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I'm a firm believer that if you know how an injury is caused you can fix it and stop it from happening again. In this article I explain how shin splints develop and what treatment works for it. In this article: What causes shin splints? Make sure it’s shin splints How do you fix shin splints? How to prevent shin splints You can watch the recording of the livestream I did below. What causes shin splints? The medical name for shin splints is Medial Tibial Stress Syndrome. I know – It’s a mouth full! But the name actually explains exactly what it is. Shin splints is an overuse injury which develops when too much strain (stress) is put on the inside (medial part) of the shin bone (tibia). Shin splints can also be described as a stress reaction in the shin bone. When we exercise, our bones and muscles and tendons etc. all develop micro-damage. This micro-damage is normal and needed because it acts as the message to the brain that it has to rebuild your body stronger. If you give your body enough time between exercise bouts, the micro-damage gets repaired and the bones, muscles ligaments etc. are all stronger than before you exercised. If, however, you train too often and at too high intensities the body can’t repair all the damage and that’s when you can develop overuse injuries like shin splints. You can overstrain the shin bone or tibia by: increasing your training volume too suddenly e.g. having the summer off and then suddenly jumping into 3 times a week hockey training, doing too many intense training sessions in a week e.g. hill running, track sessions and or tempo runs, having a running style that places more strain on the shin bone e.g. low cadence, narrow gait or over-striding, poor hip control can potentially cause your legs to turn in more during running which can lead to strain lower down, excessive foot pronation (rolling in of the foot) can also cause the legs to turn in more, straining the tibia. Remember, bones can only grow and recover if they have all the building blocks that they require. So make sure that you’re getting enough Vitamin D and calories in your diet. Your body can only absorb calcium (a building block of bones) if it has enough Vitamin D. There is also strong evidence that suggests that athletes are at a higher risk of having poor bone health and developing stress fractures if they restrict their calorie intake while training hard. Make sure it’s shin splints When shin splints first start the pain is often only noticeable at the beginning of an activity but then goes away while you train or exercise. As the condition gets worse the pain may increase and stop you from training. It will then often also hurt during normal daily activities e.g. walking. It is important to distinguish shin splints from other conditions e.g. stress fractures and exertional compartment syndrome. You likely have shin splints if the pain is: on the inner border of the shin bone where the muscles attach, the pain stretches over an area of at least 5cm, the pain does not interfere with your sleep, you don’t have any of the symptoms listed below for stress fractures or compartment syndrome. You may have a stress fracture if: you have a very localised point on the bone that is painful (less than 5cm) to press, you have pain when lying down or resting, you have pain on the front of the shin bone (not the muscles but on the bone). If any of these symptoms fit you, don’t panic – consult a sports physio or doctor and let them check it for you. You may have exertional compartment syndrome (where there is too much pressure in the calf during exercise) if: the pain is only really present during exercise and usually settles within a short period e.g. within 15 minutes of stopping, the pain is associated with cramping, burning, tingling or pressure-like calf pain, or your foot feels cold or numb while exercising. How do you fix shin splints? Rest from aggravating activities Remember that shin splints is an over-use injury of the bone where the bone has not been given enough time to recover between exercise bouts. If you continue to do exercise or activities that cause pain, the injury will just drag on. You may also be at risk of developing a full blown stress fracture if you neglect it for too long. This does not mean that you can’t do any exercise! You must just cut the stuff out that hurts. This usually includes running and jumping activities. You should still be able to swim and cycle or cross train to keep your fitness up. Strengthen your legs Start working on your glute max, glute med, hamstring, quad and calf strength. Choose exercises that does not cause any pain and that also develops your stability. Make sure that you include exercises for foot and ankle stability. Flexibility Not all my patients benefit from flexibility exercises. Some of them develop shin splints because the muscles around their ankles are too weak and their joints are too flexible. These patients benefit more from strength training and orthotics. A number of patients do present with extremely tight calves and ankles. I find that these patients often benefit from adding calf stretches and general flexibility work into their rehab programmes. Orthotics or supportive insoles If you suspect that your feet roll in or your arches drop excessively when you run or walk, you may benefit from wearing some orthotics in your trainers. These insoles act as a little support for your foot arch and can in theory reduce the strain on the shin bone by not allowing the foot to roll in excessively. Slowly return to sport It is always very tempting to jump right back into training once the pain has settled. Please don’t do this. The bone needs to slowly get used to exercise again and you risk flaring it all back up again if you go back to your normal training regime. This is where it can really help to work with a physio or other sports clinician who can work out a programme that is specific to your sport and takes your goals into consideration. If you’re a runner or you do running sports, I suggest that you follow a run/walk programme to get the shin bone used to the impact of running. You can find an example of a run/walk programme in this blog post. How to prevent shin splints Like so many other sports injuries the research seems to suggest that if you’ve had shin splints in the past, you may be at risk of getting it again in the future. These are the steps I suggest you take to prevent this from happening: Make sure your legs are strong. Do at least 2 strength training sessions per week. Plan and log your training! Make sure that you ease into training and that you allow enough recovery time between sessions. Do you have flat feet or over-pronate? You may benefit from using orthotics and having more stable running shoes. Have your running style checked. There’s no perfect running style but the research does seem to suggest that certain things e.g. a narrow gait or turning in of the legs etc. can contribute to shin splints. I get my patients to email me a video of themselves running on a treadmill and then look at it in slow motion. There are some very simple but effective cues that you can use to correct your running style depending on what is needed. Eat enough and make sure your Vitamin D levels are topped up. Sleep is extremely important for recovery so make sure you get enough! 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 Agresta C, Brown A. Gait retraining for injured and healthy runners using augmented feedback: a systematic literature review. Journal of orthopaedic & sports physical therapy 2015;45(8):576-84. Bliekendaal S, Moen M, Fokker Y, et al. Incidence and risk factors of medial tibial stress syndrome: a prospective study in Physical Education Teacher Education students. BMJ Open Sport & Exercise Medicine 2018;4(1) doi: 10.1136/bmjsem-2018-000421 Garnock C, Witchalls J, Newman P. Predicting individual risk for medial tibial stress syndrome in navy recruits. Journal of science and medicine in sport 2018;21(6):586-90. Sharma J, Weston M, Batterham A, et al. Gait retraining and incidence of medial tibial stress syndrome in army recruits. Medicine and science in sports and exercise 2014;46(9):1684. Verrelst R, Willems TM, Clercq DD, et al. The role of hip abductor and external rotator muscle strength in the development of exertional medial tibial pain: a prospective study. British Journal of Sports Medicine 2014;48(21):1564-69. doi: 10.1136/bjsports-2012-091710 Verrelst R, De Clercq D, Vanrenterghem J, et al. The role of proximal dynamic joint stability in the development of exertional medial tibial pain: a prospective study. Br J Sports Med 2013:bjsports-2012-092126. Winters M, Bakker EWP, Moen MH, et al. Medial tibial stress syndrome can be diagnosed reliably using history and physical examination. British Journal of Sports Medicine 2018;52(19):1267-72. doi: 10.1136/bjsports-2016-097037 Zimmermann WO, Helmhout P, Beutler A. Prevention and treatment of exercise related leg pain in young soldiers; a review of the literature and current practice in the Dutch Armed Forces. Journal of the Royal Army Medical Corps 2017;163(2):94-103.

When people think of exercise, a lot of times running is their first thought. It’s the most simple, in that it can be done anywhere, you don’t need equipment, it can contribute to fat loss, and it makes most people feel good after. Often times, if someone doesn’t have proper strength training to go along with running, they can end up getting burnt out, or worse, with an injury that takes them “out of the race”. Running takes a huge toll on our bodies, so it is very important that we strengthen that foundation so we can run further, faster, and longer, all while staying injury free! Walking into a gym can be scary. There are so many different types of equipment that look weird and you see all these people that you automatically decide are more fit than you, so you spot that treadmill in the corner and make a mad dash so no one steals it before you get there, right? The main thing to remember the first few times you walk through those doors is that every single one of those people were beginners at some point as well. They had to learn how everything works, just like you do. Gym workout for runners I want to make that process easier for you, if you are a beginner to the gym. If you’re a gym pro already, I still want to make it easier for you to walk in there locked and loaded with some total body workouts that will help you take your strength to new levels, while boosting your cardio endurance at the same time! How to use the programme The following four workouts can be cycled throughout the week. If you plan to go to the gym 4 times a week, you’ll do each one once. If you go three times, you can do the first 3 the first week, then start with the 4th and do the first 2 again the second week, etc. If you go 5+ times, feel free to begin cycling back through them, or trying new things to see what you like, however, I do STRONGLY recommend at least 1-2 days of rest per week! Three of the workouts are “circuit style” with two or three exercises per circuit. For those, go through each circuit three times with the prescribed reps for each exercise, with as little rest as possible. Take two minutes rest after all three sets are complete, before moving on to your next circuit. The fourth one is all cardio with the instructions in the actual exercise program. Select weights that are challenging for you, record them, and try to increase them over the next several weeks. By the time you have 2-3 reps left in the set, you should be struggling to complete it. If you can easily bang out all the reps, time to pick up a heavier weight! If you are unsure about an exercise, please take a look at the linked demonstration video. In this video Ali discussed the gym programme and how runners should use it in more detail. Download Programme If you need any further assistance, please feel free to email me at ali@finalstrawfitness.com! Happy Lifting! Ali Greenman Final Straw Fitness Ali Greenman Ali is a Certified Personal Trainer who works with women all over the world on building strength, confidence, and excitement within themselves through online health and fitness training. Throughout her own weight loss journey to lose 70 pounds, Ali had plenty of ups and downs, but finally came out the other side and loves helping others streamline the process of losing weight, and gaining strength!

A cool-down includes all the activities that you do in the hour after exercise. It can broadly be divided into an active cool-down and a passive cool-down. An active cool-down is commonly believed to be better than a passive cool-down for recovery from training and preventing injuries, but is it really? I have to admit that I very rarely do any activity that counts as an active cool-down and I can’t really say that I’ve noticed any negative effect. So what does the research say? Am I missing a key part of the injury prevention puzzle or is it something that’s only relevant to elite athletes? In this article: What's an active cool-down? What's a passive cool-down? Effects of an active cool-down on performance Removal of lactic acid DOMS and muscle damage Stiffness and range of motion Heart and Lungs Injury prevention Static stretching Foam rolling What's an active cool-down? An active cool-down is often referred to as active recovery. It usually consists of low to moderate intensity exercise that is performed within 1 hour of the main training session or competition. It’s commonly believed that an active recovery or cool-down is beneficial because it helps your body get rid of the chemical by-products caused by exercise (e.g. lactic acid) more quickly than when you just lie or sit around. This, in theory, would mean that you recover more quickly, perform better and could possibly even help you avoid injury. Researchers from the Netherlands and Australia  recently reviewed all the studies that they could find on the topic and it would seem that an active cool-down may not be as effective as we would like to think. I discuss their findings below. What's a passive cool-down? Activities like static stretches and foam rolling counts as a passive cool-down because they don’t involve any exercise. Effects of an active recovery on performance In theory one would think that if an active recovery gets rid of all the toxins etc. formed during exercise, it should help you recover better and therefor help your performance. But this does not actually seem to the case. The research have so far not produced any consistent evidence that an active recovery is any better than a passive recovery when they looked at how athletes perform on the same day as well as the following day. Removal of lactic acid Lactic acid must be one of the best known by-products of exercise and has traditionally been associated with fatigue. These days we understand that fatigue in exercise is caused by a lot more than just lactic acid and its relevance to performance is even being questioned. That said, one of the main reasons that people advocate an active cool-down is due to the belief that it allows your body to get rid of lactic acid much more quickly than if you just sit around. Spoiler alert! Your body naturally gets rid of all extra lactic acid within 20 to 120 minutes after exercise REGARDLESS of what you do. In studies where participants did get rid of their lactic acid more quickly than others, this also did not give them any performance benefits. In some studies the researchers found that an active cool-down even slowed the process. This may be down to the low fitness levels of the participants. If you’re not very fit an active cool-down may actually just add to your training load and cause more lactic acid to build up! Verdict: An active cool-down does not get rid of lactic acid any quicker than a passive cool-down. DOMS and muscle damage DOMS stands for Delayed Onset Muscle Soreness. It can be defined as the soreness that you develop in your muscles in the days after doing a hard bout of exercise. There is some evidence that an active cool-down can decrease the effects of DOMS in professional and highly trained athletes. But it doesn’t seem to have the same beneficial effects for recreational athletes. Researchers are able to tell how much muscle damage you’ve developed during exercise by testing for certain markers in your blood. An active cool-down does not seem to influence these markers nor does it allow athletes to regain their maximum muscle strength any quicker compared to a passive cool-down. Stiffness and range of motion Exercise (especially eccentric exercise) causes micro-damage in your tendons and muscles. This is part of the natural process that allows the body to rebuild itself stronger in response to exercise. This micro-trauma is the main reason why you often feel stiff in the days after a hard bout of exercise. A common belief is that an active cool-down decreases this stiffness, but you’ve guessed it – the research have shown that it doesn’t actually have much of an effect on how stiff you feel. Something that I would love to know and that's not yet been researched is what the effect of a long period of inactivity immediately after exercise is on the recovery of your joints and muscles. I definitely find that I stiffen up dramatically if I sit and work at my desk after I've gone for a run. Whereas I never feel as stiff when I potter around afterwards. I would love to know if this has any detrimental effect the next day or is it just a transient nuisance that I have to put up with for that day? Heart and Lungs There is strong evidence that an active cool-down helps your cardiovascular system (heart) and respiratory system (lungs) recover quicker. I don’t know if you’ve ever noticed how wobbly marathon runners can look when they cross the finish line. Yes, this is partly due to the fact that they’re knackered but if you suddenly stop exercising the blood can pool in your legs. This can cause light headedness, tunnel or blurred vision or may even make people pass out. An active cool-down can also decrease this effect. Injury Prevention It’s not currently clear if an active or passive cool-down has any effect on injury prevention. Static Stretching Static stretching can help you regain your range of motion and decrease the feeling of stiffness after exercise. It doesn’t have any effect on DOMS (the pain you feel after exercise). The research has also found that it may play a role in preventing muscle strains. I find in practice that children often benefit from it more than adults. They tend to struggle with excessive stiffness when they go through growth spurts which makes them vulnerable to injuries like Osgood Schlatters. Including static stretches as part of their cool-down can have a very beneficial effect on their flexibility. Foam rolling Foam rolling appears to be a useful activity to include in your cool-down as it’s been shown to effectively reduce the amount of muscle pain you feel after exercise (DOMS). The verdict: Highly trained athletes may benefit more from doing active cool-downs than recreational athletes. That said, all of us can benefit from the positive recovery effect it has on your heart and lungs. Static stretching and foam rolling are also useful modalities to include in your cool-down. 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: Capote Lavandero G, Rendón Morales PA, Analuiza A, et al. Effects of myofascial self-release. Systematic review. Revista Cubana de Investigaciones Biomédicas 2017;36(2):271-83. Dupuy O, Douzi W, Theurot D, et al. An evidence-based approach for choosing post-exercise recovery techniques to reduce markers of muscle damage, soreness, fatigue and inflammation: a systematic review with meta-analysis. Frontiers in physiology 2018;9:403. Loughran, Martin, et al. “The effects of a combined static-dynamic stretching protocol on athletic performance in elite Gaelic footballers: A randomised controlled crossover trial.” Physical Therapy in Sport 25 (2017): 47-54. Schroeder AN, Best TM. Is self myofascial release an effective preexercise and recovery strategy? A literature review. Current sports medicine reports 2015;14(3):200-08. Van Hooren B, Peake JM. Do We Need a Cool-Down After Exercise? A Narrative Review of the Psychophysiological Effects and the Effects on Performance, Injuries and the Long-Term Adaptive Response. Sports Med 2018:1-21.

The research is pretty clear that the best treatment plan for patellar tendonitis/tendinopathy should include strengthening exercises for the patellar tendon, as it is the only way to restore the strength you lost due to the injury. But doing only strength training may not be enough. In this article, we look at what exercises you should include in your treatment plan and why a one-size-fits-all approach will likely not be the best for your knee. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. What an ideal exercise plan for patellar tendonitis should include The leading research experts in the field of patellar tendonitis currently suggest that an exercise-based treatment plan should include: A thorough assessment Load management or relative rest Progressive loading with patient-specific goals in mind Strengthening exercises that target the patellar tendon specifically Exercises that strengthen the rest of the body Stretches and mobility exercises Drills and exercises that teach good landing biomechanics A slow, phased return to sport 1. A thorough assessment This is necessary because: There is no single thing that causes patellar tendonitis/tendinopathy. You have to address the cause of your specific case and not waste time working on things that aren’t needed. Patellar tendonitis can vary dramatically with regards to how irritable the tendon is (how easily the pain flares up). Your physio can gauge the irritability through an in-depth discussion about how different activities affect your pain and asking you to do specific movement tests. This the only way to establish your injured tendon’s current load tolerance (strength and endurance). This will help your physio to determine what type, volume, intensity, and frequency of exercises and activities are currently right for you and will allow your tendon to grow stronger rather than just aggravate it further. Patellar tendonitis pain can feel very similar to other conditions, e.g. patellofemoral pain, so it is important to get the diagnosis right. It is also not uncommon for other parts of your knee to be injured at the same time, and your treatment plan should take all of these into consideration. 2. Load management or relative rest You can’t just continue doing all the activities at the intensities you want to and expect your knee to recover. Once injured, you tendon loses some of its strength. This means that it’s no longer strong enough to cope with all the activities you want to do, and even simple things like climbing stairs may hurt. Here's an article about two everyday activities that may aggravate your patellar tendon pain. By reducing your sport and other daily activities to a level that doesn’t aggravate your knee, you will allow your tendon pain to settle down, which in turn will allow you to make progress with your rehab exercises. This is called relative rest. It is different from complete rest in that you can still be active, as long as you adapt your training/activity volume and intensity to suit your knee’s current state. If you continue to do things in your daily life or play sport to a level that causes your pain to increase, it really doesn’t matter what rehab you do, as it won’t be effective. Rehab exercises can only work if you ensure that everything you do in your day is pitched at the correct level. This is why we use ample time during our consultations to discuss all the aspects of our patients’ lives, not just their sport. One way of preserving your fitness while your patellar tendon injury settles down is cross training. We’ll discuss your different cross training options in a future blog post. 3. Progressive loading with patient-specific goals in mind Like we mentioned before, the patellar tendon loses some of its strength once it's injured. To rebuild that strength, you have to follow a specific strength training programme. But if you let rip with heavy loaded exercises right from the start, you may find that the tendon flares up and becomes very painful. That’s why it's important to assess the tendon’s current load tolerance. For an exercise plan to be effective the exercises have to start at an intensity that is a bit challenging, but not too challenging, for the tendon. As you train and your tendon regains its strength, the exercise intensities and volumes should then increase until you eventually achieve loads that resemble those in your sport. This is why, for instance, the exercises prescribed for a long-distance hill walker with patellar tendonitis will look very different from those prescribed to a basketball player. The hill walker needs long, steady endurance up- and downhill and good strength; they don't necessarily need the same explosive power that the basketball player might need. Likewise, if you neglect to retrain the explosive strength and landing mechanics of the basketball player, they will likely end up reinjuring their tendon. 4. Strengthening exercises that target the patellar tendon specifically There are several exercise programmes that have been shown to be effective as treatment for patellar tendonitis, and we discuss the main ones with examples of exercises further down. These include: Progressive loading exercise plan Heavy slow resistance exercise plan Eccentric decline squat exercise plan Our preferred method is to use the Progressive Loading method and to incorporate elements of the Heavy Slow Resistance plan into it. We might sometimes use eccentric exercises as part of the programme if we identify that it is something that would benefit a specific patient, but we never prescribe only eccentric exercises. Progressive loading exercise plan for patellar tendonitis Steph explains how a progressive loading plan works and demonstrates the exercises that it may include in this video, but we also highlight the main points below. How effective is it? A recent randomised controlled trial found that a progressive loading exercise programme that lasted 24 weeks resulted in a significantly better clinical outcome when compared with the traditional eccentric only squat programme for patellar tendonitis. It is also the approach advocated by the leading researchers in this field. Why we like it It’s the only exercise approach that truly retrains all the aspects needed for a successful return to sport. It includes exercises that develop: Pure strength in the patellar tendon; Explosive/fast loading; Control; Sports specific muscle/tendon function and biomechanics. And, because you’re able to choose exercises that best suit a specific patient, it causes fewer flare-ups. The focus is also on adjusting the load so that it doesn’t cause much discomfort and pain, which also makes it a much more enjoyable experience for the patient. How a progressive loading exercise plan for patellar tendonitis works A typical progressive loading plan is usually divided into four stages. The duration of each stage varies depending on how a person responds to it and on the demands (end goals) of their specific sport. You won’t necessarily start on Stage 1 - your tendon’s current strength and irritability determines where you start. It is OK to experience a bit of discomfort during or after you’ve done the exercises, but ideally is should be done pain free. If you do feel discomfort, it should not go above 3 out of 10 intensity and it should settle down to your normal level of discomfort within 24 hours of doing the exercises. If it causes stronger pain than this or you experience and increase in pain that lasts for more than 24 hours after the session, you should reduce the exercise volume or intensity. Stage 1: Isometric exercises The aim of this stage is to allow your tendon to calm down. Isometric exercises (where you hold the contraction for up to 45 seconds) have been shown to help reduce pain when you have patellar tendonitis. You can do them against a wall or use a leg press machine or a knee extension machine. Stage 2: Introduce isotonic exercises Isotonic exercises strengthen both the concentric (shortening) and eccentric (lengthening) muscle action, and they tend to resemble the way our muscles and tendons function when we do sport. Examples of isotonic exercises for the quads and patellar tendon include squats, leg press machine, lunges, and pistol squats. These should be started at a level that is slightly difficult but doesn’t irritate your tendon. They should then slowly be progressed until you can do them with heavy loads and with a single leg. Stage 3: Plyometrics to develop explosive strength You will continue with some isotonic exercises to maintain your strength, but add in plyometrics. Plyometric exercises load the tendon at speed. A mix of plyometric exercises can be used, but you’ll typically start off with double leg hops and jumps and with low effort. Then they progress to single leg or just higher effort on double legs (higher boxes). What type of jumps are included in your treatment plan and the volume/intensity of them will be determined by the type of sport you play. If you do a sport that involves no running or jumping, this stage can even be left out. Stage 4: Sport specific During this stage an athlete should start phasing back into their sport. A footballer may start adding in kicking drills and running drills, starting off easy and at low intensity and slowly ramping it up over time. A runner will likely just start a run-walk programme to ease back into continuous running. It’s important to continue doing a maintenance set of strength training exercises even after you’re returned to your sport. The intensity and frequency should vary depending on your training year; doing higher loads and more intense strength training during the off-season and then reducing it to a smaller maintenance set once the competition phase starts. Heavy slow resistance exercise plan for patellar tendonitis Steph discusses the heavy slow resistance exercise plan in this video: How effective is it? It’s been shown to provide better long term outcomes than the eccentric only protocol. It has also been shown to increase the collagen production inside the tendon and to cause positive changes within the tendon structure. Why we don’t use heavy slow resistance training on it’s own Heavy slow resistance training will always be a part of our rehab plans, but it is not enough. It is great for restoring the tendon’s strength and the muscle’s ability to produce strong contractions at slow speeds, but it doesn’t really prepare the tendon or the quad muscles for fast, explosive loads, e.g. like for a basketball player. Traditionally, it uses only double leg exercises, so you can’t really tell if the injured leg is working as hard as the uninjured one. You have to use gym equipment to achieve the loads required. It also doesn’t address any of the other strength or range of motion deficits that may be present elsewhere in the body. So we tend to combine and use the principle of heavy slow resistance training as part of our progressive loading exercise plans rather than as a standalone plan. How a heavy slow resistance exercise plan for patellar tendonitis works A pure heavy slow resistance exercise plan consists of: Three sessions a week Each session consists of three exercises: Double leg squats, double leg leg press machine, and double leg hack squats. You complete four sets of each exercise with a 2–3 min rest between sets. Rest five minutes when you switch to the next exercise. The repetitions/load changes over time Week 1: 15 repetition maximum** (RM), Weeks 2-3: 12RM Weeks 4-5: 10RM Weeks 6-8: 8RM Weeks 9-12: 6RM **Repetition maximum (RM) refers to the most weight you can lift for a defined number of exercise repetitions. 15 RM means that you're using a weight that you can lift 15 times max - after repetition number 15 you are totally fatigued and have to rest before you can do another set. So you will be using a much heavier weight for 6RM (Weeks 9-12) than for 15RM (Week 1), as you are looking to be fully fatigued after repetition Number 6. All exercises are performed from complete extension to 90 degrees of knee flexion and back again. They should be done slowly; use about 3 seconds to straighten the legs and 3 seconds to bend them to 90 degrees. Pain while doing the exercises is acceptable, but pain and discomfort should not increase after you've ended the session. If it does increase, the session’s intensity needs to be adjusted. Eccentric decline squat exercise plan for patellar tendonitis Steph discusses the decline squat programme in this video: How effective is it? The eccentric decline squat protocol has been shown to be effective in returning athletes to sport, but there is evidence that the high slow resistance and progressive loading protocols may hold more benefit. In a 2009 study by Kongsgaard et al., where they compared the eccentric protocol with the heavy slow resistance protocol, they found that the high slow resistance one: gave better long term results, and was the only one that demonstrated positive changes to the tendon structure when they checked it under ultrasound. Breda et al. compared an eccentric only exercise plan to a progressive loading plan and found that the latter produced significantly better clinical outcomes after 24 weeks. Why do we don’t like it Ten years ago, this used to be the favourite exercise plan to prescribe for patellar tendonitis. But recent research has shown that it’s perhaps not really the best option. It’s very prescriptive and it’s difficult to fit such a large volume of strength training into every single day. It doesn’t address any of the other biomechanical issues (weakness or tightness) in the rest of the body. It doesn’t include exercises that recreate the explosive loads the patellar tendon has to withstand in running and jumping sports. Because patients are encouraged to ignore pain while doing the exercises, it often causes them to push too far into pain and overload the tendon too much, hindering recovery. How the eccentric decline squat exercise plan for patellar tendonitis works The exercises are done on a 25 degree decline board. You stand with your heels on the higher end and your toes on the lower end. The angle of the decline board offloads your calf muscle and concentrates the loading force on the patellar tendon. You complete the downward squat movement (eccentric phase) slowly on your injured leg only. Then you place your uninjured leg on the board and use both legs to push back up (concentric phase) into the upright position. So, you train only the eccentric phase. It is acceptable to feel pain while completing the exercises. However, it is not acceptable if the pain continues after you stop exercising. Once you can do it at a certain level (weight) pain free, it is an indication that you should increase the weight. You should start by doing 3 sets of 15 repetitions twice a day using bodyweight only. Then you progressively increase the load until you can tolerate enough to start sport specific training (e.g. kicking drills or ease back into running). 5. Exercises that strengthen the rest of the body The body functions as a kinetic chain; weakness in one area may cause you to overuse and overload another. There is evidence that weak glutes and calf muscles may predispose you to developing patellar tendonitis. Calf raises (pictured below left) will help you to strengthen your calf muscles. Bridges (below right) will help you to strengthen your gluteal muscles. 6. Stretches and mobility exercises One automatically assumes that you would need to stretch your quadriceps muscles if you have patellar tendonitis, as they are the ones attaching onto the patellar tendon. And yes, the current research does show that stretching your quads may be beneficial. However, it also suggests that tight hamstrings and reduced dorsiflexion (how far your ankle can bend up, bringing your toes towards your shin) may put you at increased risk of developing patellar tendonitis, as these too can affect the kinetic chain mentioned above. So, it is important to also assess your quadriceps, hamstring, and dorsiflexion ranges of motion to see whether any of these need regular stretching. Remember that you don't have to be super flexible. There is a large variation between people in what is seen as a normal or functional range of motion. So, please don't over-stretch. You can actually cause yourself injuries (like high hamstring tendinopathy) if you're too aggressive with your stretching. Below are examples of stretches for (from left to right) dorsiflexion, quads, and hamstrings. 7. Drills and exercises that teach good landing biomechanics Biomechanics refers to the patterns your body uses when it moves, e.g. how much your joints bend or extend at specific moments during the movement. There is evidence that athletes who have patellar tendonitis tend to land with a stiffer knee and rather move their hips into more extension to compensate. They likely develop this movement pattern in an attempt to avoid aggravating their painful tendon. But there’s also evidence that this type of movement pattern can predispose you to developing patellar tendonitis. So, it is really important to address this as part of your rehab. It can easily be done with jumping and landing drills. However, jumping/landing drills count as very high load activities for the patellar tendon and should only be added once you’ve built enough strength in your tendon. 8. A slow, phased return to sport Once your tendon is ready to get back to sport, it's important not to jump back in too quickly. You have to slowly increase the volume and intensity, as your tendon won't yet have the stamina to cope with a full session of regular training or a match. A walk-run programme works well for runners. In other sports, like basketball, you may start with some dribbling, light contact, and a low volume of jumping and work your way up to full contact and high jumps. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Aiyegbusi, A., et al. (2019). "Lower Limb Biomechanical Variables Are Indicators of the Pattern of Presentation of Patella Tendinopathy in Elite African Basketball and Volleyball Players." Revista Brasileira de Ortopedia 54(5): 540-548. Breda, S. J., et al. (2020). "Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial." British Journal of Sports Medicine: bjsports-2020-103403. Burton, I. (2022). "Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review." Physical Therapy in Sport. Challoumas, D., et al. (2021). "Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies." BMJ Open Sport & Exercise Medicine 7(4): e001110. Christensen, B., et al. (2011). "Effect of anti-inflammatory medication on the running-induced rise in patella tendon collagen synthesis in humans." Journal of Applied Physiology 110(1): 137-141. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" British Journal of Sports Medicine 50(19): 1187-1191. de Vries, A., et al. (2016). "Effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial." Scandinavian Journal of Medicine & Science in Sports 26(10): 1217-1224. Kongsgaard, M., et al. (2009). "Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy." Scandinavian Journal of Medicine & Science in Sports 19(6): 790-802. Longo, U. G., et al. (2018). "Achilles Tendinopathy." Sports Medicine and Arthroscopy Review 26(1): 16-30. Magra, M. and N. Maffulli (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe, LWW. Malliaras, P., et al. (2015). "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." Journal of Orthopaedic & Sports Physical Therapy 45(11): 887-898. Purdam, C. R., et al. (2004). "A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy." British Journal of Sports Medicine 38(4): 395-397. Virchenko O, Skoglund B, Aspenberg P. Parecoxib impairs early tendon repair but improves later remodeling. Am J Sports Med. 2004;32:1–5.

It is quite common for injuries to flare up during their rehab, especially tendon injuries like patellar tendonitis or Achilles tendonitis. And it’s natural to then worry about whether you’ve made your injury worse and how far you’ve set back your rehab programme. In this article, I explain why injury flare-ups happen, why it does not necessarily mean that your injury is now worse, and how to get your rehab back on track after a flare-up. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Why do injury flare-ups happen? Have I made my injury worse? What to do about a flare-up How we can help We’ve also made a video about this: Why do injury flare-ups happen? With an injury flare-up, it’s always useful to try and get to the bottom of why it happened. It will tell you how to avoid it in future. It can also tell you where there might have been a gap in your rehab. Where have you not done enough work? Exercise or activity that your injured part wasn’t yet strong enough to handle Whenever you're injured, the injured part (e.g. a muscle or tendon) is weakened and doesn’t have the strength to cope with all the load that you put through it when you do your normal sport or other activities. Its capacity increases gradually as you progress your strength training as part of your rehab, but sometimes we misjudge things. It can be too much weight or intensity, but also volume or duration or frequency A flare-up happens whenever you progress your rehab exercises too quickly. It can be the total volume of exercise and/or the intensity of one or more exercises, such as the number of repetitions, the duration, or the weights. It can also be due to the type of activity you did. For example, you could have been doing slow repetitions of an exercise, but now you’ve changed to doing quick, explosive movements. Doing your exercises too often can also cause trouble. Your body requires time to rest and recover and adapt after each training session. If you do your rehab exercises before your body has fully recovered from your previous session, it can cause a flare-up. Example of a flare-up and what could have gone wrong This article and its accompanying video were inspired by a question that someone posted on our YouTube Channel. He’s a basketball player with patellar tendinopathy, i.e. a tendinitis or tendinosis in the patellar tendon, which is at the front of the knee. In this case, he had it in both tendons. He wrote that he was able to do really good squats with weights as part of his rehab programme. So, he decided 'to try my luck' by once again playing the sport that he loves, basketball. He felt OK during play, but several hours later his injury became more painful than before, to the extent that the rehab exercises that he could previously do without any problems were now causing him pain. (Before we go any further, it must be noted that I didn’t have a consultation with this person, so the analysis that follows is based only on the information at my disposal. It could be that there is other relevant information of which I'm not aware.) So, where might he have gone wrong? It may be that the weights he used for his squats were not heavy enough yet. When we jump, it sends forces of up to six times our body weight through our legs. So, you have to do quite a significant amount of squat weight to prepare your tendons for that. It may be that he has not yet built explosive strength through plyometric training. Doing slow squats with weights is different from loading the tendons quickly under force, as you would do when you jump while playing basketball. The faster you load a tendon, the higher the forces. From what our basketball player wrote, I'm not sure that he did any plyometric training before he went back to playing. It may be that the volume and intensity of play was simply too much. Maybe his tendons were able to cope with, say, ten minutes worth of playing basketball, but not yet an hour. Also, it is better to ease back into full-on sport with gentle sessions at first. It could be that this person immediately went into top-gear basketball, with the jostling and jumping that it entails. Lastly, it is important to understand that tendons usually take longer than expected to heal. A tendon can take up to 12 weeks just to get back to base-level strength, and this is before you even get to stuff like plyometrics. If you've had the tendon injury for longer than a year, it may take a year or longer to fully rehab it again. Have I made my injury worse? The big questions for our basketball player are how to know how much damage he did to his injured tendons and how far this has set back his rehab. When you’ve had a flare-up, it’s natural to think, ‘Oh man! Now I've made it worse, and it's going to take longer to recover!’ I’ve been there myself. A flare-up doesn’t always mean you’ve made your injury worse It’s counterintuitive, but the amount of pain you experience is not directly correlated to the severity of your injury. We used to think that the more painful an injury is, the more severe it should be. But then we started getting fancy machines like MRI scanners, which showed us that it is not quite that simple. What we saw was that some people with severe injuries have very little pain, while others with very little tissue damage are in a lot of pain. This made us realize that pain is just the alarm system of the body, and it's affected by many factors. One of these is, at a subconscious level, how dangerous the body perceives the situation to be. If it perceives it to be very dangerous, it increases the amount of pain. Therefore, your thoughts, feelings, and fears about the flare-up can feed into this and make your pain feel worse. So, if there's only a bit of aggravation of the injury but your mind goes, ‘Oh man! I've made this worse! This is going to take forever!’, immediately it feels worse because your subconscious then goes, ‘Oh, this is a bad injury! These are bad circumstances!’ If, however, you tell yourself, ‘Ah, stop worrying! I know the activity I did wasn't that much; I've just irritated it again. It will calm down a few days from now,’ you'll be surprised how much less painful it can feel. How to gauge whether you've aggravated your injury Ask yourself how much more intense the aggravating activity was than the activities you've been doing in the last four weeks. The volume and intensity of the activities you've been able to do pain-free previously are an indication of how strong the injured body part was before the flare-up. If the flare-up activity was just a little bit harder than what you’ve been doing before, it's very likely that you haven't made your injury worse; you've just flared up the pain signals that tell you it’s a bit more sensitive now. However, if you did do a session that was a lot harder than what you’re used to, for example, going from no jumping at all to an hour's worth of being really active and jumping, you may have made it a bit worse. But if it was only one session, there won't be that much more structural damage. It would rather be a case of the injury having become a lot more sensitive. There’s one exception to this guideline. If you feel a sharp, sudden pain while you were doing the activity and then your pain increases afterwards, it may mean that you've torn something. If that's the case, you definitely need to get it looked at. What to do about a flare-up Do not try and train through it Initially, you should treat the flare-up like an acute injury, even if you’ve come to the conclusion that you haven’t made it much worse. If you don’t force it to work into pain during the first few days, it will calm down much quicker. It should only take a week or two and you'll be back to your normal rehab routine from before you had the flare-up. Do what you can to reduce the pain Secondly, use everything you found useful previously to calm the pain. Applying ice to the painful area usually helps. Don’t use the ice for more than ten minutes at a time, and take ten-minute breaks in between, otherwise you might damage your skin. See whether you can somehow take the strain off the injured body part. For example, injured Achilles tendons take less strain if you wear shoes with a bit of a heel or if you use heel-raising inserts in your shoes. Often, a bit of movement that does not cause pain can be useful for pain management, so try and find low-intensity, pain-free activities. Using the Achilles tendon as an example again, it may like low-load calf raises. The basketball player's knees may like him to actually do some isometric squats or go for a little bit of a walk or an easy cycle ride or rather than keeping them still all day long. Reduce your rehab intensity and increase it from there Once that flare-up pain has calmed down after two or three days, take a look at your pre-flare-up exercises and then halve them. If you were using 20 kg with your squats, try 10 kg. And if you want to be more conservative, there’s nothing wrong with starting at 5 kg. Just do a gentle set and fewer repetitions than before. If this feels absolutely fine, wait to check the 24-hour response – you should not have more pain than before you did the previous day’s exercises. Tendons especially are sneaky things that don’t tell you during an activity that you’re asking too much of them; they wait until the next day before they complain. If there are no issues, you can increase the weight and reps quite significantly for the next training session, because we know that just a few days back, before the flare-up, you had the strength to deal with 20 kg. So, if you were doing 5 kg, try 10 kg for this session and check your response again. If it's not quite OK, then this can be your new limit for now. It's really important to start easier rather than harder and then increase it from there. If you start too hard, you're just going to annoy the flared-up injury further, and then you’ll have to wait even longer for it to calm down. In summary: It doesn't necessarily mean that you've made your injury worse if you have a flare-up; flare-ups are really common. Try and figure out why the flare-up happened and what part of your rehab wasn't adequate. And then, treat it aggressively by trying to calm it down, not overdoing it, and then slowly increasing your rehab. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Hanlon, S. L., et al. (2021). "Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy." J Orthop Sports Phys Ther 51(9): 440-448.

The severity of ankle fractures can vary dramatically, and the treatment has to be adjusted accordingly. In this article, we’ll cover what exercises and rehab you should do to get your broken ankle back to full function. This includes what you can do already while your ankle is still in a boot or cast and what you should do after the boot or cast has been removed. We’ll also discuss recovery times and things you should keep in mind before returning to your sport. Please check with your doctor or physiotherapist before you start any of the suggested exercises, as they may not be right for you. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: What happens to your ankle when it is stuck in a boot or cast? How long will your broken ankle take to recover? Exercises while your broken ankle is still in a cast/boot Ankle fracture rehab - when your cast/boot is finally removed How we can help We've also made a video about this: What happens to your ankle when it is stuck in a boot or cast? To appreciate what we need to do to get a broken ankle better, it helps to understand what happens to a body part that is stuck in a boot or cast. It heals This is the obvious and desired effect. Your bones need this period of immobilisation to knit together. If you remove the cast or boot too early, the bones may not knit together properly, and you may end up needing surgery. You lose muscle mass This is not great, but unfortunately it’s unavoidable. Our bodies are designed to save energy, as it is constantly expecting us to run out of food and starve. If you don’t use a muscle for a while, your brain’s control centre thinks that you don’t require that area of the body to be strong, so it reduces its muscle mass and rather sends resources to the parts that you are using. Your nerves and a part of your brain go to sleep The nerves in our bodies are constantly sending signals to our brains. The brain also has a specific area that is dedicated to managing that specific part of your body. When an area of our body is not being used and is shielded from experiencing normal sensations (like a cast stopping you from touching your leg), the nerves in that area eventually become less active, as the brain feels it’s a waste of energy to keep them active in an area that is not being used. The control centre in the brain also reduces its activity. Our brain and nerves control everything in the body, including circulation, muscle contractions, and sensation. This is why it may feel extremely strange to touch your ankle right after your cast has been removed and why it can be so difficult to get your muscles to contract during those first few days. Interesting fact: You lose most of your muscle strength in the first week or two of being stuck in a cast. This is before you start to lose muscle mass. The reason for this loss of strength is thought to be down to the control centre in the brain in charge of contracting your muscles in that area going to sleep. There are simple ways to reduce this loss, which we discuss lower down. Your cartilage gets a bit thinner Joints don’t have arteries or veins that provide them with nutrients and oxygen. They rely on the changes in pressure created when you move to push fresh nutrients and oxygen into them. This is why a joint loses some of the cartilage that lines its surfaces when it is immobilised. But don’t worry, the cartilage will repair once you start moving. It just explains why your joints can feel so uncomfortable when they first come out of a cast. Your ligaments and joint capsules become tight Being stuck in one position for some time stiffens all the soft tissue in that area, but this is reversible. How long will your broken ankle take to recover? You’re looking at a minimum of 24 weeks for your ankle to be ready for full-on sport again. Ironically, your broken bones take only 12 weeks to fully mend. The subsequent 12 weeks are needed to undo all those negative effects your joints, muscles, and nerves suffered due to being stuck in a boot or cast for so long (see previous section). The recovery can be divided into three stages: The bones knit together: This takes about six weeks. At the end of this period, the fractured ankle bones would have knitted but the area will still be quite weak. You will be wearing a cast or boot for the duration of this period. The fracture area strengthens to pre-fracture strength and beyond: This takes another six weeks. The severity of your fracture and healing response will determine when your cast or boot can be removed (usually around 10 to 12 weeks after it was applied). By the end of this stage, your mended bones will be very strong. Rehab phase - restoring full range and strength: When your ankle is taken out of the boot or cast, it will likely be very stiff and weak. Twelve weeks is the minimum time your body will need to restore your cartilage, ligaments, joint capsules, muscles, and nerves to their full function. Exercises while your broken ankle is still in a cast/boot There are certain things you can do during this period that can help reduce the negative effect immobilisation has on your body. Please check with your doctor or physiotherapist before you start any of these exercises, as it can cause harm if you do them too soon. Moving your toes Don’t be too vigorous with this at the start. All broken ankles require a few days to settle. Start with gentle movements. It can improve circulation and help to keep your nerves awake and active. Strengthening your uninjured leg You will always lose some muscle mass and strength when you have to wear a cast or boot. Now, I know this sounds bonkers, but researchers have found that if you strengthen the muscles on the limb that is not injured, it can help to preserve your muscle strength and mass in the injured limb that is stuck in the cast. This is called cross-education. Researchers think that it has to do with neural activity and that our nervous system works a bit like a mirror. If you strength train the muscles around your uninjured ankle, it activates the control centre in your brain for the area you’re training as well as for the same area on your opposite limb. Like mentioned before, most of the strength losses we seem to experience due to immobilisation seem to be linked to the nervous system becoming less active. Cross-education strength training can help to keep the nervous system active and reduce these losses. However, if you’re hobbling around on crutches and already placing a lot of weight on your uninjured leg to compensate for loss of use of the injured one, it may be best not to train it too hard, as it will already be doing a lot more work than usual. Strengthening the rest of your body This is the ideal time to ensure that the rest of your body is nice and strong. Our bodies work as kinetic chains, which means that weakness in one area can also affect the other areas. By ensuring that your whole body is strong, you will support and protect your injured ankle. It will be especially useful to focus on strengthening your core and the muscles in your thigh and gluteal area on your injured side. Choose exercises that don’t place strain on your boot or cast. A physiotherapist can provide you with a programme for this. Examples of core exercises that may be useful: Sit-ups Russian twists Planks on your knees Examples of hip exercises: Side leg lifts Clams Hip extension in four-point kneel Quad exercise (injured leg): Seated knee extension: Your boot or cast will provide plenty of resistance. Sit on a chair and extend your injured leg out in front of you, lifting your foot off the floor. Hold the position for several seconds, then lower it down and rest. Hamstring exercise (injured leg): Standing hamstring curls: Stand on your uninjured leg, holding on to a sturdy object. Slowly lift your injured foot towards your bottom, pause for a moment at the top, then lower it back down. The weight of your cast will help to strengthen your hamstrings. Ankle fracture rehab - when your cast/boot is finally removed Restoring your broken ankle to its full strength and function is about more than just exercises. I’ll discuss the most important aspects here, but I would suggest that you seek guidance from a physiotherapist, as everyone’s situation tends to be unique, and you will get better results from a bespoke plan. Load management I've put this at the top, because it is a very important part of the rehab process that is often neglected or not very well explained. When you stand or walk, your feet carry all of your weight. Being stuck in a boot for so many weeks would have weakened the muscles and ligaments that are meant to support your foot arch. So, your foot won’t be able to cope with carrying your weight when you first take it out of the boot. If you increase the amounts of standing and walking too suddenly, you can end up straining your ligaments or plantar fascia and may develop plantar fasciitis. My advice is: Always wear supportive shoes, with added arch support if needed, when you’re on your feet. This is especially important for when you’re standing still for long periods, e.g. while cooking. Once your foot and ankle have regained their strength, you can slowly transition back to wearing less supportive shoes and walking barefoot. Slowly increase the time you spend on your feet. Remember, it’s the total amount of standing and walking in a day that is important as well as for how long you do it in one go. Start with short periods of standing and walking interspersed with rest periods, and slowly build it over time. Exercises that train your nervous system As mentioned earlier, being stuck in a cast or boot causes your nerves and the central control centre in the brain to be less active and alert. This affects your body in several ways, but the main one I want to highlight here is loss of control. When you move, the central control system in your brain uses feedback from the nerves in your muscles, joints, ligaments, and tendons to understand where your limbs are in space and time and to calculate the optimal movement pattern. This is how you know where your hands and feet are even when you close your eyes and why you can walk down a flight of stairs without having to look at your feet. We call this position sense or proprioception. An injury affects these messages from the nerves, and immobilising an injured limb for some time amplifies this loss. A reduced position sense means that you could injure yourself again once you get moving, because you will be somewhat clumsy to start with. It is extremely important (and quite easy) to retrain the control and position sense in your body. You can regain your position sense with a combination of techniques: Doing your strength training exercises very slowly and looking at your limb while you’re moving it. Focus on doing smooth movements and not using momentum. Exercises that challenge your balance. Now, people tend to immediately think about standing on one leg or on balance boards when they hear mention of balancing exercises. But this will likely be too difficult for you at the start. Often, just standing on both feet and slowly transferring your weight to your injured side would be difficult enough. As with all exercises, these should be progressed in difficulty and complexity as your ankle regains strength and control. This can be followed by tandem standing (heel-to-toe on a line), balancing on one leg, balancing while closing your eyes, and finally on unstable surfaces. Strength training exercises for the ankle and foot These exercises will help to restore the strength you’ve lost in all those small, intrinsic foot muscles as well as the ones that control your ankle. The specific type and intensity of the exercises will depend on each case, so I won’t go into too much detail here. The muscles that you want to focus on include those with the following functions: Supporting your foot’s arch (intrinsic muscles) Turning your ankle out (the peroneals) Turning your ankle and foot in (tibialis posterior, tibialis anterior); they also help to support your foot’s arch Pointing your foot down and propelling you forward when you walk, run, and jump (gastrocnemius, soleus) When you strengthen these muscles, you should start in positions that place very little strain on your ankle and focus on regaining control before you start adding load. As you grow stronger, the exercises should increase in complexity as well as load until you do exercises that mimic the movements and forces required for your specific sport. Let’s take the plantar flexors (calf muscles) as an example. A good exercise to start with is seated heel raises. These can then be progressed to standing double leg heel raises, followed by adding weight or doing them on one leg, and finally plyometrics where you hop and jump. Your physio will help to guide you in when you’re ready to move on to the next type of exercise. Mobility exercises Don’t be too forceful with your stretches, as overstretching can cause your joint to be achy and painful. I find that doing active stretches and movements often and throughout the day seems to work better than doing long, sustained holds where you really try and force the movement. Repetitive movements have been shown to feed joints and help restore the cartilage. Patients seem to regain their ankle mobility at different rates, and from what I’ve observed the main factors that influence this are: How severe their fracture and intra-articular (inside the joint) injury was. How flexible or stiff their soft tissue is in general. If you are generally a flexible person (can manage most yoga poses with only a bit of effort), you will likely regain your full range of motion a bit more quickly than if you’re on the less flexible side (that guy who remains sitting bolt-upright in yoga class when he is actually trying to bend towards his toes). How diligent people are with doing their exercises. But diligence only goes so far. Even if you’re super diligent, it will still take at least 8 to 12 weeks to regain your full range of motion. This is just how long it takes the body to remodel and reverse the effects of the immobilisation. You should aim to regain your full movement in all directions. See what your uninjured leg can do and compare that with your injured side. How far can your foot point down (plantar flexion), pull up (dorsiflexion), turn in (inversion), and turn out (eversion)? Dorsiflexion is often the most difficult to restore. A good starter exercise is the knee-to-wall stretch. This can later be progressed to the typical runner's calf stretch or heel drops over the side of a step. Whatever you choose, do them as active stretches: Hold the position where you feel the restriction for 10 seconds, then move out of it for a second of two. Repeat this several times in one go – six is a good number – and do it two to three times a day. Exercises for the rest of the body Our bodies work as kinetic chains. Weakness or lack of control in one area will also affect the rest. This is why it’s important to include exercises for your core, glutes, quads, and hamstrings. These exercises should start easy and in low-load positions. However, it is really important to eventually progress them to resemble the movements used in your sport. For instance, a basketball player should include several hopping and jumping drills, whereas a walker’s rehab plan would focus more on building endurance. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Campbell, M., et al. (2019). "Effect of immobilisation on neuromuscular function in vivo in humans: a systematic review." Sports Medicine. 49(6): 931-950. Knapik, Derrick M., et al. (2013) "The basic science of continuous passive motion in promoting knee health: a systematic review of studies in a rabbit model." Arthroscopy. Oct; 29(10):1722-31. doi: 10.1016/j.arthro.2013.05.028 Haggert, M., et al. (2020). "Determining the effects of cross-education on muscle strength, thickness and cortical activation following limb immobilization: a systematic review and meta-analysis." The Journal of Science and Medicine. 2(4): 1-19. Andrushko, J. W., et al. (2018). "Unilateral strength training leads to muscle-specific sparing effects during opposite homologous limb immobilization." Journal of Applied Physiology. 124(4): 866-876.

Distal biceps tendonitis (also called lower biceps tendonitis) is an injury that typically affects people who do weight training in the gym, but it can also affect those doing certain other sports. In this article, I explain the causes of this lower biceps pain and the treatment for distal biceps tendonitis. There are also some guidelines on how to tell a distal biceps tendon tear from a tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: What is distal biceps tendonitis? Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis? Distal biceps tendonitis treatment How we can help We've also made a video about this: What is distal biceps tendonitis? Your biceps muscle is anchored to your skeleton with three tendons: two at the top (here’s a video about injuries to those) and one at the bottom. The lower biceps tendon, which is also called the distal tendon, runs across your elbow and attaches to the bones in your forearm. The biceps muscle has two functions: It flexes the arm, i.e. it bends your forearm upwards, towards your shoulder, e.g. when you do a bicep curl. It also supinates your hand, which means it turns it outwards, e.g. when you turn a doorknob clockwise with your right hand or counterclockwise with the left. A tendonitis develops when you overwork or overload the tendon. So, any exercise or work that involves flexion of the forearm or supination of the hand that you overdo can cause an injury of the distal biceps tendon. It can be a sudden overload, for example when you do one gym session that’s a lot harder than what you usually do, and the next day or hours later it starts aching. Or it can be a cumulative overload, where you've done quite a lot of hard training over several weeks, and the tendon has not had enough time between sessions to repair the micro-damage from the training, so instead the damage accumulates over time. Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis? A tendonitis might become gradually more painful during a game or training session. But sometimes, the pain only starts hours later, or you even wake up the next morning and you go, ‘What's wrong with my tendon? It's really painful!’ However, if you’ve experienced a sudden, sharp pain during a training session or game, there’s good reason to suspect that you may have a distal biceps tendon tear rather than a tendonitis. If this is the case, you need to see a doctor who can do an ultrasound scan or an MRI scan to see the extent of the damage. You could also do the hook test if you want to get an initial indication of whether you’ve ruptured your tendon. If you tense your biceps muscle, you should be able to feel the distal tendon, and you should be able to hook your finger underneath it. If you can do that, it means that the tendon is not totally torn off. It can still be a partial distal tendon tear if you felt a sudden sharp pain, but there's still some tendon left. If you can't feel your tendon and you can’t hook your finger under it, you really need to see a doctor because you may have actually ruptured your tendon totally. Another indication of a distal biceps tendon rupture is called the Popeye sign, where your muscle is bunched up on your upper arm even though you’re not tensing it. This could mean that you’ve ruptured either the distal biceps tendon or one or both of the top ones and now the muscle has contracted. Distal biceps tendonitis treatment If it is a tendonitis and not a tear, how can you get it better? When you have a tendonitis, the structure of the tendon changes; it becomes a little bit more pliable, it loses some of its strength, and it can't handle all the stress from the sports you want to be doing. If you carry on with your training or sport as if it’s business as usual, the pain will just escalate and, when eventually have no option but to take it easy and start treating it, your recovery time will be longer. Relative rest as part of distal biceps tendonitis treatment This doesn’t mean that you have to take a total break from being active. Careful strength training is the best way to get your tendon back to its full capacity, but first you have to decrease the load on it – the amount of work that you’re asking it to do. This article explains the concept of relative rest within the bigger scheme of recovering from sports injuries in some detail. How much you have to rest it and what you can do will depend on your case and how bad it is. Most of the time, if the tendon is acutely flared up, it's good to go easy on exercises that involve flexing the elbow or supinating it. So, if we think of gym exercises, it'll be things like pull-ups and biceps curls that should be reduced. Exercises where you push stuff away from you are usually okay. The golden rule here is: If it causes you any pain during this first period of recovery, just don't do it, or reduce your weight to a level where it doesn’t hurt. Let’s say you usually use 30 kg with biceps curls; it may mean that with your injured distal bicep tendon, you've got to come right down to about 10 kg and see if it can handle that. So, you have to establish a baseline of what activities the tendon can still do that don't flare it up. And then you have to use that and slowly build up from there until you get back to the weights that you used to be able to do. All this is a bit trickier if your activity isn’t weights. Some people can get distal biceps tendonitis through tennis, for example, and I know of a young girl who got it from swimming. In this case, you have to figure out where the weakness in the kinetic chain is. What is it about your technique that puts too much strain on that tendon? How can you change your technique to prevent this from happening again and to give your injured tendon some respite while you recover? Strength exercises for distal biceps tendonitis treatment Even if weight training isn’t your thing, you’ll have to do strength exercises to get the tendon back to at least its original strength, if not stronger than before. As we’ve seen above, there are two motions that you have to strengthen the tendon for. There’s flexing the elbow so that the forearm moves towards the shoulder, but there’s also turning the hand outwards. Start really easy I find with biceps tendonitis – especially the distal tendon – you have to start at a really easy level. Start much lighter than what you think you should. Especially if you're a big bloke or a really strong girl who's been doing lots of heavy lifting, you might think, ‘10 kilos, that's nothing!’ Your distal biceps tendon may not feel the same way. Monitor the 24-hour response Often, a tendon won’t tell you that it's hurting while you’re doing the activity; it will only be hours later or even the next day. So, you've got to monitor it over the 24 hours after a strength training session, and if you find that it’s fine, you can go a little bit heavier the next time. If you find that it's there-or-thereabouts, that it's not quite happy with it but it's sort of okay and it calms down within that same day, I would stick with that session until it's comfortable, and only then should you increase the weight. Recovery time Make sure you give your tendon enough recovery time between sessions. Some of our patients do well with twice a week, so that there’s a nice, big recovery gap between sessions. Others can handle three times a week. Daily activities Be aware of how your daily, non-sporting activities can influence the healing process. Everyday things like carrying shopping bags or lifting your child up can irritate that tendon. If you have a job where there's a lot of lifting involved, you're going to have to make a plan to give your tendon a bit of a rest, so have a talk with your manager. If you can skip one week of house cleaning or get someone else to carry things for you for a couple of weeks, go for it, so that you can better concentrate on your rehab for your distal biceps tendon to strengthen it back up. As it gets stronger, you can integrate those daily activities into your life again. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Donaldson, O., et al. (2014). "Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies." Shoulder & Elbow 6(1): 47-56. Luokkala, Toni, et al. "Distal biceps hook test–Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction." Shoulder & Elbow 12.4 (2020): 294-298. Bain, Gregory I., and Adam W. Durrant. "Sports-related injuries of the biceps and triceps." Clinics in Sports Medicine 29.4 (2010): 555-576.

Hip bursitis (medical name: trochanteric bursitis) is often confused with other conditions that also cause outer hip pain, and sometimes it occurs together with one of these conditions. In this article, I explain hip bursitis symptoms and causes as well as how to treat it, including massage and which exercises to avoid. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: What is a bursa and where does hip bursitis hurt? What is hip bursitis? How to diagnose hip bursitis Treatment for hip bursitis How we can help We also made a video about this: What is a bursa and where does hip bursitis hurt? A bursa is a little fluid-filled sac, and you have them wherever a muscle or tendon is close to a bone. They sit between the muscle or tendon and the bone and in some cases between muscles, and their function is to prevent friction between these various body parts. It’s almost like those inflated marine fenders hanging over the side of a boat to protect it from contact with the dock or jetty. There are plenty of bursae in the hip, because there are so many muscles in that area: the gluteus maximus, medius, and minimus, the piriformis muscle deep inside the hip, as well as quite a few smaller muscles. And these muscles are all attached to the hip bone or the top of the thigh bone with tendons. Note that there are a total of nine hip bursae in the picture, and quite often it’s more than one bursa that’s causing the pain. This is why injections to relieve hip bursitis pain sometimes don’t work; they often inject the wrong bursa. (More about that later on.) Interestingly, not everyone has exactly nine bursae – some people have fewer, and others have more. The circled area in the picture above is where you typically experience hip bursitis pain. What is hip bursitis? Bursae have many nerve endings. So, when they become injured or irritated, it causes a lot of pain. There are two main ways in which a hip bursa can get injured or an existing bursitis can be aggravated. A sudden impact This usually happens when you fall on your side, like when you fall off a bicycle or trip and fall. In this case, the pain usually sets in within a few hours to a day after the impact. Excessive friction or compression This is the more common cause of hip bursitis. Yes, a bursa is there to reduce friction, but it can only sustain a certain amount of force. If, for some reason, the compression and friction are a lot more than it can handle, it will get painful and sometimes inflamed. Note “sometimes” in the previous sentence. The research has shown that bursitis doesn't always go hand-in-hand with inflammation in the bursa. That is why anti-inflammatories don't always help. Things that can cause excessive compression or friction: Biomechanics Think of the way catwalk models walk, with an excessive sideways tilting of the hips. There’s actually a name for it – the Trendelenburg Sign, and walking or running like this stretches the muscles, tendons, and IT band tightly over the outside of the hip bone, which increases pressure on the bursae. Merely standing for a long time with your hips in this sideways tilted position could also cause problems. When you’re doing the dishes, waiting in line for something, or standing at the bus stop, it’s better to distribute your weight evenly between your legs. Another biomechanical cause of hip bursitis is when the knee turns inwards excessively when you run or walk. Again, this pulls the muscles and tendons tightly over the hip bone. People usually stand, walk, or run like this because it’s become a habit, they have weak glute muscles, or when they’re very tired. Sudden overuse This usually happens when you do certain strenuous activities without having built up to it gradually. Bursae are like many other parts of the body – if you slowly increase the amount of pressure they have to handle, they will adapt to it, but if you overdo it and/or they don’t get enough time to recover between activities, it becomes a problem. Examples include running a very hilly race without having trained for it properly or suddenly doing a lot of hill walking. The effect on the bursae becomes worse when this makes you really tired and you lose your running or walking form. Tightness Excessive tightness in the muscles that cross over the hip bursae will increase the pressure there and irritate them. Tight muscles can also pull the IT band too tightly over the outside of the hip. There are also certain conditions in the lower back that can cause tightness over the hip – more about that later. Snapping hip And lastly, there's a condition called “snapping hip”, where your IT band goes “click-click-click-click” over the outside of your hip. This is quite common in people who are hypermobile or very supple, like dancers. If your IT band keeps on flicking over the hip bone, it can irritate a bursa. How to diagnose hip bursitis Bursitis and conditions with similar symptoms Bursitis pain is easily confused with other conditions and vice versa. This is because there are several things that can cause pain in the area where the bursae are. Bursitis pain is usually over the outside of the hip, but it can refer pain down the side of the leg. It can also, if it's very irritated, cause your lower back to tighten up and make that hurt. Then again, if you have lower back pain, this can refer pain into the side of the hip and/or down the side of the leg. The tendons that attach your gluteal muscles to the hip bone are in exactly the same spot as some of your hip bursae. If you have gluteal tendinopathy it can cause pain in that same area, and you won’t know which is causing it by just pressing on it. The same goes for a torn gluteal tendon. There’s sometimes a clue in how the pain developed. For instance, when you tear a tendon you usually experience a sudden sharp pain, while bursitis tends to have a more gradual onset. If there’s a history of back pain, then you'd suspect back pain rather than pure bursitis. We also want to look at how the symptoms behave over the 24 hours after exercise. For instance, if you are okay to do lots of weight-bearing activities and it doesn't really make it worse, I would not really suspect bursitis. The same if you can stand for extended periods of time without pain, because bursitis doesn’t really like this. But if you find that stretching the hip hurts, e.g. you can’t sit with your legs crossed, I would think that there could be a bit of bursitis there, although this can also irritate gluteal tendinopathy. Treatment for hip bursitis Hip bursitis often needs to be treated together with something else. For example, someone with back pain might have hip bursitis that is caused by the back pain. And research has shown that 35% of people with glute med tendinopathy also have hip bursitis. This combination of conditions is called greater trochanteric pain syndrome, and Alison has made a series of videos about this. As with most conditions, there's no one-size-fits-all treatment. A conservative treatment approach that takes into account the sub-headings below can work really well. A small percentage of people don't react to this approach, and then hip bursitis surgery is an option, but none of my patients have needed surgery – the most invasive thing some have had to go for is a cortisone injection. Identify the cause(s) It is always important to try and identify the cause for your hip bursitis (biomechanics, overuse, etc.). If you only focus on treating the symptoms and don't address the underlying cause, you may get rid of the pain in the short term, but it will just come back later. Work on bad habits Linked to this, we need to look at bad habits, like putting most of your weight on one leg when you stand. I get all my patients with hip bursitis or any other pain on the outside of the hip to make sure that they're always standing on both feet equally, because otherwise you just annoy that sensitive tissue all the time. The same goes for crossing your legs when you’re sitting. This will also stretch the muscles and tendons over the outside of the hip, which will just keep the pain cycle going if you have a sensitive bursa or even a sensitive gluteal tendon. Exercises for hip bursitis – and which hip bursitis exercises to avoid Strengthening exercises are not my first choice for this condition. The bursae have to be properly calmed down first before strength exercises are introduced, otherwise you tend to make it worse. However, if biomechanics or something like a lack of glute strength contributed to the hip bursitis, those muscles will have to be strengthened at a later stage. It is best to avoid exercises like clams or side-leg lifts during the early stages of rehab. These exercises can often irritate the irritated bursae more because they can pinch the bursae when your leg moves out and compress the bursae by stretching the muscles and tendons over the outside of the hip when your leg moves back in. Exercises like glute bridges or leg presses will still strengthen the gluteal muscles, but because the legs move in a straight line, you avoid the positions that are most likely to irritate the bursae. Also, something like isometric wall sits would be better to start with than the repetitive motion of doing squats, where you are more likely to rub your bursa. Stretches for hip bursitis are best avoided I tend not to give my patients stretches to do, because stretching increases the compression, and nine times out of ten you will just make it worse. If stretching does not make the pain over the outside of your hip worse, it was likely not a proper bursitis and it may have just been sensitive from other things. Here's a video with more details: But what to do if you think that tightness could be a cause of the bursitis? Massage for hip bursitis Massage, whether you do it yourself or a physio or massage therapist does it, works really well, because if you can get the muscles to relax, you'll take the pressure off the bursa. However, it's not about pressing onto the bony bits where the really sensitive spots are. You want to start in the less sensitive areas and work on the trigger points. You don't want to elicit a strong pain, especially not in the first session, because if you go too heavy on it in the first session, you won't know how it's going to react, and it may cause it to flare up. A tennis ball is very handy if you want to do it yourself. Target the soft, squishy, muscley bits in your bum, not the bony bits on the hip itself. It’s better to do it against a wall than on the floor – that way you have more control. Relax the leg that is closest to the wall, press yourself into the wall with the other leg, and move the area around over the tennis ball. Here’s a video demo: How vigorously should you do this? I tell my patients that it has to feel no worse than “comfortably uncomfortable”. Sometimes, if you've had pain for a long time, it can feel quite satisfying to replicate that pain and feel how it burns. Don’t do it! Rather go gently and see how it reacts in the next 24 hours. If the pain isn’t worse than before the massage, you can go a little bit harder the next time, and vice versa if the pain is worse. Dry needling I find that, especially in the very painful early stage when you can't apply a lot of pressure, not even with massage, acupuncture can provide really good pain relief and relaxation of the muscles. I have even come across one study that found that dry needling produced similar results to cortisone injections. However, I would want that study to be replicated before I believe this 100%, because I've definitely seen in practice that, for some people, dry needling just doesn't work, and they do need to go on to injections. Hip bursitis injections We're talking hip bursitis cortisone (steroid) shots here. You can do a cortisone injection in two ways. The doctor or physio can either go on the landmarks of the body, pressing to find the painful spot and inject it “blind”. Or they can do the injection under ultrasound guidance (where they use an ultrasound scanner to locate the injured bursa) to ensure that they get it exactly in the correct spot. These scans work the same as when scanning a foetus, and you can use them to see several types of soft tissue, including bursae. I always try to refer my patients to somebody who will be doing the injection under ultrasound guidance. Anti-inflammatories Again, hip bursitis is one of those weird conditions where sometimes there's inflammation, sometimes there's not. So, for some people anti-inflammatories work really well, while for others they don’t really work. Always check with your GP before you take these, because there's certain medications that they interact with. Also, anti-inflammatories have a way of upsetting stomachs. So, it’s always better if you can get away without using them. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Barratt, P. A., et al. (2017). "Conservative treatments for greater trochanteric pain syndrome: a systematic review." British Journal of Sports Medicine 51(2): 97-104. Rothschild B. Elusive trochanteric bursitis relief. Clinical Rheumatology 2019:1-1. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia 2009;108(5):1662-70.

So, you’re doing your patellar tendonitis rehab exercises diligently, and you’re careful not to overcook things because your physio has warned you that this would be counterproductive. Yet your patellar tendon pain isn’t going away, or it flares up at unexpected times. What could be the matter? Here are some everyday movements that may be to blame and that you may want to avoid during your patellar tendonitis rehab. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Patellar tendon pain rehab – looking beyond exercises How kneeling can cause pain How deep squatting can increase pain Workarounds How we can help We’ve also made a video about this: Patellar tendon pain rehab – looking beyond exercises Injured tendons don’t like being stretched and they don’t like being compressed. If your physio knows what they’re doing, they would have ensured that your patellar tendon rehab programme avoids exercises that would do this to your tendon and cause you pain. They would also have warned you against overdoing those exercises that they did prescribe, because that will have the same effect. If this is the case and your tendon is still painful or flares up in spite of good progress with the rehab programme, it makes sense to look beyond the exercises; there may be some everyday activities that cause you ongoing patellar tendon pain. We warn our patients against two such movements or activities and advise them how to adapt things to avoid irritating their recovering patellar tendons: kneeling and squatting. How kneeling can cause pain Gardening, working with small children or animals, washing the floor, DIY – all these activities might require you to kneel from time to time. The quadriceps muscles on the front of your thigh end in the quadriceps tendon just above the kneecap or patella. The patellar tendon runs from the lower border of the kneecap and attaches to the top of your shin bone or tibia. When you’re kneeling, you’re kneeling right on that injured patellar tendon, and this compresses it against the bones in your knee joint. And, depending on how far your knee is bent while you’re kneeling, the tendon might also get stretched, which will make matters even worse. How deep squatting can increase pain Similarly, if you are squatting to do jobs or activities that are low down or to deal with something that needs you to be in this position, the patellar tendon is being pulled tight over the bony bits in your knee joint, causing it to be compressed and stretched. This is also why your physio will likely ask you to not squat too low when you do your rehab exercises in the early stages of your recovery. Workarounds Where possible, avoid compressing and/or stretching your injured patellar tendon by sitting on the floor or on a low stool instead of kneeling and squatting. If you can manage to sit with straight legs or knees that aren’t bent too much, even better. These are only temporary measures. Your rehab exercises will gradually restore your tendon’s ability to withstand both compression and stretch, and you’ll be able to do these activities without any problems once you’ve recovered. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can read more about her here, and she's also on LinkedIn.

Non-steroidal anti-inflammatory drugs (NSAIDs) like Naproxen and Ibuprofen are very effective for relieving muscle pain in various scenarios. However, this article highlights the drawbacks of using anti-inflammatories for muscle pain, whether it’s shortly after an injury or to deal with muscle soreness during or after sport. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Anti-inflammatories to relieve muscle pain (injuries and DOMS) Anti-inflammatories to enhance performance How we can help We've also made a video about this: We also have an article about the use of anti-inflammatories for tendon pain, if you’re interested in that. Anti-inflammatories to relieve muscle pain (injuries and DOMS) People use NSAIDs to relieve muscle pain in two scenarios: First, pain caused by an acute muscle injury, and also for that general muscle pain you get a day or two after a hard match, race, or training session. In both cases, this is not a good idea. Anti-inflammatories for acute muscle injuries (strains and tears) Inflammation plays a crucial role in how your body heals a muscle injuries. When you strain or tear a muscle, the cells that make up your muscle fibres get damaged. Two things then happen during the first three to seven days after the injury: inflammation sets in, and a blood clot forms in the muscle – very much like an internal scab. Think of the injured part of the muscle like a building that’s been demolished to make way for a new one. The role of the inflammatory cells is to absorb the damaged cells and get rid of them – to clear away the debris, in our analogy. The role of the internal scab is to act like scaffolding for the new cells that replace the damaged ones to attach themselves to – i.e. to erect the new building. This cleaning-away-and-rebuilding process can take up to three weeks after the injury. By taking anti-inflammatories for an injured muscle, you inhibit the inflammation and therefore the process of getting rid of the damaged cells. This has a knock-on effect on the formation of new cells to rebuild the injured part of the muscle, and so the whole healing process is compromised. Yes, anti-inflammatories do reduce the pain caused by such an injury but it may have a negative effect on your recovery. However, if you can’t stand the pain, it is better to speak to your doctor about taking something like paracetamol instead. Anti-inflammatories for muscle soreness after sport or exercise When we exert ourselves physically, our muscle cells get micro-damage. This is normal and not as bad as it sounds. Our bodies then repair our muscle fibres to be a bit better than before, and this is how we gradually get fitter and stronger through exercise. When we overdo the exertion, it can cause some muscle pain in the day or two afterwards, and this is known as DOMS (delayed-onset muscle soreness). Here also, inflammation plays an important role in the process that allows us to grow stronger in response to a workout. The research suggests that if you regularly take NSAIDs for DOMS, you may deprive yourself of the training benefits and not gain as much muscle strength as you would otherwise. Anti-inflammatories to enhance performance Some people also take anti-inflammatories to alleviate or avoid muscle pain during sport, especially endurance races, in the hope that it will enhance their performance. A recent review of the available research found no evidence that this ploy works. It analysed 23 studies involving a total of 514 athletes and found that there were “neither significant difference in the maximum performance between NSAIDs and control groups nor in the time until exhaustion nor in self-perceived pain”. Therefore, we don’t recommend that athletes take NSAIDs to enhance their performance because they are known to be bad for your kidneys and stomach lining, especially if you were to dehydrate during an endurance event. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate. References: Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries: biology and treatment. Am J Sports Med. 2005 May;33(5):745-64. doi: 10.1177/0363546505274714. PMID: 15851777 Baldwin Lanier, A. (2004). Treating DOMS in sport with NSAIDs. International SportMed Journal, 5(2), 129-140 Cornu, C., Grange, C., Regalin, A. et al. Effect of Non-Steroidal Anti-Inflammatory Drugs on Sport Performance Indices in Healthy People: a Meta-Analysis of Randomized Controlled Trials. Sports Med - Open 6, 20 (2020). https://doi.org/10.1186/s40798-020-00247-w Schoenfeld, B.J. The Use of Nonsteroidal Anti-Inflammatory Drugs for Exercise-Induced Muscle Damage. Sports Med 42, 1017–1028 (2012). https://doi.org/10.1007/BF03262309 Trappe TA, White F, Lambert CP, Cesar D, Hellerstein M, Evans WJ. Effect of ibuprofen and acetaminophen on postexercise muscle protein synthesis. Am J Physiol Endocrinol Metab. 2002;282(3):E551-6

One of the most common types of shoulder pain that I treat in clinic is sub-acromial impingement. I know, it’s a mouthful! But the name will make a lot of sense once I’ve explained how the shoulder joint works and what the cause of this type of shoulder pain is. I’ve also included some exercises that I use for shoulder impingement. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: A quick lesson in shoulder anatomy How do you know if you have shoulder impingement? The most common causes of shoulder impingement How to treat shoulder impingement Exercises for shoulder impingement A quick lesson in shoulder anatomy Your shoulder joint is formed by three bones. The collarbone and the tip of the shoulder blade (acromion) forms the roof of the shoulder joint – that’s the hard bone you can touch on top of your shoulder. The head of your arm bone (humerus) sits comfortably in the cavity they form. The space between the roof (collarbone + acromion) and the head of the humerus is called the sub-acromial space. This space is home to several tendons including the tendons of your rotator cuff and bicep muscles. It also has a bursa which is a little fluid filled sac that is meant to reduce the friction between the bones and the tendons. As you move your arm up, the shoulder blade has to tilt backwards to prevent the bones from hitting each other and squashing the tendons and bursa. If for some reason (I discuss these below) the shoulder blade does not get out of the way of the arm bone and you repeat this movement several times, this compression eventually causes inflammation in either the tendons or the bursa or both, resulting in shoulder impingement. How do you know if you have shoulder impingement? Shoulder impingement is usually caused by an activity that involves repetitive arm movements e.g. swimming, doing overhead weights, cutting hedges, painting a wall, cleaning etc. You often don’t feel any pain while you’re doing the activity but only develop the pain a few hours later or wake up with a painful shoulder the next morning. It’s important to distinguish between a muscle tear and impingement. You’ve likely torn a muscle if you’ve felt a sudden sharp pain while doing an exercise or while working.I t’s painful to reach above shoulder height or to put your arm behind you. It's normal for the pain to refer into your upper arm and down to your elbow. The most common causes of shoulder impingement There are several reasons why your shoulder blade may be slow to move out of the way of the humerus and cause shoulder impingement. The top causes I see in practice are: 1. Rounded shoulders Rounded shoulders are caused by the shoulder blades sitting in a protracted and forward tilted position. Remember that we need the shoulder blades to tilt backward to get out of the way of the humerus when the arm moves? Protracted shoulder blades cause the sub-acromial space to narrow and is one of the main causes for shoulder impingement. People end up with rounded shoulders for several reasons: They may have generally poor posture and slouch. Try this: Slouch your spine and stick your chin out. Notice what happens to your shoulders – they drop forward. Now sit up nice and straight – try and push the ceiling away with the top of your skull. Notice how your shoulders immediately fall into a better position. Over time your spine and shoulders will get stiff in this slouched position and your postural muscle will become weak (because you’re not using them!). You can turn this around by doing specific exercises, but the longer you wait the harder it will be. If you exercise the front of your chest (especially your pec muscles) a lot and don’t stretch it out to maintain your flexibility, your pecs will become tight and pull your shoulders forward. 2. When you do an activity that you’re not used to You may have fair posture, but if you do an activity that you’re not used to or do too much of the same activity your muscles around your shoulder blades may get tired and allow your shoulder blades to tilt forward. For example if you do too many hard swimming sessions without allowing enough recovery time or if you spend 3 hours cutting hedges in the garden. How to treat shoulder impingement Step 1: Get it diagnosed to make sure it’s not a muscles tear – the two conditions can feel very similar. Step 2: Correct your posture and retrain your shoulder blades to sit in a more retracted position. I show you how to do this in the video below. Step 3: Teach your shoulder blades to stay out of the way as you move your arms and strengthen the muscles that are meant to stabilise your shoulder blades. Exercises for shoulder impingement You should always work on improving your posture and teaching yourself how to move your shoulder blade before you do and strengthening exercises. In the video below, I show you how to correct your spinal posture and set your shoulder blades. I also demonstrate 2 of my favourite exercises for shoulder impingement. These may not be appropriate for you so please consult a medical professional before you try them. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate. References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon)