fat, protein and concentrated carbohydrate solutions all made it more likely for athletes to develop symptoms. All of these foods delay gastric emptying (stay for longer in the stomach) or causes more fluid to move from the body into the gut which can lead to nausea and diarrhoea. The problem is that we need carbohydrates during exercise and high concentrations of carbohydrates have been linked to better performance. Luckily researchers have found that endurance athletes seem to tolerate concentrated carbohydrates much better if they are made up of different types, such as glucose and fructose, rather than just glucose. This is because glucose and fructose are absorbed through different pathways and the processes can run in parallel, thus allowing the carbs to be absorbed more quickly. Dehydration has also been found to contribute to symptoms. The reason for this is most likely because it causes an even bigger decrease in blood flow to the digestive system. Medication can aggravate your digestive system I am often asked by people if it would help if they take pain tablets before sport. My answer is always NO! Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), of which the most well-known example must be ibuprofen, have been shown to lead to a five-fold increased risk of gastrointestinal complications in athletes. These can range from nausea to intestinal bleeds. You also risk kidney failure if you use them in a dehydrated state. 10 Steps to combat stomach problems while running Do not use aspirin or NSAIDs (especially ibuprofen) before/during training or racing. While a high fibre diet is needed to keep your bowel regular, stay away from high fibre foods the night before or on the day of competition. The same goes for spicy or fatty foods. Avoid high fructose food and drinks. Rather use drinks that contain a combination of fructose and other carbohydrates. Ingest carbohydrates with plenty of water or use drinks with lower concentrations of carbohydrates so that it can be absorbed quickly. When using a single carb solution (e.g. glucose only) it is recommended that you ingest 30–60 g/h (6% concentration) to avoid discomfort. For a combined fructose-glucose or fructose–maltodextrin solution, studies have found that athletes could tolerate 90-105g/h (8-10% concentration). Avoid solid forms of carbohydrates as this will be harder to digest and absorb. Carbohydrates enhances performance, but there is evidence that it is not necessary to ingest large amounts during exercise that lasts less than 60 minutes. In this case, rinsing your mouth with a carbohydrate solution is enough to enhance performance. The carbohydrates stimulate receptors in your mouth that activate the reward system in the brain and helps you to perform better. You must, however, make sure that you start your exercise fully carbo-loaded. Avoid dehydration by starting the race well hydrated and drinking according to thirst. You can learn more about how to tell if you are dehydrated here. Practice your nutritional strategies during training. This will “train” your gut to absorb nutrients better as well as tolerate the mechanical strain of food and drink during exercise. It may further highlight food that should be avoided. There is also research emerging that suggests that you can train your body to rely more on fat during endurance events which will decrease your need for carbohydrates, but more research is needed before one can make specific recommendations for this. Taking in nitrate during exercise can decrease the damage in the gastrointestinal system since it helps to increase the blood supply to the gut. Researchers suggest that you use a natural source e.g. beetroot juice, since it also contains vitamin C which is needed in order for the nitrate to work its magic. The only downside is that the natural food sources can also cause stomach discomfort of their own. Lastly, reduce your training intensity to a level that does not cause you stomach trouble while you test out different strategies. Keep it at this level for long enough to allow your digestive system to adapt. It is thought that regular training at a comfortable level increases the digestive system’s ability to cope with the strains caused by exercise. Once your stomach has settled, slowly increase the intensity. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: de Oliveira EP, Burini RC. Carbohydrate-Dependent, Exercise-Induced Gastrointestinal Distress. Nutrients 2014;6(10):4191-99. doi: 10.3390/nu6104191 de Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal Complaints During Exercise: Prevalence, Etiology, and Nutritional Recommendations. Sports Med 2014;44(1):79-85. doi: 10.1007/s40279-014-0153-2 Rowlands DS, Swift M, Ros M, et al. Composite versus single transportable carbohydrate solution enhances race and laboratory cycling performance. Applied Physiology, Nutrition, and Metabolism 2012;37(3):425-36. van Wijck K, Lenaerts K, Grootjans J, et al. Physiology and pathophysiology of splanchnic hypoperfusion and intestinal injury during exercise: strategies for evaluation and prevention. American Journal of Physiology-Gastrointestinal and Liver Physiology 2012;303(2):G155-G68.