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

A group of researchers from Sweden has developed a mobile app (Tät) that has been proven to effectively help people who suffer from stress urinary incontinence. They ran a randomised controlled trial with 123 women and the results were impressive. The group of women who used the app had a significant reduction in symptoms and an increase in quality of life after 3 months. They were also able to reduce the number of incontinence aids that they had to use per week. With regards to patient satisfaction, 96.7% of the women experienced the application as “good” or “very good”, and 100% would recommend the treatment programme to a friend. So what does this magical app do? It guides you through an exercise programme. Most cases of stress urinary incontinence in women can be improved if you can strengthen the muscles of the pelvic floor. Don't be put off by the word "exercise". You have to understand, that while we use the word “exercise” to describe these manoeuvres, you’re very unlikely to break into a sweat when doing them. In fact, you can be doing them in the middle of a room full of people and no one will know it! The video below must be the funniest but also most informative explanation of how the pelvic floor works that I have ever come across. It is well worth a watch! The app provides you with detailed descriptions, including pictures, of the exercises you should do and also how you should progress them. Actually, it is just one exercise, but they progress it by making you do it at a different speed and strength. For the first 3 month period, you have to do the pelvic floor exercises 3 times a day. Once you have reached a satisfactory result, you can then reduce your practice time to a maintenance dose of 3 times a week. If you suffer from urinary incontinence this app is a no brainer You can download the Tät app for free from the Play Store. What I like about the app: It allows you to set reminders on your phone to vibrate when it is time for your pelvic floor exercises. It pauses the exercise if someone phones while you are busy with them. It has a very clear explanation of how the pelvic floor functions and how to do the exercise. It has an “intensity” bar that guides you to do the exercise at the correct strength and speed and for the correct number of seconds. It also counts down the rest period between exercises. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate.

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

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

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

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

We know that different types of exercise e.g. Pilates and Yoga have been shown to be effective in the treatment of lower back pain. But what if you hate these types of exercise? Well, the good news is that new research has just been published to show that resistance training with free weights can also be effective in helping people who suffer with lower back pain – especially chronic lower back pain. In this post: Weight training for lower back pain - New Research How ‘protecting’ your back can cause lower back pain So what about this bend with your knees business? How to use free weights to strengthen your lower back Weight training for lower back pain - New Research The researchers enrolled 30 participants, who had lower back pain for more than 3 months, in a 16 week training programme. All the participants underwent MRI investigations to look at the size and shape of the muscles in their lower backs. The MRI scans also identified a total of 33 herniated discs without nerve compression, 11 herniated discs with nerve compression, 1 disc injury without herniation and 20 cases of facet joint degeneration. The aim of the study was to see if they could decrease pain, improve muscle bulk and strength in the lower back as well as improve the participants' movement patterns in the squat exercise. The researchers reported an impressive 72% and 76% reduction in pain and disability by the end of the 16 week period. They also found a significant decrease in fat infiltration as well as an increase in muscles bulk in the lower back muscles. It is important to note that in addition to exercise, the researchers also worked with the participants to address any beliefs that they may have held regarding their injury that may have hampered their recovery. We know for instance that one of the reasons that a person can continue to suffer back pain may be due to them overprotecting their backs. How ‘protecting’ your back can cause lower back pain We know that people start to move differently when they have suffered back pain. This may be because they are frightened of injuring their backs again or in an attempt to ‘protect’ their backs. They often end up splinting their spines during movements or avoiding certain movements, e.g. forward bending, altogether or overusing their superficial back muscles to keep their backs in extension. While this may sound like a clever or logical thing to do, it can actually lead to more back pain for 2 reasons: You end up with a stiff back. Our bodies and joints have to move to stay healthy and strong and pain free. The deep muscles, the multifidi, that lie right next to your spine and are meant to stabilise it during movements, become weak. We know this because studies have shown that if you looked at an MRI scan of someone with longstanding lower back pain, you often find that these deep stability muscles along the spine have a lot of fat in them and have shrunk in size. No, this does not mean that you are overweight. This is as a result of not using your back muscles enough. Because you are splinting with the big superficial muscles of the back, these smaller ones that are meant to be active throughout the day are not really working much. The end result is that they become deconditioned. People who suffer with lower back pain are usually also less active on the whole, which can contribute to these muscles becoming weaker. So what about this bend with your knees business? Yes, of course you should look at your posture when you pick things up – especially heavy things. I am by no means advocating that you just ignore your back pain and bend and move as you like after an injury. You will always have a period of a few days or even weeks, depending on the severity of your injury, during which time there will be certain movements and activities you should avoid. My point is just that they should not necessarily be avoided for the rest of your life! Any treatment plan for lower back pain should involve a slow and gradual training programme during which movement and strength training are slowly reintroduced. How to use free weights to strengthen your lower back The participants in this study all had back pain for longer than 3 months. They did not include anyone who had active nerve root compression or inflammatory disease. It is important to note that emphasis was placed on teaching the participants the correct technique to perform these exercises. I would advise that you ask a physiotherapist or experienced trainer to teach you how to do these exercises before you attempt this programme. I also think that the participants must have had a relatively OK basic level of fitness, since the single leg glute lift is not easy to perform with good form. The 16 week programme was divided into a 4 week familiarisation phase, followed by a 12 week strength phase. Familiarisation phase: Lasted for 4 weeks and included: 1. An assessment of the beliefs participants held regarding back pain. I am often surprised at how many people think that once you have suffered back pain, you are stuck with it for life. This is just one example of a belief that may hamper recovery. They often just need a period of ‘good behaviour’ combined with carefully graded exercise to get them pain free. Another example is when people think that their back pain should continually improve and that it is a bad sign if they have a slight increase in pain on certain days. The truth is that recovery never follows a linear path. Your road to recovery is much more likely to look like a mess of spaghetti as Adam Meakins have shown in the diagram below. It is normal to have good days and bad days as long as the bad days become fewer, less intense and are quicker to recovery from. 2. The participants were all taught lumbo-pelvic control. In short, this means that they were taught how to stabilise their lower backs and pelvises during movement. 3. Each participants' posture was analysed and they were taught how to correct their posture and keep their lumbar spines in a neutral position and not to overuse their back muscles when standing or sitting. 4. Strength exercises Exercise intensity: 3 exercise sessions a week, load approximately 10RM, 3 sets of 8 repetitions They used two different sets of exercises and alternated between them. They would for example do Set A twice and Set B once in week one and then switch to do Set A once and Set B twice the following week. Warm-up before sets: Self-myofascial release of glutes by rolling on a hard ball Glute raises Multi-direction lunges Standing hamstring stretch Overhead squat Assisted squats Set A included: Single leg glute bridges Goblet squats Planks Standing row exercises Set B included: Deadlifts Step-ups Lat pull-downs Side bridges Press ups Strength phase This phase stretched from weeks 5 to 16. The exercises remained the same but the load changed to approximately 6-7RM, 2 sets of 5 repetitions done in 3 sessions per week. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. You may also be interested in: Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 1: Pilates Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 2: Yoga Yoga vs. Pilates vs. Other exercise? What is the best exercise for lower back pain? Part 3: Other Exercise About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: Welch, N., Moran, K., Antony, J., Richter, C., Marshall, B., Coyle, J., et al. (2015). The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back. BMJ Open Sport & Exercise Medicine, 1(1).

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

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

Most people, when asked how much fluid they should drink in a day, will say 6 to 8 glasses. This is also the message being shouted out in most health magazines and blogs. But why then, do so few of us die when we don’t? Well, the answer to this is quite simple… there is absolutely no scientific evidence to back this up. How much water you need heavily depends on the climate you're in, what you eat (you can get up to 1 litre of fluid through a regular diet) and what activities you're doing. Caffeinated drinks e.g. tea and coffee have traditionally been bad mouthed since it is commonly believed to act as diuretics and to cause your body to lose fluid. Research has, however, shown that this may only be the case for people who are not used to drinking these substances. The American College of Sports Medicine has the following to say on caffeine: “Caffeine ingestion has a modest diuretic effect in some individuals but does not affect water replacement in habitual caffeine users, so caffeinated beverages (e.g. coffee, tea and soft drinks) can be ingested during the day by athletes who are not caffeine naïve (who regularly drinks caffeine).” In this article: So how do you know if you are drinking enough water? Daily test After sport I have read that I should drink before I get thirsty... So how do you know if you are drinking enough water? Research has shown that there are 3 ways in which a person can tell if they are dehydrated. They usually become thirsty, their urine becomes concentrated (darker colour) and they lose more than 1% of their body weight over a short period e.g. hours or a day. It is important to understand that there are 2 types of dehydration a healthy person can experience: 1. Acute or sudden dehydration which occurs over a period of hours or days. Examples of this is when you work or do exercise in the heat. This is normal and research have found that people are very good at rectifying this by drinking according to their thirst. You may also be interested to know that muscle cramps during sports are not actually caused by dehydration. 2. Chronic dehydration where a person’s fluid intake is just a bit too low over a long period of time so that it causes mild chronic dehydration. In this case, you won't notice a drop in body weight or increased thirst as your body would be used to this dehydrated state. Urine colour is your best measure for this. Chronic low-level dehydration can cause kidney stones and may also contribute to chronic kidney disease. 3-Step test to see whether you are dehydrated – daily test You have to perform this test first thing in the morning. Any one symptom on its own does not indicate dehydration. You have to display at least 2 of the 3 symptoms before you consider yourself dehydrated. You may for instance have lost a lot of weight due to eating less and doing a lot of exercise the previous day, but be well hydrated. Similarly you may be thirsty, but not have lost so much fluid that you are deemed to be dehydrated. You are very likely to be dehydrated if you display all 3 symptoms. Step 1: Urine Look at the colour of your urine after your first visit to the loo in the morning. Use the standardized urine colour chart to assess your urine’s colour. You are very likely dehydrated if you score a 4 or higher. Remember, if you have been drinking too little fluid daily for a very long time, dark urine may be the only sign that you're dehydrated. Step 2: Weight Weigh yourself after your first visit to the loo. If you have lost more than 1% of your body weight compared to the previous morning, you may be dehydrated. Step 3: Thirst Are you thirsty when you wake up? Research has shown that a combination of thirst and loss of body weight is a strong indication of dehydration. 3-Step test to see whether you are dehydrated – after sport You can use the same 3 step test described above to see if you are dehydrated after a run, long walk or even a rugby match. The only difference is that you perform it immediately after completing your sports activity and you have to make sure that you were well hydrated when you weighed yourself before the activity. It is not necessary or possible to replace all your fluids that you lose during exercise while you are training. Research conducted on athletes in laboratories has shown that a 2% loss of body weight due to dehydration can cause a decrease in performance, but this stands in stark contrast with results from field studies where the top performing athletes have been measured to have lost between 6 and 8% of their body weight. "Time and again, studies, even those by researchers expecting different outcomes, have shown that the runners who are the most dehydrated, as measured by percentage of body weight loss, run the fastest. As two examples, notice the results in figure 2.4, from the 2000 and 2001 South African Ironman Triathlons and the 2004 New Zealand Ironman Triathlon. The five fastest finishers in the South African Ironman all finished in less than 9 Hours and all lost 6% to 8% of their body weights during the race (arrowed in figure 2.4a). Three years later, this relationship was confirmed in finishers in the 2004 New Zealand Ironman Triathlon (figure 2.4b)." - taken from Waterlogged: The Serious Problem of Overhydration in Endurance Sports Dehydration has, however, also been shown to affect concentration. The effects of dehydration on your sports performance may thus depend on the type of sport that you participate in. Endurance athletes may for instance benefit more from losing some body weight while racing despite the dampening effect on their concentration. One can argue that a tennis or hockey player's performance will suffer a lot more if their concentration lapses. The American College of Sports Medicine advises that you should try and keep fluid losses below 2% of your body weight, but they warn that you should not drink too much during exercise either since this can cause dangerous electrolyte imbalances in the body (see below). While it may not be necessary to replace all your fluids while exercising, you should aim to do so afterwards. You can read about the best methods to replace fluid losses quickly and safely by following this link. I have read that I should drink before I get thirsty This is simply not true and may even be dangerous advice. Research has shown that healthy humans are more than capable of maintaining healthy hydration levels during normal daily activities as well as during exercise by simply drinking when they are thirsty. This is surely also common sense? The “drink at least 8 glasses of water” and “drink before you are thirsty” advice have only been around in the last century and the human species have very successfully managed to survive in and populate some of the harshest environments on earth. There's also evidence that the “drink before you are thirsty" advice may have been pushed by companies to increase sales. Drinking too much water without replacing the salts that you lose during sweating can lead to a condition called hyponatremia.  Hyponatremia causes swelling on the brain and it can be fatal if not treated swiftly. This is really only a problem for people who do not eat a normal diet or who drink excessive amounts of water for prolonged periods e.g. while running a marathon. In the video below, Prof Tim Noakes explains about the dangers of drinking too much water. The only time that a healthy person cannot trust their thirst sensation is if they have been chronically dehydrated over a very long period of time. Research have shown that your thirst detection can be less sensitive in these cases. You can also see this interview with former ultra-athlete Jesse Funk, which touches on the subject of drinking too much water during endurance sports: Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References: Cheuvront SN, Kenefick RW. Am I Drinking Enough? Yes, No, and Maybe. Journal of the American College of Nutrition 2016;35(2):185-92. Cohen D. The truth about sports drinks. BMJ 2012;345. Cotter JD, Thornton SN, Lee JK, et al. Are we being drowned in hydration advice? Thirsty for more? Extreme physiology & medicine 2014;3(1):18. Sawka M, Burke L, Eichner E, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Medicine and science in sports and exercise 2007;39(2):377. Valtin H. “Drink at least eight glasses of water a day.” Really? Is there scientific evidence for “8 × 8”? American Journal of Physiology - Regulatory, Integrative and Comparative Physiology 2002;283(5):R993-R1004.

I don’t know about you, but I’m steadily becoming more and more paranoid about growing older (maybe it’s the fact that I’m turning 40 next year!). I’m often amazed at the differences I observe in my older clients that I see in private practice. Some of them still dance 3 times a week and fly kites in their free time while others struggle to bend down to tie their shoe laces. This made me wonder: Is how I age predetermined by my genetics or do I have a say in this affair? For this article I specifically investigated what happens to our muscular systems and why we seem to lose muscle strength and power as we age. I won’t lie, it was rather depressing to read about all the things that may be in my future. The good news is that I’ve come to the conclusion that, while we all will grow old, there are plenty of things that we can do to maintain our strength and performance. In this article: What happens to our muscles and tendons as we age? Is it possible to avoid these changes? What triggers our bodies to build muscle? The role of chronic inflammation Vit D is also important In summary What happens to our muscles and tendons as we age? The things that I list in this section all relate to the average person. The exciting news is that this does not have to be you! But first, here’s a list of changes that happen with age: On average we can lose around 0.37% (for women) and 0.47 % (for men) of our lean muscle mass per year. For people over the age of 75 this rate increases to 0.64-0.70% per year for women and 0.80-0.98% for men. Our muscle fibres reduce in number and in size. We seem to be specifically prone to losing Type 2 (fast twitch) muscle fibres. These are the main fibres that that we use when we perform quick strong movements. Their loss may explain why so many older people struggle to get up off the floor or climb stairs. Studies in rats have shown that older muscle also forms fibrosis or scar tissue between muscle fibres which may explain why we tend to get stiffer as we age. You tend to find more fat cells between the muscles fibres of older people. There’s a reduction in the number of mitochondria within our muscles cells. Think of mitochondria as the batteries of the cells. They produce the energy for the contractions. Our tendons lose some of their stiffness so that they become less effective at propelling us forward when we run or walk. The number of nerve endings that supply a specific muscle reduces and the nerves no longer optimally activate the muscles. Is it possible to avoid these changes? Wroblewski et al (2011) investigated muscle mass and body composition in masters athletes. They found that chronic intense exercise (more than 4 sessions a week) preserved lean muscle mass into old age despite the body’s total body fat increasing. The increase in total body fat did not lead to fatty infiltration into the muscles themselves. The researchers concluded that the declines in muscle mass previously thought to be a natural part of aging, was more likely due to lifestyle choices e.g. a sedentary lifestyle and poor nutrition. McKendry et al. (2018) supported these findings in their recent review and meta-analysis. They concluded that the current evidence suggests that chronic exercise training preserves physical function, muscular strength and body fat levels in old age similar to that of young, healthy individuals. Piasecki et al (2016) found that, despite the fact that master athletes experience a drop in the number of nerve endings that supply their muscles (similar to sedentary old people), they still managed to preserve their muscle mass and performance. In a nutshell: It is possible to avoid some of the changes that has previously been contributed to “natural again”. Others may be unavoidable, but we may be able to reduce their impact through regular exercise and eating the right stuff. What triggers our bodies to build muscle? There are 2 main things that act as triggers for our bodies to build new muscle. The first is exercise and the second is when we eat protein. When we eat protein (e.g. meat, eggs, beans etc.) our bodies break it down into its simplest form namely amino acids. Our muscles then use these amino acids to build new muscle cells. It’s easy to see why it’s important to make sure that we eat enough protein during the day. When we’re young, the presence of these amino acids in our blood is enough to kick-start the muscle building process. Interestingly, this does not seem to be the case for older adults. Researchers think that this is mainly due to our cells becoming more insulin resistant with age. If our cells don’t absorb insulin properly, it can’t build new muscle despite there being enough amino acids floating around. This is where exercise can make a big difference. Not only does it stimulate your muscles to grow stronger, but it can also decrease your insulin resistance.  Researchers have found that, if older adults perform a bout of exercise shortly before eating a meal, their muscles responds just like young muscles. Fujita et al. (2007) even found that the positive effect of the exercise bout carried over to the next day! Not enough research has yet been done to provide us with specific guidelines, but I would suggest that you aim to do at least 5 sessions of moderately hard aerobic exercise a week. This can include swimming, cycling, walking, running or any other exercise that makes you breathe harder. You’ll see even greater benefits if you can also include a couple of strength and flexibility training sessions per week. In a nutshell: If we eat enough protein and exercise regularly, we can preserve our muscle strength and performance much better than people who follow sedentary lifestyles. You can read more about how to use exercise and protein together for maximum gains. The role of chronic inflammation Ageing is often accompanied by inflammatory disorders, slight elevations in circulating pro-inflammatory mediators and decreases in anti-inflammatory cytokines which result in chronic low-grade inflammation which has been shown to enhance muscle loss in older people. Strategies that decrease chronic low grade inflammation e.g. antioxidant supplements and taking omega 3 fatty acids have been shown to increase muscle volume and strength in the elderly. Other things that has been shown to contribute to low grade inflammation include smoking, alcohol, high sugar diets, processed food and stress. These are all things that are within your power to change! Vit D is also important Vit D is important to maintain strong bones, prevent muscle wasting and maintain our immune systems. If you don’t get in contact with the sun on a daily basis and/or always wear very strong sunblock, you may be at risk of being Vit D deficient. Food like eggs do contain Vit D, but it’s very difficult to get enough through your diet. Speak to your GP if you think that you may be lacking in Vit D. I don’t like swallowing tablets, but luckily you can get a mouth spray (in the UK) that I use in the winter. In summary: We can reduce the negative effect aging has on our muscles and tendons if we: Exercise regularly; eat enough protein; take steps to avoid things that cause chronic low level inflammation; and make sure that our Vit D levels are topped up regularly. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate. References Dalle S, Rossmeislova L, Koppo K. The Role of Inflammation in Age-Related Sarcopenia. Frontiers in physiology 2017;8:1045. Dickinson JM, Volpi E, Rasmussen BB. Exercise and nutrition to target protein synthesis impairments in aging skeletal muscle. Exercise and sport sciences reviews 2013;41(4):216. Drummond, M. J., Dreyer, H. C., Pennings, B., Fry, C. S., Dhanani, S., Dillon, E. L., et al. (2008). Skeletal muscle protein anabolic response to resistance exercise and essential amino acids is delayed with aging. Journal of Applied Physiology, 104(5), 1452-1461. Fujita S, Rasmussen BB, Cadenas JG, et al. Aerobic exercise overcomes the age-related insulin resistance of muscle protein metabolism by improving endothelial function and Akt/mammalian target of rapamycin signaling. Diabetes 2007;56(6):1615-22. Mckendry J, Breen L, Shad BJ, et al. Muscle Morphology and Performance in Master Athletes: A Systematic Review and Meta-analyses. Ageing research reviews 2018 Mitchell W, Atherton P, Williams J, et al. Sarcopenia, Dynapenia, and the Impact of Advancing Age on Human Skeletal Muscle Size and Strength; a Quantitative Review. Frontiers in Physiology 2012;3(260) doi: 10.3389/fphys.2012.00260 Piasecki M, Ireland A, Coulson J, et al. Motor unit number estimates and neuromuscular transmission in the tibialis anterior of master athletes: evidence that athletic older people are not spared from age‐related motor unit remodeling. Physiological reports 2016;4(19) Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. Journal of cachexia, sarcopenia and muscle 2018;9(1):3-19. Volpi, E., Mittendorfer, B., Wolf, S. E., & Wolfe, R. R. (1999). Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction. American Journal of Physiology – Endocrinology and Metabolism, 277(3), E513-E520. Wroblewski AP, Amati F, Smiley MA, et al. Chronic exercise preserves lean muscle mass in masters athletes. The Physician and Sportsmedicine 2011;39(3):172-78. Zhai Y, Xiao Q. The Common Mechanisms of Sarcopenia and NAFLD. Biomed Res Int 2017;2017

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