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I’m kicking the injury prevention series off by discussing the importance of position sense and how a lack of this can predispose you to injury. This series is useful for anyone who walks, runs or jumps as part of their exercise. The other topics that I’ll cover include core stability, glute med, glute max, hamstrings, quadriceps and calf. In this article: What is position sense? How does it affect injury? What can affect position sense? Training position sense is not rocket science! Download the exercise programme as a PDF Can tape or compression garments help? What is position sense? In short: Position sense or proprioception is the ability of your brain to know exactly where every part of your body is and how it is moving without having to look at it. The brain then uses that information to work out where to place the body part next and with how much force it should contract each muscle. Maybe a practical example will help you understand it better: Close your eyes. Now think about your right ankle. Slowly point your toes so that the ankle joint moves down. Then slowly pull your toes up so that your ankle joint moves up. Then turn your foot in and out. Do you notice how you can nearly “see” your ankle move in your mind’s eye? Your skin, muscles, tendons and joints all have little receptors in them that constantly send information back to the brain. The brain then uses this information to calculate exactly how to perform the next task e.g. how far to step or how much to contract your muscles etc. without actually having to look at the body part. It’s position sense that allows us to run up and down stairs without having to look at them or a footballer to control a ball without looking at his feet. A good example of what happens when the brain gets it wrong, is when you step down from a step that is higher than what you expected it to be and stumble. A lack of good position sense is also the reason that some elderly people struggle to walk on uneven surfaces. Their brains struggle to understand exactly where their feet are and how to control them and as a result they have to look down so that they can get extra feedback from their eyes. An example of extremely good position sense is someone who can balance and walk on a tightrope. In order to do that your brain has to be acutely aware of where every joint and body part is and has to precisely calculate how much to tense every muscle in order to perfectly balance your body. How does it affect injury in runners? The research has shown that people who score low on position sense tests in their trunks and legs may be more likely to sustain a wide variety of lower limb injuries of the joints and muscles. Some examples include ACL tears, ankle sprains and even hamstring tears. The explanation for this is quite simple. If the brain does not know exactly where your body parts are, it cannot produce well-coordinated movements. This means that you can easily overload specific joints, ligaments and muscles which can lead to strains and tears. It can affect any part of the body. A common example I see in clinic is patients who report that they often sprain their ankles, even when running on flat ground. This is not normal and often related to poor proprioception. What can affect your position sense? For good position sense you need 2 things: Your receptors in your skin, muscles, tendons and joints must work properly. You brain must be able to interpret the signals that the receptors send to it and respond appropriately. Factors that can negatively affect our position sense include: Injury – When you sustain an injury, the message between the injured body part and your brain gets interrupted so that the brain temporarily loses its ability to know exactly where that body part is. It is quite easy to retrain again, but unfortunately this often gets neglected. A good example of this is when someone has gone over on their ankle and they then find that they keep on going over on it even when walking on flat ground. Some simple proprioception exercises can often make a big difference. Disuse – Your brain needs practise to know how to control your body parts properly and if you’ve not used them for a while it gets detrained. If you’ve ever had a body part immobilised in a cast or splint, you’ll know how difficult it is afterwards to make it do what you want it to do. This is an extreme example, but a more common one is where people spend most of their time in sedentary jobs. Sitting down all day does not help to develop your brain’s control over your legs. Sure, walking around does require a basic level of position sense but you need more than that for running and walking on uneven terrain. Hyper-mobility – Thanks to genetics some people have hyper-mobile joints with lax ligaments. These people usually also have reduced proprioception or position sense in those joints. Proprioceptive training can improve this and there is also some research to show that compression garments can make a difference. Fatigue – The research has shown that people’s position sense decreases when they are tired. So if you’re planning to do complex movements during training, do them while you’re still fresh. Also, if you’re planning to do tough mudders or other obstacle races where the brain’s position sense will already be challenged due to the terrain, make sure that you’re fit enough! Training position sense is not rocket science! I tend to use 2 main types of exercises to retrain lower body position sense for walking and running: Balancing A squat movement Principles to follow when retraining position sense: always start in stable positions and practise the basic movement pattern first; then move into progressively less stable positions or onto less stable surfaces; master simple tasks first and then make them more complex; practise it often! The exercise examples start at minute 5:55 Balance I provide a lot more detail in the video (from minute 5:55), but the first 3 exercises that you’ve got to conquer are: Balancing on one leg while looking straight ahead for 30sec. Your hands should be in your sides, your pelvis should remain level, the free leg should not be pressed into your standing leg and you should not wobble. Once you’ve nailed this one move on to number 2. Balance on one leg, but now slowly turn your head from side to side. You should be able to do this for 30 seconds before you move to number 3. Balance on one leg, but this time close your eyes. Again your aim is to reach 30 seconds without falling over. This is very hard as your brain no longer gets any help from the eyes and has to only rely on what the sensors in the muscles, joints, ligaments etc. in your legs tell it. You can also make the exercises more difficult by using balance boards and standing on foam cushions etc. but make sure that you master the simple exercises on the floor before you start using other devices. Squat movements Your leg goes through exactly the same motion when you do a small squat as when you run or walk. This is therefore a very useful movement to use when you want to retrain your brain’s ability to properly control your legs during walking and running. Good squat technique also requires you to have strong leg muscles so it’s a very nice all in one exercise for strength and proprioception. Practise a slow, double leg squat to about 90 degrees knee flexion. If your calves are very tight you may struggle to go low enough – placing a book under your heels will help. Your knees should move in line with the middle of your feet and you should stick your bottom out to the back so that your knees do not cross over the front of your feet. Keep your back upright and make sure that you contract your stomach muscles throughout the movement. Once you can do a double leg squat with good form, move on to number 2. Single leg squat with support. Balance on one leg, but place the other leg on a chair behind you to provide some stability. Now slowly squat down to at least 60 degrees knee flexion. You may not be able to go that low at first, but work your way up to it. You should check that your pelvis stays level and that your knee moves in line with the middle of your foot. Your trunk should stay upright. Once you can do 3 sets of 15 with good form, move on to number 3. Single leg sit to stand. During this exercise you are going to rise from sitting using only one leg while applying all the principles that we’ve discussed in the previous 2 exercises. Then you’re going to slowly sit down again using only one leg. Depending on how strong your legs are, you may have to start on a slightly higher chair or surface. Your aim should be to be able to do 25 sit-to-stand-to-sits from a chair that allows your knee to bend to a 90 degree angle. You must aim to be able to do it without any wobble in your leg. Download the exercise programme as a PDF with pictures Can tape or compression garments help? At first glance the research appears to report conflicting results with some studies showing that tape and compression garments can improve proprioception or position sense and other studies showing absolutely no effect. On closer inspection it seems to be dependent on who it is used on. Study participants who had a position sense deficit before the tape or compression was applied, showed significant improvements in position sense when tested afterwards. Study participants who had a normal score or no problems with their position sense, showed no further benefit from covering their knees or ankles in tape or wearing compression garments. What does this mean in practise? We know that position sense is affected when you sustain an injury, so taping your injured body part can be an effective way to help improve this while you recover. BUT this is only a temporary measure and you have to do your exercises to restore it fully. 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: Bailey, Daniel, and Paul Firth. "Does kinesiology taping of the ankles affect proprioceptive control in professional football (soccer) players?." Physical Therapy in Sport 25 (2017): 94-98. Cameron, Matt, Roger Adams, and Christopher Maher. "Motor control and strength as predictors of hamstring injury in elite players of Australian football." Physical Therapy in Sport 4.4 (2003): 159-166. Cameron, Matthew L., Roger D. Adams, and Chris G. Maher. "The effect of neoprene shorts on leg proprioception in Australian football players." Journal of Science and Medicine in Sport 11.3 (2008): 345-352. Dupuy, Emma G., et al. "Ehlers-Danlos Syndrome, Hypermobility Type: Impact of Somatosensory Orthoses on Postural Control (A Pilot Study)." Frontiers in human neuroscience 11 (2017): 283. Ghai, Shashank, Matthew W. Driller, and Rich SW Masters. "The influence of below-knee compression garments on knee-joint proprioception." Gait & posture 60 (2018): 258-261. Goble, Daniel J., et al. "Brain activity during ankle proprioceptive stimulation predicts balance performance in young and older adults." Journal of neuroscience 31.45 (2011): 16344-16352. Hosp, Simona, et al. "Eccentric Exercise, Kinesiology Tape, and Balance in Healthy Men." Journal of athletic training 52.7 (2017): 636-642. Hosp, Simona, et al. "Does Kinesiology tape counter exercise-related impairments of balance in the elderly?." Gait & Posture (2018). Jahjah, Akram, et al. "The effect of ankle tape on joint position sense after local muscle fatigue: a randomized controlled trial." BMC musculoskeletal disorders 19.1 (2018): 8. Long, Zhi, et al. "Optimizing ankle performance when taped: Effects of kinesiology and athletic taping on proprioception in full weight-bearing stance." Journal of science and medicine in sport 20.3 (2017): 236-240. Michael, Jacob S., et al. "What is the effect of compression garments on a balance task in female athletes?." Gait & posture 39.2 (2014): 804-809. Miura, Kazutomo, et al. "The effect of local and general fatigue on knee proprioception." Arthroscopy 20.4 (2004): 414-418. General fatigue can influence proprioception Silvers-Granelli, Holly, et al. "Efficacy of the FIFA 11+ injury prevention program in the collegiate male soccer player." The American journal of sports medicine 43.11 (2015): 2628-2637. Zazulak, Bohdanna T., et al. "The effects of core proprioception on knee injury: a prospective biomechanical-epidemiological study." The American journal of sports medicine 35.3 (2007): 368-373.

It’s really important to understand that the act of sitting, as such, is NOT bad for your back. It is only when you sit for too long or on bad chairs or in bad positions that it becomes a problem. This article only focusses on the lower back, but your sitting position can also influence your upper back and neck. In this article: Why slouching in a chair can cause trouble Sitting upright without support can also cause problems Time is an issue The problem with soft chairs What’s the best surface to sit on? Why slouching in a chair can cause trouble When you slouch in a chair, you’re putting all the muscles and ligaments in your lower back under strain. If you keep them in that position for long enough, they will start to stretch and they may even reach a point where they cannot stretch any further. At this point you will start putting strain on your muscles, ligament or discs in your lower back. You can even aggravate the nerves in your legs if you slouch in a chair and put your legs up on a chair in front of you (like in the picture above). This position potentially puts a lot of strain on your sciatic nerve and you may find that your leg goes to sleep or your toes/foot tingles. I’ve seen patients in my practice where the sole cause of their lower back injury could be traced back to sitting in bad positions for a long time. How long you will be able to sustain poor sitting postures for before you cause yourself discomfort will all depend on your previous injuries and even your genetics. For example, my boyfriend and I find ourselves on the opposite extremes of the flexibility scale. I’m one of those annoying people who can get their heads all the way flat on their knees in yoga while he breaks out in a sweat just trying to sit upright with his knees out straight. But he seems to be able to sit in bad postures (e.g. slouching on our couch) for a very long time whereas I usually have to prop myself up with pillows while watching TV. Sitting upright without support can also cause problems Sitting upright is definitely preferred to slouching. But if you spend large parts of the day sitting, I would strongly advise that you sit in a chair that supports your lower back. When you sit upright without support, your back and hip muscles have to work very hard to maintain the position. That is fine and good for shorter periods in the day, but they will become tired, overworked and painful if you do it for prolonged periods in the day. The key is to use a chair that allows you to sit nice and upright and that supports the small of your back. Time is an issue It is obvious from the above that if you sit in a bad posture for a long time you’ll find yourself in trouble. But you’ll also find that your back can stiffen up and feel uncomfortable even while sitting on a good chair, if you don’t take regular breaks during the day. Our bodies are built for movement. Our joints don’t have arteries and veins that go directly into them. They rely on the changes in pressure, that happens with movement, to force fluid in and out of them. So your joints will not get all the nutrients they need if you don’t move enough during the day. You can read more about the negative effect of prolonged sitting on hip joints in this article. The problem with soft chairs When you sit in a soft chair the seat usually sinks in and causes the same effect as when you’re slouching in a chair. It is nearly impossible to sit in a good position on a very soft surface. Over time this will cause the ligaments and muscles will stretch to a point where they can hurt and if you have any discs that’s a little bit worn they will also start to moan. What’s the best surface to sit on? I always suggest a firm surface that’s not too hard or too soft. Every person is different so it's a bit of trial and error, but make sure that you don’t sink into it. Make sure that you sit with your bottom right back into the seat and that you can feel it supporting your lower back. The woman in the picture above can actually do with a pillow behind her back as you can see a gap between her and the back of the chair. This doesn't mean that you have to always sit on an upright chair. You can further support your lower back by placing pillows behind you when sitting on a coach or chair. The height of the chair is also important. Your knees should be at right angles when you sit. If the chair is too low, your knees will be higher than your pelvis and force your back into flexion. If it is too high you will tend to sit forward to get your feet on the floor and will not use the back support. You can compensate for a chair that is too high by placing a small step or book under your feet. Finally, get into the habit of taking regular breaks and not sitting for too long so that your joints can stay well-nourished. The evidence suggests that short bursts of exercise can also improve your mental function so now you have 2 reason to get up and do an extra set of stairs every hour! 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.

This taping technique works really well for any injury that’s caused by over-pronation e.g. shin splints (medial tibial stress syndrome) or tib post tendinopathy. However, taping is only part of the treatment. You should also strengthen the muscles around your hips and ankle. 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.

There are a multitude of strengthening exercises that you can do for knee pain, but the leg press machine is by far my favourite exercise to make your knees stronger. Now, you may very well have tried it in the past and found that it didn't work for you, but please let me explain where you may have gone wrong before you stop reading! Why I like it? No other exercise allows you to control every single variable e.g. foot position, knee angle and force to the same level as the leg press and this is crucial during the early stages of treating knee pain. It also exercises the glutes, hamstrings and quadriceps muscles which are all important to prevent as well as help treat knee pain. In this article: Knee pain: Why you have to strengthen your muscles Why the leg press may have hurt you in the past Step 1 – Establish a baseline The importance of getting your foot placement right The importance of getting the depth of the movement right The importance of getting the load right What to do if your knee hurts afterwards Knee pain: Why you have to strengthen your muscles Your main knee joint is formed by your femur at the top and your tibia at the bottom. The two bones are covered by cartilage and there are also 2 soft cartilage cushions (the menisci) inside the joint to help with shock absorption. The muscles around your knee and hip joints have 2 very important roles: To control the joint as you move – uncontrolled movements can cause strains to the ligaments and cartilage. To absorb a significant amount of the force when you walk, run and jump. So if the muscles are weak, your knee joint, cartilage and ligaments will have to carry more weight than intended which can lead to injury and pain. Why the leg press may have hurt you in the past Yes, of course the leg press does not work for every single person, but in practice I find that it is often due to how people use it. Some of the common things that you may have done include: Our knees are dynamic joints and different parts of the joint will take strain depending on how far you bend it or where you place your feet. It may be that you did not pay enough attention to this or that you followed advice that wasn’t right for your specific injury. Each person will/should have a slightly different technique on the machine as we all have differently shaped bodies. Check the relevant sections below for a detailed description of how to cater for this. You upped the weight too quickly. I find that people often underestimate how long the adaptation period can be that the body needs before it is happy for you to move on to heavier weights. You trained too often. You need to give your body enough time to recover between strength training sessions. If you’re not a trained athlete, it is good to leave at least 48 hours between sessions. You actually did another exercise on that day that flared your knee up and is wrongly blaming the leg press machine. This can easily happen because knees often only start to hurt a few hours after a gym session or even the next day. Step 1 – Establish a baseline The first step for any exercise programme aimed at improving knee pain should be to establish what activities you can do without causing your pain to increase. We call this the baseline. Once you’ve established your baseline, you should train at that level for at least 2 weeks, before you try and change anything. This can sometimes be quite challenging as it may feel that you’re not doing enough, but it is really important that you give your knee and body time to fully get used to the baseline level of exercise. When using the leg press machine, part of establishing your baseline should include exactly where on the plate your feet should be positioned, how far you bend your knees when going down and also how much weight you use. I will explain each of these in more detail below. It doesn’t matter if you can’t bend the knee fully. If you train it for long enough at the pain free level, it usually allows you to bend your knee further over time. The importance of getting your foot placement right Test this with only the weight of the plate and no extra weight on the machine. As mentioned before, different parts of the knee joint carries the weight or takes strain depending on the angle you bend your knee at. So play with your foot position by moving your feet up and down on the plate (see A in picture above) until you find a position or angle that works for you. If for instance you place your feet on the plate so that you knees are bent more than 90 degrees, you will carry the weight more in the front of the knee. This position is often painful if you suffer with patello-femoral pain e.g. runner’s knee. It is good to keep your feet hip distance apart, but your feet does not have to point straight up if it feels uncomfortable to do so. Our hips and bones are all different shapes and it is OK if your toes are slightly turned out to the sides (see B in picture above). BUT you have to make sure that your knees move in line with the middle of your feet when you use the machine. Still cannot do the full movement? That's OK. Just pick the position that allows you to go down the furthest without pain and use that as your baseline. You will be able to go down lower as your knee gets stronger in that range. The importance of getting the depth of the movement right Test this with only the weight of the plate and no extra weight on the machine. For the same reason explained above, you may find that you can, for example, only bend your knee to 60 degrees when using the leg press before you feel pain (see C in picture above). That is OK. This will be your baseline from where you start and you will initially only do the exercise to this level until it allows you to go down further. Just remember to check – can you maybe go down further if you move your feet to a different position on the plate? Some of my patients find that they can never go below 90 degrees (right angle) knee flexion. Again, that's OK. You will still get very good strength gains if you strengthen it in that range. We only use about 45 degrees knee flexion when we run or climb stairs. The importance of getting the load right So you know where to place your feet and you know how far you can bend your knees. All that is left is to decide how much you should load your knee. The total load on your knee during this exercise is made up of: The weight you use How many repetitions your do How many sets you do How long you rest between sets I usually ask my patients to start with a weight that allows them to do 3 sets of 15 repetitions without pain. You have to rest about 2 minutes between the sets. BUT you may not be able to do that, even on the lightest weight, and that's OK. If, for example, you get to rep number 8 and you feel that that's enough (because your knee just doesn’t feel right, or it's starting to hurt or it's hard work) STOP there. You can then either do 3 sets of 8 or, if your knee does not feel up to it, 1 or 2 sets of 8. The most important thing is to find the baseline weight, sets and reps your knee will tolerate without flaring up and being painful afterwards. Remember, your knee may only flare up after your gym session or the next day so err on the side of caution. Also, make sure that you don’t do any other exercises or activities on the day that you do the leg press for the first time. Otherwise you won’t be able to tell if it was the leg press or something else that made it feel sore. What to do if your knee hurts afterwards Don’t just give up. First make sure that you didn’t do anything else on the same day that may have contributed to your pain. If you followed the guidelines above and were very gentle with your attempt, your knee should calm down within a few days. Think about the reasons why the exercise may have flared it up. Did you maybe do too many sets or have it slightly too heavy? Could you place your feet in a different position. Should you maybe not go down quite so low? Adapt what you did the first time and try it again. It may be that you need some assistance to get it right and we're always happy to help. 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.

Injury usually has a way of striking just as you feel you’re on a roll or you’re finally in sight of your goal. I’m very familiar with the frustration and anger people experience when they have to watch their hard-earned form and fitness slowly slip away. Not to mention the pain of having to watch your team play without you! But the good news is that there are 5 key steps that you can take to ensure that your comeback is as speedy as possible. In this article: Step 1: Understanding your injury Step 2: Giving your injury what it needs Step 3: Keeping your fitness through other activities Step 4: Using this time to get strong Step 5: Looking at the full picture Step 1: Understanding your injury Having an accurate diagnosis of your injury is key to making a quick recovery. Knowing what you’ve injured tells you how long it will likely take to heal, what exercise you can do to help it heal and also what you should avoid. Any experienced physiotherapist should be able to help you with this. But understanding your injury involves more than just having a diagnosis. You must also understand why it happened in the first place! When you’re injured you should view it as a learning experience so that you can train smarter and avoid injury in the future. It may also be key to effective treatment as some things that you’re still busy doing may be making your injury worse. This is an integral part of my consultation process. I usually spend about a third or more of the time just getting an idea of who the person in front of me is and what factors in their training, regular life, diet, sleep etc. could have contributed to the injury. Yes, of course some injuries are down to things outside of your control, but experience has shown me that you can only truly say that once you’ve considered all possibilities. Step 2: Giving your injury what it needs All injuries require a combination of rest and exercise to heal. How long you’ve got to rest for and how quickly you can ramp up the strength training will depend on the severity of your injury. I’ve previously written in detail about how the healing process works, but in short: If you opt for rest only and no strength training, you’ll likely end up with a weakness that can easily be re-injured. I also see the opposite happen in practice. People are often keen to get back to full fitness and do too much strength training too soon which then just aggravates the injury. It is nearly impossible to dish out generic advice that can be applied to all injuries but as a rough guide I would suggest: Protect the injury for the first 3 to 5 days and apply RICE (rest, ice, compression, elevations). Keep the injured body part moving. Don’t push into pain. If you move it repetitively to where you can just feel discomfort kick in, you’ll notice that it eases off over time. As the injured body part starts to heal you can slowly introduce specific exercises to strengthen it. I’m not talking heavy weights. For something like a calf strain, I would for instance start people off doing double leg heel raises initially and once the pain allows move on to single leg ones. You want to work for endurance before you start doing heavy loads. If you’re experiencing pain or swelling during or after the exercises, you’ve likely done too much. It’s really best to get some guidance from someone experienced in treating sports injuries. Step 3: Keeping your fitness through other activities I cannot stress this point enough. If you want to make a quick comeback from injury, you have to keep your cardiovascular fitness up while recovering. This way, you only have to deal with muscles complaining and you don’t have to try and drag a tired heart and lungs around as well when you’re ready to go back to your sport I’ve seen a top triathlete run the same time in a race despite having been forced (through injury) to do most of their run training using a cross trainer. Your heart and lungs can get the benefit from doing interval sessions and long “runs” using e.g. a cross trainer while the injury to your leg benefits from the lack of impact compared to running. This also applies to other body parts. What type of cardiovascular exercise your injury allows will depend on the injury itself, but some options may be: swimming (use a float between your legs if you can’t kick) cycling cross trainer arm cycle Running may even be an option if it’s an upper body injury that stops you from swimming. Even the choice of terrain could make a difference. Your injury may for instance allow you to cycle on the flat or on a stationary bike but complain if you clip your feet in or cycle on hilly terrain. Step 4: Using this time to get strong This is the ideal time to work on core strength, upper body strength, balance or whatever area of your body you normally neglect. Having a strong and stable core not only protects against injury but also leads to better performance – it’s a no-brainer really! Your injury may also have been caused by muscles in other parts of the body being weak e.g. weak glutes can often contribute to Achilles tendon injuries. Decreased proprioception (balance) has been shown to predispose you to knee injuries including meniscus and ACL tears. So use this time to sort these areas out. Step 5: Looking at the full picture With this I mean sleep, diet, social life etc. There is strong evidence to suggest that you mess with your body’s recovery if you don’t sleep enough, don’t get enough nutrients or drink too much alcohol. Hopefully you also know by now that smoking is a bad idea – nicotine heavily interferes with the healing process so vaping is just as bad. Choose your social events carefully. For instance, it’s not the time to go dancing, stand at a concert all night or go for a long shopping spree if you’ve injured your leg. 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.

A recent study by researchers in Finland has shown that an exercise programme consisting of specific stretching and strengthening exercises can help decrease neck pain. The researchers wanted to know whether exercise could help office workers with neck pain who spend at least six hours a day at their desk and who suffered from non-specific neck pain or neck pain that was not caused by serious injury. They recruited: Sedentary office workers who spent at least 6 hours per day sitting Women and men between 30–50 years of age Who experienced pain intermittently in the neck of at least moderate intensity ( at least 3/10) Who had had at least two episodes of neck pain in the past year They excluded: People who reported chronic neck pain which they defined as continuous pain over 12 months People who had suffered serious former injury in the neck (fracture, surgery, whiplash, protruded disc etc.) The neck exercise programme Participants had to perform the exercise programme twice a week for 10 weeks (20 sessions). Each session lasted about 1 hour and was performed under supervision of a personal instructor. The programme consisted of: A 10 min warm-up using a cross trainer 10 flexibility exercises (see picture 1 below) 4 strength and 5 core exercises (see picture 2 below) A 10 minute cool down with some stretches They focussed on keeping good body alignment of the whole body throughout the exercises and incorporated breathing exercises into the execution. The main aims of the programme were to: improve body posture enhance movement control of shoulder-neck, lumbar and pelvic areas enhance stability of shoulder-neck, lumbar and pelvic areas increase flexibility of neck/shoulder area increase range of motion of thoracic spine with main emphasis on rotation increase muscular strength and/or endurance of upper-body, trunk and lower extremities Results They found the training programme reduced the intensity, frequency and strain in the neck and shoulders of the participants. A few important points The programme did not focus on just the neck and shoulder girdle. It included exercises that strengthened the rest of the body. Your neck and shoulder girdle cannot sit in a good posture if the foundation lower down is weak. The exercises do resemble Pilates type exercises, but you can apply the principles to nearly any type of exercise. They did the exercises under the guidance of a personal trainer for 10 weeks. It is really useful to get some experienced advice/supervision when you start exercising as it is not always easy to maintain good form. 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 Reference: Suni JH, Rinne M, Tokola K, et al. Effectiveness of a standardised exercise programme for recurrent neck and low back pain: a multicentre, randomised, two-arm, parallel group trial across 34 fitness clubs in Finland. BMJ Open Sport & Exercise Medicine 2017;3:e000233. doi: 10.1136/bmjsem-2017-000233

When experts examine a runner’s technique they look several different variables including how the arms move, how the legs move, where the foot makes contact with the ground, how big a person’s strides are, how many steps a person takes in 1 minute etc. etc. A recent study investigated the topic of how one can retrain a runner’s running technique as part of treatment for a variety of injuries. You can read the whole article for free here. Interestingly, it would seem that changing just one aspect of how someone runs may be enough to alleviate a whole hoard of problems. Running Cadence Cadence or step rate can be defined as the number of steps a runner gives within 1 minute. The ideal step rate is currently seen as being somewhere around 180 steps per minute. Why is this important? Runners who have a slow step turnover (below 170 steps/min) tend to experience larger impact forces with each step they give, because their foot spends more time in contact with the ground than runners with a high cadence. This may contribute to injuries like medial tibial stress syndrome (shin splints) or plantar fasciitis. A low cadence also allows the foot more time to go into over-pronation and may contribute to injuries like patello-femoral pain or tibialis posterior tendinopathy. A slower step rate can also lead to over-striding while running which can cause knee and hamstring injuries. How to find your step rate 1.  You can simply count how many steps you give in one minute. or 2.  Download a metronome app and adjust the metronome until it beeps in time with your steps. How to safely increase your cadence or step rate Experts seem to agree that it works best to increase your step rate by about 5% to 10% at a time. What I find difficult is to not increase my speed as I give quicker steps. A way around this may be to do your runs on a treadmill so that you can make sure that you run at a constant speed while trying to give quicker steps. Use a metronome app on your phone and set it to your desired cadence or step rate. Say for instance my step rate is 145 steps per minute. A 5% increase would mean that I try to give 152 steps per minute. Try to step/run in rhythm with the beat of the metronome. Practice this step rate until you feel comfortable with it. You can then increase it by another 5% and repeat the process over several weeks until you reach the desired step rate. Remember that you should not be increasing your running speed as you increase your step rate. You should be able to run at the same speed but just give more steps. Other cues that may help you to give quicker steps are to give shorter steps or lighter steps so that you cannot hear your foot strike the ground. 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: Barton CJ, Bonanno DR, Carr J, et al. Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. Br J Sports Med 2016;50:513-526.

Knowing what type of practitioner to consult for your RSI can be tricky and getting it wrong can cost you a lot of money. The short answer is: A therapist who will address the cause of the injury and provide you with practical advice that you can implement at work. I was prompted to write this article by the following question in The Guardian: “I’m getting quite bad pains from my elbow to my wrist, which I think is due to constant keyboard work. Physiotherapy costs £40 a session and I can’t get it on the NHS. I’ve bought compressed support bands for £1 at Poundland and take ibuprofen. I don’t earn much so physio will be a massive cost for me; is it really worth it, or are there cheaper solutions?” Overuse injuries, like the one described above, are caused by using the same body parts in the same positions too often. How to get rid of repetitive strain injuries If you want to get rid of RSI permanently, you need to: Make sure that your workstation is set up in a way that puts minimum strain on your body. Nowadays there is a near endless variety of office equipment to choose from. A more compact keyboard can reduce the strain on your shoulders while an upright mouse may be the key to fixing your tennis elbow – the list goes on. Take regular breaks. Most people know this. The problem is that making a cup of tea is not necessarily going to help your arms rest/recover during the break. There are specific movements or stretches that you can do to get the maximum benefit from your break. Our bodies are all different and these exercises will vary between individuals. Get fit. Our bodies were made for movement and the best way to combat overuse injuries is through exercise that moves your whole body and gets the blood flowing. While exercises done during short breaks are great, they rarely increase blood flow to the same extent as other exercise. What type of exercise should you do? This will depend on your preferences and physical condition, but I would recommend something that involves both your upper and lower body. Braces, massage, acupuncture, manipulation, medication and electrotherapy may make you feel better for a short while, but these treatments will not fix your RSI. You have to follow the 3 steps above to permanently sort out overuse injuries. Who can treat your RSI? My first choice would be a physiotherapist. Consulting one online, using a video link, may even be better than seeing one face to face in a clinic. Yes, I may be biased, but let me explain why I say this. If you do the video call from a phone or tablet, you can position the device so that the physio can observe you while you work at your desk and make real time recommendations tailored to your specific situation. A big drawback of face to face consultations done in a physio practice is that, unless the physio visits you at work/home, they can only provide generic workstation advice. Physios who provide online consultations are also able to diagnose your injury and provide you with the exercise advice that you need. They are very good at providing exercise and self-help advice because they cannot do any hands-on treatment. 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

Bones are normally very strong structures, but in some people they can become weak and easy to break – a condition known as osteoporosis. There are several factors that can cause osteoporosis ranging from malnutrition, lack of exercise, hormone levels, genetics and even certain illnesses. When a person has osteoporosis the loss of bone strength is usually as a result of 2 processes: A loss of bone mineral content and bone mineral density Changes to the micro-architecture of the bone Step 1: Build as much bone as possible when you’re young Research has consistently shown that in order to have strong bones in old age, you have to optimise your bone strength as a child. By achieving a high peak of bone mass during your growing years, you can decrease the risk of suffering osteoporosis and therefore osteoporotic fractures later in life. Kids need to follow the following steps for strong bones: Do impact sport. Studies have shown that children who take part in sports like running, basketball, ballet and hockey have higher bone mineral density than children whose main sport is swimming or children who do not take part in any sport. This is because the mechanical forces from the impact stimulate bones to increase their bone mineral density and content. Follow diets high in calcium as well as magnesium and phosphorus. These minerals are some of the key building blocks of bone. Get enough Vitamin D. Your body requires Vitamin D in order to absorb calcium from your gut. In the UK we’ve seen reports of an increased incidence of rickets under school children in recent years. This is thought to be due to children spending more time indoors and not getting enough Vitamin D from the sun. Step 2: Continue doing impact sport throughout your life The research is very clear on the fact that people of all ages who take part in impact sport have better bone health than their sedentary counterparts. Impact activities create strong bones by increasing the bone mineral content and density of your bones. Impact sport does, however, not mean that you’ve got to take up rugby or running! It can include walking, dancing, step classes – the list goes on.  Weight training may be an option if injury prevents you from doing stepping activities. You can also use weight training to increase the bone mineral density in your arms, since the activities named above mostly affect your legs and back. I can’t do impact sport. Will swimming help? Yes, there is some research that shows that swimmers have stronger bones than sedentary people. Swimming does not increase your bone mineral density but it changes the internal structure of the bone so that it is better at resisting bending and torsion forces. The picture below is a magnified image of how your bone looks inside. Swimming helps to change the structure of these “pockets” or trabeculae and make them stronger. Some research suggests that swim sprint training produces better results than swim endurance training. This can possibly be attributed to the greater forces produced by the muscles when you sprint in the pool compared to steady swimming. There is also evidence that the push swimmers perform to get away from the wall helps with increasing bone strength. While swimming may only hold a small benefits for bone strength, it does hold great benefits for your general health. Step 3: Don’t forget the building blocks! As mentioned above, you have to get enough Vitamin D as well as calcium, magnesium and phosphorus to maintain good bone health. If you live far from the equator, use sunscreen or rarely go in the sun, you may have to use Vitamin D supplements. You can find out more about Vitamin D in this blog post. Please consult your doctor before you take any supplements as they may interact with other medication that you are taking. 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: Gómez-Bruton, Alejandro, et al. "Is bone tissue really affected by swimming? A systematic review." PLoS One 8.8 (2013): e70119.

Arthritis is one of those dreaded words that most of my patients seem to fear and I’m not quite sure why. Is it that they feel it is a sign that they are getting old? Is it that they think that it means that they should give up doing the exercise or activities that they love? Or is it that they think that there is nothing that they can do to help their joints and will definitely need a knee replacement in a month? I also see a lot of patients over the age of 60 who suffer aches and pains unnecessarily because they think that it is due to arthritis and there is nothing that can be done about it. I’ve just realised that I can actually write a whole blog post about all the different options for treatment and activity changes etc. etc. that we find effective in practice to help patients regain their active lives, despite having the diagnosis of arthritis hanging over them. Today, however, I would like to focus on the positive effect that exercise can have on slowing down inflammation, decreasing the pain you experience as well as increasing the level at which people can function. Chronic inflammation as cause of arthritis Inflammation is one of our body’s most powerful processes that it uses to protect us against infections and disease. It also plays a very important part in the healing process when you sustain an injury. While acute bouts of inflammation can be very advantageous, there is strong evidence to suggest that chronic, low levels of inflammation may be to blame for a whole plethora of illnesses/conditions including arthritis. How does exercise reduce chronic inflammation? All the causes for chronic low-grade inflammation are not yet fully understood. One of the strongest correlations, in people who does not suffer from chronic disease, has been found to be the percentage body fat a person has. The more fat a person carries, the higher their inflammatory markers usually are. Regular exercise helps people to lose fat and build muscle, which is one of the mechanisms that researchers suspect may be behind the positive effect exercise has on inflammation. Looking at the research, it is however obvious that this is only one of the mechanism at work when you exercise. There are also plenty of studies that show a positive effect from exercise without any changes in body mass or composition. This is important to understand so that you don’t feel disheartened if you struggle to lose weight. While losing weight is very likely to help your arthritis, you will still reap benefits from exercise even if you don’t drop any pounds. During exercise your muscles produces high volumes of certain molecules that have been shown to reduce inflammation. These molecules are also produced at rest, but in much smaller quantities. Lastly, exercise has also been shown to help regulate blood glucose levels. Chronically elevated blood sugar levels (e.g. when you are pre-diabetic or have diabetes) has been shown to lead to chronic inflammation in the body and exercise has been proven as an effective cure for Type 2 diabetes. It is not just about reducing inflammation Chronic inflammation is a very obvious cause of arthritis, but there are several other factors that can contribute to your joints taking more strain than what they should. Lack of muscle strength, flexibility and even proprioception (joint position sense – explained below) can all contribute to excessive wear and tear of your joints. So let’s take a closer look at how joints function. Your joints are formed by the bones and ligaments that connect them. These ligaments help to stabilise the bones and stop them from moving too far. The joint surfaces are covered with slippery cartilage and the joint space is filled with very slippery fluid. Your joints tend to be designed to carry weight or force in very specific areas and as long as you stay within those parameters they cope extremely well. Tight muscles or stiffness in joints in other parts of the body can cause a joint to repetitively overload a single area of its surface – leading to excessive wear of that piece of cartilage. There is currently not a lot of evidence that improving flexibility can help to improve arthritis symptoms, but this is not a well-researched topic. In clinic I find that it is very patient specific and also depends on the extent of their joint damage. Position sense or proprioception is the ability of the brain to know where its body parts are without having to look at them. There is research to suggest that you can decrease a person's pain through proprioception exercises, but they are not yet sure why. It may have to do with the fact that when a joint’s position sense is affected, it leads to less controlled joint movement which may contribute to joint wear. Don’t worry, proprioception may sound overwhelming but it’s extremely easy to retrain. For the lower limbs, for instance, simple balancing exercises work great. Your joints are also surrounded by muscles. An obvious function of the muscles are to move the joints. A less obvious function, that most people don’t appreciate, is that the muscles also (are meant to) absorb a great amount of the shock during movement – thereby off-loading the joints and protecting them. Don’t quote me on this, but I think I’ve read that, at the hip, 60% of the force created when walking is meant to be absorbed by the muscles that surround the hip joint. Research has also shown that people who suffered from knee osteoarthritis reported decreased pain and better function after a strength training programming focussing on their quadriceps muscles. What types of exercise are best for arthritis? From the above it is clear that our aims should be to reduce chronic inflammation and increase muscles strength, flexibility and joint position sense. Research has shown that to decrease chronic inflammation the following works best: Exercise that uses concentric muscle contractions rather than eccentric. Most cardiovascular activities use concentric muscle contractions e.g. walking, running, cycling, cross trainer, swimming etc. Duration of the exercise – a longer duration of physical exercise leads to a better effect. The more muscle mass you use during the exercise, the greater the effect. Swimming or using the cross trainer may be good options as they use the whole body. Moderate exercise intensity seems to have better results than low or high intensities. As a rough guide I would say that you should aim to be breathing harder but not feel out of breath while exercising. A lot of people find that their painful joints limit what exercise they can do. The good news is that you do not have to exercise the painful body part to get the anti-inflammatory effect. If, for example, you knees stop you from walking or cycling, you can still swim while pinching a pool buoy between your legs and only use your arms. Speak to an experienced physiotherapist before you decide that you cannot exercise. They can be amazingly resourceful, but you also have to be willing to compromise and try new things. For the reasons explained in the section above, your exercise programme should also include: Strength training Flexibility exercises Proprioception 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. References: Beavers, Kristen M., Tina E. Brinkley, and Barbara J. Nicklas. "Effect of exercise training on chronic inflammation." Clinica chimica acta 411.11 (2010): 785-793. Mendes R, Sousa N, Almeida A, et al. Exercise prescription for patients with type 2 diabetes—a synthesis of international recommendations: narrative review. British Journal of Sports Medicine 2016;50(22):1379-81. doi: 10.1136/bjsports-2015-094895 Runhaar, Jos, and S. M. A. Bierma-Zeinstra. "Should exercise therapy for chronic musculoskeletal conditions focus on the anti-inflammatory effects of exercise?." (2017): 762-763. Runhaar, Jos, et al. "Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review." Osteoarthritis and Cartilage 23.7 (2015): 1071-1082. Shiny, Abhijit, et al. "Association of neutrophil-lymphocyte ratio with glucose intolerance: an indicator of systemic inflammation in patients with type 2 diabetes." Diabetes technology & therapeutics 16.8 (2014): 524-530.

Being injured really isn’t any fun.  I am often asked on social media “I’ve injured my *insert your injury*. What should I do to recover?” The problem is that by the time you ask a random question on Twitter, you’ve likely already done several things that will prolong your recovery. Four of the most common things that people do wrong can easily be remembered by the phrase: Do no HARM. (Heat/Alcohol/Running/Massage) We all know the old mantra of things you should do: Rest, Ice, Compression, Elevation (RICE). The aim of the RICE regime is to protect the first (primary) injury and limit the secondary injury by protecting tissue from further trauma and reducing bleeding and swelling. Excessive bleeding/swelling can cause lots of pressure in the muscle or joint. This increased pressure can cut off the blood circulation and oxygen supply to adjacent cells and you can end up with more damage than what the original injury actually caused (= secondary injury). The four components of HARM should all be avoided during the first few days of injury, because they will very likely increase the extent of your injury and prolong your recovery. Heat Do not apply heat to a fresh injury that you've sustained less than 7 days ago. When you sustain an injury, you also tear several blood vessels in that area. If you’re lucky, you only tear a few small ones. If the area swells up quickly, it is likely that you’ve torn a rather large one. Your aim should be to try and stop the bleeding as quickly as possible. Heat leads to an increase in blood circulation in that area and will obviously have the opposite effect – causing your injury to worsen as explained above. Ice should be your weapon of choice for an acute injury and you can read more about how to safely apply ice here. Damaged blood vessels can continue to be weak and leak for a few days after injury, so it is best to avoid heat for at least a week (this may vary according to the extent of your injury). It is also thought that heat can increase the inflammatory response. While inflammation is a very important part of the healing response, excessive inflammation can actually lead to more tissue damage. Alcohol Alcohol has a blood thinning effect which means that it decreases your blood’s ability to form clots. The longer it takes for your blood to clot, the more you will bleed into the injured area and the worse your injury will get. My advice would be to definitely stay away from alcohol for 24 hours after injuring yourself. Consider abstaining for 72 hours if your injury swelled up quickly (which may indicate damage to a slightly larger blood vessel). Running Running is bad for acute injuries (injuries that are less than 5 days old) for 2 reasons: The first is rather obvious. If you have injured any structure in your lower body, that structure is now weaker and you may tear more muscle fibres if you continue to use it. You may not realise this when you are healthy, but running is actually a full body activity. It uses a lot of shoulder and spine movement and you may even make injuries in those areas worse if you continue. One may be tempted to think “I’ve injured my arm, I should be OK to carry on running.” But, this may be a bad idea for a similar reason as the 2 cases above. Running will increase the blood circulation in the whole body. This will lead to increased bleeding and swelling at the site of injury and ultimately increase the extent of your injury regardless of where it is. Massage When you sustain an injury, that area is weak and the new cells that form can easily be torn or damaged. You can read a more detailed description of how healing takes place here. For this reason massage within the first 5 days of sustaining an injury is a taboo. After this period, it should be applied with great care and with very graded pressure. Very light strokes should be used during the first few weeks and DO NOT ALLOW ANYONE TO DIG INTO A MUSCLE within the first 3 to 4 weeks of tearing it. All pressure should be comfortably uncomfortable. 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 often use this taping technique for patients with pain over the front of their knees e.g. patellofemoral syndrome, osteoarthritis, or Osgood-Schlatters. What you need: Kinesiology tape Scissors DO NOT USE TAPE IF YOU ARE ALLERGIC TO PLASTERS! 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.